Imaging Techniques
Coronal plane
Anterior plane - Anterior cochlea, geniculate ganglion, & malleus
Middle plane - Oval window, vestibule, & IAC (also EAC & tympanic cavity)
Posterior plane - Semicircular canals & mastoid
Axial plane
Lower level - External auditory canal & cochlea (basal turn) ossicles
Middle level - Cochlea (middle & apical turns), ossicles, vestibule, & IAC
Embryology
External & middle ear - 1st & 2nd branchial arches & intervening groove (cleft)
Meckel's cartilage (1st arch) forms most of malleus & part of the incus
Reichert's cartilage (2nd arch) forms stapes, including footplate, & facial nerve canal
Inner ear - Otic capsule
Trauma
Clinical
Requires major trauma to fracture the temporal bones
Hearing loss, vertigo, CSF leak, 7th nerve paralysis
Longitudinal fractures - most common (classically >80% but many are mixed)
Pass through mastoid or EAC
All go through middle ear with high incidence of ossicular derangement (Incus & incudostapedial joint most common) and conductive hearing loss
Inner ear usually spared
Facial paralysis in about 15% (proximal tympanic segment just distal to
geniculate ganglion)
CSF leak (usually caused by fracture through tegmen or the mastoid)
- Otorrhea: perforation or tear of tympanic membrane
- Rhinorrhea: tympanic membrane intact
Injury to carotid artery, jugular vein or sigmoid sinus
Transverse fractures
Commonly involve the labyrinth
- Cochlear fracture: sensorineural hearing loss, permanent if cochlear
nerve transected
- Labyrinthine fracture: severe vertigo
Facial palsy in 50% - permanent if 7th nerve transected (usually the distal labyrinthine segment just proximal to geniculate ganglion)
Perilymph fistula (can also result from barotrauma)
- Disruption of stapes footplate, oval window or round window
- Pneumolabyrinth highly suggestive but not always present
- Labyrinthine enhancement sometimes present
Diseases of the External Ear
Inflammatory disease
Malignant external otitis
- Pseudomonas common in diabetic patients
- Can extend to skull base
Tumors of the external auditory canal
Squamous cell carcinoma
Adenocarcinoma (ceruminoma)
Diseases of the Middle ear and Mastoid
Acute otomastoiditis - an acute bacterial infection. Complications include:
Coalescence - erosion of bony septa with osteomyelitis
Subperiosteal abscess over mastoid
Labyrinthitis
Petrous apicitis
Sigmoid sinus thrombosis
Intracranial empyema, meningitis or cerebral abscess
Chronic otomastoiditis - caused by dysfunction of the eustachian tube.
Middle ear effusion
Tympanic membrane retraction
Inflammatory granulation tissue & cholesterol granuloma (hemorrhagic cysts secondary to foreign body reaction to cholesterol crystals; lined by fibrous connective tissue)
Associated with chronic otomastoiditis
Lined by keratinized stratified
squamous epithelium
Results from pars flaccida retraction & ingrowth of epithelium into trapped pockets with extension into Prussak's space
Cholesteatomas arising from the region of the pars tensa extend into the posterior tympanic cavity and involve the sinus tympani and the facial recess.
Tympanosclerosis - post-inflammatory
fixation of the ossicles with conductive hearing loss
Simple mastoidectomy - limited removal of mastoid air cells
Modified mastoidectomy - removal of external auditory canal wall along with mastoid air cells, but preserving the ossicles
Radical mastoidectomy - removal of EAC wall, mastoid air cells and the ossicles, but attempted preservation of the stapes superstructure
Prosthetic stapedectomy - Prosthetic materials include stainless steel wire, metallic piston, Teflon, Silastic or plastic
Tympanoplasty - Plastic procedures to cover perforations in tympanic membrane
Ossiculoplasty
Glomus tympanicum - arise from paraganglia along the tympanic branch of the glossopharyngeal nerve (Jacobson's nerve) within the middle ear cavity
Glomus jugulare - arise from paraganglia along the auricular branch of the vagus nerve (nerve of Arnold) in the jugular fossa
Patients present with pulsatile tinnitus, conductive hearing loss, retrotympanic mass, and cranial nerve deficits
Most tumors are slow growing but locally invasive
Differential diagnosis
- High & exposed jugular bulb
- Aberrant carotid artery
- Schwannoma
- Primary & metastatic bone tumors
- Other middle ear tumors,
cholesteatoma, squamous cell carcinoma
Diseases of the Inner Ear
Labyrinthitis
Inflammation of the membranous labyrinth
Patients present with sensorineural hearing loss and vertigo
Most commonly viral, but bacterial, autoimmune, luetic or tuberculous also possible
Source can be tympanic, meningeal, hematogenous, posttraumatic or postsurgical
Acute phase: otospongiosis - resorption of bone
Chronic phase: otosclerosis - sclerosis of bone
65% females & 80% of cases are bilateral
Onset during the 2nd and 3rd decades
Fenestral otosclerosis (most common)
- Conductive hearing loss
- Fixation of the footplate of the stapes at oval window
- Surgical correction possible
Retrofenestral (cochlear) otosclerosis (otospongiosis)
- Sensorineural hearing loss
- Cochlear implantation does not work
Can be intracanalicular, in the CP angle or intralabyrinthine (rare)
Patients present with sensorineural hearing loss, tinnitus, & disequilibrium
Arise from the nerve sheath of the vestibular division of 8th nerve
Benign, slowly growing, encapsulated neoplasm
Differential diagnosis
- Meningioma
- Epidermoid
- Other cranial nerve schwannomas
- Aneurysm
- Paraganglioma
- Primary or metastatic bone
tumor
Rare, locally invasive papillary cystadenomatous tumors
Diseases of the Petrous Apex
Cholesterol granuloma (cyst)
Chronic inflammatory cysts containing blood products & cholesterol crystals
Cyst capsule lined by fibrous tissue
Hyperintense on T1 & T2-weighted images
Arise from epithelial rests within the petrous bone
Capsule lined by stratified squamous epithelial; cyst contents are primarily desquamated keratin
CT and MR appearance similar to cholesterol granuloma
Petrous apicitis (Gradenigo's syndrome)
Otomastoiditis, 6th nerve palsy, pain in distribution of 5th nerve
Intrapetrous carotid artery aneurysm
Rare lesions
Characteristic appearance on MR, with heterogeneous texture due to thrombus of different ages & variable signal loss from complex flow within patent lumen of the aneurysm
Rare lesions arising from embryonal rests at sutural sites
CT features - heterogeneous with calcifications
MR features - most are markedly hyperintense & heterogeneous on T2W images & with heterogeneous enhancement
Facial Nerve Pathology
Inflammatory disease
Bell's palsy
- Idiopathic but usually follows a viral infection
- Usually self-limited
Ramsey Hunt syndrome - herpes zoster oticus
Lyme disease
Syphilis
Imaging - gadolinium enhancement of the 7th nerve
CAUTION: The geniculate ganglion & post-ganglionic nerve segment normally exhibit mild enhancement. Also, the stylomastoid canal contains a vascular plexus that enhances.
Schwannoma - can occur anywhere along the intrapetrous course of the 7th nerve but the region of the geniculate ganglion is most common (< 1/2 present with a 7th nerve palsy)
Hemangioma - capillary or cavernous types
Differential diagnosis
- Epidermoid tumor
- Acquired cholesteatoma
- Tympanic segment: glomus tympanicum, persistent stapedial artery, cholesteatoma
- Stylomastoid segment: glomus jugulare, parotid adenoid cystic CA
Congenital Anomalies
General principles - External & middle ear anomalies often associated with facial,
cervical & skeletal dysplasias. Patients present with external ear deformities and a conductive hearing loss. Inner ear anomalies are often isolated. Patients present with a sensorineural hearing loss.
More common anomalies of the external
& middle ear
Atresia/stenosis of the EAC (tympanic ring dysplasia/aplasia) - atresia plate with fusion of neck of malleus to plate & variable development of ossicles and middle ear cavity.
First (mandibular) branchial arch dysplasia - maldevelopment of the malleus, incus& mandible
Second (hyoid) branchial arch dysplasia - maldevelopment of the stapes and footplate, styloid process and superior cornu of the hyoid bone; also anterior migration of the facial nerve canal within the petrous bone.
Semicircular canals & vestibule - Lateral SSC invariably involved. The SSC's appear short and wide or form common lumen with vestibule.
Cochlear anomalies
Labyrinthine aplasia (Michel's deformity) - single small cystic cavity. Milder forms also occur (Cochlear aplasia/hypoplasia)
Incomplete partition (Mondini malformation) - most common inner ear anomaly. Cochlea consists of a basilar turn with a cystic cavity. Atretic or dilated vestibular aqueduct.
Perilymphatic hydrops - refers to increased pressure in the inner ear; caused by communication between the subarachnoid space and inner ear; can lead to perforation of the stapes footplate and a CSF leak and possibly meningitis.
Etiology:
- trauma most common
- defective development of the lamina cribrosa
- congenitally wide cochlear aqueduct with communication of CSF with perilymph
Endolymphatic hydrops
Symptoms: sensorineural hearing loss and vertigo
Source: can be congenital, acquired, or idiopathic
Cause: deficient absorption of endolymph
Imaging: dilated endolymphatic sac and vestibular aqueduct
Meniere's disease: idiopathic but some evidence for viral etiology
Superior Canal Dehiscence Syndrome
Cause: dehiscence of bone overlying the superior semicircular canal
Symptoms: vertigo & oscillopsia with sound or pressure stimuli
Imaging: diagnosed with thin-section coronal CT
Treatment: surgical plugging of the SSC
Aberrant carotid
Persistent stapedial artery
References
Som PM, Curtain HD, eds., Head and Neck Imaging, Mosby, St.
Louis, 1996, Chapters 26-33, pp. 1300-1549.
Harnsberger HR, Hudgins PA, Wiggins RH, Davidson HC: Diagnostic Imaging –
Head and Neck. 1st ed., Saunders, Philadelphia, 2005.
Hesselink JR, Remley KB: Skull base and temporal bone, in Edelman, Hesselink, Zlatkin & Crues, eds., Clinical Magnetic Resonance Imaging, 3rd edition, Saunders-Elsevier, Philadelphia, 2006, pp 1970-2029.
Davidson HC: Imaging of the temporal bone. MRI Clinics North Am 10:573-613, 2002.