Temporal Bone Imaging
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Editors
Marc Lemmerling Bert De Foer
Department of Radiology Department of Radiology
Algemeen Ziekenhuis Sint-Lucas Sint-Agustinus Ziekenhuis
Gent Wilrijk
Belgium Belgium
ISSN 0942-5373 ISSN 2197-4187 (electronic)
ISBN 978-3-642-17895-5 ISBN 978-3-642-17896-2 (eBook)
DOI 10.1007/978-3-642-17896-2
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014952191
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Preface
Over the past decades immense changes have occurred in medicine in general, and in the field
of radiology more specifically. In radiology departments, some became more specialised in
head and neck imaging in order to give better answers to referring ENT specialists. This
collaboration between the referring physician and the radiologist created an even more focused
interest on the temporal bone. In the 1980s, the fundamentals of temporal bone CT were
established, and in the 1990s a comparable evolution was noted in the field of temporal bone
MRI. Untill today, both imaging techniques have continuously evolved in the creation of
temporal bone images. In the last years cone-beam CT has been added to the CT instru-
mentarium, and a growing importance was seen in the use of MRI in patients with choles-
teatoma, by the application of non-EPI diffusion-weighted images. Both topics get an
important place in this book. The purpose of the book is to provide a diverse view on temporal
bone imaging issues, and is built around chapters focusing on a topographical basis on one
hand, and on a pathological basis on the other hand. It was conceived that way to make the
book easy to read and use. Without pretending to be complete it covers the broad spectrum of
temporal bone imaging questions that the radiologist should be able to answer. Also some
more exotic pathologies are illustrated, but this book does not have the ambition to bring a
huge collection of castuistic examples.
Many authors coming from all over the world have collaborated on the book. We would
like to thank them all for their enthusiasm for and contribution to this project despite their busy
agendas. We are especially surprised by the excellent quality of the images that are presented
throughout the different chapters. Radiological images are for the radiologist what paintings
are for the painter. We hope that this book will be a museum worth repetitive visits. Last but
not least, we like to acknowledge Nancy Verpoort who did a tremendous job in correcting
illustrations and texts.
Marc Lemmerling
Bert De Foer
v
Contents
Indications for Temporal Bone Imaging: The Clinician’s Approach . . . . . . . . . . 1
F. E. Offeciers
Temporal Bone Imaging Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Marc Lemmerling, Bert De Foer, and Barbara Smet
Cross-Sectional Imaging Anatomy of the Temporal Bone . . . . . . . . . . . . . . . . . 11
Marc Lemmerling, Barbara Smet, and Bert De Foer
External Ear Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Robert Hermans
Acute Otomastoiditis and its Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Marc Lemmerling
Chronic Otomastoiditis without Cholesteatoma . . . . . . . . . . . . . . . . . . . . . . . . . 61
A. Trojanowska and P. Trojanowski
Imaging of Cholesteatoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Bert De Foer, Simon Nicolay, Jean-Philippe Vercruysse, Erwin Offeciers,
Jan W. Casselman, and Marc Pouillon
Otosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Marc Lemmerling
Temporal Bone Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Sabrina Kösling and A. Noll
Temporal Bone Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Cheng K. Ong, Eric Ting, and Vincent F. H. Chong
Congenital Malformations of the Temporal Bone . . . . . . . . . . . . . . . . . . . . . . . 119
J. W. Casselman, J. Delanote, R. Kuhweide, J. van Dinther,
B. De Foer, and E. F. Offeciers
Imaging of Cerebellopontine Angle and Internal Auditory Canal Lesions. . . . . . 155
Bert de Foer, Ken Carpentier, Anja Bernaerts, Christoph Kenis,
Jan W. Casselman, and Erwin Offeciers
Inner Ear Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Christoph Kenis, Bert De Foer, and Jan Walther Casselman
vii
viii Contents
Imaging of Cochlear Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
B. M. Verbist and J. H. M. Frijns
Petrous Apex Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Marc Lemmerling
Pathology of the Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Alexandra Borges
Imaging of the Jugular Foramen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Hervé Tanghe
Vascular Temporal Bone Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Hervé Tanghe
Post-operative Temporal Bone Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Luc van den Hauwe, Christoph Kenis, Bert De Foer, and Jan Walther Casselman
MultiPlanar Reformation in CT of the Temporal Bone . . . . . . . . . . . . . . . . . . . 367
John I. Lane
Contributors
Anja Bernaerts Department of Radiology, GZA Hospitals Sint-Augustinus, Wilrijk,
Belgium
Alexandra Borges Department of Radiology, Instituto Português de Oncologia Francisco
Gentil- Centro de Lisboa, Lisbon, Portugal
Ken Carpentier Department of Radiology, GZA Hospitals Sint-Augustinus, Wilrijk,
Belgium
Jan Walther Casselman Department of Radiology, AZ Sint Jan Hospital, Brugge, Belgium;
Department of Radiology, GZA Sint Augustinus Hospital, Wilrijk, Belgium; Department of
Radiology and Medical Imaging, AZ Sint-Jan Brugge-Oostende, Bruges, Belgium; Ghent
University, Ghent, Belgium
Vincent F. H. Chong Department of Diagnostic Radiology, National University Hospital,
Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore,
Singapore, Singapore
Bert De Foer Department of Radiology, AZ Sint-Augustinus, Antwerp, Belgium; Depart-
ment of Radiology, GZA Hospitals Sint-Augustinus, Wilrijk, Belgium
J. Delanote Department of Radiology and Medical Imaging, AZ Sint-Jan Brugge-Oostende,
Bruges, Belgium
J. H. M. Frijns Department of Otolaryngology, Leiden University Medical Center, Leiden,
The Netherlands
Robert Hermans Department of Radiology, University Hospitals Leuven, Leuven, Belgium
Christoph Kenis Department of Radiology, Sint-Franciskus Hospital, Heusden-Zolder,
Belgium; Department of Radiology, AZ Sint Jan Hospital, Brugge, Belgium
Sabrina Kösling Martin Luther Universität Halle-Wittenberg, Universitätsklinik für Diag-
nostische Radiologie, Halle, Germany
R. Kuhweide Department of ENT, AZ Sint-Jan Brugge-Oostende, Bruges, Belgium
John I. Lane Division of Neuroradiology, Department of Radiology, Mayo Clinic College of
Medicine, Rochester, MN, USA
Marc Lemmerling Department of Radiology, AZ Sint-Lucas Hospital, Gent, Belgium;
Department of Radiology, Ghent University Hospital, Gent, Belgium
Simon Nicolay Department of Radiology, GZA Hospitals Sint-Augustinus, Wilrijk, Belgium
A. Noll Martin Luther Universität Halle-Wittenberg, Universitätsklinik für Diagnostische
Radiologie, Halle, Germany
ix
x Contributors
E. F. Offeciers Department of ENT, AZ Sint-Augustinus, Antwerp, Belgium; European
Institute for ENT-Head and Neck Surgery, AZ Sint-Augustinus, Antwerp, Belgium
Cheng K. Ong Department of Diagnostic Radiology, National University Hospital,
Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore,
Singapore, Singapore
Marc Pouillon Department of Radiology, GZA Hospitals Sint-Augustinus, Wilrijk, Belgium
Barbara Smet Department of Radiology, AZ Sint-Lucas Hospital, Gent, Belgium
Hervé Tanghe Department of Radiology, Section of Neuroradiology and ENT Radiology,
Erasmus Medical Centre, Erasmus University Rotterdam, CE, Rotterdam, The Netherlands
Eric Ting Department of Diagnostic Radiology, National University Hospital, Singapore,
Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore,
Singapore
A. Trojanowska Department of Radiology and Nuclear Medicine, University Medical
School, Lublin, Poland
P. Trojanowski Chair and Department of Otolaryngology Head and Neck Surgery, Uni-
versity Medical School, Lublin, Poland
Luc van den Hauwe Department of Radiology, AZ Klina, Brasschaat, Belgium; Department
of Radiology, Antwerp University Hospital, Edegem, Belgium
J. van Dinther Department of ENT, AZ Sint-Augustinus, Antwerp, Belgium; European
Institute for ENT- Head and Neck Surgery, AZ Sint-Augustinus, Antwerp, Belgium
B. M. Verbist Department of Radiology, Leiden University Medical Center, Leiden, The
Netherlands; Department of Radiology, Radboud University Nijmegen Medical Center,
Nijmegen, The Netherlands
Jean-Philippe Vercruysse Department of ENT, Heilig Hartziekenhuis, Mol, Belgium
Indications for Temporal Bone Imaging: The
Clinician’s Approach
F. E. Offeciers
Contents Abstract
Recent progress in imaging technology has greatly
1 Introduction.......................................................................... 1 improved the diagnostic quality and the therapeutic safety
2 Which Information Does the Clinician Need in the field of otology and neurotology. This makes
from the Radiologist?.......................................................... 2 imaging one of the cornerstones in the diagnostic work-up
2.1 How Does the Clinician Decide Which Imaging to Ask for? 2 and follow-up of temporal bone pathology. By confirming
3 How the Clinician Should Approach the Indication the clinically and audiometrically suspected diagnosis,
for Imaging?......................................................................... 3 imaging helps to select the best and safest diagnostic
3.1 Let Us Now See Which Elements of the Diagnostic Work- option. It allows the ear surgeon to prepare for surgery in
up Should Urge the Clinician to Ask for Imaging .............. 3
3.2 Family History for Hearing Loss and Ear Surgery.............. 3 the most efficient way, it identifies contraindications and
3.3 Personal History and Symptoms........................................... 3 concomitant ear pathology and warns against potential
3.4 Clinical Examination and Otoscopy ..................................... 4 surgical complications. This allows the clinician to
4 Conclusion ............................................................................ 5 counsel the patient in an honest and a realistic way. The
chapter describes how the clinician can decide which
imaging sequences to ask for, taking as a starting point the
conventional diagnostic aids such as personal and family
medical history, symptoms and clinical signs, micro-
otoscopy, and audiological work-up. Two pathological
situations are described in detail as examples: (1) the
patient with conductive or mixed hearing loss with an
intact tympanic membrane; (2) the pre-operative work-up
and post-operative follow-up of the cholesteatoma patient.
A close collaboration between clinician and radiologist is
crucial to ensure a correct understanding of the indications
for imaging by the clinician, and the selection and
application of the correct sequences by the radiologist.
1 Introduction
While imaging since its early days has been an important
diagnostic tool in the diagnosis of temporal bone disease,
due to the hidden nature and limited accessibility of its
structures to the clinician’s unaided or even microscope-
F. E. Offeciers (&) aided eye, recent progress in imaging technology has
European Institute for ORL, Sint-Augustinus Hospital, greatly improved the diagnostic quality and the therapeutic
Wilrijk, Belgium safety in the field of otology and neurotology.
e-mail: [Link]@[Link]
M. Lemmerling and B. De Foer (eds.), Temporal Bone Imaging, Medical Radiology. Diagnostic Imaging, 1
DOI: 10.1007/174_2014_970, Ó Springer-Verlag Berlin Heidelberg 2014
Published Online: 20 April 2014
2 F. E. Offeciers
The advent of new therapeutic possibilities necessitated colleagues. As cases in point, two clinical situations will be
improved image resolution and a better discrimination of discussed in some detail: (1) the diagnostic challenge of a
structures and tissues within the temporal bone. conductive or mixed HL with an intact tympanic membrane
As a consequence, recent MRI sequences open the door (TM); (2) the important role of imaging in the pre-operative
to the routine application of imaging in the diagnostic work- work-up and post-operative follow up of cholesteatoma
up and post-operative follow-up of cholesteatoma, in the cases.
latter case even replacing routine exploratory second stage
surgery for residual disease. Because of its enhanced reso-
lution and lower radiation dose, Cone beam CT (CBCT) is 2 Which Information Does the Clinician
finding its place in the pre-operative work-up of conductive Need from the Radiologist?
and mixed hearing loss (HL), facilitating patient counseling
and preventing erroneous indications for surgery as well as Imaging confirms or contradicts a diagnosis suspected on the
helping to avoid per-operative complications. The overall basis of the information acquired from: (1) the personal and
effect is a more focussed, safer, more successful and cost- family history; (2) the clinical examination (otoscopy, ves-
effective intervention. tibular tests); (3) the audiometry and vestibular test battery.
Within the context of the very variable regional socio- It helps to select the best and safest therapeutic option. If
economic conditions throughout the world, otologists and this means surgery, it helps to prepare the operation in the
neurotologists need to adapt to these new possibilities, most efficient way: define the urgency of the intervention
broadening their indications for imaging for the pre-operative (e.g., the timing of cholesteatoma surgery in a school
work-up and post-operative follow-up. The close collabora- attending child); select the best surgical approach; prepare
tion between clinician and otoneuroradiologist is the cor- the necessary instruments and surgical aids (e.g., LASER,
nerstone for success, necessitating frequent contacts and micro-drill, biological glue, facial nerve monitor, etc.);
discussion of the cases: a real on-going clinico-radiological identify some potential contraindications (e.g., cochleo-
conversation. The clinician should provide follow-up feed- vestibular anomalies in stapedotomy for otosclerosis);
back to his radiologist in order to corroborate or invalidate identify concomitant pathology of the temporal bone (e.g.
radiological protocols, thus offering to the radiologist the vestibular schwannoma in mixed HL); warn the surgeon
opportunity of fine-tuning his technique and skills. The about potential anatomical risk factors which could lead to
radiologist must keep the clinician informed on the devel- per- or post-operative complications (e.g., a dehiscent facial
opment of new imaging sequences and techniques, thus canal with herniation of the facial nerve impacting on the
allowing the clinician to identify new clinical applications. stapes in functional middle ear surgery). This information
The importance of an intense collaboration between will allow the surgeon to counsel the patient in an honest
clinician and radiologist cannot be sufficiently emphasised. and realistic way. As such, pre-operative imaging (or the
It is part of a culture of interaction and cross-fertilisation absence of it) has important medicolegal implications.
between different specialties.
Therefore, I urge my ENT trainees to take their questions 2.1 How Does the Clinician Decide Which
about imaging to their colleagues in the imaging depart- Imaging to Ask for?
ment. Vice versa, young radiologists should ask the clini-
cians for regular feedback on their imaging protocols and A new case starts with the patient’s personal and family
take every opportunity to attend a number of surgical history.
interventions connected to the cases they imaged, in order We listen to the complaints and symptoms: HL (time of
to familiarise themselves with the work and language of onset: congenital, early childhood, abrupt, progressive,
their clinical colleagues. posttraumatic or iatrogenic, linked to inflammation/infec-
A common complaint by radiologists is the often very tion), tinnitus (occupational or leisure noise exposure, pul-
limited clinical information they receive from the clinician. sating, objective versus subjective, etc.), balance problems
A closer collaboration automatically resolves this important (time line), ear discharge, otalgia, facial paresis or palsy
communication flaw, which often leads to either incomplete (spontaneous, posttraumatic, recurrent).
or superfluous examinations. It is the clinician’s task to This often already focuses the attention in a specific
amend this. diagnostic direction.
The various chapters in this book will provide details We then examine the patient: otoscopy (status and
related to specific pathological entities. This introductory structure of the external ear, external meatus and ear canal—
chapter aims to inform the reader on the questions the cli- dysplasia, skin lesions, bone lesions, fracture lines; status
nician puts to his radiologist, or in other words, on the kind of the TM—normal, retracted, tympanosclerosis, colour
of information the clinician will expect from his radiological change or pulsation—vascular lesions, bulging, blunting or
Indications for Temporal Bone Imaging: The Clinician’s Approach 3
lateralisation, perforation, cholesteatoma, suspect lesion— The main questions for the clinician thus are: (1) Can sur-
tumour, malignant external otitis, aeration of the middle ear). gery improve the hearing? (2) Can the operation be per-
Key information is also provided by the audiometry— formed in a safe way?
conductive HL, mixed HL or sensorineural HL—unilateral Until quite recently most such cases would not be sent
or bilateral, symmetric or asymmetric loss (caveat cere- for pre-operative imaging. However, the recent improve-
bellopontine angle lesions in asymmetric bone conduction ment in resolution and the lower radiation dose offered by
levels)—and by the vestibular test battery. CBCT is rapidly changing this attitude. The pre-operative
The above information usually suffices to decide which imaging work-up is indeed a key factor in providing an
kind of imaging information we will need, in order to answer to these questions.
confirm or contradict the suspected diagnosis.
CT is still the method of excellence to visualise bony
lesions and air—bone and soft tissue—bone contrast.
Today, CBCT is preferred to multi-detector CT because of 3.1 Let Us Now See Which Elements
its lower radiation dose and better resolution. Thus, in most of the Diagnostic Work-up Should Urge
cases concerning functional middle ear surgery (conductive the Clinician to Ask for Imaging
HL), CT will suffice. However, in case of asymmetric bone
conduction thresholds, MRI will be needed to exclude, e.g., The diagnostic methods available in patients with conduc-
a vestibular schwannoma in the internal acoustic meatus, tive HL with an intact TM are: personal and family history,
the cerebellopontine angle (CPA) or the cochleovestibular otoscopy, audiology, imaging and surgical inspection.
labyrinth. In case of a history of congenital sensorineural However, surgical inspection is only performed as a last
HL, MRI is the best tool for evaluation. resort, when all diagnostic efforts have failed to yield a
For the work-up of cochlear implant candidates, MRI is plausible pre-operative diagnosis. Today this should be
the main tool to determine the accessibility and implanti- rather the exception.
bility of the cochlea, the presence of a normally sized
cochlear nerve branch, the absence of lesions at the level the
auditory pathways or the auditory cortex and the absence of 3.2 Family History for Hearing Loss and Ear
unexpected concomitant pathology which could eventually Surgery
jeopardize the long-term safety or function of the cochlear
implant. However, CT remains important to provide the The usual suspect is otosclerosis. CBCT can confirm the
surgeon with a reliable roadmap to execute the surgery. diagnosis in over 90 % of the cases. However, osteogenesis
So in many pathological entities of the temporal bone, imperfecta can present with similar symptoms and audio-
both MRI and CT have their specific roles. grams. Imaging is needed to evaluate the operability of
It is clearly the clinician’s responsibility to instruct the these cases, because they can be difficult and sometimes
radiologist which imaging examination is needed, to indi- impossible to improve (e.g., in case of round window
cate for what purpose and to define what he wants to see. obliteration). Also, Enlarged Vestibular aqueduct (EVA)
This will direct the radiologist in selecting the correct can present with a seemingly mixed HL. These cases war-
imaging sequences. rant MRI for their diagnosis, and present a definite contra-
The various chapters in this book will elaborate in detail indication to functional stapes surgery.
how best to visualise the various temporal bone pathologies,
thus instructing the clinicians which examinations to ask for.
3.3 Personal History and Symptoms
The time of onset of the hearing loss is a crucial diagnostic
3 How the Clinician Should Approach
element. If it is congenital or has an early childhood onset, it
the Indication for Imaging?
necessitates MRI to exclude EVA or congenital cochlear
dysplasia, which are both contraindications to stapes surgery.
The following is an illustration of how the clinician should
A history of head trauma warrants CBCT to exclude or
think about the help he can get from imaging to make the
identify traumatic ossicular luxation or subluxation.
right decisions.
A fluctuating pattern of HL contradicts the nature of an
Example 1: The patient with conductive or mixed HL ossicular fixation. It necessitates repeated audiometry for
with an intact tympanic membrane Patients suffering confirmation. Repeated otoscopy and tympanometry should
from conductive or mixed HL usually seek better hearing, rule out otitis media with effusion. If connected with an
preferably by surgery instead of having to use a hearing aid. early onset, MRI should be asked for to rule out EVA.
4 F. E. Offeciers
Autophony coupled with vestibular symptoms warrants otoscopic evaluation of the patient. For the pre-operative
CBCT to rule out superior semicircular canal dehiscence work-up of a middle ear cholesteatoma, prior to first stage
(SSCD). surgery, CT scan is still the imaging evaluation tool of
Recurrent dizziness coupled with a history of head choice. It can nicely demonstrate the erosion of the ossicles
trauma or barotrauma can point to a labyrinthine fistula. and the bony spur of the epitympanic space. It delineates the
A history of recurrent inflammatory middle ear disease bony tegmen and the capsula otica (e.g. to exclude intra-
can suggest incus lysis or tympanosclerotic fixation of the cranial involvement or a fistula of the lateral semicircular
ossicles. CBCT can provide the diagnosis. canal). However, in some cases adding MR sequences is
A history of previous middle ear surgery warrants CBCT indicated. When there is doubt concerning the diagnosis or
to evaluate the condition of the ossicles (integrity, presence concerning the extent of the cholesteatoma (e.g. intracrani-
of ossicular prosthesis) and the middle ear (aeration, scar ally when the tegmen is absent on CT scan), the non-EPDW
tissue formation). sequence provides the diagnosis. In case of a labyrinthine
fistula, adding T2-weighted MR sequences to the CT scan
can inform the surgeon on the presence or absence of scar
3.4 Clinical Examination and Otoscopy tissue in the intralabyrinthine space. This knowledge helps
to counsel the patient on the degree of risk for sensory HL as
Congenital facial abnormalities coupled with congenital a consequence of the surgical dissection of the pathology
conductive HL can be associated with minor middle ear (the presence of scar tissue between the cholesteatoma
dysplasia. It needs CBCT work-up. matrix and the membraneous labyrinth makes the dissection
Otoscopic signs of TM or middle ear disease necessitate less dangerous and thus protects function).
pre-operative CT imaging (incus lysis, tympanosclerotic
fixation of the ossicles, aeration of the middle ear?). Bulging The radiologist should have a basic understanding of the
and whitish discolouration of an intact TM, or deep retraction various types of surgical techniques that are used in chronic
of the pars flaccida can suggest congenital or respectively ear disease. There are two main classes of techniques. In the
acquired cholesteatoma. Non-EPI DW MRI can confirm the canal wall down (CWD) tympanoplasty, the middle ear cav-
diagnosis. A pulsating TM suggests a vascular abnormality. ities are cleared of pathology by taking down the superior and
A colour change in a bulging part of the TM can suggest a posterior bony wall of the external auditory canal, thus cre-
tympanic glomus tumour. Full imaging work-up is needed. ating a large resection cavity as an end result. The mastoid and
The most important audiological findings that predict attic space are thus left open, in continuity with the external
trouble and thus necessitate pre-operative imaging are: fluc- auditory canal, while a small middle ear is created by restoring
tuating thresholds (EVA), unusual form of the audiogram the TM on a more medial level. (The CWD techniques are also
(malleus fixation, LVA, SCCD) and stapedial reflex presence called ‘open techniques’.) The main advantage of CWD is
(posttraumatic ossicular luxation). In case of asymmetric bone that the cavity can be monitored for residual disease by
conduction thresholds MRI is mandatory to exclude a con- otoscopy, thus obviating routine exploratory second stage
comitant CPA or intralabyrinthine lesion (e.g. schwannoma). surgery. The main disadvantages of the CWD technique are
CT can be used to detect causes like otosclerosis, tym- the usually worse results on the functional and hygienic level
panosclerosis, posttraumatic ossicular lesions, incus lysis, (non-self cleaning nor waterresistant ear) and a higher
minor ear dysplasias and SCCD. MRI must be used to comorbidity (regular cleaning needed, and recurrent inflam-
exclude a vestibular or intralabyrinthine schwannoma, to mation due to a lack of self cleaning capacity of keratine).
detect labyrinth dysplasia, and is used when there is a In the canal wall up (CWU) tympanoplasty (also call-
suspicion of cholesteatoma. Hence, imaging must be per- ed ‘closed techniques’), the external auditory canal is kept
formed whenever something is ‘out of tune’. The most intact or is surgically restored. This increases the risk for
important reasons to ask for diagnostic imaging are: atypi- residual cholesteatoma which cannot be seen by otoscopy and
cal history, cases suspect for congenital HL, suspect oto- until recently (before the advent of the non-EPDW MR
scopic image, asymmetric BC thresholds and surgical sequence) necessitated routine surgical staging in many cases.
revision cases. However, given the amount of valuable pre- However, in recent years the bony obliteration tympano-
operative information provided, which allows for efficient plasty (BOT) technique is quickly gaining ground, because it
planning and comprehensive patient counseling, a thorough combines the advantages of CWD and CWU tympanoplasty
pre-operative imaging work-up is advocated. without their respective disadvantages. In the BOT the mas-
toid, antrum and attic (the so-called paratympanic space) are
Example 2: The pre-operative work-up and post- cleared of disease and soft tissue, keeping the bony canal wall
operative follow-up of cholesteatoma cases The diagno- intact. Then the tympano-attical barrier and posterior tym-
sis of a middle ear cholesteatoma is usually based on the panotomy are blocked by sculpted cortical bone, thus
Indications for Temporal Bone Imaging: The Clinician’s Approach 5
effectively separating the middle ear space from the para- sequences. On diffusion-weighted sequences, cholesteatoma
tympanic space. Subsequently, the paratympanic space is lights up as a hyperintense lesion on b-1,000 images. It has
completely filled with bone pâté up to the cortical level. been proven that the combination of DgeT1 and non-EPDW
Finally the TM and ossicular chain are reconstructed. The yields no higher sensitivity, specificity, negative and posi-
major advantage of the BOT is the low rate of residual and tive predictive value than the non-EPDW alone. Imaging of
very low rate of recurrent disease. This technique obviates the middle ear cholesteatoma can hence be performed using
need for routine exploratory second stage surgery, on con- non-echo-planar diffusion-weighted sequences alone. The
dition that imaging can reliably diagnose residual disease in a association to T2-weighted sequences will allow the sur-
non-invasive way. The non-EPDW MR sequence provides an geon to locate a hyperintensity seen on diffusion-weighted
excellent tool to rule out or confirm residual cholesteatoma. sequences more exactly with respect to the anatomical
Over the past few years MR imaging has gained an landmarks of the temporal bone.
increasing importance for the pre-operative diagnosis and Exception should be made in case of an infected cho-
post-operative follow-up of middle ear cholesteatoma. lesteatoma and in case of suspicion of associated compli-
Whereas CT is regarded as the primary imaging tool in cations. In those cases, the combined protocol including
the clinically clear-cut middle ear cholesteatoma to evaluate DgeT1 and non-EPDW should be used.
the extension of the cholesteatoma, MRI found its place in Screening for residual cholesteatoma by imaging should
the diagnostic work-up of the clinically doubtful choleste- be performed by MRI using solely non-EPDW. This prevents
atoma and as a non-invasive screening tool for residual unwarranted routine exploratory second stage surgery as well
disease in the follow-up after primary surgery. as irradiation from repeated CT scans. The MR controls are
Mainly two types of MR imaging techniques have been usually scheduled at 1 and 5 years post-operatively.
used: the delayed gadolinium-enhanced T1-weighted
sequences (DgeT1) and the non-echo-planar diffusion-
weighted MR sequences (non-EPDW). 4 Conclusion
The rationale of the DgeT1 is based on the fact that scar
tissue and inflammation require time to enhance and that Imaging is one of the cornerstones in the diagnostic work-
early scanning might result in false-positive results. The up and follow-up of temporal bone pathology.
echo-planar diffusion-weighted MR sequences (EPDW) A close collaboration between clinician and radiologist is
have been abandoned in favour of the non-EPDW thanks to crucial to ensure a correct understanding of the indications
a higher resolution, the thinner slice thickness and the for imaging by the clinician, and the selection and appli-
complete lack of susceptibility artefacts of the latter cation of the correct sequences by the radiologist.
Temporal Bone Imaging Techniques
Marc Lemmerling, Bert De Foer, and Barbara Smet
Contents Abstract
Multi-slice CT and Cone Beam CT are actually both used
1 CT Techniques for Temporal Bone Imaging................... 7 to image the temporal bone. Two completely different
1.1 CBCT of the Temporal Bone ............................................... 7 MR protocols are used to respectively image the inner ear
1.2 MSCT of the Temporal Bone ............................................... 8
and middle ear.
2 MR Techniques for Temporal Bone Imaging.................. 8
2.1 Imaging of the Cerebellopontine Angle and Inner Ear ....... 8
2.2 Cholesteatoma Imaging ......................................................... 8
1 CT Techniques for Temporal Bone
Imaging
Multi-slice CT (MSCT) has been used for many years to
image the temporal bone. However, the last couple of years
Cone Beam CT (CBCT) is taking over that role.
1.1 CBCT of the Temporal Bone
CBCT uses a rotating gantry on which an X-ray tube and
detector is attached. A cone-shaped X-ray beam is directed
through the middle of the temporal bone onto a two-
dimensional X-ray detector. Because CBCT uses the entire
FOV of the two-dimensional X-ray detector, only a single
360 gantry rotation is necessary to acquire a 3D-volumetric
data set. Of this data reconstructions can be made in any
desired plane.
The advantages of CBCT over MSCT are the shorter
examination time, high spatial resolution, and low radiation
dose. It is also less sensitive for metallic and beam hardening
artifacts because image acquisition is based on conventional
radiographic images. The most important disadvantage of
CBCT is its high sensitivity for motion artifacts because the
patient has to hold the head perfectly still during the acqui-
M. Lemmerling (&) B. Smet sition time of approximately 40 s.
Department of Radiology, AZ St-Lucas Hospital,
Groenebriel 1, 9000 Gent, Belgium
Many manufacturers construct cone beam scanners, and
e-mail: [Link]@[Link] their parameters will differ. In some scanners the patients
B. De Foer
are in a sitting position. We chose a scanner with supine
Department of Radiology, GZA Hospitals Sint-Augustinus, patient position. Fixation of the patient’s head is done to
Oosterveldlaan 24, 2610 Wilrijk, Belgium
M. Lemmerling and B. De Foer (eds.), Temporal Bone Imaging, Medical Radiology. Diagnostic Imaging, 7
DOI: 10.1007/174_2014_1026, Springer-Verlag Berlin Heidelberg 2014
Published Online: 24 June 2014
8 M. Lemmerling et al.
prevent motion artifacts. We use the following parameters These parameters for windowing only have an indicative
(only suggestive because scanner specific): value, as each radiologist has to make his/her own choice.
• 110 kV Systematic visualization of both stapes crura and of the
• ±140 mAs suspensory ligaments in the middle ear cavity can be a
• Field of view 15 9 5 cm High Resolution helpful indicator when choosing the windowing parameters.
• Slice thickness 0.15 mm
• Scan time 40 s
Reconstructions in the axial and coronal planes are made 2 MR Techniques for Temporal Bone
of the axial raw data images with a slice thickness of Imaging
respectively 0.3 and 1 mm using special software.
The technicians are instructed to make this recon- Since many years MR is used for inner ear imaging. During
struction in a plane parallel to the lateral semicircular the last years, an increasing role is reserved for MR in the
canal. This is the axial imaging set. The coronal imaging detection of cholesteatoma.
set is reconstructed exactly perpendicular to this axial set
of images. On the most cranial axial image the superior
semicircular canal is shown. The most anterior coronal 2.1 Imaging of the Cerebellopontine Angle
image is made just anterior to the geniculate ganglion of and Inner Ear
the facial nerve. This procedure is repeated for both the
right and left temporal bones separately, and images are A lot of discussion exists on which MR imaging protocol
viewed using a window width of 3050 HU and a window should be used for the temporal bone. Controversy exists on
level of 525 HU. These parameters for windowing only which sequences should be used, what the exact slice
have an indicative value, as each radiologist has to make thickness of the images should be and even the eventual use
his/her own choice. Systematic visualization of both stapes of contrast agents. The following imaging protocol can be
crura and of the suspensory ligaments in the middle ear considered as an example of how a good protocol can look
cavity can be a helpful indicator when choosing the win- like, but each radiologist can tailor them according to per-
dowing parameters. sonal experiences or according to different indications. The
following sequences are standard in our department:
1. 5 mm thick axial TSE T2-weighted images of the brain,
1.2 MSCT of the Temporal Bone brain stem, and posterior fossa, performed to study the
brain for cerebral anomalies causing hearing loss, tin-
The images are acquired in a single imaging plane using a nitus, vertigo, … (e.g., cerebral arteriovenous malfor-
multi-slice detector scanner. The patient is lying on his/her mations, brain stem ischemia, …)
back and the gantry of the scanner is not tilted. We use the 2. 1–3 mm thick axial SE T1-weighted images of the
following imaging parameters (only indicative because temporal bone
scanner and user-specific): 3. 0.4–0.7 mm thick axial high resolution T2-weighted
• 120 kV images of the inner ear structures
• 250 mAs 4. 1–3 mm thick axial SE T1-weighted images of the
• Collimation 0.5 mm or 0.625 mm temporal bone after intravenous injection of gadolinium
• Scan time 1.0 s 5. 1–3 mm thick coronal SE T1-weighted images of the
Postprocessing is done in a similar way as data acquired temporal bone after intravenous injection of gadolinium
with CBCT. After acquiring the raw dataset images are The following changes are currently made:
reconstructed with a slice thickness of 1 mm and by using • Performing T1-weighted images in 3D technique with the
an ultra high resolution reconstruction mode. The techni- use of thin slices (e.g., 1 mm). This is especially inter-
cians are instructed to make this reconstruction in a plane esting to study the relationship between small tumors and
parallel to the lateral semicircular canal. This is the axial the cranial nerves in the internal auditory meatus
imaging set. The coronal imaging set is reconstructed • Performing reconstructions of the 3D TSE T2-weighted
exactly perpendicular to this axial set of images. On the sequence in other planes than the axial one. This is most
most cranial axial image the superior semicircular canal is often done to study the relationship between different
shown. The most anterior coronal image is made just small structures in the cerebellopontine angel and internal
anterior to the geniculate ganglion of the facial nerve. This auditory meatus, such as cranial nerves, vessels, and
procedure is repeated for both the right and left temporal small tumors
bones separately, and the images are viewed using a win- • Performing additional MR angiographic sequences,
dow width of 4000 HU and a window level of 200 HU. especially interesting if vascular lesions are detected
Temporal Bone Imaging Techniques 9
• Performing specific sequences for detection of endo- 1. 2 mm thick coronal b0 and b800 or b1000 non-EP DW
lymphatic hydrops (see chapter on inner ear pathology) images with ADC map
2. 2 mm thick axial TSE T2-weighted images
3. 2 mm thick coronal T2-weighted images
2.2 Cholesteatoma Imaging If complications (such as middle cranial fossa invasion,
facial nerve paralysis, or membranous labyrinth invasion)
Since the introduction of MR for cholesteatoma imaging, are suspected, following protocol is performed 45 min after
two completely different techniques have been introduced, intravenous injection of gadolinium:
the one basically using diffusion-weighted images (DW), 1. 2 mm thick coronal b0 and b800 or b1000 non-EP DW
the other performing T1-weighted images before and after images with ADC map
intravenous injection of gadolinium. Non-echoplanar (non- 2. 0.4–0.7 mm thick axial high resolution T2-weighted images
EP) DW proved to be better than echoplanar DW images. 3. 2 mm thick coronal TSE T2-weighted images
Following scan protocol can be used for cholesteatoma 4. 2 mm thick coronal SE T1-weighted images
imaging: 5. 2 mm thick axial SE T1-weighted images
