Presenter : Astien

Lecturer : Dr. dr. H. Undang Ruhimat, SpRad(K), MHKes.

1
 The first part of this review of the
temporal bone discussed :
1. Anatomy of the temporal bone
2. Inflammatory
3. Neoplastic processes

2
 This second part discuss :
1. Trauma
2. Posttraumatic complications.
3. Common surgical procedures
4. Postoperative imaging appearance
5. Noninflammatory /nonneoplastic entities (Few)

They are relatively :

Uncommon diagnoses
Symptoms that are either common (hearing loss) or
distinctive (sensorineural hearing loss in a child),
Important for the radiologist to be aware of and
recognize.

3
 Traumatic
Traumatic Complications Bone Trauma
Temporal bone Trauma -Ossicular Injury
- CSF Leak
- Facial Nerve Injury
- Labirynth Ossifications
Vascular Injury

Temporal Bone
Post Operatif Noninflammatory
Miringotomy /nonneoplastic entities
Mastoidectomy - Otosclerosis
- Superior Semicircular Canal
Ossicular Reconstructions Dehiscence
- Large Vestibular Aqueduct Syndrome

4
Temporal Bone Trauma

5
 Penetrating Injury (eg, stick, gunshot wound)
Blunt trauma (eg, motor vehicle accident)
Barotrauma

Thermal injury
Avulsion injury.

6
 Hemorrhagic otorrhea,
Hemotympanum,
Tympanic membrane perforation,
Vertigo,
Hearing loss,
Facial nerve palsy,
Nystagmus
Battle sign (postauricular ecchymosis from traumatic
rupture of a mastoid emissary vein)

7
 Temporal bone computed tomography (CT)
CT arteriogram/venogram
Magnetic resonance (MR) arteriogram/
venogram and
Highspatialresolution MR imaging

8
1. The traditional classification systems.

2. Ishman and Friedland classification

systems.

3. Kelly and Tami classification systems.

9
Longitudinal Fracture Type
More common (80%90%).
Paralel to longitudinal axis of the petrous portion.
Temporoparietal impact.

Transverse Fracture Type

Less common (10%20%).
Fracture line is perpendicular to the petrous
pyramid.
Frontooccipital trauma.
Higher risk of facial nerve injury.

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 Involve the petrous apex and otic capsule
Facial nerve injury, cerebrospinal fluid
Petrous (CSF) leak, sensorineural hearing loss
Type

Involve the middle ear and mastoid

Increased incidence of conductive hearing
Nonpetrous loss (involvement of the ossicular chain)
types.

11
 Otic
More common (94%97%)
capsule From a temporoparietal blow,
sparing Increased incidence of conductive
hearing loss
fracture

Otic From an occipital blow

capsule High incidence of facial nerve
paralysis
violating Sensorineural hearing loss
CSF fistula.
fracture
12
Complications of Temporal Bone Trauma

13
Ossicular Injury

CSF Leak

Facial Nerve Injury

Labyrinthitis Ossificans

Vascular Injury

14
 With longitudinal fractures or otic capsulesparing
fractures.
Conductive hearing loss hemotympanum
or tympanic membrane rupture.
If conductive hearing loss persists beyond the first
month or so after injury (by which time
hemotympanum should have resolved), ossicular
injury should be suspected.
The incus
(Haviest ossicle, has no muscular attachments, and
has the least amount of ligamentous support).

15
Incudostapedial joint separation

Incudomalleal joint separation,

Incus dislocation

Incudomalleal complex dislocation

Stapediovestibular dislocation

16
a) Axial CT image demonstrates a gap (black arrow) between the
lenticular process of the incus (white arrow) and the head of the
stapes (arrowhead) in the setting of a longitudinal fracture.
b) Axial CT image of a normal incudostapedial articulation (arrow).

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 A normal incudostapedial joint
can be appreciated on this
image, with no gap between the
head of the malleus and the
incus body and short process
(white arrow).
Incudomalleal joint separation is
easier to visualize and manifests
as a gap between the ice
cream (head of the malleus)
and the ice cream cone
(body and short process of the
incus) in the epitympanum

18
 Pneumolabyrinth
(arrowhead)
Dislocation of the
footplate of the
stapes into the
vestibule (black
arrow).
Normal Incudomaleal
junc (white arrow)

19
 CSF leak 11%45% of temporal bone
fractures,
Otic capsuleviolating fractures have a two to
four times increased risk of CSF leak.
Clinically :
CSF otorrhea
CSF rhinorrhea.
Sense of fullness in the ear and conductive
hearing loss.
Beta-2 transferrin (+) in CSF.
Beta-2 transferrin (+) too in the perilymph.

20
 CSF leak
occur in the first week after trauma
Close spontaneously
The risk of
CSF leak still (+)
meningitis

Conservative
medical
management (strict
bed rest, elevation of
bed by 30, and CSF diversion by
avoidance of Increases if the CSF
means of a lumbar
straining) leak lasts for more
drain is performed
than 1 week.

21
 Axial CT image :
defect in the anterior
tegmen (arrow)
Patient who
presented with CSF
otorrhea after trauma.
Also note
opacification of the
mastoid air cells

22
 Immediate facial paralysis.
Delayed (1 day to 16 days after injury) :
contusion, edema, or hematoma.
Prognosis : severity and timing of onset

23
 Incomplete Early complete
facial paralysis paralysis

Observation

For urgent surgical

Highdose steroids
exploration

Surgical exploration
(Impagement of bone
fragment to facial nerve
canal)

24
 Subtle enlargement
of the geniculate
fossa(arrows), which
is the most common
site for facial nerve
injury.
There is also a
complex right
temporal bone
fracture.

25
 Temporal bone fracture involves the
inner ear structures (usually an otic
capsuleviolating fracture)
labyrinthitis ossificans can result (fluid-
filled lumen of the otic capsule is
replaced by bone (or fibrous tissue if in
the early stages)

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Clinically :
Profound sensorineural hearing loss
Loss of vestibular function.
On high-spatial-resolution CT images,
osseous attenuation is noted within the
inner ear.
MR imaging are most sensitive for
detection at its earliest (fibrous) stage.

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(a) Axial CT image demonstrates an otic capsule-violating fracture (arrow).
There is mineralization of the lateral semicircular canal (arrowhead).
(b) Axial three-dimensional heavily T2-weighted MR image shows lack of fluid
signal intensity in the expected location of the right lateral semicircular
canal (white arrow) and in the left vestibule (black arrow) and lateral
semicircular canal (arrowhead) compatible with labyrinthitis ossificans. The
patient also had an otic capsule-violating fracture on the left (not shown)

28
 Arterial injury :
a. Dissection
b. Pseudoaneurysm,
c. Transection,
d. Occlusion, or
e. Arteriovenous fistulas.

Resnick et al that 24% of patients basilar

skull fractures fractures involving the
carotid canal 11% of whom had vascular
complications.
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CT angiography findings indicating
arterial injury :
1). Irregularity of the lumen
2). Intimal flap, out-pouching of the lumen
3). Lumen occlusion
4). Extravasation of contrast material

Catheter angiogram remains the reference

standard for diagnosis.

30
 Axial contrast enhanced
CT image demonstrates
a filling defect (black
arrow) in the right
sigmoid sinus
compatible with
posttraumatic
thrombosis.
Also note some air
bubbles (white arrow) at
the jugular foramen from
adjacent temporal bone
fracture (not shown).

31
Imaging of the Postoperative Temporal Bone

32
 Temporal bone imaging may be
performed in patients with a history of
otologic or neurotologic surgery,
Specifically for evaluating the results of
the surgery or for unrelated reasons.
In either case, it is important to be
familiar with some of the more commonly
performed procedures and their
corresponding imaging findings.
33
 Tympanostomy (ventilation) tubes are
commonly inserted into the tympanic
membrane via an incision in the
tympanic membrane (myringotomy) for
treating chronic or recurrent otitis media
recalcitrant to medical management
Tubes (variatif shapes, sizes, and
materials), most commonly Teflon or
silicone, (soft-tissue attenuation on CT
images)
34
 CT studies may not be obtained
specifically to evaluate tympanostomy
tubes.

It is helpful to :
Avoid misidentifying foreign bodies
Dislocated ossicles
Confirm the presence of a tube not apparent on
otoscopic evaluation .

35
 Thepresence of middle ear fluid can
obscure tympanostomy tubes, especially
those composed of plastic.

36
Tympanostomy tube. Axial CT image shows a
plastic grommet (arrow) that traverses the
tympanic membrane.
37
 For treatment of :
1. mastoiditis,
2. cholesteatoma resection,
3. cochlear implantation,
4. endolymphatic surgery,

38
Canalwall-up mastoidectomy
Posterior wall of the external auditory canal (+)
Creating a mastoid bowl or cavity.
Axial CT image shows an intact posterior wall of
the external auditory canal (arrow) and a clear
mastoid bowl ().

Canalwall-down mastoidectomy
In addition the posterior wall of the
external auditory canal is resected to
increase exposure to middle ear
contents.

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For extensive disease of the middle
ear cavity with ossicular
involvement.
This procedure includes removal of
the tympanic membrane, malleus,
and incus, with attempted
preservation of the stapes,
Middle ear cholesteatoma
Mastoid bowl () with absence of
the posterior wall of the external
auditory canal and ossicular chain.

40
 Tympanomastoidectomy refers to
mastoidectomy performed in conjunction
with a middle ear procedure, such as
tympanoplasty and/or ossicular
reconstruction.

41
A variety of techniques for ossicular
reconstruction :
1. Stapes prostheses
2. Partial ossicular replacement prothesis
3. Ossicular prothesis
4. Incus prothesis

42
 CT image of the right
temporal bone shows
a metallic stapes
prosthesis (arrow)
that extends from the
incus to the
stapedotomy site.

43
A partial ossicular replacement prosthesis
substitutes the malleus and incus, and thus
extends from the tympanic membrane to the
head of the stapes
44
 Prosthesis extends
from the tympanic
membrane to the
stapes footplate or
oval window and is
utilized if the stapes
is also diseased

45
 Coronal CT image
of the left temporal
bone shows that
the prosthesis
(straight arrow) is
detached from the
tympanic
membrane (curved
arrow) and the
head of the stapes
(arrowhead).

46
 Performed for
reconstruction of the
ossicular chain.

Incus interposition.
Axial CT image shows
a sculpted incus (white
arrow) that extends
from the manubrium of
the malleus (black
arrow) to the stapes
(arrowhead).

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 Electronic devices
Restore hearing in patients
severe sensorineural
hearing loss.
Components :
1. Microphone,
2. Speech processor,
3. Transmitter coil
externally,
Stenvers view : Expected positioning of
4. Receiver-stimulator
the cochlear implant electrodes (white internally,
arrow) in relation to the internal auditory 5. Leads to a cable ending
canal (black arrow), superior in an electrode array
semicircular canal (white arrowhead), within the cochlea.
lateral semicircular canal (black
arrowhead), and mastoidectomy cavity
().
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(a)CT image shows the electrodes (arrow), which enter the cochlea
in the region of the round window (arrowhead). Soft tissue graft
has been used to obliterate the mastoid bowl (),
(b) Stereoscopic three-dimensional color CT image provides an
overview of the cochlear implant components.

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Noninflammatory Nonneoplastic Entities

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 Otosclerosis Osteodystrophy of otic
capsule

Predilection :
+ 1% of the population
bilateral (85%)
women (65%72%),
Caucasian (African-American, Asian, and Native
American subjects )

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 Clinical Signs :
Hearing loss
2nd to 4th decades of life
Conductive hearing loss mixed hearing loss or
sensorineural hearing loss

The otic capsule is composed :

1. Inner layer : endosteum,
2. Outer layer : periosteum,
3. Middle layer: persistent primary
endochondral bone.

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 Otosclerosis =
Middle layer
Otospongiosis
Spongy
vascular vascular Becomes inactive
bone phase of
otosclerosis

Spongy areas
More sclerotic recalcify
Less vascular

53
 Nearby stapes footplate
Mechanical fixation of the stapes footplate
Fenestral Conductive hearing loss
otosclerosis

Damaging metabolic substances, toxins, or

proteolytic enzymes diffusing into the cochlear
fluid Hyalinization of the spiral ligament
Retrofenestral Sensorineural hearing loss (vestibular :
otosclerosis unsteadiness and vertigo)

54
Thickened of :
Anterior oval window
in the region of the
fissula ante fenestram
(arrowhead)
Cochlear promontory
(white arrow)
Stapes footplate is
thickened (black
arrow).

55
Obliterative fenestral otosclerosis :
(a) Coronal CT image shows loss of the normal contour of the left oval
window (arrow) compatible with obliteration.
(b) Compare with the normal contour of the right oval window (arrow).
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 Round window involvement by otosclerosis
a) Axial CT image : demineralization of the round window (arrow).
b) Axial contrast-enhanced T1-weighted MR image in the same patient
: enhancement of the right round window (arrow).
There is subtle enhancement in the left round window (arrowhead)
Demineralization reflecting otosclerosis can be seen at CT (not
shown).
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 Cochlear otosclerosis
in a 44-year-old man.
Axial CT :
Hypoattenuating
halo around the
cochlea (arrows)
abnormal spongiotic
bone in the middle
layer of the otic
capsule.

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Cochlear cleft in an 11-
year-old boy.
Axial CT image shows a
thin curvilinear lucency
around the cochlea (arrow),
representing a
nonpathologic
entity referred to as the
cochlear cleft,
and not cochlear
otosclerosis.

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 Late phase of cochlear
otosclerosis in a 54-year-
old man.
Axial CT image shows
thickened sclerotic bone in
the basal turn of the
cochlea (black arrows),
representing the sclerotic
phase of otosclerosis.
In this patient, there are still
demineralized areas in the
otic capsule visible (white
arrow).

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 Superior semicircular canal dehiscence. (a) Pschl and (b) Stenvers views
from a CT study reveal wide dehiscence of the bony covering over the
superior semicircular canal (arrows).
This 52-year-old patient presented with sound- and straining-induced
vertigo.
61
 LVA. AxialCT image
shows enlargement of
the vestibular
aqueduct (arrow).
This 11-month-old
boy presented with
sensorineural
hearing loss and has
bilateral LVA.

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 LVA with modiolar
deficiency and incomplete
partition type II.
Axial CT image depicts an
enlarged vestibular
aqueduct (black arrows),
with associated deficiency
of the cochlear modiolus
(arrowhead) and
incomplete partition of the
cochlea (white arrow).
Similar findings are seen on
the contralateral side. This
9-year-old girl has bilateral
sensorineural hearing loss.

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In this part 2 of our review are :
1. Trauma,
2. Complications
3. Common surgical procedures performed in the temporal
bone and their postoperative appearance on CT and MR
images.
4. Nonneoplastic, noninflammatory entities of the temporal
bone, namely otosclerosis, superior semicircular canal
dehiscence, and LVA syndrome, that have distinctive
clinical presentations and distinctive imaging

radiologists may easily miss or underdiagnose if they are

unaware of the precise locations to inspect on imaging
studies
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65
 Depends on :
1. Related to intracranial complications
2. Associated CSF leak common
Majority resolve spontaneously within 7 days
Persisting CSF leaks beyond 7 days require
surgical intervention
10% or < develop meningitis
3. Associated facial nerve injury (10%)

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 Recurrent cholesteatoma and otitis
media.
Formation of granulation and adhesion
Mechanical problems : subluxation,
extrusion and fracture.

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 Complications

CT MRI
Device malposition
Stimulation or Abscess,
or migration
Injury Meningitis
Breakage
Pneumolabyrinth, Labyrinthitis
Facial nerve
and bone erosion
Canal dehiscence

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 Flouride as chelating agents to limits growth
of active otosclerostic foci and
remineralisation od otosclerotic plaques.
Bilateral condition : SNHL cochlear
implantation
Provided that there is no substantial
ossification within the cochlea that may lead
to surgical challenges and complications
such as partial insertion and misplacement
of electrode arrays

69
Stapes prosthesis. a Photograph shows a Teflon type polymer stapes
prosthesis. b Coronal CBCT image of the right ear demonstrates the Teflon
prosthesis located underneath the tympanic segment of the facial canal and in
contact with it (arrowhead) and with its tip on the stapes footplate (arrow). This
correct position is confirmed on the double-oblique reformatted CBCT image
(arrow). Not the hook of the prosthesis around the long apophysis of the incus

70
Incus interposition a Diagram shows a surgically altered incus that has been placed between the malleus and stapes in
an attempt to maintain ossicular function. (From Mukherji et al. 1994. With permission) b Photograph shows an example
of a sculptured autologous incus interposition graft. The notch (arrow) will fit under the handle of the malleus and the
circular groove (arrowhead) will be placed on the head of the stapes. Incus interposition homograft. c Axial CBCT
image of the right ear shows a remodelled incus in contact with the tympanic membrane and malleus manubrium
(arrowhead) and the stapes capitulum (arrow). d Double-oblique reformatted and coronal e CBCT image of the right
ear in another patient show a remodelled incus (arrow) dislocated from the stapes capitulum (arrowhead), causing the
conductive hearing loss 71
 Patient in supine positioned
Place the lens of the eye as far as
possible out of the pathway of the x-ray
Gantry tilt avoided to facilitate image
reconstruction and reformats.
A lateral topogram is then performed.
The scan excursion is plotted from the
arcuate eminence (the summit of the
temporal bone) through the mastoid tip.
72
 Routinely collimator of 0.6 mm (collimated to at least 1
mm. wider than 1 mm is not used).
For 40 to 64 detector scanners, the effective mAs (defined as
the mA the gantry cycle time/helical pitch) is adjusted
according to the age and head size.
Neonatus : 150 effective mAs (CTDIvol [volume CT dose index] 34
milligray [mGy])
Children 1-10 yrs 200 effective mAs (CTDIvol 45 mGy)
Adolescents 250 effective mAs (CTDIvol 57 mGy) .
Adults 320 (CTDIvol 72 mGy) .

The gantry cycle time is set at 1 cycle or gantry

rotation/second. The kilovolt peak (kVp) is usually 120

73
 A helical mode is chosen.
Intravenous (IV) contrast low osmolar
type power injector standard doses of
1 mL/lb to a maximum of 80 to 100 mL for
adults.
IV contrast is used for the evaluation of
vascular pathology (e.g., dissection, tumors)
and may be considered for some types of
infections such as coalescent mastoiditis or
for the evaluation of abscesses. (it is not
routinely used to evaluate for otomastoiditis
or hearing loss.)
74
 The raw data from each ear are separated and reconstructed into 0.6 mm
(slice thickness) axial images in bone algorithm at a dual field of view
(DFOV) of 100 mm that effectively magnifies the images. Then the 0.6 mm
images for each ear are brought up on the CT scanner console, where the
raw data are displayed in three orthogonal planes. The technologist
scrolls through the sagittal data to find an image where the anterior and
posterior limbs of the lateral semicircular canal are displayed in cross
section (Fig. 1.1). An axial dataset is then made in a plane parallel to the
lateral semicircular canal (LSCC). The technologist connects the two
dots of the LSCC and makes a 0.6 mm (image thickness) 0.5 (distance
between images) axial dataset in this plane parallel to the LSCC; 0.6 0.5
mm coronal images are made in a plane perpendicular to the axial
images. The raw data are also reconstructed into 2 mm axial images in soft
tissue algorithm to include both ears and the brain at 180210 mm DFOV.
This protocol generates seven sets of images, three for each earthe
source 0.6 mm images (in a variable axial plane), the 0.6 mm reformats in
the axial plane parallel to the LSCC, the 0.6 mm reformats in the coronal
plane, and a set of 2 mm axial images in soft tissue algorithm of the entire
scan volume.

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Figure 1: Axial CT image shows: 1, mastoid antrum; 2, aditus ad antrum; 3,
epitympanum; 4, lateral semicircular canal; 5, vestibule; 6, labyrinthine
segment of the facial nerve; 7, IAC; 8, posterior semicircular canal.

81
Axial CT image shows: 1, mastoid air cells; 2, incus (short process);
3, incudomalleal joint; 4, malleus (head); 5, epitympanum (anterior
epitympanic recess); 6, basal turn of the cochlea; 7, middle turn of the
cochlea; 8, otic capsule; 9, IAC; 10, modiolus; 11, vestibule.
82
Axial CT image shows:
1. Stapes (head);
2. Incus (long process);
3. Malleus (neck);
4. Tensor tympani;
5. Carotid canal;
6. Apical turn of the cochlea;
7. Middle turn of the cochlea;
8. Basal turn of the cochlea;
9. Interscalar septum;
10. Round window niche;
11. Vestibular aqueduct;
12. Sinus tympani;
13. Stapedius;
14. Pyramidal eminence;
15. Mastoid portion of the
facial nerve;
16. Facial recess.

83
Coronal CT image shows:
1. EAC;
2. Mastoid air cells;
3. Tegmen mastoideum;
4. Tegmen tympani;
5. Tympanic segment of the
facial nerve;
6. Labyrinthine segment of the
facial nerve;
7. Petrous apex;
8. Basal turn of the cochlea;
9. Interscalar septum;
10. Middle turn of the cochlea;
11. Carotid canal;
12. Tendon of the tensor tympani;
13. Lateral process of the
malleus;
14. Lateral malleal ligament;
15. Malleus (head).

84
Coronal CT image shows:
1. Mastoid air cells;
2. Tegmen mastoideum;
3. Tgmen tympani;
4. IAC;
5. Vestibule;
6. Hypotympanum;
7. Mesotympanum;
8. Epitympanum;
9. Cochlear promontory;
10. Tympanic membrane;
11. Scutum;
12. Prussak space;
13. Malleus (head);
14. Stapes (crus);
15. Superior semicircular canal;
16. Tympanic segment of the
facial nerve;
17. Oval window;
18. Crista falciformis;
19. EAC.
85
Resection of vestibular schwannomas:
1. Translabyrinthine, For all tumor sizes
2. Retrosigmoid (suboccipital)
3. Middle cranial fossa approaches For intracanalicular tumors

86
 Ithas been
noted that temporal bone fractures do
not demonstrate normal bone healing,
possibly related to low metabolic activity
of the bone of the otic capsule (5).

87
88
 CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS

1. Longitudinal Fracture 1. Transverse Fracture

89
A limitation of the traditional
classification
system is that it does not address
oblique or mixed fractures, which,
according
to many studies, represent the
majority of temporal bone fractures (7).
bagaimana pengklasifikasian bila ada
kedua fraktur tsb?
90
 1. Cranium
Vaskular
2. Duramater
3. Subarachnoid CSF

4. Piamater
5. Brain

91
 Migratedstapes
prosthesis.

Stapesprosthesis
abnormally
protruding into the
vestibule (arrow).

92
93