Fahmi Attaufany

Supervisor : dr. Sally Mahdiani, M.Kes, SpTHT-KL

INTRODUCTION
Essential Ingredients For
Adequate
Temporal Bone Imaging

ANATOMY OF TEMPORAL
BONE

Large part of the

lateral aspect of the
skull

Each consists of 4 parts

1.

Squamous

2.

Tympanic

3.

Mastoid

4.

Petrous
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ANATOMY OF TEMPORAL BONE

Schllers projection:
(1) root of the zygoma, (2) condyle of the mandible, (3)
temporomandibular joint,(7) malleus, (8) incus, (12) air cells, (14)
anterior plate of the sigmoid sinus, (15) dural plate, (25) petrous6
apex

Stenvers projection:
(2) condyle of the mandible, (12) air cells, (16) arcuate eminence, (17) superior
semicircular canal, (18) horizontal semicircular canal, (20) internal auditory
canal, (22) basilar turn of the cochlea, (25)petrous apex, (29) vestibule
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ANATOMIC VARIATIONS

NORMAL VARIANTS
Mastoid
Diploic

Celluler
Sclerotic
Mahmood E Mafee,et all. Imaging of Head and Neck,
2nd Ed. 2005

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Cohlear Cleft

cochlear cleft is a narrow

curved lucency extending from
the cochlea towards the
promontory

Petromastoid Canal

connects the mastoid antrum

with the cranial cavity and the
subarcuate artery and vein.

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy.

Radiology department of the University Medical Centre of Utrecht, the

11

High jugular bulb

Cochlear Aqueduct

connects the perilymph with

the subarachoid space

Bulging sigmoid sinus

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

12

CONGENITAL
ANOMALIES
Atresia of the external ear canal

Fatterprekar M. Grisish, et all. 3D CT of the Temporal Bone: Anatomy and

Pathology.
Department of Radiology

13

semicircular canal
malformation

14

Cochlear deformities

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

15

Mahmood E Mafee,et all. Imaging of Head and Neck,

2nd Ed. 2005

16

VASCULAR ANOMALIES
The internal carotid artery may be aberrant,
partially absent, or completely absent

Jugular vein anomalies include a

high jugular bulb, protruding
jugular bulb, or a jugular
diverticulum

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

17

18

COMPLICATIONS IN ACUTE
MASTOIDITIS

Extension of the infectious process beyond the mastoid

system leads to intracranial and extracranial suppurative
complications, including subperiosteal abscess (A), epidural
abscess (B), subdural empyema (C), brain abscess (D),
meningitis (E), lateral sinus thrombosis (F), carotid artery
involvement (G), and apical petrositis (H).
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ACUTE INCIPIENT MASTOIDITIS

Figure 2c. Acute incipient mastoiditis in a 3-year-old girl with suspected right acute
mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show
increased attenuation of the entire right middle ear with no osseous defects. Note the
normal aeration of the tympanum and mastoid cells on the left side. (c) Axial contrast
material-enhanced CT scan shows no complications.
Snow B.J, Ballenger J. Ballengrs Otorhinolaryngology Head and Neck Surgery, 16ed.
2003

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ACUTE COALESCENT MASTOIDITIS

Figure
Figure 3c.
3c. Acute
Acute coalescent
coalescent mastoiditis
mastoiditis with
with aa subperiosteal
subperiosteal abscess
abscess in
in aa 2-year-old
2-year-old girl
girl
with
right
acute
otomastoiditis.
(a,
b)
Axial
CT
scans
of
the
temporal
bone
(a
obtained
with right acute otomastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained
inferior
inferior to
to b)
b) show
show abnormal
abnormal soft-tissue
soft-tissue attenuation
attenuation in
in the
the right
right mastoid
mastoid air
air cells
cells with
with
erosion
erosion of
of the
the external
external cortex
cortex and
and sigmoid
sigmoid plate
plate (arrows).
(arrows). Abnormal
Abnormal attenuation
attenuation was
was also
also
seen
seen on
on the
the left
left side,
side, which
which was
was probably
probably due
due to
to serous
serous otitis.
otitis. (c)
(c) Axial
Axial contrast-enhanced
contrast-enhanced
cranial
CT
scan
shows
a
subperiosteal
abscess
(arrow).
No
intracranial
complications
cranial CT scan shows a subperiosteal abscess (arrow). No intracranial complications
were
were identified.
identified.

Snow B.J, Ballenger J. Ballengrs Otorhinolaryngology Head and Neck Surgery, 16ed.
2003

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PERISINUS ABSCESS

Figure 4d. Perisinus abscess in an 18-month-old girl with left acute mastoiditis. (a, b)
Axial CT scans of the temporal bone show increased attenuation of the left mastoid air
cells with subtle erosion of the mastoid cortex (arrow in a) and superior sigmoid plate
(arrow in b). (c, d) Axial unenhanced (c) and contrast-enhanced (d) cranial CT scans
show an unsuspected small epidural abscess (arrow). The ipsilateral sigmoid sinus (S)
demonstrated normal enhancement on CT scans and normal flow void on T2-weighted
MR images. (e) Posterior coronal MR venogram shows slightly diminished venous flow
with decreased size of the left sigmoid sinus.

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PETROUS APICITIS

Figure 5e. Petrous apicitis in a 7-year-old girl with fever, right-sided facial pain, and
diplopia. (a) Axial CT scan of the temporal bone shows increased attenuation of the
mastoid air cells and erosion of the right petrous apex (arrow) with a well-pneumatized
left petrous apex. (b) Axial contrast-enhanced CT scan obtained with the soft-tissue
algorithm shows a hypoattenuating area (arrow) without a significant enhancing softtissue mass. (c, d) Axial T1-weighted (c) and T2-weighted (d) MR images show a lesion
(arrow) with low (c) and high (d) signal intensity. The patient was treated with mastoid
drainage and intravenous antibiotics. (e) Follow-up axial CT scan shows
postmastoidectomy changes and progressive reossification of the right petrous apex.
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EPIDURAL ABSCESS

Figure 6e. Epidural abscess with sigmoid sinus phlebothrombosis in a 3-year-old girl
with acute right mastoiditis but no neurologic symptoms. (a) Axial CT scan of the
temporal bone shows increased attenuation of the right middle ear with a large osseous
defect over the sigmoid sinus plate (arrow). (b) Axial contrast-enhanced CT scan shows a
large epidural fluid collection (arrow) with some septa. Mastoidectomy with surgical
drainage was performed, and intravenous antibiotic therapy was started. MR imaging was
subsequently performed. (c-e) Axial T1-weighted (c) and T2-weighted (d) MR images
and coronal MR venogram (e) show absence of flow (arrow) in the right sigmoid sinus.
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CHOLESTEATOMA
Imaging of
cholesteatoma :

CT scan :

Evaluate the extent of any

remaining cholesteatoma and
provide detailed imaging of
the temporal bone

Identification of bone defects

over the sigmoid sinus,
tegmen, and the bony facial
canal

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

25

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

26

TYMPANOSCLERO
SIS

There is calcification of the

eardrum (white arrow) and calcific
deposits

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

27

OTOSCLEROSI
S

Enchondral bone around the otic capsule becomes

calcified and sclerotic

Diagnosed :

CT scan double ring sign

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

28

LABYRINTHIT
IS

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

29

LABYRINTH
FISTULA

Coronal section through

middle ear at the level of the
oval window (black arrow).
A large cholesteatoma fills in
the middle ear and has
eroded the bone covering
the lateral semicircular canal
(white arrow).

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CHOLESTEROL
GRANULOMA
Chronic

inflammatory mucosal secretions trapped

within the pneumatized petrous apex cholesterol
granuloma

Pathologies

Encapsulated cystic lesion filled with brownish liquid

containing cholesterol clefts

Expand through the petrous apex cells

Imaging

studies :

CT scan opacification and smooth expansion of the cortical

margins of the petrous air cell
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Cholesterol
Granuloma

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NECROTIZING OTITIS
EXTERNA
(MALIGNANT OE)

E/ Pseudomonas
aeruginosa

Symptoms: Otorrhea,
otalgia, & persistent
granulation tissue

CT Scan: bony erosion

of the mastoid & middle
ear cavity

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

33

TEMPORAL BONE TRAUMA

The long axis of the

petrous bone.

The best diagnosis : CT

scan

Classify:
1)

Longitudinal ( 70 %)

2)

Transverse

3)

Mixed

Longitudina
l
fracture

Mahmood E Mafee,et all. Imaging of Head and Neck,

2nd Ed. 2005

Transverse
fracture

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TEMPORAL BONE
FRACTURE
AXIAL CT
Longitudinal

Transverse

35

Beek Erric, Pameijer Frank. Radiology Assitant-Temporan Bone Pathologhy. Radiology

department of the University Medical Centre of Utrecht, the Netherland. 2009

36

NEOPLASM
Facial Nerve Schwannoma

Rare, <1 % of all temporal bone tumors.

Tends to originate near the geniculate ganglion.
Imaging :

CT Scan smooth bony erosion in the geniculate fossa

region

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Acoustic neuromas

Incidence 5%-10% all

intracranial tumor.

Benign and account for 85 %

CPA tumor.

Usually unilateral, can be

bilateral and associated
w/neurofibromatosis II.

Arise from Schwann cells of the

vestibular division of the
vestibulocochelear nerve.

Fatterprekar M. Grisish, et all. 3D CT of the Temporal Bone: Anatomy and Pathology. Department of Radiology
Mount Sinai Medical Center New York

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Paraganglioma = glomus tumor

Second most common tumor of the temporal bone.

Most common cause for objective pulsatile tinnitus and a vascular

hypotympanic mass.

Arise from the glomus bodies along the 9th and 10th nerve

Glomus tympanicum Jacobsons or Arnolds nerve

Glomus jugular the jugular foramen

Imaging :

MRI soft tissue extent of the tumor

CT bony surgical landmarks and bony erosion

Angiography: The vascular supply of the tumor

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GLOMUS TYMPANICUM

40

GLOMUS TYMPANICUM

A soft tissue mass fills

in the middle ear
at the level of the promontory

Selective external carotid angiogram

shows a contrast blush corresponding
to the soft tissue mass in the middle
ear.
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GLOMUS JUGULARE

42

HIGHLIGHT

43

HIGHLIGHT

44

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