Temporal Bone and Lateral Skull Base Imaging

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Temporal Bone and Lateral Skull Base Imaging

Otology/Audiology
Author Credentials 

Sandra Ho, MD and Prayag Patel, MD
Resident Physician
Department of Otolaryngology
SUNY Downstate Medical Center
Brooklyn, NY

 

Module Summary

The temporal bone is a highly complex anatomic region of the head and neck. This region can harbor various disease processes that can result from locoregional to systemic symptoms. Different disease processes are better evaluated by different imaging modalities and choosing the right imaging test itself can be challenging at times. Once the appropriate imaging modality has been undertaken, and the diagnosis made, identifying the normal and affected structures within the temporal bone is important as that can dictate the appropriate medical and surgical intervention needed. 

Module Learning Objectives 
  1. Identify important anatomic structures in temporal bone imaging.
  2. Recognize the best imaging modality to choose based on the pathology.
  3. Describe imaging features of some common congenital, infectious, inflammatory, neoplastic conditions in the temporal bone.
  4. Distinguish between various lesions of the temporal bone based on CT and MR Findings.

 

Embryology

Learning Objectives 
  1. Review the branchial arches and pharyngeal pouches that form the middle and inner ear and to identify when abnormalities occur.
References 
  1. Curtin HD, Sanelli PC, Som PM. Temporal bone: embryology and anatomy. In: Som PM, Curtin HD, eds. Head and Neck Imaging, 4th ed. St Louis: Mosby, 2003; p. 1057-1093

Anatomy

Learning Objectives 
  1. Identify the four parts of the temporal bone - squamous, petrous, mastoid and tympanic segments.
  2. Describe the boundaries of the middle ear space and important structures within this space.
  3. Review the inner ear structures.
References 
  1. Juliano AF, Ginat DT, Moonis G. Imaging review of the Temporal Bone: Part 1. Anatomy and Inflammatory and Neoplastic Processes. Radiology. 2013; 269(1) 17-33
  2. LaCour J. Temporal bone imaging. Otology & neurotology. 09/01/2009;30(6):695-696. doi: 10.1097/MAO.0b013e3181b236cf
  3. Lantos JE. Leeman K2, Weidman EK, Dean KE, Peng T, Pearlman AN. Imaging of temporal bone trauma. Neuroimaging clinics of North America. 2019;29(1):129-143
  4. Nadgir R, Yousem D. Neuroradiology: The Requisites. 4th ed. Philadelphia: Elsevier, Inc; 2017. P. 378-409
  5. Lemmerling M. Smet B., De Foer B. Cross-Sectional Imaging Anatomy of the Temporal Bone. In: Lemmerling M. De Foer B. (eds) Temporal Bone Imaging. Medical Radiology. Springer, Berlin, Heidelberg, 2014; p. 11-33
  6. Chandrasekhar S, Chandrasekhar H. Temporal Bone Histology and Radiology Atlas. San Diego: Plural Publishing; 2018

Pathogenesis

Learning Objectives 
  1. Identify how various structural differences of the temporal bone can lead to pathology in the area.
References 
  1. Lemmerling M. De Foer B. (eds) Temporal Bone Imaging. Medical Radiology. Springer, Berlin, Heidelberg. 2013
  2. Small J, Noujaim D, Ginat D, Kelly H, Schaefer P. Neuroradiology: Spectrum and Evolution of Disease. Philadelphia: Elsevier; 2019

Genetics

Learning Objectives 
  1. Recognize common genetic malformations of the middle and inner ear on temporal bone imaging such as congenital cholesteatoma, Cochlear hypoplasia, Common cavity malformation, Michel Aplasia etc.
References 
  1. Joshi VM, Navlekar SK, Kishore GR, et al. CT and MR imaging of the  inner ear and brain in children with congenital sensorineural hearing loss. Radiographics. 2012; 32: 683-698
  2. Gupta SS, Maheshwari SR, Kirtane MV, et al. Pictorial  Review of MRI/CT Scan in congenital temporal bone anomalies, in patients for cochlear implant. Indian J Radiol Imaging. 2009; 19: 99-106

Patient Evaluation

Learning Objectives 
  1. Identify which imaging modality will be a better option to evaluate lesions of the temporal bone based on your differential diagnosis after patient evaluation.
References 
  1. Offeciers F.E. Indications for Temporal Bone Imaging: The Clinician’s Approach. In: Lemmerling M., De Foer B. (eds) Temporal Bone Imaging. Medical Radiology. Springer, Berlin, Heidelberg, 2014: p1-5
  2. Connor, S. Imaging of the Ear. In: Tysome J, Kanegaonkar R. (eds) Hearing: An Introduction and Practical Guide. CRC Press LLC, 2015. p. 43-58

Imaging

Learning Objectives 
  1. Give examples of the different types of imaging modalities for the temporal bone.
  2. Summarize the different criteria used when choosing an imaging modality.
References 
  1. Juliano AF, Ginat DT, Moonis G. Imaging  review of the Temporal Bone: Part 1. Anatomy and Inflammatory and Neoplastic Processes. 2013; 269(1) 17-33
  2. Caruso P, Smullen J, Liu R, Cunnane M, Curtin H. Temporal Bone Imaging Technique. In: Swartz J, Loevner L. (eds) Imaging of the Temporal Bone. 4th ed. Thieme, 2008; p. 1-24
  3. Lane J, Witte R. The Temporal Bone: An Imaging Atlas. Spring, Berlin, Heidelberg, 2010

Pathology

Learning Objectives 
  1. Identify inflammatory and infectious processes that affect the temporal bone:
  • Cholesteatoma
  • Keratosis Obturans
  • Chronic Otomastoiditis
  • Apical Petrositis
  • Necrotizing Otitis Externa
  1. Recognize vascular anomalies that affect the temporal bone:
  • Aberrant internal carotid artery
  • Persistent stapedial artery
  • High/dehiscent jugular bulb
  1. Describe temporal bone neoplasms:
  • Meningiomas
  • Schwannomas
  • Paragangliomas
  • Endolymphatic Sac Tumors
References 
  1. Swartz JD, Loevner LA. Imaging of the Temporal Bone. New York, NY: Thieme Medical Publishers, Inc; 2009
  2. Joshi VM, Navlekar SK, Kishore GR, et al. CT and MR imaging of the inner ear and brain in children with congenital sensorineural hearing loss. Radiographics. 2012; 32: 683-698
  3. Lemmerling MM, De Foer B, Verbist BM, et al. Imaging of inflammatory and infectious diseases in the temporal bone. Neuroimag Clin N Am. 2009; 19: 321-337
  4. Pisaneschi MJ, Langer B. Congenital cholesteatoma and cholesterol granuloma of the temporal bone: role of magnetic resonance imaging. Top Magn Reson Imaging. 2000; 11: 87-97
  5. Sauvaget E, Paris J, Kici S, et al. Aberrant internal carotid artery in the temporal bone: imaging findings and management. Arch Otolaryn Head Neck Surg. 2006; 132: 86-91
  6. Juliano AF, Ginat DT, Moonis G. Imaging review of the temporal bone: part I. Anatomy and inflammatory and neoplastic processes. Radiology. 2013; 269: 17-33
  7. Razek AA, Huang BY. Lesions of the petrous apex: classification and findings at CT and MR imaging. Radiographics. 2012; 32: 151-173

Surgical Therapies

Learning Objectives 
  1. Determine which surgical procedure (surgical approach) is the most appropriate based on temporal bone imaging findings.
References 
  1. Flood LM. The temporal bone: Anatomical dissection and surgical approaches. Journal of laryngology and otology. 2018;132(9):856-856 
  2. Isaacson, B. Anatomy and Surgical Approach of the Ear and Temporal Bone. Head and Neck Pathol (2018) 12: 321
  3. Sanna M, Khrais T, Falcioni M, Russo A, Taibah A. The Temporal Bone: A Manual for Dissection and Surgical Approaches. 1st ed. New York: Thieme; 2005

Staging

Learning Objectives 
  1. Explain staging of temporal bone tumors and identifying extent of tumor invasion/spread on temporal bone imaging.
References 
  1. Lionello M, Stritoni P, Facciolo MC, Staffieri A, Martini A, Mazzoni A, Zanoletti E, Marioni G. Temporal bone carcinoma. current diagnostic, therapeutic, and prognostic concepts. Journal of surgical oncology. 2014;110(4):383-392
  2. Gidley P, Franco D. Temporal Bone Cancer. Springer, 2018

Case Studies

  1. An 8 year-old F who was recently adopted comes to you with hearing impairment of unknown duration. Adoptive parents do not know any birth history. Patient complains of bilateral decreased hearing, worse on the left. Physical exam shows normal tympanic membranes bilaterally. Hearing test with severe downward-sloping to profound SNHL bilaterally. How will you proceed? What imaging study would you initially order?
  2. A 67 year-old M who has been doing mission work overseas comes to your office with a left-sided external auditory canal mass that his wife discovered when she went to visit him a week ago. Patient also with associated left-sided facial droop that he reports started 1 month ago. What would be your next step? What imaging modalities would you order to better delineate the mass? Biopsy of the mass shows squamous cell carcinoma. Upon imaging, there is a mass eroding the osseous EAC and involving the mastoid and middle ear with limited soft tissue involvement. Neck imaging with multiple unilateral lymphadenopathy, none greater than 3cm. How would you stage this patient?

Review

Review Questions 
  1. What are the different imaging modalities along with sequences used to look at middle ear pathology?
  2. What would be the optimal imaging modality to look for residual disease in a patient that is following-up from primary surgery for cholesteatoma?
  3. What imaging modality is used to determine the presence of a cochlear nerve?
  4. What are the imaging differences between a cholesterol granuloma and a meningioma?
References 
  1. Lane J, Witte R. The Temporal Bone: An Imaging Atlas. Spring, Berlin, Heidelberg, 2010
  2. Offeciers F.E. Indications for Temporal Bone Imaging: The Clinician’s Approach. In: Lemmerling M., De Foer B. (eds) Temporal Bone Imaging. Medical Radiology. Springer, Berlin, Heidelberg, 2014: p1-5
  3. Caruso P, Smullen J, Liu R, Cunnane M, Curtin H. Temporal Bone Imaging Technique. In: Swartz J, Loevner L. (eds) Imaging of the Temporal Bone. 4th ed. Thieme, 2008; p. 1-24
  4. Lemmerling MM, De Foer B, Verbist BM, et al. Imaging of inflammatory  and infectious diseases in the temporal bone. Neuroimag Clin N Am. 2009; 19: 321-337
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