Clinical Radiology (2003) 58: 681–686

doi:10.1016/S0009-9260(03)00209-5, available online at www.sciencedirect.com

Pictorial Review

Computed Tomography Imaging of the Temporal

Bone—Normal Anatomy
A. T. AHUJA*, H. Y. YUEN*, K. T. WONG*, V. YUE‡, A. C. VAN HASSELT†

Departments of *Diagnostic Radiology and Organ Imaging, †Surgery, The Chinese University of Hong Kong, Prince
of Wales Hospital, Shatin, New Territories; and ‡Otorhinolaryngology, United Christian Hospital, Kwun Tong,
Kowloon, HKSAR, China

Received: 22 January 2003 Revised: 11 April 2003 Accepted: 14 April 2003

This review describes the fundamental anatomical structures of the temporal bone as depicted on
high-resolution computed tomography, and the clinical significance of these structures. It is not an
encyclopaedic atlas, but provides the junior radiology/otorhinolaryngology resident with sufficient
knowledge for interpretation of most of the imaging studies encountered in daily clinical practice.
Ahuja, A. T. et al. (2003). Clinical Radiology 58: 681–686.
q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.

Key words: temporal bone, anatomy.

INTRODUCTION External Ear

Most radiology trainees find the anatomy of the temporal
bone daunting and the large amount of literature on the subject
adds to their anxieties when interpreting temporal bone
examinations. This paper aims to demystify the jargon and
present the key facts.
NORMAL ANATOMY OF THE
TEMPORAL BONE
This section is an overview of the basic radiological
anatomy of the temporal bone as demonstrated by 1 mm
high-resolution computed tomography (CT). It does not intend
to be exhaustive but provides the minimum anatomical
knowledge for making sensible interpretation of the images
in most clinical situations.
The auditory apparatus consists of the external ear, the
middle ear and the inner ear.
Guarantor and correspondent: Dr Hok-yuen Yuen, Department of
Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, 30-32,
Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China. Tel:
þ852-2632-2286; Fax: þ852-2648-4122; E-mail: drhyyuen@doctors.org.uk
0009-9260/03/$30.00/0 q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.
The structures of the external ear a trainee or a radiologist
must be able to recognize include the pinna, the external
auditory canal (EAC), the scutum, tympanic membrane and
tympanic annulus at its medial end (which separates the
external ear from the middle ear cavity). The pinna is an
external organ which is easily accessible for clinical examin-
ation but it should still be evaluated on images in cases of
possible involvement by disease processes such as infection in
otitis externa or developmental anomaly. The lateral third of the
external auditory canal is cartilaginous while the medial two
thirds are bony. Most of the bony portion is formed by the
tympanic temporal bone. The external auditory canal is lined by
closely adherent skin which contains hair follicles, ceruminous
and sebaceous glands at the cartilaginous portion. There is no
periosteum in the bony EAC. It is an S-shaped canal in the axial
plane measuring about 2.5 cm in length [1]. Medially the canal
ends at the tympanic membrane which separates the external
ear from the middle ear cavity. The entire external auditory
canal can be seen on axial images at and just below the level of
the temporo –mandibular joint where it is S-shaped and the
junction of the cartilaginous and bony portions is best
demonstrated (Fig. 1). The tympanic membrane forms the
lateral wall of the middle ear cavity. The membrane slants
682 CLINICAL RADIOLOGY
Fig. 1 – Axial CT image at the level of the left temporo–mandibular joint
demonstrating the S-shape and the junction of the cartilaginous and bony
portions of the external auditory canal. 1—External auditory canal (EAC),
2—cartilaginous portion of EAC, 3—bony portion of EAC, 4—pinna, 5—
tympanic membrane.
inferomedially at an angle with the floor of the external
auditory canal, stretching superiorly from the scutum down to
the tympanic annulus. The scutum is normally thin and sharply
edged; and is an important bony landmark as it is one of the
bony structures eroded/blunted early by a cholesteatoma. The
tympanic membrane consists of an upper pars flaccida and a
larger lower pars tensa. The pars tensa consists of an outer thin
layer of squamous cells, an intermediate layer of fibrous tissue
and an inner layer of mucosal cells continuous with the middle
ear cavity. The pars flaccida lacks the intermediate fibrous layer
[2]. The scutum, the tympanic membrane and the tympanic
annulus are best demonstrated on coronal images at the mid
bony portion of the external auditory canal (Fig. 2).
Fig. 2 – Coronal CT image at the mid bony portion of the left external auditory
canal showing the tympanic membrane stretching from the scutum to inferior
portion of the tympanic annulus, and the three compartments of the middle ear
cavity—epitympanum, mesotympanum and hypotympanum. 1—Pars flac-
cida, 2—pars tensa, 3—tympanic membrane, 4—scutum, 5—tympanic
annulus, 6—epitympanum, 7—mesotympanum, 8—hypotympanum,
9—tympanic segment of facial nerve.
Middle Ear
The middle ear cavity is divided into three compartments in
the coronal plane. A line drawn from the lower edge of the
scutum to the tympanic portion of the facial nerve divides
the superior compartment, the epitympanum (attic), from the
middle compartment, the mesotympanum (tympanic cavity
proper). A line drawn parallel to the floor of the external
auditory canal further divides the mesotympanum from the
inferior compartment, the hypotympanum (Fig. 2). On the axial
images lines drawn parallel to the anterior and posterior walls
of the external auditory canal are also used to divide the middle
ear cavity into three compartments, from anterior to posterior,
the protympanum, the mesotympanum and the posterior
tympanum (Fig. 3a) [2].
Epitympanum
The epitympanum contains the head of the malleus, the
malleo –incudal articulation and the body and short process of
the incus, which are best demonstrated on axial images at about
the level of the vestibule (Fig. 3c,d). The roof of the
epitympanum forms an important bony landmark, the tegmen
tympani. The tegmen serves as a barrier between the middle ear
cavity and the middle cranial fossa [3]. Once eroded, disease in
the middle ear cavity may find its way into the intracranial
cavity at the middle cranial fossa. Similarly intracranial
contents including the temporal lobe may herniate through a
defect in the tegmen tympani into the middle ear cavity. The
integrity of the tegmen tympani is best evaluated on coronal
images (Fig. 4b). The space situated between the scutum and
pars flacci da laterally and the neck of the malleus medially is
known as the Prussak’s space or the lateral epitympanic recess
(Fig. 4a) [4]. This is the site where the pars flaccida
cholesteatoma arises and is best seen on the coronal plane.
Posteriorly the epitympanum opens into the mastoid antrum via
the aditus ad antrum; this opening is well demonstrated on both
the axial and coronal images (Figs 3e and 4e). The medial wall
of the epitympanum is the cortex overlying the lateral
semicircular canal, which is therefore prone to fistularization
and saucerization by cholesteatoma in the epitympanum. The
tympanic portion of the facial nerve runs posterolaterally
inferior to the lateral semicircular canal. In this area the bony
floor of the facial nerve canal is very thin and may not be
visualized on coronal CT images (Fig. 4d). The tympanic
segment of the facial nerve can also be identified on the
axial images running from the anterior genu posterolaterally
just below the lateral semicircular canal to the posterior genu
(Fig. 3c –e).
Mesotympanum
The mesotympanum contains the rest of the ossicular chain.
On coronal images the long process of incus is vertically
oriented parallel to the malleus manubrium, continuing as the
rounded lenticular process with the “hockey stick” appearance
and with the facet to articulate with the head of the stapes
(Fig. 4c,d) [4]. The stapes consists of the head and the neck
(hub), the anterior and posterior crura and a footplate. The
stapes hub and crura are best demonstrated on axial images at
 COMPUTED TOMOGRAPHY IMAGING OF THE TEMPORAL BONE—NORMAL ANATOMY 683

Fig. 3 – Consecutive axial CT images of the right middle and inner ear from caudal to cephalic. They can be promptly recognized by the complete ring formed
by the lateral semicircular canal and the vestibule (Fig. 3d), the conical profile of the cochlea (Fig. 3b,c) and the “icecream cone” appearance of the malleo–
incudal articulation (Fig. 3c,d). 1—Manubrium of malleus, 2—basal turn of cochlea, 3—cochlear aqueduct, 4—tensor tympani muscle, 5—tensor tympani
tendon, 6—neck of malleus, 7—lenticular process of incus, 8—incudostapedial articulation, 9—hub and posterior crus of stapes, 10—facial nerve, 11—
pyramidal eminence, 12—sinus tympani, 13—bony margin inferior to the oval window, 14—vertical portion of the basilar turn of cochlea, 15—apical turn of
cochlea, 16—tympanic portion of the facial nerve canal, 17—head of malleus, 18—body of incus, 19—short process of incus, 20—lateral semicircular canal,
21—vestibule, 22—internal auditory canal, 23—posterior semicircular canal, 24—vestibular aqueduct, 25—malleoincudal articulation, 26—aditus ad antrum,
27—anterior genu of the facial nerve, 28—labyrinthine portion of the facial nerve canal, 29—superior semicircular canal. PT—protympanum, MT—
mesotympanum, PosT—posterior tympanum.
684 CLINICAL RADIOLOGY

Fig. 4 – Consecutive coronal images of the right middle and inner ear from anterior to posterior. They can be promptly recognized by identification of the
scutum and spiral appearance of the cochlea (Fig. 4a), the “hockey stick” appearance of the lenticular process of the incus (Fig. 4c) and the lateral and superior
semicircular canals protruding perpendicularly from the vestibule (Fig. 4e). 1—Scutum, 2—Prussak’s space, 3—head of malleus, 4—tensor tympani muscle,
5—tympanic portion of facial nerve canal, 6—labyrinthine portion of the facial nerve canal, (note the “cobra-eye” appearance formed by the tympanic and
labyrinthine portions of the facial nerve canal), 7—tympanic membrane, 8—tegmen tympani, 9—mesotympanum, 10—hypotympanum, 11—epitympanum,
12—crista falciformis, 13—promontory, 14—long process of incus, 15—lenticular process, 16—short process of incus, 17—incudostapedial articulation,
18—oval window, 19—internal auditory canal, 20—aditus ad antrum, 21—lateral semicircular canal, 22—vestibule, 23—round window, 24—stapes, 25—
posterior genu of facial nerve, 26—descending (vertical) portion of facial nerve canal, 27—lateral semicircular canal, 28—superior semicircular canal, 29—
arcuate eminence, 30—stylomastoid foramen.
 COMPUTED TOMOGRAPHY IMAGING OF THE TEMPORAL BONE—NORMAL ANATOMY
the level of the oval window (Fig. 3b). The stapes footplate sits
in the oval window niche and cannot always be discretely
identified on CT. Both the malleo –incudal and the incudo–
stapedial articulations are synovial joints and may be afflicted
with diseases involving other synovial joints of the body [2]. At
the posterior wall of the mesotympanum is a bony protuberance
called the pyramidal eminence where the stapedius muscle
exits to its attachment at the neck of the stapes (Fig. 3b) [4].
Lateral to the pyramidal eminence is the facial recess which
harbours the descending (mastoid) segment of the facial nerve
(Fig. 3b). Medial to the pyramidal eminence is the sinus
tympani (Fig. 3b), which may be a blind spot for the surgeon
during transmastoid surgery and therefore cholesteatoma at this
site may be overlooked [4]. Anteriorly just above the entrance
into the Eustachian tube is the bony canal for the tensor
tympani muscle (Fig. 3b) which inserts to the malleus. Both the
stapedius and tensor tympani muscles serve to dampen the
effect of high-intensity sound waves. The tensor tympani
muscle is supplied by the mandibular branch of the trigeminal
nerve (V3) while the stapedius muscle is supplied by the facial
nerve [3]. There is a bony prominence on the medial wall of the
mesotympanum called the promontory (Fig. 4c) which is
caused by protrusion of the basal turn of the cochlea. Above the
promontory is the oval window (Fig. 4d) and posteroinferior to
which is the round window niche (Fig. 4e) [2].
Hypotympanum
The floor of the hypotympanum is a thin plate of bone
separating the middle ear cavity from the jugular bulb, and in a
case of dehiscence may allow a high-riding jugular bulb to
herniate into the hypotympanum.
Inner Ear
The inner ear includes the membranous labyrinth within the
bony labyrinth (otic capsule). The membranous labyrinth
consists of the utricle, saccule, cochlear duct and the
membranous channels within the semicircular canals and the
endolymphatic duct [5]. The membranous labyrinth contains
endolymph and is surrounded by perilymph, which together
appear as low attenuation on CT and high fluid signal on T2-
weighted images [6] but cannot be independently demonstrated
by imaging. The bony labyrinth consists of the cochlea, the
vestibule, the semicircular canals and the cochlear and
vestibular aqueducts [5]; the bony anatomy of which can be
well demonstrated by CT. The cochlea contains the Organ of
Corti and is the auditory end organ receiving sound waves
transmitted by the ossicular chain. It normally consists of about
two and a half turns [3]. The base of the cochlea is at the lateral
end of the internal auditory canal (Figs 3c and 4a). The basal
turn opens into the round window niche (Fig. 4e), which is the
site for insertion of cochlear implants in the past. This
technique has changed and cochlear implants are now inserted
through a new opening made into the basal turn of cochlea just
anterior to the round window niche. The cochlea encircles a
central bony axis called the modiolus where the cochlear nerve
enters the cochlea from the internal auditory canal (Fig. 3c) [3].
A spiral lamina projects from the modiolus and can be readily
identified on CT (Fig. 3b).
685
The vestibule is the largest component of the membranous
labyrinth [7]. It consists of the superior utricle and the inferior
saccule. The semicircular ducts open into the utricle. Together
with the semicircular cristae they are the end vestibular organs
responsible for equilibrium, gravitation and the sensation of
acceleration.
There are three semicircular canals, namely the superior
(anterior), lateral (horizontal) and posterior semicircular canals.
They are perpendicular to each other. The plane of the posterior
semicircular canal is parallel to the petrous ridge (Fig. 3d,e)
while that of the superior semicircular canal is perpendicular to
it (Fig. 3f) although both are in the vertical plane. All the
semicircular canals join the vestibule with posterior limbs of
the superior and posterior canals sharing a common crus. The
vestibule is separated from the middle ear cavity by the oval
window niche (Fig. 4d). The superior semicircular canal forms
a bony ridge at the roof of the petrous bone called the arcuate
eminence giving a landmark to the surgeon entering through the
middle cranial fossa (Fig. 4f).
The cochlear aqueduct contains the perilymphatic duct and
runs inferiorly to the internal auditory canal from the basal turn
of the cochlea to the subarachnoid space superomedial to the
jugular foramen (Fig. 3a) [7]. The vestibular aqueduct contains
the endolymphatic duct and the intraosseous portion of the
endolymphatic sac. It arises from the posteromedial aspect of
the vestibule and runs first posterosuperiorly and then postero-
inferiorly in an arc to open at the posterior aspect of the petrous
temporal bone (Fig. 3d,e). The extraosseous portion of the
endolymphatic sac lies outside the vestibular aqueduct between
the layers of the posterior fossa dura [3].
The internal auditory canal shows considerable individual
variation in size and configuration but should be symmetrical in
any one person [2]. It contains the facial nerve, the cochlear nerve,
the superior vestibular nerve, the inferior vestibular nerve and the
artery of the IAC. The medial opening of the internal auditory
canal is called the porus acousticus. The internal auditory canal is
divided at its most lateral end by the horizontal crista falciformis
(Fig. 4c) and the vertical crests into four compartments. The facial
nerve is in the anterosuperior compartment, the cochlear nerve is
in the anteroinferior compartment while the superior and inferior
vestibular nerves are in the posterior superior and inferior
compartments, respectively. The facial nerve from the lateral
end of the internal auditory canal enters the petrous bone as the
labyrinthine portion running anterolaterally, superior to
the cochlea and towards the anterior genu (geniculate ganglion)
where it makes an abrupt turn to then run posterolaterally along
the medial attic wall beneath the lateral semicircular canal as the
tympanic portion (Fig. 3e) towards the posterior genu at the fossa
incudis and then turns inferiorly as the descending (mastoid)
portion to exit at the stylomastoid foramen (Fig. 4f). Coronal
images just posterior to the plane of the geniculate ganglion will
show both the distal labyrinthine (medial) and proximal tympanic
(lateral) portions in tangent giving the “cobra-eye” sign (Fig. 4a)
[2]. The greater superficial petrosal nerve arises from the
geniculate ganglion and supplies secretomotor fibres to the
lacrimal gland and taste fibres from the palate.
The chorda tympani nerve arises from the descending
segment of the facial nerve running anterosuperiorly passing
through the tympanic cavity to transmit taste fibres from the
686 CLINICAL RADIOLOGY
anterior two-thirds of the tongue to the lingual nerve as well as
secretomotor fibres to the submandibular and sublingual
glands.
CONCLUSION
This review outlines the essential normal anatomical
structures of temporal bone depicted by high-resolution CT
and their clinical significance. This should help radiologists to
make more confident diagnoses of various temporal bone
lesions.
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