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REVIEWS AND COMMENTARY 

Imaging Review of the Temporal
Bone: Part II. Traumatic, Postoperative,
and Noninflammatory Nonneoplastic

n  STATE OF THE ART

Conditions1
Amy F. Juliano, MD
The first part of this review of the temporal bone dis­
Daniel T. Ginat, MD
cussed anatomy of the temporal bone as well as inflamma­
Gul Moonis, MD
tory and neoplastic processes in the temporal bone region
(1). This second part will first discuss trauma to the tem­
poral bone and posttraumatic complications. The indica­
tions for common surgical procedures performed in the
temporal bone and their postoperative imaging appear­
ance are then presented. Finally, a few noninflammatory
nonneoplastic entities involving the temporal bone are re­
Online SA-CME
See www.rsna.org/education/search/ry viewed. They are relatively uncommon diagnoses com­
pared with infectious or inflammatory diseases. However,
because patients present with symptoms that are either
Learning Objectives: common (hearing loss) or distinctive (sensorineural hear­
After reading the article and taking the test, the reader will ing loss in a child), they are important for the radiologist
be able to:
to be aware of and recognize.
n Explain the basic clinical features and imaging
appearances of the various sequelae of temporal bone
trauma © RSNA, 2015
n Describe imaging appearances of common surgical
procedures performed in the temporal bone
n Discuss the disease process and progression of
otospongiosis and the corresponding imaging features
n Describe the clinical features, imaging technique, and
imaging appearance of semicircular canal dehiscence
and large vestibular aqueduct syndrome
Accreditation and Designation Statement
The RSNA is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing
medical education for physicians. The RSNA designates this
journal-based SA-CME activity for a maximum of 1.0 AMA
PRA Category 1 Credit™. Physicians should claim only the
credit commensurate with the extent of their participation in
the activity.
Disclosure Statement
The ACCME requires that the RSNA, as an accredited
provider of CME, obtain signed disclosure statements from
the authors, editors, and reviewers for this activity. For this
journal-based CME activity, author disclosures are listed at
the end of this article.

1
  From the Department of Radiology, Massachusetts Eye
and Ear Infirmary, 243 Charles St, Boston, MA 02114
(A.F.J.); Department of Radiology, The University of Chicago
Medicine, Chicago, Ill (D.T.G.); and Department of
Radiology, Beth Israel Deaconess Medical Center, Boston,
Mass (G.M.). Received April 3, 2014; revision requested
May 19; revision received August 13; accepted September
22; final version accepted October 3. Address
correspondence to A.F.J. (e-mail: amy_juliano@meei.
harvard.edu).

q
 RSNA, 2015

Radiology: Volume 276: Number 3—September 2015  n  radiology.rsna.org 655

STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al
I
n part 2 of this review, we will first
discuss trauma to the temporal bone
and posttraumatic complications.
Imaging of Temporal Bone Trauma
There are various types of trauma mech­
anisms that can result in temporal bone
injury. These include penetrating in­
Essentials
nn Ossicular injury is usually seen
with longitudinal fractures, and
dislocations are more common
than fractures; the incus is the
most commonly injured ossicle
owing to its larger size and lack
of ligamentous and muscular sup­
port and incudostapedial joint
separation is the most common
injury of the ossicular chain (may
be missed due to subtlety of its
imaging appearance).
nn Compared with the traditional
scheme for temporal bone
fracture classification (longitudi­
nal vs transverse), newer
classification schemes (otic
capsule violating vs sparing) have
better correlation with clinical
outcome and complications.
nn Non–echo-planar diffusion-weighted
imaging can potentially serve as
an alternative to second-look sur­
gery for the detection of recurrent
cholesteatoma, which typically
demonstrates reduced diffusion.
nn In a patient presenting with con­
ductive hearing loss without tym­
panic membrane abnormality and
with no history of middle ear in­
flammation, there should be a
high level of suspicion for fenes­
tral otosclerosis, evidenced by
demineralization in the region of
the fissula ante fenestram at CT.
nn In the late phase of otosclerosis,
demineralization may not be seen,
and instead there may be sclerotic
thickening around the oval window,
at the stapes footplate, and around
the cochlear capsule; obliterative
disease (at the oval and round win­
dows) should be reported.
656 radiology.rsna.org  n  Radiology: Volume 276: Number 3—September 2015
jury (eg, stick, gunshot wound), blunt
trauma (eg, motor vehicle accident),
barotrauma (eg, sudden change in
pressure), thermal injury, and avulsion
injury. Fractures of the temporal bone
are common in patients with major
head trauma, with a reported incidence
of 18%–22% of skull fractures involving
the temporal bone (2). It requires sub­
stantial force (1875 lb) to fracture the
temporal bone; therefore, initially, the
temporal bone injury is often overshad­
owed or masked by other associated
clinically important injuries (3). The
clinical signs and symptoms of temporal
bone fracture include hemorrhagic otor­
rhea, hemotympanum, tympanic mem­
brane perforation, vertigo, hearing
loss, facial nerve palsy, and nystagmus.
The Battle sign refers to postauricular
ecchymosis from traumatic rupture of a
mastoid emissary vein (4). It has been
noted that temporal bone fractures do
not demonstrate normal bone healing,
possibly related to low metabolic activ­
ity of the bone of the otic capsule (5).
While high-spatial-resolution tem­
poral bone computed tomography (CT)
is the modality of choice for evaluat­
ing temporal bone trauma, particularly
fractures, CT arteriogram/venogram or
magnetic resonance (MR) arteriogram/
venogram and high-spatial-resolution MR
imaging may be helpful for the assess­
ment of complications.
The traditional system for classi­
fying temporal bone fractures does so
according to their orientation relative
to the long axis of the petrous pyramid
(Fig 1) (6). The longitudinal fracture
type is more common (80%–90% of
temporal bone fractures) and results
from temporoparietal impact. The frac­
ture line is parallel to the longitudinal
axis of the petrous portion of the
temporal bone. The fracture begins in
the squamosal portion of the temporal
bone, extends along the posterior supe­
rior bony margin of the external auditory
canal, crosses the tegmen, and exits in
the middle cranial fossa anterior to the
labyrinth. This type of fracture results
in ossicular and tympanic membrane
injury. The less common transverse
fracture (10%–20%) results from fron­
tooccipital trauma, and the fracture line
is perpendicular to the petrous pyr­
amid. The fracture extends from the
foramen magnum, extends through the
petrous pyramid involving the labyrinth,
and exits into the middle cranial fossa.
A transverse fracture is associated with
a higher risk of facial nerve injury.
A limitation of the traditional classifi­
cation system is that it does not address
oblique or mixed fractures, which, ac­
cording to many studies, represent the
majority of temporal bone fractures (7).
In addition, this classification system
does not correlate well with clinical out­
come and potential complications. To
address the limitations of the traditional
system, newer classification systems have
been proposed. Ishman and Friedland (8)
classified fractures into petrous and
nonpetrous types. Petrous fractures in­
volve the petrous apex and otic capsule;
the nonpetrous fractures involve the
middle ear and mastoid. While most
complications—facial nerve injury,
cerebrospinal fluid (CSF) leak, senso­
rineural hearing loss—occurred in the
petrous group, there was increased in­
cidence of conductive hearing loss in
the nonpetrous group owing to involve­
ment of the ossicular chain.
There is a newer system proposed by
Kelly and Tami (9) that classifies frac­
tures depending on whether the otic
capsule is spared (otic capsule–sparing
fracture) or violated (otic capsule–
violating fracture). The otic capsule–
sparing fracture is much more common
(94%–97%), results from a temporopa­
rietal blow, and has an increased inci­
dence of conductive hearing loss due
to ossicular injury. The otic capsule–-vi­
olating fracture (3%–6%) results from
an occipital blow and has a higher inci­
dence of facial nerve paralysis (30%–
50%), sensorineural hearing loss,
Published online
10.1148/radiol.2015140800  Content codes:
Radiology 2015; 276:655–672
Abbreviations:
CSF = cerebrospinal fluid
DWI = diffusion-weighted imaging
LVA = large vestibular aqueduct
Conflicts of interest are listed at the end of this article.
STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 1  between two axes of rotation. Simulta­

Figure 1:  Traditional classification of temporal bone fractures. Axial CT images demonstrate (a) a longitudi-
nal fracture and (b) a transverse fracture in two different patients. The longitudinal fracture is parallel to the
long axis of the petrous pyramid (arrow, a) and traverses the mastoid portion of the temporal bone. The
transverse fracture is oriented perpendicular to the petrous pyramid (arrow, b) and traverses the basal turn of
the cochlea (arrowhead, b).
and CSF fistula. This new classification
system shows better correlation with
clinical outcome and complications (10).
On CT images, the optic capsule–violat­
ing frac­ture line can involve the vestibule,
semicircular canals, cochlea, and/or fa­
cial nerve. Although classifying temporal
bone frac­tures is useful in understand­
ing complications and for treatment
planning, on an individual case basis,
it may be more important to describe
the vital structures involved (ossicles,
otic capsule, facial nerve, tegmen, ex­
ternal auditory canal, internal audi­
tory canal, carotid canal) rather than
trying to make the findings “fit” into a
classification scheme.
Complications of Temporal Bone
Trauma
Ossicular Injury
Ossicular chain disruption is usually
seen with longitudinal fractures or otic
capsule–sparing fractures of the tem­
poral bone. Conductive hearing loss
after temporal bone trauma is usually
related to hemotympanum or tympanic
membrane rupture, but 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 is the most commonly in­
jured ossicle since it is the heaviest
ossicle, has no muscular attachments,
and has the least amount of ligamen­
tous support (11). Ossicular dislocation
is more common than ossicular fracture
(11). CT findings of ossicular injury may
be difficult to appreciate acutely due
to hemotympanum. Comparison with
the normal side and supplementary
reformatted images in planes parallel
(Pöschl) and perpendicular (Stenvers)
to the plane of the superior semicir­
cular canal may be useful for problem
solving.
There are five types of dislocations:
incudostapedial joint separation, incu­
domalleal joint separation, incus dislo­
cation, incudomalleal complex disloca­
tion, and stapediovestibular dislocation
(11). Incudostapedial joint separation is
the most common injury of the ossicular
chain. The incudostapedial articulation
is a fragile diarthrodial joint that lies
neous tetanic contractions of the tensor
tympani tendon and stapedius tendon
have also been implicated. The tensor
tympani muscle resides in a semi canal
in the anterior wall of the middle ear
cavity and passes posteriorly, forming a
right angle at the cochleariform process
to insert into the neck of the malleus.
The stapedius muscle arises from the
posterior wall of the middle ear cavity;
its tendon emerges through the tip of
the pyramidal eminence to insert into
the head of the stapes. Temporal bone
trauma of sufficient force can result in
sudden retraction of the incus medially
and the stapes posteriorly with separa­
tion of the incudostapedial joint (12).
Incudostapedial joint separation may be
missed at CT owing to subtle imaging
findings (11). On serial axial CT sec­
tions, it is manifested by a gap between
the lenticular process of the incus and
the head of the stapes (Fig 2). Incudom­
alleal joint separation is easier to visual­
ize 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 epitympa­
num (Fig 3). Total incus dislocation is
also possible when incudomalleal and
incudostapedial joint separation occur
concomitantly. The dislocated incus
may remain in the epitympanic recess,
prolapse into the hypotympanum, or ex­
trude out through the external auditory
canal and may not be visualized in situ.
If the incudomalleal joint resists separa­
tion as a result of the trauma, the incu­
domalleal complex may dislocate as one
unit into the meso- or hypotympanum.
There can be concomitant incudosta­
pedial joint separation with this type
of injury. Stapediovestibular dislocation
is very rare and occurs when there is
disruption of the annular ligament at­
taching the stapes footplate to the oval
window, which causes the stapes to be
dislocated into the vestibule (internal
dislocation) or into the tympanic cavity
(external dislocation). Stapediovestibu­
lar dislocation creates a perilymphatic
fistula, which is an abnormal communi­
cation between the middle ear and inner
ear (13). Perilymphatic fistula manifests
clinically as vertigo and fluctuating sen­

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 2  of the external auditory canal, presum­

ably related to a suction-type mecha­
nism (15). This finding may be better
appreciated on a coronal or Pöschl view
of the temporal bone CT study.
Fracture of the stapes crura typically
results from torsional injury, with the
posterior crus involved more frequently
than the anterior crus (16). The sta­
pes footplate can also implode into the
vestibule from penetrating injury and
result in a perilymphatic fistula (17).
On CT scans, the stapes crura are not
visualized in their expected location at
the oval window and can be noted in
the meso- or hypotympanum. Isolated
fracture of the incus is very rare (11).
Cochlear concussion results from in­
jury to the membranous labyrinth with
posttraumatic sensorineural hearing loss
Figure 2:  Incudostapedial separation. (a) Axial CT image demonstrates a gap (black arrow) between the and is occult on CT scans since no bone
lenticular process of the incus (white arrow) and the head of the stapes (arrowhead) in the setting of a longi- injury is present (18). MR imaging may
tudinal fracture. (b) Axial CT image of a normal incudostapedial articulation (arrow). demonstrate hemorrhage in the laby­
rinth manifesting as high signal inten­
sity on unenhanced T1-weighted images
Figure 3  Figure 4  (19).

Figure 3:  Incudomalleal joint separation. Axial CT
image demonstrates a gap (arrow) between the ice
cream (head of malleus) and the cone (body and
short process of incus). This occurred in the setting
of a longitudinal fracture. Compare with the normal
incudomalleal joint in Figure 4.
sorineural hearing loss. Pneumolaby­
rinth (air in the inner ear structures)
and opacification of the round window
are important CT findings of perilym­
phatic fistula (Fig 4) (14).
Figure 4:  Stapediovestibular dislocation with
perilymphatic fistula. Axial CT image demonstrates
pneumolabyrinth (arrowhead) and dislocation of the
footplate of the stapes into the vestibule (black
arrow). A normal incudostapedial joint can be appre-
ciated on this image, with no gap between the head
of the malleus and the incus body and short process
(white arrow).
Isolated fracture of the manubrium
(or handle) of the malleus is a rare con­
dition that presents as sudden-onset
hearing loss after digital manipulation
CSF Leak
CSF leak is seen in 11%–45% of tem­
poral bone fractures, particularly those
involving the tegmen (8,10,20). Otic
capsule–violating fractures have a two
to four times increased risk of CSF
leak. Clinically, patients present with
CSF otorrhea and CSF rhinorrhea (leak
of CSF through the Eustachian tube
into the nasal cavity in the setting of
an intact tympanic membrane). Some
patients may experience a sense of full­
ness in the ear and conductive hearing
loss. Beta-2 transferrin is found almost
exclusively in the CSF, and testing of
the leaking fluid for beta-2 transferrin
is very helpful. However, it is important
to note that beta-2 transferrin is also
present in the perilymph, and testing
for beta-2 transferrin may be positive in
cases of perilymphatic leaks. Most cases
of CSF leak occur in the first week after
trauma and close spontaneously with
conservative medical management (strict
bed rest, elevation of bed by 30°, and
avoidance of straining). If the CSF leak
does not respond to conservative mea­
sures, CSF diversion by means of a lum­
bar drain is performed. The risk of men­

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al
Figure 5  Figure 6
Figure 5:  Posttraumatic CSF leak. Axial CT image
demonstrates a defect in the anterior tegmen (arrow)
in this patient who presented withCSF otorrhea after
trauma. Also note opacification of the mastoid air
cells (∗) by CSF.
ingitis increases if the CSF leak lasts for
more than 1 week. Multidetector CT of
the temporal bone should be performed
for localization of the leak site (Fig 5).
Stone et al (21) found that multidetec­
tor CT depicted a bone defect in 70% of
cases with clinically active leaks. They
suggested that contrast-enhanced CT
cisternography or radionuclide cister­
nography (each of which involves a lum­
bar puncture) should be reserved for
patients with multiple bone defects or
patients in whom initial high-spatial-
resolution CT did not identify a bone
defect. Cisternography should be per­
formed during clinically active leaks
to improve sensitivity (21). Shetty et al
(22) found multidetector CT to be 93%
accurate and MR cisternography to be
89% accurate in diagnosing CSF leaks.
Surgical repair should be performed
if the leak persists for more than
7–10 days despite CSF diversion, be­
cause of the risk of meningitis. Menin­
gocele and encephelocele are late com­
plications of temporal bone fractures,
and MR imaging is invaluable for de­
tection utilizing a coronal true inversion
recovery pulse sequence (Fig 6). This is
a high-spatial-resolution sequence that
Radiology: Volume 276: Number 3—September 2015  n  radiology.rsna.org 659
 
Figure 6:  Posttraumatic encephelocele. Coronal T2-weighted MR image in
the same patient as in Figure 5 obtained 1 year later demonstrates an en-
cephelocele protruding into the attic via the tegmen defect (arrows). There con-
tinues to be fluid in the mastoid air cells.
provides good gray matter–white mat­ Figure 7 
ter contrast; the brain parenchyma in
turn is easily distinguishable from the
dark signal intensity of bone and air in
the mastoid and middle ear region.
Facial Nerve Injury
If the facial nerve is transected, the
patient experiences immediate facial
paralysis. Delayed facial nerve injury
(1 day to 16 days after injury) is related
to contusion, edema, or hematoma.
The severity and timing of onset of fa­
cial paralysis are important prognostic
factors. Incomplete facial paralysis can
be managed by observation and high-
dose steroids, with surgical exploration
considered only if an obvious bone frag­
ment is seen impinging the facial nerve
Figure 7:  Facial nerve injury. Axial CT image dem-
canal (23). Early complete paralysis
onstrates subtle enlargement of the geniculate fossa
may predicate the need for urgent sur­
(arrows), which is the most common site for facial
gical exploration (23–26). The perigenic­ nerve injury. There is also a complex right temporal
ulate area is more susceptible to injury bone fracture.
due to traction from the greater super­
ficial petrosal nerve (24,25). On high-
spatial-resolution CT images, one should Labyrinthitis Ossificans
search for a fracture line coursing When a temporal bone fracture involves
through the facial nerve, and for bone the inner ear structures (usually an otic
fragments, ossicles, or hematoma im­ capsule–violating fracture), labyrinthi­
pinging on the facial canal (Fig 7). tis ossificans can result, in which the
STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 8 

Figure 8:  Labyrinthitis ossificans. (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 inten-
sity in the expected location of the right lateral semicircular canal (white arrow) and in the left vestibule (black arrow) and lateral semi-
circular canal (arrowhead) compatible with labyrinthitis ossificans. The patient also had an otic capsule-violating fracture on the left (not
shown). Incidentally noted is a mildly dysmorphic right vestibule.

fluid-filled lumen of the otic capsule is
replaced by bone (or fibrous tissue if in
the early stages) (1,27). Clinically, this
is associated with profound sensorineu­
ral hearing loss and loss of vestibular
function. On high-spatial-resolution CT
images, osseous attenuation is noted
within the inner ear. The correspond­
ing MR images show loss of fluid signal
intensity within the membranous laby­
rinth and enhancement on gadolinium-
enhanced images. Heavily T2-weighted
high-spatial-resolution sequences with
high contrast-to-noise ratio, such as
true fast imaging with steady state
precession (known as FISP), are most
sensitive for detection at its earliest (fi­
brous) stage. MR findings precede CT
changes by many months, as the earlier
fibrous stage prior to ossification may
not be detectable on CT images but may
be seen on MR images as loss of fluid
signal intensity in the membranous lab­
yrinth (Fig 8) (1).
Vascular Injury
Arterial injury can occur in the form of
dissection, pseudoaneurysm, transec­
tion, occlusion, or arteriovenous fistulas.
Carotid injury is reported to be present
in 30% of patients with basilar skull
fractures (28). Resnick et al (29) found
that 24% of patients with basilar skull
fractures had fractures involving the ca­
rotid canal, 11% of whom had vascular
complications (laceration, cavernous ca­
rotid fistula, pseudoaneurysm, or dissec­
tion) directly related to the intracranial
carotid injury. The presence of a carotid
canal fracture is highly suggestive of in­
jury to the internal carotid artery pass­
ing through that canal, with a sensitiv­
ity of 60% and specificity of 67% (30).
According to McKinney et al (31), there
was a high rate of blunt vascular injury
in the presence of a carotid canal or ver­
tebral transverse foramen fracture seen
at multidetector CT, and they recom­
mended using foraminal involvement as
a screening criterion for further imaging
of these patients using CT angiography
or catheter angiography.
According to the meta-analysis by
Roberts et al (32), the diagnostic per­
formance of CT angiography varied
considerably across studies, which was
believed to be due to variation in diag­
nostic threshold across different trauma
centers. They suggested that although
CT angiography appears to lack sensi­
tivity for adequately excluding blunt ce­
rebrovascular injury, it may still prove
useful in the setting of trauma when
there is a high pretest probability of in­
jury.
CT angiography findings indicating
arterial injury include irregularity of the
lumen, intimal flap, out-pouching of the
lumen, lumen occlusion, or extravasa­
tion of contrast material. In the setting
of a high risk of vascular injury and a
negative CT angiography study, cathe­
ter angiogram remains the reference
standard for diagnosis.
Venous injury can manifest as tran­
section or thrombosis of the venous si­
nuses (Fig 9). CT venogram should be
performed in suspected cases where
the fracture line traverses the venous
sinuses. A filling defect in the sinuses
from a thrombus is highly suggestive of
venous sinus thrombosis. An MR imag­
ing or CT study will also depict venous
infarcts or hematomas.
Imaging of the Postoperative Temporal
Bone
Temporal bone imaging may be per­
formed in patients with a history of

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al
Figure 9  Figure 10  Figure 11
Figure 9:  Venous sinus injury. 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).
otologic or neurotologic surgery, specif­
ically for evaluating the results of the
surgery or for unrelated reasons. In
either case, it is important to be famil­
iar with some of the more commonly
performed procedures and their corre­
sponding imaging findings.
Myringotomy and Tympanostomy Tube
Tympanostomy (ventilation) tubes are
commonly inserted into the tympanic
membrane via an incision in the tym­
panic membrane (myringotomy) for
treating chronic or recurrent otitis me­
dia recalcitrant to medical management
(33,34). Tubes are available in different
shapes, sizes, and materials, most com­
monly Teflon or silicone, which have
soft-tissue attenuation on CT images
(Fig 10). Although CT studies may not
be obtained specifically to evaluate tym­
panostomy tubes, it is helpful to avoid
misidentifying these as unintended for­
eign bodies or dislocated ossicles and
to confirm the presence of a tube not
apparent on otoscopic evaluation (34).
The presence of middle ear fluid can
obscure tympanostomy tubes, espe­
cially those composed of plastic. The
tubes usually fall out on their own after
a few months, but medial migration of
Radiology: Volume 276: Number 3—September 2015  n  radiology.rsna.org 661
 
Figure 10:  Tympanostomy tube. Axial CT image
shows a plastic grommet (arrow) that traverses the
Figure 11:  Canal-wall-up mastoidectomy. The
tympanic membrane.
patient had a history of mastoiditis. Axial CT image
shows an intact posterior wall of the external audi-
tory canal (arrow) and a clear mastoid bowl (∗).
tympanostomy tubes into the middle
ear occasionally occurs and can result
in conductive hearing loss (35). Figure 12 
Mastoidectomy
The different types of mastoidectomy
essentially consist of resecting variable
portions of the mastoid air cells and
adjacent structures, which may be per­
formed for treatment of mastoiditis,
cholesteatoma resection, cochlear im­
plantation, or endolymphatic surgery,
among other indications (33,36). Canal-
wall-up mastoidectomy involves exen­
teration of the mastoid air cells with
preservation of the posterior wall of
the external auditory canal, creating a
mastoid bowl or cavity (Fig 11). Canal-
Figure 12:  Radical mastoidectomy. The patient
wall-down mastoidectomy consists of
had a history of extensive middle ear cholesteatoma
performing the same steps as in canal-
with ossicular erosion. Axial CT image shows a large
wall-up mastoidectomy, but in addi­
mastoid bowl (∗) with absence of the posterior wall
tion the posterior wall of the external of the external auditory canal and ossicular chain.
auditory canal is resected to increase
exposure to middle ear contents. A rad­
ical mastoidectomy can be performed
for extensive disease of the middle ear casionally, the mastoid bowl may be
cavity with ossicular involvement. This obliterated using bone, cartilage, fat,
procedure includes removal of the tym­ or hydroxyapatite to minimize the size
panic membrane, malleus, and incus, of the mastoidectomy cavity following
with attempted preservation of the canal-wall-down procedures (37). Oth­
stapes, in addition to canal-wall-down erwise, the mastoid bowl should remain
mastoidectomy (Fig 12). Tympanomas­ clear and the presence of soft-tissue at­
toidectomy refers to mastoidectomy tenuation material on CT images may
performed in conjunction with a middle represent granulation tissue or, in the
ear procedure, such as tympanoplasty appropriate scenario, recurrent choles­
and/or ossicular reconstruction. Oc­ teatoma.
STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 13  Figure 14  Figure 15 

Figure 13:  Recurrent cholesteatoma. Postopera-
tive coronal DWI shows a focus of reduced diffusion
in the region of the mastoidectomy bowl (arrow)
compatible with a cholesteatoma.
Figure 14:  Stapes prosthesis. Pöschl reformatted
CT image of the right temporal bone shows a me-
tallic stapes prosthesis (arrow) that extends from the
incus to the stapedotomy site.
Figure 15:  Total ossicular replacement prosthesis.
Axial CT image shows a hydroxyapatite prosthesis
that extends from the thick reconstructed tympanic
membrane (arrow) toward the region of the stapes
footplate (arrowhead).

Evaluation of recurrent cholestea­
toma is an important indication for im­
aging after mastoidectomy (Fig 13). On
CT images, recurrent cholesteatoma is
suspected when there is new bone ero­
sion associated with a soft-tissue focus,
although the attenuation characteristics
are nonspecific and it can be difficult
to differentiate these lesions from gran­
ulation tissue. On MR images, choles­
teatoma demonstrates high T2 and low
T1 signal, without central enhance­
ment, while granulation tissue demon­
strates internal enhancement. Further­
more, cholesteatoma characteristically
shows reduced diffusion, and MR im­
aging with non–echo-planar imaging
diffusion-weighted imaging (DWI) (1)
can potentially serve as an alternative to
second-look surgery for the detection of
recur­rent cholesteatoma. Indeed, non–
echo-planar imaging DWI confers a
positive predictive value for cholestea­
toma of 93%–100% (38,39). It is im­
portant to interpret the DWI studies in
conjunction with the conventional pulse
sequence images to avoid false-positive
interpretations, which can result from the
presence of fat grafts and hemorrhage.
Ossicular Reconstruction
A variety of techniques can be per­
formed for ossicular reconstruction
(33,36,40). Stapes prostheses are used
in patients with conductive hearing loss Figure 16 
due to otosclerosis or congenital anom­
alies and typically consist of two compo­
nents—a loop and a piston. The loop of
the stapes prosthesis usually attaches to
the lenticular process of the incus, while
the piston sits in a groove formed in the
stapes footplate (stapedotomy) by means
of laser or drill (Fig 14). A partial ossic­
ular replacement prosthesis substitutes
the malleus and incus, and thus extends
from the tympanic membrane to the
head of the stapes, while a total ossicular
replacement prosthesis extends from the
tympanic membrane to the stapes foot­
plate or oval window and is utilized if the
stapes is also diseased (Fig 15). Ossicu­ Figure 16:  Dislocated partial ossicular replace-
lar prostheses can be composed of var­ ment prosthesis. Coronal CT image of the left tem-
poral bone shows that the prosthesis (straight arrow)
ious materials including hydroxyapatite,
is detached from the tympanic membrane (curved
metal, and plastic. Ossicular prosthesis
arrow) and the head of the stapes (arrowhead).
failure most commonly results from mi­
gration or dislocation (Fig 16) but can
also result from prosthesis fracture, re­ cus interposition can be performed for
current cholesteatoma, pressure erosion reconstruction of the ossicular chain af­
of the ossicles, and perilymphatic fistula. fected by cholesteatoma or chronic otitis
Many of these complications can be iden­ media and consists of resecting, sculpt­
tified at high-spatial-resolution CT. For ing, and repositioning the incus, such
example, pressure erosion appears as that it extends from the malleus to either
hypoattenuation or truncation of the os­ the stapes or oval window (Fig 17). In­
sicles, often with associated dislocation cus interposition bone grafts are viable,
of the prosthesis; the diagnosis of peri­ as opposed to artificial prostheses (41).
lymphatic fistula can be suggested by the However, interposition grafts may be
presence of pneumolabyrinth or a new, compromised by dislocation, necrosis,
unexplained middle ear effusion (40). In­ and recurrent cholesteatoma.

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 17  Figure 18 

Figure 17:  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).
Figure 18:  Cochlear implant. Stenvers view radiograph obtained at the con-
clusion of cochlear implantation surgery shows expected positioning of the
cochlear implant electrodes (white arrow) in relation to the internal auditory
canal (black arrow), superior semicircular canal (white arrowhead), lateral semi-
circular canal (black arrowhead), and mastoidectomy cavity (∗).

individual electrodes after implantation ing structures, with a mean maximal

Cochlear Implantation
Cochlear implants are electronic de­
vices that can restore hearing in pa­
tients with severe sensorineural hearing
loss by direct stimulation of the cochlear
nerve. The basic components of a co­
chlear implant include a microphone,
speech processor, and transmitter coil
externally, and a receiver-stimulator
internally, which leads to a cable end­
ing in an electrode array within the co­
chlea. The electrode array usually con­
tains eight to 24 stimulators that are
tuned to particular acoustic frequencies
(33,36,42). Typical surgery for cochlear
implantation consists of performing
canal-wall-up mastoidectomy and intro­
ducing the electrode through the mid­
dle ear cavity through the facial recess
and into a widened round window
niche. The electrode enters the cochlea
through the round window and into the
scala tympani for approximately 1.5
turns. The round window niche is then
plugged with fascia or muscle graft af­
ter insertion of the electrodes. Intraop­
erative and postoperative radiographs,
including the Stenver view, are often
obtained to confirm proper position­
ing of the cochlear implant electrodes
(Fig 18) (42). Multiplanar high-spatial-
resolution CT images can depict the ex­
pected intracochlear positioning of the
in greater detail, and three-dimensional
stereoscopic CT images with pseudo­
color technique can be helpful for pro­
viding an overall view of the hardware
(Fig 19) (43). Complications related to
cochlear implantation occur in less than
1% of cases and include device malposi­
tion or migration, breakage, facial nerve
canal dehiscence and stimulation or
injury, pneumolabyrinth, and bone ero­
sion, which are best evaluated with CT,
and abscess, meningitis, and labyrinthi­
tis, which are best evaluated with MR
imaging (33,42). Ultimately, high-spa­
tial-resolution temporal bone CT and
MR imaging are useful for proper pre­
operative planning and avoiding compli­
cations and failure of cochlear implan­
tation. In particular, CT is useful for
delineating bony anatomy and identify­
ing potential hazards and contraindica­
tions to surgery, such as labyrinthitis
ossificans and facial nerve canal dehis­
cence, while MR imaging is useful for
delineating the integrity of the cochlear
nerve and inner ear structures (44). Pa­
tients can safely undergo 1.5-T MR im­
aging after cochlear implantation, even
with devices that contain magnetic
components, if such devices are tightly
secured prior to imaging. However, the
cochlear implants can produce artifacts
on MR images that obscure surround­
anterior-posterior dimension of 6.6 cm
and a lateral dimension of 4.8 cm (45).
Vestibular Schwannoma Surgery
Three main surgical approaches can be
implemented for resection of vestibular
schwannomas, including translabyrin­
thine, retrosigmoid (suboccipital), and
middle cranial fossa approaches. The
translabyrinthine and the retrosigmoid
approaches can be used for all tumor
sizes, while the middle cranial fossa
approach is most useful for removal of
intracanalicular tumors (46). However,
hearing preservation can be achieved
only by means of the retrosigmoid and
middle cranial fossa approaches (47).
MR imaging is routinely performed
following surgical resection, mainly to
assess for residual or recurrent tumor,
but also to evaluate for suspected com­
plications (33,46,48). A typical postop­
erative MR imaging examination consists
of an internal auditory canal protocol
that includes axial thin-section pre­
contrast T1-weighted, axial and coronal
thin-section postcontrast fat-suppressed
T1-weighted, T2-weighted fast-spin-
echo, T2-weighted fluid-attenuated in­
version recovery (FLAIR), DWI, and
high-spatial-resolution cisternography
(heavily T2-weighted) sequences, such
as constructive interference in steady

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 19 

Figure 19:  Cochlear implant. (a) Stenvers reformatted CT image shows the electrodes (arrow), which enter the cochlea in the region of the round window (arrow-
head). Soft tissue graft has been used to obliterate the mastoid bowl (∗), which was created during the cochlear implantation surgery. (b) Stereoscopic three-dimen-
sional color CT image provides an overview of the cochlear implant components.

Figure 20  bilateral (85%), predominantly affects

women (65%–72%), and is seen much
more commonly in Caucasian than in
African-American, Asian, and Native
American subjects (49). Patients pre­
sent with hearing loss, typically in the
2nd to 4th decades of life. Early on, the
type of hearing loss is almost always
conductive in nature. Later on, mixed
hearing loss or sensorineural hearing
loss sets in as the disease progresses in
extent (50).
The otic capsule is normally com­
posed of an inner layer of endosteum,
an outer layer of periosteum, and a
middle layer of persistent primary en­
dochondral bone. In otosclerosis, the
Figure 20:  Residual/recurrent vestibular schwannoma. (a) Axial T1-weighted MR image shows a fat graft dense middle layer of endochondral bone
within the decompressed right internal auditory canal (arrow) following vestibular schwannoma surgery by is resorbed and replaced by spongy vas­
means of a retrosigmoid approach. (b) Axial fat-suppressed contrast-enhanced T1-weighted MR image cular bone. Thus otosclerosis is also re­
shows enhancing tumor within the fundus of the internal auditory canal and in the cerebellopontine angle ferred to as “otospongiosis,” and this
(arrows). Signal in the fat graft is suppressed and it appears hypointense (arrowhead). phase is referred to as the vascular
phase of otosclerosis. As the disease
progresses or becomes inactive, the
state (CISS) or fast imaging employ­ the altered bony anatomy and identify­ “spongy” areas recalcify, becoming less
ing steady-state acquisition (FIESTA) ing hemorrhage. vascular and more sclerotic (50). The
(46). The use of fat suppression is use­ most common location to be involved in
ful for distinguishing enhancing tumor otosclerosis early on is around the em­
from the intrinsic high signal intensity Noninflammatory Nonneoplastic bryologic fissula ante fenestram, a thin
of the fat grafts, which are commonly Entities fold of embryonic cartilage and con­
implanted in the surgical beds during nective tissue in a small cleft just ante­
tumor resection to minimize CSF leak­ Otosclerosis rior to the oval window (51,52). When
age (Fig 20). CT can also play a role Otosclerosis is an osteodystrophy of disease is limited to this area near the
in postoperative imaging for vestibular the otic capsule affecting approximately oval window, it is referred to as fenes­
schwannoma, particularly for defining 1% of the population. It is commonly tral otosclerosis. The abnormal bone

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al
Figure 21  Figure 22
Figure 21:  Thickened stapes footplate in exten-
sive fenestral and retrofenestral otosclerosis. Axial
CT image shows extensive demineralization anterior
to the oval window in the region of the fissula ante
fenestram (arrowhead), extending over the lateral
aspect of the cochlea with involvement of the co-
chlear promontory (white arrow). The stapes foot-
plate is thickened (black arrow).
impinges on the nearby stapes footplate,
resulting in mechanical fixation of the
stapes footplate within the oval win­
dow, thereby causing conductive hear­
ing loss. The round window is another
favored site and may be involved as well
(52,53). As the disease progresses,
the remainder of the bony labyrinth
becomes involved more extensively,
resulting in retrofenestral otosclerosis,
including around the cochlea. In addi­
tion to conductive hearing loss, these
patients have sensorineural hearing loss,
thought to result from damaging meta­
bolic substances, toxins, or proteolytic
enzymes diffusing into the cochlear
fluid causing hyalinization of the spiral
ligament (54,55). Some patients have
vestibular symptoms such as unstead­
iness and vertigo (56,57). Retrofenes­
tral otosclerosis rarely occurs without
fenestral involvement, and patients al­
most never have isolated sensorineural
hearing loss.
Fenestral otosclerosis.—The char­
acteristic clinical findings of fenestral
otosclerosis are progressive conductive
hearing loss up to 50–60 dB, absent
stapedial reflexes, a normal tympanic
Radiology: Volume 276: Number 3—September 2015  n  radiology.rsna.org 665
Figure 22:  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).
membrane, and absence of middle
ear inflammation (50). Imaging is
helpful for confirming the diagnosis,
determining the extent of oval window
involvement, assessing for a retrofenes­
tral component, and excluding clinical
mimickers such as superior semicircu­
lar canal dehiscence.
High-spatial-resolution CT of the
temporal bone with a multidetector
unit with submillimeter sections and
multiplanar reformats (axial, coronal,
Stenvers, Pöschl) is the examination
of choice for evaluation of otosclerosis.
In fenestral otosclerosis, there is focal
demineralization in the region of fissula
ante fenestram, which can range from
tiny, subtle, and hazy to prominent and
well defined. This reflects replacement
of the dense otic capsule by vascular
spongiotic bone. As the disease pro­
gresses, the area of demineralization
expands and involves the oval window
(Fig 21). In the later inactive, sclerotic
phase, the abnormal spongiotic bone
becomes denser, and may in fact be­
come isodense with adjacent normal
areas of otic capsule, rendering detec­
tion at CT challenging. In this situation,
diseased regions are identified as areas
of abnormal sclerotic thickening around
the oval window. The oval window is
narrowed and the stapes footplate is
thickened (Fig 21). The formation of
thickened bony plaques may lead to
complete obliteration of the oval window,
seen in 2% of cases (50), referred to as
obliterative fenestral otosclerosis (Fig 22).
Retrofenestral locations (beyond/behind
the region of the oval window) should
be examined for signs of involvement
as well, as this may alter clinical man­
agement. The round window is a par­
ticularly important area to scrutinize,
as the round window area is small and
even a positive finding there can be sub­
tle (Fig 23a). On MR images, enhance­
ment in the region of the oval window or
round window (Fig 23b) should raise the
suspicion for otosclerosis.
When otosclerosis is suspected on
one side, it is important to scrutinize
the contralateral temporal bone for
signs of disease, since otosclerosis is
frequently bilateral. Aside from exam­
ining the region at and around the oval
window for disease, one must also as­
sess for signs of retrofenestral involve­
ment, report findings that may lead to
intraoperative complications or poor
surgical outcomes (eg, obliterated oval/
round windows, anomalous course of
STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 23 

Figure 23:  Round window involvement by otosclerosis. (a) Axial CT image demonstrates demineralization in the region of the round
window (arrow). (b) Axial contrast-enhanced T1-weighted MR image in the same patient shows enhancement in the region of the right
round window (arrow). There is subtle enhancement in the left round window (arrowhead) as well, where demineralization reflecting
otosclerosis can be seen at CT (not shown).

facial nerve, inner ear anomaly, inflam­
matory process in the middle ear and
mastoid, dehiscence of bony covering
over the tympanic facial nerve or jugu­
lar bulb), and evaluate for an alternative
process that may be a cause or the cause
of conductive hearing loss (eg, ossicular
chain anomaly or abnormality, middle
ear mass, semicircular canal dehiscence).
Treatment of fenestral otosclerosis
is surgical, consisting of stapedotomy
(creation of a tiny hole in the stapes
footplate), complete or partial stape­
dectomy, and placement of a stapes
prosthesis (Fig 14) (58). CT is useful
for identifying causes of post-stapedec­
tomy failure (59). The most common
reason is migration or dislocation of the
prosthesis. On CT images, the stapes
implant may be abnormally rotated or
displaced, the piston may protrude ex­
cessively into the vestibule (Fig 24), or
a gap may be seen between the native
incus and the stapes implant or between
the stapes implant and the vestibule.
The “lateralized piston syndrome” re­
fers to lateral migration of the implant
piston out of the oval window related to
necrosis of the incus. Incus erosion may
also occur if the implant is too long,
transmitting constant increased stress
Figure 24 
on the long process of the incus (58).
CT can be used to evaluate for labyrin­
thine fistula and labyrinthitis ossificans,
although the early fibrotic stage of laby­
rinthitis ossificans may not be apparent
at CT and may only be detected on MR
images. MR imaging is also useful for
detection of other processes within the
membranous labyrinth and vestibule,
such as infectious labyrinthitis, repar­
ative granuloma, and intravestibular
foreign body, using a combination of
heavily T2-weighted sequences and
contrast-enhanced high-spatial-resolution
T1-weighted sequences through the
temporal bone.
Retrofenestral otosclerosis.—Retro­
fenestral otosclerosis rarely occurs in
isolation and is almost always seen in
association with fenestral otosclerosis.
Demineralization occurs extensively in
the otic capsule beyond the region of
the fissula ante fenestram, typically in­ Figure 24:  Migrated stapes prosthesis. Sagittal
volving the pericochlear region (cochlear oblique reformatted CT image demonstrates a sta-
capsule), but may extend to surround pes prosthesis abnormally protruding into the vesti-
the vestibule, semicircular canals, and bule (arrow).
internal auditory canal. Demineraliza­
tion may also be seen at the round win­
dow niche, cochlear promontory, and

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al
Figure 25  Figure 26  Figure 27
Figure 25:  Cochlear otosclerosis in a 44-year-old
man. Axial CT image demonstrates the characteris-
tic hypoattenuating “halo” around the cochlea (ar-
rows), representing the abnormal spongiotic bone in
the middle layer of the otic capsule.
tympanic facial nerve canal (60). Oc­
casionally, there may be isolated round
window involvement without oval win­
dow or pericochlear involvement (61).
If there is involvement of the cochlear
promontory (Fig 21), the promontory
may have a pink- or red-tinged appear­
ance at otoscopic examination, termed
the Schwartze sign, reflecting vascular
proliferation and dilatation with increased
blood flow to the promontory (62).
On CT images, retrofenestral oto­
sclerosis involving the cochlear capsule
manifests as a characteristic “halo”
around the cochlea, referred to as the
“double ring,” “fourth ring,” or “fourth
turn” sign, representing the abnormal
hypoattenuating spongiotic bone in the
endochondral layer of the otic capsule
(Fig 25). The finding is often bilater­
ally symmetric (51). This should not be
mistaken for normal pericochlear hy­
poattenuating foci, or “cochlear clefts”
(Fig 26), seen in children with no ev­
idence of otosclerosis and no history
of osteogenesis imperfecta (63,64).
There are various theories as to what
the cochlear cleft represents (63–65),
but it is widely believed to be related
to normal variant development of the
otic capsule, since the finding is highly
Radiology: Volume 276: Number 3—September 2015  n  radiology.rsna.org 667
Figure 26:  Cochlear cleft in an 11-year-old boy.
Axial CT image shows a thin curvilinear lucency
around the cochlea (arrow), representing a non-
pathologic entity referred to as the cochlear cleft,
and not cochlear otosclerosis.
prevalent among infants and children
younger than 3 years. Among the el­
derly, Paget disease is an imaging mim­
icker of cochlear otosclerosis (50). In
the later phase of cochlear otosclerosis,
when the diseased middle layer of the
otic capsule becomes sclerotic, the only
finding on CT images may be mild ir­
regularity in the outline of the cochlear
capsule without abnormal hypoattenu­
ation or other findings discernible at
CT (Fig 27) (64). Knowledge of the
patient’s clinical history is thus crucial
to the radiologist to help avoid a false-
negative interpretation.
On MR images, retrofenestral oto­
sclerosis can be seen as a ring of abnor­
mal signal intensity in the pericochle­
ar and perilabyrinthine otic capsule,
with intermediate signal intensity on
T1-weighted images, and mild-to-
moderate enhancement on postcontrast
T1-weighted images, seen especially in
the active phase. Enhancement in the
lateral wall of the inner ear in the re­
gion of the oval window and/or round
window indicates concurrent fenestral
otosclerosis (53).
Figure 27:  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 otoscle-
rosis. In this patient, there are still demineralized
areas in the otic capsule visible (white arrow).
Treatment for retrofenestral oto­
sclerosis is usually medical, with the
use of fluorides or chelating agents to
limit the growth of active otosclerotic
foci and promote remineralization of
the otosclerotic plaques (50,56). Pa­
tients with bilateral profound sensori­
neural hearing loss may be considered
for cochlear implantation, provided
that there is no substantial ossification
within the cochlea that may lead to sur­
gical challenges and complications such
as partial insertion and misplacement
of electrode arrays (50).
Superior Semicircular Canal Dehiscence
The dense otic capsule surrounding the
membranous labyrinth normally has
two mobile windows, the oval window
and the round window. Abnormal de­
hiscence of the bony covering of the
membranous labyrinth at a third loca­
tion creates a “third window,” resulting
in abnormal movement of the endo­
lymph that can lead to a variety of ves­
tibular and cochlear symptoms induced
by sound and pressure stimuli, known
as the “third window phenomenon.”
STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 28  and abnormal communication of the

Figure 28:  Superior semicircular canal dehiscence. (a) Pöschl 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.
This third window phenomenon is char­
acterized by loss of acoustic energy and
abnormal stimulation of the vestibular
system (66). Dehiscence of the bony
covering over the superior semicircular
canal is more common than that over
the lateral and posterior semicircular
canals and is referred to as superior
semicircular canal dehiscence (Fig 28).
This was first described in 1998 by Mi­
nor et al (67). The prevalence of su­
perior semicircular canal dehiscence
is not definitely known, as it varies
depending on the method of diagnosis.
Based on cadaver examination, the prev­
alence of superior semicircular canal
dehiscence is reported to be 0.5%;
based on high-spatial-resolution CT ex­
amination, the prevalence is generally
higher, ranging from 3% to 12% (68).
The cause of superior semicircular
canal dehiscence is not well understood,
and in a majority of cases no clear un­
derlying etiology is discovered. Congen­
ital anomalies are thought to be possible
culprits, as superior semicircular canal
dehiscence has been reported in children
and in patients with anomalies such as
inner ear malformations (68). Potential
acquired causes include trauma, chronic
otitis media with cholesteatoma, and in­
creasing age and osteopenia, especially
if the bony covering over the superior
semicircular canal is inherently thin or
otherwise susceptible to external pres­
sure or other factors a priori (66,68).
Patients with superior semicircular
canal dehiscence typically present in
the 4th to 5th decade of life with ver­
tigo and oscillopsia induced by loud
sounds (Tullio phenomenon), eye move­
ments induced by pressure in the exter­
nal auditory canal (Hennebert sign), or
vestibular signs and symptoms elicited
by Valsalva maneuvers (69). The eye
movements are typically in the same
plane as that of the dehiscent semicircu­
lar canal. Patients may also experience
auditory symptoms such as conductive
hearing loss, autophony, and pulsatile
tinnitus. Another common clinical
symptom is abnormal amplification of
internal sounds of the body such as the
heartbeat and eye movement, thought
to be related to increased sensitivity to
bone-conducted sounds by some (69)
CSF space with the dehiscent supe­
rior semicircular canal by others (66).
When tested, there is a lower threshold
for elicitation of the vestibular-evoked
myogenic potential response in the af­
fected ear.
The vertical torsional nystagmus as­
sociated with the Tullio phenomenon,
the Hennebert sign elicited by the fistula
test, and vestibular-evoked myogenic
potential testing are highly sensitive and
specific for superior semicircular canal
dehiscence, but high-spatial-resolution
CT imaging of the temporal bone is
important for confirmation. On CT im­
ages, if an intact bony covering cannot
be visualized, superior semicircular
canal dehiscence can be suspected. It
is important to assess the bony covering
over all three semicircular canals as de­
hiscence over the lateral and posterior
semicircular canals is possible, although
rare (70). Alternative pathologic condi­
tions that may account for conductive
hearing loss should be sought, such as
middle ear mass, ossicular abnormality,
and fenestral otosclerosis. Studies have
shown that the prevalence of superior
semicircular canal dehiscence and the
size of the defect are overestimated
at CT, owing to difficulty detecting ex­
tremely thin but intact bone over the
canal related to limitations in scanner
resolution and partial volume effect, re­
spectively (66,70–73). Submillimeter
(0.5 mm) section thickness with images
reformatted in planes parallel (Pöschl)
and perpendicular (Stenvers) to the
plane of the superior semicircular canal
help to reduce false-positive rates and
improve specificity.
Surgery is generally reserved for
patients with clinically important ves­
tibular or auditory symptoms. The
bony dehiscence can be surgically re­
surfaced, plugged, or capped by means
of a transmastoid approach or middle
cranial fossa approach (66).
Large Vestibular Aqueduct Syndrome
Imaging is an important component in
the evaluation of pediatric sensorineu­
ral hearing loss for excluding structural
abnormalities. At high-spatial-resolu­
tion CT and MR imaging, abnormalities

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STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al
Figure 29  Figure 30  measured greater than 1.5 mm at the
Figure 29:  LVA. Axial CT image shows enlarge-
ment of the vestibular aqueduct (arrow). This
11-month-old boy presented with sensorineural
hearing loss and has bilateral LVA.
are identified in up to 37% of children
with previously unexplained sensori­
neural hearing loss (74). When CT im­
aging findings for pediatric sensorineu­
ral hearing loss are positive, the most
common finding is a large vestibular
aqueduct (LVA) (Fig 29) (74).
In 1978, Valvassori and Clemis (75)
were the first to describe an associa­
tion between sensorineural hearing loss
and LVA, diagnosed at polytomography,
and coined the term “large vestibular
aqueduct syndrome” to describe chil­
dren with LVA and sensorineural hear­
ing loss that is frequently progressive.
Symptoms of vestibular disturbance
may also occur as part of this syndrome
(76). Multiple studies since then using
CT as the imaging modality have esti­
mated the prevalence of LVA among pa­
tients with sensorineural hearing loss to
be anywhere from 0.64% to 32% (77).
The probability of progressive hearing
loss increases linearly with increasing
width of the vestibular aqueduct. In
children with LVA, sudden sensorineural
hearing loss has been reported to occur
following minor head trauma, leading
to the clinical practice of recommend­
ing against contact sports or other
Radiology: Volume 276: Number 3—September 2015  n  radiology.rsna.org 669
Figure 30:  LVA with modiolar deficiency and in-
complete partition type II. Axial CT image depicts an
enlarged vestibular aqueduct (black arrows), with
associated deficiency of the cochlear modiolus (ar-
rowhead) and incomplete partition of the cochlea
(IP-II) (white arrow). Similar findings are seen on the
contralateral side. This 9-year-old girl has bilateral
sensorineural hearing loss.
activities that may lead to increased
intracranial pressure and encouraging
the use of protective head gear when
participating in moderate-risk activities
among this patient population (77,78).
It is unclear what the exact relationship
is between LVA and sensorineural hear­
ing loss; LVA may be a cause of sen­
sorineural hearing loss, or it may be a
marker for an underlying process that
causes sensorineural hearing loss. It has
been noted that LVA often occurs along­
side other inner ear abnormalities, and
it is thought that most, if not all, LVAs
are associated with abnormalities of
the membranous labyrinth (74). There
is an association of LVA with modiolar
deficiency (79), an anomaly where the
modiolus (cone-shaped bone in the cen­
ter of the cochlea) is abnormally low
in volume (Fig 30). Some cases of LVA
have a genetic cause, with one study re­
porting 27% of LVA patients having the
SLC26A4 gene mutation (80).
In the initial description by Valvas­
sori and Clemis, the vestibular aque­
duct was considered enlarged when it
midpoint at tomography. In 2007, Bos­
ton et al (77) and Vijayasekaran et al
(78) proposed that the vestibular aq­
ueduct should be considered enlarged
on CT images when it measures greater
than 1.9 mm at the operculum and/or
greater than 0.9 mm at the midpoint in
children (ages ranging from 3 years to
14 years in their study). These are now
the most commonly used measurement
criteria and are referred to as the Cin­
cinnati criteria. It is important to take
into account both the operculum and
midpoint measurements, as otherwise
the shape of the vestibular aqueduct
(eg, flared versus bulbous) may lead to
a falsely normal measurement at one
of the two locations when in fact it is
clearly abnormally enlarged as a whole.
CT offers excellent visualization of
bone detail and hence configuration
of the vestibular aqueduct, while MR
imaging using a heavily T2-weighted
sequence allows visualization of its con­
tents, namely the endolymphatic duct
and sac. High-spatial-resolution CT is
the traditional workhorse, but each
modality has relative strengths (76).
MR imaging has the advantage of delin­
eating cranial nerves, including the co­
chlear nerve, and can offer some infor­
mation on bony structures such as the
otic capsule and vestibular aqueduct
based on the contour of the fluid within
them. The absence of ionizing radiation
in MR imaging is an important consid­
eration among the pediatric population.
On CT images, LVA typically has a
flared morphology. Heavily T2-weight­
ed MR imaging shows the enlarged
endolymphatic sac and duct within
the vestibular aqueduct (Fig 31). The
fluid in the enlarged endolymphatic sac
is often hypointense to CSF owing to
its very high protein content (79). It
is important to examine the cochlear
modiolus for abnormally decreased
volume to exclude an associated mo­
diolar deficiency. Funnel-shaped LVA
with incomplete partition type II (IP-
II) or modiolar deficiency is associated
with mutations in the SLC26A4 gene
that encodes for the pendrin protein
(Fig 30). SLC26A4 gene mutations are
seen in more than 50% of patients with
STATE OF THE ART: Imaging Review of the Temporal Bone Juliano et al

Figure 31  findings and that radiologists may eas­
ily miss or underdiagnose if they are
unaware of the precise locations to in­
spect on imaging studies. Although not
as common as infection or inflamma­
tion, these entities are nevertheless im­
portant for the radiologist to recognize,
especially since they have very charac­
teristic imaging appearances that can
point at the specific diagnoses, confer­
ring on radiologists an important role in
the clinical evaluation of these patients.
Disclosures of Conflicts of Interest: A.F.J.
disclosed no relevant relationships. D.T.G. dis­
closed no relevant relationships. G.M. disclosed
no relevant relationships.
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16. Swartz J, Kang M. Trauma to the temporal

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Figure 31:  LVA on axial heavily T2-weighted MR
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In this part 2 of our review of the
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