Otolaryngol Clin N Am

40 (2007) 439–454

Advances in Skull Base Imaging

Colin L.W. Driscoll, MDa,*, John I. Lane, MDb
a
Department of Otorhinolaryngology, Mayo Clinic College of Medicine,
200 First Street SW, Rochester, MN 55905, USA
b
Department of Radiology, Mayo Clinic College of Medicine, 200 First Street S.W.,
Rochester, MN 55905, USA

Despite being introduced in the 1970s and 1980s, CT and MRI continue to
be the primary imaging modalities for the temporal bone and skull base. Al-
though the general concepts and physics remain the same, the images obtained
currently are far superior. Augmenting these traditional modalities are nuclear
medicine imaging techniques, functional imaging, and the fusion of different
techniques [1]. Advances in these areas are expanding our options and illumi-
nating pathology in unique ways. As basic physiologic processes are better
understood, new opportunities for novel imaging techniques should arise.
This article focuses on the advantages of the latest MRI, CT, and nuclear
medicine technology and the impact it has on clinical practice and research.
Not only is the image acquisition technology changing but also our methods
for viewing the images are evolving. It is becoming increasingly uncommon
to have actual printed films, and images are routinely viewed in an electronic
format. Although this transition to electronic viewing can be uncomfortable
because it is a change, there are some distinct advantages.
To a large degree, the success of the transition to an electronic system de-
pends on the specific image viewing software and hardware. An intuitive,
easy-to-use program and computer monitors of sufficient size and quality
ease the transition. Tools that allow the clinician to quickly identify image
series of interest (eg, axial postcontrast), rapidly scroll through images,
make measurements, and compare scans from different times are all critical
for a successful experience. The ability to scroll up and down through a series
of images makes it easier to visualize the three-dimensional image of the pa-
thology in comparison to looking at traditional films. This ability is partic-
ularly important because of the large number of images obtained for most
examinations. It is not uncommon to have 400 to 1000 images for a single

* Corresponding author.
E-mail address: driscoll.colin@mayo.edu (C.L.W. Driscoll).

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.03.001 oto.theclinics.com
440 DRISCOLL & LANE

CT scan. Reviewing a stack of printed MRI or CT scans requires identifying

the different series and much organizing, which in the electronic environ-
ment is unnecessary. The clinician can simply choose the series of interest
(eg, T1 postcontrast) for review. Improved labeling by radiologists and
user-friendly software are making review an efficient task.

CT
CT scanning became widely used in the 1970s. Because of the exquisite
bony detail it can provide, it is beneficial for assessing temporal bone and
skull base lesions. Although the fundamental technology has remained the
same, every facet of the process has been improved. Higher quality images
are obtained in less time with less radiation exposure.
The most recent technologic advance is the advent of multidetector (mul-
tislice) scanners [2–4]. The current generation of 64-slice scanners (Fig. 1)
allows for rapid volumetric image acquisition with resolution in the range
of 0.3 to 0.6 mm. Because the data are acquired for an entire volume in a sin-
gle pass, there is no need for performing scans in multiple planes (axial, di-
rect coronal, and sagittal). The volumetric data can be reformatted rapidly
in any desired plane and without loss of resolution, which is a tremendous
improvement that allows visualization of the anatomy in novel ways [5]. An-
other advantage is that current scanning protocols require approximately 5
to 10 seconds for image acquisition. The incredibly rapid acquisition time
greatly reduces motion artifact and often the need for sedation in infants
or young children, which reduces not only the risk of the procedure but
also the cost to the health care system.
Enhanced resolution has improved diagnostic accuracy. Superior semicir-
cular canal dehiscence syndrome (Figs. 2 and 3), otosclerosis (Fig. 4),

Fig. 1. SOMATOM Sensation 64 scanner (Siemens, Munich, Germany) equipped with 32 detec-
tors and two sources. Images through the skull base can be obtained in less than 10 seconds. The
volumetric acquisition allows for reconstruction of the data in any plane without loss of resolution.
 ADVANCES IN SKULL BASE IMAGING 441

Fig. 2. The diagnosis of superior semicircular canal dehiscence syndrome remains difficult and
controversial. The clinical history and vestibular testing can suggest the diagnosis. The CT scan
can exclude the disease when there is clearly intact bone over the canal, but inadequate resolu-
tion may not allow thin bone to be appreciated. These images obtained on the Somoton 64 slice
scanner demonstrate the effects of resolution. The coronal images were initially reconstructed
from the processed axial data set rather than the raw data, and image quality was not optimal
(top). The image looks more typical of a coronal reconstruction from an older CT scanner. The
superior canal was considered dehiscent. The raw data were reformatted in the sagittal oblique
orientation, however, and there is clearly bone over the entire canal (bottom). Surgical repair is
clearly not indicated in this patient.

ossicular chain abnormalities (Fig. 5), labyrinthine ossification, cochlear im-

plant location, and inner ear malformations (Fig. 6) are just a few areas that
have benefited from improved resolution [6,7].

CT angiography
CT angiography can be performed on multidetector CT scanners as
a noninvasive means to obtain information concerning the skull base arte-
rial anatomy [8]. The technique can be useful for identifying an aberrant ca-
rotid artery or assessing vascular malformations or the interface between
tumors and arterial vasculature. Contrast is given during image acquisition
and the image viewing software is used to subtract out bone and other struc-
tures to allow isolated views of the arteries. The high quality of these images
often obviates the need for a formal angiogram.
442 DRISCOLL & LANE

Fig. 3. Superior canal dehiscence syndrome: Sagittal oblique reformatted images demonstrate
a normal right canal (top) and a left superior canal dehiscence. The ability to reformat in the
plane of the canal reduces the likelihood of an errant diagnosis.

Fig. 4. Axial multidetector CT images obtained on a 64-slice scanner clearly demonstrate an

otosclerotic focus classic for fenestral otosclerosis. Portions of the stapes superstructure can
be seen. Improved CT resolution allows for preoperative diagnosis of otosclerosis in most pa-
tients with this disease when hearing loss has progressed to the point at which they are surgical
candidates.
 ADVANCES IN SKULL BASE IMAGING 443

Fig. 5. Sagittal oblique reformat of a right temporal bone demonstraties a normal endolym-
phatic duct (black arrow). Typically the diagnosis of enlarged vestibular aqueduct syndrome
is made based on axial images. The sagittal oblique image orientation provides a more complete
view of the course of the duct compared with standard axial images, particularly the entrance of
the duct into the vestibule. An abnormal stapes and incus configuration is appreciated (white
arrow), and intraoperatively the patient was noted to have a malformation of the long process
of the incus and stapes superstructure.

Office-based CT scanners are becoming increasingly popular and offer the

advantage of convenience for the patient, perhaps obviating the need for
a return visit. Image quality is not as good as the latest generation standard
scanners but is certainly adequate for some clinical situations.

Rotational tomography
One limitation of conventional CT is the artifact caused by metallic im-
plants, such as a cochlear implant, stapes prosthesis, or other ossicular pros-
thesis. Rotational tomography is a technique that reduces the metallic
artifact and allows for more precise identification of prosthesis location
[9]. It uses equipment typically used for angiography and is widely available.
The DynaCT capable angiography unit has a rotating C-arm that ac-
quires images (Fig. 7). Slice thickness and voxel size are 0.4 mm, and images
are acquired in approximately 5 to 20 seconds, depending on the number of
projections. Because data are volumetric, they can be reformatted and pro-
cessed in the same manner as data acquired with a multislice CT scanner.
Another potential advantage of this technique is a reduced radiation expo-
sured10 to 15 mGy compared with 20 to 60 mGy for conventional CT [9].
Although the latest CT technology demonstrates less metallic artifact, rota-
tional tomography may result in more sharply defined prosthesis location.
This clinical technique is being used in some centers after cochlear implan-
tation, but more experience is needed to define its role compared with con-
ventional CT. Both technologies are moving closer together and are not
dissimilar beyond the physical structure of the device. Cadaver and tempo-
ral bone studies suggest that it may be useful in the evaluation of ossicular
prosthesis, but more clinical experience is needed.
444 DRISCOLL & LANE

Fig. 6. Multidetector CT demonstrates an enlarged vestibular aqueduct malformation in the

sagittal oblique (A) and axial (B) orientations. Some vestibular aqueduct malformations seem
to have a large connection from the endolymphatic sac into the inner ear, whereas in other cases
the duct narrows considerably just at this junction. Further clinical correlation is needed to as-
certain if a wider opening is related to a higher risk of hearing loss, dizziness, or intraoperative
cerebrospinal fluid leak, a potential complication of cochlear implantation.

Fig. 7. Axiom Artis dTA with syngo DynaCT (Siemens, Germany, Munich). The rotational
arm and flat panel detector are used to acquire images in 10 to 20 seconds. The standard slice
thickness is 0.4 mm. After 3 to 5 minutes of processing, the images are available for review and
can be processed further or manipulated much like conventional CT.
 ADVANCES IN SKULL BASE IMAGING 445

MRI
MRI advances relevant to imaging the skull base are being made primar-
ily along three fronts: magnet strength, scanning protocols, and coil
development.

Magnet strength
Currently, the most widely available magnet strength is 1.5 T, with many
institutions having one or more 3-T magnets (Fig. 8). Higher strength mag-
nets offer several potential advantages, including improved resolution, in-
creased signal-to-noise ratio, and faster scanning times. Higher strength
magnets also can create more problems with certain artifacts, so a stronger
magnet does not always yield better images (Fig. 9). Higher strength mag-
nets also have the potential to cause tissue injury caused by heating. Current
government regulations limit exposure to the radiofrequency energy gener-
ated by the MRI scanner. Depending on the scanning protocol, these limits
could be reached in high field strength magnets.

Scanning protocols
From a clinician’s standpoint there seems to be a never-ending number
of scanning protocols. We are facing an evolving and expanding list of

Fig. 8. GE Signa 3T MRI scanner (GE Healthcare, Chalfont, St. Giles, UK). Large patients
and patients with claustrophobia may not be able to be accommodated or tolerate the narrow
bore of high-strength MRI scanner.
446 DRISCOLL & LANE

Fig. 9. High-resolution T2 coronal images obtained on a 3T MRI in a patient with narrow

internal auditory canals. The images illustrate extensive artifacts (arrows) that render the
scan essentially useless. These sorts of artifacts can be reduced greatly by altering scanning
sequence parameters. Not only do scanners of different magnet strengths require unique scan-
ning protocols but also each individual magnet can require tweaking of protocols to maximize
performance.

protocols (eg, CISS, FIESTA, Flair, FSE T2, diffusion-weighted images,

Turbo spin echo). The days of simply sorting through T1, T2, and postcon-
trast images is gone. It is becoming more difficult to recognize the specific
type of scan and recall the particular imaging characteristics of different tis-
sues for the sequence. Increasing the confusion is the fact that some of these
protocols are proprietary names.
The physics behind the various protocols are exceedingly complex, and at
our institution we have several physicists who work full time tweaking
protocols and developing coils to maximize performance. It is beyond the
scope of this article to delve into the physics. Cunningham and colleagues
[10] recently summarized many of the issues related to high strength
magnets.
Refinement of high-resolution T2 images (Fiesta sequence) has been help-
ful in evaluating inner ear structure, the status of the auditory nerve, precise
location of a small vestibular schwannoma, and delineation of the vascula-
ture in the posterior fossa. Diffusion-weighted images help to distinguish an
arachnoid cyst from an epidermoid cyst; however, many diagnostic chal-
lenges still remain. For example, we can routinely visualize the spiral lamina
but are not yet able to appreciate Reissner’s membrane (Figs. 10–15).
Creative manipulation of MRI technology allows for excellent visualiza-
tion of the arterial and venous vasculature. For example, MRI venography
is performed without contrast using a time-of-flight technique. The veins
show up as hyperintense, which allows for identification of venous occlu-
sion, malformations, and some dural arteriovenous fistulas. Similar to CT
angiography, the phenomenal images of the arterial and venous systems
have drastically reduced the number of traditional angiograms performed.
 ADVANCES IN SKULL BASE IMAGING 447

Fig. 10. Sagittal oblique 3T MRI (Fiesta protocol) image of the right internal auditory canal
shows normal cochlear, facial, and vestibular nerve bundles. Confirming the presence of an au-
ditory nerve is a critical step before cochlear implantation.

Coil development
Standard head coils provide adequate images through the skull base. Tra-
ditional surface coils provide exquisite detail close to the scalp (1–5 cm), but
the signal degrades beyond this depth. Combining a surface coil with a stan-
dard head coil (hybrid phased array coil) has been shown to improve the
spatial resolution in the internal auditory canal (Fig. 16) [11].

Nuclear medicine imaging

Nuclear medicine modalities use radioligands that either follow metabolic
pathways or interact with specific cellular receptors [12]. This property al-
lows for functional imaging of physiologic processes. Known physiologic
characteristics of tumors can be leveraged to identify tumor location and
extent of disease. The number of radioligands is expanding, and similar to
MRI sequences it is getting complex. Close cooperation with your radiolo-
gist helps with determining the best study for the clinical situation.
Functional imaging is performed by injecting a radioligand with a short
half-life followed by imaging within minutes or hours. The time from
injection until scanning and the total number of scans acquired depends
on the specific ligand and pathology. Although the radiation exposure
is low, this advantage is somewhat offset by the high cost of producing
the radioligand compounds, the specific equipment required, and the total
448 DRISCOLL & LANE

Fig. 11. An axial MRI image (Fiesta protocol) at the level of the internal auditory canal. Even
with the benefit of multiple images through the area, it can be difficultdor impossibledto estab-
lish the presence or absence of the auditory nerve. On the right, only a single nerve bundle is vi-
sualized, and in this patient with normal facial nerve function there is likely complete agenesis of
the auditory nerve (A). Auditory brainstem response testing reveals a pattern consistent with au-
ditory neuropathy, a present cochlear microphonic consistent with intact outer hair cell function,
and otherwise absent waveforms. The sagittal oblique reconstructions of the left internal audi-
tory canal seem to show an atretic auditory nerve and normal facial and vestibular nerves (B).

Fig. 12. High-resolution axial T2 (Fiesta protocol) and postgadolinium T1 images in a patient
with labyrinthitis demonstrate loss of normal fluid signal in the cochlea and vestibule and vari-
able enhancement throughout the labyrinth. Performing MRI on patients with sudden cochlear
and vestibular function may help shed light on the underlying pathophysiology: Is it a neuroni-
tis, hemorrhage, or diffuse inflammatory process?
 ADVANCES IN SKULL BASE IMAGING 449

Fig. 13. These axial T2 images demonstrate the superb resolution possible. The right enlarged en-
dolymphatic sac and vestibular aqueduct malformation are clearly delineated. The spiral lamina
and basilar membrane can routinely be visualized. Reissner’s membrane is the next challenge.

Fig. 14. Axial MRI of patient with enlarged vestibular aqueduct syndrome. Three-dimensional
reconstructions can be created easilt but have not yet found much use clinically.
450 DRISCOLL & LANE

Fig. 15. Axial MRI scan demonstrates a recurrent epidermoid cyst involving Meckel’s cave
with extension into the posterior fossa. The diffusion weighted images help to distinguish cere-
brospinal fluid from recurrent disease.

Fig. 16. The hybrid phased array coil is a combination of a standard head coil and surface coils.
Advances in coil technology are a major factor in improving temporal bone imaging.
 ADVANCES IN SKULL BASE IMAGING 451

time that is takes to perform the examination. The only radiation expo-
sure is from the material injected. Because the scanner records radiation
emanating from the patient, additional images can be obtained without
added risk.
Positron emission tomography (PET) is commonly used to evaluate pa-
tients with squamous cell carcinoma of the head and neck, identify the pri-
mary lesion, assess nodal status, and evaluate for evidence of metastatic
disease. The nonspecific fluorodeoxyglucose ([18F] FDG) is most beneficial
in assessing malignant tumors, particularly dedifferentiated or rapidly grow-
ing tumors. Because all cells that have high metabolic activity take up [18F]
FDG, it is a nonspecific, but sensitive, test. Tumors approximately R1 cm
are identified on a PET scan, whereas smaller tumors may be missed. Prior
surgery or radiation may make identification of persistent or recurrent tu-
mor more difficult. Serial imaging may be needed to differentiate recurrent
disease from posttreatment inflammatory changes.
In some tumor types, using a more specific compound is beneficial. For
example, metaiodobenzylguanidine (MIBG) is an aralkylguanidine similar
to norepinephrine and is well suited for imaging paragangliomas (Figs. 17
and 18). Confusingly, there are already two different compounds available,
iodine I 131 MIBG and the more recently introduced iodine I 123 MIBG,
that are showing higher sensitivity, better imaging quality, and offers a lower
radiation exposure [12].
Some paragangliomas have somatostatin receptors. Octreotide, an octa-
peptide analog of somatostatin tagged with indium In 111, has been used to
diagnose and follow these tumors. Schwannomas never express somato-
statin receptors, and this property can be helpful in the differential diagnosis
of a jugular foramen lesion. Unfortunately, meningiomas also can express
somatostatin. Newer octreotide analogs are also being studied.
Skull base osteomyelitis is a challenging clinical entity. Establishing the
diagnosis, extent of disease, and response to therapy is imperfect. Prior
surgery or radiation and host factors (immunocompromised, concurrent
disorders, such as a chronic pain syndrome and chronic otitis media) com-
plicate interpretation of imaging. A testament to this difficulty is the fact
that we continue to rely heavily on the patient’s subjective complaint of pain
as an indicator of disease severity and response to therapy.
The technetium Tc 99m polyphosphate scan demonstrates increased
isotope accumulation in areas of increased blood flow and new bone for-
mation. This finding is a sensitive and specific indicator of an active in-
flammatory (eg, bacterial or fungal infection, vasculitis) or neoplastic
process. Prior surgery or radiation can diminish the specificity. The test
is specific for bone involvement. Another radioligand beneficial for diag-
nosis of skull base inflammation is gallium citrate. It leaks from the blood
vessels into areas of inflammation, including bone or soft tissue. Often the
technetium and gallium scans are obtained initially to assist with diagnosis
and determine extent of disease and then the gallium scan is repeated
452 DRISCOLL & LANE

Fig. 17. Iodine I 123 MIBG whole-body SPECT images show intense tracer uptake in the right
side of the neck extending up to the level of the skull base, consistent with an MIBG avid lesion.
Physiologic uptake is visualized in the salivary glands, liver, spleen, and gastrointestinal tract.
On the right is a collection of coronal ‘‘slices’’ obtained by a rotating gamma detector. Although
the areas of uptake can be appreciated, the exact site of the lesion and relationship to surround-
ing anatomy is obscure. If better localization is required, the images can be fused with a CT.

during therapy to help assess response. Premature cessation of treatment is

a common cause of treatment failure. These imaging modalities may
underestimate the extent and severity of disease in immunocompromised
patients or individuals with poor blood supply to the area.
One limitation of a PET scan or other nuclear medicine scan is the lack of
definition of surrounding anatomy. Fusing the PET scan data with a CT or
MRI allows for more precise localization of the pathology, which is espe-
cially helpful for performing directed biopsies. Combined PET/CT scanners
greatly facilitate obtaining both types of imaging expeditiously.
The field of nuclear medicine continues to evolve rapidly as experience is
gained with an ever-increasing number of radioligands. Close cooperation
with a radiologist results in the best choice of imaging strategy.

Summary
Advances in imaging technology are improving our diagnostic accuracy
and understanding of some disease processes. Multidetector CT provides
 ADVANCES IN SKULL BASE IMAGING 453

Fig. 18. Axial and coronal postgadolinium MRI images from the same patient presented in
Fig. 17 depict a large enhancing lesion that extends from the right neck up to the skull base
with anterior displacement of the carotid artery. This catecholamines-secreting vagal nerve par-
aganglioma has been resected, but because of the extent of disease there is some risk of recur-
rence. Identifying tumor recurrence at the skull can be difficult because of postoperative changes
and graft material. Because this tumor showed avid uptake of iodine I 123 MIBG, it may be
a more sensitive test for follow-up. This test has the added benefit of screening for other poten-
tial distant tumors, such as a pheochromocytoma.

higher quality images in less time with reduced radiation exposure. Simi-
larly, current MRI scanners have improved resolution. The field of nuclear
medicine is expanding as our understanding of basic physiologic processes
improves, providing for novel ways to diagnose and follow different patholo-
gies. Combining various imaging modalities (PET/CT) provides the clinician
with better information that enhances diagnosis and treatment planning.
Overuse of advanced imaging techniques is a growing concern. It is im-
perative that we develop evidence-based guidelines to promote the efficient
use of imaging techniques and avoid unnecessary testing.

References
[1] Leong J, Batra P, Citardi M. CT-MR image fusion for the management of skull base lesions.
Otolaryngol Head Neck Surg 2006;134:868–76.
[2] McCabe K, Rubinstein D. Advances in head and neck imaging. Otolaryngol Clin North Am
2005;38:307–19.
[3] Glenn L. Innovations in neuroimaging of skull base pathology. Otolaryngol Clin North Am
2005;38:613–29.
[4] McCollough C. Standardization in CT terminology: a physicist’s perspective. Radiology
2006;241:661–2.
[5] Karino S, Hayashi N, Aoki S, et al. New method of using reconstructed images for assess-
ment of patency of intracochlear spaces for cochlear implant candidates. Laryngoscope
2004;114:1253–8.
454 DRISCOLL & LANE

[6] Chan C, Saunders D, Chong W, et al. Advancement in post-meningitic lateral semicircular

canal labyrinthitis ossificans. J Laryngol Otol 2006;23:1–5.
[7] Young N, Hughes C, Byrd S, et al. Postmeningitic ossification in pediatric cochlear implan-
tation. Otolaryngol Head Neck Surg 2000;122(2):183–8.
[8] Vrtiska T, Fletcher J, McCollough C. State-of-the-art imaging with 64-channel multidetec-
tor CT angiography. Perspect Vasc Surg Endovasc Ther 2005;17(1):3–10.
[9] Offergeld C, Kromeier J, Ashendorff A, et al. Rotational tomography of the normal and
reconstructed middle ear in temporal bones: an experimental study. Eur Arch Otorhinolaryn-
gol 2006;264(4):345–51.
[10] Cunningham P, Law M, Schweitzer M, et al. High-field MRI. Orthop Clin North Am 2006;
37:321–9.
[11] Kocharian A, Lane J, Bernstein M, et al. Hybrid phased array for improved internal audi-
tory canal imaging at 3.0-T MR. J Magn Reson Imaging 2002;16:300–4.
[12] Ilias I, Shulkin B, Pacak K. New functional imaging modalities for chromaffin tumors,
neuroblastomas and ganglioneuromas. Trends Endocrinol Metab 2005;16(2):66–72.