3D CT of the Temporal Bone: Anatomy and Pathology

Girish M. Fatterpekar, MD Amish Doshi, MD Bradley N. Delman, MD Department of Radiology Mount Sinai Medical Center New York, NY Corresponding author: Girish Fatterpekar, MD Department of Radiology Mount Sinai Medical Center One Gustave L. Levy Place New York, NY 10029 Email: girif@hotmail.com Phone: (212) 241-1497

Abstract

he temporal bone includes many small structures within a very compact region, some measuring well under 1 mm. Their multispatial orientation makes it difficult to conceptualize the intricate three-dimensional (3D) relationship of these structures based on conventional two-dimensional (2D) imaging. The purpose of this study is to demonstrate the role played by 3D CT to better understand the complex anatomy of the temporal bone. In addition, select pathological cases are featured to highlight the role played by 3D CT to further characterize disease entities not fully evaluated by conventional two-dimensional imaging. Introduction Conventional two-dimensional imaging in the axial and coronal planes is routinely used to display the anatomy and pathology of the temporal bone. Although the trained head and neck radiologist may easily interpret such studies, the general radiologist may find it difficult when it comes to interpretation

of such scans. Also, there is a long learning curve when one starts to interpret temporal bone studies. It is the inherent multi-spatial orientation of several small structures within a compact region that makes the anatomy of the temporal bone so complex. However, we believe that 3D reconstructions of the temporal bone can help one better understand temporal bone anatomy. Such volume-rendered 3D images can be sectioned in any plane and rotated in space to better conceptualize the underlying anatomy. The purpose of this article is therefore to demonstrate the role played by 3D CT to simplify the complex anatomy of the temporal bone. In addition, using select pathological cases, we demonstrate the role played by 3D CT in further characterizing disease entities not well evaluated by conventional 2D imaging. We will first discuss the technique essential toward obtaining good 3D CT images before proceeding with the actual anatomy and pathology of the temporal bone, since the quality of reconstruction depends on optimal raw data.

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Technique To obtain good 3D reconstructions, it is absolutely essential to obtain the thinnest possible overlapping slices. We obtained our temporal bone scans using 0.75 mm collimation with a 0.75 mm slice thickness at 120 kVp, 200 mAs, a pitch of 0.8, and a 15 cm field of view with a matrix size of 512 x 512. The initial data sets were then reconstructed at 0.1 mm intervals. Each scan was obtained on a 16-slice spiral CT scanner (Somatom Sensation 16; Siemens Medical Solutions, Malvern, Pennsylvania). While obtaining 3D reconstructions, it is important to remember that any amount of gantry tilt results in distortion of the reconstructed 3D image. All studies were therefore obtained with the neck flexed such that the infra-orbito-meatal line was parallel to the scanning plane when obtaining images in the axial plane. A zero degree gantry tilt when obtaining such images ensured no distortion of the post-processed 3D images. Volume-rendered 3D images were generated from the original 2D data with different soft tissue and bone

algorithms using the TeraRecon Aquarius Workstation v3.3 (TeraRecon, Inc. San Mateo, California). These post-processed images were subsequently rotated in space and sectioned in various planes using the built-in cut-plane tool allowing optimal 3D display of the individual structures of the temporal bone. A direct 2D to 3D correlate of the raw data set in axial and coronal planes was also obtained to highlight the role played by 3D CT to evaluate the temporal bone. Additionally, the study also demonstrates the role played by 3D CT to provide information that is complementary to conventional 2D imaging, when evaluating pathology of the temporal bone. Normal Temporal Bone Anatomy The temporal bone essentially consists of the external ear including the pinna and the external auditory canal, the middle ear including the ossicles, and the inner ear comprising largely of the cochlea, vestibule and the semicircular canals (Figure 1).

Figure 1: Volume-rendered 3D CT image of the auditory system. EAC: External auditory canal. The box in the bottom right corner of each figure represents the orientation of the reconstructed image in a threedimensional plane. Thus, A denotes anterior, P: posterior, R: right side, L: left, H: head end, and F: the foot end

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Figure 2: Volume-rendered 3D CT image of the malleus.

Figure 3: Volume-rendered 3D CT image of the incus.

Middle Ear The middle ear, or tympanic cavity, helps to transmit sound waves from the external auditory canal to the inner ear via the contained ossicles, namely, the malleus, the incus, and the stapes. The malleus, shaped like a hammer, has facets on the posterior surface of the head that provide for articulation with the body of the incus (Figure 2). The neck of the malleus lies inferior to the head and provides attachment to the tensor tympani. The long process, or manubrium, of the malleus provides attachment at its tip to the tympanic membrane (Figure 2). The incus, shaped like a premolar tooth, has facets on the anterior surface of its body that articulate with the head of the malleus (Figure 3). Two diverging processes, the short process directed posterolaterally and the long process directed inferiorly, arise from the body of the incus. The long process of the incus lies posterior and parallel to the manubrium of the malleus (Figure 4). It bends medially to end in a rounded projection, the lenticular process, which articulates with the head of the stapes (Figure 3).

The stapes, shaped like a stirrup, has a head that articulates with the lenticular process of the incus (Figure 5). The neck of the stapes lies inferior to the head and provides attachment to the stapedius muscle. Two diverging processes known as the crura arise from the neck. They are connected at their inferior ends by the footplate (Figure 5). The footplate sits on the oval window allowing for transmission of sound waves to the inner ear (Figure 6).

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Figure 4: Volume-rendered 3D CT image of the malleus and incus illustrating that the long process of the incus lies parallel and posterior to the manubrium of the malleus.

Figure 5: Volume-rendered 3D CT image of the stapes.

Figure 6A

Figure 6B

Figure 6: A) (Left image) Volume-rendered 3D CT image shows the relative positions of the malleus, incus, oval window and the inner ear. B) (Right image) Widening the window level reveals the stapes sitting on the oval window, thereby allowing transmission of sound waves to the inner ear.

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Figure 9: Volume-rendered 3D CT image of the cochlea, having dissected open the overlying bony wall of the cochlea to expose the osseous spiral lamina. Figure 7: Volume-rendered 3D CT image of the inner ear.

Inner Ear The inner ear, primarily responsible for balance and hearing, consists of the cochlea, vestibule, and the semicircular canals (Figure 7). The cochlea, shaped like a conical snail shell, winds around its central axis for slightly more than 2 turns as it spirals toward the apex, known as cupola (Figure 8). A fine bony partition called the osseous spiral lamina divides the bony canal of the cochlea into an upper passage, the scala vestibuli, and a lower passage, the scala tympani (Figure 9). The vestibule is continuous anteriorly with the cochlea and posteriorly with the semicircular canals

(Figure 7). It contains the utricle and the saccule, parts of the membranous labyrinth that are primarily concerned with balance. The three semicircular canals, superior, posterior, and lateral are nearly orthogonal to each other. This configuration helps in detection of angular acceleration in any of the three dimensions. Each of the canals makes about two thirds of a circle. Of the three semicircular canals, the superior and posterior semicircular canals join to form a common limb, called the common crus (Figure 10).

Figure 8: Volume-rendered 3D CT image of the cochlea.

Figure 10: Volume-rendered 3D CT image of the semicircular canals.

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Osseous Canals of the Facial and Vestibulocochlear Nerves The internal auditory canal (IAC) contains the facial and the vestibulocochlear nerves. At the lateral end of the IAC, known as the fundus, the facial nerve lies anterosuperior, the cochlear nerve anteroinferior, and the superior and inferior vestibular nerves posterosuperior and posteroinferior respectively. As they exit the IAC, each of these nerves lies within its own bony canal. Using 3D CT, it is possible to view the individual canals for these nerves (Figure 11 and 12). With careful manual dissection of the overlying structures, it is also possible to follow the winding course of the facial nerve housed within its own bony canal as it traverses the temporal bone (Figure 13). Having exhibited the individual structures of the temporal bone, we now display serial 3D images of the temporal bone in both the axial and coronal planes, comparing each reconstructed 3D image to its corresponding 2D image (Figure 14 and 15). We believe that once the three-dimensional configuration of the individual structure is understood and the various components of the temporal bone have been examined as a composite, interpreting serial images in the axial and coronal planes becomes a lot easier.

Figure 12: Volume-rendered 3D CT image of the temporal bone showing the canal for the cochlear nerve.

Two-dimensional images represent these various structures as lines and circles of varying dimensions. Using corresponding 3D CT images of varying thicknesses helps to improve the perception and assessment of the temporal bone (Figure 14 and 15).

Figure 11: Volume-rendered 3D CT image of the temporal bone revealing the dissected (cut) first portion of the facial nerve canal and the canal for the superior vestibular nerve.

Figure 13: Volume-rendered 3D CT image of the canal for the facial nerve as it traverses the temporal bone. The facial nerve exits the anterosuperior aspect of the internal auditory canal as the labyrinthine segment housed within its own bony channel, the fallopian canal. It then makes a hairpin turn (the anterior genu) and courses as the tympanic segment along the medial wall of the tympanic cavity below the lateral semicircular canal. At the posterior genu, it makes another turn and heads vertically down as the mastoid segment to exit the temporal bone at the stylomastoid foramen. The canal for the chorda tympani, a branch of the mastoid segment of the facial nerve, is also present.

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Temporal Bone Pathology Having demonstrated the capability of 3D CT to depict the normal anatomy of the temporal bone, we now highlight its role in evaluating temporal bone pathology.

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Figure 14P
Figure 14: (A P) From inferior to superior, serial 2D and corresponding 3D images of the temporal bone in axial plane. sp: styloid process, smf: stylomastoid foramen, ns: nerve to stapedius, ms: mastoid segment of the facial nerve, ct: chorda tympani, c aqueduct: cochlear aqueduct, V aqueduct: vestibular aqueduct, PSCC: posterior semicircular canal, pg: posterior genu, LSCC: lateral semicircular canal, CN: cochlear nerve, IV: Inferior vestibular nerve, IAC: internal auditory canal, ts: tympanic segment of the facial nerve, SV: superior vestibular nerve, fc: fallopian canal of the facial nerve, ag: anterior genu, SSCC: superior semicircular canal.

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Figure 15: (A O) From anterior to posterior, serial 2D and corresponding 3D coronal plane images of the temporal bone. ag: anterior genu, ts: tympanic segment of the facial nerve, fc: fallopian canal of the facial nerve, CN: cochlear nerve, SV: superior vestibular nerve, SSCC: superior semicircular canal, IAC: internal auditory canal, LSCC: lateral semicircular canal, ms: mastoid segment of the facial nerve, c aqueduct: cochlear aqueduct, smf: stylomastoid foramen, PSCC: posterior semicircular canal, V aqueduct: vestibular aqueduct.

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Illustrated Case 1
Congenital aural atresia

The illustrated case is of an 11-year-old boy with hemifacial microsomia. Although the congenital anomalies were identified on conventional 2D im

ages, this case demonstrates that the multiplanar capabilities of 3D CT reconstructions greatly aid in evaluating the extent of the anomalies (Figure 16).

Figure 16: 11-year-old boy with hemifacial microsomia. (A) 2D and 3D axial and coronal CT images reveal a small tympanic cavity with malformed ossicles (arrow). The stapes is not seen and there is a suggestion of an atretic oval window (curved arrow).

(B) 3D CT volume-rendered images of the bony labyrinth indicate an absent oval window with an atretic round window. A normal inner ear is shown for comparison. Though the malformed ossicles were easily identified, and a suggestion of absent oval window was made on the 2D images, these anomalies were demonstrated more convincingly on the reconstructed 3D images. In addition, the atretic round window was revealed only on the 3D CT reconstructions.

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Illustrated Case 2
Dysplastic semicircular canals

The illustrated case is of a 25-year-old male with bilateral sensorineural hearing loss. The dysplastic lateral semicircular canal is easily recognized with

2D imaging. However, the recognition of the absent common crus is made possible only from the 3D renderings of the inner ear (Figure 17). Such additional information gained helps us better understand the embryology of the temporal bone.

Figure 17: 25-year-old male with bilateral sensorineural hearing loss. (A) (Left images) 2D and 3D axial CT images reveal enlarged, dysplastic lateral semicircular canals bilaterally (curved arrow). (B) (Right images) 2D coronal CT images show segments of the posterior and superior semicircular canals (arrow). Corresponding 3D coronal CT images (thickened to 3 mm reconstructions) reveal an abnormal orientation of the posterior (arrow) and superior semicircular canal (curved arrow) with a suggestion of absent common crus (hatched arrow). (C) (Below) 3D CT reconstructions demonstrate the dysplastic lateral semicircular canals. The common crura are not seen bilaterally. Though an abnormal orientation of the posterior and superior semicircular canals was noted on the axial and coronal 2D scans, the absent common crura could only be identified on the 3D CT reconstructions.

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Illustrated Case 3
Acoustic neuroma

The illustrated case is of a 53-year-old female with known right acoustic neuroma. The ballooning of the internal auditory canal easily establishes the diagnosis of acoustic neuroma on 2D imaging. The presence of normal-sized bony neural canals at the

fundus of the IAC establishes the acoustic neuroma to be purely intracanalicular. This information could be obtained only with the aid of the reconstructed 3D images (Figure 18).

Figure 18: 53-year-old female with known right acoustic neuroma. (A) (Left) 2D and 3D axial CT images reveal a widened right internal auditory canal consistent with the provided diagnosis of right acoustic neuroma. (B) (Below) 3D CT reconstructions clearly show the individual neural canals at the lateral end (fundus) of the IAC. There is no discrepancy in the size of these neural canals on comparison of the two sides. This suggests that the acoustic neuroma is purely intracanalicular and does not extend through the bony neural canals. This information could not be obtained based on the 2D data set alone.

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Illustrated Case 4
Cholesteatoma

The illustrated case is of an 88-year-old male with cholesteatoma. The diagnosis of cholesteatoma is easily established with conventional 2D imaging. However, the extent of the erosive process involving

the basal turn of the cochlea and the round window was made only after a review of the reconstructed 3D images (Figure 19).

Figure 19: 88-year-old male with cholesteatoma. (A) (Left) 2D and 3D axial CT images expose a soft tissue mass in the left tympanic cavity causing erosion of the malleus and incus (arrow). The stapes is not seen in the 2D images but can be seen on the 3 mm thick reconstructed 3D CT (curved arrow). There appears to be erosion into the basal turn of the cochlea (hatched arrow). (B) (Below) 3D CT reconstructions disclose absence of a portion of the basal turn of cochlea, likely from the erosive process of the cholesteatoma. Also, visualization of the other inner ear structures shows that the erosive process extends into the round and oval windows. This was not readily identified when the 2D data set was initially interpreted.

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Conclusion This article illustrates the role played by 3D CT in evaluating anatomy and pathology of the temporal bone. Though there is a learning curve when one starts using the TeraRecon Aquarius Workstation, we have found the software to be extremely user-friendly. Once one becomes familiar with the various keys, the time to generate such 3D images averages about 15 minutes per temporal bone study. We also feel that the superior resolution capability of the TeraRecon software has greatly enhanced the generation of these 3D reconstructions. The authors strongly believe that such volume-rendered 3D reconstructions allow better understanding of the temporal bone anatomy. Also, the complementary information gained while evaluating temporal bone pathology aids greatly in the evaluation of various disease entities. Such information allows for better pre-surgical planning and also aids in our understanding of the embryology of the temporal bone. References
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