The Temporal Bone


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Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

John I. Lane, MD Mayo Clinic ASNR 2016

No Disclosures

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection



Acute vertigo



Sudden hearing loss



Facial paralysis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection (EAC) Malignant External Otitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Malignant External Otitis MDCT Axial

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Malignant External Otitis MDCT Axial

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection (Middle Ear) Coalescent Mastoiditis Labyrinthitis Meningitis / cerebral abscess Dural venous thrombosis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Coalescent Mastoiditis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Mastoiditis + subperiosteal abcess

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Mastoiditis + subperiosteal abcess

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Courtesy of Dave DeLone. MD

Mastoiditis + Bezold’s abcess

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Labyrinthitis / Ossificans

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Subdural Sequestrum Abscess Labyrinthine

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Cerebral Abscess

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Complication of acute otitis media

Dural Venous Thrombosis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone CSF leak / Encephalocele

O

Recurrent Meningitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone CSF leak / Encephalocele

Recurrent Meningitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Inflammatory Mimics

Langerhans Cell Histiocytosis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection



Acute vertigo



Sudden hearing loss



Facial paralysis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection



Acute vertigo



Sudden hearing loss



Facial paralysis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Vertebrobasilar ischemia Meniere’s (15 min – 24 hours) Vestibular Neuritis (daysweeks) Vestibulocochlear Migraine Perilymph Fistula BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Mandatory imaging if: Focal neurologic deficit Gait or truncal ataxia Positional nystagmus Intact Head Impulse Test

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Head Impulse Test

Normal Vestibular Response H

Peripheral Vestibular Deficit

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Labyrinthine Artery (AICA)

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Posterior Circulation Stroke

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Vertebral Dissection

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Dural Arteriovenous Fistula

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Vertebrobasilar ischemia Meniere’s (15 min – 24 hours) Vestibular Neuritis (daysweeks) Vestibulocochlear Migraine Perilymph Fistula BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Menieres Endolymphatic Hydrops

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Vertebrobasilar ischemia Meniere’s (15 min – 24 hours) Vestibular Neuritis (daysweeks) Vestibulocochlear Migraine Perilymph Fistula BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Vestibular Neuritis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Vertebrobasilar ischemia Meniere’s (15 min – 24 hours) Vestibular Neuritis (daysweeks) Vestibulocochlear Migraine Perilymph Fistula BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Vertebrobasilar ischemia Meniere’s (15 min – 24 hours) Vestibular Neuritis (daysweeks) Vestibulocochlear Migraine Perilymph Fistula BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Perilymph Fistula

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo Vertebrobasilar ischemia Meniere’s (15 min – 24 hours) Vestibular Neuritis (daysweeks) Vestibulocochlear Migraine Perilymph Fistula BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo: BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo: BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo: BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo: BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Acute vertigo: BPPV

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection



Acute vertigo



Sudden hearing loss



Facial paralysis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden hearing loss Conductive (CHL) Sensorineural (SNHL)

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden hearing loss Conductive (CHL) Sensorineural (SNHL)

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Manubrium of Malleus Fx

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Vertebrobasilar ischemia Meniere’s Labyrinthine fistula Viral / auto-immune labyrinthitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Vertebrobasilar ischemia Meniere’s Labyrinthine fistula Viral / auto-immune labyrinthitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Viral Labyrinthitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Autoimmune Labyrinthitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Susac’s Syndrome

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Labyrinthine hemorrhage IAC/CPA tumor Intracranial hypotension Vestibulocochlear migraine

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Labyrinthine hemorrhage IAC/CPA tumor Intracranial hypotension Vestibulocochlear migraine

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Labyrinthine hemorrhage IAC/CPA tumor Intracranial hypotension Vestibulocochlear migraine

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

CPA/IAC Mengioma

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Foreign Body Granuloma

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Labyrinthine hemorrhage IAC/CPA tumor Intracranial hypotension Vestibulocochlear migraine

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Intracranial Hypotension

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Superficial Siderosis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Sudden SNHL / Tinnitus Labyrinthine hemorrhage IAC/CPA tumor Intracranial hypotension Vestibulocochlear migraine

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Intracranial Hypotension

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection



Acute vertigo



Sudden hearing loss



Facial paralysis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone CN VII: Differentiating central from peripheral weakness

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone House – Brackman Scale • • • • • •

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Normal Slightly weak Obviously weak Disfiguringly weak Minimal movement No movement

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Facial paralysis Bell’s Palsy Ramsey Hunt (H. Zoster Oticus)

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Bell’s Palsy Bell’s Palsy

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Acute Labyrinthitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Tuberculous Meningitis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Neurosarcoidosis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Mastoiditis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Hemangioma Benoit M, Otolaryngol Head Neck Surg. 2010 Jan;142(1):108-14. Facial nerve hemangiomas: vascular tumors or malformations?

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

Longitudinal Fx: CN 7 Palsy

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone Non-traumatic Otologic Emergencies •

Infection



Acute vertigo



Sudden hearing loss



Facial paralysis

Non-traumatic Emergency Head and Neck Imaging:

The Temporal Bone

John I. Lane, MD Mayo Clinic ASNR 2016

Acute Orbit Abnormalities 2016

May 21

Red eye Acute vision loss Ophthalmoplegia

Eye and Orbit

The Red Eye Infection vs. Pseudotumor

? Proptosis

“Dirty fat” Dr. John S. Kennerdell

Infection Inflammation (NSOI) Hemorrhage Venous congestion Lymphoid lesion

Ali Sepahdari

Preseptal Postseptal

Preseptal Skin involved spared?

Eye and Orbit

Post septal Infection vs. Pseudotumor

? Proptosis

Is it infection? Where from? Sinuses Teeth Skin Lacrimal sac

Sinus?

Periorbital collection (abscess)

“Dirty Fat”

Orbital cellulitis

Source ?

Teeth

Periodontal membrane Lamina dura

Caries

Lacrimal sac

Shunts and implants

Ahmed shunt Scleral band

Other complications

Nonspecific Orbital Inflammation (NSOI) (Idiopathic orbital inflammation, Orbital inflammatory syndrome, Orbital pseudotumor) Diagnosis of exclusion

Eye Muscles Nerve Lacrimal Fat

Periscleritis Myositis Perineuritis (not optic neuritis) Dacryoadenitis Diffuse

Periscleritis/ Perineuritis

Perineuritis

Myositis

Dacroadenitis

Diffuse Ali Sepahdari Pakdaman MN, Sepahdari AR, Elkhamary SM. Orbital inflammatory disease: Pictorial review and differential diagnosis. World journal of radiology 2014; 6:106-115

Are we done yet??? Exclude: endophthalmitis fungus fistula cav sinus thrombosis vasc malf hemorrhage

Endophthalmitis

s

Invasive fungal disease

“Dirty fat” / proptosis Exclude: 1. Carotid cavernous fistula 2. Cavernous sinus thrombosis

“Dirty fat” / proptosis Exclude: 1. Carotid cavernous fistula 2. Cavernous sinus thrombosis

Acute Vision loss optic neuritis vs meningioma compression ischemic AAION NAION Retinal artery occlusion

Optic neuritis

Meningioma

Ischemic optic neuropathy (ION) Anterior AION Posterior PION Arteritic Non arteritic Retinal artery

Mod from Dragos Catalin Jianu and Silviana Nina Jianu (2013). Giant Cell Arteritis and Arteritic Anterior Ischemic Optic Neuropathies, Updates in the Diagnosis and Treatment of Vasculitis, Prof. Lazaros Sakkas (Ed.), InTech, http://www.intechopen.com/books/updates-in-the-diagnosis-andtreatment-of-vasculitis/giant-cell-arteritis-and-arteritic-anterior-ischemic-optic-neuropathies

Diffusion ?