Common Otologic Surgical Procedures: Clinical Decision-Making Pearls and the Role of Imaging

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Key points

  • Assessment of middle ear ossicles, facial nerve course, position of the sigmoid, and integrity of tegmen and semicircular canals are important roadmaps preoperatively.

  • Identifying aberrancies in the course of facial nerve is a critical component to preoperative planning and counseling for any patient undergoing middle ear surgery.

  • Every temporal bone is unique. As such, radiographic imaging provides the surgeon with a road map on what to expect intraoperatively.

Introduction: a Surgeon’s perspective

Neuro-otologists rely on the expertise and judgment of a skilled neuroradiologist to identify radiographic abnormalities in the complicated regional anatomy of the temporal bone and middle and posterior fossa, and more importantly, to alert the surgeon to potential operative pitfalls. This article highlights some of the common otologic surgical procedures that stress this important dynamic.

Operative decision-making in neuro-otology is based on a triad of the patient’s history, physical

Tympanic membrane perforation and tympanoplasty

A TM perforation causes hearing loss by disrupting the conversion of acoustic sound energy entering the EAC into mechanical energy that normally occurs with the movement of the middle ear ossicles, which are connected to the TM. The goals of preoperative assessment and operative intervention are to address the perforation with a successful hearing outcome. CT of the temporal bone showing a poorly pneumatized mastoid or a mastoid cavity that is poorly aerated is reflective of underlying

Chronic otitis media

Chronic otitis media is a common finding among patients presenting to an otolaryngologist. Radiographically, this condition may manifest as opacification or mucosal thickening of the middle ear or mastoid air cells without osseous erosion or coalescence. The scutum is typically not blunted, and the tegmen intact (Fig. 3). Radiographic finding of chronic otitis media is not a surgical indication in the absence of other clinical symptoms or findings.Symptoms of Chronic Otitis Media

  1. Presence of a TM perforation with

    • Hearing Loss

Cholesteatoma

Cholesteatoma is a benign squamous epithelial proliferation that is locally destructive with the potential to erode delicate bony structures within the middle ear (ossicles, fallopian canal, scutum, tegmen epitympanum, otic bone), inner ear structures (cochlea and semicircular canals), and extend into the mastoid cavity or skull base (Fig. 4). It is congenital, primary acquired (typically found in the pars flaccida or the posterosuperior quadrant of the TM), or secondary acquired (located

Hearing loss

The radiographic evaluation of a patient with hearing loss is broad, with special distinction to be made between congenital versus acquired. Hearing loss is categorized into conductive, sensorineural, or mixed as determined by the patient’s audiogram, and this information is critical to appropriate analysis of radiographic findings that may otherwise be nonspecific.Congenital Causes of Hearing Loss (Fig. 7)

  1. Mondini malformation

  2. Absent or narrow IAC

  3. Incomplete partition

  4. Enlarged vestibular aqueduct

  5. Congenital fixed stapes footplate

  6. Atresia

Cerebrospinal fluid leak and tegmen dehiscence

Defects of the lateral skull base, also known as tegmen dehiscences, are a diagnostic and management quandary for clinicians. These defects may result in herniation of meninges and cerebral tissue with resultant meningocele or encephalocele, respectively (Fig. 10). If the dura mater has also been violated, leakage of CSF from the subarachnoid space to the sinonasal or tympanic cavities can develop. The identification and repair of these communications is paramount because they can result in

Superior semicircular canal dehiscence

The phenomenon of SSCD was described in 1998 as sound- or pressure-induced vertigo in the setting of dehiscence of the bone separating the superior semicircular canal from the MCF.14 Patients are usually of similar demographic to those with spontaneous CSF leaks, and some have hypothesized that these might be different presentations of the same pathology.15 Although many patients have both hearing loss and vertigo, they may also present with only one of the findings.Clinical Presentation of Superior Semicircular Canal Dehiscence

  1. Autophony

  2. Tullio phenomenon:

Acoustic neuroma

Vestibular schwannomas are benign neoplasms generally arising from the vestibular divisions of cranial nerve VIII. Although some of these tumors, particularly those associated with neurofibromatosis 2, are aggressive and can grow quickly, most of these tumors are slow growing and some may not have clinically significant growth at all. For this reason, patient symptomatology and imaging findings of interval growth are important in the decision to intervene. Furthermore, intervention takes the

Vascular malformations of the temporal bone

The differential diagnosis of pulsatile tinnitus is an extensive one because multiple anomalies can result in this symptom. The types of pulsatile tinnitus are divided based on whether they are synchronous with arterial or venous pulsations. Table 1 provides an overview of the different causes of these types of pulsatile tinnitus. For the purposes of this review, the focus is glomus tumors and carotid diverticulum.

Concluding remarks

Anatomic understanding of the temporal bone is essential for appropriate diagnosis of otologic and neuro-otologic processes. The role of the ear organs as constituents of the lateral skull base is an important concept in understanding the interplay between otologic and neurosurgical pathologies. Often, lesions of the cerebellopontine angle or internal auditory canal may present with hearing loss, tinnitus, or imbalance, whereas complicated otologic processes may result in meningitis or dural

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