Injury retrotympanic white, blue and red. Clinicalradiological correlation Poster No.: C-0211 Congress: ECR 2013 Type: Educational Exhibit Authors: R. Esteban Saiz, R. Castañón Martinez, M. Rebolledo Vicente, I. bañales arnaiz, R. Virués Vázquez, M. I. Castro Canelada; Mérida ( BADAJOZ)/ES Keywords: DOI: Ear / Nose / Throat 10.1594/ecr2013/C-0211 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 23
Learning objectives Review the set of diseases and their complications, affecting the middle ear in adults. Revise radiological signs of different types of injuries and their usefulness to diagnosis. Highlight the clinical findings and the different imaging techniques that allow a correct differential diagnosis. Background Otoscopic findings provide the radiologist and clinician with very useful information that allows the diagnosis of lesions affecting the middle ear. Based on the integrity of the tympanic membrane, tympanic rupture location, color and location of the lesion retrotympanic (fig1): 1- whitish lesions (cholesteatomas, schwannomas). 2- red lesions (paragangliomas, glomus tympanic glomus jugulare, aberrant internal carotid artery). 3- blue injuries (cholesterol granulomas, chronic otitis media with hemorrhage, dehiscent jugular bulb). Imaging techniques (MDCT and MRI) will enable the localization and identification of these lesions, determine their extent and evaluate possible complications. Images for this section: Page 2 of 23
Fig. 1: OTOSCOPIAS IMAGES Page 3 of 23
Imaging findings OR Procedure details Cholesteatoma Cholesteatoma is a non-neoplastic lesion of the temporal bone. The middle ear cholesteatoma occurs most often in children under 50 years. Macroscopically is a well-circumscribed mass whitish or gray (fig 1). Histologically comprises an outer matrix formed by keratinized squamous epithelium produces abundant keratin lamellae that accumulate inside the cyst. The matrix is surrounded by an outermost layer with collagen and elastin fibers, inflammatory cells, called granulation tissue "perimatriz". They are classified based on their pathogenesis as congenital or acquired. By location they are classified as: - The pars flaccid Cholesteatoma: located in the upper third of the tympanic membrane Prussak space filling, initially in lateral position to the ossicular chain (Fig. 2, 3, 4). - The pars tense Cholesteatoma: develop from a defect in the lower 2/3 of the tympanic mb initially located medially to the ossicular chain (Fig. 5, 6). The middle ear cholesteatoma may present with the following clinical signs: discharge from the ear, hearing loss, facial paralysis, vertigo... Rarer otalgia, tinnitus or headache. High resolution CT is the technique of choice for the study of middle ear cholesteatoma. The most common findings are: - Lesion with soft tissue density in the middle ear. - Retraction of the tympanic membrane. - Escutum effacement. Page 4 of 23
- Erosion of tegmen timpani, destruction of the ossicular chain. MRIprovides additional information that can contribute to the characterization of cholesteatoma. They have specific signal intensity: generally are hypo / isointense and hyperintense on T2-T1 compared to brain parenchyma. They show uptake after administration of gadolinium. The diffusion potentiated sequence is most useful for characterization: manifest as hyperintense in isotropic image of said sequence (Figure 7). The differential diagnosisof middle ear cholesteatoma is done with: - Cholesterol Granuloma: appear hyperintense on T1 and T2. Not appear as a hyperintense on image isotropic diffusion-enhanced image. - Paragangliomas: show intense uptake after contrast administration. - Facial nerve Schwannomas or geniculate ganglion: mass appear as a segment along the facial nerve tympanic showing contrast enhancement. - Hemangioma of the facial nerve. Otomastoiditis Its imaging is CT. Typical findings on CT consists of a thickening of the walls of the mastoid air cells and a partial or generalized hypercondensation. The mastoid antrum and the rest of the middle ear cavities are filled with granulation tissue and secretion of inflammatory or eburneización present (Fig. 8). We can determine the degree of bone involvement in the process, because Cando septa of the cells appear osteoporotic this indicates osteomyelitis or abscesiformes collections (Fig 9). Glomus tumors They also receive names and chemodectomas paragangliomas. Page 5 of 23
They originate in a few corpuscles called chemoreceptors, which have a regulatory function and venous blood pressure. There are many parts of the body, but in the petrous region are two locations: the jugular occupying the posterior tympanic elongated hole located in the wall of the promontory of OM. It is the most common tumor of the middle ear, although it is a rare injury. These tumors are more common in women and is shown its family. They grow slowly and the symptoms are due to compression they produce. The initial symptom is usually a unilateral pulsatile tinnitus synchronous with the pulse, sometimes is a conductive hearing loss or clinic location pairs in jugular. Often facial nerve injury. The otoscopy is characteristic and corresponds to an intact tympanic membrane through which there is a pulsatile mass, soft red wine color and located in hipotímpano (Fig 10). To diagnose the nature and extent of such tumors using the contrast CT iv administration, to determine bone erosions, which is the key to differentiate anatomical variants (Fig. 11, 12). In recent elongated hole edges remain sharp posterior and retains its cortical, while glomus tumors, there is destruction of the bone cortex and infiltrating erosion. MRI is indicated when intracranial extension is suspected. In T1 and T2 can be seen with a mass of intermediate intensity signal due to the presence of vessels and fibrotic areas. After intravenous administration of contrast, these tumors are enhanced variably and according to their vascular component (Figure 13). The differential diagnosis of glomus tumors can arise with hemangiomas. These tumors usually occur in children, they have a very aggressive and are characterized by invading the whole pyramid. Jugular bulb High jugular bulb. It is said that the jugular bulb is high when the level is situated above the temporal bone girdle. Due to this high position, the bone covering the jugular bulb can be thin, thereby bulb vulnerability in case of trauma. Anomaly is the most common vascular rock (Figure 14). Page 6 of 23
Protruding jugular bulb. The second most common vascular anomaly, is observed as a vascular mass in the middle ear. This entity includes two components soil dehiscence middle ear and a protrusion of the jugular bulb through the defect. Patients may complain of headaches and pulsatile tinnitus deafness (usually driving jugular bulb compression of the ossicles, eardrum...). A bluish mass can be seen behind the eardrum and can cause bleeding after myringotomy. CT shows a soft tissue mass in the middle ear intensified and a bone defect above the jugular bulb on the floor of hipotímpano. Venography jugular bulb confirms that extends through the defect in the middle ear. Temporal fractures Fractures are classified as longitudinal time (with the same direction as the long axis of the bone), transverse (perpendicular to the long axis of the bone) or mixed. Classifying most mixed fractures. Most temporary fractures seen in axial images. Longitudinal fractures are due usually to death on the temporoparietal region. It is accompanied by a high incidence of ossicular disorders, however the inner ear structures are usually respected. Eardrum perforations are frequent. In 10-20% of cases facial paralysis is seen. If squamous epithelial debris invade the fracture callus before developing it increases the risk of forming a cholesteatoma acquired. Cholesteatoma appearing in this clinical setting can be dangerous and very aggressive. Transverse fractures are usually caused by a frontal impact or occipital (Figure 15.16). Labyrinth involvement is relatively common. This can lead to deafness or severe vertigo complementary. The facial nerve compression may be due to a transverse or longitudinal fracture but is most common in the first. Among the imaging studies, the technique of choice is CT. The diagnosis of temporal fractures is a difficult task. An indirect sign of its existence is the presence of air in the temporomandibular joint. Images for this section: Page 7 of 23
Fig. 2: CT reconstructions right ear with axial, coronal, with bone window. Occupation by soft tissue density material, expansive aspect, at the mastoid antrum, attic and diffusely in the eardrum, committing to the path of N. facial. No partial destruction in associations and medial displacement of the bones, osteolysis and thinning coat tegmen, plus labyrinthine fistula. Page 8 of 23
Fig. 3: TC left ear reconstructions in axial, coronal, with bone window. The left ear shows a soft tissue mass occupying the antro-tympanic attic and part of the tympanic cavity. It has destroyed the ossicular chain and eroded the wall of the attic. Was included the portion of the facial nerve in the dough. Page 9 of 23
Fig. 4: CT reconstructions right ear with axial, coronal, with bone window. In the right ear postsurgical changes are observed in the mastoid and petrous pyramid, with occupancy material or mass of soft tissue density, partly at the cavity and the tympanic cavity, with mass effect on the bones that luxan or displaced medially and present aspect demineralized. Page 10 of 23
Fig. 5: CT reconstructions right ear with axial, coronal, with bone window. Partial occupation of the eardrum mainly the lower 2/3 of a soft tissue density, is positioned in a position medial to the ossicular chain and also occupies the facial recess. No erosion escutum appreciated. The ossicular chain is partially conserved, there probably stapes erosion / anvil. No occupation additus ad antrum or mastoid antrum. Page 11 of 23
Fig. 6: CT reconstructions right ear with axial, coronal, with soft window. Page 12 of 23
Fig. 7: In the diffusion-enhanced sequence, there is a hyperintense relative to the occupation of the right ear eardrum by Cholesteatoma. Page 13 of 23
Fig. 8: CT reconstructions right ear with axial, coronal, with bone window. The right ear shows occupation of the antrum and attic storage attic wall and ossicular chain. Also retained is the tympanic tegmen the external semicircular canal and facial nerve step by the eardrum. CAE inner ear and unaltered. Page 14 of 23
Fig. 9: CT with IV contrast right ear with axial plane reconstruction with bone window and soft. Occupation by soft tissue density of the eardrum, additus ad antrum and mastoid antrum rights in relation to otitis media. Images consistent with ruptured right ear tegmen timpani with adjacent parenchymal right temporal lobe area support cerebritis / abscess. Page 15 of 23
Fig. 10: Otoscopy-intact tympanic membrane through which there is a pulsatile mass, soft red. Page 16 of 23
Fig. 11: TC left ear with axial plane reconstruction with bone window and soft. A lesion density contrast soft tissue captured in the space left carotid. Erodes the jugular foramen on that side and base of skull adyacente.hallazgos regarding jugular-tympanic glomus tumor. Page 17 of 23
Fig. 12: RECONSTRUCTION tympanic glomus jugulare oblique. Page 18 of 23
Fig. 13: SEQUENCES axial MR T1, T2 and T1 contrast. Image captante mass of approx. 17 mm in diameter and 12mm in diameter craniocaudal transverse, extending to rock right from the jugular foramen to the middle ear. Mass relatable to the diagnosis of a glomus jugular-tympanic. Page 19 of 23
Fig. 14: TC left ear with axial plane reconstruction with bone window and soft. Page 20 of 23
Fig. 15: Transverse fracture in middle ear mastoid occupancy cells and the tympanic cavity. Page 21 of 23
Fig. 16: Axial MR SEQUENCES, T2-weighted and FLAIR sequence Occupation of the petrous apex and right ethmoid cells by hematic material Page 22 of 23
Conclusion The coloration of lesions seen by the otoscope retrotimpánicas with radiological findings will allow to reach, in most cases, a definitive diagnosis and narrow the differential diagnosis. References Archana B. Rao, MD. Paragangliomas of the head and neck: Radiologic- Pathologic correlation. Radiographics 1999; 19:1605-1632. Direct Diagnosis in Radiology. Head and Neck. U. Moedder. Ed Thieme. Diagnostic Imaging. Head and Neck. Harnsberger. Ed Amirsys. Firts Edition. Diagnostic and Surgical Imaging Anatomy. Brain Head and Neck Spine. Harnsberger Osborn Macdonald Ross. Ed. Amirsys. First Edition. Personal Information Page 23 of 23