Middle Ear

University of Iowa
Iowa Research Online

Theses and Dissertations
Spring 2013
Usefulness of dental cone beam computed

tomography (CBCT) for detetion of the
anatomical landmarks of the external, middle and
inner ear
Mahdieh Taleb Mehr
University of Iowa
Copyright 2013 Mahdieh Taleb Mehr
This thesis is available at Iowa Research Online: http://ir.uiowa.edu/etd/2643
Recommended Citation
Taleb Mehr, Mahdieh. "Usefulness of dental cone beam computed tomography (CBCT) for detetion of the anatomical landmarks of
the external, middle and inner ear." MS (Master of Science) thesis, University of Iowa, 2013.
http://ir.uiowa.edu/etd/2643.
Follow this and additional works at: http://ir.uiowa.edu/etd
Part of the Oral Biology and Oral Pathology Commons

USEFULNESS OF DENTAL CONE BEAM COMPUTED TOMOGRAPHY (CBCT)
FOR DETECTION OF THE ANATOMICAL LANDMARKS OF THE EXTERNAL,
MIDDLE AND INNER EAR
by
Mahdieh Taleb Mehr
A thesis submitted in partial fulfillment

of the requirements for the Master of
Science degree in Oral Science
in the Graduate College of
The University of Iowa
May 2013
Thesis Supervisor: Professor Axel Ruprecht

Copyright by
MAHDIEH TALEB MEHR
2013
All Rights Reserved

Graduate College
The University of Iowa
Iowa City, Iowa
CERTIFICATE OF APPROVAL
___________________________
MASTERS THESIS
___________________________
This is to certify that the Master's thesis of
Mahdieh Taleb Mehr
has been approved by the Examining Committee for the

thesis requirement for the Master of Science degree in
Oral Science at the May 2013 graduation.
Thesis Committee: ___________________________________

Axel Ruprecht, Thesis Supervisor
___________________________________
Trishul Allareddy
___________________________________
Michael Finkelstein
___________________________________
Fang Qian
I lovingly dedicate this thesis to my mother and brother, whose love and support has
always encouraged me each step of the way.
ii
The whole problem with the world is that fools and fanatics are always so certain of
themselves, but wiser men so full of doubts.
Bertrand Russell
iii
ACKNOWLEDGMENTS
This dissertation would not have been possible without the help of Dr. Axel
Ruprecht who served as my thesis supervisor and extended his valuable assistance in the
preparation and completion of this study. I wish to express my heartfelt gratitude to him
for guiding me throughout my academic program. My sincere appreciation goes to other
members of my thesis committee, Dr. Veeratrishul Allareddy, Dr. Michael Finkelstein,
and Dr. Fang Qian for their valuable advice and guidance throughout this study.
It is with immense gratitude that I acknowledge the support and help of my
Professors Dr. John Hellstein, Dr. Michael Finkelstein, Dr. Steve Vincent and Dr. Sherry
Timmons for their valuable guidance in my residency program.
I extend my appreciation to Dr. Wendy Smoker for her valuable input in
generating a case report and literature review paper and also the efforts she took in
teaching me neuroradiology during my hospital rotations.
My sincere thanks to my past colleagues Dr. Rujuta Katkar and Dr. Gayle
Reardon and my coresidents Ali, Sindhura, Krishna, Chelsia, Brian and Emily for their
encouragement, love and support.
I owe my deepest appreciation to my mother (Marzieh Forati), stepfather
(Hormoz Aalidaai) and brother (Saeed Talebmehr) for their unending love and support
throughout my academic career.
iv
ABSTRACT
Thesis problem: Cone beam computed tomography (CBCT) can provide images
with identical information and considerable dose reduction compared with reasonably
low costs compared to multislice computed tomography (MSCT) especially where
multiple follow up imaging studies are needed. The purpose of this study was to evaluate
the diagnostic usefulness of CBCT, using i-CATs software, for detection of the
anatomical landmarks of the external, middle and inner ear to answer this question
whether MSCT Can be replaced by dental CBCT for evaluation of the temporal bone.
Material and methods: Cone beam computed tomography (CBCT) images of 63
subjects made with the same machine, with unknown clinical histories and no evidence of
pathosis on CBCT images, were evaluated by two oral and maxillofacial radiologists
retrospectively. Seven anatomical points (scutum, oval window, incudomalleolar joint,
the tympanic/horizontal and mastoid/vertical segments of the facial nerve, anterior and
posterior crura of stapes) of the right and left temporal bone (total of 120 temporal bones)
were evaluated. The results were provided as percentage of the points identified by each
radiologist. The intra and inter observer agreement were calculated using kappa statistic.
Results: The scutum, the tympanic/horizontal segment of the facial nerve canal
and the oval window of the right and left temporal bone of 63 cases (total 126 temporal
bones) were visualized by the first observer as well-defined structures in 100%, 96.03%
and 100% of the cases, respectively. The tympanic/horizontal segment of the facial nerve
canal was visualized as a poorly-defined structure in 2.38 % and could not be identified
in 1.59% of the cases. The anterior and posterior crura of stapes, the mastoid/vertical
segments of the facial nerve canal and the incudomalleolar joint were visualized as well-
defined structures in 24.60%, 53.17%, 99.21% and 57.94% of the cases, as poorly
defined structures in 32.54%, 41.27%, 0.79% and 39.68% of the cases respectively. The
anterior and posterior crura of stapes, the mastoid/vertical segments of the facial nerve
v
canal and the incudomalleolar joint could not be identified in 42.86%, 5.56%, 0% and
2.38% of the cases respectively. The intra- and inter-observer agreement ranged from
strong for tympanic/horizontal and mastoid/vertical segments of the facial nerve canal to
poor for the anterior and posterior crura of stapes and also the incudomalleolar joint.
Conclusion: The i-CAT CBCT machine is a promising replacement for MSCT in
evaluation of the temporal bone where there is no need for evaluation of the anterior and
posterior crura of stapes and the incudomalleolar joint which are the smallest anatomical
structures in the temporal bone. Other CBCT machines with higher contrast to noise ratio
should be evaluated for detection of those anatomical structures since CBCT can reduce
the patient dose substantially where multiple follow up CT studied are needed.
Key words: Computed tomography; cone beam CT; multislice helical CT; middle
ear; inner ear; temporal bone.
vi
TABLE OF CONTENTS
LIST OF TABLES ............................................................................................................. ix
LIST OF FIGURES ........................................................................................................... xi
CHAPTER I. INTRODUCTION .........................................................................................1
Computed tomography .....................................................................................1

Types of computed tomography scanners ........................................................1
Cone beam computed tomography ...................................................................5
Temporal bone ..................................................................................................8
External ear ................................................................................................8
Middle ear ................................................................................................12
Inner ear ...................................................................................................22
Literature review .............................................................................................29
Purpose ...........................................................................................................32
Hypothesis ......................................................................................................32
Questiions .......................................................................................................33
CHAPTER II. MATERIAL AND METHODS .................................................................34
Inclusion criteria .............................................................................................34

Exclusion criteria ............................................................................................34
Exclusion criteria ............................................................................................34
Anatomical landmarks ....................................................................................35
An overview of statistical methods.................................................................41
Kappa interpretation ................................................................................41
Remark ....................................................................................................42
CHAPTER III. RESULTS .................................................................................................43
Observer 1 first observations ..........................................................................43

Left side observations ..............................................................................43
Right side observations............................................................................45
Both side observations .............................................................................47
Observer 1 second observations .....................................................................47
Observer 2 first observations ..........................................................................47
Observer 2 second observations .....................................................................47
Intra-observer reliability .................................................................................58
Inter-observer reliability .................................................................................60
CHAPTER IV. DISCUSSION...........................................................................................76
CHAPTER V. CONCLUSION ..........................................................................................82
vii
REFERENCES ..................................................................................................................83
viii
LIST OF TABLES
Table
1. Summary of first observations of seven variables on the left side by the

observer 1; (N=63). ...................................................................................................44
2. Summary of first observations of seven variables on the right side by the

observer 1; (N=63). ...................................................................................................46
3. Summary of the first observations of seven variables on both sides by the

observer 1; (N=126). .................................................................................................48
4. Summary of second observations of seven variables on the left side by the

observer 1; (N=63).. ..................................................................................................49
5. Summary of second observations of seven variables on the right side by the

observer 1; (N=63)... .................................................................................................50
6. Summary of second observations of seven variables on both sides by the

observer 1; (N=126)... ...............................................................................................51
7. Summary of first observations of seven variables on the left side by the

observer 2; (N=63). ...................................................................................................52
8. Summary of first observations of seven variables on the right side by the

observer 2; (N=63). ...................................................................................................53
9. Summary of first observations of seven variables on both sides by the

observer 2; (N=126). .................................................................................................54
10. Summary of second observations of seven variables on the left side by the
observer 2; (N=63).. ..................................................................................................55
11. Summary of second observations of seven variables on the right side by the
observer 2; (N=63).. ..................................................................................................56
12. Summary of second observations of seven variables on both sides by the

observer 2; (N=126). .................................................................................................57
13. Comparison of the first and second observation of right temporal bones by
each observer; (N=63). .............................................................................................65
14. Comparison of the first and second observation of left temporal bones by
each observer; (N=63) ..............................................................................................67
15. Comparison of the first and second observation of bilateral temporal bones by
each observer; (N=126). ...........................................................................................69
16. Comparison of the first and second observation of right temporal bones
between the observers; (N=63) .................................................................................71
ix
17. Comparison of the first and second observation of left temporal bones
between the observers; (N=63) .................................................................................73
18. Comparison of the first and second observation of bilateral temporal bones
between the observers; (N=126). ..............................................................................75
x
LIST OF FIGURES
Figure
1. CT scanner generations ...............................................................................................3
2. Principles of spiral CT scanners .................................................................................4
3. Cone beam computed tomography .............................................................................7
4. Lateral, superior and inferior views of the temporal bone..........................................9
5. The scutum and external auditory canal. ..................................................................10
6. Blunting of scutum by cholesteatoma. ......................................................................11
7. The ossicles of the middle ear...................................................................................14
8. The ossicles of the middle ear on CBCT ..................................................................15
9. The ossicles of the middle ear on CBCT ..................................................................16
10. The ossicles of the middle ear on CT. ......................................................................17
11. Inner ear. ...................................................................................................................20
12. Inner ear on CBCT. ...................................................................................................21
13. Inner ear. ...................................................................................................................23
14. Inner ear on CBCT....................................................................................................26
15. The facial nerve. .......................................................................................................28
16. The oval window and scutum. ..................................................................................36
17. The tympanic section of the facial nerve canal and the oval window. .....................37
18. The incudomalleolar joint. ........................................................................................38
19. The anterior crus of stapes (AC), posterior crus of stapes (PC).. .............................39
20. The mastoid portion of the facial nerve canal...........................................................40
xi
1
CHAPTER I
INTRODUCTION
Computed tomography
In the 1950s and 1960s, Allen Cormack developed image reconstruction
mathematics to produce cross-sectional images of the head. In 1972 Godfery Hounsfileld
in Britain used these mathematics to invent a revolutionary imaging technique called
computed tomography or CT. Hounsfield and Cormack shared the 1979 Nobel Prize in
Physiology/Medicine for their pioneering work (1).
Types of computed tomography scanners
CT scanners have improved tremendously during the years after their first
introduction by Hounsfield. The first generation scanners (Figure 1A) employed a source
of radiation collimating the x-ray beam to a narrow (pencil-width) beam of x rays
measuring approximately 3mm in width. The x-ray tube and the detector were rigidly
linked moving simultaneously across the patient in linear translation. After completion of
one linear translation the assembly rotated around the patient by 1 where the second
translation occurred collecting a second set of data. This is referred to as translate-
rotate mechanical motion. The scanner repeated this process 180 times to collect 180
views over 180 for each slice (2, 3).
The second generation scanner (Figure 1B) used an x-ray beam collimated to a
10 fan-shaped beam with a corresponding array of multiple detectors rather than the
pencil beam used by the first generation scanners. The second generation also used a
complicated translate-rotate mechanical motion; however, multiple angles were obtained
with a single translation across the patient resulting in a reduced scan time with
substantial improvement in image quality (2, 3).
To increase the speed of scan, the third and fourth generation scanners (Figure 1C
and 1D) were developed. Both the scanners used a wide fan-shaped beam; however, the
2
fourth generation scanners utilized a fan beam with a larger angle across the patients
body extending from side to side. This allowed complete elimination of the back and
forth linear translation and its replacement with a continuous smooth rotational
movement of 360 or less in order to collect data from each slice. The other major
difference between the third and fourth generation was the motion of the detectors. In the
third generation scanners, the x-ray source and the detector array were mounted on the
opposite side of the patient from one another and rotated around the patient
simultaneously. In the fourth generation detectors, the detector array was stationary
within the gantry, with a greater number of detectors compared to the third generation,
and only the x-ray tube rotated. The term conventional or standard CT refers to CT
scanners where the patient is scanned one slice at the time (2, 3).
The introduction of spiral or helical scanners (Figure 2) in the early 1990s caused
a revolution in diagnostic imaging with the latest advance being the relatively recent
introduction of multislice CT (MSCT) scanners in 1998 (4). The images are obtained as
the patient table moves inside the gantry while the x-ray tube and the detector rotate
simultaneously in a plane perpendicular to the long axis of the patient. This result is a
spiral or helical movement of the x-ray tube and detector with respect to the patient
allowing for fast and continuous acquisition of data. Spiral CT scanners may be single
slice (SSCT) or multi slice (MSCT). The main difference between SSCT and MSCT is in
the design of the detector array. The SSCT detector array is one dimensional in that only
one detector row occupies the width of the array in the z direction whereas in MSCT each
individual detector element in the z direction is divided into several smaller detector
elements forming a two dimensional array. As a result multiple rows of detectors are
struck by the fan beam (4).

3
Figure 1. The first generation CT scanners (A) utilized a pencil beam fixed with a single
detector moving simultaneously by translation-rotation motion (the straight arrows). The
second generation scanners (B) were similar to the first generation scanners but used
multiple pencil beams coupled with multiple detectors and had a wider angle of rotation.
The third generation scanners (C) utilized a fan beam and an array of multiple detectors
rotating simultaneously around the patient. The fourth generation scanners (D) used a
wider fan beam rotating around the patient while a stationary ring of multiple detectors
received the attenuated x-ray photons exiting the patient. Based on: Computed
Tomography: Euclid Seeram. Physical Principles, Clinical Applications, and Quality
Control, 3rd Ed., Saunders, 2009.
4
Figure 2. Principles of spiral CT scanners. The patients table moves to the left side
while the tube head continuously rotates around the patient resulting in a spiral pattern of
scanning. Based on: Elliot K. Fishman. Multidetector-row computed tomography to
detect coronary artery disease: the importance of heart rate. European Heart Journal
Supplements (2005) 7 (Supplement G), G4G12.
5
Cone beam computed tomography
Cone beam computed tomography, commonly referred to by the acronym CBCT,
is an imaging technique initially developed for angiography in 1982; however, it was not
possible to produce clinical systems that were both inexpensive and small enough to be
used in dental offices until the late 1990s when an Italian and a Japanese group, working
independently of each other, developed a new CBCT scanner (also referred to as digital
volume tomography (DVT)) specifically for dental and maxillofacial use (5, 6). Dental
CBCT machines have become increasingly important in treatment planning and diagnosis
in different fields of dentistry such as oral and maxillofacial surgery, endodontics,
implantology and orthodontics (7). Recent applications of CBCT in the medical field
include radiotherapy guidance, mammography and angiographic interventions (8, 9).
CBCT machines produce their images by using a rotating gantry to which a
coupled x-ray tube and detector are mounted. The x ray beam is cone shaped (Figure 3).
Single projection images, known as basis, frame or raw images, are acquired after
multiple sequential exposures are made at fixed intervals during one rotation around the
patients head, ranging from 180 to 360 depending on the type of the machine used.
Projection data is referred to the complete series of basis images which are similar to
cephalometric radiographic images, each slightly offset from one another. Sophisticated
algorithms including back-filtered projection are applied to the projection data by
software programs to generate a 3D volumetric dataset. The 3D volumetric dataset is then
used to produce high quality primary reconstruction images of the maxillofacial regions
in three orthogonal planes usually axial, coronal and sagittal. Panoramic views of the
jaws with views orthogonal to them and cephalometric views can also be reconstructed
from the same image dataset. Cephalometric images can be made as lateral, antero-
posterior (AP) or postero-anterior (PA) (10).
The effective dose ranges and image quality vary among different CBCT
machines and are also dependent on the size of the field of view (FOV) and the parameter
6
settings used for that area; however, the CBCT images are generated at relatively low
radiation doses and reasonably low costs compared to multislice computed tomography
(MSCT) (10, 11). Different machines offer different scan volumes ranging from 44 cm
to 1525 cm. The tube current and voltage range from 1 to 16 milliampere (mA) and 60
to 120 kiloelectronvolt (kVp) and can vary with respect to the size of the FOV and the
patient age and size (12-14). The scan times in the current generation range from 5.6 to
37 second (s); however, some CBCT machines such as i-CAT, Imaging Science
International, NewTom 3G, AFP Imaging CORP, Galileos, Sirona Dental Systems
and ProMax 3D, Planmeca use a pulsed source of radiation, thus the exposure time is
considerably shorter than the acquisition time (10).
CBCT can obtain images from areas other than the maxillofacial region such as
the temporal bone. This raises the question as to whether this technique can replace the
more expensive techniques, such as MSCT, which also expose the patient to a
considerably higher radiation dose (15-18). A few studies, which will be reviewed later in
this section, have been carried out to evaluate the possibilities of using CBCT in temporal
bone imaging (15, 19-24).
7
Figure 3. Computed tomography utilizes a fan shaped beam (A) whereas CBCT used a
cone-shaped beam (B) to produce images. Based on: William C. Scarfe, Allan G.Farman,
Predag Sukovic, Can Dent Assoc 2006, 72(1); 75-80.
8
Temporal bone
There are two temporal bones in the human skull contributing to the sides and
base of the skull bilaterally. Each temporal bone is composed of five morphologically
distinct parts: the squamous part (anterosuperior), the tympanic part (inferior and lateral),
the styloid process (inferior), the petrous part (medial), and the mastoid part
(posterior).The petrous part of the temporal bone encloses the auditory system which is
composed of three parts: the external ear, the middle ear and the inner ear (figure 4)(25).
External ear
The external ear is an air-filled canal extending from the auricle to the tympanic
membrane or ear drum. The tympanic membrane has a small, thin, triangular and flaccid
area on its superior aspect, known as the pars flaccida from where many primary
acquired cholesteatomas of the middle ear originate. The remainder of the membrane,
known as the pars tensa, is thick and more rigid. The thickened peripheral rim of the pars
tensa where the connective tissue matrix of the membrane attaches to the bony tympanic
sulcus is known as the tympanic annulus. Adjacent to the pars flaccida is a wedge-
shaped, bony wall whose sharp inferior portion is known as the outer attic wall or
scutum. Of importance to the radiologist is checking that scutum has a sharp point on CT
scans. Blunting of this area is a sign of cholesteatoma (Figure 5 and 9) (25-31).

9
Figure 4. Lateral (A), superior (B) and inferior (C) views of the temporal bone in
association with other bones in the skull. The petrous part of the temporal bone has been
traced (D) on a temporal bone separated from the skull shown from the superior aspect.
10
Figure 5. Coronal CBCT section (A) shows scutum (arrow) and the external auditory
canal (EAC).
11
Figure 6. Coronal MSCT section shows blunting of scutum by cholesteatoma.

12
Middle ear
Located between the tympanic membrane and the inner ear, the middle ear is a
narrow, air-filled chamber that contains the auditory ossicles (malleus, incus and stapes).
The small size of the middle ear cavity, sometimes referred to as the tympanic cavity, and
the numerous structures found within it contribute to the complexity of this region (25).
Ossicles
Malleus (hammer in Latin) is the largest of the ossicles and is shaped like a
hammer or club. It is composed of a head, neck, handle (manubrium) and anterior and
lateral processes. The head, an oval-shaped structure articulates with the body of incus
posteriorly at the malleoincudal or incudomalleolar joint. Incudomalleolar
dislocation/subluxation, a complication sometimes observed in patients with trauma to
the temporal bone, can best be visualized on axial and/or sagittal CT images. The neck,
the narrowed part below the head, lies against the pars flaccida of the tympanic
membrane. Inferior to the neck is an enlargement from which the anterior and lateral
processes project. The anterior process connects to the petrotympanic fissure by
ligamentous fibers. The lateral process projects laterally from the neck and is attached to
the upper part of the tympanic membrane. The handle is embedded in the tympanic
membrane with its tip at the umbo (Figure 7) (25).
Incus (anvil in Latin) is shaped like an anvil and is located between malleus and
stapes. It has a body, a short process, a long process and a lenticular process. The body
articulates with the head of malleus. The long process lies parallel to the handle of
malleus. Its inferior end bends medially and terminates in the rounded lenticular process
that articulates with the head of stapes at the incudostapedial joint (Figure 7) (25).
Stapes (stirrup in Latin), is the smallest bone in the body. It has a head (caput),
neck, anterior crus, posterior crus, and a base or footplate. The head articulates laterally
with the lenticular process of incus via the incudostapedial joint. The neck connects the
13
head to the anterior and posterior crura. The crura diverge from the neck and are
connected at their ends to the footplate. The footplate is attached to and completely fills
the oval window in the medial wall of the tympanic cavity through which it transmits the
vibrations of the tympanic membrane and ossicles to the inner ear (Figure 7) (25, 32).
In general, most parts of the ossicular chain can be visualized best on thin axial
CT sections. These structures include the head of malleus, the body and short process of
incus, the footplate and the crura of stapes, and incudomalleolar and incudostapedial
joints (Figure 8 and 10). Coronal and modified Poschl 1 CT sections allow for better
visualization of the handle of malleus, long process of incus and the right-angle junction
of incus long and lenticular processes (Figure 9). The incudomalleolar articulation can
also be visualized in sagittal CT sections with the classic molar tooth appearance;
however, there has been little research investigating the applicability of dental CBCT
images in viewing this area (Figure 10)(32, 33).
1 Images obtained at a standard 45 degree angle to the mid-sagittal, and longitudinal to

the petrous bone, simulate the plain radiograph skull projection known as the Stenvers projection
(an occipito-frontal with the head rotated 45 degree and a 12 degree tilt away from the feet) The
plane of the Stenvers sections is perpendicular to the course of the superior semicircular canal.
Images perpendicular to this projection, providing cross-sectional images of the petrous bone,
simulate the plain radiograph skull projection known as the Pschl projection, also called the
axial projection of the pyramid or the transverse pyramidal plane (54, 55).
14
Figure 7. The ossicles of the middle ear seen from the anterior aspect.
15
Figure 8. The ossicles of the middle ear. A. Axial CBCT section through the level of the
epitympanum shows the ice-cream cone structure (ICC) made by the head of malleus
(HM), body of incus (BI), the short process of incus (SI) and the incudomalleolar joint
(IMJ), it also shows the aditus (AD) to the mastoid antrum (*). Note that the short process
of incus (SI) points at the aditus (AD) to the mastoid antrum (*). B. Axial CBCT section
through the mesotympanum shows the handle of malleus (HLM), the long process of
incus (LI), the internal auditory canal (IAC), the vestibule (VB), the cochlear promontory
(arrowhead) and the carotid canal (CC).
16
Figure 9. The ossicles of the middle ear. A. Modified Pschl views with a small axial
view on the top right showing the location and orientation of the Pschl planes, B.
Coronal CBCT section at the level of incus, and C. Coronal CBCT section at the level of
malleus show the head of malleus (HM), the body of incus (BI), the incudomalleolar joint
(IMJ), the long process of incus (LI), stapes (ST), the oval window (straight arrow),
scutum (arrowhead), the bony annulus (curved arrow), the handle of malleus (HNM),
Prussaks space (PS) and the tympanic membrane (TM). Note that stapes (ST) is hardly
identifiable on these CBCT sections.
17
Figure 10. A. The axial multislice CT shows the anterior crus of stapes (AC), the
posterior crus of stapes (PC), the handle of malleus (HM), the long process of incus (LI),
the oval window (OW) and the vestibule (VB). B. The sagittal multislice CT shows the
classic molar tooth appearance made by the long process of incus (LI) and handle of
malleus (HM), and the mandibular condyle (MC).
18
Walls of the middle ear cavity
The middle ear is shaped like a box with 6 sides: the roof, the floor, and the
anterior, posterior, medial and lateral walls.
The roof, also known as tegmen tympani, separates the tympanic cavity from the
middle cranial fossa (34).
The anterior wall, also known as the carotid wall, separates the tympanic cavity
from the carotid canal. The Eustachian tube (the auditory tube or pharyngotympanic tube)
and the semi-canal for the tenser tympani muscle also extend to the anterior wall of the
tympanic cavity (Figure 11).
The medial wall, also known as the labyrinthine wall, separates the tympanic
cavity from the inner ear. There is a rounded prominence on this wall, the cochlear
promontory, formed by the first turn of the cochlea. Located superoposterior to the
promontory is the oval window (fenestra ovale, vestibular window) which connects the
middle ear cavity to the vestibule of the inner ear. Inferoposterior to the promontory, and
more posterior than the oval window, lies the round window (fenestra cochlea), which is
an opening to the cochlea of the inner ear and is closed by a membrane. Located
superoposterior to the oval window is the prominence of the tympanic portion of the
facial nerve, and superior to that is the prominence of the lateral semicircular canal
(horizontal) (Figure 11 and 12).
The lateral wall, also known as the membranous wall, separates the tympanic
cavity from the external auditory canal. It is formed almost entirely by the tympanic
membrane which has the handle of malleus embedded in it. It also contains the bonny
annulus which attaches the thickened peripheral rim of the tympanic membrane to the
bony tympanic sulcus located on the medial end of the external auditory canal. As
mentioned earlier, the bony wall adjacent to the pars flaccida of the tympanic membrane
is wedge-shaped and its sharp inferior portion is known as the outer attic wall or scutum
(Figure 9)(28, 30).

19
The floor, also known as the jugular wall, separates the tympanic cavity from the
jugular bulb (Figure 11).
The posterior wall, also known as the mastoid wall, connects the tympanic cavity
to the mastoid air cells through an opening in its superior part, the aditus to the mastoid
antrum (aditus ad antrum mastoideum) (Figure 8). Widening of the aditus opening is a
sign of cholesteatoma (31). The most prominent area in the posterior wall is a minute
triangular shaped spicule of bone, the pyramidal eminence, situated at the level of the
oval window with its apex projecting towards the window. The vertical part of the facial
nerve canal is located in the posterior wall just posterior to the pyramidal eminence. The
posterior wall is indented by two recesses that surround the pyramidal eminence and the
facial canal. Located lateral to the facial canal and the pyramidal eminence is the facial
recess and medial to them is the sinus tympani (tympanofacial recess). These recesses
may be sites of occult extension of diseases of the middle ear cavity. These structures are
visualized best in axial sections but are hard to detect on coronal sections (Figure 11 and
12) (35).
20
Figure 11. Simplified anatomy of the left middle ear seen from the lateral, showing the
internal carotid artery (ICA), the jugular vein (JV), the Eustachian tube (ET), the
semicanal for tensor tympani muscle (TT), the chorda tympani nerve (CT), the cochlear
promontory (P), the oval window (O), the round window (R), the facial nerve (CN VII),
the first genu of the facial nerve (G1), the second genu of the facial nerve (G2), the lateral
semicircular canal (LSC), the pyramidal eminence (PY), the sinus tympani (ST), the
facial recess (FR), the aditus to the mastoid antrum (AD).
21
Figure 12. A, B and C. The axial CBCT sections show the structures on the posterior,
anterior and medial walls of the middle ear, the mandibular condyle (MC), the external
auditory canal (EAC), the carotid canal (CC), the cochlear promontory (arrowheads), the
basal turn of the cochlea (BC), the pyramidal eminence (PY), the sinus tympani (ST), the
facial recess (FR), the vertical or mastoid part of the facial nerve (MF), the basal, middle
and apical turns of the cochlea (C), Eustachian tube (ET), the semicanal for tensor
tympani muscle (TT), round window (RW), oval window (arrow), long process of incus
(LI), handle of malleus (HNM), the origin of the tendon of the stapedius muscle (TSM),
vestibule (VS) and the internal auditory canal (IAC).
22
Inner ear
Labyrinth
The inner ear is situated in the petrous part of the temporal bone medial to the
middle ear. It is composed of the bony and the membranous labyrinths. The bony
labyrinth contains the sacs and ducts of the membranous labyrinth. The membranous
labyrinth is filled with endolymph and separated from the bony labyrinth by the
perilymph. The bony labyrinth is surrounded by the otic capsule which is made of a
denser bone than the rest of the petrous part. The bony/membranous labyrinth is
composed of three parts: the vestibule, the three semicircular canals, and the cochlea
(Figure 13).
The vestibule (Figure 12, 13 and14) is a somewhat ovoid cavity situated in the
middle of the labyrinth, anterior to the semicircular canals and posterior to the cochlea. It
is the largest cavity of the bony labyrinth. It communicates medially with the middle ear
cavity through the oval window.
Three semicircular canals (superior (anterior), posterior and lateral) (Figure 13
and 14) are situated posterosuperior to the vestibule and directly superior to the jugular
bulb.
The cochlea (Figure 12, 13 and 14) is the most anterior part of the labyrinth. It is
a snail shell-like cavity laid on its side which makes two and half turns around a
horizontal axis called the modiolus. The cochlea is located in the temporal bone with the
modiolus tip pointing in an anterior, lateral and slightly inferior direction. The bulge of
the basal turn forms the cochlear promontory (Figure 12, 13 and 14) (25).
23
Figure 13. The inner ear seen from the anterior aspect.
24
Facial nerve
The facial nerve enters the internal auditory canal through the internal acoustic
opening (porus acusticus internus) and exits the anterosuperior portion of the lateral end
of the canal (fundus) where it enters the facial nerve canal. The facial nerve canal
(fallopian canal) comprises of three segments (labyrinthine, tympanic and mastoid) and
two genua (Figure 12, 13, 14 and 15).
The labyrinthine segment is the narrowest and shortest segment of the facial nerve
and is located between the porus acusticus interna and the first or anterior genu. The
anterior genu is a bend in which the geniculate ganglion, a bulbous enlargement of the
canal, is located. The labyrinthine segment courses anterolaterally at a 125 angle relative
to the long axis of the internal auditory canal. It is best visualized on axial CT sections.
The tympanic segment (horizontal segment) exits posterolaterally from the
geniculate ganglion, at the first genu, at an angle of 75 or less to the labyrinthine
segment. The tympanic segment is approximately 10 mm in length and can be visualized
on axial sections running anteroposteriorly along the superior portion of the medial wall
of the tympanic cavity at the level of the incudomalleolar ice-cream cone 2 .On coronal
sections, the cross section of the facial nerve canal can be found between the lateral
semicircular canal and the oval window. Pathological conditions of the middle ear cavity
such as cholesteatoma and otitis media may cause erosion of this segment of the canal
and thereby cause facial palsy.
As the tympanic segment of the facial nerve extends posteriorly, it courses
inferiorly and laterally towards the posterior wall of the tympanic cavity where it bends
inferiorly with an angle of 95 to 125 to the horizontal segment; this bend is known as
2 The ice-cream cone structure seen in the middle ear cavity on axial sections at the level
of the epitympanum represents the head of malleus (the ice-cream) and the body of incus (the
cone) with the tip of the cone (the short process of incus) pointing towards the aditus of the
mastoid antrum
25
the posterior or second genu. The facial nerve canal then continues in the posterior wall
as the vertical or mastoid segment of the canal for 13mm and opens to the outer surface
of the cranium through the stylomastoid foramen. This segment of the facial nerve canal
is bounded medially by the sinus tympani, laterally by the facial recess and anteriorly by
the pyramidal eminence. Additional structures medial to this segment include the tendon
of the stapedius muscle, the posterior semicircular canal and the jugular bulb (Figure 26,
27 and 30). The medial aspect of the mastoid segment may be either dehiscent or
separated from the jugular bulb by a layer of bone measuring 7 mm or more in width.
This part of the facial nerve may be compromised by erosive jugulotympanic
paragangliomas in the region of the jugular fossa. (25, 36)

26
Figure 14. Coronal CBCT sections, from posterior to anterior, at the level of the inner
ear showing the superior (anterior) semicircular canal (SSC), the crus commune (CR), the
posterior semicircular canal (PSC), the lateral semicircular canal (LSC), the petromastoid
canal (PM), the vestibule (VB), the mastoid segment of the facial nerve canal (MF), the
second genu of the facial nerve canal (SG), the tympanic segment of the facial nerve
canal (TF), the stylomastoid foramen (SM), the sinus tympani (ST), the internal auditory
canal (IAC), the crista falciformis (arrowhead), the opening of the cochlear aqueduct
(CA), the jugular foramen (JF), and the hypoglossal canal (HC).
27
Figure 14 (continued). F to J. Coronal CBCT sections at the level of the inner ear, from
posterior aspect anterior, showing the superior (anterior) semicircular canal (SSC), the
lateral semicircular canal (LSC), the vestibule (VB); the oval window (straight arrow),
the round window (sigmoid arrow); the tympanic (TF) and labyrinthine (LT) segments of
the facial nerve canal, the internal auditory canal (IAC), the crista falciformis
(arrowhead), the basal turn (BC), middle turn (MC) and apical turn (AC) of the cochlea,
the modiolus (M), and the external auditory canal (EAC).
28
Figure 15. The facial nerve. A. and B. Axial, C. modified Stenvers and D. Stenvers
CBCT sections, with a small axial section on the top right indicating the orientation and
approximate location of the reconstructed Stenvers and modified Stenvers sections, show
the internal auditory canal (IAC), the labyrinthine segment of the facial nerve canal (LF),
the geniculate ganglion (GG) , the second genu of the facial nerve canal (open curved
arrow) , the canal of the greater petrosal nerve (GP), the tympanic segment of the facial
nerve canal (TF), the mastoid segment of the facial nerve canal (open straight arrow); and
the stylomastoid foramen (SM).
29
Literature review
Gupta and colleagues performed a preliminary evaluation of the diagnostic value
of an experimental CBCT system on the imaging of the temporal bone using 4 partially
manipulated cadaveric specimens. They found that CBCT offers well-defined
visualization of structures such as the ossicular chain, the bony labyrinth of the inner ear,
internal cochlear anatomy, and the facial nerve. They also noted reduced metal artifacts
with ocular implant imaging. They suggested that lack of soft-tissue contrast in their
temporal bone specimens did not interfere with diagnostic accuracy due to the presence
of many high-contrast structures in the temporal bone and the positive effect of higher
spatial resolution on resolving some low-contrast structures such as the facial nerve;
however, their sample size of 4 temporal bones was small and the experimental CBCT
machine that they utilized was different from the CBCT machines available in the market
today(37).
Peltonen and the fellow researchers (15) evaluated the accuracy of CBCT in
detecting the clinically important landmarks of the middle ear and showing the positions
of the middle-ear implants. They also performed a contrast-to-noise ratio (CNR) analysis
by imaging a specially built phantom insert with different protocols using the 3D
Accuitomo CBCT (Morita co., Kyoto, Japan). They used dry temporal bone specimens,
one non-operated and five postmortem operated. The image quality for all the temporal
bones was good and of diagnostic value and the surgical landmarks as well as positions
and details of the implants could be accurately observed. They also proposed that the
highest contrast-to-noise ratio and best image quality were achieved with a tube voltage
of 80 kVp and a current of 4 mA, indicating the highest contrast resolution with these
imaging values.
The use of dry skulls in this research resulted in images with different qualities
from images made of living humans due to absence of soft tissue and thereby different
30
levels of scattered radiation reaching the image receptor. The anatomical landmarks
evaluated in this study were not specified. Their sample size of 6 was small.
Dalchow and colleagues (19) evaluated the clinical applicability and the value of
digital volume tomography (hereafter also referred to as CBCT) for visualization of the
temporal bone. They initially examined 12 temporal bone specimens with 3D Accuitomo
CBCT (Morita co., Kyoto, Japan). They investigated the middle ear space, auditory
canals, and the mastoid air cells in three planes orthogonal to each other. Image sections
were selected to illustrate the oval window niche, stapes footplate, and cochlea with the
labyrinth. Furthermore, radiologic control examinations were performed after insertion of
middle-ear implants and a cochlear implant. They concluded that CBCT is useful in
assessing the position of the cochlear implant as well as the normal anatomy of the
middle ear.
Again, dry temporal bone specimens were utilized for their research resulting in
images with different qualities from images made of human subjects due to absence of
soft tissue and surrounding anatomical structures and, as a result, a different level of
scattered radiation reaching the image receptor. Their sample size was also small.
Dalchow and colleagues (20) evaluated the diagnostic value of CBCT in cases of
erosion of the ossicular chain. 25 patients with the history of a progressive hearing loss
were examined with 3D Accuitomo CBCT (Morita co., Kyoto, Japan). The results were
compared with pre- and intraoperative findings to evaluate the middle ear and the
ossicular chain. They concluded that CBCT is an excellent technique to examine middle
ear clefts and the inner ear, and suggested the application of diagnostic possibilities in the
lateral skull base.
This research was done to evaluate the erosion of the ossicular chain. They did
not evaluate the usefulness of CBCT in identifying other delicate structure of the auditory
system such as the facial nerve canal.

31
Peltonen and colleagues (21) evaluated the applicability of CBCT in otological
imaging, and compared its accuracy with the routinely used MSCT for imaging of the
middle/and inner/ear areas. Thirteen non-operated temporal bones were imaged with 3D
Accuitomo CBCT (Morita co., Kyoto, Japan) and Aquilion MSCT (Toshiba, Tokyo,
Japan). Sixteen landmarks of the middle and adjacent inner ear were evaluated and
compared for their conspicuity according to a modified Likert scale. They found no
significant differences between these imaging techniques. Although the middle ear itself
was visible in all cases with CBCT, parts of the inner ear were cut off in four cases
due to the limited field of view of CBCT. The cochlear and vestibular aqueducts were not
visualized in either of the CT techniques. The contrast-to-noise ratio was more than 50%
lower in CBCT than in MSCT, but still adequate for the diagnostic task. They concluded
that CBCT is at least as accurate as routinely used MSCT in revealing the clinically and
surgically important middle-ear structures. The results showed that high quality imaging
of the middle ear is possible with the CBCT device that they used. They also used dry
temporal bone specimens for their research which resulted in images with different
qualities than the images made from human subjects. Their sample size was also small.
Barker and colleagues (22) investigated the utility of CBCT in facilitating
cochlear implantation. Five cadaveric heads had cement introduced into the 10 cochleas.
A modified Siemens PowerMobil CBCT scanner (Siemens Medical Solutions, Erlangen,
Germany) and a conventional CT scanner were compared to assess the extent of cochlear
obliteration. The cement was drilled-out (under CBCT guidance, if required) and
cochlear implant electrode arrays (from 3 different manufacturers) inserted. They
concluded that CBCT is useful for intraoperative imaging to facilitate electrode array
placement in the obliterated or congenitally abnormal cochlea.
Rafferty and colleagues (23) described the usefulness of CBCT in image-guided
surgery of the temporal bone. Temporal bone dissection was performed on five cadaver
heads using the modified C-arm Siemens PowerMobil CBCT scanner (Siemens Medical
32
Solutions, Erlangen, Germany) as an image guidance system. CBCT provided
submillimeter accuracy at high speed with low radiation dosage to offer utility as an
intraoperative imaging system.
Dahmani-Causse and colleagues (24) assessed the morphologic concordance
between vertical NewTom VGI CBCT (NewTom, Verona, Italy) and Philips helicoid 40-
channel MSCT (Philips Medical, Cleveland, OH) and compared the two techniques
qualitatively in stapes and footplate assessment and measurement of footplate thickness,
and quantitatively in terms of dosimetry. The study was performed on 12 temporal bones
from fresh human cadavers. Each underwent CBCT and MSCT. There was no significant
difference in morphologic assessment of the temporal bones on the two techniques.
Footplate thickness showed less overestimation on CBCT than on MSCT. CBCT
delivered 22 times less radiation than MSCT under their experimental conditions. They
included that CBCT provides reliable morphologic assessment of temporal bone with
higher spatial resolution than on MSCT and significantly reduced radiation dose.
Again, they used the temporal bone specimens for their research which results in
images with different qualities than images taken from human subjects since there is no
soft tissue and as a result different levels of scattered radiation will reach the image
receptor.
Purpose
To evaluate the diagnostic usefulness of cone beam computed tomographic
images (CBCT) using i-CAT CBCT machine (i-CAT Next Generation, Imaging Sciences
International, PA) and XORAN software for detection of the anatomical landmarks of the
external, middle and inner ear.

33
Hypothesis
i-CAT CBCT (i-CAT Next Generation, Imaging Sciences International, PA /
XORAN software) can be a replacement for MSCT for evaluation of the delicate
anatomical structure of the external, middle and inner ear.
Questions
Can we replace MSCT with dental i-CAT CBCT machine (i-CAT Next
Generation, Imaging Sciences International, PA / XORAN software) to evaluate the
anatomy of the temporal bone?

34
CHAPTER II
MATERIAL AND METHODS
Cone beam computed tomography images of 63 subjects with unknown clinical
histories were selected from the archive of the oral and maxillofacial radiology
department of the University of Iowa. Since this study is a preliminary descriptive study,
the sample size was determined according to time and availability.
All the images were made with the same CBCT machine (i-CAT Next
Generation, Imaging Sciences International, PA), at 0.4mm slice thickness with the tube
current at 23.87 mA and tube voltage at 120kVp. XORAN software was utilized to
visualize the images.
The images were selected based on the following inclusion and exclusion criteria:
Inclusion criteria:
Sufficient FOV to include the external, middle and inner ear.
Acceptable image quality
Exclusion criteria
Motion artifact
Attenuation artifact/beam hardening artifact caused by metallic dental
restorative materials and metallic crowns
Prior surgery, trauma or developmental abnormalities in the temporal
bone
Presence of pathosis in the temporal bone
The study was approved by The University of Iowa Institutional Review Board
(IRB ID: 201205777).

35
Anatomical landmarks
Seven anatomical points were chosen based on their clinical/surgical relevance in
the most common pathological conditions of the auditory system such as chronic otitis
media, chronic mastoiditis, cholesteatoma, otosclerosis and traumatic injuries. The
selected anatomical points are as follows:
1. Scutum in the coronal plane at the level of the head of the malleus and
oval window (Figure 16).
2. Oval window in the coronal plane where the stapes bone can be visualized
as a horizontal line running towards the oval window (figure 16).
3. The tympanic/horizontal segment of the facial nerve in the coronal plane
at the level of the oval window. It is seen as a round structure with/without
bony outline between the oval window inferiorly and the lateral
semicircular canal (LSC) superiorly (Figure 17).
4. The incudomalleolar (malleo-incudal) joint in the axial plane superior to
the level of the oval window and at the level of the horizontal portion of
the facial nerve canal. (Figure 18)
5. Anterior crus of stapes in the axial plane at the level of the oval window
and vestibule. (Figure 19)
6. Posterior crus of Stapes in the axial plane at the level of the oval window
and vestibule. (Figure 19)
7. The vertical/mastoid segment of the facial nerve in the axial plane is seen
posterior to the pyramidal eminence as a small, round structure. (Figure
20)
36
Figure 16: The coronal CBCT section shows the oval window and scutum.
37
Figure 17: The coronal CBCT section shows the lateral semi-circular canal (LSC), the
tympanic section of the facial nerve canal and the oval window.
38
Figure 18: The axial CBCT section through the mesotympanum shows the head of
malleus (HM), the body of incus (LI) and the incudomalleolar joint (arrow).
39
Figure 19: The axial MSCT section shows the anterior crus of stapes (AC), posterior
crus of stapes (PC) and the oval window.
40
Figure 20: The axial CBCT section shows the mastoid portion of the facial nerve canal
(MF) located posterior to the pyramidal eminence (PY).
41
Two oral and maxillofacial radiologists, with 43 and 8 years of experience in
radiology, evaluated the seven previously described anatomical landmarks on the right
and left temporal bone of each subject (total of 126 temporal bones) two times with at
least one week interval between the first and the second observation. The observers did a
pilot study on the right and left temporal bones of 17 subjects (total of 34 temporal bones)
two times with at least a week interval and were calibrated before starting on the
evaluation of the cases. The results were recorded by the radiologists attributing a value
of 0 if the anatomic structure in question could not be identified, 1 if identified
but poorly-defined and 2 if identified and well-defined. The data were recorded in
an excel spreadsheet.
An Overview of Statistical Methods
Descriptive statistics were conducted for all variables in the study, frequency
distribution tables were generated. The weighed kappa statistic was used to evaluate
intra-observer agreement (comparison of scores given at two different time points by the
same rater) and inter-observer agreement (comparison of scores given by two different
raters) on visualization of the anatomical landmarks. Each score of the seven anatomical
landmarks of the external, middle and inner ear was rated on the same anatomical
location and on the same subject by two observers. SAS for Windows (v9.3, SAS
Institute Inc, Cary, NC, USA) was used for the data analysis.
Interpretation of the Kappa Coefficient
The closer the kappa value is to one, the greater the agreement between the two
assessments. The following is an approximate guide for interpreting level of an
agreement that corresponds to kappa coefficient:
0 = No agreement
0 0.20 = poor agreement
0.21 0.40 = Fair agreement

42
0.41 0.60 = Moderate agreement
0.61-0.80 = Substantial agreement
0.81-0.99 = Strong agreement
1.00 = Perfect agreement
Remark
(1) Kappa coefficient is used to evaluate agreement between two raters or two
measurements. Kappa can also exhibit negative values when observed agreement is less
(or worse) than chance.
(2) The difference between the percent agreement and kappa coefficient is
that percent agreement is an intuitive approach to measuring agreement but does not
adjust for chance. Kappa provides a measure of agreement beyond that which would be
expected by chance, as estimated by the observed data.
(3) Weighted kappa was used in this study since the rating category is defined
on a ranked-ordered scale.
(4) In some cases, the total percent agreement should be reported for the study
due to the kappa statistics limitation -effects of case distribution (i.e. kappa is
significantly reduced if one classification category dominates, such as a classification of
well defined).
43
CHAPTER III
RESULTS
Sixty-three subjects aged 5-72 years (mean 33.83(std=22.2) years), including 15
males, 47 females, and one with unspecified sex, were included in the study.
Observer 1 first observations:
Left side observations
The scutum, the tympanic/horizontal segment of the facial nerve canal, the
mastoid/vertical segments of the facial nerve canal and the oval window of the left
temporal bone of 63 cases were visualized as a well-defined structure on the coronal
CBCT sections in all the cases (100%). The anterior and posterior crura of stapes, and the
incudomalleolar joint of the left temporal bone of 63 cases were visualized on the axial
CBCT sections as a well-defined structure in 19.05%, 55.56% and 52.38% of the cases,
as a poorly defined structure in 31.75%, 41.27% and 44.44% of the cases respectively.
The anterior and posterior crura of stapes and the incudomalleolar joint of the left
temporal bone of 63 cases could not be identified on the axial CBCT sections in 49.21%,
3.17% and 3.17% of the cases respectively. (Table 1)

44
Table 1. Summary of first observations of seven variables on the left side by observer
1(N=63).
Variable Frequency Percent (%)

Scutum/Coronal
0=Not-identified 0 0.00
1=Poorly-defined 0 0.00
2= Well-defined 63 100.00
Tympanic/horizontal segment of the facial
nerve canal/Coronal
Oval window/Coronal
Anterior crus of stapes/Axial
Posterior crus of stapes/Axial
Mastoid/vertical segment of the facial nerve
canal/Coronal
Incudomalleolar joint/Axial
45
Right side observations
The scutum, the tympanic/horizontal segment of the facial nerve canal and the
oval window of the right temporal bone of 63 cases were visualized as a well-defined
structure on the coronal CBCT sections 100%, 92.06% and 100% of the cases. The
tympanic/horizontal segment of the facial nerve canal was visualized as a poorly-defined
structure in 4.76 % and could not be identified in 3.17% of the cases. The anterior and
posterior crura of stapes, the mastoid/vertical segments of the facial nerve canal and the
incudomalleolar joint of the right temporal bone of 63 cases were visualized on the axial
CBCT sections as a well-defined structure in 30.16%, 50.79%, 98.41% and 63.49% of
the cases, as a poorly defined structure in 33.33%, 41.27%, 1.59% and 63.49% of the
cases respectively. The anterior and posterior crura of stapes, the mastoid/vertical
segments of the facial nerve canal and the incudomalleolar joint of the right temporal
bone of 63 cases could not be identified on the axial CBCT sections in 36.51%, 7.94%,
0% and 1.59% of the cases respectively. (Table 2)

46
Table 2. Summary of first observations of seven variables on the right side by
observer 1(N=63).

Scutum/Coronal
nerve canal/Coronal 2 3.17
2= Well-defined
Oval window/Coronal
canal/Coronal
47
Both side observations
The scutum, the tympanic/horizontal segment of the facial nerve canal and the
oval window of the right and left temporal bone of 63 cases (total 126 temporal bones)
were visualized as a well-defined structure on the coronal CBCT sections 100%, 96.03%
and 100% of the cases. The tympanic/horizontal segment of the facial nerve canal was
visualized as a poorly-defined structure in 2.38 % and could not be identified in 1.59% of
the cases. The anterior and posterior crura of stapes, the mastoid/vertical segments of the
facial nerve canal and the incudomalleolar joint of the right and left temporal bone of 63
cases (total 126 temporal bones) were visualized on the axial CBCT sections as a well-
defined structure in 24.60%, 53.17%, 99.21% and 57.94% of the cases, as a poorly
defined structure in 32.54%, 41.27%, 0.79% and 39.68% of the cases respectively. The
anterior and posterior crura of stapes, the mastoid/vertical segments of the facial nerve
canal and the incudomalleolar joint of the right and left temporal bone of 63 cases (total
126 temporal bones) could not be identified on the axial CBCT sections in 42.86%,
5.56%, 0% and 2.38% of the cases respectively.
Observer 1 second observations:
Observer 1 second readings are summarized in tables 4, 5 and 6.
Observer 2 first observations:
Observer 2 first readings are summarized in tables 7, 8 and 9.
Observer 2 second observations:
Observer 2 second readings are summarized in tables 10, 11 and 12.

48
Table 3. Summary of the first observations of seven variables on both sides by
observer 1(N=126).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
canal/Coronal
49
Table 4. Summary of second observations of seven variables on the left side by
observer 1(N=63).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
canal/Coronal
50
Table 5. Summary of second observations of seven variables on the right side by
observer 1(N=63).

Scutum/Coronal
nerve canal/Coronal 2 3.17
2= Well-defined
Oval window/Coronal
canal/Coronal
0=Not-identified 0 0
51
Table 6. Summary of second observations of seven variables on both sides by
observer 1(N=126).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
canal/Coronal
52
Table 7. Summary of first observations of seven variables on the left side by
observer 2(N=63).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
Frequency missing=1
Frequency missing=1
canal/Coronal
53
Table 8. Summary of first observations of seven variables on the right side by
observer 2(N=63).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
Frequency missing=2
Frequency missing=1
canal/Coronal
54
Table 9. Summary of first observations of seven variables on both sides by
observer 2(N=126).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
Frequency missing=3
Frequency missing=2
canal/Coronal
55
Table 10. Summary of second observations of seven variables on the left side by
observer 2 (N=63).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
canal/Coronal
56
Table 11. Summary of second observations of seven variables on the right side by
observer 2(N=63).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
canal/Coronal
57
Table 12. Summary of second observations of seven variables on both sides by
observer 2 (N=126).

Scutum/Coronal
nerve canal/Coronal
Oval window/Coronal
canal/Coronal
58
Intra-observer reliability
Observer 1
Perfect agreement was found between the two measurements made by observer 1 for
tympanic/horizontal and mastoid/vertical segments of the facial nerve canal, with a kappa
coefficient of 1.00. Kappa coefficients of 0.78 for incudomalleolar joint, 0.66 for anterior
crus of stapes, and 0.59 for posterior crus of stapes indicated moderate to substantial
agreement between the two measurements. Since the scutum and oval window were
visualized as a well-defined structure in 100% of the cases, there was no Kappa
calculated for these anatomical landmarks. More detailed results are summarized in Table
13.
Observer 2
Kappa coefficients of 0.28, 0.47 and 0.31 for anterior crus of stapes, posterior crus of
stapes, and for incudomalleolar joint, indicated fair to moderate agreement between the
two measurements made by observer 2. The total percent agreements for the
tympanic/horizontal and mastoid/vertical segments of the facial nerve canal were 90.5%
and 93.7%. More detailed results are summarized in Table 13.
Observer 1
Strong agreement was found between the two measurements made by observer 1 for
anatomical landmark incudomalleolar joint, with a kappa coefficient of 0.83, while kappa
coefficients of 0.49 for anterior crus of stapes and of 0.52 for posterior crus of stapes
indicated moderate agreement between the two measurements made by observer 1. Since
59
the scutum, tympanic/horizontal and mastoid/vertical segments of the facial nerve canal
and oval window were visualized as a well-defined structure in 100% of the cases; Kappa
was not calculated for these anatomical landmarks. More detailed results were
summarized in Table 14.
Observer 2
Kappa coefficients of 0.33 for anterior crus of stapes and of 0.27 for posterior crus of
stapes indicted fair agreement between the two measurements made by observer 2. The
total percent agreements were 96.8%, 95.2% and 60.3% for the tympanic/horizontal and
mastoid/vertical segments of the facial nerve canal, and incudomalleolar joint. More
detailed results were summarized in Table 14.
Observer 1
Perfect or strong agreement was found between the two measurements made by observer
1 for anatomical landmarks tympanic/horizontal and mastoid/vertical segments of the
facial nerve canal, and incudomalleolar joint, with Kappa coefficients ranging from 0.81
to 1.00. Kappa coefficients of 0.58 for anterior crus of stapes and of 0.56 for posterior
crus of stapes indicated moderate agreement between the two measurements. More
Observer 2
Kappa coefficients of 0.30 for anterior crus of stapes, 0.39 for posterior crus of stapes,
and 0.23 incudomalleolar joint, indicated fair agreement between the two measurements
made by observer 2. The total percent agreements were 93.7% and 94.4%for the
tympanic/horizontal and mastoid/vertical segments of the facial nerve canal. More

60
Inter-Observer Reliability
Observer 1 first observations vs. observer 2 first
observations
Strong agreement was found between the two observers for anatomical landmark
incudomalleolar joint, with Kappa coefficient of 0.90. Kappa coefficients of 0.57 for
posterior crus of stapes and of 0.69 for anterior crus of stapes indicated moderate and
substantial agreement between the two observers. The total percent agreements for the
tympanic/horizontal and mastoid/vertical segments of the facial nerve canal, were 88.9%
and 93.7%. More detailed results were summarized in Table 16.
Observer 1 first observations vs. observer 2 second
observations
Kappa coefficients of 0.24 for posterior crus of stapes, 0.28 for anterior crus of stapes,
and 0.31 for incudomalleolar joint indicated fair agreement between the two observers.
The total percent agreements were 87.3% and 96.8% for the tympanic/horizontal and
mastoid/vertical segments of the facial nerve canal. More detailed results were
Observer 1 second observations vs. observer 2 first
observations
Substantial agreement was found between the two observers for anatomical landmark
incudomalleolar joint, with a kappa coefficient of 0.75. Kappa coefficients of 0.45 for
anterior crus of stapes and of 0.47 for posterior crus of stapes indicated moderate
agreement between the two observers. The total percent agreements were 88.9% and
93.7% for the tympanic/horizontal and mastoid/vertical segments of the facial nerve
canal. More detailed results were summarized in Table 16.

61
Observer 1 second observations vs. observer 2 second
observations
Kappa coefficients of 0.15 for anterior crus of stapes, 0.29 for posterior crus of stapes and
0.31 for incudomalleolar joint indicated poor to fair agreement between the two
observers. The total percent agreements were 87.3% and 96.8% for the
observations
anterior crus of stapes and of 0.52 for posterior crus of stapes indicated moderate and
substantial agreement between the two observers. The total percent agreement was
98.4% for the tympanic/horizontal and mastoid/vertical segments of the facial nerve
observations
stapes indicated poor agreement between the two observers. The total percent agreements
were 98.4%, 96.8%, and 46% for the tympanic/horizontal and mastoid/vertical segments
of the facial nerve canal, and incudomalleolar joint. More detailed results were

62
observations
posterior crus of stapes and of 0.62 for anterior crus of stapes indicated moderate to
substantial agreement between the two observers. The total percent agreement was 98.4%
for the tympanic/horizontal and mastoid/vertical segments of the facial nerve canal. More
observations
stapes indicated poor agreement between the two observers. The total percent agreements
were 98.4%, 96.8% and 52.4% for the tympanic/horizontal and mastoid/vertical segments
of the facial nerve canal and incudomalleolar joint. More detailed results were
observations
Strong agreement was found between the two observers for anatomical landmark
posterior crus of stapes and of 0.62 for anterior crus of stapes indicated moderate and
substantial agreement between the two observers. The total percent agreement was 93.7%
and 96% for the tympanic/horizontal and mastoid/vertical segments of the facial nerve

63
observations
Kappa coefficients of 0.18 for anterior crus of stapes, 0.13 for incudomalleolar joint, and
0.21 for posterior crus of stapes indicated poor and fair agreement between the two
observers. The total percent agreements were 92.9% and 96.8%for the

observations
anterior crus of stapes and of 0.46 for posterior crus of stapes indicated moderate
agreement between the two observers. The total percent agreements were 93.7% and 96%
for the tympanic/horizontal and mastoid/vertical segments of the facial nerve canal. More
observations
Kappa coefficients of 0.17 for anterior crus of stapes, 0.19 for posterior crus of stapes,
and 0.18 for incudomalleolar joint indicated poor agreement between the two observers.
The total percent agreements were 92.9% and 96.8% for the tympanic/horizontal and
mastoid/vertical segments of the facial nerve canal. More detailed results were

64
Table 13. Comparison of the first and second observations of right temporal
bones by each observer (N=63).
Intra-observer agreement
Anatomical landmarks Observer 1 (1st Vs. Observer 2(1st Vs.
2nd) 2nd)
Scutum/Coronal
Both not-identified 0%(0) 0%(0)
Both poorly-defined 0%(0) 0%(0)
Both well-defined 100% (63) 100% (63)
Total percent agreement 100% (63) 100% (63)
Kappa* - -
Tympanic/horizontal segment of the
facial nerve canal/Coronal
Both not-identified 3.2%(2) 0%(0)
Both poorly-defined 4.8%(3) 0%(0)
Both well-defined 92.0%(58) 90.5%(57)
Total percent agreement 100%(63) 90.5%(57)
Kappa* 1.00(1.00-1.00) -0.04**(-0.08-0.00)
Oval window/Coronal
Kappa* - -
Both not-identified 30.2% (19) 4.8% (3)
Both poorly-defined 20.6% (13) 7.9% (5)
Both well-defined 22.2% (14) 36.5% (23)
Total percent agreement 73.0% (46) 49.2% (31)
Kappa* 0.66 (0.51-0.81) 0.28 (0.12-0.44)
Kappa* 0.59 (0.42-0.76) 0.47 (0.23-0.70)
65
Table 13_continued
2nd) 2nd)
Mastoid/vertical segment of the facial
nerve canal/Coronal
Total percent agreement 100% (63) 93.7% (59)
Kappa* 1.00 (1.00-1.00) -0.02** (-0.06-0.01)
Kappa* 0.78 (0.63-0.94) 0.31(0.04-0.58)
*Kappa statistics (95% confidence interval)
- Kappa coefficient is not calculated due to the same rating category obtained from both
raters or from both measures made by the same rater, i.e. no agreement can be evaluated
in this situation.
** No agreement between either the two measurements or between the two raters. The
total percent agreement should be reported in this case due to the Kappa statistics
limitation -effects of case distribution (i.e. kappa is significantly reduced if one
classification category (category=well defined in this study) dominates.
#Total percent agreement indicted that Rater1 and Rater2 or (measure1 and measure 2)
agreed with each other a certain percentage of the classifications.
66
Table 14. Comparison of the first and second observations of left temporal bones
by each observer (N=63).
2nd) 2nd)
Scutum/Coronal
Kappa* - -
Both not-identified 0%(0) 0% (0)
Both poorly-defined 0%(0) 0% (0)
Both well-defined 100% (63) 96.8% (61)
Kappa* - -0.02** (-0.04-0.01)
Oval window/Coronal
Kappa* - -
Kappa* 0.49 (0.29-0.69) 0.33 (0.17-0.48)
Kappa* 0.52 (0.33-0.71) 0.27 (0.01-0.59)
67
Table 14_continued
2nd) 2nd)
nerve canal/Coronal
Both not-identified 0%(0) 0.0% (0)
Both poorly-defined 0%(0) 0.0% (0)
Both well-defined 100% (63) 95.2% (60)
Kappa* - -0.02**(-0.05-0.01)
Incudomalleolar joint
Kappa* 0.83 (0.70-0.96) 0.16** (-0.11-0.42)
in this situation.
68
Table 15. Comparison of the first and second observations of bilateral temporal
bones by each observer; (N=126).
Anatomical landmarks Observer 1 (1st Observer 2(1st Vs.
Vs. 2nd) 2nd)
Scutum/Coronal
Kappa* - -
Both not-identified 1.6 (2) 0% (0)
Both poorly-defined 2.4 (3) 0% (0)
Kappa* 1.00 (1.00-1.00) -0.03** (-0.05 - -0.01)
Oval window/Coronal
Kappa* - -
Kappa* 0.58 (0.45-0.70) 0.30 (0.19-0.41)
Kappa* 0.56 (0.43-0.69) 0.39 (0.20-0.57)
69
Table 15_continued
Anatomical landmarks Observer 1 (1st Observer 2(1st Vs.
Vs. 2nd) 2nd)
nerve canal/Coronal
Kappa* 1.00 (1.00-1.00) -0.03* (-0.05- -0.01)
Both poorly-defined 34.9% (44) 11.1% ((14)
Kappa* 0.81(0.71-0.91) 0.23 (0.04-0.42)
in this situation.
70
Table 16. Comparison of the first and second observations of right temporal
bones between the observers (N=63).
Inter-observer agreement
Observer 1- Observer 1- Observer 1- Observer 1-
Anatomical landmarks 1st vs. 1st vs. 2nd vs. 2nd vs.
observer 2- observer 2- observer 2- observer 2-
1st 2nd 1st 2nd
Scutum/Coronal
Both not-identified 0%(0) 0%(0) 0%(0) 0%(0)
Both poorly-defined 0%(0) 0%(0) 0%(0) 0%(0)
Both well-defined 100% (63) 100% (63) 100% (63) 100% (63)
Total percent agreement 100% (63) 100% (63) 100% (63) 100% (63)
Kappa* - - - -
Tympanic/horizontal
segment of the facial
nerve canal/Coronal
Both not-identified 0% (0) 0% (0) 0% (0) 0% (0)
Both poorly-defined 0% (0) 0% (0) 0% (0) 0% (0)
Both well-defined 88.9% (56) 87.3% (55) 88.9% (56) 87.3% (55)
Total percent agreement 88.9% (56) 87.3% (55) 88.9% (56) 87.3% (55)
Kappa* -0.04** (- 0.08** (- -0.05** (- 0.09** (-0.16-
0.08-0.00) 0.16-0.33) 0.10-0.00) 0.33)
Oval window/Coronal
Kappa* - - - -
Anterior crus of
stapes/Axial
Both not-identified 19.0% (12) 9.5% (6) 15.9% (10) 6.3% (4)
Both poorly-defined 30.2% (19) 7.9% (5) 19.0% (12) 4.8% (3)
Kappa* 0.69 (0.54- 0.24 (0.09- 0.45 (0.29- 0.15 (0.05-
0.84) 0.38) 0.60) 0.26)
71
Table 16_continued
1st 2nd 1st 2nd
Posterior crus of
stapes/Axial
Kappa* 0.57 (0.41- 0.28 (0.07- 0.47 (0.32- 0.29 (0.10-
0.73) 0.49) 0.63) 0.48)
Mastoid/vertical
nerve canal/Coronal
Kappa* -0.02** (- -0.02** (- -0.02** (- -0.02** (-
0.06-0.01) 0.04-0.01) 0.06-0.01) 0.04-0.01)
Kappa* 0.90 (0.79- 0.31(0.05- 0.75 (0.58- 0.31 (0.07-
1.00) 0.57) 0.91) 0.59)
in this situation.
72
73
Table 17. Comparison of the first and second observations of left temporal bones
between the observers; (N=63).
1st 2nd 1st 2nd
Scutum/Coronal
Kappa* - - - -
Tympanic/horizontal
nerve canal/Coronal
Kappa* 0.00** (0.00- 0.00** 0.00** 0.00* (0.00-
0.00) (0.00- (0.00- 0.00)
0.00) 0.00)
Oval window/Coronal
Kappa* - - - -
Anterior crus of
stapes/Axial
Kappa* 0.54 (0.37- 0.13 (0.04- 0.62 (0.47- 0.18 (0.07-
0.70) 0.23) 0.78) 0.30)
74
Table 17_continued
1st 2nd 1st 2nd
Posterior crus of
stapes/Axial
Kappa* 0.52 (0.32- 0.15 (0.01- 0.45 (0.25- 0.12 (0.01-
0.72) 0.38) 0.64) 0.32)
Mastoid/vertical
nerve canal/Coronal
Kappa* 0.00** (0.00- 0.00** 0.00** 0.00** (0.00-
0.00) (0.00- (0.00- 0.00)
0.00) 0.00)
Kappa* 0.74 (0.58- -0.04** (- 0.74 (0.57- 0.06** (-0.20-
0.90) 0.29-0.22) 0.90) 0.32)
in this situation.
75
76
Table 18. Comparison of the first and second observations of bilateral temporal
bones between the observers; (N=126).
1st 2nd 1st 2nd
Scutum/Coronal
Kappa* - - - -
Tympanic/horizontal
nerve canal/Coronal
Kappa* -0.03** (- 0.10** (- -0.03** (- 0.10** (-0.12-
0.05 - - 0.12-0.33) 0.05 - - 0.33)
0.01) 0.01)
Oval window/Coronal
Kappa* - - - -
Anterior crus of
stapes/Axial
Kappa* 0.62 (0.50- 0.18 (0.09- 0.53 (0.42- 0.17 (0.09-
0.73) 0.26) 0.65) 0.25)
77
Table 181_continuied
1st 2nd 1st 2nd
Posterior crus of
stapes/Axial
Kappa* 0.55 (0.42- 0.21 (0.06- 0.46 (0.34- 0.19 (0.07-
0.67) 0.36) 0.59) 0.32)
Mastoid/vertical
nerve canal/Coronal
Kappa* -0.02**(- -0.01** (- -0.01** (- -0.01** (-
0.03-0.01) 0.03-0.01) 0.03-0.01) 0.03-0.01)
Kappa* 0.82(0.72- 0.13 (-0.06- 0.74 (0.63- 0.18 (0.00-
0.92) 0.31) 0.86) 0.36)
in this situation.
78
79
CHAPTER IV
DISCUSSION
The temporal bone is one of the most complex bones in the body and contains
very delicate anatomical structures. It houses the auditory system which plays an
important role in hearing and balance and can be involved by fractures, developmental
abnormalities, infectious conditions, and benign and malignant tumors. Treatment of
these conditions usually involves MSCT imaging which exposes the patient to a much
higher radiation dose compared to CBCT. The patient cumulative absorbed dose could
eventually increase to a substantial amount as a result of multiple follow up CT studies
required for treatment. CBCT can provide images with identical information, isometric
voxel size, and reduced metal- and beam-hardening artifacts, considerable dose reduction
and reasonably low costs compared to MSCT especially where multiple follow up
imaging studies are needed (15, 16, 21, 32, 37-39). Some CBCT scanners use a digital
flat-panel detector which offers much smaller detector element size compared with
MSCT detector and as a result higher spatial resolution. The flat-panel detectors however
have a lower dynamic range because a smaller detector element receives fewer x-ray
photons. This results in inferior contrast resolution and a design that favors spatial
resolution over soft-tissue contrast; however, temporal bone imaging benefits from a
system with high spatial resolution more than high soft tissue contrast because it contains
many high-contrast-resolution structures such as the ossicular chain and various bony
canals(37). The purpose of this study was to evaluate the diagnostic usefulness of CBCT,
using XORAN software, for detection of the anatomical landmarks of the external,
middle and inner ear to answer this question whether MSCT can be replaced by dental
CBCT for evaluation of the temporal bone.
Our results show that scutum can be optimally evaluated using CBCT images as it
was visualized as a well-defined structure in 100% of the cases on CBCT by both the
80
observers. Scutum is a pointed, wedge-shaped bony wall where the pars flaccida of the
tympanic membrane attaches to the superior aspect of the external auditory canal. This
anatomical structure is of importance because the majority of acquired cholesteatomas of
the middle ear arises primarily from the pars flaccida of the tympanic membrane and
Prussaks space 3 and characteristically erodes the scutum (28, 29, 40-44). Our finding is
in agreement with the results of the study performed by Peltonen and colleagues (21) who
were able to visualize scutum as a well-defined structure in all the CBCT images
acquired from 13 dry temporal bone specimens using a 3D Accuitomo CBCT unit;
however, the absence of the soft tissue and other adjacent anatomical structures of the
skull, and as a result less scattered radiation, makes the images evaluated in this study
different from the images acquired from human subjects.
The oval window was visualized in 100% of the CBCT images by both the
observers. The oval window is an important anatomical structure in evaluation of
otosclerosis. Otosclerosis (spongiosis) is an autosomal dominant disease with variable
penetrance and expression (45). The pathogenesis of this disease is still unknown (46,
47). This disease is characterized by pathological bone remodeling involving the otic
capsule that can result in spongiosis and/or sclerosis of this region and impingement of
abnormal bone on stapes footplate leading to progressive conductive, sensorineural, or
mixed hearing loss. The fissula ante fenestram, which is a small cleft located in the bone
just anterior to the oval window, is considered to be the most common location of
involvement of otosclerosis(48, 49). Our finding is in agreement with the results of the
study carried out by Peltonen and colleagues (21) showing that 100% of the CBCT
images, acquired from 13 dry temporal bone specimens using 3d Accuitomo CBCT
3 Prussaks space is a small space in the middle ear cavity that lies between the pars
flaccida of the tympanic membrane and the neck of malleus with the superior boundary being the
lateral malleolar ligament (which extends from scutum to the neck of malleus) and the inferior
boundary the lateral process of malleus (30, 56).
81
machine, showed the oval window as a well-defined structure; however, the acquisition
conditions in this study were not those of clinical examination where image quality may
be greatly affected by soft tissue attenuation effects, scatter radiation and metallic or
kinetic artifacts. Redfors and colleagues (50) however could not identify the oval window
on CBCT images made by 3D Accuitomo machine in most of the cases and the reason for
that might have been the fact that all the sixteen human subjects had had a stapedectomy
and the oval windows were all affected by otosclerosis and surgery.
Observer 1 identified the incudomalleolar joint as a well-defined structure in
57.94% and a poorly-defined structure in 39.68% of the cases. Although there was a
strong intra-observer agreement for observer 1, fair intra-observer agreement for
detection of this landmark by observer 2 and poor inter-observer agreement between
observer 1 first observations and observer 2 second observations and also between second
observations of the observers may be suggestive of inadequacy of i-CAT CBCT machine
in showing this delicate anatomical landmark. Evaluation of incudomalleolar joint is
important in detection of fixation and/or erosion of this joint caused by various

pathological conditions such as otitis media, cholesteatoma and less commonly benign or
malignant tumors of the middle ear cavity. Otitis media is the second most common
disease of childhood after upper respiratory tract infection. Chronic otitis media can
spread to the mastoid air cells and cause otomastoiditis which can cause retraction and
perforation of the tympanic membrane, acquired cholesteatoma, ossicular fixation and

erosion, and sclerosis of the surrounding bone (Figure 52) (32, 51). Incudomalleolar
dislocation/subluxation is a complication sometimes observed in patients with trauma to
the temporal bone (25, 52). CBCT proved to be at least as accurate as routinely used
MSCT in revealing the incudomalleolar joint in a study done by Peltonen and colleagues
(21) however, the acquisition conditions in this study were different from clinical
examination as they imaged the dry temporal bones. Image quality may be greatly
affected by soft tissue attenuation effects, scatter radiation and metallic or kinetic artifacts
82
in clinical examinations. Gupta and colleagues (37) also resulted that CBCT offers well-
defined visualization of the ossicular chain and incudomalleolar joint; however, their
sample size of 4 temporal bones was small and the experimental CBCT machine that they
utilized is different from the CBCT machines available in the market today.
The tympanic/horizontal and mastoid/vertical segments of the facial nerve were
identified as a well-defined structure in 96.03% and 99.21% by observer 1 with strong
intra-observer agreement between the first and second observations. The total percent
intra-observer agreement for the tympanic/horizontal and mastoid/vertical segments of
the facial nerve by the second observer was 93.7% and 94.4%. This may indicated that i-
CAT CBCT machine is a reliable imaging modality for evaluation of these anatomical
structures. Pathological conditions of the middle ear cavity such as cholesteatoma and
otitis media may cause erosion of the horizontal segment of the canal and thereby cause
facial palsy. The vertical segment of the facial nerve canal is bounded medially by the
sinus tympani and jugular bulb, laterally by the facial recess and anteriorly by the
pyramidal eminence. The medial aspect of the mastoid segment may be either dehiscent
or separated from the jugular bulb by a layer of bone measuring 7 mm or more in width.
This part of the facial nerve may be compromised by erosive jugulotympanic
paragangliomas in the region of the jugular fossa (36). Gupta and colleagues (37)
reported that the facial nerve could be directly imaged using CBCT over its entire course
and all its branches could be individually identified. However, they used dry temporal
bone specimens and an experimental CBCT machine different from the ones in use
today; moreover, their sample size of 4 was small.
The anterior and posterior crura of stapes were identified by observer 1 as a well-
defined structure in 24.60% and 53.17%, as a poorly defined structure in 32.54% and
41.27% and could not be identified in 42.86% and 5.56% of the cases. There was
moderate intra-observer agreement for the observer 1, fair intra-observer agreement for
observer 2 and poor to moderate inter-observer agreement between the observers. This is
83
suggestive of lower diagnostic ability of i-CAT CBCT images used in the present study
in identifying these delicate anatomical landmarks. The CBCT images used in the present
study were made from the oral and maxillofacial region with a large FOV that included
the temporal bone at the edges of the volume. The large FOV results in a much higher
scattered radiation and consequently a lower signal-to-noise ratio. Acquiring small
volume CBCT images targeted to the middle ear cavity could theoretically result in
images with a higher signal-to-noise ratio which might show the more delicate
anatomical structures of the temporal bone such as the anterior and posterior crura of
stapes more clearly. In a study performed by Dahmani and colleagues (53), a FOV of
CBCT corresponding to a cylinder of 127.5 cm, allowed complete imaging of one
temporal bone specimen at a time. This will be especially beneficial in patients with
unilateral involvement of the temporal bone who need only one temporal bone to be
evaluated through imaging. Imaging of both the temporal bones however will increase
the radiation dose to the patient. Peltonen and colleagues(21) performed a study to access
the applicability of CBCT in the temporal bone region in comparison with MSCT and
concluded that CBCT is at least as accurate as routinely used MSCT in revealing the
anterior and posterior crura of stapes; however, the acquisition conditions in this study
were not those of clinical examination, where image quality may be greatly affected by
soft tissue attenuation effects, scatter radiation and metallic or kinetic artifacts.
Some CBCT software such as Anatomage can be used to develop oblique planar
images in relation to the long axis of the petrous bone which will be beneficial in
evaluation of the complex anatomy of the petrous portion of the temporal bone. Oblique
planar images can be obtained at a standard or corrected angulation according to the
anatomy of each individual patient. Images obtained at a standard 45 degree angle to the
mid-sagittal, and longitudinal to the petrous bone, simulate the plain radiograph skull
projection known as the Stenvers projection (an occipito-frontal with the head rotated 45
degree and a 12 degree tilt away from the feet). The plane of the Stenvers sections is
84
perpendicular to the course of the superior semicircular canal. Images perpendicular to
this projection, providing cross-sectional images of the petrous bone, simulate the plain
radiograph skull projection known as the Pschl projection, also called the axial
projection of the pyramid or the transverse pyramidal plane. We recommend a modified
Stenvers projection in which the oblique planar reconstruction is obtained by corrected
adjustment of the Stenvers plane through the longitudinal axial of the petrous portion of
the temporal bone. This will subsequently provide modified Pschl views. Lane, et al.,
(2006) recommend a more extensive imaging protocol with multi-planar reconstruction
tailored towards specific elements combining single oblique sagittal and coronal, double-
oblique axial, sagittal and coronal planes at specific orientations to variable primary
reference planes(54, 55).
One of the limitations of this study was that despite all the effort taken to calibrate
the observers, there may have been some bias in the study where there was disagreement
between the two observers in visualization of the delicate anatomical landmarks.
Presence of a third observer is recommended if the similar study is to be done in order to

decrease the bias caused by disagreement between the observers.
85
CHAPTER V
CONCLUSION
The I-CAT CBCT machine is a promising replacement for MSCT in evaluation of
the temporal bone where there is no need for evaluation of the anterior and posterior
crura of stapes and the incudomalleolar joint which are the most delicate anatomical
structures in the temporal bone. Other CBCT machines with higher contrast to noise ratio
should be evaluated for detection of those anatomical structures because CBCT can
reduce the patient dose substantially especially where multiple follow up CT studied are
needed.
86
REFERENCES
1. Siewerdsen JH, Jaffray DA. Cone-beam computed tomography with a flat-panel

imager: Magnitude and effects of x-ray scatter. Medical physics JID - 0425746.
2001;28(2):220-31.
2. Bushong SC. Radiologic science for technologists : Physics, biology, and protection.
St. Louis, MO : Mosby; 2001.
3. Goldman LW. Principles of CT and CT technology. J Nucl Med Technol;35(3):115.
4. Goldman LW. Principles of CT: Multislice CT. J Nucl Med Technol;36(2):57.
5. Arai YF, Tammisalo EF, Iwai KF, Hashimoto KF, Shinoda K. Development of a
compact computed tomographic apparatus for dental use. Dentomaxillofac Radiol.
1999;28(4):245-8.
6. Mozzo P, P. A new volumetric CT machine for dental imaging based on the cone-
beam technique: Preliminary results. Eur Radiol;8(9):1558-64.
7. Hatcher DC. Operational principles for cone-beam computed tomography. J Am Dent

Assoc. 2010;141(3):3S-6S.
8. Lai C, Shaw C, Chen L, Mustafa C, Altunbas M, Liu X, et al. Visibility of

microcalcification in cone beam breast CT: Effects of X-ray tube voltage and radiation
dose. Med Phys. 2007;34(7):2995-3004.
9. Orth RC, Wallace MJ, Kuo MD. C-arm cone-beam CT: General principles and
technical considerations for use in interventional radiology. Journal of Vascular and
Interventional Radiology. 2009 7;20(7, Supplement):S538-44.
10. White SC, Pharoah MJ. Oral radiology. 6th ed. White SC and Pharoah MJ, editors.
St. Louis, Missouri: Mosby; 2009.
11. Carrafiello G, Dizonno M, Colli V, Strocchi S, Pozzi Taubert S, Leonardi A, et al.

Comparative study of jaws with multislice computed tomography and cone-beam
computed tomography. Radiol Med. 2010 Jun;115(4):600-11.
12. Jacobs R. Dental cone beam CT and its justified use in oral health care. JBR-BTR.
2011 Sep-Oct;94(5):254-65.
13. Lofthag-Hansen S. Cone beam computed tomography radiation dose and image
quality assessments. Swed Dent J Suppl. 2009;209:4-55.
87
14. Lofthag-Hansen S, Thilander-Klang A, Ekestubbe A, Helmrot E, Grondahl K.

Calculating effective dose on a cone beam computed tomography device: 3D accuitomo
and 3D accuitomo FPD. Dentomaxillofac Radiol. 2008 Feb;37(2):72-9.
15. Peltonen LI, Aarnisalo AA, Kaser Y, Kortesniemi MK, Robinson S, Suomalainen A,
et al. Cone-beam computed tomography: A new method for imaging of the temporal
bone. Acta Radiol. 2009 Jun;50(5):543-8.
16. Faccioli N, Barillari M, Guariglia S, Zivelonghi E, Rizzotti A, Cerini R, et al.

Radiation dose saving through the use of cone-beam CT in hearing-impaired patients.
Radiol Med. 2009 Dec;114(8):1308-18.
17. Miracle A, Mukherji SK. Conebeam CT of the head and neck, part 2: Clinical
applications. AJNR Am J Neuroradiol. 2009;30(7):1285-92.
18. Akpek SF, Brunner TF, Benndorf GF, Strother C. Three-dimensional imaging and
cone beam volume CT in C-arm angiography with flat panel detector. Diagnostic and
interventional radiology (Ankara, Turkey) JID - 101241152. 2005;11(1):10-3.
19. Dalchow CV, Weber AL, Yanagihara N, Bien S, Werner JA. Digital volume
tomography: Radiologic examinations of the temporal bone. AJR Am J Roentgenol. 2006
Feb;186(2):416-23.
20. Dalchow CV, Weber AL, Bien S, Yanagihara N, Werner JA. Value of digital volume
tomography in patients with conductive hearing loss. Eur Arch Otorhinolaryngol. 2006
Feb;263(2):92-9.
21. Peltonen LI, Aarnisalo AA, Kortesniemi MK, Suomalainen A, Jero J, Robinson S.
Limited cone-beam computed tomography imaging of the middle ear: A comparison with
multislice helical computed tomography. Acta Radiol. 2007 Mar;48(2):207-12.
22. Barker E, Trimble K, Chan H, Ramsden J, Nithiananthan S, James A, et al.

Intraoperative use of cone-beam computed tomography in a cadaveric ossified cochlea
model. Otolaryngol Head Neck Surg. 2009 May;140(5):697-702.
23. Rafferty MA, Siewerdsen JH, Chan Y, Daly MJ, Moseley DJ, Jaffray DA, et al.
Intraoperative cone-beam CT for guidance of temporal bone surgery. Otolaryngol Head
Neck Surg. 2006 May;134(5):801-8.
24. Dahmani-Causse MF, Marx MF, Deguine OF, Fraysse BF, Lepage BF, Escude B.
Morphologic examination of the temporal bone by cone beam computed tomography:
Comparison with multislice helical computed tomography. European annals of
otorhinolaryngology, head and neck diseases JID - 101531465. 1107.
25. Standring S, Gray H,. Gray's anatomy [electronic resource] : The anatomical basis of
clinical practice / editor. Edinburgh : Churchill Livingstone/Elsevier; 2008.
88
26. Kelly KE, Mohs DC. The external auditory canal. anatomy and physiology.
Otolaryngol Clin North Am. 1996 Oct;29(5):725-39.
27. Alvord LS, Farmer BL. Anatomy and orientation of the human external ear. J Am
Acad Audiol. 1997 Dec;8(6):383-90.
28. Swartz JD, Varghese S. Pars flaccida cholesteatoma as demonstrated by computed

tomography. Arch Otolaryngol. 1984 Aug;110(8):515-7.
29. Swartz JD. Cholesteatomas of the middle ear. diagnosis, etiology, and complications.
Radiol Clin North Am. 1984 Mar;22(1):15-35.
30. Nardis PF, Bellelli A, D'Ottavi LR. Cholesteatoma of the prussak's space. diagnosis
with computerized tomography. Radiol Med. 1992 Mar;83(3):216-8.
31. Gaurano JL, Joharjy IA. Middle ear cholesteatoma: Characteristic CT findings in 64
patients. Ann Saudi Med. 2004 Nov-Dec;24(6):442-7.
32. Swarts JD. The middle ear and mastoid. In: Swartz JD, Loevner LA, editors. Imaging
of the temporal bone. 4th ed. New York, N.Y.: Thieme Medical Publishers; 2009. p. 58-
246.
33. Clement PA, De Smedt E. High-resolution computerized tomographic scans of the

normal and abnormal ear. Am J Otolaryngol. 1982 Jul-Aug;3(4):286-94.
34. Kutz JW,Jr, Husain IA, Isaacson B, Roland PS. Management of spontaneous
cerebrospinal fluid otorrhea. Laryngoscope. 2008 Dec;118(12):2195-9.
35. Mazziotti S, Arceri F, Vinci S, Salamone I, Racchiusa S, Pandolfo I. Role of coronal

oblique reconstruction as a complement to CT study of the temporal bone: Normal
anatomy. Radiol Med. 2006 Jun;111(4):607-17.
36. Philips CD, Hanshisaki G, Veillon F. Anatomy and developement of the facial nerve.
In: Swarts JD, Loevner LA, editors. 4th ed. New York, NY: Thieme; 2008. p. 444-79.
37. Gupta R, Bartling S, Basu S, Ross W, Becker H, Pfoh A, et al. Experimental flat-
panel high-spatial-resolution volume CT of the temporal bone. AJNR.American journal
of neuroradiology JID - 8003708. 2004;25(8):1417-24.
38. Swartz JD. An overview of congenital/developmental sensorineural hearing loss with

emphasis on the vestibular aqueduct syndrome. Semin Ultrasound CT MR. 2004
Aug;25(4):353-68.
39. Swartz JD. Temporal bone trauma. Semin Ultrasound CT MR. 2001 Jun;22(3):219-
28.
89
40. Park KH, Park SN, Chang KH, Jung MK, Yeo SW. Congenital middle ear
cholesteatoma in children; retrospective review of 35 cases. J Korean Med Sci. 2009
Feb;24(1):126-31.
41. Darrouzet V, Duclos JY, Portmann D, Bebear JP. Congenital middle ear
cholesteatomas in children: Our experience in 34 cases. Otolaryngol Head Neck Surg.
2002 Jan;126(1):34-40.
42. Louw L. Acquired cholesteatoma pathogenesis: Stepwise explanations. J Laryngol

Otol. 2010 Jun;124(6):587-93.
43. McKennan KX, Chole RA. Post-traumatic cholesteatoma. Laryngoscope. 1989

Aug;99(8 Pt 1):779-82.
44. Preciado DA. Biology of cholesteatoma: Special considerations in pediatric patients.

Int J Pediatr Otorhinolaryngol. 2012 Jan 19.
45. Saeed SR, Briggs M, Lobo C, Al-Zoubi F, Ramsden RT, Read AP. The genetics of
otosclerosis: Pedigree studies and linkage analysis. Adv Otorhinolaryngol. 2007;65:75-
85.
46. Bloch SL, Sorensen MS. Otosclerosis: A perilabyrinthine threshold phenomenon.

Acta Otolaryngol. 2012 Jan 4:[Epub ahead of print].
47. Markou K, Goudakos J. An overview of the etiology of otosclerosis. Eur Arch

Otorhinolaryngol. 2009 Jan;266(1):25-35.
48. Horner KC. The effect of sex hormones on bone metabolism of the otic capsule--an
overview. Hear Res. 2009 Jun;252(1-2):56-60.
49. Lee TC, Aviv RI, Chen JM, Nedzelski JM, Fox AJ, Symons SP. CT grading of
otosclerosis. AJNR Am J Neuroradiol. 2009 Aug;30(7):1435-9.
50. Redfors YD, Grondahl HG, Hellgren J, Lindfors N, Nilsson I, Moller C. Otosclerosis:
Anatomy and pathology in the temporal bone assessed by multi-slice and cone-beam CT.
Otology & neurotology : official publication of the American Otological Society,
American Neurotology Society and] European Academy of Otology and Neurotology JID
- 100961504. 2012;33(6):922-7.
51. Morris PS, Leach AJ. Acute and chronic otitis media. Pediatr Clin North Am. 2009
Dec;56(6):1383-99.
52. Meriot P, Veillon F, Garcia JF, Nonent M, Jezequel J, Bourjat P, et al. CT

appearances of ossicular injuries. Radiographics. 1997 Nov-Dec;17(6):1445-54.
90
53. Dahmani-Causse M, Marx M, Deguine O, Fraysse B, Lepage B, Escude B.

Morphologic examination of the temporal bone by cone beam computed tomography:
Comparison with multislice helical computed tomography. Eur Ann Otorhinolaryngol
Head Neck Dis. 2011 Nov;128(5):230-5.
54. Lane JI, Lindell EP, Witte RJ, DeLone DR, Driscoll CL. Middle and inner ear:
Improved depiction with multiplanar reconstruction of volumetric CT data.
Radiographics. 2006 Jan-Feb;26(1):115-24.
55. Branstetter BF,4th, Harrigal C, Escott EJ, Hirsch BE. Superior semicircular canal
dehiscence: Oblique reformatted CT images for diagnosis. Radiology. 2006
Mar;238(3):938-42.
56. Miyanaga S, Morimitsu T. Prussak's space: Chronological development and routes of

aeration. Auris Nasus Larynx. 1997 Jul;24(3):255-64.

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University of Iowa

Iowa Research Online

Usefulness of dental cone beam computed

Copyright 2013 Mahdieh Taleb Mehr

This thesis is available at Iowa Research Online: http://ir.uiowa.edu/etd/2643

Follow this and additional works at: http://ir.uiowa.edu/etd

Part of the Oral Biology and Oral Pathology Commons

FOR DETECTION OF THE ANATOMICAL LANDMARKS OF THE EXTERNAL,

MIDDLE AND INNER EAR

A thesis submitted in partial fulfillment

Thesis Supervisor: Professor Axel Ruprecht

MAHDIEH TALEB MEHR

All Rights Reserved

This is to certify that the Master's thesis of

Mahdieh Taleb Mehr

has been approved by the Examining Committee for the

Thesis Committee: ___________________________________

for guiding me throughout my academic program. My sincere appreciation goes to other

members of my thesis committee, Dr. Veeratrishul Allareddy, Dr. Michael Finkelstein,

It is with immense gratitude that I acknowledge the support and help of my

Timmons for their valuable guidance in my residency program.

I extend my appreciation to Dr. Wendy Smoker for her valuable input in

teaching me neuroradiology during my hospital rotations.

encouragement, love and support.

I owe my deepest appreciation to my mother (Marzieh Forati), stepfather

throughout my academic career.

low costs compared to multislice computed tomography (MSCT) especially where

Material and methods: Cone beam computed tomography (CBCT) images of 63

retrospectively. Seven anatomical points (scutum, oval window, incudomalleolar joint,

Conclusion: The i-CAT CBCT machine is a promising replacement for MSCT in

ear; inner ear; temporal bone.

LIST OF TABLES ............................................................................................................. ix

LIST OF FIGURES ........................................................................................................... xi

CHAPTER I. INTRODUCTION .........................................................................................1

Computed tomography .....................................................................................1

CHAPTER II. MATERIAL AND METHODS .................................................................34

Inclusion criteria .............................................................................................34

CHAPTER III. RESULTS .................................................................................................43

Observer 1 first observations ..........................................................................43

CHAPTER V. CONCLUSION ..........................................................................................82

1. Summary of first observations of seven variables on the left side by the

2. Summary of first observations of seven variables on the right side by the

3. Summary of the first observations of seven variables on both sides by the

4. Summary of second observations of seven variables on the left side by the

5. Summary of second observations of seven variables on the right side by the

6. Summary of second observations of seven variables on both sides by the

7. Summary of first observations of seven variables on the left side by the

8. Summary of first observations of seven variables on the right side by the

9. Summary of first observations of seven variables on both sides by the

12. Summary of second observations of seven variables on both sides by the

1. CT scanner generations ...............................................................................................3

2. Principles of spiral CT scanners .................................................................................4

3. Cone beam computed tomography .............................................................................7

4. Lateral, superior and inferior views of the temporal bone..........................................9

5. The scutum and external auditory canal. ..................................................................10

6. Blunting of scutum by cholesteatoma. ......................................................................11

7. The ossicles of the middle ear...................................................................................14

8. The ossicles of the middle ear on CBCT ..................................................................15

9. The ossicles of the middle ear on CBCT ..................................................................16

10. The ossicles of the middle ear on CT. ......................................................................17

11. Inner ear. ...................................................................................................................20

12. Inner ear on CBCT. ...................................................................................................21

13. Inner ear. ...................................................................................................................23

14. Inner ear on CBCT....................................................................................................26