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ORIGINAL ARTICLE

Radiological study of the temporal bone in

chronic otitis media: Prospective study of
50 cases
Thripthi Rai
Department of ENT, Mysore Medical College and Research Centre, Mysore, Karnataka, India

Aim: To assess radiological findings in Chronic otitis media (COM), its involvement in middle ear and adjacent
Abstract
structure and to compare with similar published data. The ability of the radiological investigations to detect the
various pathological and anatomical variations were evaluated and compared with intraoperative findings. COM
is a long standing inflammation of the middle ear cleft without reference to etiology or pathogenesis. Due to the
strategic location of the tympanomastoid compartment, separated from the middle and posterior cranial fossa
by the thinnest of bony partitions, otitis media has the potential for intracranial extension. Hence, it becomes very
important to know the location and extent of the disease before proceeding to surgical treatment. Radiological
examination of the temporal bone helps us to achieve this objective. The present work has been undertaken to
study the role of radiological imaging of the temporal bone as a diagnostic modality in COM and its use in
determining the lines of management as in the type of surgical intervention required. Materials and Methods: This
is a prospective study in which total of 50 cases with COM were studied. Results: HRCT is reliable for all the
parameters like scutum erosion, ossicular erosion, mastoid pneumatisation, low lying dura, anterior lying sigmoid,
Korner’s septum, cholesteatoma extension in the middle ear and mastoid, and presence of complications such as
mastoiditis and mastoid abscess, mastoid cortex dehiscence, sigmoid sinus plate erosion, facial canal dehiscence,
tegmen mastoideum erosion and labyrinthine fistula and intracranial complications with a P < 0.05 but not reliable
for tegmen tympani erosion and posterior fossa dural plate erosion. Conclusion: HRCT is highly reliable and
findings are in par with intraoperative findings in this study.

Keywords: Cholesteatoma, Chronic otitis media, Complications of chronic suppurative otitis media, High resolution
computed tomography scan, Imaging, Pre-operative assessment, Radiology, Surgery, Temporal bones, X-ray mastoids
schuller’s view

Introduction and the COM with cholesteatoma; this is because of higher

Chronic otitis media (COM) is a long standing inflammation
of the middle ear cleft without reference to the etiology or
pathogenesis. It also implies concomitant inflammation, to a
greater or lesser extent, of the mastoid air cell system, owing
to its anatomical linkage to the middle ear. The diagnosis
of COM implies a permanent abnormality of the pars tensa
or flaccida, most likely a result of earlier acute otitis media,
negative middle ear pressure or otitis media with effusion and
production of pus, often from the adjacent mucosa.
Many otolaryngologists consider it important to differentiate
between the two types of COM: The chronic mucosal disease
risk of complications associated with the cholesteatoma group,
which can lead to life threatening conditions.
Advent of higher antibiotics has not reduced the incidence of
COM in a case of chronic discharging ear. The pathology in such
an ear is irreversible and takes a long course, only to destroy
the useful hearing or to render the patient morbid or even kill
by itself with intracranial complications, which develop during
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Address for correspondence: Dr. Thripthi Rai, DOI:

Department of ENT, Mysore Medical College and Research Centre, 10.4103/0971-7749.131865
Karnataka, Mysore - 570 001, India. E‑mail: shettyabijit@gmail.com

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Rai: Temporal bone in chronic otitis media: A radiological study
its course. Hence, it is important to recognize the disease early
to adopt a surgical procedure to save the patient from loss of
hearing and to prevent the grave intracranial complications.
Furthermore, the differentiation between the two types,
which is based on clinical grounds, is very helpful for further
management and pre‑operative planning. Routine computed
tomography scanning prior to cholesteatoma surgery can
only be justified if it influences clinical management[1-5]. The
radiological findings of the temporal bone in patients with COM
evaluate the extent and sites of involvement of the middle ear
and mastoid air cells system and study the inter‑relationships of
the tympanomastoid compartment with the adjacent, critical,
and important neurovascular structures.[6-12]
Schuler described the first view to visualize pathologic
lesions in the area frequently involved in chronic disease,
namely attic‑aditus‑antrum or the key area. It is CT which
has made the most important contribution to radiology in
otolaryngology. Today, the helical  (or spiral) CT allows for
continuous rotation of gantry and thus, continuous acquisition
of images. A  block of ultrathin sections  (0.35  mm thick)
covering the entire temporal bone can be acquired in less
than a minute. It not only displays internal bony architecture
of the skull base, but also evaluates the soft‑tissue pathology
associated with a bone the disease process, which helps in
deciding the approach to surgery and also the expected
intra‑operative and post‑operative complications.[13-21]
Materials and Methods
This is a prospective study in which total of 50 cases with COM
were studied. The ability of the radiological investigations to
detect the various pathological and anatomical variations
were evaluated and compared with intraoperative findings.
Aim was:
1. To study the radiological findings of the temporal bone in
patients with COM with and without cholesteatoma
2. Extent and sites of involvement of the middle ear and the
mastoid air cell system in these patients
3. Inter‑relationships of the tympanomastoid compartment
with the adjacent, critical and important neurovascular
structures
4. To evaluate the results and compare data with similarly
published studies.
In this period of 18 months, 50 patients of COM were selected
randomly from the Out‑patient Department. All these patients
were studied according to the proforma and the patients were
investigated as follow.
Hemoglobin %, total leucocyte count, differential leucocyte
count, erythrocyte sedimentation rate, bleeding time, clotting
time, urine for albumin, sugar and microscopy, pus for
culture, and sensitivity X‑ray mastoids Schuller’s view and
high resolution computed tomography  (HRCT) temporal
bones scans.
Indian Journal of Otology | April 2014 | Vol 20 | Issue 2 |
All the HRCT scans were performed at our institute on the
high speed dual slice fast CT machines. Patients were scanned
in axial and coronal  (supine and prone) axes. Scout films
were taken routinely in all patients before starting the scan.
Scanning commenced from the lower margin of the external
auditory meatus and extended upward to the arcuate eminence
of the superior semicircular canal as seen on lateral tomogram.
Slight extension of the head was given to avoid gantry tilt and
thereby protect the lens from radiation. Coronal images were
obtained perpendicular to the axial plane from the cochlea to
the posterior semicircular canal.
Preparation of patients: Prior to performing the scan
particularly in infants and children less than 6  years,
sedation was usually required. The purpose of sedation as to
avoid motion artifact and to ensure a CT scan of diagnostic
quality. From 6 years onward the need for sedation generally
decreased. Sedatives in our institution were syrup pen
tazoscine administered orally.
Consent was obtained from each patient along the counseling
of the patient and a close relative regarding the nature of the
disease and the surgery. Outcome was explained to the patient
with possible complications and improvements.
All the patients underwent mastiodectomy by a post‑aural
approach and intraoperative findings were noted. Eleven
patients were given general anesthesia because of their
ages and complications involved while the rest underwent
surgery under local anesthesia. Meticulous intraoperative
and post‑operative care was taken. Systemic antibiotics and
analgesics were given as a routine. Most of the patients were
discharged on the 5th post‑operative day. The patients were a
followed‑up week for 1 month, monthly for 6 months and once
in 2 months later on. All the patients were followed‑up until the
end of the study. All radiological findings were tabulated and
correlated with intra‑operative findings. False positive, false
negative, sensitivity, specificity, and P value were calculated
and tabulated.
Results
X‑ray mastoid Schuller’s view has got good reliability
with P < 0.05 regarding the type of pneumatisation and any
anatomical abnormalities such as low lying dura and anterior
lying sigmoid sinus.
HRCT is reliable for all the parameters like scutum erosion,
ossicular erosion, mastoid pneumatisation, low lying dura,
anterior lying sigmoid, Korner’s septum, cholesteatoma
extension in the middle ear and mastoid, and presence of
complications such as mastoiditis and mastoid abscess, mastoid
cortex dehiscence, sigmoid sinus plate erosion, facial canal
dehiscence, tegmen mastoideum erosion and labyrinthine fistula
and intracranial complications with a P < 0.05 but not reliable for
tegmen tympani erosion and posterior fossa dural plate erosion.
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Rai: Temporal bone in chronic otitis media: A radiological study
In findings of adjacent neurovascular structures, facial canal
dehiscence was commonest followed by anterior lying sigmoid
sinus and low lying dura.
The radiological findings of the temporal bone in patients with
COM were the presence of non‑dependent soft‑tissue mass
in maximum numbers followed by ossicle erosion, scutum
erosion, sigmoid sinus plate erosion, labyrinthine fistula,
tegmen erosion and mastoid cortex erosion. Other findings
included masoiditis with sub‑periosteal abscess.
In ossicular erosion, incus was most commonly involved
followed by stapes and malleus. Most of the mastoids in this
study were sclerotic followed by pneumatised and diploic.
The extent of involvement of middle ear and mastoid in
cholesteatoma in decreasing order of frequency are highest
involvement of epitympanum and antrum followed by aditus,
mastoid air cells, posterior tympanum, mesotympanum,
hypotympanum, protympanum, and peri‑labyrinthine air
cells. In general, it enhanced the knowledge of surgical
anatomy otolaryngiologist.
Discussion
In this study, the youngest patient was 5 years and the eldest
was 56 years. 20 patients (40%) between 21 years and 30 years.
The mean age was about 26.88 years, which is similar to study
by Gerami et  al.[22] Paparella and Kim  (1977),[23] claim an
average of about 35.1 years, the variation is because of COM
is more common amongst children in our country.
Male:Female ratio was 0.923:1 which is in accordance with
Vlastarakos et al. (2010).[24]
Nearly, 96% belonged to the low socio‑economic status
suggesting that lack of hygiene poor nutritional status and
reduced resistance to infection are the probable causative factors.
The most common presenting symptom was otorrhea followed by
hearing loss and otalgia. Tinnitus, vertigo, nausea, vomiting, fever
with chills and rigors, and facial nerve palsy were slightly more in
the present series. This probably indicates that the patients come
to hospital relatively late and are reluctant for initial treatment.
Examination of pinna, pre‑auricular and post‑auricular
region revealed pre‑auricular scar in 2% and post‑auricular
scar in 16% implying possibility of previous history of mastoid
abscess resolving by spontaneous rupture. Post‑auricular
swelling was present in 6% implying the presence of acute
mastoid abscess out of which one patient had discharging
sinus. Mastoid tenderness was present in 12% suggesting
acute mastoiditis.
Left ear discharge was seen in 38%, right ear in 40% and
bilateral discharge in 22% of patients.
50
On tympanic membrane examination, attic perforation was
seen in 18% and marginal perforation in 22% patient. Central
perforation was seen in 36% and in 24% tympanic membrane
was not visualized due to polyp occupying entire external
auditory canal in 9 patients and sagging posterior bony canal
wall in 3 patients.
Facial palsy was observed in 6% patients, 4% had positive
fistula test and 2% had nystagmus.
Majority of the cases were attico‑antral disease (AAD) that is
64% and remaining 36% were tubo‑tympanic disease (TTD)
36% patients underwent canal wall up mastoidectomy and
64% patients underwent canal wall‑down mastoidectomy
which included one radical mastoidectomy for cochlear
promontory fistula.
Mastoid was found to be well‑pneumatised in 44%, sclerotic
in 50% and diploic in 6% in X‑ray mastoid Schuller’s view as
well as intraoperatively. Hence X‑ray is 100% sensitive and
specific to know the type of mastoid pneumatisation.
Low lying dura was correctly detected in 2% of patients by X‑ray
mastoids Schuller’s view giving it 100% sensitivity and specificity.
However, X‑ray failed to detect one case of anterior lying
sigmoid out of two making it only moderately sensitive in
detecting this anatomical variation.
HRCT had 100% sensitivity which is in agreement with studies
by Sirigiri and Dwaraknath.  (2011),[25] but 90% specificity,
which is slightly higher than 84% as given by Sirigiri and
Dwaraknath  (2011), [25] to detect cholesteatoma in the
protympanum which is in agreement [Table 1].
In case of mesotympanum, HRCT had a sensitivity of 90%,
which is similar to findings by Walshe et  al.  (2002),[26] and
specificity of 87.5% in detecting cholesteatoma [Table 1].
In posterior tympanum, HRCT had a sensitivity of 100%,
which correlates well with studies by Walshe et al. (2002),[26]
whereas, specificity was 87.1%, which is slightly higher
than  75% as given by Sirigiri and Dwaraknath  (2011)[25]
[Table 1].
In epitympanum, HRCT had sensitivity and specificity of
96.5% and 100%, which are similar to findings by Sirigiri and
Dwaraknath (2011)[25] [Table 1].
In hypotympanum, HRCT sensitivity was 100% which correlates
well with observations by Sirigiri and Dwaraknath (2011),[25]
and specificity was 81.8% which is slightly higher, for HRCT
to detect cholesteatoma [Table 1].
In case of aditus, HRCT sensitivity was 92.3%, which is similar
to observations by Sirigiri and Dwaraknath  (2011),[25] and
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Rai: Temporal bone in chronic otitis media: A radiological study
Table  1: Sites and extent of involvement of the middle
ear and the mastoid air cell system
Extent HRCT
Protympanum 11
Mesotympanum 14
Posterior‑tympanum 16
Epitympanum 28
Hypotympanum 14
Peri‑labyrinthine cells 7 4
Aditus 26
Antrum 28
Mastoid air cells 24
HRCT: High resolution computed tomography, IO: Intra‑operative
specificity was 91.6%, which is way higher compared to 75%
seen by Sirigiri and Dwaraknath (2011).[25]
In the antrum, HRCT sensitivity was 92.8%, which is similar
to observations by Sirigiri and Dwaraknath  (2011),[25] and
specificity 90.9%, which is way higher compared to 66% seen
by Sirigiri and Dwaraknath (2011)[25] [Table 1].
In mastoid air cells, HRCT sensitivity was 88.8% and specificity
was100% which is similar to observations by Gerami and
Naghavi (2009) [Table 1].
In the peri‑labyrinthine cells, HRCT sensitivity was
100%, which correlates well with studies by Sirigiri
and Dwaraknath  (2011), [25] while specificity was 93.4%
[Table 1].
HRCT was 84% sensitive and 88.8% specific in identifying soft
tissue mass. Mafee et al. (1988),[27] and O’Reilly et al. (1991),[28]
have similar results, whereas Jackler et  al.  (1984),[29] and
Garber and Dort (1994),[30] found it to be less sensitive and
specific. However, HRCT is less sensitive in differentiating
cholesteatoma from granulations.
Bony erosion correctly predicted presence of cholesteatoma
in 78% cases. This value is close to data by O’Reilly
et al. (1991),[28] who found in 79% and Jackler et al. (1984),[29]
ODonoghue (1987),[31] and Alzoubi et al. (2008),[32] who found
in 80% cases. Mafee et al. (1988),[27] found bone destruction
in 100% cases of acquired cholesteatoma.
Scutum erosion was seen in 65% cases with cholesteatoma
which is less than that seen by Gaurano and Joharjy (2004),[33]
who found it in 86%. However, HRCT detected scutum erosion
accurately in all cases. Hence, HRCT is 100% sensitive and
specific to detect scutum erosion as per this study. This is in
accordance to study by Rocher et al. (1995),[34] but contrasts
with study by Vlastarakos et al. (2010),[24] where no correlation
was found [Table 1].
HRCT detected erosion in Malleus correctly in all 30%
cases. So HRCT is 100% sensitive and specific to diagnose
Indian Journal of Otology | April 2014 | Vol 20 | Issue 2 |
Malleus erosion. This is correlating with studies by Zhang
et  al.  (2004), [35] Rocher et  al.  (1995), [34] and Chee and
IO Tan (2001).[36]
7
10 HRCT detected erosion in Incus correctly in only 48%,
11 whereas it was present in 56% cases. So there were 4 false
29 negative cases making HRCT 85% sensitive and 100% specific
6 which correlates with studies by Zhang et al. (2004),[35] and
Chee and Tan (2001).[36]
26
28 HRCT detected erosion in Stapes correctly in only 30%
27 out of 40%. So with 5 false negative cases, HRCT was
75% sensitive and 100% specific. This is similar to studies
by O Donoghue (1987),[31] but contrasts to studies by Chee
and Tan  (2001),[36] where excellent correlation was found
and Zhang et al. (2004),[35] who found that HRCT was poor
in detecting Stapes erosion [Table 1].
Ossicular erosion was seen in 87% cases with cholesteatoma
which is less than that seen by Gaurano and Joharjy (2004),[33]
who found it in 92% cases. HRCT correctly detected
ossicular erosion in 85.7% cases which is similar to studies
by Mafee et al. (1988),[27] Garber and Dort (1994),[30] Jackler
et al. (1984),[29] and Swartz (1983),[37] but contrasts with study
by O’Reilly (1991),[28] where poor correlation was seen. Most
commonly involved ossicle was incus in 56% cases, which is
similar to study by Mafee et al. (1988),[27] O’Reilly (1991),[28]
and Jackler et al. (1984)[29] [Table 1].
In HRCT, mastoid was found to be well‑pneumatised in
44%, sclerotic in 50% and diploic in 6% HRCT as well
as intra‑operatively. Hence HRCT is 100% sensitive and
specific to know the type of mastoid pneumatisation.
This is in agreement with findings of Vlastarakos
et al. (2010),[24] who found strong agreement with HRCT
findings and those intraoperatively in case of mastoid‑air
cell complex [Table 1].
In this study, HRCT for facial canal dehiscence had 4 false
negative cases, making it 33.33% sensitive but 100%
specificity for facial canal dehiscence. Similar results
were found by Alzoubi et  al.  (2008),[32] and Garber and
Dort  (1994),[30] but poor and insignificant correlation was
observed by O’Reilly  (1991), [28] Rocher et  al.  (1995), [34]
Chee and Tan (2001),[36] Zhang et al. (2004),[35] Gerami and
Naghavi  (2009),[22] and Jackler  (1984),[29] whereas Mafee
et al.[27] Found HRCT to be 100% accurate.
HRCT was found to be poorly sensitive to detect
Tegmen Tympani erosion which agrees with results by
Jackler (1984),[29] O’Reilly (1991),[28] and Gerami and Naghavi
(2009),[22] but which disagrees with findings by Vlastarakos
et al. (2010),[24] and Chee and Tan (2001),[36] where moderate
agreement was seen and Rocher et al. (1995),[34] Zang et al.
(2004),[35] and Alzoubi et al. (2008),[32] who found it 100%
sensitive [Table 1].
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Rai: Temporal bone in chronic otitis media: A radiological study
HRCT was found to be 100% sensitive and specific to detect
cochlear promontory fistula in this study, which is similar to
study by Alzoubi et al. (2008).[32]
HRCT was also found to be 100% to detect cortical erosion
of mastoid detecting all 8% cases correctly which disagrees
with findings of Sirigiri and Dwaraknath (2011),[25] where it
was only 75% sensitive.
With 2 false negative cases, HRCT was 75% sensitive for detecting
sigmoid sinus plate erosion which is again in contrast to studies
by Vlastarakos et al. (2010),[24] where it was 100% sensitive.
Furthermore, HRCT has 33.33% sensitivity in detecting
Tegmen mastoideum erosion but is 100% specific.
In case of posterior fossa dural plate erosion, HRCT was poorly
sensitive as it missed all the 6% cases. This is similar to study
by O’Reilly et al. (1991).[28]
HRCT was also 25% sensitive in detecting Lateral semicircular
canal erosion. This is similar to study by O’Reilly (1991),[36]
Vlastarakos et  al.  (2010),[24] and Zhang et  al.  (2004),[35] but
in contrast to studies by  Gerami and Naghavi  (2009),[22]
and Jackler  (1984), [29] where it was poor and Alzoubi
et al. (2008),[32] Chee and Tan (2001),[36] Mafee et al.[27] and
Rocher (1995),[34]  where it was 100% sensitive.
HRCT was found to be an excellent tool to detect the other
complications such as mastoiditis and mastoid abscess with
100% sensitivity and specificity [Table 1].
Except for one case of Perisinus abscess HRCT detected
all the other 10% Intra‑cranial complications correctly
giving it high sensitivity to detect these. The complications
were 2 cases of sigmoid sinus thrombosis, one each case of
meningitis  (diagnosed clinically) with pneumocephalus,
subdural empyema and brain abscess.
In this study, low lying dura was correctly detected in 2% which
of patients by HRCT giving it 100% sensitivity and specificity.
This correlates with studies by Zhang et  al.  (2004),[35] and
Chee and Tan (2001).[36] The incidence of low lying dura is
less compared to study by Zelikovich (2004),[38] who found it
in 7.7% cases and Liu Zhaohui et al. (2006),[39] who found it
in 21.8% [Figure 1].
However, HRCT failed to detect one case of anterior lying
sigmoid out of two making it 50% sensitive, but 100% specific
in detecting this anatomical variation. The incidence of
anterior lying sigmoid in this study is low compared to study
by Zelikovich (2004),[38] who found it in 36.5% cases and higher
than findings by Tomura et al. (1995),[40] who found it in 1.6%.
In this study, HRCT correctly detected the presence of Korner’s
septum in 2% of patients implying 100% sensitivity and
52
specificity. Other findings like an incomplete bony covering
of a high‑positioned jugular bulb, severe asymmetry of the
jugular foramen, a deep sinus tympani was seen in 2.4%, 4%
and 5.9% of patients in studies by Tomura et al. (1995),[40] but
not seen in this study [Figure 2].
Hence, overall HRCT has got a P < 0.05 for all the parameters
mentioned above except for tegmen tympani and posterior
fossa dural plate erosion.
In this study, facial nerve dehiscence was present in 6.25%
of patients with cholesteatoma according to HRCT and
intra‑operatively it was 18.75%. This is much less than
incidence seen by Magliulo et  al.  (2011),[41] in their study
where it was 27%. Their sensitivity and specificity were 69%
and 87% respectively. The site was tympanic segment in all
cases whereas according to Magliulo et al. (2011),[41] it was
tympanic segment in 92% cases.
In this study, non‑dependent soft‑tissue opacity was present
in 90% of patients with COM with cholesteatoma. This is
similar to findings by Sirgiri and Dwaraknath (2011),[31] who
reported it in 92%.
In this study, 71% of patients with COM with cholesteatoma
had scutum erosion. This is higher than findings by
Suat Keskin et  al.  (2011),[42] who found it in 54% of their
patients [Table 1].
In this study ossicle erosion was seen in 75% of patients with
COM with cholesteatoma. This is similar to findings by Suat
Keskin et al. (2011),[42] who found it in 76.78% of their patients.
Incus was the commonest ossicle to be involved in 56% which
is less compared to 86.1% seen by Mohammadi et al. (2012).[43]
Stapes was second most common seen in 40% and malleus
least common seen in 30% patients. This is similar to studies
by Garap and Dubey (2001),[44] who found it in 41% for stapes
and 32% for malleus [Table 1].
In this study, well‑pneumatised mastoid was seen in 44%,
sclerotic in 50% and diploic in remaining 6%. These values
are comparable to studies by Sethi et al. (2006),[45] who found
well‑pneumatised mastoid in 48% and poorly pneumatised
in 52% patients [Table 1].
In this study, labyrinthine fistula was seen in 15% of patients
with cholesteatoma. Out of this 12% were seen in Lateral
semicircular canal and 3% in cochlear promontory. This
values is slightly higher than 9% of  lateral semi circular
canal (LSCC) fistula seen by Suat Keskin et  al.  (2011)
[Figure 3].[42]
In this study, sigmoid sinus plate erosion was found by HRCT
in 18% of patients with cholesteatoma. This value is higher
than 14% as reported by Abdel, Rahim Ahmed Abdel, Karim
et al. (2010) [Table 1].
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Rai: Temporal bone in chronic otitis media: A radiological study

In our study, mastoid cortex erosion was seen in 12% of Conclusions

patients with cholesteatoma. This value is higher to 7% as seen
by Suat Keskin et al. (2011)[42] [Table 1 and Figure 4]. The role of plain film radiography is found to be limited to
know the type of mastoid pneumatisation as well as to detect
In our study tegmen erosion was seen in 12%, out of which the presence of any abnormality in dural plate, sigmoid sinus
tegmen tympani was involved in 3% and tegmen mastoideum plate and the sinodural angle.
in 9%. This value is much higher than studies by Suat Keskin
et al. (2011),[42] who found tegmen erosion in only 5% patients
Table  2: Findings in temporal bone in patients with
[Table 1]. chronic otitis media
Findings HRCT IO
In this study, mastoiditis complicated with subperiosteal Well‑pneumatized mastoid 22 22
abscess was found in 8% cases of COM. This is similar to Sclerotic mastoid 25 25
findings by Leskinen and Jero (2005),[46] who found it in 7% Diploic mastoid 3 3
cases. Non‑dependent soft tissue mass 29 32
Scutum erosion 23 23
The extent of involvement of middle ear and mastoid in Ossicle erosion 24 58
cholesteatoma in HRCT are as follows: Epitympanum, Labyrinthine fistula 2 5
antrum, aditus, mastoid air cells, posterior tympanum, Sigmoid sinus plate erosion 6 8
mesotympanum, hypotympanum, protympanum, and Mastoid cortex erosion 4 8
peri‑labyrinthine air cells are 88%, 88%, 81%, 75%, 50%, Tegmen erosion 1 4
44%, 44%, 34%, and 24% respectively. This is similar to Mastoiditis with sub‑periosteal abscess 4 4
HRCT: High resolution computed tomography; IO: Intra‑operative
studies by Sirigiri and Dwaraknath  (2011),[25] who found
it in epitympanum, antrum, aditus, mastoid air cells,
posterior tympanum, mesotympanum, hypotympanum,
protympanum and peri‑labyrinthine air cells are 88%,
88%, 84%, 76%, 52%, 44%, 44%, 36%, and 24% respectively
[Table 2].

Figure 1: Coronal section showing left low lying dura Figure 2: Axial section showing Right Korner’s Septum

Figure 3: Axial section showing left lateral semicircular canal erosion Figure 4: Coronal section showing left mastoid cortex erosion

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Rai: Temporal bone in chronic otitis media: A radiological study
The CT scan is the standard imaging technique for the temporal
bone. HRCT has got high reliability for the parameters such as
scutum erosion, ossicular erosion, mastoid pneumatisation, low
lying dura, anterior lying sigmoid, Korner’s septum, cholesteatoma
extension in the middle ear and mastoid, and the presence of
complications such as mastoiditis and mastoid abscess, mastoid
cortex dehiscence, sigmoid sinus plate erosion, facial canal
dehiscence, tegmen mastoideum erosion and labyrinthine fistula,
and intracranial complications with a P < 0.05 but unreliable for
tegmen tympani and posterior fossa dural plate erosion.
In findings of adjacent neurovascular structures, facial canal
dehiscence was commonest followed by anterior lying sigmoid
sinus and low lying dura.
The radiological findings of the temporal bone in patients with
COM were the presence of non‑dependent soft‑tissue mass
in maximum numbers followed by ossicle erosion, scutum
erosion, sigmoid sinus plate erosion, labyrinthine fistula,
tegmen erosion, and mastoid cortex erosion. Other findings
included masoiditis with sub‑periosteal abscess.
In ossicular erosion, incus was most commonly involved
followed by stapes and malleus. Most of the mastoids in this
study were sclerotic followed by pneumatised and diploic.
COM can be at times life‑threatening and warrants that
all Otolaryngologist surgeons be familiar with the standard
approach to these patients. Advent of HRCT and improvements
in radiological technique has definitely improved study of
the temporal bone in patients with COM, which includes
evaluation of the extent and sites of involvement and
inter‑relationships of the tympanomastoid compartment
with adjacent neurovascular structures. Therefore, this study
concludes that HRCT can be recommended not only in cases
suspected with potential complications but also in all cases of
COM to know the extent of disease, varied pneumatization
and the presence of anatomical variations, which should alert
the clinician and guide in surgical approach and treatment
plan. A skillful, aware, and alert surgeon still remains the key
to successful diagnosis and surgical treatment of COM.
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How to cite this article: Rai T. Radiological study of the temporal
bone in chronic otitis media: Prospective study of 50 cases. Indian
J Otol 2014;20:48-55.
Source of Support: Nil. Conflict of Interest: None declared.
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