Documente Academic
Documente Profesional
Documente Cultură
Introducti
on
Embryology of ear
The ear is the first organ of special
senses to become differentiated in man,
inner ear reaches full adult size by
midterm
The external and middle ear develop
from 1st and 2nd brachial arch
Neural sound perceiving apparatus of
inner ear develops from ectodermal
otocyst
3
External Ear
PINNA (auricle) :
# sixth week of embryonic life,
# six tubercles appear around 1st
branchial cleft.
# They progressively coalesce to
form the auricle
External auditory meatus
# develops from the first
branchial cleft.
# 16th embryonic week,
# cells proliferate and form a
meatal plug.
# Recanalisation of this plug forms
the epithelial lining of the bony meatus.
# External ear canal is fully formed
by the 28th week of gestation
4
MIDDLE EAR
Tympanic membrane:
Develops from all the three
germinal layers. Outer epithelial
layer by ectoderm, Middle fibrous
layer by mesoderm & Inner
mucosal layer by endoderm.
Middle ear cavity :
# Develops from endoderm of
tubotympanic recess which arises
from 1st and partially from 2nd
pharyngeal pouches.
# Head of Malleus and short
process of incus are derived from
mesoderm of 1st arch
# Rest of malleus and incus with
stapes suprastructure develop
nd
Inner ear
Starts by 3rd week of fetal life and completed by 16th wks
The inner ear is derived from the ectoderm in the
region of the hindbrain.
A thickening of the ectoderm, the otic placode
becomes invaginated to form the auditory/otic vesicle.
OTIC PLACODE
OTIC PIT
OTIC VESICLE
6
10
Bony labyrinth
11
2. Semicircular Canal:
They are three in number, the
lateral, posterior and
superior, and lie in planes at
right angles to one another.
12
4. Vestibular aqueduct
Tubular structure that arises
from vestibule and runs
along posterior inferior
aspect of petrous bone
Contains endolymphatic
duct and sac
Normally measures less
than 1.5mm in diameter or
approximates the size of
post. SCC which runs
anterior and parallel the
aqueduct.
13
Membranous labyrinth
Cochlear duct : Also called the scala media. It
is a blind coiled tube. It appears triangular on
cross-section and its three walls are formed by:
(a) the basilar
membrane, which
supports the organ of
corti,
(b) the Reissner's
membrane which
separates it from the
scala vestibuli,
(c) the stria vascularis,
which contains vascular
epithelium and is
14
Divided by a bony
lamina (falciform
crest) into
A. Smaller superior
part
Superior vestibular
N.
Facial Nerve
B. Larger Inferior part
Inferior vestibular N.
16
Fig.1.-----Axial HRCT of
Inner Ear
White arrowhead : Modiolus with cochlea
White arrow : I A C
18
Fig. 3 Sagittal T2 MR
Images
Showing the four nerves within IAC : The facial nerve (arrow head),
cochlear nerve (curved arrow) and superior and inferior vestibular
nerves (arrowhead)
20
Tumors and
infection
22
3D CISS
Three dimensional (3D) constructive interference
in steady state (CISS) is a heavily T2 weighted
fully refocused gradient echo MR sequence.
Being heavily T2 weighted it is better suited for
imaging of structures surrounded by fluid like 7 th
8th nerve complex and membranous labyrinth.
3D sequence , so reconstruction in any plane
possible.
Other uses:1. Evaluation of cranial nerves
2. Diagnosis of NCC
3. Evaluation of CSF rhinorrhea
23
4. Evaluation of ventricular system etc.
24
CONGENITAL ANOMALIES
25
Congenital malformation of
inner
ear and Jackler et al
Cochlear abnormalities
are numerous
classified them on the basis of arrested development during
organogenesis
26
TIMELINE OF CONGENITAL
MALFORMATION OF INNER EAR
27
29
Common cavity
Defined by absence of normal differentiation
between the cochlea and vestibule
25% of cochlear malformation
Arrest during 4th arrest of gestation
Associated with poor
differentiation of
membranous labyrinth
as well resulting in
severe to profound
hearing loss
30
Common cavity
31
Cochlear Aplasia
32
33
Cochlear Hypoplasia
Stenotic IAC
35
Axial CT shows
absence of the
modiolus with a cystic
cochlear apex
(straight arrow) ,
dilatation of vestibular
aqueduct
(arrowhead) and
vestibule (curved
arrow)
37
38
40
CT:
1. Posterior carotid plate is
absent
2. Horizontal part of carotid
canal appears to merge with
lateral cochlear promontory
MRI :
1. Routine MR sequence are
not helpful.
2. MRA shows unusual
posterolateral course of ICA
44
45
46
Venous variants
1. High riding Jugular bulb : Large jugular
bulb reaching above the internal auditory
canal with intact sigmoid plate
2. Dehiscent Jugular Bulb : The sigmoid plate
is deficient, the bulb protrudes into the
middle ear cavity. It is a common cause of
aretro-tympanic vascular mass.
3. Jugular bulb diverticulum
47
48
INFLAMMATORY
CONDITIONS
LABYRINTHITIS
Inflammation of
membranous labyrinth.
Viruses are the most
common etiologic agents,
but can be bacterial or
autoimmune .
Types:
1. Tympanic labyrinthitis : Infection spreads from
middle ear via oval or round window or labyrinthine
fistula
2. Meningogenic : Infection spreads along CSF spaces
via IAC or cochlear aqueduct. Usually bilateral.
3. Hematogenic labyrinthitis : spread of infection by
blood-stream. Virus e.g, measles and mumps,
syphilis etc
50
4. Post traumatic labyrinthitis.
Imaging features:
CT : # Usually normal in acute stage
# Ossification of membranous labyrinth in late
chronic phase
MRI : contrast enhanced MR is the method of choice
# T1- CEMR shows moderate to intense
enhancement within normal fluid filled structure
of inner ear
# Usually viral conditions causes subtle
enhancement and bacterial causes intense
enhancement.
Complication : Labyrinthitis ossificans is a Sequela
of chronic labyrinthitis, usually Pyogenic in origin.
51
52
Labyrinthitis ossificans
53
54
CHOLESTEATOMA WITH
COMPLICATION
MRI features of cholesteatoma ::-Hypointense on T1WI & Hyperintense on T2 WI
No enhancement or faint peripheral rim
enhancement
Delayed Contrast scan (after 45min)
continued enhancement of inflammatory or
granulation tissue and not in cholesteatoma.
DWI Cholesteatoma shows restricted
diffusion and are hyperintense on b= 1000/m2.
55
CHOLESTEATOMA WITH
COMPLICATION
A . Labyrinthine fistula -- Most frequent
complication with middle ear cholesteatoma
(prevalence of 5% 10%).
C/F : Episodic vertigo, sensorineural hearing loss,
tinnitus
CT Findings :1. Dehiscent lateral semicircular canal support
the diagnosis
2. Uncommonly , dehiscence of cochlear
promontory or fistula in oval window.
MRI Findings :- a labyrinthine fistula causing
labyrinthitis, shows enhancement of the
56
57
60
Petrous apicitis
Petrous apicitis is infection with involvement of
bone at the very apex of thepetrous temporal
bone.
Pathology : Osteitis developing from infected
and obstructed air cells in a pneumatised
petrous apex
C/F: Presents with Gradenigos syndrome
CT scan :
1. Erosive lysis with ill-defined
irregular edges of petrous
apex
2. Peripheral enhancement of
petrous apex with dural
enhancement and thickening
MRI:
1. Fluid signal intensity in
petrous apex often with
peripheral enhancement
2. More sensitive in detecting
dural thickening and
enhancement as well
asleptomeningitis,
cerebritisandcerebral abscess
62
64
65
66
BELLS PALSY
Bell's palsyis characterized by rapid onsetlower motor
neuron facial nerveparalysis, often with resolution in 6 8 weeks.
Etiology :
1. Idiopathic
2. Reactivation of Herpes Simplex Virus infection
in geniculate ganglion.
Pathogenesis : Secondary to swelling and edema of the
7th nerve within the facial nerve canal
Indication for imaging : MRI not done routinely . Indicated
if :# Decompressive surgery is being planned
# Atypical: No recovery in 6 wks, recurrent
palsy, multiple cranial nerve involvement.
67
68
Facial Schwannomas
Facial nerve Schwannoma are uncommon tumors
arising from the Schwann cell sheath
Site : Geniculate ganglion, followed by labyrinthine and
tympanic segment.
Pathology : Originate from surface of the nerve, and
splay the nerve fibres over their eccentric growth
C/F : 1. Persistent and gradually facial paresis.
2. Conductive hearing if tympanic segment
involved causing ossicular compression
3. In CP angle or IAC : Presents with sensorineural
deafness with facial paresis being rare in these cases.
4. Other like, tinnitus, hemifacial spasm, and
otalgia
69
Imaging features
HRCT :
Enhancing soft tissue density lesion along facial nerve
Intracanalicular or CP angle tumor can cause bony
erosion of anterosuperior portion of IAC
MRI:
T1: Iso- to hypo intenserelative to gray matter
T2: Hyperintense ;large lesion may show
heterogeneous signal
T1 C+ (GAD): Homogeneous enhancement with larger
lesionsshowing cystic degeneration as focal
intramurallow signal intensity
70
71
72
FACIAL NERVE
HEMANGIOMA
Rare tumor of vascular origin (0.7% of all intratemporal tumors)
This along with other vascular malformations are
termed as Intra-temporal Benign Vascular Lesions
IMAGING FINDINGS
MRI :
# Intratemporal hemangiomas characteristically have
variable signal intensity on T1-weighted images
increased signal intensity on T2-weighted images
avid contrast enhancement.
# Low-signal-intensity foci may be seen on T1- and
T2-weighted images, corresponding to the ossific
matrix of the lesion
CT Scan : Enables exquisite visualization of associated
bone changes
Tumor causes erosion which are irregular with
indistinct margins giving a Honeycomb pattern of
eroded bone.
74
75
Anatomy: Cerebellopontine
angle
CRANIAL NERVE -
- Anterolateral surface of
77
78
Acoustic Schwannoma
[75%]
Meningioma [10%]
Epidermoid [5%]
Non acoustic
Schwannoma [4%]
Aneurysm
Metastasis
Paraganglioma
Ependymoma
Choroid plexus
papilloma
Uncommon tumor
Arachnoid cyst
Lipoma
Dermoid
Brain stem glioma
Osteocartilagenous
tumor
79
Vestibular Schwannoma
Benign tumor arising from Schwann cells
that wrap vestibulocochlear nerve
70- 80 % of CPA lesions
Age 5th -6th decade.
B/L acoustic Schwannoma pathognomonic for NF-2.
Origin : Most from Inferior Vestibular Nerve, at glialschwann cell interface
Morphology :
# Entirely intracanalicular
# Intracanalicular with cisternal
component Ice-cream cone appearance.
# Rarely purely intracisternal.
80
81
MR IMAGING FEATURES
T1WI: 2/3rd are hypointense and 1/3 rd are isointense.
may contain hypo intense cystic areas
T2WI :
# Heterogeneously hyperintense
# Small leson : "Filling defect" in high signal CSF of CPA-lAC
cistern
# may have associated peri-tumoural Arachnoid cysts
T1 C+ (Gd) :
# contrast enhancement is vivid
# Heterogeneous in larger tumors
# Occasionally, may show extension into the cochlea and dural
tail of enhancement.
82
83
MENINGIOMA
Extra-axial neoplastic lesions arising from
Arachnoid cap cells.
2nd most common CPA tumor (10%)
Site : arises from the meninges covering posterior petrous bone.
Female > Male (2-3:1) , peak age = 60yrs.
C/F : Small Meningioma -entirely asymptomatic
Large tumors headache, paresis or neurological deficit.
Morphology :
# "Mushroom cap" (hemispherical) with broad base towards
posterior petrous wall (75%)
# Plaque-like : +/- bone invasion with hyperostosis (20%)
# Ovoid mass : mimicking Acoustic Schwannoma
84
Imaging features
NECT :
# Frequently hyperdense with focal areas of
calcification
# Bony hyperostosis of petrous bone
CECT : Presence of broad dural base with dural tail
and intense enhancement is typical.
MRI :
# Isointense to brain parenchyma in T1 & T2WI
# Blooming s/o calcification in GRE
# Dural tail with other features of extra-axial lesion
# May rarely extends into IAC and presents with
diagnostic dilemma.
ANGIOGRAPHY : Homogenous blush which lasts till
late venous phase (Mother In Law sign)
85
86
87
88
Clinical feature:
Pulsating tinnitus with conductive hearing loss
Invasion into cochlea leads to sensorineural hearing loss
Otoscopy : Tympanic membrane appears blue
Glomus tympanicum : Isolated to
middle ear cavity
Soft tissue density protruding from
cochlear promontory .
Homogenous enhancement on
post contrast scan.
Glomus Jugulare :
Confined to jugular fossa and
large at presentation
Invades the hypo-tympanum and
infralabryrinth compartment
Tumor can follow the Jugular
venous system upto lower cervical
jugular vein.
89
MRI features :
T1WI Low signal intensity
T2WI High signal Intensity
T1C+ -- Marked intense enhancement
Salt pepper appearance (T1 + T2) : Salt
represents areas of hemorrhages and pepper
represents areas of flow void.
90
92
3D FLAIR : Significant
enlargement [3350%] of the
endolymphatic compartment
in the cochlea;
in the vestibule and
semicircular
canal endolymphatic hydrops96
[>50%] has displaced almost
Imaging : CECT
a. Heterogeneous lesion with motheaten retrolabyrinth petrous bone
b. Intratumoral spiculated bone seen
c. Intense enhancement in seen
97
MRI Features :
T1 /T2WI : Mixed signal intensity lesion
where focal high signal intensity d/t
subacute hemorrhage and low signal
intensity d/t calcification or hemosiderin.
Blood filled cysts and protein cyst, both
appearing hyperintense on T1/T2WI
suggests the diagnosis
Masses larger than 2 cm shows flow voids
T1C+ : Heterogeneous enhancement
98
Conclusion
MR provides accurate anatomical delineation
of complex soft tissue of inner ear
3D reconstruction improves preimplant
evaluation
Detailed delineation of 7th & 8th nerve
complex in temporal bone as well as
membranous labyrinth
Depiction of tumor size and extension into
CP angle determines the approach to surgical
removal.
100
References
1. Diagnostic Radiology- Neuroradiology AIIMS
MAMC- PGI Course series . 3rd edition.
2. CT and MRI of whole body John R Haaga 5 th edition
3. Joshi VM,Navlekar SK et.al -Ct and MRI imaging of
the inner ear and brain in children with
sensorineural hearing loss. Radiographics.2012
May-Jun;32(3):683-98
4. Jeremy Hornibrook, Mark Coates, Tony Goh, Philip
Bird et.al MRI imaging of the inner ear for Menieres
disease. Journal of the New Zealand Medical
Association. 27 August 2010, Vol 123 No 1321
5.
101
THANK
102