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| ORIGINAL ARTICLE |
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| Year : 2014 | Volume
: 20
| Issue : 2 | Page : 48-55 |
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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
| Date of Web Publication | 3-May-2014 |
Correspondence Address:
Thripthi Rai
Department of ENT, Mysore Medical College and Research Centre, Karnataka, Mysore - 570 001
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-7749.131865
Aim: To assess radiological findings in Chronic otitis media (COM), its involvement in middle ear and adjacent 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
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 |
| Introduction | |  |
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 and the COM with cholesteatoma; this is because of higher 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 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],[2],[3],[4],[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],[7],[8],[9],[10],[11],[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],[14],[15],[16],[17],[18],[19],[20],[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:
- To study the radiological findings of the temporal bone in patients with COM with and without cholesteatoma
- Extent and sites of involvement of the middle ear and the mastoid air cell system in these patients
- Inter-relationships of the tympanomastoid compartment with the adjacent, critical and important neurovascular structures
- 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.
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 5 th 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.
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.
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]. | Table 1: Sites and extent of involvement of the middle ear and the mastoid air cell system
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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 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 Malleus erosion. This is correlating with studies by Zhang et al. (2004), [35] Rocher et al. (1995), [34] and Chee and Tan (2001). [36]
HRCT detected erosion in Incus correctly in only 48%, whereas it was present in 56% cases. So there were 4 false negative cases making HRCT 85% sensitive and 100% specific which correlates with studies by Zhang et al. (2004), [35] and Chee and Tan (2001). [36]
HRCT detected erosion in Stapes correctly in only 30% 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].
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 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].
In our study, mastoid cortex erosion was seen in 12% of patients with cholesteatoma. This value is higher to 7% as seen by Suat Keskin et al. (2011) [42] [Table 1] and [Figure 4].
In our study tegmen erosion was seen in 12%, out of which tegmen tympani was involved in 3% and tegmen mastoideum 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 1].
In this study, mastoiditis complicated with subperiosteal abscess was found in 8% cases of COM. This is similar to findings by Leskinen and Jero (2005), [46] who found it in 7% cases.
The extent of involvement of middle ear and mastoid in cholesteatoma in HRCT are as follows: Epitympanum, antrum, aditus, mastoid air cells, posterior tympanum, mesotympanum, hypotympanum, protympanum, and peri-labyrinthine air cells are 88%, 88%, 81%, 75%, 50%, 44%, 44%, 34%, and 24% respectively. This is similar to 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]. | Table 2: Findings in temporal bone in patients with chronic otitis media
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| Conclusions | | |
The role of plain film radiography is found to be limited to know the type of mastoid pneumatisation as well as to detect the presence of any abnormality in dural plate, sigmoid sinus plate and the sinodural angle.
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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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
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