If start from inferior
BUT to be not
confusing start
from the top
* level 1 Jugular f. f. lace rum
*level 2 will see carotid canal, Eustachian tube
*level 3 otic capsule will appear (basal turn of cochlea), round window
* level 4 Basal turn,banna sign=cochlear smile ,round window niche, cochlear
aqueduct ,facial recess &sinus s tympani
*level 5 basal, middle apical turn appear Round window niche
*level 6 internal auditory canal appear.
The vestibular organ
Vestibular Nerve Anterior vertical canal
Facial Nerve
Horizontal canal
Vestibulocochlear
(VIII) Nerve
Cochlear Nerve Posterior vertical canal
Cochlea Saccade Utricle
Facial nerve canal
The facial nerve is seen in the internal auditory canal
and entering the temporal bone (medial white arrow).
The lateral white arrow represents the tympanic
segment of the facial nerve running in the facial canal
and curving around the oval window niche.
At this point, the nerve runs in a horizontal plane in a
posterior direction superiorly to the oval window .
The incus (orange arrow) is seen connecting to the
stapes (blue arrow).
Long crus of the incus is seen connecting to the Stapes
(blue arrow).
Facial nerve in internal auditory canal and tympanic
segment (white arrows).
Facial nerve in axial cut
Facial nerve canal
The facial nerve is seen in the internal auditory canal and entering the temporal bone
(medial white arrow).
The lateral white arrow represents the tympanic segment of the facial nerve running in
the facial canal and curving around the oval window niche.
At this point, the nerve runs in a horizontal plane in a posterior direction superiorly to
the oval window .
The incus (orange arrow) is seen connecting to the stapes (blue arrow).
Long crus of the incus is seen connecting to the Stapes (blue arrow).
Facial nerve in internal auditory canal and tympanic segment (white arrows).
Normal variant
Several normal variants may simulate disease or should be
reported because they can endanger the surgical approach.

Variants which may simulate disease:
Variants which may simulate disease:
Cochlear cleft (otosclerosis)
Petro mastoid canal (fracture)
Cochlear aqueduct (fracture)
Variants which may pose a danger during surgery:
High jugular bulb or jugular bulb diverticulum
Bulging sigmoid sinus
On the left an illustration of a chlesteatoma
Petro mastoid canal
The petro mastoid canal or subarcuate canal connects
the mastoid antrum
with the cranial cavity and houses the subarcuate
artery and vein.
Its diameter is around 0.5 mm.
It can be confused with a fracture line.
On the left a 40-year old female with a sclerotic
mastoid.
The petromastoid canal is easily seen. (arrow)
Petromastoid canal
Cochlear cleft
High jugular bulb
On the left axial and coronal images of a 64-year old
male.
The jugular bulb rises above the lower limb of the
posterior semicircular canal (arrows).
The jugular bulb is often asymmetric, with the right
jugular bulb usually being larger than the left.
If it reaches above the posterior semicircular canal it is
called a high jugular bulb.
& #8232;If the bony separation between the jugular
bulb and the tympanic cavity is absent, it is termed a
dehiscent jugular bulb.
Rarely an out pouching is seen – this is known as
a jugular bulb diverticulum.
High jugular bulb: axial and coronal
image
Jugular bulb diverticulum
On the left axial and coronal images of a 50-year old
male.
Incidental finding of a jugular bulb diverticulum
(arrows).
Bulging sigmoid sinus
The sigmoid sinus can protrude into the posterior
mastoid.
It can be accidentally lacerated during a
mastoidectomy and therefore should be
mentioned in the radiological report when
present.
On the left an axial image of a 43-year old male, post-
mastoidectomy.
The sigmoid sinus bulges anteriorly
Bulging sigmoid sinus
Large vestibular aqueduct bilaterally (black arrows). The
bony modiolus is not visible (white arrow).
MRI
External auditory canal atresia
The
cochlea
Cochlear deformities
is normal.
The cochlea develops between 3 and 10 weeks of gestation.
Early developmental arrest leads to an inner ear that consists of a
small cyst, the so-called Michel deformity.
Developmental arrest at a later stage leads to more or less severe
deformities of the cochlea and of the vestibular apparatus.
An incomplete partition of the cochlea is called a Mondini
malformation
Instead of the normal two-and-one-half turns, there is only a
normal basal turn and a cystic apex.
On the left a 2-year old girl.
The images are of a CT-examination is done prior to cochlear
implantation.
A minor deformity of the cochlear apex is visible – there is no
separation of the second and third turn and the bony modiolus is
absent.
The vestibular aqueduct is normal.
Minor cochlear deformity
Lateral semicircular canal malformation
Malformations of the vestibule and semicircular canals vary
from a common cavity to all these structures to a hypo
plastic lateral semicircular canal.
During embryogenesis the lateral semicircular canal is the
last structure to form, thus in malformations of the
semicircular canals the lateral canal is most commonly
affected.
On the left a 10-year old boy, scheduled for cochlear
implantation.
There is a widening and shortening of the lateral
semicircular canal.
The vestibule is relatively large (arrow).
Malformed lateral semicircular
canal
Malformed lateral and superior
semicircular canal
Normal pneumatization (left) and a
completely sclerotic mastoid (right)
Chronic otitis media
On the left a 14-year old boy.
The eardrum is thickened.
A small amount of soft tissue (arrow) is visible between the
scutum and the ossicular chain but no erosion is present.
This favors the diagnosis of chronic otitis media.
Tympanosclerosis
On the left an 11-year old girl with bilateral ear
infections.
There is calcification of the eardrum (white arrow) and
calcific deposits on the stapes and the tendon of the
stapedius muscle (black arrow).
Chronic otitis media
On the left a 37-year old female who was admitted with
a peritonsillar abces.
She also suffered from chronic otitis media.
CT shows a tympanostomy tube (yellow arrow) and
almost opacification of the tympanic cavity and
mastoid air cells with soft tissue.
Calcification is visible around the head of the stapes
(blue arrow).
No erosions are present.
Cholesteatoma
Cholesteatoma is believed to arise in retraction pockets of the
eardrum.
It gradually enlarges over time due to exfoliation and
encapsulation of the tissue.
Most cholesteatomas are acquired, but some are congenital.
The ENT surgeon often states that cholesteatoma is a clinical
diagnosis. Scraps of cholesteatoma are visible in the external
auditory canal.
On CT a small cholesteatoma presents as a soft tissue mass.
& #8232;In more extensive disease erosions may be present.
Large cholesteatomas can erode the auditory ossicles and the
walls of the antrum and extend into the middle cranial fossa.
The most affected structures are:
Auditory ossicles, especially the long process and lenticular processes of
the incus as well as the head of the stapes
Wall of the lateral semicircular canal
Lateral epitympanic wall (the scutum)
On the left a 20-year old woman with recurrent otitis.
There were granulations on the left ear drum.
CT demonstrates a soft tissue mass between the ossicular chain and the
lateral tympanic wall, which is eroded.
this favors the diagnosis of cholesteatoma
Cholesteatoma is believed to arise in retraction pockets of the eardrum.
It gradually enlarges over time due to exfoliation and encapsulation of
the tissue.
Most cholesteatomas are acquired, but some are congenital.
The ENT surgeon often states that cholesteatoma is a clinical diagnosis.
Scraps of cholesteatoma are visible in the external auditory canal.
On CT a small cholesteatoma presents as a soft tissue mass.
& #8232;In more extensive disease erosions may be present.
Large cholesteatomas can erode the auditory ossicles and the walls of
the antrum and extend into the middle cranial fossa.
There are two patterns of spread:
Pars flaccida cholesteatoma
The lesion starts anterosuperiorly in 'Prussaks space',
the area just below the scutum, which is limited by the
tympanic membrane, the malleus, and the lateral
ligament of the malleus.
A cholesteatoma will then extend laterally towards the
ossicular chain and into the epitympanum.
Pars tensa cholesteatoma
The cholesteatoma begins posterosuperiorly and
extends posteriorly towards the facial recess and
tympanic sinus, and medially towards the ossicular
chain.
Cholesteatoma of the right ear with destruction
of body of the incus and the scutum
Cholesteatoma with erosion of the
wall of the lateral semicircular
canal
Automastoidectomy due to a large
cholesteatoma
Chronic mastoiditis. No
cholesteatoma
Chronic mastoiditis. No
cholesteatoma
Cholesteatoma with fistula to the
lateral semicircular canal (arrow)
On the left an image of a 53-year old man complaining
of vertigo.
He had undergone several ear operations in the past.
The CT shows erosion of the wall of the lateral
semicircular canal (arrow) due to cholesteatoma.
Cholesteatoma with lateral displacement of the
incus with erosion of its lenticular process and of
the stapes
On the left a 22-year old man suffering from persistent
otitis.
The right ear shows a soft tissue mass medial to the
ossicular chain with lateral displacement of the incus
with erosion of its lenticular process and of the stapes,
compatible with a pars tensa cholesteatoma (arrow).
Cholesteatoma with lateral displacement of the incus
with erosion of its lenticular process and of the stapes
On the left coronal images
of the same patient.
Metallic stapedial prosthesis. Lucency between vestibule
and cochlea as a manifestation of otosclerosis (arrow)
MRI
