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CONDUCTIVEHEARINGLOSSWITHNORMALTYMPANICMEMBRAN
F.BENOUDIBA,JLSARRAZINServicedeNeuroradiologieCHUKremlinBicêtre
JFIMBarcelonanov1st2014
Conductivehearinglosswithnormaltympanicmembran§ 4 different kinds of pathologies
ú Otosclerosis ú Post traumatic ú Chronic otitis ú Malformations: minor aplasia, gusher syndrom
Diagnosis
§ Anamnesis and clinical findings § Personal and family medical history § Partial or bilateral hearing loss § Acquired, increasing hearing loss § Normal tympanic membran § Conductive or mixed hearing loss § Absence of stapedial reflex § IMAGING RECOMMANDATION: CT
CTSCAN
§ No injection, Bone CT § Thin sections // skull
base, above the crystaline § // LSCC § Sections: 0,4mm,
reconstructions 0,5mm § Coronal reconstructions
perpendicular to LSCC § Oblique reconstructions
perpendicular to the stapes footplate: « V » ossicular
CBCT:XRaycomptutedtomography
§ Sectionalimaging,3Dreconstruction§ Boneanalysis§ LessirradiationthanCTscan(4to12less)§ Lessartifacts
CBCT:XRaycomptutedtomography§ 250to360aquisitions§ Isotopricvoxel§ Spatialresolution:100μ
ANALYSECEPHALOMETRIQUETRIDIMENSIONNELLE(J.TREIL)
LogicielDolphin
3D
CTfindings:thesurgeonexpectations
Pre operative Ø Diagnosis
Ø Diagnosis ⊕ > 90% Ø Différential diagnosis or other pathology associated Ø Surgical anatomical informations
Ø Oval window niche size, position of VII, occlusion of the oval window, vascular variants
Ø Prognosis evaluation: round window occlusion, cochlear otosclerosis, endosteum extension
Readingmethod
§ External auditory meatus: ú walls, content
§ Middle ear ú walls, content: size, shape, ossicular morphology,
aeration of the tympanic cavity ú Fenestral: thickness, size of recess, thickness of
the stapes footplate < 0,7 mm (axial ) ú Position of the facial nerve, especially up to the
oval window
Readingmethod
§ Inner ear: ú Malformation of semi-circular canal or
vestibular abnormality ú Fenestration of the LSCC ú Exclude a gusher syndrom: modiolus
>2,7mm
Keypoints
§ Conductive hearing loss are not only secondary of middle ear or windows pathologies
§ Inner ear lesions can also be responsible as: ú Labyrinthine malformation ú Fixed stapes footplate
Pathologies§ Malformation
ú Fixation of the ossicular chain Fixation of the head of the
malleus (Goodhill syndrom): calcified bridge between the head of the malleus and the lateral or the the anterior wall of the attic wall.
Rare 1% Inflammatory or traumatic
secondary ossification.
Pathologies§ Malformation
Fixation of the long process of the incus Absence of the long process of the incus Absence or distorsion of the stapes Agenesia of the round window
Pathologies
§ Malformatiion ú Gusher syndrom: inherited
hearing loss X-linked Perilymphatic communication with sub arachnoid space.
ú Geyser fluid through the
stapes floot plate during surgical platinotomy with cophosis
Pathologies
§ Superior canal dehiscence (Minor’s syndrom) : Importance of the 2D reconstruction perpendicular to the axis of the canal
Temporalboneinjury
§ Third leading cause of conductive hearing loss
§ CT scan: incudostapedial or incudomalleus discolation (55 - 60%)
§ Fracture of the stapes Diastasis > 1 mm
Temporalboneinjury
Pathologies
§ Otospongiosis ú Common ú Perifenestral bony labyrinth pathology where
spongy bone foci appear ú Bilateral 2 /3, often asymmetrical ú 0,5 à 1% of caucasian population ú Women more often (sex ratio 2/1) from 15 to 45
years old. ú Very rare less than 10 years old
CTscanú Lytic foci on anterior
margin of oval window (Fissula antefenestram)
ú Extension to the stapes footplate with fixation of the stapes
ú Spreads to involve all margins of oval and round window
CT
CBCT
Otospongiosis:CTscan § Isolated lesion on the stapes
footplate
ú Unusual (0.02 %). ú Normal size of the stapes
footplate < 0,3 mm on histological section
ú Size on CT varies from 0,4 to 0,55.
ú Physiological anterior thickening close to the anterior branch of the stapes
ú Only an important thickening is available(> 0,7 mm ) to be significant.
Otospongiosis:CTscan
§ Extensiontoendosteum
Otospongiosis:CTscan§ Hypertrophic Foci
ú May result a fixation of the ossicular chain to the medial wall of the tympanic cavity (stapes, malleus and incus rarely)
ú It can narrow the oval window: surgical difficulty
Otospongiosis:CTscan§ Foci of the round
window: poorpostoperativeresults
§ Superior canal dehiscence
Otospongiosis:CTscan§ Labyrinthine foci are rarely
isolated, usually associated with anterior location.
§ Double ring appearance. § Posteriorlabyrinth lesions
are unusual, most frequently seen around the lateral canal
§ Foci located to the internal auditory meatus are very rare.
DifferentialDiagnosis
§ Osteogenesis imperfecta
§ Phosphate metabolism disturbance
§ Paget disease
Preoperativestaging§ Superior canal dehiscence § Ovalwindow’ssize§ Prolapsedfacialnerve§ Vascularvariants§ Enlargedmodiolus
Failureandsurgicalcomplicationsimaging
§ Failure : Hearing loss persistence or recurrence: prothesis dysfunction
§ Complication : sensorineural hearing loss
(vertigo): inner ear suffering
Failureandsurgicalcomplicationsimaging
§ Conductive hearing loss § CT
ú Displacement or migration of prosthesis
ú Erosion of incus ú Fibrosis ú Attic ankylosis ú Otosclerosis proliferation ú Prosthesis too short ú Incus dislocation
§ Sensorineural hearing loss
§ CT +/- MRI § Perilymphatic fistula § Intravestibular prosthesis § Inner ear infection § Granuloma around the oval
window
Prosthesisdisplacement
CBCT
Erosionofincus CBCT
CT
Intravestibularprosthesis
§ Intravestibular penetration>1 mm (WITH clinical inner ear symptoms)
Pneumolabyrinth§ Air in inner ear cavities § Pathognomonic of a
perilymphatic fistula § But it can be observed after
stapedectomy without pejorative significance
NoexplanationonCT
§ No pneumolabyrinth
§ Airy middle ear cavity § Prosthesis well
positioned
§ Non specific opacity in the middle ear cavity
OR
MRI
Perilymphaticfistula
§ Pneumolabyrinth: suggestive of PLF if seen afar surgery
§ Surgical revision if: Vertigo, nystagmus Conductive hearing loss
Infection
Intra-labyrinthichemorrhage
Conclusion
§ Imaging has a key role
§ CT scan or cone beam are the best imaging
§ Child conductive hearing loss : CT systematic
§ Adult conductive hearing loss : useful for the diagnosis
§ Systematic in pre-operative or if failure or complication before surgical revision