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30.08.2015
This pictorial review illustrates the imaging findings in some of the commonly encountered causes of PT. Radiological evaluation can be simplified if the type of PT and appearance of TM are known. DSA helps to exclude with more certainty a potentially treatable vascular abnormality like a DAVF.
The window levels in CTA must be set so as to distinguish between calcification and arterial enhancement.
ICA dissections typically begin about 2-3 cm above the carotid bifurcation and usually stop before the petrous ICA.
Fat-saturated axial T1W MR images elegantly demonstrate the crescentric high signal intensity mural haematoma narrowing the signal void of the vessel (Fig. 2: Coronal T1W MR image in a patient with neck trauma followed by severe left-sided neck pain and PT. The high signal intensity mural haematoma (arrow) adjacent to the left ICA lumen confirms the diagnosis of dissection.
The cresentric high signal intensity mural haematoma (arrow) narrows the left ICA flow void. Clinical presentation: Patient often presents with objective PT and normal otoscopy findings. Pathology: DVAFs commonly arise due to recanalisation of thrombosed venous sinuses with the transverse and sigmoid sinus being the most frequent locations. The dilated vasculature leads to increased blood flow near the temporal bone and causes PT. DVAFs which drain exclusively into cortical veins are associated with increased risk of ICH. Contrast-enhanced CT (CECT) may show enlarged tortuous draining veins in an aggressive DVAF. Venous collateral flow in dural sinus thrombosis may be very prominent and may mimic a DVAF. MRA shows a leash of nodular and seripiginous vessels (arrows) in the region of the left jugular bulb in keeping with a DVAF. Clinical presentation: Patient commonly presents with objective PT and vascular TM on otoscopy. Embryology: An aberrant ICA occurs due to failure of formation of the proximal ICA and replacement by the inferior tympanic artery which enters the skull base lateral to the expected course of the vertical portion of the carotid canal (which is absent). It then crossses the mesotympanum and exits anteromedially to become the horizontal portion of the carotid canal (Fig. An aberrant ICA may mimic a glomus tumour sitting on the promontory on a single coronal HRCT image or on CECT images. Tubular appearance of the vessel on NECT images and an enlarged inferior tympanic canaliculus are diagnostic (Fig.
Source MRA images show the aberrant vessel in the MEC (coursing more laterally than normal) and forming of a "7" or "reversed-7" configuration (Fig. 8: Axial HRCT of the temporal bone in a patient with right-sided arterial PT and vascular TM. An aberrant ICA (arrow) is seen coursing through the right MEC and becoming continuous with the horizontal portion of the carotid canal.
The aberrant ICA is seen to enter the right MEC through the enlarged inferior tympanic canaliculus (arrow).
Clinical presentation: Patient may present with venous hum in the ear and a bluish TM on otoscopy. Patholohy: DJB is a venous variant where the jugular bulb enters the MEC through its dehiscent floor.
It must be differentiated from a high-riding jugular bulb and jugular bulb diverticulum both of which show intact floor of the MEC.


HRCT is often diagnostic showing a soft tissue density structure in continuity with the jugular bulb protruding through the deficient floor of the MEC (Fig.
Contrast-enhanced MRI (CEMRI) shows an avidly enhancing MEC mass connecting to an avidly enhancing jugular bulb. 11: Coronal HRCT of the temporal bone in a patient with right sided venous PT and bluish appearance of the right TM on otoscopy. The right jugular bulb (asterisk) is seen protruding superiorly through the deficient bony floor (arrow) of the right MEC. The right DJB (asterisk) is seen protruding through the deficient bony floor (arrow) of the right MEC.
Glomus tympanicum arises from the Jacobsen's nerve over the cochlear promontory and glomus jugulare arises from the adventitia of the jugular bulb. GJT is seen as a mass extending from the jugular bulb to the MEC (with erosion of its bony floor) and permeative erosion of the bony walls of the jugular foramen (Fig.
A mass is seen centered in the right jugular foramen (black asterisk) with extension into the right middle ear cavity (white asterisk) and associated bony destruction (white arrows).
The right jugular foramen mass (asterisk) shows hyperintense foci on T1W images in keeping with haemorrhage within the lesion. Intense post contrast enhancement in the right jugular foramen mass (asterisk) confirms the diagnosis of GJT.
Clinical Presentation: Patient presents with CHL or mixed hearing loss and sometimes with PT. Pathology: Otosccerosis is an otodystrophy of the otic capsule characterised by replacement of the normal ivory-like enchondral bone by spongy vascular new bone. HRCT of the temporal bone is the modality of choice for the evaluation of otosclerotic plaques. These plaques (as small as 1 mm) are seen as hypodense foci in the region anterior to the oval window and in the peri-cochlear region (Fig.
Paget's disease is also an otodystrophy which may affect the otic capsule and rarely present with PT in the lytic phase. 18: Axial HRCT of the temporal bone in a patient with right-sided mixed hearing loss and PT.
Hypodense demineralised otosclerotic plaques are seen in the right fenestral region (white arrow) and pericochlear region (black arrow).
19: Axial NECT of the skull base in a patient with right-sided PT and known Paget's disease.
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Morphological alterations and lesions of the skull Review of cases in MRI and CT scan of the brain.
Facial nerve schwannoma is a rare benign tumour of Schwann cells that can affect anywhere along the facial nerve from its origin to its extracranial ramifications in the parotid space of the extracranial head and neck. It often affects multiple segments of the facial nerve with a predilection for the region around the geniculate ganglion. Patients may present with gradual facial nerve paralysis over many years or sensorineural hearing loss due to local mass effect from the tumour. The lesion may spread along the greater superficial petrosal nerve anteromedially if large. Imaging features: Glomus tympanicum appears as an enhancing mass on the cochlear promontory with “salt and pepper” appearance on MRI. Salt and pepper appearance refers to punctate hyperintensity (salt) and flow voids (pepper) on T1 weighted images. Acute or chronic infection of the middle ear and mastoid can spread to the facial nerve due to its course within the temporal bone. Guillain-Barre Syndrome is an acute inflammatory demyelinating polyradiculopathy of uncertain aetiology.


Miller Fisher Syndrome is a variant of Guillain- Barre Syndrome which involves the cranial nerves.
It is thought to be due to reactivation of latent herpes simplex virus in the geniculate ganglion. Imaging features: Longitudinal fracture typically runs parallel to the petrous pyramid through the middle ear. The smooth bony margins of the jugular foramen help to exclude more aggressive lesions like a glomus jugulare or jugular foramen meningioma.
Misdiagnosis of an aberrant ICA as glomus tumour can be catastrophic as it may lead to a biopsy. There is also enhancement of the mastoid segment of the facial nerve which lies in the region of the inflammatory phlegmon, in keeping with facial nerve involvement.
At surgery Glomus Jugulare tumor was removed.glomus tumor glomus tumor is very painful tumor usually found at finger tips.
The tumour extends laterally involving the mastoid segment and superiorly involving the IAC segment of the facial nerve. A piece of surgical Teflon (blue arrow) has been inserted in between the AICA and the right facial nerve with good post operative outcome. Mohamed Sheeraye - Carotid body tumor- Hopital de Balbala- Djibouti 40 YRS OLD FEMALE WITH - UNCONTROLLED HYPERTENSION - MASS RT SIDE OF THE NECKGlomus Tympanicum Pulsation Glomus tympanicum is a slow growing benign vascular tumour involving the middle ear. It is derived form glomus bodies which are chemoreceptors found along certain blood vessels and nerves within the proximity of middle ear region. Its presenting symptoms include hearing loss (conductive type), pulsing tinnitus, ear pain or rarely bleeding from the ear.
This video shows a pulsatile red vascular mass (synchronous with the patient heart beat) at its typical position (behind the lower quadrant of the middle ear). The Glomus-group is sent to investigate the case and in the end the butler is the murderer. Several authors have suggested that the carotid body tumor represents a proliferative response of the normal organ to some unknown disturbance within the nervous system, rather than a true neoplasm.
Bungeler (1952) suggested that this was some form of adaptive hyperplasia, which was produced by traumatic destruction of the cortical projection fields of the X nerve. In contrast to this hypothesis, is the realization that a significant number of these lesions undergo malignant transformation with metastasis, which establishes the carotid body tumor as a true neoplasm. Study of the familial occurrence of chemodectomas has established a definite genetic influence in the development of these neoplasms. They proposed that hypoxia, acting from birth, served as a stimulus for chemoreceptor tissue hyperplasia, which eventually led to tumor formation. There is subjective tinnitus where the ringing or the wheezing is heard by the patient alone and objective tinnitus in which the doctor can also hear the noise by using acoustic instruments. Some of these are unilateral (can be heard in one ear) or bilateral where it is heard in both the ears.
Persons suffering from Pulsatile Tinnitus can hear their own heartbeats while Somatic Tinnitus resonances lie outside the ear, probably beyond the cochlear nerves and is believed to arise from central crosstalk within the grey matters. Atheroscl*** Carotid Artery Disease in which the arteries become narrowed due to heavy cholesterol buildup that result in uneven blood flow to the head and neck area. Glomus tumor that consists of bunches of tissues and entangled blood vessels in the ear or the immediate surrounding area can become a cause of tinnitus.
Intracranial vascular lesion often causes tinnitus of aneurism and arteri-venous malformation or deformity that is usually typified by abnormal or irregular connection between the artery and the vein.. Prahlada NB, Senior consultant & Head, ENT-Head & Neck Surgery and Skull Base Surgery, BGS Global Hospital, Bengaluru.



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