0:00

This is a 50-year-old male who

0:03

presented with ear pain.

0:06

And upon viewing through the otoscopy,

0:11

the head-neck clinician said that there was an

0:15

inflammatory mass in the right

0:17

external auditory canal.

0:19

In most instances,

0:21

if they are able to identify the tympanic

0:24

membrane beyond the infection,

0:26

they don't do imaging because they are able to treat

0:30

that clinically without evaluation with imaging.

0:35

However,

0:36

in the instance where the canal is obliterated,

0:40

they can't tell whether this inflammatory process is

0:44

extending from the external auditory canal into the

0:49

middle ear cavity and across the tympanic membrane.

0:54

So for that instance,

0:56

they will generally refer for imaging.

0:59

So our job is to identify the tympanic membrane.

1:03

Now, when you have soft tissue that's up

1:05

against the tympanic membrane,

1:06

it's kind of hard to see something separate from it.

1:08

And this was the example in this case.

1:11

So here we have the bone window and the

1:13

soft tissue window on the axial scans.

1:15

And we see what the clinician is seeing.

1:17

Here's the external auditory canal,

1:18

cartilaginous portion, bony portion,

1:21

and we have a soft tissue mass that is present in

1:24

the external auditory canal. Now, I might ask you,

1:26

is the tympanic membrane here?

1:28

Is the tympanic membrane here?

1:30

Is the tympanic membrane here?

1:33

We can't really tell at first blush.

1:36

So how do we tell?

1:38

Well, you want to scroll, obviously, up and down.

1:42

And what we can see is that there is soft tissue,

1:48

which is between the neck of the malleus

1:54

and the long process of the incus.

1:56

So what we're seeing are those two dots that I've

2:00

referred to previously. Let me point these out.

2:03

So this guy here is our neck of the malleus,

2:07

and this guy here is our long process of incus.

2:11

And as you recall,

2:12

the long process of the incus is

2:14

going to insert on the stapes,

2:16

which has soft tissue associated with it,

2:19

as well as you come to the vestibule

2:21

and the oval window.

2:23

So, by virtue of demonstrating soft tissue associated

2:28

with an incorporating portions of the ossicles,

2:32

we know that this infection has therefore crossed

2:36

the tympanic membrane. If the ossicles are clean,

2:40

it may be limited to the external ear,

2:43

external auditory canal.

2:45

The fact that we have soft tissue encasing portions

2:49

of the middle ear ossicles, tells us that this is an

2:52

infection that, by rights, has crossed the tympanic

2:56

membrane and therefore is potentially

2:59

more dangerous.

3:00

So let's just scroll a little bit more here,

3:03

make sure that we're comfortable with this.

3:05

Here we can actually see Prussak's space between

3:09

the malleus and the area of the scutum.

3:12

Here is the short process of the incus,

3:16

the head of the malleus.

3:18

And this is not air; this is soft tissue.

3:21

So this infection is crossing the tympanic membrane and

3:25

going from just external otitis to otitis

3:29

media in the middle ear cavity.

3:32

You can see this also, the soft tissue on the

3:36

soft tissue windows and on the coronal image,

3:41

if we scroll to that same level,

3:43

we again see that the Prussak's space is opacified.

3:49

We have the umbo of the malleus on the tympanic

3:53

membrane, and there's soft tissue along the umbo,

3:58

and therefore, we have involvement of the

4:00

middle ear cavity. In this case,

4:03

this ended up being a fungal infection that did require

4:07

oral antibiotics, as well as drops to cure

4:13

the external auditory canal

4:15

portion of the infection.