Cochlear implant is the treatment of choice for deep sensorineural hearing loss, notably in
those patients for whom conventional amplification devices do not provide significant
clinical improvement. Imaging plays an important role in the workup of cochlear implant
candidates not only to identify inner ear congenital and acquired abnormalities or cochlear
nerve anomalies but also to detect temporal bone abnormalities that may be encountered during
surgery and may alter surgical approach.
Some variations are potential surgical hazards that may lead to problems during the surgery
and may alert the surgeon regarding potential surgical dangers and complications.
The radiologist and surgeon must be familiar with these imaging findings. Both computed
tomography and magnetic resonance imaging should be used as they delineate, in different
manners, cochlear and middle ear anatomy as well as other anatomical variants.
Mastoid pneumatization is important for planning the surgery. It is classified into
pneumatic, diploic, sclerotic, and mixed. Effusion of the middle ear cleft should also be
reported.
Korner's septum divides the mastoid process into a superficial squamous portion and a deep
petrous portion. It may mislead the surgeon to the mastoid antrum during surgery. Mastoid
emissary veins participate in extracranial venous drainage of the posterior fossa dural
sinuses. Most of them disappear, however, some persist and enlarge.
Low lying dura represents difficulty to access the aditus, lateral semicircular canal, and
posterior tympanotomy. It is often associated with sclerotic mastoid. Posterior tympanotomy
is a well known otologic procedure that allows surgeons to access the middle ear cavity. The
surgeon opens a window in the posterior wall of the middle ear in the angle between the
chorda tympani and the mastoid part of the facial nerve. Laterally or anteriorly positioned
mastoid part of the facial nerve may hinder the access to the facial recess or may even force
the surgeon to change his approach.
The sigmoid sinus passes along the posteromedial border of the mastoid air cells. An
anteriorly located sinus produces a deep bulge in the mastoid and may reach the posterior
wall of the external auditory canal being separated from it only by a thin bony plate.
Jugular bulb variations are common, the roof of a normal jugular bulb lies either at or
slightly below the level of the external auditory canal floor and is separated from the
middle ear cavity by the thin bony sigmoid plate. The average width of the jugular bulb is 1
cm. A jugular bulb larger than 1 cm is called a giant or mega jugular bulb. A jugular bulb
that extends over the basal turn of the cochlea or abuts the round window is called a high
riding jugular bulb. Dehiscence of the sigmoid plate with upward protrusion of the bulb into
the posterior hypotympanum is called a dehiscent jugular bulb, which may obliterate a round
window niche.
The aberrant internal carotid artery is an enlarged inferior tympanic artery that occurs as a
result of agenesis or underdevelopment of the cervical segment of the internal carotid
artery. It runs along the medial aspect of the middle ear coursing anteriorly across the
cochlear promontory to join the horizontal carotid canal through a dehiscence in the carotid
plate.
Cochlear duct patency and axis, patency of the round window niche and the patent even caliber
of the cochlea must be adequately evaluated by both computed tomography and magnetic
resonance imaging. Otospongiotic foci compromise the insertion of the cochlear implant
electrode if they occlude the round window niche or cochlear duct. Labyrinthitis ossificans
may partially or completely obliterate cochlear lumen. Fibrosis may precede ossification and
areas of fibrosis and ossification may coexist. Cochlear ossification with luminal
obstruction is not a contraindication for implantation, however, it is important to be
identified preoperatively.
Vestibular aqueduct (VA) is considered dilated if its width is greater than the width of the
posterior SCC or if its midpoint width is greater than 1.5 mm. Computed tomography shows
dilatation of the VA only whereas magnetic resonance imaging shows the dilatation of the VA
and of the endolymphatic sac.