A Novel Functional Imaging Method of the Eustachian Tube...Poster Design & Printing by...
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A Novel Functional Imaging Method of the
Eustachian Tube Cuneyt M. Alper1,2, Tanya J. Rath3,4, J. Douglas Swarts2, Miriam S. Teixeira2, William J. Doyle2
1) Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, 2) Department of Otolaryngology, University of Pittsburgh School of Medicine
3) Department of Radiology, University of Pittsburgh School of Medicine, 4) Division of Neuroradiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
INTRODUCTION
DISCUSSION
RESULTS
A. 1.25 mm in soft tissue
algorithm, soft tissue window
(Window 145, Level - 55).
The paratubal fat (black
arrows) is seen similar in
density to subcutaneous fat
(white arrow) displayed as
dark grey. No definite air
density could be visually seen
in the eustachian tube when
using air (white asterisk) in the
nasopharynx as a reference.
B. Displayed in thinner 0.625
mm bone algorithm with a
lower level (Window 432,
Level -200), small foci of air
(black arrows) were
suspected in the eustachian
tube using air (white asterisk)
in the nasopharynx as a
reference.
C. When the window was
narrowed and dichotomized
(Window 1, Level -200) to
show only air displayed as
black, versus all other
densities displayed as white,
only 2 small foci of possible
air(black arrow) could be
seen, suggesting that air
passing through the
eustachian tube during the
forced response test is not
clearly detected by CT due to
inadequate special resolution
and partial volume averaging
with adjacent paratubal fat.
Figure 2. Figure 2 A, B. Axial 0.625 mm low dose eustachian tube CT
(kVp 100 mA 200 ; Window 974/Level 271) after instilling water soluble
iodinated contrast in to the middle ear cavity and eustachian tube. A.
Iodinated contrast which is displayed as white is easily seen within the
eustachian tube (white arrows) and in the nasopharynx (black asterisk)
B. An oblique reformat along the long axis of the eustachian tube
following the instillation of water soluble contrast into the eustachian
tube. The entirety of the cartilaginous portion of the eustachian tube
(black arrows) is easily visualized with dense contrast from the bony
eustachian tube to the nasopharynx. Contrast is seen pooling in the
nasopharynx (black asterisk)
ABSTRACT
Outcome Objectives: 1) Image the
Eustachian tube (ET) lumen by CT
scanning during ET function (ETF)
testing; 2) Characterize the differences
in image quality for different scanning
protocols, and 3) Establish a novel
research methodology for studying ET
anatomy and physiology.
Methods: In a cadaver head without
craniofacial or otologic abnormalities,
the tympanic membrane was
perforated and ETF test was done
using the forced response test (FRT)
in a CT scanner. Opening (OP), steady
(PS) and closing (CP) pressures were
measured during forced air flow from
the middle ear (ME) to the
nasopharynx across the open ET.
Temporal bone CT scans with 0.625
mm thickness were done at a low and
standard radiation doses before and
during the steady flow (SF) phase of
the FRT, after instilling iodinated
contrast into the ME and ET, and after
the FRT cleared the contrast from the
ET. Multiplanar reformats of the ET
were created using post-processing
software.
Results: The average OP, PS and CP
values were 488±249, 376±101 and
211±62 daPa. While a distinct ET
lumen could not be demonstrated
during the FRT done with air at any
radiation dose, CT with intra-luminal
contrast clearly demonstrated the
entire ET lumen. Post-contrast FRT
demonstrated residual contrast
outlining the lumen.
Conclusion: Standard temporal bone
CT dose provided a slightly better
signal-to-noise than low dose CT but
neither provided adequate spatial
resolution to demonstrate an air filled
ET during FRT. ET lumen was easily
visualized with iodinated water soluble
contrast at all radiation doses.
Combining ETF testing and CT
imaging has potential research
applications.
This is the first report of combining a reliable ET
function test (FRT) with CT scan for visualizing the
ET lumen. While ET lumen is closed at rest (unless
patulous), and current standard imaging techniques
fail to capture the tube during this short opening
time. FRT maintains a steady opening through the
lumen while constantly running air with a pump.
However, even though the lumen is kept open, the
CT scan was unable to demonstrate a distinct air
column. Instilling water soluble contrast facilitated
the visualization of the ET lumen , however, running
FRT after contrast still showed contrast but no air
column. Running FRT pump at high speed or using
standard temporal bone and high dose CT scan
protocols did not change the outcome. In conclusion,
there was no difference in the ability to detect air
with any of the techniques though the radiologists
found the standard T bone CT and high dose to be
visually more pleasing with less noise.
Scanning of a cadaveric head was performed helically
on a 64-channel multidetector CT scanner (GE
LightSpeed VCT; GE Healthcare, Milwaukee, WI).
Forced Response Test (FRT) was performed by running
air with a pump from the external ear canal, through
middle ear and the ET into the nasopharynx. FRT
standard speed was 23 cc/min., and high speed was 60
cc/min. This was repeated after injection of water
soluble iodinated contrast (IC) through the middle ear.
The sequence of CT protocols performed were as
follows with example images provided in Figure 1:
1. A (localizer) -Low dose (100kVp, 180mA, pitch
0.969)
2. B (helical) -Low dose (100kVp, 200mA, pitch 0.531)
with standard speed FRT
3. B CT technique with IC
4. B CT technique with IC and standard speed FRT
5. Standard dose Temporal bone CT (120kVp, 195 mA)
with standard speed FRT
6. B CT technique with IC and high speed FRT
7. High dose CT (120fVp 320 MA) with IC and high
speed FRT
Axial 0. 625 mm bone and 1.25 mm soft tissue
reconstructions were performed for all scans. An edge
enhancing reconstruction kernel was used (Bone Plus;
GE Healthcare, Milwaukee, WI). All reformats were
performed by a CAQ certified neuroradiologist (T.J.R)
using dedicated post-processing software (Vitrea®
Core; Vital Images, Minnetonka, MN). Axial oblique
and coronal oblique 1 mm thick reconstructions with 1
mm increment parallel and perpendicular to the long
axis of the ET were obtained.
We would like to acknowledge Barton F. Branstetter IV,
MD, Professor of Radiology, University of Pittsburgh, for
his review of images and input with respect to this
project.
The Eustachian tube (ET) is a natural tube that
connects the middle ear (ME) to the back of the
nose (nasopharynx). The posterior 1/3 of the ET is
a bony extension of the ME with a patent lumen
while the anterior 2/3 is a membrano-cartilaginous
structure that opens into the nasopharynx. The
physiologic functions attributed to the ET are middle
ear pressure regulation, clearance of secretions and
protection from reflux of nasal secretions. The ET is
usually closed due to the natural pressure of the
surrounding tissue and is opened intermittently by
the active contraction of the tensor veli palatini
(mTVP) and levator veli palatini (mLVP) muscles,
allowing equilibrium between the ambient and
middle ear pressures.
Inefficient ET openings are associated with the
progressive development of ME under pressure and
set the basis for several middle ear diseases such
as acute and chronic otitis media, otitis media with
effusion (OME), retraction pockets, cholesteatoma,
barotrauma and hearing loss.
The ET is located at the base of the skull and its
complexity and difficult access resulted in frustrated
attempts of imaging studies previously. Another
challenge comes from the fact that the ET has a
virtual lumen that only opens for a few hundred
milliseconds during middle-ear and ambient
pressure equalization (0.2 – 0.4 sec on average).
An example of ET imaging is nasopharyngoscopy, a
routine outpatient procedure in which a flexible or
rigid endoscope is introduced through the nostrils
allowing examination of the nasal cavity and the
back of the nose. It requires expensive equipment,
the use of topical anesthesia and decongestants, is
uncomfortable and cannot be tolerated by many
patients, especially young children. Although it is
very useful for assessment of peritubal diseases
and nasal and pharyngeal infectious or
inflammatory processes, it only allows the
visualization of the opening of the tube and
sometimes a few millimeters of the lumen.
Magnetic Resonance Imaging (MRI) and
Computerized Tomography (CT) are imaging
techniques largely used by the medical community
to study biological tissues from all regions of the
body. The development of high resolution three-
dimensional (3-D) reconstruction software has
broadened their use to explore the anatomy of small
structures such as the ET. Initially, MRI seemed
ideal as it does not involve ionizing radiation
exposure, but unfortunately it is limited by very long
scan time, significant imaging artifacts and large
asymmetric voxel sizes. When those variables are
applied to small areas, the 3-D reconstructions yield
a poorly defined image. On the other hand, recent
publications have shown that the faster helical CT
scans can provide clear reconstructions of the
lumen and surrounding tissues along all ET
segments. Although promising, this is only possible
in patients with a patulous ET, a situation in which
the tube remains abnormally open. This limits the
usefulness of the technique to only a subset of
patients, as the great majority of ET problems come
from failure to dilate the cartilaginous segment due
to strictures or poor muscular efficiency.
A study was conducted in order to develop a novel
functional imaging model for visualization of the ET.
METHODS AND MATERIALS
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Inc, 2005.
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ACKNOWLEDGEMENT
REFERENCES
Cuneyt M. Alper, M.D. Professor of Otolaryngology
Director, Pediatric Otolaryngology
Fellowship Program
Children’s Hospital of Pittsburgh of UPMC
Department of Otolaryngology
University of Pittsburgh School of Medicine
Email: [email protected]
Phone: 412-692-8577
Website: http://www.chp.edu/CHP/ent
CONTACT
University of Pittsburgh
Supported in Part by:
National Institute of Health
P-50 Grant DC007667
R21 Grant DC013167
Figure 1. Figure 1 A, B & C. Axial CT, low dose eustachian tube all
obtained during the same forced response test displayed in different
techniques.
A B
A
C
B