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Normal CT Temporal Bone Report Template
Normal temporal bone CT report template: external canal, ossicles, middle ear spaces, mastoid, inner ear structures and the facial nerve canal, side by side, with notes on cholesteatoma, dehiscence and conductive-loss wording.
EXAMINATION: CT temporal bones without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Hearing loss”] COMPARISON: None available. TECHNIQUE: Thin-section axial helical images through the temporal bones without intravenous contrast, with coronal (and Pöschl and Stenvers) reformats in bone algorithm. Dose reduction techniques were used. FINDINGS: RIGHT TEMPORAL BONE External auditory canal: Patent. Normal bony canal. No soft tissue or erosion. Tympanic membrane and middle ear: The tympanic membrane is normal in position. The middle ear cavity is clear. No soft tissue in Prussak's space, the epitympanum, mesotympanum or hypotympanum. Ossicles: The malleus, incus and stapes are intact and normally articulated. No erosion. Scutum: Sharp and intact. Tegmen tympani and mastoideum: Intact. Mastoid: Well aerated. No opacification or coalescence. Facial nerve canal: Normal course and caliber of the labyrinthine, tympanic and mastoid segments. No dehiscence. Inner ear: The cochlea has a normal two-and-a-half-turn morphology with a normal modiolus. The vestibule and semicircular canals are normal; the superior semicircular canal is covered by bone. The vestibular aqueduct is normal in caliber. The internal auditory canal is normal in caliber. Vascular: The jugular bulb and carotid canal are normally positioned and covered by bone. No sigmoid plate dehiscence. LEFT TEMPORAL BONE [Mirror the right-sided findings, section for section.] Visualized brain and skull base: Unremarkable. IMPRESSION: 1. Normal CT of the bilateral temporal bones. No middle ear or mastoid disease, ossicular abnormality or inner ear anomaly.
Dictation notes
- Cholesteatoma is a diagnosis of location plus erosion — soft tissue in Prussak's space with scutum blunting or ossicular erosion earns the word; nonspecific middle ear opacification does not.
- For a conductive loss with an intact tympanic membrane, say explicitly whether the stapes footplate and oval window are normal — fenestral otosclerosis is a subtle hypodense focus at the fissula ante fenestram, and it is the finding they are asking about.
- Superior semicircular canal dehiscence is confirmed on the Pöschl (in the plane of the canal) reformat, not the standard coronal; name the plane you used before you call it.
- An enlarged vestibular aqueduct (midpoint over about 1 mm, operculum over about 2 mm) is the most common imaging finding in pediatric sensorineural loss — measure it rather than eyeball it.
- Dictate the two sides as parallel sections so an asymmetry cannot hide in a shared sentence; a single “bilateral mastoids are clear” line covers a lot of ground.
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