Temporal bone osteoradionecrosis is a rare but significant complication of radiation for head and neck malignancies. Various management techniques have been described, but no clear protocol exists.

A retrospective case review of patients with temporal bone osteoradionecrosis managed over 15 years was carried out to highlight multidisciplinary team (MDT) management. The review findings were compared with the published literature and a protocol was derived for the management of future cases.

A total of 20 patients were included. The sites of osteoradionecrosis included the external auditory canal, the middle ear and the lateral skull base, presenting with features including recalcitrant pain, infection, neuropathies and intracranial sepsis. Treatments included hyperbaric oxygen, antibiotics, debridement and, in advanced cases, lateral temporal bone resection with vascularised tissue transfer. Post-operative and long-term outcomes were discussed.

Early temporal bone osteoradionecrosis may be managed conservatively. Refractory osteoradionecrosis can be life-threatening because of intracranial complications and sepsis. Such cases need an MDT approach with radical skull-base surgery for removal of necrotic foci and reconstruction using vascularised tissue transfer.

To assess the perceived benefits of a novel educational approach for otolaryngology trainees: a virtual reality temporal bone simulator drilling competition.

Regional otolaryngology trainees participated in the competition. Drilling activities using the Voxel-Man TempoSurg simulator were scored by experts. Questionnaires that contained questions covering motivators for attending, perceived learning and enjoyment were sent to participants. Agreement with statements was measured on a 10-point Likert scale (1 = strongly disagree, 10 = strongly agree).

Eighteen trainees participated. The most cited reason for attending was for learning and/or education (61 per cent), with most attendees (72 per cent) believing that competition encourages more reading and/or practice. Seventeen attendees (94 per cent) believed Voxel-Man TempoSurg-based simulation would help to improve intra-operative performance in mastoidectomy (mean 7.83 ± 1.47, p < 0.001) and understanding of anatomy (mean 8.72 ± 1.13, p < 0.001). All participants rated the competition as ‘fun’ and 83 per cent believed the competitive element added to this.

The virtual reality temporal bone competition is a novel educational approach within otolaryngology that was positively received by otolaryngology trainees.

Temporal bone dissection is a difficult skill to acquire, and the challenge has recently been further compounded by a reduction in conventional surgical training opportunities during the coronavirus disease 2019 pandemic. Consequently, there has been renewed interest in ear simulation as an adjunct to surgical training for trainees. We review the state-of-the-art virtual temporal bone simulators for surgical training.

A narrative review of the current literature was performed following a Medline search using a pre-determined search strategy.

Sixty-one studies were included. There are five validated temporal bone simulators: Voxel-Man, CardinalSim, Ohio State University Simulator, Melbourne University's Virtual Reality Surgical Simulation and Visible Ear Simulator. The merits of each have been reviewed, alongside their role in surgical training.

Temporal bone simulators have been demonstrated to be useful adjuncts to conventional surgical training methods and are likely to play an increasing role in the future.

Aneurysmal bone cysts are expansile benign lesions associated with compressive destruction and obscure pathogenesis. The most common sites of temporal bone involvement are the petrous apex, squamous portions and mastoid.

This paper reports a right temporal aneurysmal bone cyst in a 51-year-old man who presented clinically with facial palsy, and hearing loss and impaired vestibular function. Magnetic resonance imaging and computed tomography findings were consistent with a diagnosis of aneurysmal bone cyst. Inter-operative findings showed that the lesion had caused compressive damage to the internal auditory canal. Following surgical excision, the patient experienced vertigo, indicating recovery of vestibular function. Follow-up imaging revealed complete resection without clinical recurrence.

To our knowledge, this is the first report of aneurysmal bone cyst invasion of the inner auditory canal. Our clinical experience indicates that vestibular nerve damage recovery is relatively uncommon. This case report will hopefully inform future studies.

This study aimed to analyse a three-dimensional transcanal transpromontorial approach to the internal auditory canal using three-dimensional computed tomography.

This study was a retrospective investigation of 48 ears of 24 patients using three-dimensional reconstruction data from normal temporal bone computed tomography. The inner structures of the temporal bone were three-dimensionally reconstructed. Eight points were marked in the three-dimensional object with reference to the axial, coronal and sagittal plane images of the computed tomography scans. Distances and angles to each point were measured from the oval and round windows.

The point of the facial nerve from the internal auditory canal to the labyrinthine segment could be traced between the cochlear apex and the geniculate ganglion based on the oval window.

This technique helps with identifying the locations of important surgical landmarks using three-dimensional reconstructions of pre-operative computed tomography scans and to identify the facial nerve from the internal auditory canal during surgery.

This study aimed to analyse the computed tomography parameters for effective ventilation in patients with adhesive otitis media.

Twenty-six patients with unilateral adhesive otitis media were included in the study. The patients’ temporal bone computed tomography images were retrospectively reviewed. Eustachian tube length and diameter were measured. Mastoid pneumatisation and middle-ear size were evaluated by measuring petroclival and Eustachian tube–tympanic cavity ventilation angles.

The average Eustachian tube length was 38.4 mm and 38.9 mm in adhesive otitis media and healthy ears, respectively. The Eustachian tube diameter of the adhesive otitis media ears (1.47 mm) was significantly narrower than that of the healthy ears (1.83 mm). There were no significant differences in the angles between adhesive otitis media and healthy ears.

A narrow Eustachian tube diameter was associated with developing adhesive otitis media. Measuring Eustachian tube diameter is simple and can be routinely performed when examining temporal bone computed tomography images for Eustachian tube function evaluation.

The Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (‘P-POSSUM’) is a two-part scoring system that includes a physiological assessment and a measure of operative severity. This study sought to determine whether risk estimates for this scoring system could be used in major head and neck reconstructive surgery.

A retrospective review was performed of patients undergoing resection for a temporal bone malignancy in a single head and neck centre in Dublin, Ireland, from 2002 to 2021.

The mean ± standard deviation morbidity estimate calculated using the scoring system was 47.6 per cent ± 19.5 per cent. The actual rate of complications was 47 per cent. The optimal cut-off for the scoring system was calculated using the Youden index from the receiver operating characteristic curve, which was 40.5 per cent in this case.

The study indicates that the Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity is a useful tool for predicting morbidity risk in patients undergoing head and neck resection with reconstruction for temporal bone malignancies.

This study aimed to analyse the effectiveness of using the bony sigmoid sinus plate for repair of meato-mastoid fistulae.

A retrospective study of all cases between January 2013 and December 2019 at our secondary-tertiary centre was conducted. Inclusion criteria for study were: (1) cases with focal meato-mastoid fistulae and (2) focal meato-mastoid fistulae that were repaired by using bony sigmoid sinus plate using the bony sigmoid sinus plate technique. There were 13 cases that fulfilled these criteria.

The outcome of the repair of meato-mastoid fistulae with bony sigmoid sinus plate was very encouraging. All 13 cases did well. Two patients had delayed epithelialisation at 9 and 12 months after surgery.

The technique of repairing meato-mastoid fistulae by using bony sigmoid sinus plate is simple, repeatable and provides effective physiological reconstruction of the posterior canal wall. Bony sigmoid sinus plate is easily and locally available in all cases undergoing cortical mastoidectomy. This plate of bone has a curvature, consistency and structure that match well with that of the posterior or superior canal wall. In addition, this technique is cost-effective with good patient compliance.

This study aimed to investigate the effects of automated metrics-based summative feedback on performance, retention and cognitive load in distributed virtual reality simulation training of mastoidectomy.

Twenty-four medical students were randomised in two groups and performed 15 mastoidectomies on a distributed virtual reality simulator as practice. The intervention group received additional summative metrics-based feedback; the control group followed standard instructions. Two to three months after training, participants performed a retention test without learning supports.

The intervention group had a better final-product score (mean difference = 1.0 points; p = 0.001) and metrics-based score (mean difference = 12.7; p < 0.001). At retention, the metrics-based score for the intervention group remained superior (mean difference = 6.9 per cent; p = 0.02). Also at the retention, cognitive load was higher in the intervention group (mean difference = 10.0 per cent; p < 0.001).

Summative metrics-based feedback improved performance and lead to a safer and faster performance compared with standard instructions and seems a valuable educational tool in the early acquisition of temporal bone skills.

Certain factors have been linked to lateral skull base demineralisation or erosion, which may predispose to spontaneous cerebrospinal fluid leak. There are relatively few quantitative reports of skull base changes in patient populations.

A novel refined measurement algorithm for quantification of tegmen bone mineral density was developed, and bone mineral density between obese and non-obese patient groups was compared. Computed tomography scans were analysed by three blinded reviewers, and tegmen bone mineral densities were compared.

There were 23 patients in the obese group and 27 matched controls in the non-obese group. Inter-rater reliability was ‘strong’ to ‘near complete’ (κ = 0.75–0.86). No differences in tegmen bone mineral density were found between the groups (p = 0.64). The number of active blood pressure medications correlated positively with lateral skull base bone mineral density.

A novel, refined, quantitative measurement algorithm for the assessment of tegmen bone mineral density was developed and validated. Obesity was not found to significantly affect tegmen bone mineral density.

This study aimed to formulate a scoring system based on high-resolution computed tomography scans to predict ease of electrode insertion during cochlear implantation via posterior tympanotomy in paediatric patients.

A scoring system Cochlear Implantation Radiological Assessment Score (CIRAS) was formulated based on six parameters. This score was correlated with intra-operative findings, and receiver operating characteristic analysis was performed to determine the optimal cut-off score to predict difficulty of surgery and to establish the inherent validity of the scoring system by area under curve.

Receiver operating characteristic analysis showed that optimal cut-off score was 8 (93.1 per cent specificity and 56.52 per cent sensitivity), and area under the curve was 0.828. Patients with CIRAS of more than 8 had significantly higher time for surgery (p < 0.05).

CIRAS is an easy to administer tool by utilising classical axial and coronal sections, without any numerical measures. Pre-operative assessment by this score gives a good idea of intra-operative challenges.

To evaluate the outcomes for patients after lateral temporal bone resection surgery for cutaneous squamous cell carcinoma and basal cell carcinoma, and to ascertain predictors of survival and treatment failure.

A retrospective review was conducted of the medical records for all patients who underwent lateral temporal bone resection for cutaneous squamous cell carcinoma or basal cell carcinoma between 2007 and 2019 in Western Australia.

Thirty-seven patients underwent lateral temporal bone resection surgery. Median follow-up duration was 22 months. Twenty-five patients had squamous cell carcinoma and 12 had basal cell carcinoma. The overall survival rate at two years for patients with squamous cell carcinoma was 68.5 per cent. Pre-operative facial nerve involvement (determined via clinical or radiological evidence) was identified as a predictor of mortality (hazard ratio = 3.411, p = 0.006), with all patients dying before two years post-operatively. Locoregional tumour control was achieved in 81 per cent of cases (n = 30).

Lateral temporal bone resection offers acceptable local control rates and survival outcomes. Caution should be used in offering this surgery to patients with clinical or radiological evidence of facial nerve involvement because of the relatively poorer survival outcomes in this subgroup.

Spontaneous cerebrospinal fluid leak of the temporal bone is an emerging clinical entity for which prompt and accurate diagnosis is difficult given the subtle signs and symptoms that patients present with. This study sought to describe the key temporal bone abnormalities in patients with spontaneous cerebrospinal fluid leak.

A retrospective cohort study was conducted of adult patients with biochemically confirmed spontaneous cerebrospinal fluid leak. Demographics and radiological features identified on computed tomography imaging of the temporal bones and/or magnetic resonance imaging were analysed.

Sixty-one patients with spontaneous cerebrospinal fluid leak were identified. Fifty-four patients (88.5 per cent) underwent both temporal bone computed tomography and magnetic resonance imaging. Despite imaging revealing bilateral defects in over 75 per cent of the cohort, only two patients presented with bilateral spontaneous cerebrospinal fluid leaks. Anterior tegmen mastoideum defects were most common, with an average size of 2.5 mm (range, 1–10 mm).

Temporal bone computed tomography is sensitive for the identification of defects when suspicion exists. In the setting of an opacified middle ear and/or mastoid, close examination of the skull base is crucial given that this fluid is potentially cerebrospinal fluid.

This paper describes the construction of portals for electrode placement during cochlear implantation and emphasises the utility of pre-operative temporal bone three-dimensional computed tomography.

Temporal bone three-dimensional computed tomography was used to plan portal creation for electrode insertion.

Pre-operative temporal bone three-dimensional computed tomography can be used to determine the orientation of temporal bone structures, which is important for mastoidectomy, posterior tympanotomy and cochleostomy, and when using the round window approach.

It is essential to create appropriate portals (from the mastoid cortex to the cochlea) in a step-by-step manner, to ensure the safe insertion of electrodes into the scala tympani. Pre-operative three-dimensional temporal bone computed tomography is invaluable in this respect.

Aerosol generation during temporal bone surgery caries the risk of viral transmission. Steps to mitigate this problem are of particular importance during the coronavirus disease 2019 pandemic.

To quantify the effect of barrier draping on particulate material dispersion during temporal bone surgery.

The study involved a cadaveric model in a simulated operating theatre environment. Particle density and particle count for particles sized 1–10 μ were measured in a simulated operating theatre environment while drilling on a cadaveric temporal bone. The effect of barrier draping to decrease dispersion was recorded and analysed.

Barrier draping decreased counts of particles smaller than 5 μ by a factor of 80 in the operating theatre environment. Both particle density and particle count showed a statistically significant reduction with barrier draping (p = 0.027).

Simple barrier drapes were effective in decreasing particle density and particle count in the operating theatre model and can prevent infection in operating theatre personnel.

To depict various temporal bone abnormalities on high-resolution computed tomography in congenital aural atresia patients, and correlate these findings with auditory function test results and microtia subgroup.

Forty patients (56 ears) with congenital malformation of the auricle and/or external auditory canal were evaluated. Auricles were graded according to Marx's classification, divided into subgroups of minor (grades I and II) and major (III and IV) microtia. Other associated anomalies of the external auditory canal, tympanic cavity, ossicular status, oval and round windows, facial nerve, and inner ear were evaluated.

Minor and major microtia were observed in 53.6 and 46.4 per cent of ears respectively. Mean hearing levels were 62.47 and 62.37 dB respectively (p = 0.98). The malleus was the most commonly dysplastic ossicle (73.3 vs 80.8 per cent of ears respectively, p = 0.53). Facial nerve (mastoid segment) abnormalities were associated (p = 0.04) with microtia subgroup (80 vs 100 per cent in minor vs major subgroups).

Microtia grade was not significantly associated with mean hearing levels or other ear malformations, except for external auditory canal and facial nerve (mastoid segment) anomalies. High-resolution computed tomography is essential in congenital aural atresia, before management strategy is decided.

This study aimed to evaluate the association between cochlear nerve canal dimensions and semicircular canal abnormalities and to determine the distribution of bony labyrinth anomalies in patients with cochlear nerve canal stenosis.

This was a retrospective study in which high-resolution computed tomography images of paediatric patients with severe-to-profound sensorineural hearing loss were reviewed. A cochlear nerve canal diameter of 1.5 mm or less in the axial plane was classified as stenotic. Semicircular canals and other bony labyrinth morphology and abnormality were evaluated.

Cochlear nerve canal stenosis was detected in 65 out of 265 ears (24 per cent). Of the 65 ears, 17 ears had abnormal semicircular canals (26 per cent). Significant correlation was demonstrated between cochlear nerve canal stenosis and semicircular canal abnormalities (p < 0.01). Incomplete partition type II was the most common accompanying abnormality of cochlear nerve canal stenosis (15 out of 65, 23 per cent).

Cochlear nerve canal stenosis is statistically associated with semicircular canal abnormalities. Whenever a cochlear nerve canal stenosis is present in a patient with sensorineural hearing loss, the semicircular canal should be scrutinised for presence of abnormalities.

Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline.

This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management.

A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review.

Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately.

This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.

To investigate the prevalence of bony dehiscence in the tympanic facial canal in patients with acute otitis media with facial paresis compared to those without facial paresis.

A retrospective case–control study was conducted on acute otitis media patients with facial paresis undergoing high-resolution temporal bone computed tomography.

Forty-eight patients were included (24 per group). Definitive determination of the presence of a bony dehiscence was possible in 44 out of 48 patients (91.7 per cent). Prevalence of bony dehiscence in acute otitis media patients with facial paresis was not different from that in acute otitis media patients without facial paresis (p = 0.21). Presence of a bony dehiscence was associated with a positive predictive value of 66.7 per cent in regard to development of facial paresis. However, an intact bony tympanic facial canal did not prevent facial paresis in 44.8 per cent of cases (95 per cent confidence interval = 34.6–55.6).

Prevalence of bony dehiscence in acute otitis media patients with facial paresis did not differ from that in acute otitis media patients without facial paresis. An intact tympanic bony facial canal does not protect from facial paresis development.

To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol.

A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention.

Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients.

Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.