Page 9 of 11
RD7.2 | Imaging in ENT — Graded Quiz
Click any question card to reveal the correct answer.
A 4-year-old with uncomplicated acute suppurative otitis media (ASOM) is brought to the ENT clinic. There are no red-flag features — no post-auricular swelling, no facial weakness, no vertigo and no neurological signs. Which is the most appropriate imaging decision?
Correct. Uncomplicated ASOM is diagnosed and managed clinically; the principle is restraint — image only when a complication is suspected. Reaching for the scanner here would expose a child to radiation/contrast with no benefit.
Restraint is the first principle of otitis-media imaging: uncomplicated ASOM is a clinical diagnosis and needs no scan; image only when red flags (mastoiditis, facial palsy, vertigo, intracranial signs) appear.
The governing principle is to image the complication, not the infection. With no red flags, uncomplicated ASOM needs no imaging. Routine CT/MRI is unjustified, plain mastoid films are obsolete, and contrast brain CT is for suspected intracranial spread only.
Click to reveal answer
When imaging chronic suppurative otitis media (CSOM) to assess the disease and plan surgery, which modality is first-line and which single feature does it characterise best?
Correct. HRCT temporal bone is the first-line study in CSOM because disease here is judged by what it does to bone — it exquisitely demonstrates ossicular erosion, scutum blunting, tegmen and canal-wall integrity, all of which guide surgery.
CT is for bone, MRI is for soft tissue: HRCT temporal bone is the first-line study in CSOM for ossicular/scutum/tegmen detail; MRI is reserved for soft-tissue questions such as cholesteatoma versus granulation.
Modality choice follows the physics: CT = bone, MRI = soft tissue/nerve. CSOM surgical planning hinges on bony detail (ossicles, scutum, tegmen), so HRCT temporal bone is first-line. MRI characterises soft tissue, plain films are obsolete, and ultrasound/neck CT are inappropriate.
Click to reveal answer
An HRCT temporal bone in a patient with CSOM shows a soft-tissue density filling the middle ear and attic. Which feature on the scan most reliably indicates that this represents cholesteatoma (unsafe disease) rather than a simple inflammatory effusion or granulation?
Correct. The combination of non-dependent soft tissue and bony erosion (scutum blunting, ossicular erosion) is the radiological signature of cholesteatoma — it expands and erodes bone, unlike a dependent effusion or simple granulation.
Two questions read every temporal-bone scan: where is the disease and what has it destroyed? Non-dependent soft tissue with bony erosion = cholesteatoma (unsafe CSOM), changing management to surgical exploration.
Cholesteatoma is recognised by non-dependent soft tissue plus bone erosion. Dependent fluid, an air-fluid level or non-eroding opacification suggests benign effusion/inflammation; calcification suggests tympanosclerosis. Bony destruction with non-dependent soft tissue is what flags unsafe disease.
Click to reveal answer
A 45-year-old man has sudden-onset unilateral sensorineural hearing loss with tinnitus and mild imbalance; the contralateral ear is normal. Otoscopy is unremarkable. Which imaging study is most appropriate to exclude a retrocochlear (CPA/IAM) lesion?
Correct. Unilateral/asymmetric SNHL must be investigated to exclude a retrocochlear lesion such as vestibular schwannoma; gadolinium-enhanced MRI of the IAM/posterior fossa is the gold standard for the cochlear nerve and CPA.
Asymmetric/sudden SNHL = scan the nerve with gadolinium-enhanced MRI IAM/posterior fossa to exclude vestibular schwannoma; CT images bone and cannot answer a retrocochlear question.
Retrocochlear pathology lives in soft tissue at the CPA/IAM, so MRI with gadolinium is the study of choice. CT (bone) cannot exclude a schwannoma; skull X-ray is obsolete; carotid Doppler and non-contrast brain CT do not assess the cochlear nerve.
Click to reveal answer
A gadolinium-enhanced MRI of the internal auditory meatus in a patient with progressive asymmetric SNHL shows an enhancing mass centred at the porus acusticus, with a small intracanalicular component and a larger cisternal component giving an 'ice-cream-cone' appearance. What is the most likely diagnosis?
Correct. An enhancing CPA/IAM mass centred on the porus acusticus with intracanalicular and cisternal components ('ice-cream-cone' shape) is the classic appearance of a vestibular schwannoma — the commonest serious treatable cause of asymmetric SNHL.
The enhancing CPA/IAM 'ice-cream-cone' mass on gadolinium MRI is the signature of vestibular schwannoma; recognising it determines whether the tumour is watched, irradiated or operated.
An enhancing mass at the CPA/IAM is a vestibular schwannoma. Cholesteatoma is a middle-ear bone-eroding lesion; mastoiditis is air-cell coalescence; otosclerosis is otic-capsule lucency; EVA is a congenital bony anomaly — none sits at the porus as an enhancing 'ice-cream-cone' mass.
Click to reveal answer
A profoundly deaf 2-year-old is being assessed for cochlear implantation. Which combined imaging strategy best informs whether implantation is feasible and which side to implant?
Correct. Cochlear-implant work-up requires both: HRCT to assess the bony cochlea/labyrinth (patency, malformation, ossification) and MRI to confirm the presence of the cochlear nerve and patent fluid-filled cochlea. Together they decide feasibility and side.
Paediatric cochlear-implant assessment uses HRCT (bony cochlea, ossification, malformation) and MRI (cochlear nerve and fluid) together — the scan determines whether and which side to implant, the essence of integrating imaging into management.
Implant planning needs bone and nerve information, so it combines HRCT (bony cochlea/labyrinth, ossification) with MRI (cochlear nerve presence, cochlear fluid). Plain films, ultrasound or neck CT cannot supply this, and imaging is mandatory — a CT/MRI pair, not none.
Click to reveal answer