NAEOTOM Alpha Class - Clinical Case Video: Middle Ear

Let's talk about an interesting case. There was this 75 year old female who came to the hospital because she had a bit of instability. When they did a routine check up, they found out she was gradually losing her hearing on the right side, the kind of hearing loss that's conductive. So to figure out what was causing it, they used a dual source photon counting detector, CT, the Neatom Alpha, to take a closer look. The pictures from this high resolution scan showed a kind of lumpy mass. It was about 7 by 6 by 4mm, sitting up in the front part of the epidemium and stretching a bit into the mesotypinum. On the inside it was touching the part of the facial nerve canal that's near the eardrum, and on the outside it was up against the malleus. Part of this mass had gone all chalky and looked like semolina, that grainy stuff that made the doctors think it was probably tophaceous gout. After that, they had to do an operation. They did a tympanoplasti, which means they cut out the mass and fixed up the chain of little bones in the ear, the ossicular chain, by reshaping the incus. When they looked at the bit they'd cut out under the microscope, the histopathology report said it was indeed a gout tophis, just like they thought from the CT scan. Six months after the surgery, when she went back for a checkup, her hearing hadn't improved much according to the audiometry test, but when they looked in her ear with an otomicroscope it seemed to be healing OK. Then she went to another place and had ACT scan with an energy integrating detector CT that showed the reshaped ankus wasn't quite connecting properly with the stapes. There was also this tiny calcified lump at the front of her middle ear so she had to go under the knife again. They found out it was either some gout tophist that was left behind or had come back and they cut it out. Plus they put in a total osicular replacement prosthesis, TRP for short because the front part of the stapes was broken to try and help her hear better. Three months later she had another CT scan, this time again with the photon counting CT neatom alpha. And guess what? The inside part of the TORP had moved out of place. Instead of sitting nicely in the middle of the Oval window, it had slipped back into the retro tympanon. So they had to do yet another operation to swap out the first TORP for a second one. A metal MX A/C T total processes 5mm. Four months after that, they did one more CT scan and this time it showed the second torp was in the right place and the good news was the patient was doing better. Now, tophaceous gout in the middle ear is really rare, but it can cause this conductive hearing loss. The strange thing is it might not show any of the usual signs you'd expect. Like this woman, she didn't have any of the typical gout symptoms in her other joints and her blood test for uric acid came back normal. Doctors often mistake it for other more common things like cholesteatoma or osteoma. The best way to treat it is to cut it out surgically and rebuild that chain of little bones. When it comes to spotting this rare problem on a scan it shows up as that semolina like lump in the middle ear. To really see all the tiny bits and bobs in there you need ACT scan of the temporal bones that can take super detailed pictures. In the past with the old EIDCT they'd try things like putting in metal grids to make the detector opening smaller so they could get really thin slices and they'd use special software to make the pictures look sharper. But the problem was it meant using more radiation and the pictures got really noisy. The photon counting CT is different. It gives you CT data where you can tell the different energy levels and it can take much clearer pictures without all that electronic noise. In the ultra high resolution mode it uses a super precise collimation like 120 by 0.2mm getting data from these small detector bits called subpixels. These subpixels are sort of fenced in by a strong electric field and read out separately which is what makes the pictures so sharp. And the best part is you don't need to do any extra fiddling around mechanically so you don't waste any radiation dose like in this patient's case. The amount of radiation used with the photon counting Connecticut was only 115 milligray compared to a whopping 478 milligray with the old EIDCT. And the pictures still looked great. Even though the slices were super thin, just 0.2mm, and they used a sharp reconstruction kernel called HR 80. The pictures weren't noisy. That meant they could use this cool 3D imaging technique called cinematic rendering technique to make these lifelike 3D pictures. It was so clear you could easily see where the prosthesis was and plan the next operation accurately.

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