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Evaluation of Foramen Tympanicum Using Cone-Beam Computed The Journal of Craniofacial Surgery & Volume 25, Number 2, March 2014 Brief Clinical Studies he foramen tympanicum or foramen of Huschke represents a Evaluation of Foramen Tdevelopmental defect or formation in the anteroinferior aspect of the external auditory canal (EAC), posteromedial to the temporo- Tympanicum Using Cone-Beam mandibular joint (TMJ), and is an unusual condition in human skulls.1,2 Foramen tympanicum occurs during embryological de- Computed Tomography in velopment of the viscerocranial bone and was described first by Emil Huschke.3Y5 In most children, the foramen tympanicum gra- Orthodontic Malocclusions dually becomes smaller and completely closes before the age of 5 years, but it occasionally persists. An anomaly of the tympanic Nihat Akbulut, DDS, PhD,* Sebnem Kursun, DDS, PhD,Þ ring during embryogenesis could lead to an abnormal ossification of Secil Aksoy, DDS, PhD,þ Hakan Kurt, DDS, PhD,Þ the tympanic bone and to a persistent foramen tympanicum.6 Also, Kaan Orhan, DDS, PhDÞþ genetic factors may lead to delays in ossification.7 It was stated that the tympanic bone dehiscence present at the precise point of fusion Abstract: The foramen tympanicum is a persistent anatomic for- of the 2 prominences should be considered an anatomic variant only mation of the temporal bone due to a defect in ossification normal after the age of 5 years.2,8 bone physiology in neonatal or postnatal period. This study deter- Foramen tympanicum may be associated with salivary discharge mined the occurrence and location of the foramen tympanicum in a into the EAC during joint movements, or it may be associated with a Y Y Turkish sample using cone-beam computed tomography. Scans of symptomatic TMJ herniation into the EAC.2 4,9 13 Moreover, foramen 370 sites in 185 patients were retrospectively analyzed to determine tympanicum may lead to the trespassing of infections from the infratemporal fossa to the EAC and from the EAC to the infratemporal foramen tympanicum occurrence, sizes, and locations according to 5,14 their orthodontic malocclusions. Measurements were done on axial fossa or TMJ cavity. Tumors of the mastoid process and ear may extend into the TMJ, whereas otitis or otomastoiditis may involve the and sagittal sections to identify the dimensions. Differences in TMJ and can even result in ankylosis.15,16 Moreover, the connection foramen tympanicum incidence by measurements, sex, side, maloc- into EAC during athroscopy or arthrography can result in otologic clusions, and location were statistically evaluated. Foramen tym- complications.17,18 panicum was determined in 42 (22.7%) of 185 patients. No statistical These anatomical variations can be detected in clinical practice using difference was found considering location and sex (P 9 0.05), but it radiography. Conventional radiographs have several drawbacks, in- was found more bilaterally in female patients within significance level cluding errors of projection and errors of identification. Conventional at P = 0.024. Mean sizes did not differ significantly by sex but were radiographic techniques collapse a three-dimensional structure onto a found to be greater in females. In axial diameter, the average mea- two-dimensional plane. The resulting superimposition of anatomical surement was found wider on the right side of all patients (P =0.017). structures complicates image interpretation and landmark identification, The findings showed a greater foramen tympanicum dimension among and this distortion and magnification may lead to errors of identifica- tion.19,20 The use of cone-beam computed tomography (CBCT) was class II than among class I and III subjects (P G 0.05). Knowledge about first reported by Mozzo et al21 and has been proposed in the last decade these structures is helpful for the interpretation of imaging (especially for maxillofacial imaging.22,23 A CBCT scan uses a different type of cone-beam computed tomography) and provides valuable information acquisition than that used in medical CT (MDCT). Rather than capturing especially before orthognathic surgery to avoid intraoperative recon- an image as separate slices as in MDCT, CBCT produces a cone-shaped struction and complications. x-ray beam that allows an image to be captured in a single shot. The resultant volume can be reformatted to provide multiple reconstructed images (eg, sagittal, coronal, and axial) that are similar to traditional Key Words: Foramen tympanicum, foramen of Huschke, MDCT images.20,21 Cone-beam CT thus offers the distinct advantage of cone-beam computed tomography, orthodontic malocclusions a lower radiation dose than MDCT and the possibility of importing and exporting individualized, overlap-free reconstructions.24,25 Moreover, these possibilities and increasing access to CBCT imaging for surgeons and orthodontics are enabling the movement from two-dimensional cephalometric analysis to three-dimensional analysis before orthodontic analysis. Studies of CBCT applications in orthognathic surgery have From the *Oral and Maxillofacial Surgery Department, Faculty of Dentistry, examined both CBCT-generated two-dimensional cephalometric pro- Gaziosmanpaza University, Tokat; †Department of Dentomaxillofacial jections from CBCT data sets and three-dimensional cephalometric Radiology, Faculty of Dentistry, Ankara University, Besevler, Ankara; analysis, which in dicated a reliable and accurate tool for linear and and ‡Department of Dentomaxillofacial Radiology, Faculty of Dentistry, 19,21,23 Near East University, Mersin, Turkey. three-dimensional measurements before surgery. Several studies of detection of this anatomical variation, using Received July 17, 2013. 1,2,10,26 Accepted for publication August 27, 2013. conventional CT and cadaver studies, have been published. 1 Address correspondence and reprint requests to Sebnem Kursun, PhD, However, only 1 study has been conducted on CBCT imaging, but Dentomaxillofacial Radiology Department, Faculty of Dentistry, Ankara to our knowledge, no attempt has been made to study the visualization University, 06500 Ankara, Turkey; E-mail: [email protected] of foramen tympanicum according to orthodontic malocclusions using Ethical approval was obtained from the Human Research Ethics Committee. CBCT imaging. Hence, it was considered worthwhile to assess the Clearance certificate: 13-KAEK-132. occurrence and location of the foramen tympanicum according to No funding was received for this study. orthodontic malocclusions and sex in a Turkish sample using CBCT. This report will be presented at the 21st International Conference on Oral and Maxillofacial Surgery, Barcelona, Spain (October 21Y24, 2013), as oral presentation. The authors report no conflicts of interest. MATERIALS AND METHODS Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 Data from CBCT examinations of 370 sites in 185 patients who DOI: 10.1097/SCS.0000000000000440 had been referred to our outpatient clinic during a 5-year period * 2014 Mutaz B. Habal, MD e105 Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 25, Number 2, March 2014 were analyzed retrospectively. The overall mean age was 28.6 years (range, 7Y84 [SD, 15.5] years). Informed consent was obtained from all patients before CBCT examinations. The mean age of the male patients was 29.04 (SD, 15.66) years (n = 185) (range, 7Y73 years), whereas the mean age of the female patients was 28.21 (SD, 15.43) years (n = 100) (range, 9Y84 years). Patients with evidence of bone disease (especially osteoporosis), FIGURE 2. Image showing the measurement of the size of the foramen both relevant drug consumption, skeletal asymmetries or trauma, con- in the axial and sagittal planes. genital disorders, anamnesis of surgical procedures in the TMJ, and pathological disorders of the maxilla and mandible as well as syndromic patients were excluded from the study. The study protocol Mean axial diameter was 0.5 mm, mean sagittal diameter was 1 mm, was carried out according to the principles described in the Declara- and mean coronal diameter was 1 mm. Axial images were acquired tion of Helsinki, including all amendments and revisions. Only in the orbitomeatal plane. the investigators had access to the collected data. The institutional Foramen tympanicum was identified on axial images and con- review board of the faculty reviewed and approved informed consent firmed their existence on coronal and sagittal reformatted images. forms. There was no preference for sex regarding sample choice. For every patient, we noted location of the foramen tympanicum Only high-quality scans were included. Low-quality images, such as (unilateral or bilateral) and calculated its prevalence as a percentage. those containing scattering or insufficient accuracy of bony borders, The size of the foramen was measured both in the axial and sagittal were excluded. planes and noted its size (Fig. 2). The prevalence of the persistent Patients were grouped by occlusion type according to mainly ANB foramen tympanicum according to sex and orthodontic malocclusions and the sagittal interjaw base relationship. All patients’ orthodontic was also calculated. analyses were made using CBCT-generated cephalograms. Statistical analyses were performed using SPSS software (ver- According to ANB angle, the 3 groups were defined as follows: sion 12.0.1; SPSS, Inc, Chicago, IL). Wilcoxon matched-pairs as skeletal class I (62 patients, 124 sides), class II (65 patients, 130 sides), signed
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