Should I order a temporal computed tomography (CT) scan for a patient with temporal pain?

Should You Order a Temporal CT for Temporal Pain?

No, do not order a routine head CT or temporal CT for isolated temporal pain without additional otologic or neurologic symptoms. Temporal pain alone is not an indication for CT imaging of the temporal bone or head.

Clinical Context and Appropriate Indications

The evidence provided addresses temporal bone CT in the context of specific otologic symptoms (tinnitus, hearing loss, facial nerve palsy), not temporal pain. Temporal bone CT is indicated only when specific clinical findings suggest temporal bone pathology [1, 1.

When Temporal Bone CT IS Appropriate:

For Pulsatile Tinnitus with Vascular Retrotympanic Lesion:

• High-resolution CT (HRCT) temporal bone without IV contrast is the first-line imaging modality when otoscopic examination reveals a vascular retrotympanic mass [1, 1
• This can diagnose glomus tympanicum, aberrant internal carotid artery, persistent stapedial artery, dehiscent jugular foramen, and otosclerosis [1, 1
• IV contrast is not necessary as bony and air contour changes are sufficient for diagnosis 1

For Ossicular Chain Evaluation:

• HRCT with bone algorithm reconstructions is the imaging modality of choice for diagnosing small ossicular fractures or breaks 2
• Requires multiplanar reconstructions (axial, coronal, oblique) to fully assess the ossicular chain 2
• Particularly valuable in post-traumatic hearing loss or conductive hearing loss 2

For Facial Nerve Palsy:

• Dedicated temporal bone CT with thin sections provides useful information regarding temporal bone fractures, presurgical osseous anatomy, nerve involvement with inflammatory middle ear disease, and foraminal expansion 1
• However, MRI is the mainstay for evaluating both intracranial and extracranial portions of the facial nerve 1

When CT Should NOT Be Ordered:

For Sudden Sensorineural Hearing Loss (SSNHL):

• Routine head CT should NOT be ordered in the initial evaluation of SSNHL [1, 1
• Head CT receives an appropriateness rating of only 3 (usually not appropriate) from the American College of Radiology, meaning the risk-benefit ratio is unfavorable [1, 1
• Routine head CT is a very low-yield examination with significant cost and radiation exposure (RRL of 3, with 1-10 mSv radiation dose) [1, 1
• This represents unnecessary harm without clinical benefit 1

For Isolated Temporal Pain:

• There is no evidence supporting temporal bone CT for temporal pain alone
• Temporal pain without otologic symptoms (hearing loss, tinnitus, vertigo, otorrhea) or neurologic findings does not warrant temporal bone imaging

Critical Distinctions

Standard Head CT vs. High-Resolution Temporal Bone CT:

• Standard head CT with 5mm cuts through the brain lacks the resolution to adequately visualize small ossicular structures and temporal bone detail 2
• HRCT temporal bone requires thin sections with bone algorithm reconstructions and smaller field-of-view for adequate evaluation [1, 2
• CTA of the head is not indicated for ossicular chain injuries 2

Common Pitfalls to Avoid

• Do not order routine head CT for isolated temporal pain - this provides no diagnostic value and exposes patients to unnecessary radiation [1, 1
• Do not confuse standard head CT with dedicated temporal bone CT - they serve entirely different purposes and have vastly different resolution 2
• Do not order temporal bone CT without specific otologic findings on history and physical examination [1, 1
• Ensure otoscopic examination is performed before ordering any temporal bone imaging, as findings guide appropriate imaging selection [1, 1

Recommended Approach for Temporal Pain

For a patient presenting with temporal pain:

• Perform thorough history focusing on trauma, otologic symptoms (hearing changes, tinnitus, vertigo, otorrhea), and neurologic symptoms
• Complete physical examination including otoscopy and cranial nerve assessment
• If isolated temporal pain without otologic or neurologic findings: no imaging indicated
• If pulsatile tinnitus with vascular retrotympanic lesion on otoscopy: order HRCT temporal bone without contrast [1, 1
• If focal neurologic deficits present: consider MRI brain rather than CT [1, 1
• If trauma with conductive hearing loss: order HRCT temporal bone with bone algorithm reconstructions 2