3D Accuitomo Clinical Case Evidence
The Advantages of DVT for Ear-, Nose- & Throat-Diagnostic
Thinking ahead. Focused on life.

Editorial

Dear Colleagues,
I am very happy to present you now some data on cone
beam tomography (digital volume tomography) with thisbooklet. This imaging procedure is highly interesting in
otorhinolaryngology and I am convinced that it will playa major role in future routine diagnosis. In order to summarize detailed knowledge on this procedure we decided
to create this booklet. Special thanks to my co-worker Dr.
Christian Güldner and of course also to Morita Company
that ﬁnally made this booklet possible. Please informyourself of the modern technique. It does not only on theachievements of the examiner but mainly on the theoreticalbackground that each physician is supposed to have.

Jochen A. Werner, MD
Professor and Chair
Dept. of Otolaryngology, Head & Neck Surgery
UKGM, Campus Marburg

2Index of Contents[04 - 05]

Introduction of 3D Accuitomo – Compact, High-Resolution, Low-Dose[06 - 09]

Efficient Workflow Integration of DVT[10 - 11]i-Dixel Image Processing Software
Temporal Bone Cases[12 - 13]

Anatomy of the Temporal Bone in Digital Volume Tomography[14 - 15]

Axial Plain, caudal[16 - 17]

Axial Plain, cranial[18 - 19]

Coronal Plain, from anterior to posterior[20 - 21]

Sagittal Plain, from lateral to medial[22 - 23]

Osteoma of temporal bone
Anterior Skull Base Cases[24 - 25]

Anatomy of the Anterior Skull Base in Digital Volume Tomography[26 - 30]

Coronal Plain, from anterior to posterior[32 - 33]

Axial Plain[34 - 35]

Sagittal Plain[36 - 37]

Nose and paranasal sinus

3Introduction of 3D Accuitomo – Compact, High-Resolution, Low-Dose

Advantages of Cone Beam
3D Accuitomo 170 is a cone-beam CT or also called DVT;
digital volume tomography, which is designed for imaging
of head-and-neck regions, especially for temporal bone andsinuses. With one single rotation of the x-ray tube and area
detector around the head of the patient, it provides high-resolution volumetric data of a small region, which is suitable
for specialized medical applications of otorhinolaryngology
and maxillofacial ﬁelds.
The patient is in sitting position during scan, instead of lying
on the table. The patient chair moves up/down, left/right andback/forth to position the imaging area to the region of interest. X-ray tube assembly and two-dimensional x-ray area
detector are mounted on each side of the arm, which rotates
360 degrees around the patient during scan. 512 projected
x-ray images are generated during one rotation, which takes
about 18 seconds in the standard scan mode. The projected
images are reconstructed into a volume data by the ﬁltered
back-projection method. The volume data can be shown as
tomographic images sliced from any desired angles, or as
three dimensional volume rendering images.

4This system is also designed to be space-efﬁcient compared
to existing CT systems in the market, it is even suitable fora small clinic. This type of device can be a far more practicaland useful tool than an existing CT for special applications
requiring detailed imaging of the ﬁne bone structures of the
middle ear, etc.
By using an area detector with very small pixels, it is possible to obtain high-resolution images, compared to a medical
CT. Because of the two dimensional detector, the resolutionof the sagittal and coronal slices is as high as the one of
the axial slices. The volume data consists of small isometriccubes called voxels. The minimum selectable voxel size is
80 micrometers, which can depict very minute object. This isparticularly useful in visualizing small bone structures suchas temporal, maxilla or mandibular bones.

In this case, a large voxel size is used to create the volumedata in order to reduce the data size and processing time.
The minimum size is 40 mm in diameter and 40 mm inheight, which is suitable for the middle ear or a couple ofteeth. In this case, the minimum voxel is used to depict
more precise structure of bony tissues. A middle sized imaging area with a middle sized voxel can be useful for sinus
region, for example.
If a larger image includes a smaller region of interest in it,
the zoom reconstruction function can create more precise
image of the region from the original projection data byrecalculating with a smaller voxel, without taking anotherscan.

The imaging area size is selectable, depending on the applications. This is effective to reduce unnecessary x-ray exposures to the patient. The imaging area is cylindrical and the
maximum size is 170 mm in diameter and 120 mm in height,
which covers most of the major part of head-and-neck regions.

5

Efﬁcient Workﬂow Integration of DVT

Sharing Image Data
Installing i-Dixel software on all intra-clinic computers enables sharing of image data on each linked client computer.
Observation of images on non-network computers can beachieved with the One Data Viewer, and the One Volume
Viewer without installing i-Dixel.
3D Accuitomo 170

One Data Viewer & One Volume Viewer Software
These unique J. Morita applications let you view three dimensional images and volume rendered images even if thecomputer does not have i-Dixel software installed.
CT data can be exported from the i-Dixel application andlater stored on a DVD.
This DVD can then be used on a computer outside the clinic
to view CT images, volume rendered images and patient
information.
Additional functions include zoom, black and white reverse,
brightness, and contrast adjustment as well as optional
length and angle measurement capabilities.

i-Dixel software

Intra-clinic network
Out of network computer
In external clinic networks without 3D Accuitomo
170, 3D-CT images can be viewed on a PC with bothof the following methods:

i-Dixel Viewer
Software6

i-Dixel software

One Data Viewer
One Volume
Viewer

i-Dixel software

i-Dixel Conforms to the Following
DICOM Standards:
1. Modality worklist management
service class
2. Storage service class
3. Modality performed procedure
step service class
4. Print management service classOne Volume Viewer

7

Efﬁcient Workﬂow Integration of DVT

i-Dixel Image Processing Software
It can be used as a database to archive a wide variety ofimage information. Its multiple image processing functions
can easily access and manipulate many types of informationfor 2D and 3D images.
Volume Rendering
Volume rendering of CT data produces three dimensional
images. Select the area of interest and adjust the controls
for the histogram to create a detailed image of very ﬁne
structures.
Real Time Re-Slice
Slices and volume rendered images can be linked and easily
manipulated in real time.
Curved MPR (cMPR)This way of image processing allows you to observe an
orthogonal representation of the dental arch or any arbitrary
curve.
Report Comments
It is easy to enter comments for any image. These comments can be printed with a conventional Windows printeror a DICOM printer.

8

Report Comments• XYZ view windows• Re-slice• Zoom• Rotate• Histogram• Edge Enhancement• Distance and Angle Measurement• Negative Image• Mirror Image• Slice Distance Measurement• Surface Rendering• DICOM 3.0 Compatible• Brightness Conversion• Spatial Frequency Filter• Patient Orientation Display• Density Measurement9i-Dixel Image Processing Software

The Multiple Image Processing Functions and Easy Access
The arm rotates 360° around the center of the exposure
region in 18 seconds (Standard Mode) as the x-ray heademits a cone-shaped beam. The multiple projections created during the arm’s rotation are converted to a digital
signal by the ﬂat panel detector and transmitted to thecomputer. After any necessary supplemental or corrective processing, the digital information is converted into athree dimensional CT image using an image reconstruction algorithm, and a high resolution image appears on
the computer’s display. The voxel of 3D Accuitomo is an
isotropic cube that produces images with equally ﬁne
detail in all three dimensions and minimizes artifacts produced by slice pitch and helical pitch; therefore resolution
is never degraded by re-slicing. Conversely the rectangular voxel used for conventional CT imaging resultsin some image degradation when it is re-sliced. i-Dixel
image processing software can be used as a database toarchive a wide variety of image information. Its multiple
image processing functions can easily access and manipulate many types of information for 2D and 3D images.
These unique J. Morita applications let you view three
dimensional images and volume rendered images.
As a brochure can not offer this dynamic i-Dixel feature
we added graphics which give orientation and show theposition of the sagittal, coronal and axial plain.

10

The X-Plain (Sagittal)

Degrees of Freedom (Two-Direction Scout)
The region of interest can be easily targetedby making images from two directions. Thenby clicking on the center of the region the
Accuitomo chair automatically moves into
position.

The Y-Plain (Coronal)

The Z-Plain (Axial)

11Temporal Bone Cases
Anatomy of the Temporal Bone in Digital Volume Tomography
Digital Volume Tomography can be used for the display ofthe complex threedimensional anatomy in the temporalbone very well. This is due to the fact that DVT enables highresolution, low artifacts and 3 orthogonal plains in one
examination. Possible indications for the DVT in temporalbone diagnostics can be inﬂammatory diseases, control of
middle ear prosthesis and cochlear implants as well as theevaluation of the inner ear itself. The absolute preconditionof successful use of DVT in the lateral skull base are excellent skills of the sophisticated threedimensional anatomyof the temporal bone.

The position of the laser target beams for the display of thetemporal bone is shown in the ﬁgure on page 3. The beams
are oriented to the temporal line, the posterior wall of theexternal auditory canal and the lateral corner of the eye.

The axial plain is used best for the imaging of the following structures of the temporal bone: malleus head andneck, incus body, mallaoincudal joint, incudostapedial joint,
pneumatisation of the mastoid, sigmoid sinus, facial recess,tympanic sinus, pyramidal eminence.
The coronal plain is suitable for the evaluation of the longprocess of the incus, malleus manubrium, internal carotid
artery, tympanic segment of the facial nerve. The sagittal
plain is favoured in the display of the mastoid portion of the
facial nerve as well as the semicircular canals. It also enables analogical orientation to mastoidectomy.
Digital Volume Tomography can be also useful in the diagnosis of inﬂammatory diseases, such as acute or chronicmastoiditis, cholesteatoma or postinﬂammatory conductive
hearing loss where osseous destructions can be well evaluated. Also in cases of erosion of the labyrinth DVT is an useful diagnostic modality.

12

Positioning of the laser target beams at the lateral skull base.

The favourable projections are summarised in the following table:
Best projection
Structure

axial

Malleus manubrium

coronalX

Malleus neck

X

X

Malleus head

X

X

Malleoincudal articulation

X

Incus lenticular process

X

Incus long process

X

Incus body

X

Incudostapedial articulation

X

Stapes suprastructure

X

Stapes footplate

X

Attic

X
X

AntrumX

Pneumatisation of the MastoidX

TegmenSigmoid sinus

sagittal

X

X

X

Round window

X

Facial nerve (horizontal segment)

X

Facial nerve (vertical segment)

X

Semicircular canals

X

13

Axial Plain, caudal

[01]
[02]
[03]
[04]
[05]
[06]
[07]

[01] Temporomandibular joint

14

[02]

Eustachian tube

[03]

Internal carotid artery[04]

Cochlear aqueduct[05]

External auditory canal[06]

Sigmoid sinus[07]

Mastoid cells

[02]
[03]
[08]
[09]
[10]
[11]

[02]

Eustachian tube

[03]

Internal carotid artery[08]

Basal turn of cochlea[09]

Manubrium mallei[10]

Long process of incus[11]

Facial recessus

15

Axial Plain, cranial

[12]
[13]
[08]
[14]
[15]
[16]
[10]

[08] Basal turn of cochlea[10] Long process of incus[12] Apical turn of cochlea[13]

Middle turn of cochlea[14]

Internal auditory canal[15]

Malleus neck[16] Vestibulum

16

[12]
[08]
[17]
[14]
[18]

[08]

Basal turn of cochlea[12] Apical turn of cochlea[14]

Internal auditory canal[17]

Malleus head[18]

Incus body17

Coronal Plain, from anterior to posterior

[19]
[20]
[21]
[22]
[23]
[24]
[25]
[18]

18

[18]

Incus body[22]

Oval window[19]

Superior semicircular canal[23]

Round window[20] Horizontal semicircular canal[24]

Stapes[21] Facial nerve (tympanal segment)[25]

Incudostapedial joint

[19]
[20]
[22]
[14]
[23]
[26]

[14]

Internal auditory canal[19]

Superior semicircular canal[20]

Horizontal semicircular canal[22]

Oval window[23]

Round window[26]

Bulbus venae jugularis

19

Sagittal Plain, from lateral to medial

[20]
[28]
[27]
[01]
[07]

[01] Temporomandibular joint[07]

Mastoid cells[20]

Horizontal semicircular canal[27]

Facial nerve (mastoid segment)[28] Ambomalleal joint

20

[19]
[20]
[29]
[26]
[06]

[06]

Sigmoid sinus[19]Superior semicircular canal[20]

Horizontal semicircular canal[26]

Bulbus venae jugularis[29]

Posterior semicircular canal

21

Osteoma of temporal boneCase: The patient reported a swelling behind the left
ear, which exists since more than 10 years with very
slow growing. Now he wished the operative extirpation, so a cone beam tomography was done. The pictures show a osteoma of the temporal bone. History
conﬁrmed this diagnosis.

22

23

Anterior Skull Base Cases
Anatomy of the Anterior Skull Base in Digital Volume Tomography

Digital Volume Tomography shows the bony anatomy very
well and is able to give a roadmap for paranasal sinus surgery. The main indications for cross section imaging in theﬁeld of the anterior skull base are:• Suspected intracranial or intraorbital complicationsof a rhinosinusitis.
• Suspected atypical infections or neoplasms.
• Speciﬁc pathological conditions, such as mucoceles,
benigns tumors to conﬁrm the extent of the lesion.
• In the case of planned optical nerve or orbital
decompression.
Since the introduction of the enlarged cylindrical volume
Digital Volume Tomography can be also used for the evaluation of the paranasal sinuses and its surrounding structures.
The anatomical key structures are clearly identiﬁable using
DVT-scans of a volume of 10x10 cm from the anterior nasal
spine to the posterior wall of the sphenoid sinus. DVT canalso be used in cases of nasal bone fractures and blow-outfractures very well. DVT in the case of rhinosinusitis shouldbe performed only in cases after sufﬁcient medical treatment to conﬁrm the chronic residual disease that has to betreated surgically, if the above mentioned conditions are not
fulﬁlled.

24

The coronal plain is used as the standard plain for thispurpose as we know from CT scans for the evaluation of
the sinuses from anterior to posterior with the nasolacrimal
duct, agger nasi, uncinate process, bulla ethmoidalis, anterior ethmoidal artery, septum and turbinates.
The sagittal plain is an excellent completion for the displayof the frontal recess and duct, the course of the skull baseand the infraorbital nerve, in the cases of fractures of thenasal bone and the orbital ﬂoor as well as for the evaluationof the anterior ethmoidal artery.
The axial plain is used best for the diagnosis of fractures(maxiallary sinus, nasal bone) or for the extent of inﬂammatory diseases at one glance.
The laser target beams should be positioned as the following ﬁgure shows to gain sufﬁcient display of the paranasal
sinuses. Of course the individual anatomy or the diagnostic
purpose has to be considered.

Positioning of the laser target beams in the case of a DVT of the paranasal sinuses.

25

Coronal Plain, from anterior to posterior

[01]
[02]
[03]
[04]
[05]
[06]
[07]

[01] Aggar nasi cell[02]

Middle turbinate

[03]

Orbit

[04]

Nasolacrimal duct[05] Septum[06]

Inferior turbinate[07] Maxillary sinus

26

[08]
[09]

[08]

Uncinate process[09]

Infraorbital nerve

27

Coronal Plain, from anterior to posterior

[10]
[11]
[12]

28

[10]

Christa galli[11]

Lamina cribrosa[12]

Bulla ethmoidalis

[13]
[11]

[11]

Lamina cribrosa[13] Anterior ethmoid artery29

Coronal Plain , from anterior to posterior

[14]
[15]
[16]
[17]
[18]

[14]

Optic nerve[15]

Foramen rotundum[16]

Sphenoid sinus[17] Vidianus nerve
[18]

30

Nasopharynx

31

Axial Plain

[05]
[04]
[20]
[02]
[07]
[19]
[16]

[02]

Middle turbinate[04]

Nasolacrimal duct

[05]

Septum[07]

Maxillary sinus[16]

Sphenoid sinus[19]

Foramen sphenopalatinum[20] Vomer

32

[02]
[22]
[21]
[23]
[16]

[02]

Middle turbinate[16]

Sphenoid sinus[21]

Basal lamella of middle turbinate[22] Anterior ethmoid cells[23]

Posterior ethmoid cells

33

Sagittal Plain

[13]
[24]
[25]
[06]
[26]

[06]

Inferior turbinate[13] Anterior ethmoid artery[24] Anterior skull base

34

[25]

Posterior ethmoid artery[26]

Hard palate

[03]
[09]
[27]
[07]

[03]

Orbit

[07]

Maxillary sinus[09]

Infraorbital nerve[27]

Fossa pterygopalatina

35

Nose and paranasel sinus

Case: The patient reported about a chronic
pain on the right maxillary sinus. Before theplanned endonasal sinus surgery a cone
beam tomography of nose and paranasal
sinus were performed. A free bony course of
the nervus infraorbitalis through the pathology of the right maxillary sinus could beseen. [This status was also seen in intraoperative endoscopic view]

36

37

Notes38

39

Thinking ahead. Focused on life.
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