Photon-counting CT for preoperative assessment of stapes footplate fixation in otosclerosis.

PURPOSE: To describe the photon-counting CT (PCCT) imaging findings of surgically confirmed stapes footplate fixation in otosclerosis and to assess the frequency of missed diagnoses on initial radiology reports. METHODS: This retrospective case series included 18 patients with surgically confirmed otosclerosis who underwent temporal bone PCCT between March 2023 and December 2024. PCCT images were retrospectively reviewed for imaging findings of stapes footplate involvement, such as increased thickness or hypoattenuation of the stapes footplate, and correlated with intraoperative findings. Original radiology reports were reviewed to determine whether these findings were identified preoperatively. RESULTS: Imaging findings of stapes footplate involvement were identified on retrospective PCCT review in all 18 cases, correlating with intraoperative confirmation. However, in 8 of 18 patients (44%), these findings were retrospectively identifiable on PCCT but not reported in the initial radiologic interpretation. CONCLUSION: PCCT enables excellent visualization of morphologic changes associated with surgically confirmed stapes footplate fixation in otosclerosis. Nearly half of these findings were not recognized on the initial radiology interpretation, highlighting an opportunity to improve radiologist awareness and reporting of subtle fenestral otosclerosis. Greater familiarity with these imaging findings may enhance preoperative assessment and facilitate surgical planning.