31 year old doing some doing roof work when he fell. Seen in the ED with right ear bleeding and right-sided decreased hearing.

The normal left side is depicted in the right images (standard convention). Coronal view [top right] shows the middle ear ossicles (arrow) in the middle ear cavity, and axial view [bottom right] shows the normal “ice cream cone” appearance (arrow).

By comparison, the right middle ear ossicles are missing in the middle ear cavity [top left] (arrow with ?) and found in the external auditory canal (arrow with !!) instead. Axial view [bottom left] shows a distinct lack of the ice cream cone appearance. The middle ear and external ear canals are also filled with fluid/blood. The tympanic membrane is clearly ruptured since the middle ear ossicles are outside.