Purpose <p>This article presents clinical scenarios in which patients with conductive hearing loss may not have an explanatory finding on temporal bone CT.</p> Methods <p>A literature review regarding patients with conductive hearing loss and no attributable imaging findings was performed. Illustrative examples correlating audiological exams and photon counting detector CT scans are provided. Common explanations of conductive hearing loss, e.g.: otosclerosis, are reviewed.</p> Conclusion <p>Patients with conductive hearing loss are assumed to have attributable imaging findings on temporal bone CT. While this is true in many cases, no imaging study is 100% accurate, and pathophysiological conditions resulting in conductive hearing loss exist for which temporal bone CT may not be sensitive. Radiologists should keep these conditions in mind to avoid over-interpreting exam findings.</p>