Diagnosis Of Cholesteatoma Research Articles

Diagnosis of cholesteatoma by the b1000 value DWI MRI according to the signal intensity

Objective: The cholesteatoma (CL) can be evaluated visually or numerically on an apparent diffusion coefficient (ADC) map, which obtained from at least two different b-valued diffusion-weighted imaging (DWI). In this study, we aimed to evaluate the signal intensity (SI) of the lesion both visually and numerically only on the DWI image without ADC. In case of positive results a second ‘b’ value is not required, so this method could be shorten the duration of the MRI examination.
 Material and Methods: Between January 2017 and May 2018, we included patients with chronic otitis media (COM) with a clinical suspicion of primary CL who underwent DWI. Two radiologists and one ear, nose, throat specialist evaluated the radiological images and the pathology results.
 Results: The mean SI measurement was significantly higher in the CL group by both observers (observer LR; CL: 107.94 ± 53.36, COM: 37.34 ± 14.70, observer FC; CL: 108.56 ± 50.00, COM: 37.06 ± 15.44; p<0001). ROC analysis showed that a mean SI value of 48.6 was the cut-off value in predicting the diagnosis of CL. The mean SI was significantly higher in the CL group (p<0.001).
 Conclusion: We demonstrated a significant difference between CL and COM concerning the diagnosis by visual and numerical signal evaluation only via b1000 valuable images. In false-positive cases, ADC is still confirmatory for high diagnostic accuracy.

Role of DWI in differentiation between cholestatoma and recurrent otitis media

Abstract Background Cholesteatoma and otitis media are common middle ear pathologies. They may cause serious complication such as hearing loss, facial nerve paralysis or intra-cranial complications in advanced cases. They are mainly diagnosed by otoscope yet CT examination is essential to confirm the diagnosis in some cases as well as assess its extensions for proper surgical excision. However, CT is poor in differentiation of cholesteatoma from other middle ear pathologies. Between the two diseases, there are a grey zone. Depending on CT images in differentiation between cholestatoma and otitis media, radiologist will be susptable for misdiagnosis. Objective To determine the diagnostic accuracy of DWI and the difference between the ADCs of middle ear cleft cholestatoma and those of non-cholesteatomatous tissue especially recurrent otitis media on single-shot echo planar DW images. In a case of cholestatoma, the results will be confirmed by intra-operative findings and histopathological data. In a case of otitis media, we will follow up the patients clinically if signs and symptoms resolve or not; or follow up by CT examination. Methods This study was conducted on patient with suspected cholesteatoma suspected clinically or by CT examination or known patients and patient also with suspected otitis media recurrence who underwent already surgery or preparing to that; at Ain Shams university hospitals. The patients referred from the otolaryngology department at Ain Shams university hospitals and from other private clinics. The patients was investigated using magnetic resonance imaging (MRI). Results MRI examination was advocated to differentiate between cholesteatoma from other middle ear pathologies. Delayed post contrast T1 images were used but showed low sensitivity for smaller lesions as well as patient inconvenience due to delayed imaging after 30-45 minutes. In recent years, diffusion weighted sequences have been used in diagnosis of cholesteatoma due to its bright signal on DWIs. In our study we used thin cut multi-shot EPI diffusion weighted images in the assessment of cholesteatoma and otitis media suspected clinically or by CT examination or known patients. It showed very good sensitivity and excellent specificity in detection of diffusion restriction of cholestatoma compared to chronic otits media which appear as a facilitated diffusion. The use of multi-shot techniques improved its sensitivity compared to single shot images yet it is still relatively less than non-EPI techniques. Conclusion DWI is a beneficial tool in the evaluation of cholesteatoma and differentiate between it and otitis media with excellent specificity that reduces the need of second look surgeries in multiple cases. The use of multi-shot diffusion weighted techniques improved its sensitivity significantly compared to single shot techniques. It still could not detect lesions smaller than 4 mm.

Importance of signal intensity on T1-weighted spin-echo sequence for the diagnosis of chronic cholesteatomatous otitis.

The aim of our study was to evaluate the importance of a non-injected T1-weighted spin-echo sequence (T1WSE) combined with a non-echo-planar diffusion-weighted (non-EPDW) sequence for the pre-operative detection of cholesteatoma by the radiologist on MRI, compared to surgery. In this retrospective case review, 113 patients with chronic otitis underwent surgery (gold standard) for a clinical suspicion of cholesteatoma. Our primary outcome was to compare non-EPDW images + a contrast-free T1WSE sequence for cholesteatoma detection. Our secondary outcome was to quantify the signal intensity value of the suspected lesions, relative to the signal intensity of the cerebellum (Sic) to calculate Signal Intensity Ratios (SIR = SI/Sic). The SIR values of cholesteatomatous and non-cholesteatomatous tissue were compared to surgical findings. Receiver-operating characteristic curve analysis determined an optimum SIR cut-off value for the prediction of cholesteatoma. The sensitivity (96.9%) of non-EPDW for the diagnosis of cholesteatoma was high, with good specificity (74.2%), and increased to 85.5% when combined to a T1WSE sequence. Additionally, the mean SIR values (on T1WSE) of cholesteatoma were significantly lower than non-cholesteatomatous tissue (p < 0.05). When nonEPDW and T1WSE were combined, a cut-off SIR value < 1.04, diagnosed cholesteatoma pre-operatively with very high specificity and sensibility (92.7% and 90.3% respectively). Our study showed that combining a nonEPDW sequence with the quantitative analysis of contrast-free T1W SE sequence in pre-operative patients enables the correct diagnosis of cholesteatoma with good sensitivity and specificity (> 90%) and reduces risks of false-positive cases for surgeons.

The value of turbo spin-echo diffusion weighted imaging in the diagnosis of temporal bone cholesteatoma

Objective:The aim of this study is to evaluate the diagnostic value of turbo spin-echo（TSE） diffusion weighted imaging（DWI） in temporal bone cholesteatoma. Method:A prospective evaluated of 76 patients with suspected sacral cholesteatoma was performed using a Philips Ingenia 3.0T superconducting magnetic resonance scanner and a 32-channel head coil with turbo spin-echo diffusion weighted imaging（TSE-DWI） sequence and conventional magnetic resonance scan, and underwent surgery within the next two weeks. The pathological result is the gold standard, and the imaging diagnosis and surgery are performed. The intraoperative observation and pathological results were compared. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of TSE-DWI sequence in the diagnosis of temporal bone cholesteatoma were calculated. Result:Of the 76 patients with suspected temporal bone cholesteatoma, TSE-DWI scan was performed, 44 cases were diagnosed as cholesteatoma and 32 cases were non-cholesteatoma. Based on the pathology results, 46 cases were diagnosed as cholesteatoma, 30 cases were non-cholesteatoma. The accuracy of TSW-DWI sequence in the diagnosis of cholesteatoma was 89.47%, 3 cases were false negative and 5 cases was false positive. The sensitivity, specificity, positive predictive value and negative predictive value of TSE-DWI in the diagnosis of temporal bone cholesteatoma were 89.13%, 90.00%, 93.18%, and 84.38%, respectively. Conclusion:The TSE-DWI sequence has high signal-to-noise ratio and can improve the diagnostic accuracy and specificity. TSE-DWI sequence is of great value in clinical diagnosis and treatment.

Is diffusion-weighted magnetic resonance imaging (DW-MRI) a requirement for suspected cholesteatoma in patients to undergo primary surgery?

Aim: In this study, the aim was to investigate the correlation of preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) with postoperative pathology findings in patients undergoing tympanomastoidectomy with suspicion of primary cholesteatoma. Materials and Methods: The study consisted of the retrospective evaluation of preoperative MRIs, surgical findings and pathology results of patients who underwent tympanomastoidectomy and had preoperative DW-MRI at the Department of Otorhinolaryngology between the years 2017 and 2019. Results: The study was conducted with 199 patients who underwent tympanomastoidectomy surgery. A retrospective examination of patient files revealed that 80 (40.2%) of the patients underwent echoplanar diffusion-weighted magnetic resonance imaging (DW-MRI) because of suspected cholesteatoma in the preoperative period. Of these 80 patients, cholesteatoma was detected in 22 (27.5%) as a result of pathological analysis and/or surgery, but no diffusion restriction was found in MRI interpretation; in 44 (55%) of them, both cholesteatoma in pathological analysis and/or surgery and diffusion restriction in MRI interpretation were detected. In 10 (12.5%) of these 80 patients, cholesteatoma was not detected either in the MRI interpretation or in the pathological analysis and/or surgery. In the remaining 4 (5%) patients, there was a cholesteatoma suspicion in MRI, but it was not detected as a result of pathological analysis or surgery. In this study, the sensitivity of MRI for the diagnosis of cholesteatoma was 66.6%, and its specificity was 71.4%. Conclusion: MRI provides moderately (66.6%) reliable information in the diagnosis of cholesteatoma patients. However, it is more reliable (71.4%) when it comes to exclusion of the disease. Therefore, it should not be used as the sole determining factor in patients who will undergo primary surgery with suspected cholesteatoma. As much as our study results provide guidance for a more accurate use of imaging methods, series with higher numbers of patients are needed.

Clinical analysis of missed diagnostic congenital cholesteatoma

Objective:The clinical symptoms, imaging features and surgical treatment of congenital cholesteatoma are reported. Method:The clinical data of 20 patients with congenital cholesteatoma diagnosed and treated in our hospital from January 2016 to May 2018 were retrospectively analyzed, including the age of onset, clinical symptoms, signs, audiology, HRCT of temporal bone, surgical methods and so on. Result:In 20 patients with congenital cholesteatoma, the clinical manifestations were hearing loss in the affected ears, including 5 cases with ear fullness and 4 cases with tinnitus. There were 13 cases of local yellow-white shadow of tympanic membrane, 5 cases of normal tympanic membrane and 2 cases of tympanic membrane bombe. Pure tone audiometry showed conductive deafness in 14 cases and mixed deafness in 6 cases. CT scan of temporal bone showed that 15 cases had pneumatic type of mastoid, 4 cases had diploectic type and 1 case had sclerostic type. There were 15 cases of interspersed flocculent shadow and 5 cases of mass shadow. Among the 20 cases of chronic otitis media with cholesteatoma, 6 have cholesteatoma in epitympanum, 4 in tympanic cavity, 3 in tympanic cavity and epitympanum, 2 in mastoid and tympanic antrum, 1 in mastoid, tympanic antrum and tympanic cavity, 1 in tympanic antrum, tympanic cavity and petrous apex, 1 in tympanic cavity, hypotympanum, posterior tympanum and ostium tympanicum tubae auditivae, 1 in aditus ad antrum, epitympanum and posterior tympanum, 1 in tympanic cavity, epitympanum and posterior tympanum. Intact canal wall mastoidectomy and tympanoplasty were performed in 7 cases, open mastoidectomy and tympanoplasty in 5 cases, middle ear exploration and tympanoplasty in 4 cases, atticotomy with reconstruction and tympanoplasty in 3 cases and subtotal temporal bone resection in 1 case. Conclusion:For patients with intact tympanic membrane presenting with hearing loss, the tympanic membranes should be carefully examined, and thin-section CT and MRI of temporal bone should be performed in time to avoid missed diagnosis of congenital cholesteatoma. Once diagnosed, surgery should be performed as soon as possible.

The value of turbo spin-echo diffusion-weighted imaging apparent diffusion coefficient in the diagnosis of temporal bone cholesteatoma

To explore the value of the applying the apparent diffusion coefficient (ADC) to the quantitative diagnosis of temporal bone cholesteatoma. Seventy-one patients clinically suspected of temporal bone cholesteatoma were enrolled prospectively. These patients underwent ear magnetic resonance imaging (MRI) and turbo spin-echo diffusion-weighted imaging (TSE-DWI) using a Philips Ingenia 3 T superconductive MRI system, and their ADCs were measured. Subsequently, all enrolled patients underwent surgery within 15 days of the MRI. Using receiver operating characteristic (ROC) curve analysis, the optimal threshold and diagnostic performance for diagnosing temporal bone cholesteatoma were determined. Logistic regression modelling was used to combine ADCs and T1-weighted imaging (T1WI) sequences and calculate the combined diagnostic performance. Based on the pathology results, patients were categorised into the cholesteatoma group (CS group, n=43) and the non-cholesteatoma group (NCS group, n=28). In the CS group, ADCs were significantly lower (mean, 0.87±0.31×10-3 mm2/s) than in the NCS group (mean, 1.87±0.49×10-3 mm2/s; p<0.001); the area under the ROC curve (AUC) was 0.915. Based on the optimal threshold of ADC, ≤1.23×10-3 mm2/s, the diagnostic performance was high; the sensitivity and specificity for diagnosing cholesteatoma were 95.35% and 85.71%, respectively. By combining the ADC and T1WI sequence, AUC increased to 0.953, and the sensitivity and specificity were 90.7% and 96.43%, respectively. ADC quantitative analysis has a high value in the preoperative diagnosis of cholesteatoma, and the combination of ADC and T1WI sequences can improve the diagnostic accuracy and specificity and thereby facilitate clinically effective diagnosis.

Bell’s palsy due to congenital cholesteatoma of petrous apex: a case report

Congenital cholesteatoma (CC) is a rare disease, it accounts for 2-5% of all cholesteatomas [2] most common site being middle ear. Case report: We reported a case of 23-year-old female presented with progressive left sided facial asymmetry for 4 years and progressive hearing loss in the left ear for 2 years. She had normal left tympanic membrane and complete left lower motor neuron facial nerve palsy. High resolution computed tomography with contrast temporal bone showed extensive bony destruction, petrous apex and soft tissue lesion. Patient then proceed with transmastoid translabyrinthine approach. Diagnosis of cholesteatoma confirmed by histopathological examination (HPE). Congenital cholesteatoma of petrous apex is a rare case. It is a challenge to diagnose congenital cholesteatoma pre-operatively without specific radiological sign. This is because the disease is generally difficult to differentiate with mucocele and cholesterol granuloma on CT scan. Therefore, intraoperative diagnosis more accurate rather than the preoperative diagnosis.&#x0D; Bangladesh Med J. 2018 Jan; 47 (1): 41-43

Blast-Induced Cholesteatomas After Spontaneous Tympanic Membrane Healing

To characterize blast-induced cholesteatomas (BIC) in terms of symptoms, presentation, and location within the middle ear cleft (MEC). A search for all English language articles in "MEDLINE" via "PubMed" and "Google Scholar" was conducted. A total of 67 ears with BIC were included. Fifty-eight ears in which the traumatic perforation failed to spontaneously close were excluded, leaving seven case reports (eight patients, nine ears) for statistical analysis. Time between blast exposure to spontaneous tympanic membrane (TM) closure was 16 days to 10 months. Time between blast exposure and cholesteatoma diagnosis was 5 months to 4 years. The cholesteatomas were diagnosed due to symptoms in two ears, as asymptomatic finding on physical examination in one ear and as asymptomatic finding in axial imaging in three ears. BICs can develop behind intact tympanic membrane or along with TM perforation. Based on the current review, when a TM perforation and spontaneous healing were documented, after blast exposure, MRI scan is an integral component of the follow-up. The optimal timing for MRI performance after blast exposure, is yet to be identified.

Role and utility of HRCT and MRI in detection and evaluation of cholesteatoma

Cholesteatoma is a common benign lesion of the middle ear characterised by accumulation of keratinous debris. It is associated with local bony erosions and hence serious intracranial and labyrinthine complications which prompts surgical intervention. Earlier, High resolution computed tomography (HRCT) was used in combination with clinical examination to arrive at a diagnosis. Computed tomography (CT) gives excellent definition of bony structures, but lacks sensitivity in differentiating between various causes of soft tissue densities. Magnetic resonance imaging (MRI) is more useful in evaluation of soft tissue details. We conducted this study with an aim of evaluating the role of diffusion weighted imaging in diagnosis of cholesteatoma and its utility to differentiate cholesteatoma from granulation/ inflammatory tissue. The study was conducted on forty patients between March 2018 and February 2019 who were clinically suspected of chronic suppurative otitis media with cholesteatoma. These patients were subjected to HRCT and Diffusion weighted MRI (DW-MRI) examination of temporal region and findings were correlated with intraoperative and histological features. Our study found that, HRCT had a sensitivity of 83.3% and specificity of 58.3% in detection of cholesteatoma, while MRI was found to accurately predict the presence of cholesteatoma in 91.6% of the cases evaluated. The sensitivity, specificity, positive predictive value and negative predictive value were 91.6%, 91.6%, 95.6% and 84.6%, respectively. Hence, we conclude that diffusion weighted magnetic resonance imaging is a useful technique for cholesteatoma imaging with high sensitivity and specificity. Combination of HRCT and MRI will be helpful to make an accurate diagnosis.

Assessment of chronic suppurative otitis media patients with cholesteatoma on the basis of gadolinium enhanced T1-T2 weighted images of MRI

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The propensity for ossicular destruction is much greater in case of unsafe CSOM due to presence of cholesteatoma and/or granulations. Partial or total destruction of ossicles is seen in approximately 80% of patients with cholesteatoma, whereas in chronic otitis media without cholesteatom, ossicular chain erosion can be seen in approximately 20% cases.The present study aims to evaluate the clinical profile of patients of unsafe chronic suppurative otitis media with cholesteatoma and assesses patients on the basis of gadolinium enhanced T&lt;sub&gt;1&lt;/sub&gt;-T&lt;sub&gt;2&lt;/sub&gt; weighted images of MRI.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study was conducted among patients who were fulfilling the criteria for unsafe CSOM i.e., retraction pocket in pars tensa, marginal perforation, perforation in pars flaccida, presence of granulation tissue, presence of polyp, blood stained discharge etc. were selected for the study. MRI was performed in all cases by using gadolinium enhanced T&lt;sub&gt;1&lt;/sub&gt;-T&lt;sub&gt;2&lt;/sub&gt; sequences for diagnosis of cholesteatoma. Mastoidectomy was done to confirm the findings of MRI. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In maximum number of cases perforation was found in attic region. Most common complication of disease is the ossicular chain erosion. In present study sensitivity was 84%, specificity was 100% and positive predictive value and negative predictive value were 100% and 66% respectively.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It can be concluded that MRI can differentiate cholesteatoma from other inflammatory etiology. By using MRI with 1.5 or 3T unit a small cholesteatoma (even 2-3 mm) can be easily detected at its early stage and further complications can be prevented.&lt;/p&gt;

Role of Diffusion-Weighted Propeller Magnetic Resonance Imaging in Cholesteatoma Diagnosis

AbstractBackground: Cholesteatoma is a pseudotumor with ex-pansive growth that causes destruction of surrounding bone structures and thus damage of surrounding structures like facial nerve or inner ear. Early diagnosis and detection of any recurrence are essential. Radiological detection using Com-puted Tomography (CT) is the technique of choice due to its ability to detect bone destruction epically the destruction of ossicles which is characteristic. However, CT does not have high spatial resolution of tissue which is of particular necessary in congenital, recurrent, abnormal site or post-operative cholesteatoma. MRI overcomes the shortcomings of CT and can be useful in such cases.Aim of Study: The aim of this study was to discuss the role of diffusion-weighted Propeller MRI in the diagnosis of cholesteatoma in non-operated and operated temporal bone.Patients and Methods: A prospective study was performed on 37 patients. All the patients had undergone DW-MRI and CT temporal bone, 29 of them had undergone MRI examination with contrast. Clinical and surgical findings were correlated with diffusion-weighted Propeller MRI results.Results: Sensitivity, specificity, positive and negative predictive values were 100%, 85.7%, 96.8% and 100%, respectively.Conclusion: Diffusion-weighted Propellar MRI imaging is an effective technique in cholesteatoma diagnosis in operated and non operated patients.

Role of Multi Detector Computed Tomography in Preoperative Evaluation of Middle Ear Cholesteatoma

AbstractBackground: Middle ear cholesteatoma is an ectopic squamous stratified epithelium in the middle ear. It is a actually risky disease as it leads to destruction of ossicles and/or walls of middle ear that causes severe complications as hearing loss and brain abscess. Pre-operative assessment of cholesteatoma by Multi-Detectors Computed Tomography (MDCT) is essen-tial for accurate diagnosis and appropriate management to prevent recurrence after surgery.Aim of Study: To assess the diagnostic accuracy of pre-operative MDCT of middle ear cholesteatoma with surgical correlation.Patients and Methods: A prospective study was conducted in Tanta University Hospitals from July 2015 to December 2016 on 30 patients with middle ear cholesteatoma. All patients had a pre-operative MDCT scans. The pre-operative MDCT findings were recorded and correlated with surgical and histopathological results. Sensitivity and specificity of pre-operative MDCT findings were calculated considering oper-ative findings as gold standard.Results: The study included 30 patients, 17 were females and 13 were males with a mean age of 35 years. The diagnostic accuracy of the pre-operative MDCT findings when correlated to intraoperative ones was 100% in detecting soft tissue mass inside the middle ear, 100% in detecting the location of cholesteatoma, 100% in detecting ossicular erosion, 93.3% in detecting scutum erosion and 100% in confirming the diagnosis of cholesteatoma proved by post-operative his-topathological examination. The mean sensitivity of MDCT in preoperative diagnosis and evaluation of middle ear chole-steatoma was 97.4% while the mean specificity was 95.8%.Conclusion: Middle ear cholesteatoma is a distinctive clinical entity with characteristic findings on MDCT scan, that guides in the surgical approach and management plan.

The role of diffusion-weighted magnetic resonance imaging using PROPELLER sequence in diagnosis of postoperative cholesteatoma

The role of diffusion-weighted magnetic resonance imaging using PROPELLER sequence in diagnosis of postoperative cholesteatoma

Assessment of Mass Effect Sign at High-Resolution Computed Tomography in Prediction of Cholesteatoma.

The aim of this study was to assess the accuracy of mass effect sign in the diagnosis of cholesteatoma at high-resolution computed tomography (HRCT). This prospective study included 32 ears in 24 patients with chronic otitis media who underwent HRCT of the temporal bone. Otoscopic and operative notes were recorded. Image analysis was done both qualitatively and quantitatively. In the qualitative analysis, mass effect was evaluated visually by comparing both ears together in 4 certain anatomical sites. Ossicular erosions, erosion of tegmen tympani, erosion of tympanic segment of facial nerve canal, and the presence of lobulated nondependent opacity were also evaluated. In the quantitative analysis, we calculated the difference between the distances of the described anatomical sites in both ears. Qualitative analysis of mass effect sign showed 97.1% accuracy in detecting cholesteatoma. Ossicular erosions showed 69.2% accuracy in the diagnosis of cholesteatoma. In the quantitative analysis, we found that the cutoff point of 0.45 mm in the difference of aditus measure between both ears showed 85.3% accuracy in differentiating cholesteatoma from otitis media. The cutoff point of 0.75 mm in the differences in supratubal measure showed 86.1% accuracy. The cutoff point of 0.45 mm in the medial to incus measure showed 100% accuracy. High-resolution computed tomography is highly valuable for the detection of mass effect sign, which has great importance in diagnosing cholesteatoma.

Long-Term Hearing Outcomes following Total Ossicular Reconstruction with Titanium Prostheses.

(1) Characterize a large cohort of patients undergoing total ossicular chain reconstruction with titanium prosthesis. (2) Analyze long-term hearing outcomes of the same cohort. Case series with chart review. Tertiary care center. This study reviews patients who underwent total ossicular chain reconstruction (OCR) with titanium prostheses (TORPs) at a single tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if length of follow-up was 2 years or more. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 2 years. In total, 153 patients were identified who met inclusion criteria. The mean age of included patients was 40 years (range, 6-89 years). Sixty patients (39%) had a history of OCR, and 120 patients (78%) had a diagnosis of cholesteatoma at the time of OCR. Preoperatively, the mean ABG was 36 ± 12, whereas the mean ABG at 2-year follow-up improved to 26 ± 13. This was statistically significant (P < .0001) using a Wilcoxon matched-pairs signed rank test. Twelve patients (8%) required revision OCR. Two revisions were performed due to prosthesis extrusion (<1%). Titanium prostheses lead to significant improvement in hearing over long periods. The results are sustained as far out as 5 years following surgery. In addition, rates of revision surgery with titanium TORPs are low. Based on this series, there are no readily identifiable predictors for outcomes following total OCR.

Utility of Non-EPI DWI MRI in the Management of Pediatric Cholesteatoma

Abstract Introduction Cholesteatoma in children can be acquired or congenital and is generally extensive. The most commonly used technique for the removal of cholesteatoma is intact canal wall mastoidectomy. This invariably leads to second-look surgery to assess for recurrence or residual cholesteatoma. Magnetic resonance imaging (MRI) with non–echo-planar imaging (non-EPI) diffusion-weighted imaging (DWI) is an accurate noninvasive imaging option that can be used in diagnosing primary cholesteatoma. This can also be used to diagnose residual or recurrent cholesteatoma in patients who have undergone intact canal wall mastoidectomy. Case Report A 7-year-old male patient presented with a 1-week history of foul-smelling discharge from the right ear. On examination, a polypoidal mass with keratinized debris was seen. A diagnosis of cholesteatoma of right ear was made. Imaging with high-resolution computed tomography (HRCT) of the temporal bone and non-EPI DWI MRI confirmed the same. The child underwent an intact canal wall mastoidectomy and was followed up at 2 years with non-EPI DWI MRI to monitor any residual or recurrent cholesteatoma. Conclusion Non-EPI DWI MRI provides a convenient, accurate, and noninvasive method of evaluating and monitoring for residual or recurrent cholesteatoma and thus helps avoid unnecessary second-look surgery.

Cholesteatoma: multishot echo-planar vs non echo-planar diffusion-weighted MRI for the prediction of middle ear and mastoid cholesteatoma.

Objective:We aimed to compare a newer readout-segmented echoplanar imaging (RS-EPI) technique with the established single shot turbo spin echo (SS-TSE) non-EPI diffusion-weighted imaging (DWI) in detecting surgically validated cholesteatoma.Methods:We retrospectively reviewed 358 consecutive MRI studies in 285 patients in which both RS-EPI and non-EPI DWI sequences were performed. Each diffusion sequence was reviewed independently and scored negative, indeterminate or positive for cholesteatoma in isolation and after reviewing the T 1W sequence. Average artefacts scores were evaluated and the lesion size measured as a distortion indicator. The imaging scores were correlated with surgical validation, clinical and imaging follow-up.Results:There were 239 middle ear and central mastoid tract and 34 peripheral mastoid lesions. 102 tympanomastoid operations were performed. The positive predictive value ( PPV), post-operative PPV, primary PPV, negative predictive value were 93%, 95%, 87.5%, 70% for RS-EPI and 92.5%, 93.6%, 90%, 79% for non-EPI DWI. There was good agreement between the two techniques (k = 0.75). Non-EPI DWI is less susceptible to skull base artefacts although the mean cholesteatoma measurement difference was only 0.53 mm.Conclusion:RS-EPI has comparable PPV with non-EPI DWI in both primary and post-operative cholesteatoma but slightly lower negative predictive value. When there is a mismatch, non-EPI DWI better predicts the presence of cholesteatoma. There is good agreement between the sequences for cholesteatoma diagnosis. The T 1W sequence is very important in downgrading indeterminate DWI signal lesions to a negative score.Advances in knowledge:This is, to our knowledge, the first study to compare a multishot EPI DWI technique with the established non- EPI DWI in cholesteatoma diagnosis.

Role of Multi-Detector Computed Tomography in Diagnosis and Staging of Cholesteatoma

AbstractBackground: Pathology of the middle ear is the third most common reason of visiting a general practitioner or a family doctor. In children and teenagers, inflammatory conditions of the middle ear are the most frequent reasons to prescribe antibiotics and perform surgery.In the majority of these cases, proper diagnosis is made by clinical examination alone and patients will not benefit from additional diagnostic imaging studies. However, the prevalence of ear infections increased significantly and this may suggest that the current approach to preventing and treating middle ear inflammation is not adequate. Therefore, especially in complicated and recurrent conditions, imaging plays an important role; imaging findings may fundamentally influence the treatment. Also, in non-inflammatory conditions of external and middle ear Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) would provide a diagnosis and/or necessary information for surgery in a significant number of cases.Aim of Work: Evaluation the role of Multi-Detector Computed Tomography (MDCT) in diagnosis Chronic Sup-purative Otitis Media (CSOM) with or without cholesteatoma and staging of middle ear Cholesteatoma and assess its impact on the selection of the surgical procedure.Patients and Methods: A prospective study included 30 patients with mean age 30.4 years with CSOM with or without cholesteatoma. They were evaluated regarding to their clinical symptoms, temporal multidetector computed tomography findings, and postoperative results. MDCT staging classified cholesteatoma according to its site in the tympanic cavity (S); erosion of the ossicular chain (O); and associated complications (C).Results: MDCT imaging of these patients showed opaci-fication of middle ear cavity with integrity of the ossicular chain with 100% accuracy. Nondependent soft tissue masses in the middle ear, eroded scutum (n=20), eroded ossicles (n= 20), intact tegmen tympani (n=30), lateral mastoid fistula (n=2) and labyrinthine fistula (n=1) were observed in CSOM with cholesteatoma. All these patients underwent surgical intervention that confirmed the diagnosis of the presence of cholesteatoma in all these patients. But it also added the presence of lateral mastoid fistula and labyrinthine fistula in 1 other patient and discovered the presence of facial nerve injury in 1 patient.Conclusion: MDCT scanning has limitations, but it is a useful in diagnosis, staging and surgic

Ossicular Erosion from a Posterior Pars Tensa Retraction Cholesteatoma

A 14-year old female with Down syndrome presented with a 3-year history of recurrent purulent left otorrhea. The discharge had become more frequently blood-tinged. Otologic examination revealed a stenotic ear canal with polypoid granulation obstructing the view of the tympanic membrane. High resolution computerized tomographic (HRCT) imaging of the temporal bone was performed to assess the status of the middle ear and mastoid. Particular attention was given to assess for bony erosion associated with cholesteatoma formation.&#x0D; Comparison of the scutum on coronal view (Figure 1) did not show a marked visual difference in the sharpness of the scutum edge. As erosion of the scutum edge is the hallmark radiological finding in the diagnosis of a pars flaccida or attic retraction-based acquired cholesteatoma, a confident radiologic diagnosis of cholesteatoma via this pathophysiologic mechanism could not be given.&#x0D; Figure 1.Coronal HRCT images of the scutum. The left scutum (white arrow) does not appear to be blunted when compared to the right scutum, which is known to be intact. The left middle ear space is entirely filled with a soft tissue lesion, whilst there is only soft tissue in the right epitympanum lateral and superior to the ossicles.&#x0D; &#x0D; Meticulous examination of the ossicles on axial view (Figure 2) showed a subtle thinning of the short process of the incus by sharply marginated, seemingly expansile soft tissue medially located between the incus and the tympanic segment of the facial nerve.&#x0D; Exploratory surgery via an initial external end-aural approach revealed the presence of a posterior pars tensa retraction cholesteatoma underneath the granulation polyp. The cholesteatoma had extended medial to the ossicular chain, causing erosion of the long process and medial portion of the short process of the incus, as well as the entire stapes superstructure. Definitive surgery consisting of a canal-wall down mastoidectomy via a post-auricular approach, cartilage graft tympanoplasty without ossicular chain reconstruction, meatoplasty and partial mastoid obliteration was performed.&#x0D; This case is particularly instructive with regards to two issues: otologic disease in Down syndrome and radiological evidence of erosive middle ear disease. An increased incidence of otologic conditions in Down syndrome is well established in the medical literature. These include external auditory canal stenosis, ossicular chain abnormalities and otitis media with effusion (OME).1,2 Cholesteatoma as a sequelae of undiagnosed or untreated OME has to be suspected in children with Down syndrome, especially in those with recurrent otorrhea and persistent hearing loss. Unfortunately, the identification of a cholesteatoma may be difficult due to stenosis of the external auditory canal or a sub-optimal otologic examination due to behavioral problems in children with Down syndrome.2 These factors were both present in this particular case, as the cholesteatoma remained undiagnosed for several years despite regular consultations with an otolaryngologist.&#x0D; Radiologic evaluation with high-resolution computerized tomographic (HRCT) imaging is extremely important in these situations. As described by Barath et al., the “typical findings associated with cholesteatoma include a sharply marginated expansile soft-tissue lesion, retraction of the tympanic membrane, scutum blunting, and erosion of the tympanic tegmen and ossicles. Holotympanic absence of bony changes is suggestive of otitis media without cholesteatoma formation, whereas presence of bony erosions (along with clinical suspicion) indicates cholesteatoma.”3 In this particular case, the presence of soft tissue within the epitympanum and antrum accompanied by the subtle evidence of ossicular erosion were crucial in the decision to advise and perform surgery. Although it may be argued that a high clinical suspicion based on the suggestive otological history in a child with Down syndrome may be enough to warrant surgical exploration, it cannot be disputed that the radiological findings help in advising patients pre-operatively about the indications for and expected outcomes of surgical management. In this case, it also impacted on the surgical approach – a transmeatal procedure appropriate for a limited middle ear exploration was initially performed, with conversion to a standard post-auricular approach appropriate for more extensive mastoid surgery once the presence and extent of the cholesteatomatous disease was confirmed intra-operatively.&#x0D;