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To report on the value and limitations of new MRI techniques in pre- and post-operative MRI of cholesteatoma. The current value of magnetic resonance imaging (MRI) in diagnosing congenital, acquired, and post-operative recurrent or residual cholesteatoma is described.
High resolution computed tomography (HRCT) is still considered the imaging modali...
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Context 1
... However, a marked hyper- intensity on DWI is considered diagnostic for cholesteatoma, but one must be careful not to misin- terpret the numerous artefacts on DWIs as cholesteatomas. The dif- ferential diagnosis and imaging characteristics of cholesteatoma on MRI are summarized in Table 1, and 3 case illustrations are described in Figures 1, 2, and 3. ...
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Citations
... Thorough examination, including the patient's history, otoscopy, and imaging studies, is important for the diagnosis of CMC. 3 When a normal tympanic membrane is visualized on otoscopy, without a history of otologic disease, the cholesteatoma is considered to have a congenital origin. A cholesteatoma can be distinguished from other diseases, such as cholesterol granuloma, mucocele, and endolymphatic sac tumor, using imaging studies. ...
... Diffusion restriction is observed on DWI. 1,3 In the present case, results of the otoscopic examination and imaging were consistent with the diagnostic criteria for a congenital cholesteatoma. ...
A congenital mastoid cholesteatoma (CMC) is a keratinizing epithelium originating from embryological epithelial tissue of the mastoid. It is often not diagnosed until it becomes large because of its rarity and indolent nature. Although there are a few reports on giant CMC, its exact extensions have not been well described, and detailed information regarding surgical methods is lacking, especially in giant CMC involving the occipital condyle and the middle and posterior cranial fossae. In this article, we report a case involving a 70-year-old woman with a giant CMC that extended inferiorly to the occipital condyle. The CMC eroded the middle and posterior cranial fossae, sigmoid sinus plate, and fallopian canal of the facial nerve. For complete removal, we used a subtotal petrosectomy in conjunction with an exposure of the cranial cervical junction and a wide decompression of the suboccipit. The boundaries of exposure were similar to those of a petro-occipital transsigmoid approach which is usually used for management of tumor involving the jugular foramen. The wide exposure allowed for complete removal of the lesion without any complications. Thus, we recommend this surgical approach for management of the giant CMC involving the occipital condyle and the middle and posterior cranial fossae.
... This permitted more precise detection of small-sized cholesteatoma. [12][13][14] Nonetheless, non-EPI DW does not visualize the anatomical landmarks of the ME and mastoid. Therefore, the fusion of HRCT and DWMRI combines the accuracy of soft tissue recognition of diffusionweighted images and the anatomical precision of the HRCT images. ...
Background:
The role of imaging in cholesteatoma continues to evolve with excellent bony details provided by high-resolution computed tomography and high soft tissue identification for cholesteatoma by diffusion-weighted magnetic resonance imaging. The fusion of highresolution computed tomography and diffusion-weighted magnetic resonance imaging combines the advantages of both imaging techniques.
Methods:
A random sample of 40 consecutive patients with chronic suppurative otitis media with cholesteatoma was included in this study. Both high-resolution computed tomography of the petrous bone and non-echoplanar diffusion-weighted magnetic resonance imaging were performed. This was followed by their fusion. Patients were classified according to The European Academy of Otology and Neurotology, in cooperation with the Japanese Otological Society Joint Consensus Statement on the Definitions, Classification, and Staging of Middle Ear Cholesteatoma. All patients were operated, and the technique was tailored according to the data obtained from the preoperative fusion of computed tomography and diffusion-weighted magnetic resonance imaging and the intraoperative findings.
Results:
Patients were equally divided between males and females with a mean age of 26.8 years of which 52.5% were left-sided ears. The fusion of high-resolution computed tomography and diffusion-weighted magnetic resonance imaging had a 100% sensitivity and 88.9% specificity regarding The European Academy of Otology and Neurotology, in cooperation with the Japanese Otological Society classification. On the other hand, it showed 100% specificity and 100% sensitivity for all middle ear subsites except sinus tympani which obtained 55.56% sensitivity and 100% specificity. In all patients with preoperative fusion showing cholesteatoma not reaching the mastoid antrum (30%), exclusive endoscopic approach was employed, and no postauricular incision was needed.
Conclusion:
The fusion of high-resolution computed tomography and diffusion-weighted magnetic resonance imaging images is an accurate tool for localizing cholesteatoma in various middle ear cleft subsites. This makes it a valuable tool for cholesteatoma classification and staging and surgical planning preoperatively.
... For years, diffusion-weighted (DW) magnetic resonance imaging (MRI) has been used to evaluate middle ear cholesteatoma, primarily for detecting residual or recurrent cholesteatoma during postoperative follow-up [8][9][10][11][12]. Modern MRI techniques increasingly appear to be the imaging study of choice for the preoperative evaluation of cholesteatoma. ...
... In theory, after intravenous administration of gadolinium, the enhancement of the surrounding epithelial (matrix) and granular (perimatrix) layers can be seen as a thin, enhanced line (peripheral rim) on T1-weighted images. On non-EPI DW-MRI sequences, a cholesteatoma is characterized by a clear hyperintensity compared to the surrounding brain parenchyma (Figure 4, Table 4) [12]. With all these characteristics, an MRI has traditionally been considered the primary non-invasive method for excluding residual or recurrent cholesteatoma during postoperative follow-up, thus avoiding unnecessary second-stage surgery in most cases, especially in the pediatric population [9,12,[17][18][19][20]. ...
... On non-EPI DW-MRI sequences, a cholesteatoma is characterized by a clear hyperintensity compared to the surrounding brain parenchyma (Figure 4, Table 4) [12]. With all these characteristics, an MRI has traditionally been considered the primary non-invasive method for excluding residual or recurrent cholesteatoma during postoperative follow-up, thus avoiding unnecessary second-stage surgery in most cases, especially in the pediatric population [9,12,[17][18][19][20]. According to previous research, the sensitivity and specificity of DW-MRI detection of cholesteatomas have been reported as 91% to 94% and 92% to 96%, respectively [1,[21][22][23]. ...
Objective:
This study aims to assess the efficacy of diffusion-weighted (DW) and T1-weighted (T1W) magnetic resonance imaging (MRI) combined with high-resolution computed tomography (HRCT) (together as DW-T1W-CT) in the preoperative evaluation of the presence and extent of cholesteatoma, which helps determine whether a patient is suitable for transcanal endoscopic ear surgery (TEES).
Methods:
This retrospective study included 35 patients (18 male and 17 female) aged from 2 to 81 years diagnosed with chronic otitis media with or without cholesteatoma, who had received surgical treatment and a preoperative MRI and HRCT during the period of December 2015 to December 2020 at Cathay General Hospital. We compared the preoperative DW-T1W-CT findings with the intraoperative findings and final pathologic diagnosis. The accurate predictive value was evaluated using the presence of cholesteatoma and its extent.
Results:
Regarding the efficacy of detecting cholesteatoma, we found a sensitivity of 92% (23/25 cases with cholesteatoma), a specificity of 90% (9/10 cases without cholesteatoma), and an overall accurate predictive value of 91.4% (32/35) by using combined DW-T1W-CT imaging. With regard to evaluating the extent of cholesteatoma, the combined DW-T1W-CT images obtained an accurate predictive value of 84% (21/25 cases of cholesteatoma).
Conclusion:
Combined DW-T1W-CT has been proven to be a reliable tool in detecting the presence of cholesteatoma. It is also useful in preoperatively depicting the extent of cholesteatoma, which is crucial for determining whether a patient is suitable for TEES, aiding in surgical planning and patient consultation.
... Some reports have suggested that diffusion-weighted MRI helps to diagnose and identify postoperative residual or recurrent disease during follow up 28 . Improvements in MRI techniques have led to a more definitive diagnosis of cholesteatoma using diffusion-weighted imaging 29 . This provides great ease of postoperative follow-up of patients for recurrent or residual cholesteatoma. ...
Objective:
Cartilage is a rigid material that is highly resistant to infection and retraction and is tolerated well by the middle ear. The purpose of this study was to review retrospectively the results of cases of mastoid cavity obliteration with cartilage performed after canal wall down (CWD) mastoidectomy and to discuss the literature.
Method:
Of 983 patients who underwent surgery for chronic otitis media between January 2000 and June 2012, 54 patients who underwent CWD mastoidectomy plus mastoid cavity obliteration with cartilage and who were followed up regularly were selected from the database and invited for re-evaluation. All patients who came for a follow up after the invitation were examined and their data were evaluated retrospectively.
Results:
Thirty-five of the patients who accepted the invitation were included in the study. All of the patients in the study underwent mastoid cavity obliteration with conchal and/or tragal cartilage grafts. The duration of follow up ranged from 21 to 41 months (average, 27.3 months). Epithelization occurred in all patients with dry cavity, except one who had residual cholesteatoma and underwent revision surgery.
Conclusion:
The results of this study indicate that cartilage can be preferred for obliteration of mastoid cavity after CWD mastoidectomy.
... At present, the use of imaging methods has allowed greater certainty in the diagnosis of cholesteatoma, especially computed axial tomography and magnetic resonance imaging, in T1 diffusion-weighted sequences 11,12 . ...
Introduction:
Chronic suppurative otitis media (CSOM) is a persistent inflammation of the middle ear, with cholesteatoma as one of its many complications. Cholesteatoma is a progressive, non-neoplastic formation of keratinized squamous epithelium that causes bone destruction in the middle ear. There are multiple theories that may explain its physiopathogenesis; however, none of them have been proved yet. Inflammatory mediators, such as interleukins (ILs), have a role in the genesis of the cholesteatoma and it is necessary to study their role in detail.
Objective:
The objective of this study was to compare the IL (IL-2 and IL-9) expression in patients with CSOM with and without cholesteatoma.
Methodology:
A cross-sectional study, comparing two groups of patients with CSOM, five of them without cholesteatoma and eleven with cholesteatoma. Samples of problem tissue (inflammatory tissue and cholesteatoma) and control tissue (retroauricular tissue for both groups) were studied. Histopathological and immunohistochemistry analyses were conducted, in addition to imaging and morphometric analysis was performed. The statistical comparison was performed by t-test for independent groups.
Conclusions:
There are statistical differences on the IL-2 and IL-9 expression in the cholesteatoma tissue compared with the inflammatory tissue.
... 5 The additional value of MRI in primary acquired cholesteatoma is due mainly to its capacity to unequivocally confirm the diagnosis of cholesteatoma in cases of clinical doubt; in its capacity to distinguish cholesteatoma from other soft tissues, such as fibrosis, granulation tissue and cholesterol granuloma; and it's potential to document invasion of the labyrinth and of the intracranial space. 6 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 1 -T 2 weighted images of MRI. ...
p class="abstract"> Background: 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<sub>1</sub>-T<sub>2</sub> weighted images of MRI.
Methods: 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<sub>1</sub>-T<sub>2</sub> sequences for diagnosis of cholesteatoma. Mastoidectomy was done to confirm the findings of MRI.
Results: 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.
Conclusions: 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.</p
... The theory of congenital cholesteatoma origin assumes that the pathology is present before birth and the diagnosis is most often made by a combination of otoscopy and HRCT. In a completely aerated tympanic cavity absent of any associated soft tissue, HRCT has a high negative predictive value when excluding cholesteatoma [10]. Microsurgical excision is the accepted treatment and associated laser vaporization of contact points has been shown to limit the rate of recurrence [11]. ...
The occurence of cholesteatoma and cochlear implant is rare. Secondary cholesteatomas may develop as a result of cochlear implant surgery. Primarily acquired cholesteatoma is not typically associated with congenital sensorineural hearing loss or cochlear implant in children. The occurrence of congenital cholesteatoma during cochlear implant surgery has never been reported before, partly because all patients are preoperatively submitted to imaging studies which can theoretically exclude the disease.
Case presentation
We have reported a rare case of congenital cholesteatoma, found during sequential second side cochlear implantation in a 3-year-old child. The child underwent a computed tomography (CT) scan and magnetic resonance imaging (MRI) at 12 months of age, before the first cochlear implant surgery, which excluded middle ear pathology. The mass was removed as an intact pearl, without visible or microscopic violation of the cholesteatoma capsule. All the areas where middle ear structures were touching the cholesteatoma were vaporized with a laser and the cochlear implant was inserted uneventfully. Further follow-up excluded residual disease.
We believe that primary, single stage placement of a cochlear implant (CI) with simultaneous removal of the congenital cholesteatoma can be performed safely. However, to prevent recurrence, the capsule of the cholesteatoma must not be damaged and complete laser ablation of the surface, where suspicious epithelial cells could remain, is recommended. In our opinion, cholesteatoma removal and cochlear implantation should be staged if these conditions are not met, and/or the disease is at a more advanced stage. It is suspected, that the incidence of congenital cholesteatoma in pediatric CI candidates is much higher that in average pediatric population.
... In particular, high-resolution computed tomography (CT) is now considered the 'gold standard' technique because it provides precise information about the extent and location of the present tissue and is able to delineate perfectly the 'anatomical landmarks' [1] . However, its drawback is the low specificity in differentiating cholesteatoma from other types of tissues (inflammatory tissue, polyps, exudate, etc.), especially when the middle ear is without air content and when there is no apparent erosion of bone structures (ossicular chain, lateral semicircular canal, fallopian canal, tegmen tympani/antri, etc.) [1][2][3][4][5] . ...
We have analyzed the preoperative diagnosis of cholesteatoma through the use of diffusion-weighted intensity magnetic resonance (DWI-MR) in 16 consecutive patients suffering from chronic otitis media with clinical and radiological (by computed tomography) suspicion of cholesteatoma. In particular, we compared the radiological data with intraoperative ones, verifying the correspondence (in terms of sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy) between what is reported by DWI-MR and what is actually detectable at the time of surgery. Furthermore, we identified the most reliable DWI-MR sequence [single-shot (SSh) echo planar imaging (EPI) vs. multi-shot turbo spin-echo not-EPI] to detect cholesteatoma and reduce the time for examination. The obtained data on computed tomography scans revealed low diagnostic accuracy (56%); DWI-MR, instead, showed higher values, especially using not-EPI sequences (93.75 vs. 68.75% obtained by SSh-EPI sequences). © 2014 S. Karger AG, Basel.
... 3 Recent advances in the application of diffusion-weighted magnetic resonance imaging may in the future make this step unnecessary in many cases. [4][5][6][7][8] One of the arguments in favor of the canal wall down (CWD) technique is that a CWD procedure will leave a mastoid cavity that should, after initial healing, require minimal intervention. It has the advantage of being readily accessible for inspection for recurrence of disease, and thus a second scheduled operation is not necessary. ...
Objectives/HypothesisAn analysis of the frequency and intensity of postoperative aftercare required for modified radical mastoidectomy (MRM) and patterns of healing in the postoperative period. Study DesignA retrospective review of all primary modified radical mastoidectomies carried out for cholesteatoma under the care of the senior author between the years of 2004 and 2009 with minimum follow-up of 2 years. Methods
The time and number of interventions required to achieve a stable and dry mastoid cavity were collected. Cross-sectional and longitudinal analysis of the behavior of the cavities was carried out. ResultsOverall, 73 cases (71 patients) were identified. Patients were followed up for a median of 45.7 months (interquartile range, 31.8-70.5). After initial debridement, most cavities settled rapidly, but this was not always predictable, with a large proportion requiring further clinical intervention after the cavity was stable, sometimes for prolonged periods of time. At the time of analysis, 73% had achieved a stable cavity, 17 (23%) still required attention (nine for wax removal and eight for debridement); two were lost to follow-up. No revision surgeries were required. At 6 months, 36% of cavities were settled, 42% at 1 year, 53% at 18 months, and 62% at 2 years. After two standard postoperative visits, a total of 632 visits were made by these patients. Conclusions
Following MRM, the majority of patients achieve a dry, self-cleaning mastoid cavity. This might require periods of intense care interspersed with periods of quiescence. These results allow the benefits of this procedure to be put in the context of the entire patient journey. Level of Evidence4. Laryngoscope 124:2380-2385, 2014
... MRI could be used to delineate the extent of cholesteatoma in the presence of an effusion, but currently we do not use it routinely. Limitations include lower resolution [17,18], non-portrayal of bony anatomy and longer scan time, mandating general anesthesia in a high proportion of children. ...
A review of recent publications is combined with our clinical experience to provide salient tips for optimizing the care of children with congenital cholesteatoma.
Increasing utilization of surgical adjuncts such as endoscopy and KTP laser provides the opportunity to improve postoperative outcomes by reducing residual cholesteatoma rates and improving hearing outcomes. Nevertheless, the best prospect of leaving the child with a normal ear is achieved by prompt removal after early detection when the lesion is still small.
Education of primary care providers to promote early identification and referral of congenital cholesteatoma remains an important objective and responsibility for otolaryngologists in order to obtain optimal outcome.
