Detection of postoperative relapsing/residual cholesteatomas with diffusion-weighted echo-planar magnetic resonance imaging

PURPOSE

To assess the capability of echo-planar diffusion-weighted magnetic resonance imaging (MRI) (EPI-DWI) in diagnosing relapsing/residual cholesteatomas after canal wall-up mastoidectomy.

MATERIALS AND METHODS

In a blinded study design, we investigated with MRI, including standard spin-echo sequences, 18 patients evaluated with clinical examination and computed tomography (CT) suspected for relapsing/residual cholesteatoma 7 to 19 months after a canal wall-up mastoidectomy. Images were evaluated by two radiologists blinded to patients' identities, CT findings, and clinical data set, who decided in a consensus agreement whether there was a pathologic signal increase in the petrous bone in a single-shot EPI-DWI sequence. All the patients underwent a second tympanoplasty or revision surgery of the mastoidectomy cavity within 15 days after magnetic resonance investigation.Sensitivity, specificity, and predictive values were evaluated separately for standard sequences and EPI-DWI.

RESULTS

In EPI-DWI, five of six patients with cholesteatoma showed a bright signal, whereas those patients with a noncholesteatomatous tissue showed no anomalies. The only misdiagnosed cholesteatoma was a pearl 2 mm in diameter. Sensitivity, specificity, and positive predictive values, and negative predictive values of EPI-DWI in diagnosing relapsing/residual cholesteatomas were 86, 100, 100, and 92%, respectively.

CONCLUSION

EPI-DWI may be a useful tool in differentiating between cholesteatomatous and noncholesteatomatous tissues after closed cavity mastoidectomy. Further investigations are, however, required to establish the practical utility of EPI-DWI on larger series as a screening modality in the follow-up after closed cavity mastoidectomies.

[Main symptom otorrhea: diagnosis and therapy]

Otorrhea is an ambiguous symptom that underlies diverse clinical pictures. Fundamentally, the treatment of uncomplicated acute otitis externa and media can be carried out by the family physician. An ENT specialist should be definitely consulted in cases of complications or development of a chronic condition.

Jugular foramen syndrome caused by choleastatoma

Unilateral paresis of 9th-11th cranial nerves together is defined as jugular foramen (Vernet's) syndrome. A cholesteatoma case that penetrated into intracranial area after eroding temporal bone and led to jugular foramen syndrome is presented here, since such a case has not been reported in the literature hitherto. A 46-year-old male patient was evaluated for hoarseness. It was learnt from his anamnesis that he had been operated for otitis media nearly 20 years ago. Uvula deviated towards right. Loss of gag reflex was remarkable on the left. Paresis was found on the left vocal cord. There was weakness in rotation of the head to the right. Computerized tomography (CT) scan revealed that the temporal bone lost its integrity and that there was an extra-axial hypodense mass neighboring pontocerebellum. Post-contrast magnetic resonance imaging showed that the mass, which showed thin, regular circular contrasting and which was hypointense in T1-weighted MR and hyperintense in T2-weighted MR, extended to the left jugular foramen. The mass was totally removed with left sub-occipital approach in the treatment. After the treatment, hoarseness, weakness in the rotation movement of the head and loss of gag reflex recovered totally, while deviation in the uvula was permanent. Cholesteatomas can extend to posterior fossa and cause jugular foramen syndrome. Early surgery is important to completely reverse the lost nerve functions in treatment.

Résultats à long-terme des cholestéatomes congénitaux de l’oreille moyenne de l’enfant

OBJECTIVES

To report the long term results of congenital cholesteatoma of the middle ear in children.

PATIENTS AND METHODS

Retrospective study of thirty two children with 33 congenital cholesteatoma (1 bilateral cholesteatoma) operated on by the same surgeon. The mean age was 6 years. The most common clinical presentation was unilateral hearing loss. A trans-canal approach was performed in 4 cases and an intact canal wall technique in 29 cases. A two staged surgery was necessary in 28 patients, whom a residual cholesteatoma was observed in 7 patients. A third stage was performed in 11 patients because of a residual cholesteatoma in 2 two cases and a functional failure in 9 cases.

RESULTS

At five years postoperative audiometry (air bone gap inferior or equal to 20 dB HL), a functional success was obtained in 50% of cases.

CONCLUSION

The diagnosis of congenital cholesteatoma must be evoked in every atypical otitis media with effusion or unilateral transmission hypoacusis. The intact canal wall technique in two stages is the most appropriate treatment, since congenital cholesteatoma in children appears aggressive in a well pneumatized mastoid. The choice for an intact canal wall technique is also justified by the ambition of a conservative surgery in the young child. The functional results are generally satisfactory in early diagnosed cases. Thus, ENT and pediatric physicians have a unique role in detecting congenital cholesteatoma in the early period of life, and in ensuring a long term follow-up.

Usefulness of delayed postcontrast magnetic resonance imaging in the detection of residual cholesteatoma after canal wall-up tympanoplasty

OBJECTIVES/HYPOTHESIS

Imaging takes an increasing place in the follow-up of patients who have undergone surgery for cholesteatoma, with computed tomography (CT) as the first line imaging technique. However, in case of complete opacity of the tympanomastoid cavities, CT is not able to differentiate residual cholesteatoma from postoperative scar tissue. The aim of this study was to assess the usefulness of magnetic resonance imaging (MRI) using delayed postcontrast T1-weighted images for the detection of residual cholesteatoma after canal wall-up tympanoplasty (CWU) in cases where CT was not conclusive.

STUDY DESIGN

Prospective study.

METHODS

MRI, with delayed postcontrast T1-weighted images (30-45 minutes after contrast injection), was performed before revision surgery in 41 consecutive patients who had undergone CWU for cholesteatoma and presenting with a nonspecific complete opacity of the mastoid bowl on CT. In all the cases, imaging results were compared with operative findings at surgical revision.

RESULTS

A residual cholesteatoma was found in 19 of 41 patients at revision surgery and was correctly detected on MRI in 17 patients. In the two remaining cases, cholesteatoma pearls smaller than 3 mm were not seen. There was no false-positive case. Statistics were as follows: sensitivity 90%; specificity 100%; positive predictive value 100%; negative predictive value 92%.

CONCLUSION

When postoperative CT is not conclusive because of complete opacity of the tympanomastoid cavities, MRI with delayed postcontrast T1-weighted images is a reliable additional technique for the detection of a residual cholesteatoma when its diameter is at least 3 mm.

Does occurrence of keratinizing stratified squamous epithelium in the middle-ear cavity always indicate a cholesteatoma?

The origin and behaviour of keratinizing stratified squamous epithelium, an essential component of cholesteatoma occurring in the middle-ear cavity, has puzzled otologists for decades. In this experimental study in 16 cats, central (n = 23) and peripheral (n = 9) tympanic membrane perforations were observed for up to 63 days before sacrifice. The tympanic membranes with bony rim were excised, decalcified and embedded in Epon 812. Sections were stained with toluidine blue and examined using a light microscope. The perforation had been sealed by meatal epithelium exhibiting pronounced hyperplasia and keratin formation, lying on a bed of granulation tissue. Subtotal central perforations healed within 14 days, forming a bowl-shaped tympanic membrane and leaving parts of the handle of the malleus (with meatal epithelium) protruding freely into the middle-ear cavity. Stratified squamous epithelium, morphologically identical with that of external ear canal epidermis, could be observed on the malleus even 63 days after operation. This meatal epithelium was non-keratinizing, non-invasive, and showed no destructive properties typical of acquired cholesteatoma. During certain circumstances, the cell cycle of hyperplastic epidermal epithelium within the middle-ear cavity can evidently be arrested and inactivated by a local defence mechanism.

Unusual association of congenital middle ear cholesteatoma and first branchial cleft anomaly: management and embryological concepts

OBJECTIVE

To report two cases of an undescribed association of first branchial cleft fistula and middle ear congenital cholesteatoma and to discuss management and embryological hypothesis.

DESIGN

Retrospective study and review of the literature

RESULTS

Both patients were young girls free of past medical or surgical history. Surgical removal of the first cleft anomaly found in the two cases a fistula routing underneath the facial nerve. Both cholesteatomas were located in the hypotympanum, mesotympanum. In one case, an anatomical link between the two malformations was clearly identified with CT scan.

DISCUSSION

The main embryological theories and classification are reviewed. A connection between Aimi's and Michaels' theories (congenital cholesteatoma) and Work classification might explain the reported clinical association.

Congenital cholesteatoma

PURPOSE OF REVIEW

Congenital cholesteatomas have historically been considered a rare disorder. However, a review of the literature reveals an incidence ranging from 4 to 24%, and these values are probably underestimated. This article summarizes the general diagnostic criteria of congenital cholesteatomas, their usual presenting symptoms and findings, perioperative studies, a proposed staging system to assist with predicting postoperative outcomes, general surgical procedures, and recidivism rates.

RECENT FINDINGS

Congenital cholesteatomas have been defined as evidencing no prior history of otorrhea, tympanic perforation, or previous otologic procedures; a normal pars flaccida and tensa; and a pearly white mass medial to the tympanic membrane. Their cause remains controversial; however, the epithelial rest theory is most commonly accepted. The incidence of this disorder seems to be on the rise; however, this may be a result of increased awareness and reporting. The most common sites of presentation on physical examination are the anterior-superior and posterior-superior quadrants of the tympanic membrane. Conductive hearing loss is the most common presenting symptom. There is a lack of uniformity of reporting and classifying congenital cholesteatomas. Staging systems have recently been proposed. One in particular is reported and correlates with outcomes of treatment. Treatment of congenital cholesteatomas is still surgical. A comparison is made between canal wall up and canal wall down tympanomastoidectomy for the treatment of nonlocalized cholesteatoma pearls. Postoperative hearing results are associated with the status of the ossicular chain perioperatively.

SUMMARY

Heightened awareness and early diagnosis of congenital cholesteatomas is imperative. Early treatment decreases the extent of the disease and reduces the risk of recidivism and complications. Management of this disease is surgical. Preoperative computed tomography should be considered to assist in preoperative planning and prediction of postoperative issues. Consideration of a standard staging system and classification is important for consistent reporting and comparison.

Middle Ear Carcinoma Originating from a Primary Acquired Cholesteatoma: A Case Report

OBJECTIVES

To describe middle ear carcinoma originating from the matrix of primary acquired cholesteatoma in a 43-year-old man and to discuss the relationship between middle ear carcinoma and cholesteatoma.

STUDY DESIGN

Case report.

SETTING

Department of Otolaryngology, Head and Neck Surgery of Niigata University Medical and Dental Hospital, which is a tertiary care center, Niigata, Japan.

PATIENT

A 43-year-old man demonstrated symptoms resembling those of cholesteatoma: facial palsy, gradually progressive hearing loss, and chronic draining of the right ear. Other objective findings also supported a finding of cholesteatoma, but a computed tomographic scan and magnetic resonance imaging scan showed a well-enhanced mass and extensive bony erosion in the middle ear. At surgery, a granulous tumor in the mastoid cavity was diagnosed as squamous cell carcinoma, and closely coexisting cholesteatoma was found. Surgical specimen demonstrated carcinoma and cholesteatoma in the same field.

INTERVENTION

Radiation and chemotherapy were performed followed-up by mastoidectomy.

CONCLUSION

Because middle ear carcinoma has a poor prognosis, it is important to detect lesions early. It is necessary to consider that middle ear carcinoma arises from not only chronic otitis media or surgical invasion but also from primary acquired cholesteatoma.

[Analysis of preoperative findings and ossicular condition in chronic suppurative otitis media]

OBJECTIVE

To discussion the relationship of preoperative findings and ossicular condition in chronic suppurative otitis media.

METHOD

The correlation between the ossicular conditions and classification of tympanic membrane perforation, ear discharge, air conduction pure tone average, air-bone gap, pneumatization, complication, and cholesteatoma in 251 patients(288 ears) with chronic suppurative otitis media was analysed.

RESULT

The air-conduction threshold and air-bone gap in patients with ossicular discontinuity are higher than that in patients with ossicular continuity. Ossicular discontinuity in patients with perforation of the pars flaccida of tympanic membrane, persistently draining ears, complications, and cholesteatoma occurred significiantly more frequently than those without these conditions.

CONCLUSION

The air-conduction threshold and air-bone gap are the more reliable indications to identify the ossicular conditions in patients with chronic suppurative otitis media. There are significiant correlation between the ossicular conditions in patients with chronic otitis media and their classification of tympanic membrane perforation, ear discharge, complication, and cholesteatoma.

Traumatic Cholesteatoma Presenting as a Brain Abscess: A Case Report

OBJECTIVE

To discuss the clinical aspects and management of traumatic cholesteatomas of the temporal bone.

STUDY DESIGN

Case report.

SETTING

University hospital, tertiary referral center.

PATIENT, INTERVENTION, AND RESULTS

The authors describe an uncommon case of otogenic brain abscess resulting from an infected cholesteatoma arising from an old temporal bone fracture line involving the external auditory canal in an otherwise healthy 21-year-old man. The patient was successfully treated with brain abscess drainage, tympanomastoidectomy, and broad-spectrum intravenous antibiotic therapy.

CONCLUSIONS

The authors recommend long-term follow-up in any patient with a longitudinal or mixed temporal bone fracture with low threshold for obtaining temporal bone computer tomography imaging for any new otologic complaints. Traumatic cholesteatomas complicated by brain abscess should be treated with broad-spectrum intravenous antibiotic therapy and aggressive surgical intervention.

[Clinical study of congenital cholesteatoma of the middle ear]

We studied 35 ears of 34 patients with congenital cholesteatoma who were operated between June 1992 and May 2003, focusing on the localization and progression of congenital cholesteatoma. Patients were 2 to 55 years of age. Congenital cholesteatoma was diagnosed based on two intraoperative findings: 1) no continuity between the tympanic membrane and cholesteatoma, 2) no presence of perforation, retraction, or granulation of the tympanic membrane. All patients had closed-type cholesteatoma, and none formed open-type cholesteatoma, which grows as a flat sheet of epidermis. The primary site of congenital cholesteatoma was classified into 3 types; 1) anterior-superior quadrant, 2) posterior-superior quadrant, and 3) epitympanic, and the origin of these three types of congenital cholesteatoma was difficult to explain by a single theory. We operated on 31 ears by canal wall up tympanoplasty and on 4 ears by canal wall down tympanoplasty. On all but 4 ears, we performed planned-staged operation, including second-look operations, in case of recurrence or residual cholesteatoma. Improvement in hearing after surgery was seen in 22 of the 26 ears treated and followed up for more than 6 months after surgery. By drawing all localization of congenital cholesteatoma in 35 ears, we studied the progression of congenital cholesteatoma and speculated on the original primary site. Congenital cholesteatoma in restricted areas consequently implies good results in hearing after surgery, making earlier diagnosis and treatment desirable.

Subjective evaluation of post-tympanoplasty hearing in relation to the pure tone threshold

OBJECTIVE

In the year 2000, the Otological Society of Japan proposed a new criteria to assess the levels of hearing known as Criteria 2000. However, these criteria are intended to assess pure tone threshold after tympanoplasty and the results do not necessarily reflect the hearing condition from the patient's perspective. Thus, it is essential to study the relationship between the subjective evaluation of post-operative hearing based on the patient's own assessment and the objective assessment by audiometry.

METHODS

The present study is a questionnaire-based survey on the levels of post-operative hearing in 460 patients whose degree of satisfaction with their levels of hearing was assessed by visual analogue scale (VAS). The hearing level was assessed based on the Criteria 2000 established by the Otological Society of Japan.

RESULTS

The post-operative results indicated a success rate of 78.7%. According to the questionnaire-based survey, 64.4% patients considered their hearing as "improved". The average VAS score was the highest in the "improved" group and gradually decreased when in the "deteriorated" group. The highest success rate was obtained in patients who assessed their hearing as "improved" and the lowest rate was seen in those who assessed their hearing as "deteriorated". On the other hand, the success rate in the three groups, "slightly improved", "unchanged", and "slightly deteriorated", was almost similar and did not relate to the objective audiometry findings. Therefore, except for the "improved" and deteriorated" groups, there is no relation between the subjective self-assessment and the objective post-operative hearing.

CONCLUSION

A bi-directional approach, one from an audiological (objective) and one from the patient's perspective (subjective), especially using VAS, is quite useful for the post-operative assessment of hearing.

Brain abscess secondary to the middle ear cholesteatoma: a report of two cases

We experienced two cases of brain abscess secondary to middle ear cholesteatoma. One, a 61-year-old woman, presented with left otalgia, appetite loss and nausea. The computed tomography obtained on admission revealed a middle ear cholesteatoma. The magnetic resonance image showed the presence of a brain abscess in the cerebellum. The brain abscess was drained and the cholesteatoma was removed using the canal down procedure under general anesthesia. Part of the cholesteatoma invaded the posterior cranial fossa was could not be removed from the otological surgical field. The patient has been under observation as an outpatient for 6 months already and no abnormal signs have been detected. The other patient, a 55-year-old man, was admitted to our hospital for a detailed examination because he had right otalgia and progressive headache. The examination of spinal fluid obtained by lumbar puncture showed marked elevation of the white blood cells count. Computed tomography revealed a middle ear cholesteatoma. The magnetic resonance image obtained on admission showed an area of low-intensity encapsulated by an area of high-intensity in the right temporal lobe. The abscess was drained and the cholesteatoma was removed using the canal down procedure under general anesthesia. The patient has been under observation for 1 year already and has presented no signs of recurrence.

[Chronic otitis media]

In the presence of persistent or recurrent otorrhea with or without hearing impairment, a chronic infection of the middle ear should be suspected. Otoscopy is performed to distinguish between the less serious central perforation of the tympanic membrane and the peripheral bone-eroding infection, cholesteatoma. The diagnosis is purely clinical. Prior to an operation, a hearing test, radiography of the mastoid air cells and treatment of any infection are a must. Central perforation of the tympanic membrane is a relative indication for surgery, while in the case of a cholesteatoma complete removal of the process is mandatory to avoid potentially serious complications. Reconstruction of the ossicles takes second place in importance to complete removal of the cholesteatoma. All patients with this condition--in particular children--should be kept under surveillance over the long term.

Otologische Befunde von Erwachsenen mit isolierter Gaumenspalte oder Lippen-Kiefer-Gaumen-Spalte

BACKGROUND

Children with cleft palate often develop middle ear ventilation disorders due to chronic Eustachian tube dysfunction. This may lead to hearing loss. The insertion of ventilation tubes is a widely accepted measure to avoid sequelae of middle ear ventilation disorders and hearing loss. On the other hand, long-term therapy with ventilation tubes may inflict iatrogenic complications. The objective of the study was the evaluation of otoscopic and audiometric long-term findings in adult cleft patients who had been treated with ventilation tubes since childhood when chronic otitis media with effusion had been observed.

PATIENTS AND METHODS

Ninety-two cleft palate patients had been followed up otoscopically and audiometrically for years. The average age was 19.3 years (minimum: 14, maximum: 39 years) at the time the last status was taken.

RESULTS

Otoscopy revealed a perforation of the tympanic membrane in 3.8% of the 184 ears. 12% of the patients developed cholesteatoma, however three quarters of these occurred after age 11. 86.4% of the 92 patients had normal hearing in pure tone audiometry.

CONCLUSION

Compared with adult cleft patients who did not receive ventilation tubes, our patients had a similar low incidence of eardrum perforations but a higher incidence of cholesteatomas while hearing loss occurred less often. Whether the higher incidence of cholesteatomas is caused iatrogenically or due to a longer follow-up period remains unclear. Whether the use of long-lasting ventilation tubes affects the incidence of cholesteatomas must be proved in further studies.

A retrospective study on cholesteatoma otitis media coexisting with cholesterol granuloma

To investigate the etiology and pathogenesis of cholesteatoma otitis media accompanied by cholesterol granuloma and the relationship between cholesteatoma and cholesterol granuloma, 63 cases of middle ear cholesterol granuloma treated in our hospital during the period from March 1988 to May 2000 were retrospectively reviewed. All cases were surgically and pathologically verified. 15 cases of cholesteatoma coexisting with cholesterol granuloma were found among the 63 patients. All 15 cases had a long-term history of otitis media, such as otorrhea (sanguine purulent otorrhea and bloody otorrhea in 8 cases) and perforation of the eardrum (perforation of pars flaccida in 8 cases). Temporal bone CT scans showed cholesteatoma in 11 cases. All patients were treated surgically, and cholesteatoma and cholesterol granuloma were found coexisting alternately, the latter lying mainly in the tympanic antrum, attic and mastoid air cells. Chocolate-colored mucus was accumulated in well-developed mastoid air cells, and glistening dotty cholesterol crystals were also found. In most cases, enlarged aditus, destruction of lateral attic wall, erosion of ossicular chain, exposure of horizontal segment of facial nerve and tegmen of attic were observed. Occlusion of Eustachian tube was noted in 6 cases, and occlusion of tympanic isthmus was revealed in all cases. A post-operative dry ear was achieved in all patients, and hearing improvement was achieved in all 12 cases following tympanoplasty. Cholesteatoma and cholesterol granuloma in middle ear may share a common pathophysiological etiology: occlusion of ventilation and disturbance of drainage. The diagnosis should be considered when patients presented with chronic otitis media with bloody otorrhea. CT and magnetic resonance imaging are useful for the diagnosis before operation. The surgical approach depends on the location, extension and severity of the lesion. The purpose of surgery is to remove the lesion and create an adequate drainage.

[Myospherulosis of the middle ear -- a rare differential diagnosis of cholesteatoma]

BACKGROUND

Myospherulosis is a chronic-inflammatory lesion that is most commonly iatrogenic of origin and occurs in tissues exposed to petrolatum-based products. The disease does not exhibit characteristic symptoms and is therefore not diagnosed in some instances. In previous otorhinolaryngological studies, myospherulosis was mainly found in paranasal sinuses, while only four otitic cases have been reported.

METHODS

A 48-year-old female Egyptian patient suffered from bilateral chronic otitis media that had been treated in Egypt by tympanoplasty. The patient presented few months later at the university ENT department (Mainz) with deteriorated otorrhea and otalgia. Clinical, otoscopical, and radiological examination led to the diagnosis of cholesteatoma. During revision surgery of the right side, ointment-like material was found, which was embedded in granulation tissue. Middle ear biopsies were taken from both sides and routinely processed for standard histological examination and transmission electron microscopy.

RESULTS

Histological examination of the right middle ear biopsy showed cystic tissue spaces lined by histiocytes and foreign-body giant cells in a fibrous stroma. In the tissue spaces, scattered debris and sac-like structures containing round spherules of aggregated erythrocytes were found. In addition, erosion of adjacent bone matrix was seen. Diagnosis of myospherulosis was made. By contrast, histological evaluation of the left middle ear biopsy revealed cholesterol granuloma.

CONCLUSION

Myospherulosis of the middle ear has been hitherto diagnosed in a very few otitic cases, but might be overlooked as it mimicks other chronic proliferative and inflammatory lesions such as cholesteatoma in the present case. Thus myospherulosis should be considered in otitic cases with a suspicious history (exposure to petrolatum-based products). Furthermore, patients with myospherulosis have a significantly higher likelihood of developing postoperative complications. Since the lesion exhibits distinct histological findings, microscopy plays a central role for the diagnosis of this important disease.

[Cholesterol granuloma media: 8 cases report]

OBJECTIVE

To investigate the etiology, pathogenesis diagnosis and therapy of cholesterol granuloma media.

METHOD

Eight cases (9 ears) of middle ear cholesterol granuloma were retrospectively reviewed. Nine ears all have a speciality of conductive deafness with a light to middle level, blue eardrum and tympanogram all showing B type (except one case of eardrum perforation in the tension part). Seven cases (8 ears) were cured by tympanic cavity exploration opening epitympanum, tympanic antrum, mastoid cells and thoroughly eliminating granulation tissue. Grommet insertion and modified radical mastoidectomy were performed on 5 cases and 2 cases, respectively. The other one case was only carried out with eardrum puncture.

RESULT

Seven cases (8 ears) after operation were followed up for six monthes to six years. Six cases (7 ears) were cured out without recurring; one case (1 ear) recurred. One case was not followed up.

CONCLUSION

Otoblennorrhea of blood without obvious reason and blue eardrum should be coupled with CT to enhance the diagnosis rate before operation. CG should be treated by operation to clean disease location, air and drainage tympanicus cavity and mastoid.

Value of echo-planar diffusion-weighted MRI in the detection of secondary and postoperative relapsing/residual cholesteatoma

PURPOSE

To assess the utility of echo-planar diffusion-weighted magnetic resonance imaging (EPI-DWI) in the diagnosis of secondary cholesteatoma of the middle ear and in the differential diagnosis between residual/relapsing cholesteatoma and non-cholesteatomatous tissues (scar, granulation and inflammatory tissue) after conservative mastoidectomy.

MATERIALS AND METHODS

Twenty-four patients, who had previously undergone clinical and CT investigation, were prospectively examined by standard and EPI-DWI magnetic resonance imaging (MRI) after conservative mastoidectomy. Secondary cholesteatoma was suspected in 5 patients and residual/relapsing cholesteatoma in 19 patients. Two radiologists, blinded to patient's identity, clinical data and CT findings, reached consensus on the presence of tissue consistent with cholesteatoma in conventional CT and areas of altered signal in EPI-DWI in the petrous bone. All patients underwent mastoidectomy, second time of tympanoplasty or review surgery within 15 days from MR investigation. Sensitivity, specificity and negative and positive predictive values were evaluated separately for standard and EPI-DWI MRI.

RESULTS

In EPI-DWI sequences, 11/12 patients with cholesteatoma showed an area of hyperintense signal, whereas patients with non-cholesteatomatous tissue showed no pathologic signal in the petrous bone. In the single case of cholesteatoma undetected on EPI-DWI a cholesteatomatous pearl approx. 2 mm in diameter was visible in the surgical cavity. Sensitivity, specificity, positive and negative predictive values were 92%, 100%, 100%, 92% for EPI-DWI MRI and 92%, 25%, 55%,75% for standard MRI, respectively.

CONCLUSIONS

EPI-DWI sequences are useful in the diagnosis of secondary cholesteatoma and in the differential diagnosis between residual/relapsing cholesteatoma and non-cholesteatomatous tissues after conservative mastoidectomy. However, the usefulness of EPI-DWI sequences as a screening test after conservative mastoidectomy requires further assessment.

Paraganglioma presenting as chronic otitis media with cholesteatoma: pitfalls and strategies

The coexistence of paraganglioma with cholesteatoma is a very rare clinical disorder. The clinical presentations are nonspecific. There may be radiological characteristics of either cholesteatoma or paraganglioma in the middle ear area, but the diagnosis of the coexistence of the 2 is usually made only postoperatively. Here is such a case that is made more interesting not only because it initially presented with conductive hearing loss but also because the clinical picture mimicked chronic otitis media. The patient underwent postauricular tympanomastoidectomy with extended facial recess approach to remove the tumor. No evidence of recurrence and complications were noted.

Recognize cholesteatomas early

Cholesteatomas are benign tumors that develop in the middle ear, and their rapid growth patterns can impinge on local structures, resulting in adverse sequelae such as hearing loss, pain, or neuropathies. These late signs and symptoms can be avoided by early identification and prompt intervention. Primary care providers should be aware of the incidence, prevalence, identification, and associated symptoms of cholesteatomas to reduce the later untoward affects and promote prompt referral.

Canal wall down tympanoplasty surgery with or without ossiculoplasty in cholesteatoma: hearing results

Aim of the study was to evaluate the functional results, in two homogeneous groups, for severity of the disease, submitted to canal-wall-down tympanoplasty (TPL CWD), with and without ossiculoplasty. A total of 60 patients who underwent canal-wall-down tympanoplasty for cholesteatoma were evaluated: 31 underwent ossiculoplasty (group A) and 29 classic Wullstein type III and IV operation (group B). Hearing results were evaluated 2 years after surgery according to the AAO-HHS guidelines. Pre-operative audiometrics revealed an air conduction PTA (AC-PTA) of 45.12 dB in group A, and 56.25 dB in group B. Bone conduction PTA (BC-PTA) was 16.86 dB in group A and 26.06 in group B. Two years after surgery, AC-PTA was 42.98 dB in group A and 58.65 dB in group B; BCPTA was 18.79 dB in group A and 25.13 dB in group B. The mean pre-operative ABG was 28.44 dB in group A and 30.14 dB in group B. Two years after surgery, group A showed a mean ABG of 24.06 and group B of 35.54 dB, the difference between the two groups was significant (p = 0.03). In conclusion, the functional results observed in the present study support the need to reconstruct the ossicular chain in canal-wall-down tympanoplasty, in fact, ossiculoplasty is associated with a better hearing gain than the classic Wullstein operations.

Imaging of the postoperative middle ear

The aim of this article is twofold: (a) to present the principles and the indications of surgical treatment of middle ear pathologies; and (b) to review the imaging findings after middle ear surgery, including the normal postoperative aspects and imaging findings in patients presenting with unsatisfactory surgical results or with suspicion of postoperative complications. This review is intentionally restricted to the most common diseases involving the middle ear: chronic otitis media and otosclerosis. In these specific fields of interest, CT and MR imaging play a very important role in the postoperative follow-up and in the work-up of surgical failures and complications.

Endoscope Affects Decision Making in Cholesteatoma Surgery

OBJECTIVE: The aim of the present study was to evaluate the use of intraoperative otoendoscopy as a factor that could influence surgical decisionmaking in cholesteatoma surgery.

MATERIALS AND METHODS: The material of this study included 82 ears with acquired cholesteatoma that were operated on. They were divided into 4 groups according to the surgical technique chosen and the use of the endoscope. Group I included 22 ears that underwent canal wall-down (CWD) tympanomastoid surgery, group II included 20 ears that underwent CWD tympanomastoid surgery with intraoperative use of endoscopy, group III included 20 ears that underwent canal wall-up (CWU) tympanomastoid surgery, and group IV included 20 ears that underwent CWU tympanomastoid surgery with intraoperative use of endoscopy. Endoscopy was used as a complementary tool to microscopy. The follow-up period ranged from 12 to 48 months.

RESULTS: Intraoperative remnants of cholesteatoma matrix were detected during both CWU and CWD by the use of the rigid endoscope. However, its incidence was higher in the CWU group (50%) than in the CWD (30%) group. Most of these remnants were in the sinus tympani (37.5%). The mean duration of follow-up was 18.19 (±8.7) months. Postoperative residual cholesteatoma was much higher in the CWU group (25%) than in the CWD group (5%). All residuals were from groups of patients in whom intraoperative endoscopy was not used in the primary surgery.

CONCLUSION: Our results showed that the use of the endoscope gave the surgeon better control over the pathology, thus achieving better eradication. Stated differently, the use of the endoscope raised the surgeon's confidence level about total removal and thus encouraged the surgeon to keep the canal wall intact while removing cholesteatoma in hidden areas. Therefore, the use of endoscope could be considered an additional tool that may affect decision-making in cholesteatoma surgery.

[Unusual case of the ear cholesteatoma]

The authors present a case of temporal and occipital bone extensive destruction with epidural abscess of posterior cranial cavity and abscess of occipito-nuchal region created by giant cholesteatoma of the middle ear. There has been discussed a diagnosing troubles as well as performed surgical treatment.

A case of giant cholesteatoma extending to the posterior fossa

We present a 43-year-old male patient who developed a giant cholesteatoma with lateral sinus obliteration and involvement of the posterior cranial fossa. The only complaints were left-sided aural discharges and total sensorineural hearing loss. Examination revealed a mass lesion consistent with cholesteatoma within the left middle ear. Computed tomography and magnetic resonance imaging showed an extensive acquired cholesteatoma in the left middle ear, invading the posterior cranial fossa and leading to lateral sinus obliteration. The patient underwent left radical mastoidectomy. He had an uneventful postoperative follow-up for 13 months. This case emphasizes the value of preoperative radiologic assessment of giant cholesteatomas that may present with relatively few or limited symptoms.

[The role of high-resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) in the diagnosis of preoperative and postoperative complications caused by acquired cholesteatomas]

The role of high-resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) in the diagnosis of preoperative and postoperative complications caused by acquired cholesteatomas will be described in this paper. The pre- and postoperative imaging of the temporal bone was performed with HRCT and MRI.HRCT and MRI were performed in the axial and coronal plane. MRI was done with T2 weighted and T1 weighted sequences both before and after the intravenous application of contrast material. All imaging findings were confirmed clinically or surgically. The preoperative cholesteatoma-caused complications depicted by HRCT included bony erosions of the ossicles, scutum, facial canal in the middle ear, tympanic walls including the tegmen tympani, and of the labyrinth. The preoperative cholesteatoma-caused complications depicted by MRI included signs indicative for labyrinthitis, and brain abscess. Postoperative HRCT depicted bony erosions caused by recurrent cholesteatoma,bony defects of the facial nerve and of the labyrinth, and a defect of the tegmen tympani with a soft tissue mass in the middle ear. Postoperative MRI delineated neuritis of the facial nerve, labyrinthitis, and a meningo-encephalocele protruding into the middle ear. HRCT and MRI are excellent imaging tools to depict either bony or soft tissue complications or both if caused by acquired cholesteatomas. According to our findings and to the literature HRCT and MRI are complementary imaging methods to depict pre- or postoperative complications of acquired cholesteatomas if these are suspected by clinical examination.

Relationship of preoperative findings and ossicular discontinuity in chronic otitis media

BACKGROUND

Ossicular discontinuity may result from chronic otitis media, with or without cholesteatoma, and usually cannot be determined unless an operation is performed. If preoperative information can be used to determine whether or not the ossicular chain is intact, the patient can be better informed and the surgeon can be better prepared before surgery.

OBJECTIVE

To examine the correlation between preoperative findings and the status of the ossicular chain at surgery.

STUDY DESIGN

Retrospective.

SETTING

A tertiary referral center.

PATIENTS

Data from 190 patients (212 ears) who were undergoing their first operations for chronic otitis media were reviewed.

INTERVENTION

The operations for the cholesteatoma or noncholesteatoma ears were classified into different groups and analyzed separately. Ossicular discontinuity was identified only if the discontinuity of the ossicular chain was confirmed at the time of operation.

RESULTS

The cholesteatoma group consisted of 59 ears, and the noncholesteatoma group contained 153 ears. In the cholesteatoma group, two statistically significant preoperative parameters were observed to be significantly correlated with ossicular discontinuity: persistently draining ears (p = 0.026) and a cholesteatoma that extended to the tympanic sinus (p = 0.006). In the noncholesteatoma group, only one parameter was observed to be predictive of ossicular discontinuity. In this group of patients, perforation of the tympanic membrane with an edge adherent to the promontory occurred significantly more frequently in patients with ossicular discontinuity (p = 0.004) than in those with intact ossicular chains. Surprisingly, an air-bone gap was not significantly correlated with ossicular discontinuity. The cholesteatoma and granulation tissue in the middle ear cavity may serve as transmission bridges of acoustic energy, resulting in narrowed air-bone gaps.

CONCLUSIONS

In the cholesteatoma group, both cholesteatoma extension into the tympanic sinus and persistently draining ears were predictive of ossicular discontinuity. In the noncholesteatoma group, perforation edges adhering to the promontory also revealed a higher incidence of ossicular discontinuity. Therefore, all these findings can be considered as potential preoperative predictors of ossicular discontinuity in chronic otitis media.

[Retrospective results of radiation therapy of the eustachian tube in chronic otitis media]

BACKGROUND

The treatment results of symptomatic radiation therapy of the Eustachian tube in chronic otitis media had to be evaluated retrospectively.

PATIENTS AND METHODS

Between 1980 and 1997, 66 patients were referred for therapy. The median age was 58 years. In the clinical presentation, all the patients had a hearing impairment, 35 patients complained of pain, 21 had otorrhea. In their history, 20 patients indicated chronic recurrent infections. The complaints lasted for 4.7 years in the median, primary conservative (adstringentia, antibiotics) and surgical treatment (paracentesis, tympanic tubule, tympanoplastic) did not lead to lasting cure. In 40 of 66 patients, finally radiation therapy was done of both Eustachian tubes. With opposed fields and cobalt-60 photons a total dose of 6 Gy at single doses of 1 Gy, three times a week, was applied. Under the causes for exclusion of radiation therapy were non-acceptance of the patients (nine), prior radiation therapies (six) or spontaneous improvement after initial presentation in our department. The treatment results were evaluated by interviews of the patients and regular otorhinolaryngological examinations.

RESULTS

There were no side effects noticed. 28 of 40 (70%) patients reported a significant improvement that could be verified by objective otorhinolaryngological examinations. In the group of 26 nonirradiated patients, 22 could be interviewed indicating in 16 cases (72%) that the complaints were unchanged and chronic otitis media was lasting. In a subgroup analysis concerning the duration of otitis media radiation therapy proved more effective in an acute and subacute stadium of disease of up to 5 years duration, while the patients resistant to radiation therapy were entirely in a chronic stage of disease exceeding 5 years duration.

CONCLUSIONS

Radiation therapy is an effective tool for symptomatic improvement of the therapy-resistant chronic otitis media. A dose of 6 Gy seems to be sufficient to achieve an antiinflammatory effect. Radiotherapy should be applied earlier after initial conservative and surgical treatment.

[Invasive cholesteatoma of the old radical mastoidectomy]

OBJECTIVE

The aim of this study is to show the importance of computed tomography scanning (CT) and magnetic resonance imaging (MRI) in ancient radical cavities and to determinate the risk factors of an invasive cholesteatoma recurrency.

MATERIAL AND METHOD

We present 4 cases of medial invasion in the petrous bone of a cholesteatoma without specific symptomatology which appeared many years after undergoing radical mastoidectomy for an acquired cholesteatoma.

CONCLUSION

The analysis of this series allowed to put in evidence the factors of suspicion of an underlying cholesteatoma. They are: the age, an aural discharge, numerous surgical interventions, immunodeficiency, cholesteatoma in childhood and antecedent of facial nerve palsy. This trial emphasizes the importance of imaging (CT and MRI) in front of an ancient radical cavity which presents one or some of these factors in order to eliminate a recurrence of an invasive cholesteatoma. Let us note that the demand of the patients is sometimes aesthetic or functional.

Detection of postoperative residual cholesteatoma with delayed contrast-enhanced MR imaging: initial findings

Our objective was to assess the value of delayed contrast-enhanced T1-weighted spin-echo MR imaging in the detection of residual cholesteatoma in patients who have undergone canal wall-up tympanoplasty procedure. The MR imaging was obtained prior to revision surgery in 18 patients with opacity of the post-operative cavity at CT examination 12-18 months after canal wall-up tympanoplasty. In each patient the following was performed: precontrast T1- and T2-weighted images; and early and delayed contrast-enhanced axial and coronal T1-weighted imaging. Early and delayed MR imaging results were separately compared with surgical second-look findings. Sensitivity, specificity, and predictive values were evaluated for early and delayed post-contrast MR imaging, compared with second-look surgery findings. A residual cholesteatoma was correctly identified in 8 of 9 cases with delayed contrast-enhanced T1-weighted MR imaging. Mean sensitivity, specificity, positive predictive value, and interobserver agreement (evaluated by kappa statistics) were, respectively, 85.2, 92.6, 92.6%, and kappa=0.78 for the delayed contrast-enhanced MR imaging technique. The same parameters were, respectively, 96.3, 33.3, 60.6, and 0.30 for the early contrast-enhanced T1-weighted MR images. We conclude that delayed contrast-enhanced T1-weighted MR imaging is reliable for the detection of residual cholesteatomas of the middle ear in patients who have undergone canal wall-up tympanoplasty.

Fibromyxoma of the middle ear (a case report)

Fibromyxoma of the middle ear (a case report). We report an extremely rare case of fibromyxoma of the middle ear which was first suspected to be a cholesteatoma. Surgery was performed through a postauricular incision and pathologic study of the tumor gave us the final diagnosis. Fibromyxoma is an uncommon benign tumour of the head and neck region which usually arises in the jaw (1). Its local aggressivity and gelatinous consistency explain the difficulties to remove it radically and its frequent recurrences after treatment (2). Surgical resection with a wide excision seems to be the treatment of choice. Some authors advocate the use of Argon or CO2 laser to achieve the treatment. A review of the poor literature about this subject is discussed in this article.

[Missed diagnostic cholesteattomaous otitismedia]

OBJECTIVE

To explore the missed diagnostic cholesteattomaous otitismedia lacked of clinical symptoms in order to minimize the mistake in clinical diagnose.

METHODS

A retrospective study of 31 cases with the missed diagnostic cholesteattomaous otitismedia, confirmed by surgery and pathology, was conducted.

RESULTS

Twenty-one cases (67.7%) had not obvious otorrhea. There were only slight finding such as attic retraction, apophysis, small granulation tissue, ear wax covered or tiny, even non, perforation in the pars flaccida or the superior and posterior pars tensa of the ear-drum. In general, the hearing loss is slight or medium conductive deafness. The type B curve was showed in tympanogram. The diagnosis rate of X-ray was only 41.9%, and 80.7% for the computed tomography. The middle ear structures aggressed by cholesteames was epitympanum, ossicular chain, tympanic antrum, mastoid process and mesotympanum. The complications occurred in 11 cases (35.5%) were the expose of facial nerve or and the meninges, or, and the labyrinth fistula.

CONCLUSION

The cases with the cholesteatoma lack obvious clinic symptoms would result in the missed diagnosis because of slow and long term during cholesteatoma development. Sometimes misdiagnosed or missed diagnosis happened to in such cases of cholesteatoma with little clinical manifestation, and it is so dangerous for the patients in such case. Therefore, otolaryngologist must pay more attention to the missed diagnostic cholesteattomaous otitismedia.

Diffusion-weighted imaging for differentiating recurrent cholesteatoma from granulation tissue after mastoidectomy: case report

Identification of recurrent cholesteatoma and differentiation from postoperative granulation tissue is important in a patient who has undergone mastoidectomy for cholesteatoma. We describe the diffusion-weighted imaging findings and apparent diffusion coefficient values in a case of recurrent cholesteatoma. This case suggests possible differentiation of cholesteatoma from granulation tissue on the basis of diffusion-weighted imaging findings.

[Results after rebuilding the ossicular chain using the autogenous incus, ionomer-cement-and titanium implants (tympanoplasty type III)]

BACKGROUND

A defective ossicular chain can reliably be reconstructed with standardized techniques using e. g. modern alloplastic materials. The comparison of clinical and functional results have proved its worth. Prospective clinical trial as well as collecting and evaluating relevant intraoperative and postoperative findings may be helpful to find the appropriate bone substitute in each case when rebuilding middle ear structures.

METHOD

In 354 middle ears (332 patients) the defective or destroyed ossicular chain was rebuilt with the carefully trimmed autogenous incus (n = 83), with ionomer-cement implants (n = 100) and with titanium prostheses (n = 171). The follow-up of the earmicroscopic findings and middle ear function extended over a period of 1.5 years postoperatively on an average (min. 3 months, max. 6 years). The modified otologic record form named "Würzburger Ohrbogen" was used for preoperative and operative data, the "Ohrnachsorgebuch" for the postoperative follow-up.

RESULTS

Using incus the air bone gap was improved up to 15 dB in the main speech area. Thus the average remaining conduction deficit was less than 10 dB. The "taking" of ionomer based cement prostheses and titanium prostheses was equally good. The cement implants showed a tendency to protrusion (n = 3), 2 titanium implants were extruded. The air bone gap decreased about 10 to 35 dB using titanium total prosthesis and about 15 to 20 dB using ionomer-cement total prosthesis. The remaining air bone gap with titanium implants was slightly less than with the ionomer-cement PORP (10-15 dB). The air bone gap using the titanium TORP was diminished in a reach of 10 to 35 dB, with the ionomer cement prosthesis between 15 to 20 dB. The remaining gap in the main speech area was slightly favorable to titanium (less than 15 dB) compared with the ionomer-cement TORP. Comparing higher frequencies the air bone gap of titanium was recognizable due to its light weight, but less impressive than expected. Revision surgery (n = 50) has to be performed by reason of cholesteatoma (n = 9), adhesive process (n = 8), dislocation of alloplastic prostheses (n = 8) and because of proposed "second look" (n = 14).

CONCLUSIONS

Compared with other materials autogenous implants used for reconstruction of the incus have proved their value, however a deterioration of the sound transmission may develop in the long run. The middle ear compatibility of ionomer-cement implants is similar to titanium implants. The functional results of the titanium implants seem to be slightly superior.

Chronic silent otitis media

Otitis media occurs along a continuum. For example, otitis media with effusion characterized by fluid pathology can lead to chronic otitis media plus chronic mastoiditis, characterized by the presence of intractable tissue pathology such as cholesteatoma, cholesterol granuloma or granulation tissue. The literature defines chronic otitis media as having a tympanic membrane perforation and otorrhea. Amongst many other sequelae, which can result from the continuum, an important common one is chronic silent otitis media. This overlooked entity which includes pathology beneath an intact tympanic membrane is commonly seen in our human temporal bone laboratory and in patients. The clinical pathological correlates of this important disease are discussed herein.

[Congenital cholesteatoma in children--case reports]

The authors present three cases of congenital cholesteatoma in children. In two cases primary surgery was curative, in third patient one year after first surgery the residual cholesteatoma was diagnosed, and second surgery was performed. Finally in all cases good anatomical and functional effect was obtained. The natural history of congenital cholesteatoma, as well as surgical techniques which can be applied depending on type and location of congenital cholesteatoma are discussed. The authors emphasise the importance of early recognition of the disease. Exploratory tympanotomy, or CT scan should be applied in all cases where suspected changes are observed during otoscopy.

[The enlargement of the meatal entrance in canal-wall-down operations]

BACKGROUND

The canal-wall-down operation may narrow the meatal entrance.

METHODS

By means of excision of skin from the cavum conchae and conchal cartilage an adequate-sized meatus can be created.

RESULTS

17 children were treated in case of cholesteatoma with canal-wall-down operation and metoplasty. The meatal entrance was sufficiently enlarged in all patients.

CONCLUSIONS

The presented metoplasty supplies good functional and cosmetic results.

Congenital middle ear cholesteatomas in children: our experience in 34 cases

OBJECTIVES

To evaluate clinical data, extensions, residual disease rate, and functional results in cases of congenital cholesteatoma in pediatric patients compared with cases of acquired forms.

STUDY DESIGN AND SETTING

In a retrospective study conducted at a single tertiary care center over a decade, 34 congenital cholesteatomas (mean patient age, 6.6 years) isolated from a series of 215 cholesteatomas in children were treated surgically and followed up for an average of 83 months. Surgical treatment consisted of the closed technique (CT), open technique tympanoplasty in CT [TOT], radical mastoidectomy (RM), or Rambo's technique. The main outcome measures were surgical findings, residual lesion rate, and hearing assessment.

RESULTS

The first surgical procedure was CT in 85.3%, TOT in 8.8%, RM in 2.9%, and Rambo's technique in 2.9% of patients. Two, 3, and 4 operations were necessary in 76.5%, 11.4%, and 11.4% of children, respectively. Residual lesions were observed in 34.6% of those multi-operated patients (7 CT and 2 TOT), 24.1% in those treated with CT, and 29.2% in those treated with CT with a planned second look. Mean postoperative pure tone average and air-bone gap were 26 and 21 dB, respectively. A speech reception threshold of less than 30 dB HL was achieved in 66% of patients. A total of 26 ossiculoplasties had to be performed (8 partial and 18 total); the mean postoperative air-bone gap was lower after the former (15 dB) than after the latter (22 dB). A high-frequency pure-tone hearing loss of more than 10 dB was uncommon (5.8%). Unsurprisingly, the residual lesion rate seems to be higher for congenital than for acquired cholesteatomas, but hearing results are significantly better.

CONCLUSION

In most cases, staged CT appears to be the best technique to treat these lesions, which often develop in a well-pneumatized mastoid.

Congenital cholesteatoma of the tympanic membrane

We present two cases of congenital cholesteatoma of the tympanic membrane. Congenital cholesteatoma within the tympanic membrane is a rare entity with only few cases documented. The aetiopathogenesis of this lesion is still unknown. An embryologic origin is hypothesized when cholesteatoma develops in patients without previous history of otitis as in the two cases we report. In cases with previous history of inflammatory process of the external or middle ear an acquired origin is suspected due to the proliferation of the basal cell layer of the tympanic membrane epithelium. Despite the rarity of the congenital tympanic membrane cholesteatoma, we think that its early diagnosis is of utmost importance to allow an easy removal and avoid middle ear involvement.