MRI for the diagnosis of recurrent middle ear cholesteatoma in children--can we optimize the technique? Preliminary study

Non-echo Planar Diffusion-Weighted Imaging in the Detection of Recurrent or Residual Cholesteatoma: A Systematic Review and Meta-Analysis of Diagnostic Studies

We performed a systematic review and meta-analysis of patients with suspected recurrent cholesteatoma who underwent non-echo planar imaging (non-EPI) using diffusion-weighted magnetic resonance imaging (MRI), with surgery as the reference standard. We searched Medline, Google Scholar, and the Cochrane database for diagnostic test accuracy studies. The following prespecified subgroup analyses were performed: patient age, number of radiologists interpreting MRI, study design, and risk of bias. We used a bivariate model using a generalized linear mixed model to pool accuracies. Of the 460 records identified, 32 studies were included, of which 50% (16/32) were low risk of bias. The overall pooled sensitivity was 92.2% (95% CI 87.3-95.3%), and specificity was 91.7% (85.2-95.5%). The positive likelihood ratio was 11.1 (4.5-17.8), and the negative likelihood ratio was 0.09 (0.04-0.13). The pooled diagnostic odds ratio was 130.3 (20.5-240). Heterogeneity was moderate on visual inspection of the hierarchical summary receiver operating characteristic curve. Subgroup analyses showed prospective studies reporting higher accuracies (p=0.027), which were driven by higher specificity (prospective 93.1% (88.4-96.0%) versus retrospective 81.2% (81.0-81.4%)). There was no difference in subgroups comparing patient age (p=0.693), number of radiologists interpreting MRI (p=0.503), or risk of bias (p=0.074). No publication bias was detected (p=0.98). In conclusion, non-EPI is a highly sensitive and specific diagnostic test able to identify recurrent cholesteatomas of moderate to large sizes. This test can be considered a non-invasive alternative to second-look surgery.

Diffusion-weighted magnetic resonance imaging for diagnosis of post-operative paediatric cholesteatoma

OBJECTIVES

High rates of recidivism are reported after paediatric cholesteatoma surgery. Our practice has adapted to include non-echoplanar diffusion-weighted magnetic resonance imaging for the diagnosis of residual or recurrent cholesteatoma. This audit aimed to evaluate the performance of non-echoplanar diffusion-weighted magnetic resonance imaging in our paediatric population.

METHODS

A retrospective review was conducted of non-echoplanar diffusion-weighted magnetic resonance imaging scans performed to detect residual disease or recurrence after surgery for cholesteatoma in children from 1 January 2012 to 30 November 2017 in our centre. Follow-up diffusion-weighted magnetic resonance imaging scans were reviewed to 16 August 2019.

RESULTS

Thirty-four diffusion-weighted magnetic resonance imaging scans were included. The sensitivity and specificity values of diffusion-weighted magnetic resonance imaging for detecting post-operative cholesteatoma were 81 per cent and 72 per cent, respectively. Positive predictive and negative predictive values were 72 per cent and 81 per cent, respectively.

CONCLUSION

Use of diffusion-weighted magnetic resonance imaging is recommended as a replacement for routine second-look surgical procedures in the paediatric population. However, we would caution that patients require close follow up after negative diffusion-weighted magnetic resonance imaging findings.

Pearls of Temporal Bone Imaging in Children with Hearing Loss

Hearing loss is one of the most common indications for temporal bone imaging in children. Hearing loss may be congenital or acquired, and it may be conductive, sensorineural, or mixed audiologically. Temporal bone imaging plays an important role in the assessment and management of this condition. An understanding of the embryology of ear structures better enables the radiologist to interpret abnormalities on imaging of the temporal bone. Here, we provide a general review of ear development and a description of known genetic defects that contribute to congenital ear anomalies associated with hearing loss. We provide appropriate imaging techniques for the temporal bone depending on the clinical presentation and a systematic approach to imaging for children with hearing loss. Diagnostic imaging for developmental anomalies of the ear and cholesteatoma will be discussed.

Non-EPI versus Multishot EPI DWI in Cholesteatoma Detection: Correlation with Operative Findings

BACKGROUND AND PURPOSE

Although multishot EPI (readout-segmented EPI) has been touted as a robust DWI sequence for cholesteatoma evaluation, its efficacy in disease detection compared with a non-EPI (eg, HASTE) technique is unknown. This study sought to compare the accuracy of readout-segmented EPI with that of HASTE DWI in cholesteatoma detection.

MATERIALS AND METHODS

A retrospective review was completed of consecutive patients who underwent MR imaging for the evaluation of suspected primary or recurrent/residual cholesteatomas. Included patients had MR imaging examinations that included both HASTE and readout-segmented EPI sequences and confirmed cholesteatomas on a subsequent operation. Two neuroradiologist reviewers assessed all images, with discrepancies resolved by consensus. The ratio of signal intensity between the cerebellum and any observed lesion was noted.

RESULTS

Of 23 included patients, 12 (52.2%) were women (average age, 47.8 [SD, 25.2] years). All patients had surgically confirmed cholesteatomas: Six (26.1%) were primary and 17 (73.9%) were recidivistic. HASTE images correctly identified cholesteatomas in 100.0% of patients. On readout-segmented EPI sequences, 16 (69.6%) were positive, 5 (21.7%) were equivocal, and 2 (8.7%) were falsely negative. Excellent interobserver agreement was noted between reviews on both HASTE (κ = 1.0) and readout-segmented EPI (κ = 0.9) sequences. The average signal intensity ratio was significantly higher on HASTE than in readout-segmented EPI, facilitating enhanced detection (mean difference 0.5; 95% CI, 0.3-0.8; P = .003).

CONCLUSIONS

HASTE outperforms readout-segmented EPI in the detection of primary cholesteatoma and disease recidivism.

Identification of risk factors for residual cholesteatoma in children and adults: a retrospective study on 110 cases of revision surgery

Introduction

Residual disease after cholesteatoma removal is still a challenge for the otorhinolaryngologist. Scheduled “second-look” surgery and, more recently, radiological screenings are used to identify residual cholesteatoma as early as possible. However, these procedures are cost-intensive and are accompanied by discomfort and risks for the patient.

Objective

To identify anamnestic, clinical, and surgery-related risk factors for residual cholesteatoma.

Methods

The charts of 108 patients, including children as well as adults, having undergone a second-look or revision surgery after initial cholesteatoma removal at a tertiary referral hospital, were analyzed retrospectively.

Results

Gender, age, mastoid pneumatization, prior ventilation tube insertion, congenital cholesteatoma, erosion of ossicles, atticotomy, resection of chorda tympani, different reconstruction materials, and postoperative otorrhea did not emerge as statistically significant risk factors for residual disease. However, prior adenoid removal, cholesteatoma growth to the sinus tympani and to the antrum and mastoid, canal-wall-up 2 ways approach, and postoperative retraction and perforation were associated with a statistically higher rate of residual disease. A type A tympanogram as well as canal-wall-down plus reconstruction 2 ways approach for extended epitympanic and for extended epitympanic and mesotympanic cholesteatomas were associated with statistically lower rates of residual disease. A score including the postoperative retraction or perforation of the tympanic membrane, the quality of the postoperative tympanogram and the intraoperative extension of the cholesteatoma to the sinus tympani and/or the antrum was elaborated and proved to be suitable for predicting residual cholesteatoma with acceptable sensitivity and high specificity.

Conclusion

Cholesteatoma extension to the sinus tympani, antrum and mastoid makes a residual disease more likely. The canal-wall-down plus reconstruction 2 ways approach seems safe with similar rates of residual cholesteatoma and without the known disadvantages of canal-wall-down surgery. The described score can be useful for identifying patients who need a postoperative radiological control and a second-look surgery.

Diffusion-weighted magnetic resonance imaging in the detection of residual and recurrent cholesteatoma in children: A systematic review and meta-analysis

OBJECTIVE

To examine the performance of diffusion-weighted magnetic resonance imaging (DW-MRI) in the detection of residual and recurrent cholesteatoma in children.

METHODS

A systematic review and meta-analysis was conducted as per PRISMA guidelines using the following databases from their date of inception: MEDLINE, PubMed, Embase, Cochrane Library, Web of Science. Bivariate meta-analysis using a random effects model was used to calculate summarized pooled estimates of sensitivity, specificity, and diagnostic odds ratios, using second-look surgery as the gold standard comparison.

RESULTS

A total of ten articles (141 cases) were included for qualitative and quantitative analysis. Pooled sensitivity and specificity of non-echo planar imaging (non-EPI) DW-MRI were 89.4% (95%CI 51.9%-98.5%) and 92.9% (95%CI 81.4%-97.5%) respectively. DW-MRI appears limited in its ability to detect lesions less than 3 mm in size.

CONCLUSION

Non-EPI DW-MRI is highly specific but carries uncertain sensitivity in the detection of residual and recurrent cholesteatoma in children. Further research is warranted to determine the specific role of DW-MRI in this patient group, namely when and how often children should be referred for imaging and in which cases the method can be used to completely replace second-look surgery.

Diffusion weighted imaging for the detection and evaluation of cholesteatoma

Cholesteatoma is a collection of keratinous debris and stratified squamous epithelium. It is trapped in the middle ear and can lead to bony erosion. The disease is treated surgically often followed by a second-look procedure to check for residual tissue or recurrence. Cholesteatoma has specific signal-intensity characteristics on magnetic resonance imaging with very high signal intensity on diffusion weighted imaging (DWI). Various DWI techniques exist: Echo-planar imaging (EPI)-based and non-EPI-based techniques as well as new approaches like multi-shot EPI DWI. This article summarizes all techniques, discusses the significance in detecting cholesteatoma and mentions actual studies. Further recommendations for daily clinical practise are provided.

Comparing diffusion weighted MRI in the detection of post-operative middle ear cholesteatoma in children and adults

INTRODUCTION

There is a limited evidence base for the use of diffusion weighted MRI (DWMRI) in the assessment of post-operative cholesteatoma in children. This is important to address as this technique is particularly relevant in a paediatric setting.

METHODS

We searched a prospectively collected database of patients undergoing DWMRI for the assessment of residual and recurrent cholesteatoma. Imaging findings were correlated with findings at revision surgery. 320 investigations were divided into paediatric and adult groups (90 in children, 230 in adults) and compared.

RESULTS

Operative findings were available for 158 cases, of which 54 were children. The accuracy of DWMRI in children was 96.3%, and in adults was 88.5%. There were no statistically significant differences in the sensitivity, specificity, positive or negative predictive values between adults and children.

DISCUSSION

An increasing number of patients are not undergoing confirmatory surgery after negative DWMRI scans. False negative results are commonly secondary to small foci of disease; false positives have several possible causes. Performing MRI on children can be challenging, but sedation may be helpful in younger children.

CONCLUSION

The performance of diffusion weighted MRI is similar in paediatric and adult settings. This study suggests that DWMRI may be used in clinical practice in a similar way in children and adults.

Diagnostic accuracy of diffusion-weighted MR imaging versus delayed gadolinium enhanced T1-weighted imaging in middle ear recurrent cholesteatoma: A retrospective study of 39 patients

OBJECTIVE

MR imaging using diffusion-weighted (DW) images and delayed gadolinium-enhanced T1-weighted images is evolving into an alternative to second look surgery in detection of recurrent cholesteatomas. The aim of this study was to retrospectively compare the DW images, the post-gadolinium T1-weighted images and the combination of both methods in this indication.

PATIENTS AND METHODS

We retrospectively evaluated the MR examination of 39 patients clinically suspected for a recurrent cholesteatoma. Patients in the study underwent DW sequences, delayed gadolinium enhanced T1-weighted sequences as well as standard uninjected protocol using T1 and T2 sequences. Three blinded radiologists evaluated three data sets: a set of post-gadolinium T1-weighted images, a set of DW images and a set of the combination of both methods. The interobserver agreement was evaluated and the diagnostic accuracy of each method was described by sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The performances of the three techniques were also evaluated using ROC curves, from which the AUC were compared. Results were compared with surgical results or a two-year follow-up.

RESULTS

The overall sensitivity and specificity were respectively 63% and 71% for the post-gadolinium T1-weighted images, 88% and 75% for the DW images and 84% and 75% for the combined images. The PPV and NPV were respectively 89% and 33% for the post-gadolinium T1-weighted images, 93% and 62% for the DW images and 93% and 55% for the combined images. The sensitivity and the NPV were significantly different between the three methods (P<0.0001 and P=0.027). There was no statistically significant difference in specificity or PPV between the three methods (P=0.931 and P=0.650). The diagnostic accuracy evaluated with the AUC showed no statistically significant difference between the DW images and the combined images (P=0.433).

CONCLUSION

MR imaging reliably identifies those patients suspected for recurrent cholesteatoma who require a surgical second look by using DW MR imaging. The combination with delayed gadolinium enhanced T1-weighted sequences does not significantly increase the diagnostic accuracy of the examination.

Magnetic resonance imaging at one year for detection of postoperative residual cholesteatoma in children: Is it too early?

OBJECTIVE

To compare the residual cholesteatoma detection accuracy of diffusion-weighted (DW) and T1 delayed sequences for magnetic resonance at one year postoperative with second-look surgery in pediatric patients who have undergone primary middle ear surgery for cholesteatoma.

METHODS

This was a prospective monocentric consecutive study conducted in a tertiary academic referral center. Children were referred for MR imaging (MRI) one year after surgery. A 1.5T MRI was utilized, using nonecho-planar DW images and delayed gadolinium-enhanced T1-weighted images. Accuracy of magnetic resonance imaging was assessed by two radiologists before surgery. Interobserver and intraobserver agreements were assessed using the κ test. Magnetic resonance imaging data were compared with surgery, which was considered as the gold standard.

RESULTS

Twenty-four consecutive unselected pediatric patients were included. Sensitivity, specificity, positive predictive value, and negative predictive value for the first observer were of 40%, 86%, 67%, and 67%, respectively, and those for the second observer were 30%, 86%, 60%, and 63%, respectively. The only two cholesteatoma with a size superior to 3mm were diagnosed before surgery, but the majority of small cholesteatoma were not detected.

CONCLUSIONS

MRI is a key examen to diagnosed the residual cholesteatoma but is limited by the size of the lesion under 3mm. Delaying the realization of MRI during follow-up could increase sensitivity, thus avoiding misdiagnosis as well as unnecessary second look surgery.

Non-echoplanar diffusion-weighted MRI in children and adolescents with cholesteatoma: reliability and pitfalls in comparison to middle ear surgery

BACKGROUND

Currently, there is only limited and contradictory evidence of the role of diffusion-weighted MRI (DW-MRI) in the management of children with cholesteatoma.

OBJECTIVE

To provide surgically controlled data that may allow to replace second-look surgery by non-echoplanar DW-MRI in children.

MATERIALS AND METHODS

Fifty-five children and adolescents with a median age of 8.6 years (2.2-17.7 years) underwent 61 preoperative half-Fourier acquisition single-shot turbo spin-echo (HASTE) DW-MRI of their petrous bone. Surgical interventions followed within 24 h (79%), within 5 months (20%) or at 18 months (1 case).

RESULTS

Surgery detected a cholesteatoma or retraction pocket in 41 of 61 cases (67%). In 49 cases (80%), the MR result was confirmed by surgical findings. Two MR findings were false-positive and 10 false-negative (including cholesteatomas <4 mm). HASTE DW-MRI alone had a sensitivity of 76% and a specificity of 90%. The positive predictive value was 94%, the negative predictive value 64%. In combination with preoperative otoscopy, sensitivity was 90% and negative predictive value 82%.

CONCLUSION

DW-MRI correctly detected the majority of lesions but could not reliably exclude small cholesteatomas and empty retraction pockets. We would therefore not generally recommend MR as a substitute for second-look surgery.

Diseases of the middle ear in childhood

Middle ear diseases in childhood play an important role in daily ENT practice due to their high incidence. Some of these like acute otitis media or otitis media with effusion have been studied extensively within the last decades. In this article, we present a selection of important childhood middle ear diseases and discuss the actual literature concerning their treatment, management of complications and outcome. Another main topic of this paper deals with the possibilities of surgical hearing rehabilitation in childhood. The bone-anchored hearing aid BAHA(®) and the active partially implantable device Vibrant Soundbridge(®) could successfully be applied for children. In this manuscript, we discuss the actual literature concerning clinical outcomes of these implantable hearing aids.