Cholesteatoma Pearls: Practical Points and Update

Cholesteatoma in the pediatric aerodigestive population

OBJECTIVES

To report the prevalence of cholesteatoma and related comorbidities in pediatric aerodigestive patients requiring tracheostomy or airway reconstruction procedures. To use study findings to inform clinical management of these complex patients.

METHODS

A repository of clinical data drawn from our institution's electronic medical records was queried to identify airway reconstruction (airway) and complex hospital control (control) patient cohorts. Retrospective chart review was then performed to investigate the occurrence of cholesteatoma and related pathologies in these patients, as well as clinical management.

RESULTS

The prevalence of cholesteatoma in airway and control patients was 6/374 (1.60 %) and 35/30,565 (0.11 %), respectively. The relative risk of cholesteatoma diagnosis in airway patients was 14.01 (95 % CI 6.06-32.14). Airway patients were more likely than control patients to have pressure equalization tube history (relative risk 3.25, 95 % CI 2.73-3.82). Age at cholesteatoma diagnosis and first surgical intervention was younger in airway compared to control patients (5.43 vs. 8.33, p = 0.0182, and 6.07 vs. 8.82, p = 0.0236). However, time from diagnosis to intervention and extent of surgery were similar between the groups.

CONCLUSION

This is the first study to investigate the prevalence of cholesteatoma in the pediatric aerodigestive population. The relative risk of cholesteatoma diagnosis was found to be 14 times higher in patients with tracheostomy or airway reconstruction history. Underlying eustachian tube and palatal dysfunction are likely contributing factors to the elevated risk. Additionally, cholesteatoma in this population was diagnosed and required surgical intervention at a younger age, which may suggest a more aggressive disease course. Providers should maintain a high degree of suspicion for cholesteatoma in this complex population.

Imaging findings in otitis media and resulting secondary lesions in dogs and cats - an image essay

Over the past 2 decades, the increasing availability of computed tomography (CT) and magnetic resonance imaging (MRI) as well as the growing professional expertise have significantly improved the diagnostics of middle and inner ear diseases in dogs and cats. In answering some of the diagnostic questions, CT and MRT demonstrate equivalent performance. For most questions, however, there are differences in the diagnostic performance due to the physical imaging properties of the 2 modalities.CT is more sensitive in demonstrating involvement of the bulla wall and is more effective for detecting abnormal content within the tympanic bulla. In addition, with CT it is often easier to guide tissue samplings. On the other hand, structural changes of the soft tissues of the skull, head, meninges, brain, and nerves are not or only insufficiently detectable on CT images. MRI is clearly superior here. Therefore, MRI is essential for the characterization of materials inside the bulla cavity and for demonstrating the extent of any central spread of otitis media (OM).In this image essay, CT and MRI features of OM and resulting secondary lesions described in the literature are analyzed and summarized. Own image examples are used for illustration. Information on the etiology, pathogenesis, pathomorphology, and clinical signs important for understanding these changes are presented in concise descriptions.

Exploring trends and developments in cholesteatoma research: a bibliometric analysis

PURPOSE

Examination of the scientific literature on cholesteatoma from past to present using bibliometric methods.

METHODS

A total of 2353 articles on cholesteatoma between 1980 and 2023 were obtained from the Web of Science database and statistically analysed using bibliometric techniques.

RESULTS

The journals with the highest number of contributions to the literature were Otology & Neurotology (n = 192), Acta Oto-Laryngologica (156) and Laryngoscope (149). The most impactful journals based on h-index and total citation (TC) counts were Laryngoscope (h:36, TC: 4241), Otology & Neurotology (29, 3141), and American Journal of Otology (26, 2071) respectively. The most prolific author was Kojima H. (n = 49). According to the findings of the Reference Publication Year Spectroscopy (RPYS) analysis, there has been a significant increase in academic interest in Cholesteatoma since its first description in 1959, particularly following the expansion of its definition in 1977. Subsequently, the trend of increased interest has risen rapidly in later years, with notable peaks in research intensity observed in 1989, 2006, and 2011. The highest academic trend occurred in 2006. In recent years, trending topics have included innovative approaches such as diagnostic and imaging methods particularly alongside technological developments, endoscopic surgery, recurrence and complications, prognosis and quality of life, artificial intelligence, and obliteration.

CONCLUSION

In conclusion, the evolution of cholesteatoma and its research priorities reveal temporal shifts and emerging areas of interest over time. Primarily, diagnosis, treatment, and surgical approaches remain central. Additionally, research has expanded to encompass developments in surgical techniques, imaging modalities, cellular biology, pathology, and molecular mechanisms.

Tracing of Helicobacter pylori in the middle ear and mastoid mucosa of patients under 18 years of age with chronic otitis media (with and without cholesteatomas)

OBJECTIVE

It has been estimated that about 5 million people of those affected with otitis media have cholesteatoma, however, its pathophysiology is unclear. In this study we aimed to detect Helicobacter pylori via polymerase chain reaction and real-time polymerase chain reaction in young patients with chronic otitis media.

METHODS

Patients included in our prospective cross-sectional study had middle-ear/mastoid inflammation and underwent surgical procedures. Middle-ear mucosa samples were collected, and genomic DNA was extracted for H pylori detection by polymerase chain reaction and real-time polymerase chain reaction analyses. Sociodemographic data and gastroesophageal reflux symptoms were analysed.

RESULTS

We included 49 patients with mean age of 12.7 ± 3.8 years. Twenty per cent of the patients were diagnosed with cholesteatoma. No increase in H pylori-amplified fluorescence was observed, indicating absence of H pylori.

CONCLUSION

Due to the absence of amplification for H pylori and the fact that albumin was amplified in all samples, we conclude that H pylori does not appear to be a causal factor.

Polish version of the COMQ-12 questionnaire, a new validated tool for the assessment of the quality of life in patients with chronic otitis media

<b><br>Introduction:</b> The COMQ-12 questionnaire is a tool to assess the quality of life in patients with chronic otitis media in many countries. The questionnaire consists of 12 questions: seven relating to the severity of symptoms, two regarding the impact of the disease on lifestyle and work, two concerning the impact on the need for healthcare, and one is a general question. Each question is rated on a scale from 0 to 5.</br> <b><br>Aim:</b> To present the validation process and the final version of the Polish version of the COMQ-12 questionnaire.</br> <b><br>Material and methods:</b> The Polish version of the COMQ-12 questionnaire was prepared based on an independent translation of the English version by three physicians (two otolaryngology specialists and one physician in the process of specialization in otolaryngology). The questionnaire was validated in a study including 60 participants: 30 patients with chronic otitis media and 30 volunteers without a history of middle ear diseases or hearing disorders. Each participant was asked to complete the COMQ-12 questionnaire twice at an interval of 4 weeks apart. The internal consistency, reliability, and construct validity of the questionnaire were analyzed using Cronbach's alpha and McDonald's omega coefficients, Spearman's rho correlation coefficient, and the Mann-Whitney test, respectively.</br> <b><br>Results:</b> High internal consistency, reliability, and construct validity of the Polish version of the COMQ-12 questionnaire were shown in the course of statistical analysis. The overall internal consistency was 0.95 and 0.97 as assessed by Cronbach's alpha and McDonald's omega coefficients, respectively. Spearman's rho correlation coefficient was above 0.89 for each question. Statistically significant differences in the COMQ-12 total scores were obtained between patients with chronic otitis media and the control group.</br> <b><br>Conclusions:</b> The Polish version of the COMQ-12 questionnaire can be a valuable clinical tool for the assessment of the quality of life in patients suffering from chronic otitis media.</br>.

Improved reconstruction for highly accelerated propeller diffusion 1.5 T clinical MRI

PURPOSE

Propeller fast-spin-echo diffusion magnetic resonance imaging (FSE-dMRI) is essential for the diagnosis of Cholesteatoma. However, at clinical 1.5 T MRI, its signal-to-noise ratio (SNR) remains relatively low. To gain sufficient SNR, signal averaging (number of excitations, NEX) is usually used with the cost of prolonged scan time. In this work, we leveraged the benefits of Locally Low Rank (LLR) constrained reconstruction to enhance the SNR. Furthermore, we enhanced both the speed and SNR by employing Convolutional Neural Networks (CNNs) for the accelerated PROPELLER FSE-dMRI on a 1.5 T clinical scanner.

METHODS

Residual U-Net (RU-Net) was found to be efficient for propeller FSE-dMRI data. It was trained to predict 2-NEX images obtained by Locally Low Rank (LLR) constrained reconstruction and used 1-NEX images obtained via simplified reconstruction as the inputs. The brain scans from healthy volunteers and patients with cholesteatoma were performed for model training and testing. The performance of trained networks was evaluated with normalized root-mean-square-error (NRMSE), structural similarity index measure (SSIM), and peak SNR (PSNR).

RESULTS

For 4 × under-sampled with 7 blades data, online reconstruction appears to provide suboptimal images-some small details are missing due to high noise interferences. Offline LLR enables suppression of noises and discovering some small structures. RU-Net demonstrated further improvement compared to LLR by increasing 18.87% of PSNR, 2.11% of SSIM, and reducing 53.84% of NRMSE. Moreover, RU-Net is about 1500 × faster than LLR (0.03 vs. 47.59 s/slice).

CONCLUSION

The LLR remarkably enhances the SNR compared to online reconstruction. Moreover, RU-Net improves propeller FSE-dMRI as reflected in PSNR, SSIM, and NRMSE. It requires only 1-NEX data, which allows a 2 × scan time reduction. In addition, its speed is approximately 1500 times faster than that of LLR-constrained reconstruction.

Occurrence of mucosa-affecting diseases of the upper airways in middle ear cholesteatoma patients: a nationwide case-control study

PURPOSE

Exploring a possible link between upper airway inflammation and the development of cholesteatoma by studying the association between mucosa-affecting diseases of the upper airways and cholesteatoma surgery.

METHODS

This is a nationwide case-control study of 10,618 patients who underwent surgery for cholesteatoma in Sweden between 1987 and 2018. The cases were identified in the National Patient Register and 21,235 controls matched by age, sex and place of residency were included from national population registers. Odds ratios (OR) and corresponding 95% confidence intervals were used to assess the association between six types of mucosa-affecting diseases of the upper airways and cholesteatoma surgery.

RESULTS

Chronic rhinitis, chronic sinusitis and nasal polyposis were more common in cholesteatoma patients than in controls (OR 1.5 to 2.5) as were both adenoid and tonsil surgery (OR > 4) where the strongest association was seen for adenoid surgery. No association was seen between allergic rhinitis and cholesteatoma.

CONCLUSION

This study supports an association between mucosa-affecting diseases of the upper airways and cholesteatoma. Future studies should aim to investigate the mechanisms connecting mucosa-affecting diseases of the upper airways and cholesteatoma formation regarding genetic, anatomical, inflammatory and mucosa properties.

Readout-Segmented Echoplanar (RESOLVE) Diffusion-Weighted Imaging on 3T MRI in Detection of Cholesteatoma-Our Experience

Background  Several research studies have demonstrated the utility of diffusion-weighted imaging (DWI) in detecting middle ear cholesteatomas, especially with the non-echoplanar imaging (non-EPI) DWI technique. REadout Segmentation Of Long Variable Echo trains (RESOLVE), a multishot-EPI DWI, has better spatial resolution at a thinner section acquisition with reduced image distortion compared to the single-shot-EPI DWI technique. Purpose  In this study, we evaluated the diagnostic ability of RESOLVE -DWI in middle ear cholesteatomas with surgical and histopathological support. Patients and Methods  Fifty patients with clinical suspicion of primary cholesteatoma or postoperative recurrence were subjected to routine sequences and RESOLVE-DWI on magnetic resonance imaging (MRI). Thirty-eight patients had unilateral disease, while 12 patients had bilateral disease. The bilateral temporal bones of 50 patients were evaluated on MRI. The results attained by RESOLVE-DWI were correlated with intraoperative and histopathological findings. Results  RESOLVE-DWI truly detected 55 of the 58 surgically proven cholesteatomas. RESOLVE-DWI could not detect three cholesteatoma lesions due to their small size and falsely diagnosed one case each of impacted wax and non-cholesteatomatous otitis media as cholesteatoma. With a 95% confidence interval, RESOLVE-DWI showed 94.8% sensitivity, 95.2% specificity, 96% positive predictive value, 93% negative predictive value, and 95% diagnostic accuracy in cholesteatoma detection. Conclusion  RESOLVE-DWI is a sensitive and specific DWI technique for detecting middle ear cholesteatoma. However, RESOLVE-DWI has limitations in the diagnosis of small (<3 mm) cholesteatomas.

Monozygotic twins and cholesteatomas: nature or nuture?

PURPOSE

Cholesteatoma is a rare middle ear pathology. It can be classified into acquired and congenital forms. Although benign, cholesteatomas can cause significant morbidity including hearing loss, infection, facial palsy and thrombosis. Congenital cholesteatomas are incredibly rare and bilateral disease has not commonly been published in the literature.

METHOD

We describe the case of female identical (monozygotic, monochorionic, diamniotic) twins who both developed congenital cholesteatomas. In this report, we review the aetiology, treatment, embryology and pathology of cholesteatoma.

RESULTS

The patients have been followed up 15 years after their initial surgery with promising results - pure-tone audiometry and repeat scans have not illustrated any disease recurrence.

CONCLUSION

This paper presents one of the only cases of female monozygotic twins presenting with unilateral and bilateral cholesteatomas.

Middle Ear Cholesteatoma and Vestibular Schwannoma Resection Followed by Cochlear Implant: Surgical Challenges and Audiological Outcomes

(1) Background: The occurrence of vestibular schwannoma (VS) associated with cholesteatoma is rare. A hearing impairment is one of the most significant issues in such cases. Moreover, the presence of middle and inner ear pathologies combined may represent a surgical challenge. No studies have described a combined surgical approach for these coexisting conditions (VS and cholesteatoma), nor the hearing rehabilitation outcomes of using cochlear implants for these patients. (2) Case Report: This paper is on a female patient who underwent simultaneous surgical treatments for VS and middle ear cholesteatoma in the right ear followed by a cochlear implant, describing the technique and the audiological results. (3) Conclusions: The surgical approach was successful and enabled the resection of lesions with the auditory nerve and cochlea preservation. Cochlear implantation in the right ear showed positive postoperative results, with an improvement in the results with the CI in silent and noisy environments.

Expression of MMP-14 and its role in bone destruction in middle ear cholesteatoma: A prospective observational study

Cholesteatoma is a noncancerous cystic lesion caused by an abnormal growth of keratinizing squamous epithelium which is invasive and capable of destroying structures. A prospective study on the expression of membrane type1-matrix metalloproteinases (MMP-14) and its related influencing factors in middle ear cholesteatoma was conducted to fully understand the pathogenesis of cholesteatoma in the molecular level. We examined the expression of MMP-14 by immunohistochemical staining 39 middle ear cholesteatoma specimens and 10 external auditory meatus epithelial cell specimens. The cholesteatoma specimens were divided into 4 groups according to the degree of destruction of the ossicles during surgery. The associated factors affecting MMP-14 expression were analyzed using statistical methods; The positive expression of MMP-14 in the epithelium of the external auditory canal was significantly different between middle ear cholesteatoma and normal patients (P < .05); Gender, age, and the degree of hearing loss had no statistically significant effect on MMP-14 expression (P > .05); The expression of MMP-14 was positively correlated with the severity of bone destruction (R = 0.535, P < .05); MMP-14 plays an important role in the pathological development of the epithelium of cholesteatoma; MMP-14 expression in middle ear cholesteatoma tissue was not strongly correlated with the level of hearing loss, age or gender, but was positively correlated with the degree of middle ear bone destruction.

Analysis of mRNA m6A modification and mRNA expression profiles in middle ear cholesteatoma

Introduction: Middle ear cholesteatoma is characterized by the hyperproliferation of keratinocytes. In recent decades, N6-methyladenosine (m6A) modification has been shown to play an essential role in the pathogenesis of many proliferative diseases. However, neither the m6A modification profile nor its potential role in the pathogenesis of middle ear cholesteatoma has currently been investigated. Therefore, this study aimed to explore m6A modification patterns in middle ear cholesteatoma. Materials and methods: An m6A mRNA epitranscriptomic microarray analysis was performed to analyze m6A modification patterns in middle ear cholesteatoma tissue (n = 5) and normal post-auricular skin samples (n = 5). Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed to predict the potential biological functions and signaling pathways underlying the pathogenesis of middle ear cholesteatoma. Subsequently, m6A modification levels were verified by methylated RNA immunoprecipitation-qPCR (MeRIP-qPCR) in middle ear cholesteatoma tissue and normal skin samples, respectively. Results: A total of 6,865 distinctive m6A-modified mRNAs were identified, including 4,620 hypermethylated and 2,245 hypomethylated mRNAs, as well as 9,162 differentially expressed mRNAs, including 4,891 upregulated and 4,271 downregulated mRNAs, in the middle ear cholesteatoma group relative to the normal skin group. An association analysis between methylation and gene expression demonstrated that expression of 1,926 hypermethylated mRNAs was upregulated, while expression of 2,187 hypomethylated mRNAs and 38 hypermethylated mRNAs was downregulated. Moreover, GO analysis suggested that differentially methylated mRNAs might influence cellular processes and biological behaviors, such as cell differentiation, biosynthetic processes, regulation of molecular functions, and keratinization. KEGG pathway analysis demonstrated that the hypermethylated transcripts were involved in 26 pathways, including the Hippo signaling pathway, the p53 signaling pathway, and the inflammatory mediator regulation of transient receptor potential (TRP) channels, while the hypomethylated transcripts were involved in 13 pathways, including bacterial invasion of epithelial cells, steroid biosynthesis, and the Hippo signaling pathway. Conclusion: Our study presents m6A modification patterns in middle ear cholesteatoma, which may exert regulatory roles in middle ear cholesteatoma. The present study provides directions for mRNA m6A modification-based research on the epigenetic etiology and pathogenesis of middle ear cholesteatoma.

The role of planned two-stage surgery in the management of congenital cholesteatoma

OBJECTIVE

The purpose of this study is to verify the role of "planned two-stage surgery" in the management of advanced congenital cholesteatoma regarding disease recurrence rates, complications and the need for salvage surgery.

METHOD

Retrospective review of all congenital cholesteatoma under the age of 18 years underwent surgery from October 2007 to December 2021 in a single tertiary referral center. Patients with Potsic stage I/II who had closed-type congenital cholesteatoma received one-stage surgery. Advanced cases or those with open-type infiltrative congenital cholesteatomas underwent planned two-stage surgery. The second stage of surgery was performed 6-10 months after the first stage of surgery. Ossiculoplasty would be performed in the second operation if a significant air-bone gap was detected in the preoperative pure-tone audiometry test.

RESULTS

Twenty-four patients were included in the series. Six patients received one-stage surgery and no recurrence was noted in this group. The remaining 18 underwent planned two-stage surgery. Residual lesions found in the second operative phase were observed in 39% of patients who received planned two-stage surgery. Except for one patient whose ossicular replacement prosthesis protruded and two patients who had perforated tympanic membranes, none of the 24 patients required salvage surgery during follow-up (mean, 77 months after surgery), and no major complications occurred.

CONCLUSIONS

Planned two-stage surgery for advanced-stage or open infiltrative congenital cholesteatoma could timely detect residual lesions to avoid extensive surgery and reduce complications.

A Case of a Congenital Cholesteatoma Without Growth for a Long Term

Congenital cholesteatoma is typically an expanding cystic mass of keratinizing squamous epithelium located medial to the intact tympanic membrane in patients with no prior history of perforation, otorrhea and ear. It is generally thought to be a progressive disease and is usually surgically removed upon detection as the first-choice treatment. As such, it is rare to be observed for a long term without progression. Here we report a rare case of congenital cholesteatoma that remained in an undetectable size and did not deteriorate mild hearing loss for 12 years. A seven years old boy was referred to us with right hearing impairment. Pure-tone audiometry found conductive hearing loss with an air-bone gap of 25 dB and a high-resolution computed tomography (CT) scan found the eroded long process of incus but did not detect any soft tissue density indicating congenital cholesteatoma. He initially did not wish to undergo surgery. His hearing level and image finding remained virtually unchanged during the next 12 years of the follow-up period. Twelve years later, endoscopic ear surgery was performed, which revealed a very small cholesteatoma mass, an eroded long process of the incus and ossicular chain discontinuities. We suspect that the cholesteatoma was originally larger, partially eroded the incus, then regressed to a very small size, and remained small for at least 12 years under our observation.

Structure-constrained deep feature fusion for chronic otitis media and cholesteatoma identification

Chronic suppurative otitis media (CSOM) and middle ear cholesteatoma (MEC) were two most common chronic middle ear disease(MED) clinically. Accurate differential diagnosis between these two diseases is of high clinical importance given the difference in etiologies, lesion manifestations and treatments. The high-resolution computed tomography (CT) scanning of the temporal bone presents a better view of auditory structures, which is currently regarded as the first-line diagnostic imaging modality in the case of MED. In this paper, we first used a region-of-interest (ROI) network to find the area of the middle ear in the entire temporal bone CT image and segment it to a size of 100*100 pixels. Then, we used a structure-constrained deep feature fusion algorithm to convert different characteristic features of the middle ear in three groups as suppurative otitis media (CSOM), middle ear cholesteatoma (MEC) and normal patches. To fuse structure information, we introduced a graph isomorphism network that implements a feature vector from neighbourhoods and the coordinate distance between vertices. Finally, we construct a classifier named the "otitis media, cholesteatoma and normal identification classifier" (OMCNIC). The experimental results achieved by the graph isomorphism network revealed a 96.36% accuracy in all CSOM and MEC classifications. The experimental results indicate that our structure-constrained deep feature fusion algorithm can quickly and effectively classify CSOM and MEC. It will help otologist in the selection of the most appropriate treatment, and the complications can also be reduced.

Comparison of Diagnostic Performance and Image Quality between Topup-Corrected and Standard Readout-Segmented Echo-Planar Diffusion-Weighted Imaging for Cholesteatoma Diagnostics

This study compares the diagnostic performance and image quality of single-shot turbo spin-echo DWI (tseDWI), standard readout-segmented DWI (rsDWI), and a modified rsDWI version (topupDWI) for cholesteatoma diagnostics. Thirty-four patients with newly suspected unilateral cholesteatoma were examined on a 1.5 Tesla MRI scanner. Diagnostic performance was evaluated by calculating and comparing the sensitivity and specificity using histopathological results as the standard of reference. Image quality was independently reviewed by two readers using a 5-point Likert scale evaluating image distortions, susceptibility artifacts, image resolution, lesion conspicuity, and diagnostic confidence. Twenty-five cholesteatomas were histologically confirmed after surgery and originated in the study group. TseDWI showed the highest sensitivity with 96% (95% confidence interval (CI): 88–100%), followed by topupDWI with 92% (95% CI: 81–100%) for both readers. The sensitivity for rsDWI was 76% (95% CI: 59–93%) for reader 1 and 84% (95% CI: 70–98%) for reader 2, respectively. Both tseDWI and topupDWI revealed a specificity of 100% (95% CI: 66–100%) and rsDWI of 89% (95% CI: 52–100%). Both tseDWI and topupDWI showed fewer image distortions and susceptibility artifacts compared to rsDWI. Image resolution was consistently rated best for topupDWI, followed by rsDWI, which both outperformed tseDWI. TopupDWI and tseDWI showed comparable results for lesions’ conspicuity and diagnostic confidence, both outperforming rsDWI. Modified readout-segmented DWI using the topup-correction method is preferable to standard rsDWI and may be regarded as an accurate alternative to single-shot turbo spin-echo DWI in cholesteatoma diagnostics.

Use of bonalive in obliterative mastoidectomy: anatomical results and clinical outcome

PURPOSE

To investigate safety and efficacy of mastoid obliteration in canal-wall-down tympanoplasty performed for cholesteatoma using bioactive glass (BAG). The authors routinely adopt CWD tympanoplasty in case of massive cholesteatoma or revision surgery, performing obliteration with BAG to reduce the mastoid cavity and related disadvantages. We assessed anatomical results, infection control and cholesteatoma recurrence in obliterative mastoidectomy using BAG.

METHODS

The authors evaluated 66 patients treated with obliterative mastoidectomy using BAG during the period 2010-2021. 48.5% of the cases had first diagnosis of cholesteatoma, 48.5% had cholesteatoma recidivisms, and two patients underwent obliteration to improve clinical outcome. BAG granules were always moistened with venous blood to enhance their adhesion and reduce the risk of dispersion. Anatomical results were evaluated in otomicroscopy and infection control was assessed during follow-up visits. Periodical otomicroscopy was performed to check recurrent cholesteatoma. MRI-DWI was indicated only in case of clinical suspect of cholesteatoma.

RESULTS

Authors followed 66 patients during a mean of 23 months. No post-operative wound infections occured. The mean re-epithelialization time was 45 days. At the last visit, control of infection was achieved in 97% of patients and a clinical stable anatomical cavity in all patients. No clinical suspect for recurrent cholesteatoma was found.

CONCLUSIONS

The use of bioactive glass is safe and effective as obliteration material in cholesteatoma surgery. Authors pay a particular attention to obliterate only patients without suspect of epithelial residual, to correctly calibrate the ear canal and to completely cover the granules with graft.

Epigenetic Regulation as a New Therapeutic Target for Middle Ear Cholesteatoma

HYPOTHESIS

To evaluate the effectiveness of the menin-MLL inhibitor, MI503, as a conservative treatment of middle ear cholesteatoma (cholesteatoma) in a mouse model and to confirm its safety profile regarding auditory function in vivo.

BACKGROUND

Cholesteatoma is a mass formed by the keratinizing squamous epithelium in the tympanic cavity and/or mastoid and subepithelial connective tissue and by the progressive accumulation of keratin debris with/without a surrounding inflammatory reaction. Although the main treatment is surgical therapy, the techniques to prevent recurrence remain a critical area of research. Recently, the use of MI503 in experiments resulted in the inhibition of the growth of cholesteatoma in vivo under histone modification.

METHODS

After cholesteatoma was induced in ICR mice (n = 7) by keratinocyte growth factor expression vector transfection, MI503 (50 μM) or phosphate-buffered saline was topically injected for 14 days. The effects of MI503 against cholesteatoma were analyzed by micro-computed tomography images. For the in vivo ototoxicity study, a single intratympanic injection of MI503 (50 or 500 μM) or phosphate-buffered saline (n = 4 each) was done in the ICR mice. An auditory brainstem response was performed at days 0, 1, and 14. For morphological analysis, immunostaining for Phalloidin/F-actin and Myo7a was performed.

RESULTS

MI503 reduced keratinocyte growth factor-induced cholesteatoma in vivo (4 of 4 [100%]). No difference was found in the mean variation of the average of the auditory brainstem response thresholds between the three groups in the in vivo ototoxicity study, thus confirming its safety profile regarding auditory function. MI503 does not demonstrate any deleterious effects on murine hair cells when assessed by immunostaining.

CONCLUSION

These findings demonstrate an encouraging safety profile for the use of menin-MLL inhibitor for the conservative treatment of cholesteatoma.

Characteristics and Clinical Management Strategy of Petrous Apex Cholesterol Granulomas

Purpose: To evaluate the clinical characteristics of petrous apex cholesterol granulomas (PACG) and assess outcomes after different treatment strategies. Method: A consecutive case series of 34 patients with a PACG. Main outcomes were PACG growth, symptoms, and the outcomes of different treatment strategies: wait-and-scan (WS) and surgical drainage. Results: Thirty-four patients were analyzed; mean follow-up time was 7.1 years. Twenty-one patients (61.7%) showed symptoms, mostly more than one. Most symptoms reported were cranial nerve palsy (58.8%) and headache (35.3%). Twenty-one patients (61.8%) received solely wait-and-scan (WS), and thirteen patients (38.2%) underwent surgery, five of whom (38.5%) after an initial WS period. In the solely WS group, one (4.8%) developed new symptoms, and two (9.5%) reported symptom progression despite a stable granuloma size. Two (9.5%) showed granuloma growth on follow-up scans without symptom progression. Surgery consisted of drainage. Eleven (84.6%) of these thirteen patients reported partial recovery; one (7.7%) reported no recovery; and one (7.7%) reported full recovery of reported symptoms related to PACG. Among the patients with cranial nerve involvement, 7.7% showed full recovery after surgery; 84.6% showed partial recovery; and 7.7% did not recover. Adverse events occurred in five out of 13 patients who underwent surgery, all with full recovery. Conclusions: This study confirms that PACG are slow-growing lesions with a low risk of adverse events. Solely using wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth.

Outcomes of transcanal endoscopic middle ear surgery for congenital cholesteatoma

BACKGROUND

Transcanal endoscopic surgery offers advantages for congenital cholesteatoma (CC) which is expanding cystic mass located on an intact tympanic membrane.

OBJECTIVES

To determine the efficacy of transcanal endoscopic ear surgery for the treatment of CC.

MATERIAL AND METHODS

Eleven patients with CC confined to the middle ear underwent transcanal endoscopic ear surgery by surgeons who were skilled in otoscopic surgery. According to the Potsic classification, four, three, and four patients had lesions in stages 1, 2, and 3, respectively. The mean follow-up duration was 24.5 months. We retrospectively analyzed the recurrence rate, complications, and average hearing thresholds of the patients with CC.

RESULTS

All CCs were successfully resected via the transcanal endoscopic approach, without any immediate or serious complications. The only complication was external auditory canal stenosis due to postoperative scarring, which occurred in a patient with a stage-3 cholesteatoma that recurred and required reoperation and second-stage ossicular chain reconstruction. Two more patients underwent one-stage ossicular chain reconstruction. All three patients received a total artificial ossicular replacement prosthesis, and two of them also received cartilage grafts.

CONCLUSIONS AND SIGNIFICANCE

Transcanal endoscopic ear surgery is an effective method to treat CC belonging to Potsic stages 3 or below.

Autoincudotomy as an uncommon etiology of conductive hearing loss: Case report and review of literature

Ossicular pathology is a recognized etiology of conductive hearing loss. Ossicular pathology includes 2 main categories, that is, ossicular chain fixation and ossicular discontinuity. Ossicular discontinuity can be congenital or acquired. Auto-incudotomy is an uncommon form of acquired ossicular discontinuity that usually occurs as a sequel of spontaneous expulsion of cholesteatoma. Typically, it manifests with conductive hearing loss without evidence of cholesteatoma. In this report, we presented CT imaging finding of a 34-year-old male with tympanic membrane perforation and defective long process of the incus (auto-incudotomy) with minimal middle ear granulation tissue and adhesions, sequela of cholesteatoma. Radiologists should pay attention for evaluation of ossicles especially in patients presented with conductive hearing loss.

Novel candidate genes for cholesteatoma in chronic otitis media

Cholesteatoma is a rare and benign disease, but its propensity to cause erosive damage through uninhibited growth can be detrimental to hearing and health. Prior reports indicated a genetic component to pathogenesis in at least a subset of patients. In this study, we aimed to identify rare DNA variants in affected patients. The salivary DNA of six patients whose middle ear tissues were obtained during tympanoplasty/mastoidectomy surgeries were submitted for exome sequencing. Tissue samples from the same patients were previously submitted for mRNA sequencing and analyzed for differentially expressed genes (DEGs). From the generated exome sequence data, rare predicted-to-be-damaging variants were selected within previously identified DEGs, and the candidate genes within which these rare variants lie were used for network analysis. Exome sequencing of six DNA samples yielded 5,078 rare variants with minor allele frequency <.001. A total of 510 variants were predicted to be deleterious and 52 were found to lie within previously identified DEGs. After selecting variants based on quality control measures, 12 variants were identified all from one pediatric patient. Network analysis identified ten significant cellular pathways, including protein transport, viral process, regulation of catalytic activity and cell cycle, and apoptotic and rhythmic processes. We hypothesize that the candidate genes identified in this study may be part of key signaling pathways during the mucosal response to middle ear infection. The occurrence of multiple rare variants may play a role in earlier onset of cholesteatoma formation in chronic otitis media.

Sequestered, Iatrogenic Epidermoid Implantation Cysts Associated With Retroauricular (Wilde's) Incision

OBJECTIVE

To report two patients with iatrogenic, epidermoid implantation cysts associated with the standard retroauricular (Wilde's) incision, to establish their etiology, to explore means to prevent them, and to ensure that this experience adds to the learning curve of the surgical training of the residents.

METHODS

Case series with the review of literature.

RESULTS

One of the two patients, who had an unremarkable follow-up period after cortical mastoidectomy and cartilage tympanoplasty performed three years back, presented with a retroauricular cystic swelling visible since two months. It was hyperintense on T2-weighted magnetic resonance imaging. A sequestered cystic mass was encountered at surgery in the subcutaneous plane in association with the retroauricular scar tissue from previous surgery. In the other patient, two similar cysts (one of them sequestered) were incidental findings at revision tympanomastoid surgery. Histopathology in both instances was consistent with epidermoid cyst. Given their subcuticular location and intimate association with a pre-existing surgical scar, they were considered to be of implantation in origin. This was a potential outcome of persistent inversion of one or both skin edges following simple interrupted suturing. The reason could be a faulty surgical technique, due to improper placement of the needle with respect to skin, inadequate or uneven tissue bite, a tight knot, or failure to manually evert the apposing edges at the point(s) of suspicion.

CONCLUSIONS

Sequestered epidermoid implantation cysts due to persistent inversion of sutured skin edges are unusual complications. The illustrations in this case series emphasize the need to adhere to the basic principles of surgical practice. They provide a caveat to the resident surgeons and the faculties who supervise them, that inadvertent and apparently innocuous misses, even at the elementary steps of surgery (like suturing), could lead to complications that are unwanted and potentially avoidable.

The Clinical Role of Diffusion-Weighted MRI for Detecting Residual Cholesteatoma in Canal Wall up Mastoidectomy

OBJECTIVES

The purpose of this study was to assess the value of the diffusion MRI with the non-echoplanar imaging (Non-EPI) technique for follow-up the post-operative patients to detect residual cholesteatomas.

STUDY DESIGN

This prospective study was performed on 40 patients. All patients were at least one year after Canal Wall Up mastoidectomy surgery for cholesteatoma and scheduled for a second-look surgery.

PATIENTS AND METHODS

This prospective study was performed on 40 patients. All patients were subjected to Canal Wall Up surgery and planned for the second-look operation. After one year as removal of choleasteatoma is uncertain in first surgery. The study done at Tertiary referral centers (Ain shams, Mansoura, and Minia university hospitals), non-echoplanar diffusion MRI (NEP-DWI) technique for follow-up the post-operative patients to detect residual cholesteatomas, then second look surgery done 2 weeks after MRI.

RESULTS

Forty patients underwent MRI with Non-echoplanar diffusion-weighted imaging (NEP-DWI). Twenty-six patients had positive MRI results with the remaining 14 patients had negative results. These results were compared to operative findings. All positive MRI cases showed positive intra-operative findings. Ten of negative MRI cases showed negative intra-operative findings. Four of DWI-negative cases showed small cholesteatomas.

CONCLUSION

The use of NEP-DWI is a valuable tool in detecting residual cholesteatoma that could replace the second look surgery in many cases.

Congenital cholesteatoma in identical twins

Congenital cholesteatoma in identical twins has only been described once in Otolaryngology literature thus far^. This report describes a case of monozygotic twins with a history of recurrent acute otitis media and bilateral middle ear effusions without tympanic membrane perforation. Upon myringotomy with pressure equalization tube insertion, both were found to have right-sided cholesteatoma with nearly identical location and pattern of progression. In the context of previous case series demonstrating familial clustering and reports of possible genetic associations of this condition, the authors present an important addition to the current understanding of congenital cholesteatoma disorder.

Keratinocyte Growth Factor Stimulates Growth of p75+ Neural Crest Lineage Cells During Middle Ear Cholesteatoma Formation in Mice

During development, cranial neural crest (NC) cells display a striking transition from collective to single-cell migration and undergo a mesenchymal-to-epithelial transformation to form a part of the middle ear epithelial cells (MEECs). While MEECs derived from NC are known to control homeostasis of the epithelium and repair from otitis media, paracrine action of keratinocyte growth factor (KGF) promotes the growth of MEECs and induces middle ear cholesteatoma (cholesteatoma). The animal model of cholesteatoma was previously established by transfecting a human KGF-expression vector. Herein, KGF-inducing cholesteatoma was studied in Wnt1-Cre/Floxed-enhanced green fluorescent protein (EGFP) mice that conditionally express EGFP in the NC lineages. The cytokeratin 14-positive NC lineage expanded into the middle ear and formed cholesteatoma. Moreover, the green fluorescent protein-positive NC lineages comprising the cholesteatoma tissue expressed p75, an NC marker, with high proliferative activity. Similarly, a large number of p75-positive cells were observed in human cholesteatoma tissues. Injections of the immunotoxin murine p75-saporin induced depletion of the p75-positive NC lineages, resulting in the reduction of cholesteatoma in vivo. The p75 knockout in the MEECs had low proliferative activity with or without KGF protein in vitro. Controlling p75 signaling may reduce the proliferation of NC lineages and may represent a new therapeutic target for cholesteatoma.

Immunohistochemical localization of d ‐ β ‐aspartic acid in congenital and acquired middle ear cholesteatoma

Objective/Hypothesis

Middle ear cholesteatoma is characterized by abnormal growth of the keratinizing squamous epithelium of the temporal bone. d‐β‐aspartic acid is the major isomer of d‐aspartic acid found in elderly tissue. We assessed the immunoreactivity to k‐β‐aspartic acid of congenital and acquired middle ear cholesteatomas.

Study Design

Case–control studies.

Material and Methods

Tissue samples were collected from 21 patients comprising 21 ears with congenital middle ear cholesteatoma and 26 patients comprising 29 ears with acquired type. Their clinical and histopathological features were investigated. We divided the middle ear cholesteatoma samples into three layers: the perimatrix, matrix, and cystic contents. The patterns of immunoreactivity to d‐β‐aspartic acid expression were then assessed immunohistochemically.

Results

Two patterns of immunoreactivity to d‐β‐aspartic acid were detected in middle ear cholesteatoma: infiltrative and diffuse. In congenital middle ear cholesteatoma, d‐β‐aspartic acid expression was observed throughout all the layers (perimatrix, matrix, and cystic contents), and immunoreactivity to d‐β‐aspartic acid was dramatically strong in all layers. The expression levels of d‐β‐aspartic acid to the cystic content and perimatrix were significantly higher in congenital middle ear cholesteatoma than in the acquired type.

Conclusions

This study showed the expression levels of d‐β‐aspartic acid in middle ear cholesteatoma to differ significantly between congenital and acquired middle ear cholesteatoma. Our results indicate that overexpression of d‐β‐aspartic acid is likely to be involved in the pathogenesis of cholesteatoma, and we speculate that d‐β‐aspartic acid could be a novel biomarker for, and a therapeutic target in, congenital and acquired middle ear cholesteatoma.

Level of Evidence

4

A Systematic Review of Cases with Bezold's Abscess

OBJECTIVE

The objective for this systematic review is to characterize clinical presentations of Bezold's abscesses to improve awareness and promote earlier diagnoses and prompt intervention in this increasingly rare otologic infection.

DATA SOURCES

Pubmed/Medline, CINAHL (EBSCOhost), and Web of Science articles in all languages were searched.

STUDY SELECTION

Inclusion criteria were that the article was either a case report, case series, or retrospective review with individual case data available. Non-English articles were excluded if they lacked an English language abstract and if that abstract lacked information on baseline demographics, clinical presentation, and management.

DATA EXTRACTION

Included studies were evaluated using fulltext review and demographics, etiology, microbiology, antibiotic usage, and surgical variables were collected.

DATA SYNTHESIS

Data were qualitatively synthesized, with means and averages obtained for all continuous variables.

CONCLUSIONS

Bezold's abscess remains a rare otologic infection, but they are relatively commonly associated with serious neurologic and systemic complications. Delay in diagnosis was a frequent commonality and diagnostic vigilance is tantamount in avoiding this sequelae. Aggressive surgical extirpation and long-term antibiotic treatment is recommended.

Pediatric tinnitus: The role of neuroimaging

Tinnitus is defined as the perception of sound without an external source and can be categorized as either pulsatile or nonpulsatile (ie, continuous). A variety of etiologies have been reported to cause pediatric tinnitus, many with long-lasting implications due to hearing and concentration impairments. Therefore, imaging can be an essential part of the accurate and timely diagnosis of treatable etiologies. We describe neuroimaging findings in different etiologies of pediatric tinnitus. Etiologies of pulsatile tinnitus are frequently vascular in nature and include vascular loops, congenital vascular anomalies or variants, high riding jugular bulbs with or without a jugular bulb diverticulum, idiopathic intracranial hypertension, aneurysms, internal auditory canal hemangiomas, and petrous apex cephaloceles. Etiologies of continuous tinnitus frequently affect the middle/inner ear structures and include vestibular schwannomas, cholesteatomas, trauma, Chiari malformations, and labyrinthitis ossificans. CT and MR are often complementary modalities: CT is better suited to evaluate the integrity of the temporal osseous structures and MR is better suited to evaluate the vestibulocochlear nerve and to assess for the presence of any masses or malformations. Prompt diagnosis of the etiology of tinnitus in pediatric patients is important to avoid any potential long-term developmental impairments. In the approach to pediatric tinnitus, categorizing the symptoms as either pulsatile versus nonpulsatile and then being aware of the possible causes and imaging findings of either can assist both the clinician and the radiologist in making an expeditious diagnosis.

Determinants influencing cholesteatoma recurrence in daily practice: a retrospective analysis

Background

Cholesteatoma is a benign but destructive epithelial lesion in the middle ear and/or mastoid. It is hard to translate data from previous research to daily clinical practice. In this study, factors influencing recurrence rates in daily clinical practice were identified.

Method

The study included 67 patients who were treated for a cholesteatoma with combined approach tympanoplasty. The average follow-up time was 35 months.

Results

The recurrence rate was 23.3 per cent in adults and 45.5 per cent in children. Predictors of recurrence were younger age and a low tegmen. A cholesteatoma in a child and the simultaneous presence of a low tegmen led to recurrence in 82.8 per cent of the patients.

Conclusion

Patients – especially children – with a low tegmen have an increased risk of recurrence. It is recommended that ENT surgeons be aware of recurrence in children, particularly in the case of a low tegmen.

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.

Microarray analysis and functional prediction of differentially expressed circular RNAs in acquired middle ear cholesteatoma

BACKGROUND

Middle ear cholesteatoma is characterized by hyper-proliferation of keratinocytes. Circular RNA (circRNA) plays an essential role in the pathogenesis of many proliferative diseases. However, the role of circRNA in the etiopathogenesis of middle ear cholesteatoma is rarely investigated so far. We aimed to investigate the differential expression profiling of circRNAs between acquired middle ear cholesteatoma and normal skin, and to identify potential circRNAs contributing to the etiopathogenesis of middle ear cholesteatoma. Microarray analysis and functional prediction were performed to investigate the circRNA expression profiling between middle ear cholesteatoma and normal skin. Validation of differentially expressed circRNAs was conducted by qRT-PCR. Prediction of m⁶A modification was also carried out.

RESULTS

Microarray analysis displayed that totally 93 up-regulated and 85 down-regulated circRNAs were identified in middle ear cholesteatoma. Through validation, expressions of hsa_circRNA_104327 and hsa_circRNA_404655 were significantly higher, while hsa_circRNA_000319 was significantly down-regulated in cholesteatoma. GO classification, KEGG pathway, and ceRNA network analyses suggested that these differentially expressed circRNAs might play important roles in the etiopathogenesis of middle ear cholesteatoma. Prediction of m⁶A modification exhibited that hsa_circRNA_000319 possessed 4 m⁶A sites with very high confidence, and hsa_circRNA_404655 had 3 m⁶A sites with high confidence.

CONCLUSIONS

Our study revealed that these differentially expressed circRNAs might contribute to the etiopathogenesis of middle ear cholesteatoma. Further researches should be conducted to investigate the exact mechanism of these differentially expressed circRNAs in the etiopathogenesis of middle ear cholesteatoma. Targeting on these circRNAs may provide a new strategy for middle ear cholesteatoma therapy in the future.

Neuroimaging of Dizziness and Vertigo

Dizziness and vertigo are common symptoms in the primary care and emergency settings, resulting in a significant decrease in quality of life and a high cost burden to the US health care system. The etiology of these symptoms is difficult to elucidate owing to a wide range of diseases with overlapping manifestations. The broad differential diagnosis based on whether the disease process is central or peripheral is showcased. Each differential will be categorized into neoplastic, infectious or inflammatory, structural, traumatic, and iatrogenic causes. Computed tomography scans, MRI, and vascular imaging are frequently complimentary in providing diagnoses and guidance in management.

Denosumab and bisphosphonate associated bilateral osteonecrosis of the external auditory canal

We present a case of non-surgically managed bilateral osteonecrosis of the external auditory canal with a history of long-term medical therapy for osteoporosis. A 79-year-old woman with severe osteoporosis and destructive osteoarthritis received >10 years of once weekly bisphosphonate therapy before switching to denosumab. Four months later, the patient presented with bilateral loss of hearing and right-sided otalgia. Necrotising otitis externa, cholesteatoma and malignancy were considered but with histology, microbiological and CT assessment, bilateral osteonecrosis of the external auditory canal was diagnosed. Surgical debridement with canalplasty was avoided due to our patient's comorbidities. Treatment continued for 5 months with regular aural toilet, Terra-Cortril ointment and bismuth-iodine-paraffin paste packing. At 1-year follow-up, bilateral external auditory canals were completely re-epithelialised with no pain or affected hearing. We report the first case of bilateral osteonecrosis of the external auditory canal associated with denosumab and bisphosphonates with successful conservative management.

In vitro study on immune response modifiers as novel medical treatment options for cholesteatoma

OBJECTIVES

To investigate cytokine profile of cholesteatoma and to collect information about important intercellular signaling pathways by establishing two different cell culture models, to block important intercellular signaling pathways in cholesteatoma by applying immune system modifier drugs to develop alternative medical therapy options for cholesteatoma.

METHODS

To observe the pathogenesis of cholesteatoma and to apply the immunomodulatory drugs, cholesteatoma tissue culture models were constituted with HEKa cells and cholesteatoma keratinocytes, which were obtained from 3 patients who underwent operations for cholesteatoma. Medicines including 5-fluorourasil, imiquimod, cyclosporine, and tacrolimus were applied on both cholesteatoma keratinocytes and HEKa cells. After 48 h of incubation, IL-1, IL-6, IL-8, IL-10, TNF-α, and Ki67 levels were measured to determine cell viability rates.

RESULTS

In the cholesteatoma control group, IL-6 and TNF-α levels were found higher than in the HEKa control group. All repurposed drugs in the study demonstrated anti-inflammatory, anti-proliferative, and cytotoxic effects on cholesteatoma. Imiquimod and tacrolimus in particular are potential treatment prospects for cholesteatoma due to their strong anti-inflammatory and cytotoxic effects.

CONCLUSION

Medical therapy options for cholesteatoma are still missing and surgery is not the ultimate solution. We have focused on intercellular inflammatory processes, which play significant roles in the pathogenesis of cholesteatoma in our paper. Inflammation and proliferation of cholesteatoma decreased after all repurposed drug applications in our study. Anti-inflammatory and anti-proliferative effects of tacrolimus and imiquimod was more significant than other drugs in the study. For this reason, tacrolimus and imiquimod should be examined in depth with in vivo studies in terms of efficacy and safety for medical treatment of cholesteatoma.

Cholesteatoma: Influence of surgical technique and EAONO/JOS stage on audiological results

INTRODUCTION AND OBJECTIVE

The treatment of cholesteatoma is surgical in most cases. When it is indicated, it is preferable to choose a reconstructive surgical technique with the dual purpose of eradicating the disease and preserving or improving the patient's hearing. In 2017, the European Academy of Otology and Neuro-Otology/Japanese Otological Society (EAONO/JOS) published a new cholesteatoma classification. The aims of this study are to determine the influence of the surgical technique use and this classification on patient's hearing outcomes.

METHODS

A retrospective study that include patients who underwent reconstructive surgery of cholesteatoma between 2012 and 2017 is carried out. Based on pre-surgical computed tomography (CT) images, disease is staged according to the EAONO/JOS classification. Hearing outcomes obtained by pre and postoperative pure tone audiometry are analysed according to the surgical technique used and according to the stage of the disease.

RESULTS

143 patients with no statistically significant differences in hearing thresholds before surgery are included. One year after surgery, all the patients' airbone pure tone average (PTA) and mean differential auditory threshold have improved significantly (P = .01 and P = .001). Those patients who undergo tympanoplasty with two-stage canal wall up mastoidectomy presente better postsurgical air PTA and postsurgical mean differential auditory threshold outcomes (P=.007 and P=.014) than those patients who underwent tympanoplasty with canal wall down mastoidectomy. Moreover, the patients who underwent tympanoplasty with two-stage canal wall up mastoidectomy had improved airbone PTA and mean differential auditory threshold one year after the surgery with statistical significance (P=.001 and P=.013). The mean differential auditory threshold is also better (P=.008) in the patients who undergo tympanoplasty with canal wall down mastoidectomy one year after the procedure.

CONCLUSIONS

Reconstructive surgical techniques improve hearing one year after surgery. In our study, this improvement is significantly greater with tympanoplasty with two-stage canal wall up mastoidectomy.

The Effect of Oral Montelukast Administration in Cholesteatoma Development and Inflammation: An Experimental Animal Model

HYPOTHESIS

We hypothesized that oral montelukast treatment could inhibit cholesteatoma formation in an experimental animal model.

BACKGROUND

Inflammation and excessive proliferation have been described in the histopathology of cholesteatoma. The aim of this study was to determine the effect of oral montelukast on cholesteatoma development.

METHODS

Eighteen healthy female Wistar albino rats weighing 250 g were chosen for the study. The animals were divided into two groups: group 1 received montelukast and group 2 was the control group. Intratympanic propylene glycol injection was administered into the left ears and physiologic serum was instilled into the right ears of the animals on the first, eighth, and fifteenth days. The effects of montelukast administration were evaluated by histological examination of the tympanic membrane and middle ear.

RESULTS

Group 1 (montelukast group) showed significant differences in terms of cholesteatoma formation, granulation, epithelial invagination, and inflammation. Cholesteatoma formation in the left ear was observed in 2 (22%) and 8 (89%) rats in groups 1 and 2, respectively (p = 0.015).

CONCLUSION

Development of cholesteatoma and inflammation was significantly lower in the montelukast-administered group. Thus, oral montelukast was found effective in preventing cholesteatoma formation.

Isolated Congenital Mastoid Cholesteatoma with no Involvement of Aditus Ad Antrum and Middle Ear

Cholesteatoma is a non-neoplastic, keratinized squamous epithelial lesion that affects the temporal bone. The middle ear is the most frequent, while the isolated cholesteatoma of the mastoid is rare. The aim of this study was to describe a rare case of isolated mastoid cholesteatoma with no involvement of aditus ad antrum and middle ear including a literature review of the topic. This case report describes the case of a 58 years old female with a cholesteatoma isolated in the mastoid region, evidenced by imaging (computer tomography and magnetic resonance). A mastoidectomy was performed: mastoid process was completely involved, but antrum was not reached. Moreover, it reached the soft tissue of stylomastoid foramen as well as the posterior belly of the digastric muscle. In the literature few articles described cases of cholesteatoma isolated in the mastoid region. Research was conducted using PubMed and reference list and there were considered only reports about cholesteatoma exclusively located in the mastoid process without involvement of antrum or middle ear. Fourteen articles were included in this review, with a total number of 23 cases of cholesteatoma isolated in the mastoid region. All papers analyzed reported the cases of isolated mastoid cholesteatoma that presented a congenital origin. Its diagnosis is difficult, therefore, imaging evaluation is mandatory and surgery is the treatment of choice. Mastoid cholesteatomas without involvement of aditus ad antrum and middle ear are rare and only 23 cases are reported in literature. Our case is in line with all clinical and diagnostic features of this rare disease, but it is the only one that evidenced an exposure of the soft tissue of stylomastoid foramen as well as the posterior belly of the digastric muscle. The treatment of choice was the surgical one, avoiding damaging of important anatomo-functional structure.

Post-surgery cholesteatoma complicated by facial nerve paralysis: A case report from Afghanistan

INTRODUCTION

Cholesteatoma is a benign tumoral lesion of squamous epithelial cells in middle ear that can exist as congenital or acquired forms.

PRESENTATION OF CASES

A 35-year-old housewife presented to ENT clinic of a private hospital in Kabul, Afghanistan, with a complete facial nerve paralysis in the right side. In her antecedents, there is a tympanomastoidectomy due to chronic middle ear infection. First symptom was right side earache without any discharge. She started to notice a progressive nodule in the posterior-inferior side of her right ear. The patient was taken to the operating room. She underwent general anesthesia, an extensive cholesteatoma was removed, and a limited area of the fallopian canal in which facial nerve oedema or redness was evident. Post-operative House Brackmann grade was 1 on day 15 after the surgery.

DISCUSSION

Cholesteatoma is primarily managed surgically and currently there is no suitable medical substitute treatment strategy for cholesteatoma. Hearing improvement, making the ear dry and total omission of cholesteatoma are primary goals of surgical interventions in cholesteatoma management.

CONCLUSION

Cholesteatoma after surgical manipulations of middle ear is a rare complication with notable morbidity that has been reported almost from all around the world but our patient is the first reported case of cholesteatoma formation after surgical management of COM from Afghanistan that presented with facial nerve paralysis and hear decline.

Tinnitus, Hyperacusis, Otalgia, and Hearing Loss

PURPOSE OF REVIEW

This article reviews the causes of tinnitus, hyperacusis, and otalgia, as well as hearing loss relevant for clinicians in the field of neurology.

RECENT FINDINGS

Important causes of unilateral and bilateral tinnitus are discussed, including those that are treatable or caused by serious structural or vascular causes. Concepts of hyperacusis and misophonia are covered, along with various types of neurologic disorders that can lead to pain in the ear. Hearing loss is common but not always purely otologic.

SUMMARY

Tinnitus and hearing loss are common symptoms that are sometimes related to a primary neurologic disorder. This review, tailored to neurologists who care for patients who may be referred to or encountered in neurology practice, provides information on hearing disorders, how to recognize when a neurologic process may be involved, and when to refer to otolaryngology or other specialists.

Association of Matrix Metalloproteinase-2 mRNA Expression with Subtypes of Pediatric Cholesteatoma

Objective

Cholesteatoma is a clinically heterogeneous disease, with some patients showing spontaneous regression, while others experiencing an aggressive, lethal disease. Cholesteatoma in children can be divided into two types: congenital and acquired. Identifying good prognostic markers is needed to help select patients who will require immediate surgical intervention. Matrix metalloproteinase-2 (MMP2) was previously reported to play an important role in cholesteatoma progression, by promoting bone destruction and keratinocyte infiltration. Herein, we analyzed MMP2 mRNA expression level in cholesteatoma using RNA-in situ hybridization in formalin-fixed, paraffin-embedded (FFPE) tissue samples.

Methods

Sixty patients with cholesteatoma under 15 years old, who underwent their primary surgery at Aichi Medical University's Otolaryngology Department, were analyzed for MMP2 expression level, using RNA-in situ hybridization.

Results

There were no significant differences in MMP2 mRNA expression level between congenital cholesteatoma and acquired cholesteatomas. In congenital cholesteatoma, higher MMP2 signals were observed in the open type than in the closed type (p < 0.001). In acquired cholesteatoma, higher MMP2 signals were observed in the pars tensa than in the pars flaccida (p < 0.001). MMP2 mRNA expression level was almost exclusively found in the fibroblasts or in the inflammatory cells in the stroma, but not in the epithelium.

Conclusion

Our study reveals that MMP2 mRNA expression level is strongly associated with the subtypes of cholesteatoma. The findings suggest that the level of expression of MMP2 mRNA may be related to the pathogenesis and aggressive features of cholesteatoma.

Projected Cost Simulation in Chronic Ear Surgery: Cost in Chronic Ear Surgery

OBJECTIVE

To examine the projected healthcare costs of intact canal wall (ICW) and canal wall down (CWD) tympanomastoidectomy surgery and associated clinic follow-up visits in the management of chronic ear disease.

STUDY DESIGN

A review of literature was performed to analyze the cholesteatoma recidivism rates of ICW and CWD tympanomastoidectomy. Projected Medicare cost simulation applied to representative samples of patients undergoing otologic surgery and follow-up clinic appointments projected over 15 years with an annual 25% cholesteatoma recidivism rate.

SETTING

Tertiary academic center.

PATIENTS

Simulated patient population status postchronic ear surgery and representative follow-up clinic visits with or without in-office mastoid debridement procedures.

INTERVENTIONS

Therapeutic and rehabilitative.

MAIN OUTCOME MEASURES

Healthcare cost.

RESULTS

Simulation of cost for chronic ear surgery with follow-up visits produced a higher mean cost for the ICW group compared with the CWD group at year 1 ($9112.06 versus $4954.16). However, CWD patients accumulate cost over time due to routine mastoid debridements. The accumulated costs for the CWD group surpassed the ICW group at 12.54 (CI: 12.02-13.11) years.

CONCLUSIONS

Using a projected cost analysis model, intact canal wall tympanomastoidectomy incurs a larger upfront cost than the canal wall down technique. However, long-term mastoid cavity maintenance costs accumulate to surpass the intact canal wall group at 12.54 years.

Cholesteatoma of Maxillary Sinus Simulating Neoplasia: A Rare Case Report

The term cholesteatoma refers to “chole”: cholesterol, “steat”: fat and “oma,”: “tumor”. This tumor has been reported to be the most common in the middle ear. The occurrence of such a tumor in the maxillary sinus is deemed to be very rare and hardly 4 cases were reported in India and 26 cases described worldwide. This case report intends to discuss the uniqueness and indolent nature of this lesion in terms of histopathology and radiography.

Menin-MLL inhibitor blocks progression of middle ear cholesteatoma in vivo

OBJECTIVE

Cholesteatoma is an epithelial lesion that expands into the middle ear, resulting in bone destruction. The acceleration of the proliferative activity of epithelial stem/progenitor cells is involved in the pathogenesis of cholesteatoma. Recently, the use of a menin-mixed lineage leukemia 1 (MLL1) inhibitor, MI503, in experiments has resulted in inhibition of the growth of tumors under histone modification. In this study, we investigated the effects of the menin-MLL inhibitor against cholesteatoma growth in an in vivo model.

METHODS

We first correlated the expression level of histone H3 trimethylation at lysine 4 (H3K4me3) among cholesteatoma cases, chronic otitis media cases and normal skin tissues. Based on the role of keratinocyte growth factor (KGF) in the development of cholesteatoma, KGF-expression vector was transfected into the ear and we analyzed the expression level of H3K4me3. After cholesteatoma was induced, MI503 was administered daily into the ear for 14 days.

RESULTS

We detected the highest labeling index of H3K4me3 in the cholesteatoma specimens. After KGF-expression vector transfection in the mouse ear, a high expression level of H3K4me3 was observed in the epithelial layers. The use of MI503 reduced cholesteatoma in the in vivo model and decreased the proliferation of epithelial stem/progenitor cells in a dose-dependent manner.

CONCLUSION

We demonstrated that inhibition of the menin-MLL interaction may be a potentially useful strategy in the conservative treatment of cholesteatoma.

Suggestion of a Modified Classification for Congenital Middle Ear Cholesteatoma: Based on the Clinical Characteristics and Staging of Fifty-Seven Patients

Objective: To explore more refined classification methods of congenital middle ear cholesteatoma (CMEC) based on two existing staging systems. Subjects and Methods: This study involved a retrospective data review of 57 patients (61 ears involved) with CMEC requiring the surgical treatment. Patients were classified into different stages according to Nelson, Potsic, and Modified Nelson staging system. Preoperative data and intraoperative findings were recorded. Results: The mean age at operation was 15 ± 15.04 years with a median of 10 years. The main clinical manifestation was hearing loss (72.13%). CMEC mass was mainly located in the posterior portion of the tympanic cavity (65.57%). No patient was classified into Potsic stage II. The erosion of incus happened in all cases. Patients with Nelson type 2 and type 3 had erosions to the structures out of middle ear, such as dura mater, lateral semicircle canal, and facial canal. Postoperative follow-up time was more than 24 months. Recurrence occurred in four patients (6.56%), all of them in Nelson type 2, who had received canal wall down mastoidectomy (three cases) and canal wall up mastoidectomy (one case). Conclusions: Nelson staging system was more suitable for advanced CMEC patients than Potsic staging system. The rare case of Potsic stage II restricted the application of Potsic staging system. Moreover, since both of two staging systems do not distinguish the type of involved ossicles, the authors recommended to subdivide Nelson type 2 into type 2a and type 2b based on the erosion of the ossicular chain, as well as subdivide Nelson type 3 into type 3a and 3b based on the erosion of structures out of middle ear, which was named as Modified Nelson staging system.

Factors affecting complications and comorbidities in children with cholesteatoma

OBJECTIVE

To evaluate the effects of age, race, payer status, and socioeconomic status on complications and comorbidities in children with cholesteatoma.

METHODS

An analysis of the Kids' Inpatient Database was performed on cases of cholesteatoma between 2006 and 2016, along with associated complications or co-morbidities and surgical interventions.

RESULTS

1552 cases of pediatric cholesteatoma represented 5.6 cases per 100,000 total discharges over the study period. The mean age was 9.9 (±5.4) years. Compared to children in the 4th age quartile, those in the 1st age quartile had decreased risk of conductive hearing loss (OR 0.64 [0.42-0.99]), venous thrombosis (OR 0.24 [0.06-0.88]), intracranial abscess (OR 0.35 [0.13-0.96]), and facial nerve palsy (0.44 [0.20-0.97]), but increased risk of chronic otitis media (OR 2.24 [1.23-4.10]). Compared to children identified as Other race, children identified as Black had increased risk of acute otitis media (OR 9.20 [1.35-62.78]). Both children identified as Black (OR 9.90 [1.48-66.35]) or Hispanic (OR 6.24 [1.01-38.51]) had increased risk of facial nerve palsy. Relative to children in the 4th income quartile, children in the 1st income quartile had increased risk of acute mastoiditis (OR 1.87 [1.15-3.03]) and subperiosteal abscess (OR 6.75 [2.22-20.56]). Children in the 2nd income quartile were less likely to receive ossicular chain surgery (OR 0.31 [0.13-0.72]).

CONCLUSION

Differences pertaining to age, race, payer status, and socioeconomic status exist in the presentation and surgical management of children hospitalized with cholesteatoma. Older children are at increased risk of intracranial complications. Patients of Black and Hispanic race might have a higher risk of facial nerve palsy. Compared to children of higher income families, those from lower income families more frequently develop acute mastoiditis and subperiosteal abscess. Providers should be mindful of these risk factors when caring for children with cholesteatoma.