Growth and Late Detection of Post-Operative Cholesteatoma on Long Term Follow-Up With Diffusion Weighted Magnetic Resonance Imaging (DWI MRI): A Retrospective Analysis From a Single UK Centre

ESR Essentials: imaging of middle ear cholesteatoma-practice recommendations by the European Society of Head and Neck Radiology

Although non-malignant, middle ear cholesteatoma can result in significant complications due to local bone erosion and infection. The treatment of cholesteatoma is surgical, but residual disease is common and may be clinically occult, particularly when the canal wall is preserved or reconstructive techniques are employed. Imaging plays a pivotal role in the management of patients with middle ear cholesteatoma-aiding clinical diagnosis, identifying complications, planning surgery, and detecting residual disease at follow-up. Computed tomography is the primary imaging tool in the preoperative setting since it can provide both a surgical roadmap and detect erosive complications of cholesteatoma. The ability of magnetic resonance imaging with non-echoplanar diffusion-weighted sequences to accurately detect residual disease has led to a shift in the diagnostic paradigm for post-surgical follow-up of cholesteatoma, such that routine "second-look" surgery is no longer required. The following practice recommendations are aimed at helping the radiologist choose appropriate imaging approaches and understand the key diagnostic considerations for the evaluation of pre- and post-surgical middle ear cholesteatoma. KEY POINTS: In the preoperative setting, CT is the first-line imaging modality and MRI is reserved for rare clinical scenarios (low evidence). Non-echoplanar imaging (EPI) DWI is the optimal MRI sequence for the detection of residual cholesteatoma (moderate evidence). Non-EPI DWI plays an important role in the postoperative surveillance of cholesteatoma (moderate evidence).

Pediatric Cholesteatoma Follow-Up: Residual and Recurrence in 239 Cases with Over 5-Year Hindsight

INTRODUCTION

Pediatric cholesteatoma is an aggressive disease which requires long-term evaluation to assess management strategies. The objective was to determine optimal follow-up duration in pediatric cholesteatoma to detect residual and recurrent diseases.

METHODS

This cohort study was set in a tertiary referral center. All consecutive patients with a minimum 5-year follow-up were included. Medical history, initial extension, surgical procedures, and follow-up were collected. The main outcome measure were Kaplan-Meier survival curves of residual and recurrence cumulative incidence.

RESULTS

Totally 239 ears with the first tympanoplasty between 2008 and 2014 were studied including 25% congenital. At first surgery (S1), mean age was 8.4 years and mean follow-up time 7.9 years. Mastoidectomy was performed in 69% and stapes was absent in 38% of cases. Notably, 83% (199 ears) had a second procedure (S2) of which 186 were planned. After S1, maximum cumulated incidence of residual was 45% [95%CI, 38%; 52%] at 74 months, with probability of residual of 39% at 3 years. After S2 (n = 199), maximum cumulated residual incidence was 21% [95%CI, 12%; 32%] at 62 months and 16% at 3 years. Concerning recurrence, maximum cumulated incidence after S1 (n = 239) was reached at 98 months with 21% [95%CI, 12%; 32%], 13% at 3 years and 16% at 5 years. Congenital disease had significantly less residuals after S1 (p = 0.02), but similar recurrence rate (p = 0.66) compared with acquired.

CONCLUSIONS AND RELEVANCE

We recommend MRI follow-up of at least 5 years after the last surgery for residual disease and clinical follow-up of at least 10 years to detect recurrence.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Evaluation of magnetic resonance imaging to detect cholesteatoma in clinical healthcare

BACKGROUND

Non-Echo-Planar Diffusion Weighed Magnetic Resonance Imaging (non-EPI DW MRI) plays a role in the planning of cholesteatoma surgery.

OBJECTIVES

To outline the usage of Non-EPI DW MRI in cholesteatoma diagnostics and to determine its accuracy, using otosurgery diagnostics as reference standard.

MATERIAL AND METHODS

A retrospective descriptive study. All subjects operated, with suspicion of cholesteatoma as indication, that had a preceding examination with non-EPI DW MRI, between October 2010 and March 2019. Calculating sensitivity, specificity, predicative values, and likelihood ratios, using non-EPI DW MRI as index test and diagnosis from otosurgery as reference standard.

RESULTS

Fifty-two subject episodes were included. Non-EPI DW MRI had a sensitivity of 0.50, specificity of 0.75, positive and negative predictive values of 0.74 and 0.52 and, positive and negative likelihood ratios of 2.0 and 0.67 respectively.

CONCLUSIONS AND SIGNIFICANCE

There is a clear annual trend with increased numbers of executed examinations during the study period. The diagnostic accuracy of non-EPI DW MRI does not reach acceptable levels in the existing everyday routine practice conditions. The accuracy of the examination increases when interpreted by an experienced radiologist and when using the definition of cholesteatoma recommended by EAONO/JOS.

Updates in paediatric cholesteatoma

PURPOSE OF REVIEW

The management of paediatric patients with cholesteatoma is complex, as the disease process is more aggressive in children than adults. New technologies and practice adaptations currently help optimize the surgical management and monitoring of these challenging patients.

RECENT FINDINGS

Several options of surgical management are available and are associated with equal if not improved outcomes. Technologic advancements in endoscopic ear surgery, the discovery of chemical-assisted dissection of cholesteatoma and advanced imaging protocols have enabled surgeons to better care for patients with this complex disease process.

SUMMARY

The advances in endoscopic ear surgery, the discovery of Mesna as a chemically assisted dissection agent to improve recidivism rates and the use of specific diffusion-weighted MRI protocols enable the otologic surgeon to better care for these paediatric patients.

Proposal of a magnetic resonance imaging follow-up protocol after cholesteatoma surgery: a prospective study

BACKGROUND

Non-echo planar (EPI) diffusion-weighted (DW) MRI has become an effective tool for the follow-up after cholesteatoma surgery and decreased the rate of second-look surgeries.

OBJECTIVES

To shed light on the optimal imaging follow-up protocol to detect postoperative residual or recurrent cholesteatoma.

MATERIALS AND METHODS

64 patients were included in this prospective study. Three different surgical procedures were considered: canal-wall-up (26 patients), canal-wall-down (20 patients), and obliterative (18 patients). The imaging follow-up protocol included non-EPI DW MRI during the following postoperative periods: 1 month, 6 months, and 1, 3, 5, and 7 years after the primary surgery.

RESULTS

MRI-positive lesions were present in 18.75% of patients. 50% of the MRI-positive findings occurred at the 1-month follow-up. The other peak of MRI positivity occurred at the 3-year follow-up. The last MRI-positive finding appeared at the 5-year follow-up.

CONCLUSIONS

The timing for the imaging protocol proposed by this prospective study to detect recidivism after cholesteatoma surgery stressed the importance of performing non-EPI DW MRI for detecting residual, though rare, disease. Likewise, extending the follow-up to a least 5 years after primary surgery was also recommended to detect any recurrent cholesteatoma that would appear unlikely to be present beyond this time set.

Post-operative MRI detection of residual cholesteatoma in pediatric patients - The yield of serial scans over a long follow-up

OBJECTIVES

Non-echo-planar diffusion weighted magnetic resonance imaging (Non-EPI DWI MRI) is commonly used for follow-up after cholesteatoma surgery. MRI has a critical role in the evaluation of residual disease, where physical examination will commonly demonstrate an intact tympanic membrane. The aim of our study was to assess the timing of residual cholesteatoma identification on serial MRI scans and the yield of MRI follow up after canal wall up tympano-mastoidectomy.

METHODS

A retrospective chart review of children that underwent canal wall up tympano-mastoidectomy due to cholesteatoma in Schneider Children's Medical Center during 2004-2016, and were followed up both clinically and with MRI.

RESULTS

Seventy-seven children (89 ears) were included, who altogether underwent 166 surgeries (77 revisions). Average follow-up was 66 ± 34.4 months. During follow up, 244 scans were performed; 19 cases of residual disease were diagnosed by MRI and confirmed in surgery. The mean time from surgery and an MRI positive for residual disease was 29.7 ± 16 months (range: 10-66). In 9/19 cases (47%), at least one negative MRI preceded the scan positive for residual disease, and in 4 cases at least two initial scans were negative.

CONCLUSIONS

MRI plays an important role in the diagnosis of residual disease after cholesteatoma surgery. In our cohort. Almost half of the cases diagnosed with residual disease had at least one negative scan prior to the positive one, emphasizing the importance of close radiological follow-up with serial scans after surgery.

Radiological Follow-up After the Bony Obliteration Tympanoplasty in Detecting Residual Cholesteatoma: Towards an Optimal Postoperative MR Imaging Protocol

INTRODUCTION AND AIM

There is no consensus in literature on the most optimal follow-up imaging protocol for non-echoplanar diffusion-weighted magnetic resonance imaging (non-EP DW MRI) after the canal wall-up bony obliteration tympanoplasty. Clearly, no residual cholesteatoma should be missed but on the other hand, unnecessary MR controls should be avoided. The aim of this study is to evaluate the postoperative results of non-EP DW MRI after canal wall-up bony obliteration tympanoplasty surgery at our Institute and to propose an optimal postoperative MR imaging scheme based on our data.

MATERIAL AND METHODS

Retrospective cohort study; all 271 patients who underwent the bony obliteration tympanoplasty between January 2010 and January 2016 with follow-up at our Institute were included. A postoperative MR imaging was systematically performed at 1 year after surgery and repeated at either 5 or both 3 and 5 years after surgery, based on the preferences of the surgeon. Variables of interest were retrieved from electronic patient records.

RESULTS

The median follow-up time was 60 months (inter-quartile range 56-62 mo). Two hundred seventy-one patients (100%) received a 1-year MRI, 107 (39%) a 3-year MRI, and 216 (79.7%%) a 5-year MRI. Residual cholesteatoma was found in nine cases (3.3%), corresponding with an estimated residual rate at 5 years follow-up of 3.7% when using Kaplan-Meier analysis. Of these nine cases, six cases of residual cholesteatoma (66.7%) were detected at the 1-year MRI (12-14 mo postsurgery), two cases (22.2%) at the 3-year MRI (35-39 mo postsurgery), and one case (11.1%) at the 5-year MRI (51 mo postsurgery, in this patient no 3-year MRI was performed). An uncertain MRI result was found in 15 cases, presenting as relatively hyperintense lesions. However, subsequent follow-up scans did not show persistent evidence for residual disease in 14 of these 15 cases.

CONCLUSIONS

A postoperative MRI scan after 1 and 5 years is essential to detect early and late residual cholesteatoma. In our cohort, 22.2% of residual cases were detected at the 3-year MRI. However, this percentage could potentially have been higher when all patients would have received a 3-year MRI. Therefore, in order to detect residual disease as soon as possible, we propose to perform an MRI scan at 1, 3, and 5 years after the bony obliteration tympanoplasty. In cases with an unclear MR result, we suggest a repeat MRI after 12 months.

MRI of middle ear cholesteatoma: The importance of observer reliance from diffusion sequences

BACKGROUND AND PURPOSE

Diffusion-weighted imaging(DWI) in MRI has been developed as an important tool for the detection of cholesteatoma. Various DWI sequences are available. This study aims to evaluate the importance of the observer's reliance level for the detection of cholesteatoma.

METHODS

Forty patients meeting the following criteria were included in the study: (1) chronic otitis media, (2) preoperative MRI including various DWI sequences, and (3) middle-ear surgery. The MRI protocol contained the following sequences: (1) axial and (2) coronal echoplanar imaging (EPI) readout-segmented (RESOLVE) DWI with Trace acquisition and (3) coronal non-EPI half-Fourier acquired single-shot turbo spin-echo (HASTE) DWI. Cholesteatoma diagnosis was based on standard diagnostic criteria for cholesteatoma with DWI. Additionally, the radiologists were asked to grade personal reliance on their diagnosis using a Likert-type scale from 1 = very insecure to 5 = very secure.

RESULTS

Axial and coronal RESOLVE DWI showed a sensitivity of 77.3% and a specificity of 72.2%, respectively. The mean reliance was 3.9 for axial and 3.8 for coronal images. HASTE DWI had a sensitivity/specificity of 81.8%/66.7% with the highest reliance of all evaluated sequences (4.4). Cases with a reliance level of 5 showed a sensitivity/specificity of 100% in all sequences. A reliance level of 5 was given in the axial and coronal RESOLVE DWI in 32.5% of cases and in the HASTE DWI in 57.5%.

CONCLUSION

The evaluated DWI sequences showed comparable results. The reliance level significantly improved the predictor of cholesteatoma disease with MRI techniques.

Secondary Obliteration Surgery for Troublesome Mastoid Cavities: A Prospective Series of 228 Pediatric and Adult Cases

OBJECTIVE

To present the results of a 15-year longitudinal study in a pediatric and adult population with secondary obliteration of troublesome mastoid cavities.

STUDY DESIGN

Prospective longitudinal study.

PATIENTS

Children (≤16 yrs) and adults who had obliteration surgery (228 ears) between 2000 and 2017.

INTERVENTIONS

Therapeutic.

SETTING

Tertiary referral center.

MAIN OUTCOME MEASURES

1) Incidence of recurrent or residual cholesteatoma; 2) creation of a dry ear at 5 years postsurgery; 3) postoperative complications; 4) waterproof status of ear; 5) number of subsequent ear surgery required.

RESULTS

Thirty-one pediatric and 197 adult cases contributed to the study. At 5 years 11 of 98 (10.8%) had been lost to follow-up. Using Kaplan-Meier survival analysis, the residual rate after 5 years was 4.2% (95% CI: 0.3%-8.2%) and the recurrence rate was 1% (95% CI: 0.0%-3.0%). Of the 223 ears available for assessment, 209 (93.7%) achieved a dry state, 6 (2.7%) had intermittent discharge, 6 (2.7%) had flap necrosis requiring flap trimming, and 1 (0.4%) developed meatal stenosis. Using a cross-sectional analysis at 12 months of follow-up, the otorrhea risk was 19.2% and the risk of definitive waterproofing was 10.9%. There was a reoperation risk of 10% within 5 years which included second-stage ossiculoplasty.

CONCLUSIONS

Secondary mastoid obliteration is a safe and useful technique in treating the troublesome mastoid cavity in both children and adults. It is associated with a low cholesteatoma recidivism rate and high rate of a trouble-free ear in the long term.

Evaluation of Long-term Cholesteatoma Recidivism: Using the JOS, EAONO-JOS, and STAMCO Cholesteatoma Staging Systems

OBJECTIVE

To assess the prognostic value of the Japanese Otological Society (JOS), EAONO-JOS, and STAMCO classifications in predicting the severity of acquired cholesteatoma and to identify other factors that could influence residual and recurrent cholesteatoma, as well as adverse events (AE).

METHOD

A retrospective chart review of patients undergoing primary cholesteatoma surgery in our tertiary referral center. Primary outcome measures were based on three groups of follow-up (FU): Group A, studying residual cholesteatoma, FU > 52 weeks of last-look surgery or magnetic resonance imaging, diffusion-weighted imaging; group B, studying recurrent disease, FU > 52 weeks of last outpatient clinic visit; and group C, studying AE, FU > 12 weeks after surgery. Cholesteatomata were staged according to the JOS, EAONO-JOS, and STAMCO classifications. Kaplan-Meier curves were used to determine the prognostic value of the various classifications and to identify other determining factors, while correcting for FU.

RESULTS

FU was found to be a significant confounder. No correlation was found between staging and the occurrence of residual or recurrent disease, nor the occurrence of AE. Type of surgery was a significant determinant of all three primary outcome measures. A higher age was associated with a lower risk of residual disease.

CONCLUSION

In our population the JOS, EAONO-JOS, and STAMCO classifications have limited prognostic value. Three main confounders were identified that pose a challenge in developing a universal classification: FU, surgery type, and age. Cholesteatoma staging should be postponed until a system is developed which significantly correlates cholesteatoma stage to cholesteatoma severity, to have implications for management strategies.

Optimal Duration of MRI Follow-up to Safely Identify Middle Ear Residual Cholesteatoma

BACKGROUND AND PURPOSE

Previous studies have demonstrated the usefulness of non-EPI DWI for detection of residual cholesteatoma. However, limited data are available to determine the suitable duration of imaging follow-up after a first MR imaging with normal findings has been obtained. The present study aimed to determine the optimal duration of non-EPI DWI follow-up for residual cholesteatoma.

MATERIALS AND METHODS

A retrospective, monocentric study was performed between 2013 and 2019 and included all participants followed up after canal wall up tympanoplasty with at least 2 non-EPI DWI examinations performed on the same 1.5T MR imaging scanner. MR images were reviewed independently by 2 radiologists. Sensitivity and specificity values were calculated as a function of time after the operation. Receiver operating characteristic curves were analyzed to determine the optimal follow-up duration.

RESULTS

We analyzed 47 MRIs from 17 participants. At the end of the individual follow-up period, a residual cholesteatoma had been found in 41.1% of cases. The follow-up duration ranged from 20 to 198 months (mean, 65.9 [SD, 43.9] months). Participants underwent between 2 and 5 non-EPI DWI examinations. Analyses of the receiver operating characteristic curves revealed that the optimal diagnostic value of non-EPI DWI occurred 56 months after the operation when the first MR imaging performed a mean of 17.3 (SD, 6.8) months after the operation had normal findings (sensitivity = 0.71; specificity = 0.7, Youden index = 0.43).

CONCLUSIONS

Repeat non-EPI DWI is required to detect slow-growing middle ear residual cholesteatomas. We, therefore, recommend performing non-EPI DWI for at least the first 5 years after the initial operation.

Perioperative cost evaluation of canal wall down mastoidectomy

INTRODUCTION

To evaluate perioperative costs of canal wall-down (CWD) mastoidectomy as an initial surgery compared to revision surgery following initial canal wall-up (CWU) mastoidectomy.

METHODS

This study is a retrospective chart review of adult patients who underwent CWD mastoidectomy for chronic otitis media with or without cholesteatoma at a tertiary referral center. Patients were divided into groups that had previous CWU surgery and were undergoing revision CWD and those that were having an initial CWD mastoidectomy. Cost variables including previous surgeries, imaging costs, audiometric testing, and post-operative visits were compared between the two groups using t-test analysis.

RESULTS

There was no significant difference with regards to the cost of post-operative visits, peri-operative imaging, or revision surgeries between the two groups. Hearing outcomes based on mean speech reception threshold (SRT) were not statistically different between the two groups (p = 0.087). There was a significant difference in total cost with the revision group having a higher mean cost by $6967.84, most of which was accounted for by the difference in the cost of the previous surgeries of $6488.53.

CONCLUSIONS

The revision CWD surgery group had increased total cost that could be attributed to the cost of previous surgery. Increased peri-operative cost was not noted with the initial CWD surgery group for any individual variables examined. Initial CWD mastoidectomy should be considered in the proper patient population to help decrease healthcare costs.

Apparent diffusion coefficients for predicting primary cholesteatoma risk of recurrence after surgical clearance

PURPOSE

Beside the well-known accuracy of non-EPI DWI techniques and relative ADC maps in detecting cholesteatomatous tissue, ADC can also represent a useful tool for stratifying cholesteatoma risk of recurrence. Aim of this study is to test the role of ADC in determining risk of recurrence for primary middle ear cholesteatoma, proposing stratification based on pre-operative mean (mADC) and normalized (nADC) ADC values.

METHODS

In this prospective study, 60 patients with primary unilateral middle ear cholesteatoma underwent a three-years-long follow-up to assess the presence of recurrent disease after macroscopically complete excisional surgery. Baseline MRI examination mADC and nADC values in the group with early evidence of recurrent cholesteatoma were compared to the group with no evidence of recurrence by using T statistics.

RESULTS

ADC values on pre-operative MRI examination were lower in cholesteatomas with early evidence of recurrence, and statistical significance was slightly higher for nADC compared to mADC measurements. We also determined a cut-off between the two groups, proposing stratification in high-risk of recurrence cholesteatomas (mADC≤ 1000 or nADC< 1.3) and low-risk cholesteatomas (mADC>1000 or nADC≥1.3).

CONCLUSIONS

ADC values resulted discriminating in identifying cholesteatomas with higher risk of early recurrence, both for mean and normalized ADC, with optimized tissue characterization and outcome prediction.

Recent advances in MRI of the head and neck, skull base and cranial nerves: new and evolving sequences, analyses and clinical applications

MRI is an invaluable diagnostic tool in the investigation and management of patients with pathology of the head and neck. However, numerous technical challenges exist, owing to a combination of fine anatomical detail, complex geometry (that is subject to frequent motion) and susceptibility effects from both endogenous structures and exogenous implants. Over recent years, there have been rapid developments in several aspects of head and neck imaging including higher resolution, isotropic 3D sequences, diffusion-weighted and diffusion-tensor imaging as well as permeability and perfusion imaging. These have led to improvements in anatomic, dynamic and functional imaging. Further developments using contrast-enhanced 3D FLAIR for the delineation of endolymphatic structures and black bone imaging for osseous structures are opening new diagnostic avenues. Furthermore, technical advances in compressed sensing and metal artefact reduction have the capacity to improve imaging speed and quality, respectively. This review explores novel and evolving MRI sequences that can be employed to evaluate diseases of the head and neck, including the skull base.