cholesteatoma
TRANSCRIPT
Cholesteatoma
Kenneth C. IversonUniversity of South Carolina
School of MedicineClass of 2007
Case Study
• 8 year old female• History of chronic Eustachian tube
dysfunction• Recurrent acute otitis media since age 3• Multiple failed audiograms at school due to
“fluid in the ears”• History of recent bloody otorrhea• No facial palsy, vertigo, or ear surgery
Case Study
• Physical exam
Cholesteatoma
• Trapped keratinizing squamous epithelium– Temporal bone– Middle ear– Mastoid
• Bony erosion of surrounding structures– Direct pressure inducing remodeling– Enzymatic activity at margins
Epidemiology
• Exact prevalence is unknown
• Incidence estimated between 3 and 12.6 per 100,000
Types and Etiologies
• Congenital
• Primary acquired
• Secondary acquired
Pathogenesis
Clinical manifestations
• Common– Painless otorrhea– Refractory/recurrent ear infections– Conductive hearing loss
• Uncommon– Vertigo/Sensorineural – Facial nerve paralysis– CNS infections– Brain herniation/CSF leak– Pneumocephalus
Diagnosis
Imaging
• Purpose:– Diagnosis– Determining extent– Risk assessment
• Modalities:– Plain film– Computed tomography scans– Magnetic Resonance imaging
Dr. Hendrik Willem Stenvers (1889-1973) Utrecht, Niederlande, Neurologe.
Pionierarbeiten auf dem Gebiet der Neuroradiologie, insbesondere der Aufnahmetechnik des Felsenbeins.
High Resolution CT Imaging
• Coronal sections• 512 matrix• 250 mm field of view• 1.5 mm contiguous slices• 25 slices per exam• 0.017 mSv per slice
– (Yates et al, 2002)
Goals of CT Imaging
• Middle ear ventilation• Ossicular destruction• Epitympanum access• Mastoid cortex• Tegmen integrity• Labyrinth involvement• Facial nerve involvement• Surgical changes
– (Yates et al, 2002)
Differential Diagnosis
• Chronic serous otitis media• Jugulotympanic paragangliomas• Cholesterol granulomas• Neurofibromas• Hemangiomas• Arachnoid cyst
CT Disadvantages
• Granulation tissue vs. cholesteatoma• Specific soft tissue problems
– Dural involvement– Abscess– Brain herniation– Labyrinth involvement– Sigmoid sinus thrombosis
• MRI needed
MR Imaging
• Hypointense on T1– Isointense to brain
• Intermediate on T2• Nonenhancing• Granulation tissue does enhance• Recurrence detection
– Lesions >2mm– 90% sensitive, 100% specificity
• (Ayache et al, 2005)
MR Imaging
• T2 • Delayed contrast T1
MR Imaging DW Fast SE
• DW b factor = 0/mm2
• 100% Sensitive
• DW b factor = 800/mm2
• (Debrulle et al, 2006)
Treatment
• Surgery
• Mastoidectomy
• Residual 13-36%
• Recurrence 5-13%
References• Ayache D, et al. Usefulness of Delayed Postcontrast Magnetic Resonance
Imaging in the Detection of Residual Cholesteatoma after Canal Wall-Up Tympanoplasty: Laryngoscope 115: 607-610, 2005
• Chakers DW, et al. Epitympanic Cholesteatoma Head and Neck Case 102: American College of Radiology Learning Files: 1996
• Cummings CW, et al: Otolaryngology: Head and Neck Surgery, 4th ed. Philadelphia: Elsevier, 2005
• Debrulle F, et al. Diffusion-weighted MR Imaging Sequence in the Detection of Postoperative Recurrent Cholesteatoma: Radiology 238 (2): 604-610, 2006
• El-Bitar MA, et al. Congenital middle ear cholesteatoma: need for early recognition – role of computed tomography scan: Int J of Ped Otolaryngology 67: 231-235, 2003
• Grainger, et al. Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. Churchill Livingstone, 2001.
• Grossman RI and Yousem DM. Neuroradiology, 2nd ed. Philadelphia: Mosby, 2003
• Yates PD, et al. CT scanning of middle ear cholesteatoma: what does the surgeon want to know?: British J of Radiology 75: 847-852, 2002
Questions?
