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Cholesteatoma

Cholesteatoma. Kenneth C. Iverson University of South Carolina School of Medicine Class 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”

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Cholesteatoma

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  1. Cholesteatoma Kenneth C. Iverson University of South Carolina School of Medicine Class of 2007

  2. 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

  3. Case Study • Physical exam

  4. Cholesteatoma • Trapped keratinizing squamous epithelium • Temporal bone • Middle ear • Mastoid • Bony erosion of surrounding structures • Direct pressure inducing remodeling • Enzymatic activity at margins

  5. Epidemiology • Exact prevalence is unknown • Incidence estimated between 3 and 12.6 per 100,000

  6. Types and Etiologies • Congenital • Primary acquired • Secondary acquired

  7. Pathogenesis

  8. 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

  9. Diagnosis

  10. Imaging • Purpose: • Diagnosis • Determining extent • Risk assessment • Modalities: • Plain film • Computed tomography scans • Magnetic Resonance imaging

  11. 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)

  12. 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)

  13. Differential Diagnosis • Chronic serous otitis media • Jugulotympanic paragangliomas • Cholesterol granulomas • Neurofibromas • Hemangiomas • Arachnoid cyst

  14. CT Disadvantages • Granulation tissue vs. cholesteatoma • Specific soft tissue problems • Dural involvement • Abscess • Brain herniation • Labyrinth involvement • Sigmoid sinus thrombosis • MRI needed

  15. 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)

  16. T2 Delayed contrast T1 MR Imaging

  17. DW b factor = 0/mm2 100% Sensitive DW b factor = 800/mm2 (Debrulle et al, 2006) MR Imaging DW Fast SE

  18. Treatment • Surgery • Mastoidectomy • Residual 13-36% • Recurrence 5-13%

  19. 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

  20. Questions?

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