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Winkie Lynch Acc 140663

Winkie Lynch Acc 140663. Trisha Oura, DVM 10/25/2010. Winkie Lynch. 11 yo MC Shih Tzu Presents for evaluation of large soft palate mass 6 mos progressive respiratory stridor and increased effort, decreasing activity, recent onset dysphagia Palate mass seen on exam by rDVM. Winkie Lynch.

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Winkie Lynch Acc 140663

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  1. Winkie LynchAcc 140663 Trisha Oura, DVM 10/25/2010

  2. Winkie Lynch • 11 yo MC Shih Tzu • Presents for evaluation of large soft palate mass • 6 mos progressive respiratory stridor and increased effort, decreasing activity, recent onset dysphagia • Palate mass seen on exam by rDVM

  3. Winkie Lynch • Sedated oral exam: large mass deviating the soft palate ventrally, obstructing view of the epiglottis • FNA of mass: kertainized squamous debris • Inconclusive interpretation due to low cellularity • CT:

  4. Primary Differential:Cholesteatoma

  5. DDX • Severe otitis media • Usually not expansile • Neoplasia • Middle/inner ear • Usually soft tissue swelling w/ contrast enhancement • Usually permeative lysis of tympanic bulla/petrous temporal bone • External ear • Soft tissue mass within ear canal (enhancement)

  6. What is a Cholesteatoma? • Epidermoid cyst within the middle ear • Keratin debris surrounded by keratinized stratified squamous epithelium • VRUS paper describes 3 components (cyst, matrix, perimatrix) but not really used

  7. How are Cholesteatomas Formed? • Congenital • Start with a normal, intact tympanic membrane • No otitis media • Inclusion or rest of squamous epithelium forms a cyst • Can be recognized late in life • Acquired 1. Metaplastic transformation of normal epithelium 2. Retraction of tympanic membrane into middle ear 3. Migration of epithelium from perforated membrane into middle ear 4. Basement membrane breach w/ migration of cells from membrane into subepithelial space • Most cases in dogs occur w/ otitis media (therefore = acquired)

  8. How are Cholesteatomas Formed? • Slow or rapid expansion of cyst • Keratin or sebaceous material accumulates • Mild-severe inflammatory response • Cytokine production varies • Can become infected

  9. Role of Cholesterol? • Cholesterol granuloma reported in few dogs • Benign expansive lesions that develop in middle ear and other normally aerated bony cavities • Occurs w/ hemorrhage, obstruction of ventilation • Cholesterol precipitates (from RBC membrane or mucosa) to form crystals  granulomatous reaction • 24% of people w/ cholesteatoma have cholesterol granulomas • Also occur w/ chronic otitis media, tumors

  10. Signalment/Signs • Incidence > 11% of dogs with otitis media • Several case series: • M > F, mean age ~ 7 yo • Many with history of chronic otitis • Clinical signs (similar between reports): • Head tilt • Peripheral vestibular • Ataxia • Pain on opening mouth • Increased respiratory noise/respiratory effort (rare)

  11. CT Findings • CT features of middle ear cholesteatoma in dogs. VRUS. 2010. 51(4):374-379 • Unilateral expansile mass w/o contrast enhancement** • Keratin debris = avascular = no enhancement • Severe bone changes (slow progressive growth) • Lysis, proliferation, sclerosis • Minimal air remains in the tympanic bulla • Rarely, periosteal reaction associated with adjacent TMJ **prev. reports with heterogeneous enhancement

  12. CT Findings Trigeminal canal enlargement Pre-contrast cholesteatoma Post-contrast cholesteatoma

  13. Imaging Findings ** if cholesteatoma and cholesterol granuloma coexist, appearance can be heterogeneous and difficult to interpret

  14. Treatment/Prognosis • Surgical removal • Removal all keratin debris and epithelium • Recurrence • Risk factors: inability to open mouth, neurologic signs, bone lysis, P.aeruginosa • Recurrence in humans ~ 5-50% • If no TECA-BO, need chronic treatment with open external ear canal to allow removal of debris • Winkie had TECA-LBO & VBO • Cultured S.pseudointermedius, E. faecalis

  15. References • Hardie EM, KE Linder, AP Pease. Aural cholesteatoma in twenty dogs. Vet Surg 2008;37:763-770. • Little CJ, et al. Inflammatory middle ear disease of the dog: clinial and pathological features of cholesteatoma, a complication of otitis media. Vet Rec 1991;128:319-322. • Travetti O, et al. Computed tomography features of middle ear cholesteatoma in dogs. Vet Radiol US 2010;51:374-379.

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