Evaluating the utility of non-echo-planar diffusion-weighted imaging in the preoperative evaluation of cholesteatoma: A meta-analysis

Surgical management of secondary acquired cholesteatoma depends on its characteristics

OBJECTIVE

Cholesteatoma secondary to tympanic perforation, known as "secondary acquired cholesteatoma" may progress slower than a retraction pocket cholesteatoma, with less bone destruction and fewer intracranial complications. However, complete surgical removal remains difficult because the pathological epithelium on the marginal side of the extension is not covered by the subepithelial layer of the cholesteatoma matrix, making the boundary with the middle ear mucosa difficult to identify. Therefore, considering the pathophysiology of secondary acquired cholesteatoma, suitable preoperative evaluation and surgical techniques are required. In this study, we aimed to evaluate (i) the extension of secondary acquired cholesteatoma according to the size and location of tympanic membrane perforation; and (ii) the microscopic surgical outcomes, including the rate of residual cholesteatoma, requirement for specialized surgical management, and changes in hearing.

METHODS

This retrospective study included data of cases with secondary acquired cholesteatoma (n = 66; 66 ears of 64 patients, 2 patients had bilateral ear involvement), including those who underwent a staged operation (n = 25).

RESULTS

The perforation level of the tympanic membrane was associated with the cholesteatoma extension. When the cholesteatoma extended around the stapes, staged operation was chosen. Six cases of spontaneous resolution of stapes lesions at the time of staged surgery were observed. A significant postoperative improvement in hearing was observed; however, five cases experienced sensorineural hearing loss.

CONCLUSION

Surgery, including staged surgery of the stapes lesions, along with careful observation of the perforation, is required in secondary acquired cholesteatoma. For lesions that are visible yet challenging to remove, it is imperative to exercise prudent judgment, taking into account the possibility of spontaneous resolution.

PROPELLER diffusion weighted imaging for diagnosis of cholesteatoma in comparison with surgical and histopathological results: emphasis on false positivity and false negativity

PURPOSE

To investigate the role of non-echo planar diffusion weighted imaging (DWI) using "periodically rotated overlapping parallel lines with enhanced reconstruction" (PROPELLER) sequence for the diagnosis of cholesteatoma compared to surgical and histopathological results in an attempt to determine the factors causing false negative and false positive diagnoses.

METHODS

Patients who had PROPELLER DWI before ear surgery were retrospectively reviewed. The presence of a lesion with diffusion restriction on PROPELLER DWI was accepted as positive for cholesteatoma, and the results were compared to the intraoperative and histopathological findings.

RESULTS

A total of 112 ears in 109 patients were reviewed. On PROPELLER DWI, a lesion with diffusion restriction was found in 101 (90.2%) ears, while in 11 (9.8%) of the patients, no diffusion restriction was found. Surgery and histopathological analysis revealed a cholesteatoma in 100 (89.3%) ears, while in 12 (10.7%) ears, no cholesteatoma was found surgically. There were 96 (85.7%) true positives, 7 (6.2%) true negatives, 5 (4.5%) false positives and 4 (3.6%) false negatives. The accuracy, sensitivity, specificity, positive predictive and negative predictive values of non-echo planar DWI were calculated to be 91.96%, 96%, 58.33%, 95.05%, and 63.64%, respectively.

CONCLUSION

Non-echo planar DWI using PROPELLER sequence has high accuracy, sensitivity and positive predictive value and can be used for the detection of cholesteatoma. The external auditory canal, postoperative ears and small lesions should be evaluated with caution to avoid false results.

The diagnostic utility of diffusion-weighted magnetic resonance imaging and high-resolution computed tomography for cholesteatoma: A meta-analysis

Objective

The purpose of this meta-analysis was to compare the efficiency of high-resolution computed tomography (HRCT) and diffusion-weighted magnetic resonance imaging (DWI) in guiding the diagnosis of middle ear cholesteatoma in clinical practice.

Materials and methods

Cochrane Library, Medline, Embase, PubMed, and Web of Science were searched for studies that evaluated the sensitivity and specificity of HRCT or DWI in detecting middle ear cholesteatoma. A random-effects model was used to calculate and summarize the pooled estimates of sensitivity, specificity, and diagnostic odds ratios. Postoperative pathological results were considered as the diagnostic gold standard for middle ear cholesteatoma.

Results

Fourteen published articles (860 patients) met the inclusion criteria. The sensitivity and specificity of DWI when diagnosing cholesteatoma (regardless of type) were 0.88 (95% confidence interval [CI], 0.80-0.93) and 0.93 (95% CI, 0.86-0.97), respectively, while those of HRCT were 0.68 (95% CI, 0.57-0.77) and 0.78 (95% CI, 0.60-0.90), respectively. Notably, the sensitivity and specificity levels of DWI were similar to those of HRCT (p = .1178 for sensitivity, p = .2144 for specificity; pair-sampled t tests). The sensitivity and specificity of DWI or HRCT for the diagnosis of primary cholesteatoma were 0.78 (95% CI, 0.65-0.88) and 0.84 (95% CI, 0.69-0.93), respectively, while that for recurrent cholesteatoma were 0.93 (95% CI, 0.61-0.99) and 0.94 (95% CI, 0.82-0.98), respectively.

Conclusion

DWI and HRCT have similar levels of high sensitivity and specificity in detecting various cholesteatomas. Also, the diagnostic efficiency of HRCT or DWI for recurrent cholesteatoma is identical to that of primary cholesteatoma. Therefore, HRCT may be used in clinical settings to reduce the use of DWI and save clinical resources.

Lay summary

Data on the use of diffusion-weighted magnetic resonance imaging and high-resolution computed tomography in the diagnosis of cholesteatoma were obtained through a literature search. They were analyzed to guide the clinical diagnosis and treatment of cholesteatoma.

Level of evidence

NA.

An Elusive Diagnosis: Delays in Treatment and Opportunities for Improvement in Temporal Encephalocele and CSF Leak

Objective

Symptoms of temporal encephalocele or cerebrospinal fluid (CSF) leak causing middle ear effusion or otorrhea can be nonspecific and mistaken for other common diagnoses, leading to delays in diagnosis, failed treatments, and a risk of meningitis. This study sought to investigate the association between symptomatology and time to definitive surgical management.

Study Design

Retrospective cohort.

Setting

Single tertiary care academic medical center.

Patients

Adults treated surgically for temporal encephalocele or CSF leak. Revision cases were excluded.

Interventions

Chart review was performed to identify pertinent symptoms at presentation. Multivariable regression was performed to analyze the association between symptoms and time to definitive management.

Main Outcome Measures

Otologic and related symptoms present prior to middle cranial fossa (MCF). Time between symptom onset and surgical treatment.

Results

Thirty-four patients had symptoms present a median of 15.5 months (interquartile range, 8-35 months; range, 1 month to 12 years) prior to surgery. The most common symptoms were subjective hearing loss in the affected ear (76.5%) and aural fullness (73.5%). Otorrhea was present in 55.9%, and 42.9% had a history of otorrhea after myringotomy with or without tube insertion. Meningitis occurred in 5 patients (14.7%). Only the absence of otalgia was statistically significantly associated with decreased time between symptoms onset and surgery (P = 0.01).

Conclusions

Encephalocele and CSF leak were most commonly associated with aural fullness and hearing loss. Medical treatment for presumed Eustachian tube dysfunction or chronic ear disease were commonly observed. Patients had symptoms for a median of almost 1 and a half years prior to surgical management.

Utility of Non-EPI DWI MRI Imaging in Cholesteatoma: The Indian Perspective

The purpose of this prospective observational study was to evaluate the diagnostic performance of non-EPI-based techniques, in detecting both primary and residual/recurrent cholesteatoma in a tertiary care center. 56 patients (25 female and 31 male) aged between 6 and 59 years were prospectively evaluated for the presence or absence of cholesteatoma. This included both primary and postoperative recurrent cholesteatoma (16). All the patients underwent sequential CT scans of temporal bones and non-EPI DWI (Non-Echo Planar Diffusion-Weighted Imaging) MRI techniques. The findings were correlated with surgical findings regarding the presence or absence of cholesteatoma. The size of cholesteatoma that was diagnosed on non-EPI DWI MRI was measured. The smallest size was 6 mm and the largest one was 21 mm. The accuracy of non-EPI DWI MRI in diagnosing cholesteatoma (primary and recurrent) was 97.5%. Whereas in diagnosing recurrent cholesteatoma accuracy was 100%. Accuracy of non-EPI DWI MRI is very high in diagnosing cholesteatoma especially in recurrent cholesteatoma and can potentially replace second look surgery when intact canal wall techniques are used. The technique is best used with a CT Scan of the temporal bone to depict bony changes, anatomical variants, or complications. The combination of HRCT and non-EPI DWI needs to be employed in diagnosing primary and recurrent cholesteatoma to maximize the diagnostic benefit as they are complimentary.

Mastoid Obliteration Decreases the Recurrent and Residual Disease: Systematic Review and Meta-analysis

OBJECTIVE

Our study aims to evaluate the effectiveness of mastoid obliteration compared to the canal wall up (CWU) technique in cholesteatoma surgery based on the systematic review of the literature and the meta-analysis of the data.

METHODS

The systematic search was performed in four major databases (MEDLINE, Web of Science, Embase, and CENTRAL) on October 14, 2021. Studies comparing the CWU technique and mastoid obliteration were included. The exclusion criteria were less than 12 months follow-up, congenital cholesteatoma, indefinite description of the surgical method, and animal studies. The protocol was registered on Prospero (registration number: CRD42021282485). The risk of bias was evaluated with the ROBINS-I tool. Residual and recurrent disease proportions as primary outcomes, quality of life, ear discharge, infection rates, hearing results, and operation time as secondary outcomes were analyzed. In the quantitative synthesis, the random effect model was used, and heterogeneity was identified.

RESULTS

A total of 11 articles with 2077 operations' data were found eligible. All the identified studies were retrospective cohorts. The odds of pooled residual and recurrent disease proportion were significantly lower in the obliteration group compared to CWU (OR = 0.45, CI:0.28;0.80, p = 0.014). However, when separated, the proportion of ears with recurrent (OR = 0.41, CI:0.11;1.57, p = 0.140) or residual (OR = 0.59, CI:0.23, 1.50, p = 0.207) disease did not show a significant difference, even though the odds were quite similar. The qualitative synthesis identified no significant difference in the secondary outcomes, but obliteration elongated the operation time.

CONCLUSION

Mastoid obliteration significantly decreased the proportion of residual and recurrent cholesteatoma in pooled analyses compared to the CWU technique with low-quality of data.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

The Efficacy of DW and T1-W MRI Combined with CT in the Preoperative Evaluation of Cholesteatoma

Objective: This study aims to assess the efficacy of diffusion-weighted (DW) and T1-weighted (T1W) magnetic resonance imaging (MRI) combined with high-resolution computed tomography (HRCT) (together as DW-T1W-CT) in the preoperative evaluation of the presence and extent of cholesteatoma, which helps determine whether a patient is suitable for transcanal endoscopic ear surgery (TEES). Methods: This retrospective study included 35 patients (18 male and 17 female) aged from 2 to 81 years diagnosed with chronic otitis media with or without cholesteatoma, who had received surgical treatment and a preoperative MRI and HRCT during the period of December 2015 to December 2020 at Cathay General Hospital. We compared the preoperative DW-T1W-CT findings with the intraoperative findings and final pathologic diagnosis. The accurate predictive value was evaluated using the presence of cholesteatoma and its extent. Results: Regarding the efficacy of detecting cholesteatoma, we found a sensitivity of 92% (23/25 cases with cholesteatoma), a specificity of 90% (9/10 cases without cholesteatoma), and an overall accurate predictive value of 91.4% (32/35) by using combined DW-T1W-CT imaging. With regard to evaluating the extent of cholesteatoma, the combined DW-T1W-CT images obtained an accurate predictive value of 84% (21/25 cases of cholesteatoma). Conclusion: Combined DW-T1W-CT has been proven to be a reliable tool in detecting the presence of cholesteatoma. It is also useful in preoperatively depicting the extent of cholesteatoma, which is crucial for determining whether a patient is suitable for TEES, aiding in surgical planning and patient consultation.

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.

Comparative evaluation of temporal subtraction computed tomography and non-echoplanar diffusion-weighted imaging for the mastoid extension of middle ear cholesteatoma

OBJECTIVE

Preoperative imaging assessment influences the decision to perform mastoidectomy for the mastoid extension of middle ear cholesteatoma. This study compared the performance of temporal subtraction CT (TSCT) and non-echoplanar diffusion-weighted imaging (non-EP DWI) in evaluating such mastoid extensions.

METHODS

We retrospectively evaluated 239 consecutive patients with surgically proven middle ear cholesteatoma between April 2016 and April 2021. The diagnostic performance of TSCT, wherein the presence of black color indicated progressive bone erosion, and non-EP DWI, wherein high signal intensity in the mastoid region suggested mastoid extension, was compared using Fisher's exact test.

RESULTS

In 34 patients with evaluable TSCT images, black color was significantly more common in patients with mastoid extension than in those without; the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of TSCT were 1.00, 0.95, 0.94, 1.00, and 0.97, respectively. In 90 patients with evaluable non-EP DWI, high signal intensity was significantly more common in patients with mastoid extension than in those without; the sensitivity, specificity, PPV, NPV, and accuracy of non-EP DWI were 0.88, 0.85, 0.91, 0.81, and 0.87, respectively. In 16 patients with both evaluable TSCT and non-EP DWI, the diagnostic performance of the TSCT was slightly superior to that of the non-EP DWI for predicting mastoid extension, although the difference was not significant.

CONCLUSIONS

TSCT images generated using consecutively acquired preoperative high-resolution CT images are useful for predicting mastoid extension of middle ear cholesteatoma, and the diagnostic performance of TSCT is non-inferior to that of non-EP DWI.

Materials used for mastoid obliteration and its complications: a systematic review

OBJECTIVE

The objectives of this review are to identify the types of materials with their associated complications and respective considerations when used to obliterate the mastoid cavity.

METHODS

A systematic search was performed across PubMed, Embase, Medline and Cochrane databases from January 2009 to January 2020 for randomized controlled trials and observational studies of patients that underwent mastoid obliteration. Studies that fulfilled the inclusion criteria were screened and scored according to the MINORS and relevance scores to determine final inclusion. Types of complications were grouped into minor and major complications based on the Clavien-Dindo classification.

RESULTS

Two thousand five hundred and seventy-eight ears were evaluated. There were a total of 165 (7.9%) minor and 142 (6.8%) major complications in the autologous group. Overall complication rate is 14.8%. The major complications were largely recurrent and residual disease requiring revision surgery. There were 10 (18.5%) minor complications and three (5.6%) major complications in the allogenic group. The cumulative complications risk is 24%. For the synthetic group, there were 39 (8.0%) minor and 34 (7.6%) major complications. The cumulative complication rate is 16.6%.

CONCLUSION

Current evidence on materials for mastoid obliteration has been evolving. Each material has its strengths and limitations. The trend over the last decade favours the use of autologous materials. The principle of using a material remains being cautious of not reimplanting skin that can lead to the development of a cholesteatoma. The choice of materials is dependent on patient factors as well as the surgeons' preference and experience.

Early non-EPI DW-MRI after cholesteatoma surgery

OBJECTIVE

Middle ear cholesteatoma may lead to the erosion of the bony structures of the temporal bone, possibly causing intra- and extracranial complications. Surgical treatment is mandatory, and due to possible residual/recurrent disease, the use of reliable diagnostic methods is essential. Our study aimed to evaluate the reliability of non-EPI DW-MRI for the follow-up of cholesteatoma after surgery.

METHODS

In a study group including 53 consecutive patients who underwent surgery for cholesteatoma at a tertiary university hospital, an imaging protocol was applied, including non-echo planar diffusion-weighted imaging magnetic resonance (MR) at 1 month after surgery and then at 6 and 12 months after surgery. Based on the combination of preoperative assessment and intraoperative findings, the study group was divided into 3 subgroups: petrous bone (PB) cholesteatoma, complicated cholesteatoma and uncomplicated cholesteatoma. PB cholesteatoma patients were treated by a subtotal petrosectomy, whereas complicated and uncomplicated cholesteatoma patients were treated either by a canal wall up procedure or a retrograde (inside-out) canal wall down technique with bone obliteration technique (BOT).

RESULTS

The results show that patients who had positive findings on non-EPI DW-MRI scans 1 month after surgery consequently underwent revision surgery during which residual cholesteatoma was noted. All the patients who displayed negative findings on non-EPI DWI-MRI scan at 1 month after surgery did not show the presence of a lesion at the 6- and 12-month evaluations. The 6 patients who displayed residual cholesteatoma at the 1-month follow-up presented dehiscence/exposure of the facial nerve canal at the primary surgery, mostly at the level of the labyrinthine segment.

CONCLUSION

Non-EPI DW-MRI is a useful and reliable tool for follow-up cholesteatoma surgery, and when applied early, as was done in the protocol proposed in the present study, this tool may be used to detect the presence of residual cholesteatoma in some patients, prompting the planning of early revision surgery.

[Combination of CT and MRT in the diagnostic of middle ear cholesteatoma. Fusion technology is precise localization tool]

Computed tomography (CT) and magnetic resonance imaging (MRI) methods of the middle ear cholesteatoma diagnostic have its advantages and disadvantages. Fusion technology is a post-processing process of CT and MRI images. Its main advantage is the localization of MR-hyperintensive cholesteatoma within the bony anatomical structures obtained on CT, which provides the surgeon with important information both before planning the primary surgical intervention and during a second revision for recurrent cholesteatoma.

New and Advanced Magnetic Resonance Imaging Diagnostic Imaging Techniques in the Evaluation of Cranial Nerves and the Skull Base

The skull base and cranial nerves are technically challenging to evaluate using magnetic resonance (MR) imaging, owing to a combination of anatomic complexity and artifacts. However, improvements in hardware, software and sequence development seek to address these challenges. This section will discuss cranial nerve imaging, with particular attention to the techniques, applications and limitations of MR neurography, diffusion tensor imaging and tractography. Advanced MR imaging techniques for skull base pathology will also be discussed, including diffusion-weighted imaging, perfusion and permeability imaging, with a particular focus on practical applications.

Long-term surgical outcomes of intracranial epidermoid tumors: impact of extent of resection on recurrence and functional outcomes in 63 patients

OBJECTIVE

The authors' objective was to reevaluate the role of microsurgery for epidermoid tumors by examining the associations between extent of resection (EOR), tumor control, and clinical outcomes.

METHODS

This was a retrospective study of patients with microsurgically treated intracranial epidermoid tumors. The recurrence-free and intervention-free rates were calculated using the Kaplan-Meier method. EOR was graded as gross-total resection (GTR) (total resection without residual on MRI), near-total resection (NTR) (a cyst lining was left in place), subtotal resection (STR) (> 90% resection), and partial resection (PR) (any other suboptimal resection) and used to stratify outcomes.

RESULTS

Sixty-three patients with mean clinical and radiological follow-up periods of 87.3 and 81.8 months, respectively, were included. Sixteen patients underwent second resections, and 5 underwent third resections. The rates of GTR/NTR, STR, and PR were 43%, 35%, and 22%, respectively, for the initial resections; 44%, 13%, and 44% for the second resections; and 40%, 0%, and 60% for the third resections (p < 0.001). The 5- and 10-year cumulative recurrence-free rates after initial resection were 64% and 32%, respectively. When stratified according to EOR, the 10-year recurrence-free rate after GTR/NTR was marginally better than that after STR (61% vs 35%, p = 0.130) and significantly better than that after PR (61% vs 0%, p < 0.001). The recurrence-free rates after initial microsurgery were marginally better than those after second surgery (p = 0.102) and third surgery (p = 0.065). The 5- and 10-year cumulative intervention-free rates after initial resection were 91% and 58%, respectively. When stratified according to EOR, the 10-year intervention-free rate after GTR/NTR was significantly better than that after STR (100% vs 51%, p = 0.022) and PR (100% vs 27%, p < 0.001). The 5-year intervention-free rate after initial surgery was marginally better than that after second surgery (52%, p = 0.088) and significantly better than that after third surgery (0%, p = 0.004). After initial, second, and third resections, permanent neurological complications were observed in 6 (10%), 1 (6%), and 1 (20%) patients, respectively. At the last follow-up visit, 82%, 23%, and 7% of patients were free from radiological recurrence after GTR/NTR, STR, and PR as the initial surgical procedure, respectively.

CONCLUSIONS

GTR/NTR seems to contribute to better disease control without significantly impairing functional status. Initial resection offers the best chance to achieve better EOR, leading to better disease control.

Survey of the Use of Diffusion-Weighted Imaging for Cholesteatoma in the United Kingdom

BACKGROUND

Non-echoplanar diffusion-weighted MRI (DWMRI) has a role in the surgical planning for cholesteatoma.

AIMS/OBJECTIVES

The aim of the study was to assess the use of DWMRI in the management of cholesteatoma across the UK, and measure clinicians' confidence in the use of DWMRI.

MATERIALS AND METHODS

Telephone survey in 139 Otolaryngology Departments in the United Kingdom between March 2017 and July 2017, and asking radiology delegates at the British Society of Head and Neck Imaging 2017 meeting.

RESULTS

The response rate was 101 out of 139 Trusts (73%). Of those respondents who did have DWMRI available, 68/88 respondents (77%) use it for cholesteatoma. The mean confidence (±standard deviation) of the respondents with DWMRI in identifying cholesteatoma presence was 7.3 ± 2.1, in identifying volume of cholesteatoma was 6.8 ± 1.8, and in identifying subsites of cholesteatoma was 4.6 ± 2.1.

CONCLUSIONS AND SIGNIFICANCE

DWMRI has a well-defined role in the follow-up of patients after cholesteatoma surgery, and those primary cases of cholesteatoma where the diagnosis is in question. The use of DWMRI for cholesteatoma is variable across the UK, but there are certain clinical scenarios where there is not enough awareness regarding the benefits of imaging (such as petrous apex cases of cholesteatoma).

Predicting Recidivism for Acquired Cholesteatoma: Evaluation of a Current Staging System

OBJECTIVE

Assess the utility and prognostic capabilities of the European Academy of Otology and Neurotology (EAONO) and Japanese Otological Society (JOS) cholesteatoma classification system, specifically for retraction pocket cholesteatoma.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral hospital.

PATIENTS

Adults and children with retraction pocket cholesteatoma.

INTERVENTIONS

Primary and planned second-look tympanoplasty with mastoidectomy.

MAIN OUTCOME MEASURES

Incidence of recurrent or residual cholesteatoma at planned second-look surgery. Independent variables of age, gender, size of canal defect, and mucosa status were assessed. Additionally, the cholesteatoma classification, stage, and extent according to the EAONO/JOS system were recorded during the primary surgery.

RESULTS

A total of 125 cases were included. Twelve (9.6%) cases had recidivism over an average time of 7.5 months: the recurrence rate was 4% (n = 5), residual rate was 5% (n = 6), and one patient had both recurrent and residual disease (0.8%). Residual cholesteatoma occurred more frequently in children (p = 0.04, RR = 7.9 [1.0, 63.6]). Supratubal recess (S1) disease was associated with both recurrent cholesteatoma (p = 0.04, RR = 5.9 [1.3, 27.2]) and recidivism (p = 0.01, RR = 4.2 [1.5, 11.9]). Larger canal defects also showed an association with residual disease (p = 0.017).

CONCLUSION

Younger patients and those with large ear canal defects tend to have residual disease at second-look surgery. Supratubal recess disease is also associated with recurrence. Despite the utility of the EAONO/JOS classification and staging system for cholesteatoma description and type, the prognostic value remains uncertain.

Application of a novel transcanal keyhole technique in endoscopic cholesteatoma surgery

BACKGROUND

It is difficult to deal with epitympanic cholesteatoma in otologic surgery. The keyhole technique can realize minimally invasive surgery and reconstruct the middle ear canal.

OBJECTIVE

To explore the clinical application of keyhole technique in primary and second-look surgery in middle ear cholesteatoma.

MATERIALS AND METHODS

34 cases were analyzed retrospectively in terms of residual and recurrence rate, safety (adverse events) and hearing performance at long-term follow-up. The application of the technique in primary or second stage operation was evaluated and the operation was performed by transanal endoscopy or combined approach.

RESULTS

The cholesteatoma revealed by CT before operation was limited to the attic in 23 patients, of which 16 had the same imaging range as that of the keyhole technique. The preoperative imaging findings of 11 showed that the attic cholesteatoma may have extended into the mastoid, of which only 6 cases were confirmed by keyhole technique. An endoscopic second-look surgery using the keyhole technique was performed for these patients, 2 were confirmed to have residual lesions in the attic.

CONCLUSIONS

The keyhole technique under otoendoscopy can be used flexibly and conveniently in the second-look surgery to make up for the shortage of diffusion-weighted magnetic resonance imaging.

Non-echoplanar diffusion weighed imaging and T1-weighted imaging for cholesteatoma mastoid extension

OBJECTIVES

A broad mastoid extension limits cholesteatoma resection via a transmeatal approach including endoscopic ear surgery. Therefore, a preoperative diagnosis of mastoid extension is a the most critical factor to determine whether to perform mastoidectomy. The purpose of this study was to assess the efficacy of non-echoplanar diffusion-weighted imaging (non-EPI DWI) and T1-weighted imaging in the evaluation of mastoid extension in cholesteatomas of the middle ear.

METHODS

Patients who underwent magnetic resonance imaging (MRI) for pretreatment evaluation before primary surgery for pars flaccida or tensa cholesteatoma, which revealed a high-signal intensity in the mastoid on T2-weighed imaging were retrospectively evaluated. Two board-certified radiologists retrospectively evaluated the extent of cholesteatomas on MRI with non-EPI DWI, non-EPI DWI- and T1-weighted axial imaging. The presence of a high signal intensity on non-EPI DWI or low or high signal intensity on T1-weighted imaging in the mastoid was evaluated. All cases were subclassified as M+ (surgically mastoid extension-positive) or M- (surgically mastoid extension-negative).

RESULTS

A total of 59 patients with middle ear cholesteatoma were evaluated. There were 37 M+ cases and 22 M- cases. High-signal intensity on non-EPI DWI exhibited a sensitivity of 0.89 and specificity of 0.82, whereas partial low-signal intensity on T1-weighted imaging exhibited a sensitivity of 0.84 and specificity of 0.91 for detecting mastoid involvement. Complete high-signal intensity on T1-weighted imaging exhibited a sensitivity of 0.73 and specificity of 0.89 for detecting non-involvement of the mastoid. The sensitivity (0.92) and specificity (0.96) of combined non-EPI DWI and T1-weighted imaging evaluation were higher than those of with non-EPI DWI or T1-weighted imaging alone. The interobserver agreement for the presence of high-signal intensity in the mastoid cavity on non-EPI DWI was very good at 0.82, that of a partial low-signal intensity area in the mastoid cavity lesions on T1-weighted imaging was good, at 0.76 and that of complete high-signal intensity in the mastoid cavity lesions on T1-weighted imaging was good, at 0.67.

CONCLUSIONS

The signal intensity on non-EPI DWI and T1-weighted imaging of the mastoid could be used to accurately assess the extent of middle ear cholesteatoma, which could facilitate surgical treatment planning.

Positive predictive value for diffusion-weighted magnetic resonance imaging in pediatric cholesteatoma: A retrospective study

OBJECTIVES

The aims of this study were first to calculate the Positive Predictive Value (PPV) of DW-MRI to detect cholesteatoma and then to analyze false positives.

METHODS

All temporal bone MRI with DWI sequences performed in our pediatric university hospital between 2005 and 2015 were included retrospectively. 46 patients with a cholesteatoma diagnosis on the MRI report and who underwent surgery were studied.

RESULTS

The number of DW-MRI for identification of cholesteatoma has grown in ten years. We calculated an 89% Positive Predictive Value. DW-MRI sensitivities were 100.0% and 70.7% for respectively keratin and squamous epithelium.

CONCLUSION

DW-MRI hypersignal is not synonymous of cholesteatoma diagnosis. Indeed, this diagnosis relies on the importance of a proper otoscopic examination, a suggestive medical history, CT scan data and analysis of other MRI sequences, including T1-weighted sequence, to rule out other etiologies of middle ear DW-MRI hypersignal.

Endoscopic Management of Primary Acquired Cholesteatoma

Endoscopic ear surgery is increasingly accepted as a primary modality for cholesteatoma surgery. A major advantage is the enhanced visualization of the middle ear in traditionally poorly accessible locations by the microscope. We discuss novel techniques for selective mastoid obliteration when a canal wall down mastoidectomy is necessary. Postoperatively, indications for non-echo planar diffusion-weighted imaging MRI versus second-look surgery are discussed. Finally, outcome data for endoscopic versus microscopic ear surgery are reviewed, which show equivalent outcomes regarding residual and recurrent disease, similar rates of complications, decreased pain, and shorter healing time.

The Medially-Invasive Cholesteatoma: An Aggressive Subtype of a Common Pathology

OBJECTIVE

Describe the outcomes of treatment for patients with cholesteatomas that are medially invasive to the otic capsule, petrous apex, and/or skull base.

STUDY DESIGN

Retrospective case series.

SETTING

Two tertiary care academic centers.

PATIENTS

Patients surgically managed for medially-invasive cholesteatoma at two tertiary care institutions from 2001 to 2017.

INTERVENTIONS

Surgical management of medially-invasive cholesteatomas.

MAIN OUTCOME MEASURES

The presenting symptoms, imaging, pre- and post-operative clinical course, and complications were reviewed.

RESULTS

Seven patients were identified. All patients had pre-operative radiographic evidence of invasive cholesteatoma with erosion into the otic capsule beyond just a lateral semicircular canal fistula. Five patients had a complex otologic history with multiple surgeries for recurrent cholesteatoma including three with prior canal wall down mastoidectomy surgeries. Average age at the time of surgery was 41.3 years (range 20-83). Two patients underwent a hearing preservation approach to the skull base while all others underwent a surgical approach based on the extent of the lesion. Facial nerve function was maintained at the pre-operative level in all but one patient. No patient developed cholesteatoma recurrence.

CONCLUSIONS

The medially-invasive cholesteatoma demonstrates an aggressive, endophytic growth pattern, invading into the otic capsule or through the perilabyrinthine air cells to the petrous apex. Surgical resection remains the best treatment option for medially-invasive cholesteatoma. When CSF leak is a concern, a subtotal petrosectomy with closure of the ear is often necessary.

Negative Predictive Value of Non-Echo-Planar Diffusion Weighted MR Imaging for the Detection of Residual Cholesteatoma Done at 9 Months After Primary Surgery Is not High Enough to Omit Second Look Surgery

OBJECTIVES

To evaluate non echo-planar diffusion weighted magnetic resonance imaging (non-EP DW MRI) at 9 months after primary surgery to rule out residual cholesteatoma in patients scheduled before second-look-surgical exploration.

STUDY DESIGN

Prospective observational study.

SETTING

Secondary teaching hospital.

PATIENTS/INTERVENTIONS

Patients who were scheduled for second-look-surgery after primary canal wall up repair of cholesteatoma underwent 1.5 T MRI including non-EP DWI and high-resolution coronal T1 and T2-FS SE sequences.

MAIN OUTCOME MEASURES

Imaging studies were evaluated for the presence of cholesteatoma by three independent observers. Intraoperative observations were regarded the standard of reference. Ear, nose, throat (ENT) surgeons were blinded for imaging findings. The primary outcome was the negative predictive value (NPV) of MR imaging, secondary outcomes were sensitivity, specificity, and positive predictive value.

RESULTS

Thirty-three patients underwent both MRI and surgery, among whom 22 had a cholesteatoma. Mean time between primary surgery and MRI was 259 days (standard deviation [SD] 108). NPV of non-EP DW MRI in detecting recurrent cholesteatoma was 53% (95% CI: 32-73%). Sensitivity and specificity were 59% (39-77%) and 91% (62-98%), respectively. The positive predictive value was 93% (69-99%). In five out of nine false-negative cases, recurrent cholesteatoma measured 3 mm or less. Using a 3 mm detection threshold, NPV increased to 79%.

CONCLUSION

Non-EP DW MRI cannot replace second look surgery in ruling-out residual cholesteatoma at 9 months after primary surgery. It could be used in a follow-up strategy in low risk patients. Further research is needed which types of residual cholesteatoma are not revealed by MRI.

Beyond the brain: Extra-axial pathology on diffusion weighted imaging in neuroimaging

Diffusion-weighted imaging (DWI) has a central role in the assessment of the brain parenchyma, particularly in the context of acute stroke. However, the applications of DWI extend far beyond the brain parenchyma and include the assessment of the extra-axial structures of the head and neck that are included in routine brain imaging. In this pictorial review, the added-value of DWI over other conventional sequences is illustrated through discussion of a broad range of disorders affecting the vasculature, skull, orbits, nasal cavity and salivary glands. This article highlights the requirement for all structures, both intra- and extra-axial, to be carefully reviewed on DWI.

Value of DW-MRI in the preoperative evaluation of congenital cholesteatoma

OBJECTIVE

This study evaluated the clinical value of diffusion-weighted magnetic resonance imaging (DW-MRI) in the diagnosis and staging of congenital cholesteatoma (CC).

PATIENTS AND METHODS

We retrospectively reviewed 24 patients with CC. All the patients underwent computed tomography (CT) and DW-MRI preoperatively; thereafter, surgery was performed. DW-MRI examination was performed with a 3 T MRI system using three-dimensional reversed fast imaging with steady-state precession and diffusion-weighted magnetic resonance sequence. The preoperative and operative CT and DW-MRI findings were compared.

RESULTS

Using DW-MRI, cholesteatoma was successfully detected in 17 (71%) of the 24 patients with CC. Among the seven patients with false-negative results, the cholesteatoma mass diameter was <5 mm in six patients and ≥5 mm in one patient. One of these patients had open type congenital cholesteatoma (OTCC). The detection rates for closed type cholesteatoma and OTCC were 85% (17/20) and 0% (0/4), respectively, using DW-MRI. Using CT and DW-MRI, the correct stage was identified in 88% (15/17) and 59% (10/17) of the patients with aeration around the CC and in 0% (0/7) and 100% (7/7) of those without aeration around the CC, respectively.

CONCLUSION

CT is the primary imaging tool for evaluating suspected CC in patients with aeration around the CC. However, CT is unreliable for the detection of the extension and staging of CC when the middle ear is filled with nonspecific imaging. DW-MRI is useful for the preoperative diagnosis and staging of CC > 5 mm in diameter with or without surrounding granulation tissue. Thus, we recommend using DW- MRI at least when CT fails to localize CC as a soft tissue mass because of non-specific tissue filling the middle ear and the mastoid.

Measuring growth of residual cholesteatoma in subtotal petrosectomy

BACKGROUND

Little is known about the growth rate of cholesteatoma in patients.

OBJECTIVE

Investigate the growth of residual cholesteatoma in subtotal petrosectomy based on volume measured in MRI scans.

MATERIALS AND METHODS

Retrospective case series in a Tertiary Medical Centre. Thirteen residual cholesteatomas were identified in 10 patients after subtotal petrosectomy for which a wait-and-scan policy was adopted. Volume of the residual cholesteatoma was calculated by manual segmentation as well as the 'box method'.

RESULTS

Mean growth rate was 27.9 mm3/month (SD 22.8), with a large individual variation ranging from 2.2 to 69.8 mm3/month. No complications were reported in 10 patients with a wait-and-scan policy for residual cholesteatoma in subtotal petrosectomy. The box method overestimates growth rate compared to the reference method manual segmentation and a linear increase of this systematic error was seen with increasing size of the cholesteatoma.

CONCLUSIONS

Residual cholesteatoma growth rate shows a large individual variation. A wait-and-scan policy could be considered in case of a (small) residual in subtotal petrosectomy with ample room to grow before destroying any remaining structures. Furthermore, the clinically more applicable and less time-consuming box method can be used to accurately measure volumes of small cholesteatomasup to a volume of 500 mm³.

The diagnostic accuracy of 1.5 T versus 3 T non-echo-planar diffusion-weighted imaging in the detection of residual or recurrent cholesteatoma in the middle ear and mastoid

PURPOSE AND BACKGROUND

This study retrospectively compares diagnostic performance of 1.5 T versus 3 T non-echo planar diffusion weighted imaging with or without additional T1 and T2 sequences in the detection of residual and/or recurrent cholesteatoma.

METHODS

Patients with clinically suspected recurrent cholesteatoma or postoperative routine survey MR who subsequently underwent surgical procedure were retrospectively included (135 patients, 164 operated ears) from a large database. Patients underwent 1.5 T (128 ears) or 3 T MRI (36 ears), with non-echo planar DWI, T1 and T2 acquisitions. Two radiologists independently reassessed the images. Definitive surgical diagnosis was used as gold standard. Sensitivity, specificity and diagnostic odds ratio were evaluated.

RESULTS

According to surgical diagnosis a cholesteatoma was present in 124 of 164 ears, corresponding with a prevalence of 75%. Sensitivity and specificity were lower for 3 T compared to 1.5 T, irrespective of whether additional T1 and T2-weighted sequences were used or not. Diagnostic odds ratios were higher for 1.5 T (34 and 12 for reader 1 and 2, respectively) compared to 3 T (3 and 4 for reader 1 and 2, respectively). Adding T1 and T2 sequences lowers sensitivity but increases specificity.

CONCLUSION

Non-epi DWI for the detection of residual/recurrent cholesteatoma is preferably performed on 1.5 T scanners over 3 T. The use of additional sequences regarding detection of cholesteatoma is debatable as it lowers sensitivity but increases specificity. However, these sequences may also be of use in diagnosing complications and planning surgical procedures in some hospitals.

The value of arterial spin labelling in adults glioma grading: systematic review and meta-analysis

This study aimed to evaluate the diagnostic performance of arterial spin labelling (ASL) in grading of adult gliomas. Eighteen studies matched the inclusion criteria and were included after systematic searches through EMBASE and MEDLINE databases. The quality of the included studies was assessed utilizing Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The quantitative values were extracted and a meta-analysis was subsequently based on a random-effect model with forest plot and joint sensitivity and specificity modelling. Hierarchical summary receiver operating characteristic (HROC) curve analysis was also conducted. The absolute tumour blood flow (TBF) values can differentiate high-grade gliomas (HGGs) from low-grade gliomas (LGGs) and grade II from grade IV tumours. However, it lacked the capacity to differentiate grade II from grade III tumours and grade III from grade IV tumours. In contrast, the relative TBF (rTBF) is effective in differentiating HGG from LGG and in glioma grading. The maximum rTBF (rTBFmax) demonstrated the best results in glioma grading. These results were also reflected in the sensitivity/specificity analysis in which the rTBFmax showed the highest discrimination performance in glioma grading. The estimated effect size for the rTBF was approximately similar between HGGs and LGGs, and grade II and grade III tumours, (-1.46 (-2.00, -0.91), p-value < 0.001), (-1.39 (-1.89, -0.89), p-value < 0.001), respectively; while it exhibited smaller effect size between grade III and grade IV (-1.05 (-1.82, -0.27)), p < 0.05). Sensitivity and specificity analysis replicate these results as well. This meta-analysis suggests that ASL is useful for glioma grading, especially when considering the rTBFmax parameter.

Cholesteatoma: multishot echo-planar vs non echo-planar diffusion-weighted MRI for the prediction of middle ear and mastoid cholesteatoma

Objective

We aimed to compare a newer readout-segmented echoplanar imaging (RS-EPI) technique with the established single shot turbo spin echo (SS-TSE) non-EPI diffusion-weighted imaging (DWI) in detecting surgically validated cholesteatoma.

Methods

We retrospectively reviewed 358 consecutive MRI studies in 285 patients in which both RS-EPI and non-EPI DWI sequences were performed. Each diffusion sequence was reviewed independently and scored negative, indeterminate or positive for cholesteatoma in isolation and after reviewing the T ₁W sequence. Average artefacts scores were evaluated and the lesion size measured as a distortion indicator. The imaging scores were correlated with surgical validation, clinical and imaging follow-up.

Results

There were 239 middle ear and central mastoid tract and 34 peripheral mastoid lesions. 102 tympanomastoid operations were performed. The positive predictive value ( PPV), post-operative PPV, primary PPV, negative predictive value were 93%, 95%, 87.5%, 70% for RS-EPI and 92.5%, 93.6%, 90%, 79% for non-EPI DWI. There was good agreement between the two techniques (k = 0.75). Non-EPI DWI is less susceptible to skull base artefacts although the mean cholesteatoma measurement difference was only 0.53 mm.

Conclusion

RS-EPI has comparable PPV with non-EPI DWI in both primary and post-operative cholesteatoma but slightly lower negative predictive value. When there is a mismatch, non-EPI DWI better predicts the presence of cholesteatoma. There is good agreement between the sequences for cholesteatoma diagnosis. The T ₁W sequence is very important in downgrading indeterminate DWI signal lesions to a negative score.

Advances in knowledge

This is, to our knowledge, the first study to compare a multishot EPI DWI technique with the established non- EPI DWI in cholesteatoma diagnosis.

Using Non-Echoplanar Diffusion Weighted MRI in Detecting Cholesteatoma Following Canal Wall Down Mastoidectomy - Our Experience with 20 Patient Episodes

OBJECTIVE

To our knowledge, there is no study exploring specifically the diagnostic performance of diffusion-weighted imaging (DWI) in patients with previous canal wall down (CWD) surgery when combined with appropriate clinical evaluation. The aim of the present study was to evaluate the performance of DWI in the detection of residual or recurrent disease in patients who have had a previous CWD mastoidectomy.

MATERIALS AND METHODS

We identified 13 patients with a CWD mastoidectomy subsequently having at least one further DWI prior to further mastoid exploration that generated a total of 20 patient episodes. Magnetic resonance imaging was performed on a 1.5 T superconductive unit using a standard head matrix coil. Coronal 2 mm thick TSE T2-weighted images (TR: 4640 ms; TE: 103 ms; matrix: 245,384; field of view: 150×200 mm) were performed. Operative findings were reviewed for all 20 patient episodes to compare DWI findings with intraoperative findings. Based on this, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated.

RESULTS

DWI had a sensitivity of 93%, specificity of 60%, PPV of 87%, NPV of 75%, and accuracy of 80%.

CONCLUSION

Given the high sensitivity of DWI in the detection of residual or recurrent disease, the present study supports DWI as a useful tool in the detection of residual or recurrent cholesteatoma in cases following CWD surgery, where clinical acumen suggests an ongoing disease process despite no overt cholesteatoma being visible.

The Role of Non-Echoplanar Diffusion-Weighted Magnetic Resonance Imaging in Diagnosis of Primary Cholesteatoma and Cholesteatoma Recidivism as an Adjunct to Clinical Evaluation

Introduction:

The aim of this study was to analyze the sensitivity and specificity of non-echoplanar (non-EPI) diffusion-weighted (DW) magnetic resonance imaging (MRI) for the detection of cholesteatoma, with a focus on its value as an adjunct to clinical examination.

Methods:

In a prospective cohort study, 92 cases were divided into 2 groups: “clinically cholesteatoma” ( n = 79) and “clinically no cholesteatoma” ( n = 13). Non-EPI DW MRI was performed preoperatively in all cases. The presence of a cholesteatoma was assessed by clinicians otoscopically, by neuroradiologists on non-EPI DW MRI, by the surgeon intraoperatively, and finally by the pathologist postoperatively. Data analysis was performed for specificity, sensitivity, positive predictive value, negative predictive value, and interrater variability.

Results:

The sensitivity and specificity were 89.3% and 75%, respectively, in the “clinically cholesteatoma” group and 0% and 100% in the “clinically no cholesteatoma” group. Non-EPI DW MRI had a positive predictive value of 98.5% when cholesteatoma was suspected clinically and a negative predictive value of 84.6% when cholesteatoma was not suspected clinically.

Conclusion:

If cholesteatoma is suspected clinically, non-EPI DW MRI is not necessary. If there is no clinical suspicion of cholesteatoma in second-look situations, sensitivity is low and serial follow-up MRI with long intervals is advised.

Cholesteatoma vs granulation tissue: a differential diagnosis by DWI-MRI apparent diffusion coefficient

PURPOSE

To diagnose cholesteatoma when it is not visible through tympanic perforation, imaging techniques are necessary. Recently, the combination of computed tomography and magnetic resonance imaging has proven effective to diagnose middle ear cholesteatoma. In particular, diffusion weighted images have integrated the conventional imaging for the qualitative assessment of cholesteatoma. Accordingly, the aim of this study was to obtain a quantitative analysis of cholesteatoma calculating the apparent diffusion coefficient value. So, we investigated whether it could differentiate cholesteatoma from other inflammatory tissues both in a preoperative and in a postoperative study.

METHODS

This study included 109 patients with clinical suspicion of primary or residual/recurrent cholesteatoma. All patients underwent preoperative computed tomography and magnetic resonance imaging with diffusion sequences before primary or second-look surgery to calculate the apparent diffusion coefficient value.

RESULTS

We found that the apparent diffusion coefficient values of cholesteatoma were significantly lower than those of non cholesteatoma. In particular, the apparent diffusion coefficient median value of the cholesteatoma group (0.84 × 10^- 3 mm²/s) differed from the inflammatory granulation tissue (2.21 × 10^- 3 mm²/s) group (p < 2.2 × 10^- 16). Furthermore, we modeled the probability of cholesteatoma by means of a logistic regression and we determined an optimal cut-off probability value of ~ 0.86 (specificity = 1.0, sensitivity = 0.97), corresponding to an apparent diffusion coefficient cut-off value of 1.37 × 10^- 3 mm²/s.

CONCLUSIONS

Our study has demonstrated that apparent diffusion coefficient values constitute a valuable quantitative parameter for preoperative differentiation of cholesteatomas from other middle ear inflammatory diseases and for postoperative diagnosis of recurrent/residual cholesteatomas.

Accuracy of turbo spin-echo diffusion-weighted imaging signal intensity measurements for the diagnosis of cholesteatoma

PURPOSE

We aimed to evaluate the diagnostic accuracy of turbo spin-echo diffusion-weighted imaging (TSE-DWI) at 3 T, for cholesteatoma (CS) diagnosis, using qualitative and quantitative methods with numerical assessment of signal intensity (SI), signal intensity ratios (SIR), and apparent diffusion coefficient (ADC) values.

METHODS

In this retrospective study, two blinded observers independently evaluated the preoperative TSE-DWI images of 57 patients who were imaged with a presumed diagnosis of CS. Qualitative assessment with respect to the SI of the adjacent cortex and quantitative measurements of SI, SIR, and ADC values were performed.

RESULTS

Surgery with histopathologic examination revealed 30 CS patients and 27 patients with non-cholesteatoma (NCS) lesions including chronic inflammation and cholesterol granuloma. On TSE-DWI, 96.7% of the CS lesions and none of the NCS lesions appeared hyperintense compared with the cortex. The mean SI and SIR indices of the CS group were significantly higher and the mean ADC values significantly lower compared with those of the NCS group (P < 0.001). Using specific cutoff values for SI (92.5) and SIR (0.9), CS could be diagnosed with 100% sensitivity and specificity. The use of quantitative imaging further increased the sensitivity of the TSE-DWI technique.

CONCLUSION

The quantitative indices of SI, SIR, and ADC of TSE-DWI appear to be highly accurate parameters that can be used to confirm the diagnosis of CS.

Diffusion-Weighted Magnetic Resonance Imaging of Cholesteatoma Using PROPELLER at 1.5T: A Single-Centre Retrospective Study

PURPOSE

The purpose of this study was to evaluate the sensitivity, specificity, and positive and negative predictive values of the diffusion-weighted periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) technique in the detection of cholesteatoma at our institution with surgical confirmation in all cases.

METHODS

A retrospective review of 21 consecutive patients who underwent diffusion-weighted PROPELLER magnetic resonance imaging (MRI) on a 1.5T MRI scanner prior to primary or revision/second-look surgery for suspected cholesteatoma from 2009-2012 was performed.

RESULTS

Diffusion-weighted PROPELLER had a sensitivity of 75%, specificity of 60%, positive predictive value of 86%, and negative predictive value of 43%. In the 15 patients for whom the presence or absence of cholesteatoma was correctly predicted, there were 2 cases where the reported locations of diffusion restriction did not correspond to the location of the cholesteatoma observed at surgery.

CONCLUSION

On the basis of our retrospective study, we conclude that diffusion-weighted PROPELLER MRI is not sufficiently accurate to replace second look surgery at our institution.

Non-echoplanar diffusion weighted imaging in the detection of post-operative middle ear cholesteatoma: navigating beyond the pitfalls to find the pearl

Abstract

Non-echoplanar diffusion weighted magnetic resonance imaging (DWI) has established itself as the modality of choice in detecting and localising post-operative middle ear cleft cholesteatoma. Despite its good diagnostic performance, there are recognised pitfalls in its radiological interpretation which both the radiologist and otologist should be aware of. Our article highlights the various pitfalls and provides guidance for improving radiological interpretation and navigating beyond many of the pitfalls. It is recommended radiological practice to interpret the diffusion weighted images together with the ADC map and supplement with the corresponding T1 weighted and T2 weighted images, all of which can contribute to and enhance lesion localisation and characterisation. ADC values are also helpful in improving specificity and confidence levels. Given the limitation in sensitivity in detecting small cholesteatoma less than 3 mm, serial monitoring with DWI over time is recommended to allow any small residual cholesteatoma pearls to grow and become large enough to be detected on DWI. Optimising image acquisition and discussing at a joint clinico-radiological meeting both foster good radiological interpretation to navigate beyond the pitfalls and ultimately good patient care.

Teaching Points

• Non-echoplanar DWI is the imaging of choice in detecting post-operative cholesteatoma.

• There are recognised pitfalls which may hinder accurate radiological interpretation.

• Interpret with the ADC map /values and T1W and T2W images.

• Serial DWI monitoring is of value in detection and characterisation.

• Optimising image acquisition and discussing at clinico-radiological meetings enhance radiological interpretation.

Imaging innovations in temporal bone disorders

The development of new imaging techniques coupled with new treatment algorithms has created new possibilities in treating temporal bone diseases. This article provides an overview of recent imaging innovations that can be applied to temporal bone diseases. Topics covered include the role of magnetic resonance (MR) diffusion-weighted imaging in cholesteatomas and skull base epidermoids, whole-body molecular imaging in paragangliomas of the jugular foramen, and MR arterial spin labeling perfusion for dural arteriovenous fistulas and arteriovenous malformations.

Non-echoplanar diffusion-weighted MRI in children and adolescents with cholesteatoma: reliability and pitfalls in comparison to middle ear surgery

BACKGROUND

Currently, there is only limited and contradictory evidence of the role of diffusion-weighted MRI (DW-MRI) in the management of children with cholesteatoma.

OBJECTIVE

To provide surgically controlled data that may allow to replace second-look surgery by non-echoplanar DW-MRI in children.

MATERIALS AND METHODS

Fifty-five children and adolescents with a median age of 8.6 years (2.2-17.7 years) underwent 61 preoperative half-Fourier acquisition single-shot turbo spin-echo (HASTE) DW-MRI of their petrous bone. Surgical interventions followed within 24 h (79%), within 5 months (20%) or at 18 months (1 case).

RESULTS

Surgery detected a cholesteatoma or retraction pocket in 41 of 61 cases (67%). In 49 cases (80%), the MR result was confirmed by surgical findings. Two MR findings were false-positive and 10 false-negative (including cholesteatomas <4 mm). HASTE DW-MRI alone had a sensitivity of 76% and a specificity of 90%. The positive predictive value was 94%, the negative predictive value 64%. In combination with preoperative otoscopy, sensitivity was 90% and negative predictive value 82%.

CONCLUSION

DW-MRI correctly detected the majority of lesions but could not reliably exclude small cholesteatomas and empty retraction pockets. We would therefore not generally recommend MR as a substitute for second-look surgery.

Updates and knowledge gaps in cholesteatoma research

The existence of acquired cholesteatoma has been recognized for more than three centuries; however, the nature of the disorder has yet to be determined. Without timely detection and intervention, cholesteatomas can become dangerously large and invade intratemporal structures, resulting in numerous intra- and extracranial complications. Due to its aggressive growth, invasive nature, and the potentially fatal consequences of intracranial complications, acquired cholesteatoma remains a cause of morbidity and death for those who lack access to advanced medical care. Currently, no viable nonsurgical therapies are available. Developing an effective management strategy for this disorder will require a comprehensive understanding of past progress and recent advances. This paper presents a brief review of background issues related to acquired middle ear cholesteatoma and deals with practical considerations regarding the history and etymology of the disorder. We also consider issues related to the classification, epidemiology, histopathology, clinical presentation, and complications of acquired cholesteatoma and examine current diagnosis and management strategies in detail.

Diagnostic capacity of non-echo planar diffusion-weighted MRI in the detection of primary and recurrent cholesteatoma

INTRODUCTION AND AIMS

the aim of this study was to determine the certainty of non-echo-planar imaging diffusion-weighted magnetic resonance imaging (non-EPI DW MRI) in the diagnosis of primary and recurrent cholesteatoma in patients with clinical suspicion of cholesteatoma, assessing the sensitivity and specificity of the test in both groups.

METHODS

Seventy-five patients with clinical suspicion of cholesteatoma were included in our study. Forty-eight cases had primary suspicion of cholesteatoma and 27 cases had recurrent suspicion of cholesteatoma. All patients received non-EPI DW MRI tests before surgery, and radiological and surgical findings were compared.

RESULTS

Sensitivity, specificity and the positive and negative predictive value for primary diagnosis of cholesteatoma group were 91.2%, 50%, 81.6% and 70%, respectively. For the recurrent cholesteatoma group these results were 100%, 66.7%, 90.9% and 100%, respectively.

CONCLUSION

Non-echo-planar imaging diffusion-weighted magnetic resonance imaging is a high sensitivity imaging test for detecting cholesteatoma, for both primary diagnosis and for recurrent cases.