Imaging of non-operated cholesteatoma: Clinical practice guidelines

Improving access to imaging availability in otology clinic

RATIONALE

Radiologic imaging is an essential component in the workup of many patients with neuro-otologic conditions. However, patients often present for consultation with a neurotologist without the imaging that they have already undergone as part of their workup by a referring clinician. This disconnect causes frustration for clinicians and possible delays in care for patients. Anecdotally, clinicians felt that patients who had contact with clinic coordinators before their appointment were more likely to have their prior imaging available for review at the time of their initial consultation.

AIMS AND OBJECTIVES

We aimed to increase the rate at which new patients brought their prior imaging to their initial consultation to at least 80% by improving previsit communication with patients and referring providers.

METHODS

Key stakeholders identified pain points in the flow of information from patients' outside facility workups. We then used the Plan-Do-Study-Act quality improvement framework to develop, implement and iterate on two interventions intended to improve communication with patients, referring clinics and outside imaging centres. Chart review was used to assess the proportion of patients with imaging available for review at the time of initial consultation and a short satisfaction survey was sent to attending neurotologists in the pre and postintervention periods.

RESULTS

Before any interventions, 56.5% of typical new patients who reported having prior imaging had that imaging available for review at the time of their initial consultation. Following our interventions, this percentage increased to 73.5% and then 80.9% of new patients, respectively. Additionally, physicians reported improved satisfaction in several areas and spent less time reviewing imaging outside of clinic visits after our interventions.

CONCLUSIONS

Improved communication and tracking of image receipt in clinics receiving many referrals saves physicians' time, reduces frustration and cuts down on the overall administrative burden following patients' appointments.

New Compartmental Reading Method for MRI Enables Accurate Localization of Cholesteatomas With High Sensitivity and Specificity

OBJECTIVES

Cholesteatoma is an inflammatory disease, frequently observed in childrens and young adults, with a risk of relapse or recurrence. The few studies which analyzed cholesteatoma localization on magnetic resonance imaging (MRI) usually merged CT-MR images or relied on their authors' anatomical knowledge. We propose a compartmental reading method of the compartments of the middle ear cavity for an accurate localization of cholesteatomas on MR images alone.

MATERIAL AND METHODS

Our method uses easily recognizable anatomical landmarks, seen on both computed tomography (CT) and MRI, to delimit the middle ear compartments (epitympanum, mesotympanum, hypotympanum, retrotympanum, protympanum, antrum-mastoid cavity). We first tested it on 50 patients on non-enhanced temporal bone CT. Then, we evaluated its performances for the localization of cholesteatomas on MRI, compared with surgery on 31 patients (validation cohort).

RESULTS

The selected anatomical landmarks that delimited the middle ear compartments were applicable in 98 to 100% of the cases. In the validation cohort, we were able to accurately localize the cholesteatoma on MRI in 83% of the cases (n = 26) with high sensitivity (95.7%) and specificity (98.6%).

CONCLUSION

With our compartmental reading method, based on the recognition of well-known anatomical landmarks to differentiate the compartments of the middle ear cavity on MRI, we were able to accurately localize the cholesteatoma with high (>90%) sensitivity and specificity. Such landmarks are widely applicable and only require limited learning time based on key images. Accurate localization of the cholesteatoma is useful for the choice of surgical approach.

Eyes in Ears: A Miniature Steerable Digital Endoscope for Trans-Nasal Diagnosis of Middle Ear Disease

The aim of this work is to design, fabricate and experimentally validate a miniature steerable digital endoscope that can provide comprehensive, high-resolution imaging of the middle ear using a trans-nasal approach. The motivation for this work comes from the high incidence of middle ear diseases, and the current reliance on invasive surgery to diagnose and survey these diseases which typically consists of the eardrum being lifted surgically to directly visualize the middle ear using a trans-canal approach. To enable less-invasive diagnosis and surveillance of middle ear disease, we propose an endoscope that is small enough to pass into the middle ear through the Eustachian tube, with a steerable tip that carries a 1 Megapixel image sensor and fiber-optic illumination to provide high-resolution visualization of critical middle ear structures. The proposed endoscope would enable physicians to diagnose middle ear disease using a non-surgical trans-nasal approach instead, enabling such procedures to be performed in an office setting and greatly reducing invasiveness for the patient. In this work, the computational design of the steerable tip based on computed tomography models of real human middle ear anatomy is presented, and these results informed the fabrication of a clinical-scale steerable endoscope prototype. The prototype was used in a pilot study in three cadaveric temporal bone specimens, where high-quality middle ear visualization was achieved as determined by an unbiased cohort of otolaryngologists. This is the first paper to demonstrate cadaveric validation of a digital, steerable, clinical-scale endoscope for middle ear disease diagnosis, and the experimental results illustrate that the endoscope enables the visualization of critical middle ear structures (such as the epitympanum or sinus tympani) that were seldom or never visualized in prior published trans-Eustachian tube endoscopy feasibility studies.

Subjective Visual Vertical Testing in Patients With Chronic Suppurative Otitis Media

OBJECTIVE

To analyze the results of the subjective visual vertical test using the "bucket method" in patients with chronic suppurative otitis media (CSOM).

STUDY DESIGN

Cross-sectional, controlled study.

SETTING

Outpatient otology clinic in a tertiary care hospital.

SUBJECTS AND METHODS

Patients had CSOM, defined as the presence of chronic infection or inflammation of the middle ear cleft, associated with a perforation of the tympanic membrane, frequent or intractable middle ear suppuration, with or without cholesteatoma. Controls were selected using a nonprobability, purposive sampling method. We excluded patients with neurologic or metabolic diseases, cognitive deficits, otosclerosis, vestibular migraine, Ménière's disease, past use of ototoxic medication, or head and neck cancer. The volunteers were subjected to the subjective visual vertical test using the "bucket method." The results obtained in our study and control groups were analyzed using nonparametric tests.

RESULTS

Our study comprised 51 patients with CSOM and 50 controls. In the CSOM group, we observed that 72.5% of the patients had vestibular symptoms in the past year, and 70.5% had abnormalities identified in at least 1 vestibular function test. The subjective visual vertical test revealed that patients with CSOM (with and without cholesteatoma) had significantly higher deviations of the true vertical as compared with controls (CSOM, 3.66°; controls, 0.76°; P < .001).

CONCLUSION

Our results revealed that CSOM was associated with high rates of vestibular symptoms, abnormal vestibular function tests, and abnormal subjective vertical visual results.

The Antrum-Malleus-Tegmen Score: A Pilot Study Assessing Preoperative Radiographic Predictors for Transcanal Endoscopic Cholesteatoma Dissection

OBJECTIVE

Identify features on computed tomography (CT) that predict mastoidectomy conversion (MC) during transcanal endoscopic ear surgery (TEES).

STUDY DESIGN

Retrospective case-control.

SETTING

University otology practice.

PATIENTS

Consecutive patients with cholesteatoma.

INTERVENTION

TEES cholesteatoma dissection versus those requiring MC.

MAIN OUTCOME MEASURES

Antrum opacification, depth of scutum involvement, and erosion of the mastoid trabeculae, ossicular chain, and tegmen were evaluated. Univariable and multivariable regression analysis was performed. The Antrum-Malleus-Tegmen (AMT) score was created using receiver operating characteristic curves to assess feasibility of performing TEES for cholesteatoma dissection.

RESULTS

There were 39 TEES and 19 MC cases. Groups had similar age (median 28.5 yr), gender, laterality, and revision surgery status. Median surgical time for MC cases was longer than TEES (231 min vs. 171 min, p < 0.001). Radiographic predictors of MC by multivariable regression included antrum opacification (p = 0.036), malleus erosion (p = 0.044), and tegmen erosion (p = 0.023). The AMT score predicted the feasibility of TEES without MC with a sensitivity of 90% and specificity of 75% when ≥2 of the following conditions were met on preoperative CT: intact tegmen, intact malleus, and absence of antrum opacification.

CONCLUSIONS

An aerated antrum, intact malleus, and intact tegmen suggest that TEES cholesteatoma dissection without the need for mastoidectomy is highly likely. A score of ≥2 on the AMT score predicts this with a positive predictive value of 88% and negative predictive value of 78%.

[Is routine histopathologic examination of middle ear cholesteatoma necessary?]

BACKGROUND

In the course of restoration of the middle ear, routine histological examinations are initiated in many cases, although a middle ear cholesteatoma can be clinically diagnosed in a normal case.

AIM OF THE STUDY

To determine the correlation between the surgeons' diagnosis and that of the pathologist and comparison with literature data. To check the rate of unexpected diagnoses. Analysis of the costs and survey of German ENT clinics with regard to handling of the histological examination in suspected cholesteatoma.

MATERIALS AND METHODS

Retrospective evaluation of cholesteatoma cases of the ENT Department of the University Medical Center of Mainz from 2010-2015. Germany-wide postal survey of ENT clinics.

RESULTS

In all, 449 operations for the rehabilitation of a middle ear cholesteatoma, of which there were 312 (69.5%) first diagnoses and 137 (30.5%) recurrences. A histological examination was conducted in 78.6%. For first diagnoses, the sensitivity of the clinical assessment was 97.9%, specificity 10%, positive predictive value 96.3%, and negative predictive value 16.7%. Recurrences showed values of 100%, 40%, 97.1% and 100%. Unexpected malignant findings did not occur. This routine histological examination was performed by 58.6% of German ENT hospitals. A total of 80% of those questioned this to be useful. A histological examination cost an average of 14.06 €.

CONCLUSION

Intraoperatively, there is a high degree of accuracy in diagnosing cholesteatoma. The cost factor of the histological examination is low and should not be the basis for the decision. The ear microscopy and the experience of the ear surgeon should be decisive for the decision for histological examination.

Chronically Discharging Ears: Evalution with High Resolution Computed Tomography

Chronic suppurative otitis media (CSOM) refers to the middle ear inflammation which is clinically characterized by the discharging ear, hearing deficit, fever and otalgia. Although a clinical diagnosis, imaging is imperative to rule out associated complications which apart from causing hearing deficit, may prove fatal at times.

Both high resolution computed tomography (HRCT) and MRI are helpful in evaluating middle ear pathologies, usage being indication specific. Due to its excellent spatial resolution, HRCT is invaluable in assessment of chronically discharging ears, especially to look for bone erosion and the integrity of the ossicles. Due to its better spatial resolution, HRCT is preferred in suspected intra temporal complications whereas MRI is more useful in evaluating intracranial extension.

Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study

OBJECTIVES

To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting.

DESIGN AND SETTING

Multicentre retrospective study in eight tertiary referral hospitals over 17 years.

PARTICIPANTS

Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised.

MAIN OUTCOME MEASURES

Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded.

RESULTS

In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves.

CONCLUSIONS

We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.

Role of High Resolution Computed Tomography of Mastoids in Planning Surgery for Chronic Suppurative Otitis Media

Chronic suppurative otitis media (CSOM) presents with a typical history of recurrent otorrhoea with tympanic membrane perforation. The diagnosis of cholesteatoma is usually made on otologic examination. High resolution computed tomography (HRCT) is indicated to evaluate the extension and the complications of cholesteatoma. The aim of the work was to study the role of HRCT in detecting, evaluating diagnosing and managing CSOM. All patients presenting with CSOM who were planned for mastoid exploration surgery in department of ENT, Gauhati Medical College and Hospital within a period of 2 years-from 1st January, 2013 to 31th December, 2014, were taken up for the study. HRCT mastoids done routinely before cholesteatoma surgery, but with improved resolution, to characterize all middle ear structures and complications of the disease prior to surgery, might guide as road map during mastoid explorations for unsafe CSOM. The important role of HRCT lies on the early detection of cholesteatoma, and more conservative surgical procedures can be used to eradicate the disease.

Computed Tomography Staging of Middle Ear Cholesteatoma

Background

To establish computed tomography (CT) staging of middle ear cholesteatoma and assess its impact on the selection of the surgical procedure.

Material/Methods

Prospective study was conducted on 61 consecutive patients (mean age 26.8 years) with middle ear cholesteatoma. CT scan of the temporal bone and surgery were performed in all patients. CT staging classified cholesteatoma according to its location in the tympanic cavity (T); extension into the mastoid (M); and associated complications (C). Cholesteatoma was staged as stage I (T1, T2), stage II (T3, M1, M2, C1), and stage III (C2).

Results

The overall sensitivity of CT staging of cholesteatoma compared to surgery was 88% with excellent agreement and correlation between CT findings and intra-operative findings (K=0.863, r=0.86, P=0.001). There was excellent agreement and correlation of CT staging with surgical findings for T location (K=0.811, r=0.89, P=0.001), good for M extension (K=0.734, r=0.88, P=0.001), and excellent for associated C complications (K=1.00, r=1.0, P=0.001). Atticotympanotomy was carried out in stage I (n=14), intact canal wall surgery was performed in stage II (n=38), and canal wall down surgery was done in stage III (n=5) and stage II (n=4).

Conclusions

We established CT staging of middle ear cholesteatoma that helps surgeons to select an appropriate surgery.

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.

A mistaken identity: rhabdomyosarcoma of the middle ear cleft misdiagnosed as chronic suppurative otitis media with temporal lobe abscess

A 5-year-old girl presented with a 3-month history of left side facial palsy, followed sequentially by purulent ear discharge, complete external ophthalmoplaegia and blurred vision. On clinical examination she was febrile with left-sided conductive hearing loss. She was clinically diagnosed to have chronic suppurative otitis media of the unsafe type with petrous apicitis, middle cranial fossa abscess and cavernous sinus involvement. Preliminary CT scan findings were reported as a large left temporal lobe abscess and left otitis media with cholesteatoma. MRI of the brain obtained later corroborated the abnormalities detected on the CT scan. Ten days after admission, a mass was seen protruding from the external auditory canal. A biopsy of the mass was obtained and sent for histopathological examination. Meanwhile, review of the MRI suggested an aggressive neoplasm such as sarcoma/rhabdomyosarcoma. Histopathology clinched the final diagnosis of an anaplastic type of embryonal rhabdomyosarcoma of the middle ear cleft.

Use of non-echo-planar diffusion-weighted MR imaging for the detection of cholesteatomas in high-risk tympanic retraction pockets

BACKGROUND AND PURPOSE

Non-echo-planar DWI MR imaging (including the HASTE sequence) has been shown to be highly sensitive and specific for large cholesteatomas. The purpose of this study was to determine the diagnostic accuracy of HASTE DWI for the detection of incipient cholesteatoma in high-risk retraction pockets.

MATERIALS AND METHODS

This was a prospective study of 16 patients who underwent MR imaging with HASTE DWI before surgery. Surgeons were not informed of the results, and intraoperative findings were compared against the radiologic diagnosis. Sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

Among the 16 retraction pockets, 10 cholesteatomas were diagnosed intraoperatively (62.5%). HASTE showed 90% sensitivity, 100% specificity, 100% positive predictive value, and 85.7% negative predictive value in this group of patients. We found only 1 false-negative finding in an infected cholesteatoma.

CONCLUSIONS

We demonstrate a high correlation between HASTE and surgical findings, suggesting that this technique could be useful for the early detection of primary acquired cholesteatomas arising from retraction pockets and could help to avoid unnecessary surgery.