Apparent diffusion coefficients for predicting primary cholesteatoma risk of recurrence after surgical clearance

Temporal bone CT-based anatomical parameters associated with the development of cholesteatoma

BACKGROUND

Cholesteatoma is caused by disorders of the middle ear ventilation that trigger a progressive series of events responsible for its formation. The aim of this study was to identify possible radiological CT-derived parameters predisposing to ventilation disorders and cholesteatoma.

METHODS

In this retrospective study, patients diagnosed with cholesteatomatous chronic otitis media who underwent temporal bone CT and open tympanoplasty surgery have been included, as well as control patients with clinical examination negative for organic otological pathology who underwent temporal bone CT for other reasons. For each patient, the following parameters have been extracted from CT volumes: degree of mastoid pneumatization, prominence of the cog, patency of the Eustachian tube, antrum width, aditus width, anterior and posterior epitympanic widths, and epitympanic height.

RESULTS

Sixty patients have been included, thirty of whom belonged to the group of patients with cholesteatoma and the remaining part to the group of patients without organic otological pathology. The prevalence of a low degree of mastoid pneumatization was significantly higher among patients with cholesteatoma, as well as for the prevalence of cog prominence (p < 0.001). All the continuous variables were found to have statistical significance (p < 0.05) in the comparison between groups except for the width of the antrum.

CONCLUSION

Mastoid pneumatization degree, prominence of the cog and epitympanic measures based on temporal bone CT could be good radiological correlates of the ventilatory capabilities of the epitympanum which, if compromised, can facilitate the development of cholesteatoma.

Advanced imaging of head and neck infections

When head and neck infection is suspected, appropriate imaging contributes to treatment decisions and prognosis. While contrast-enhanced CT is the standard imaging modality for evaluating head and neck infections, MRI can better characterize the skull base, intracranial involvement, and osteomyelitis, implying that these are complementary techniques for a comprehensive assessment. Both CT and MRI are useful in the evaluation of abscesses and thrombophlebitis, while MRI is especially useful in the evaluation of intracranial inflammatory spread/abscess formation, differentiation of abscess from other conditions, evaluation of the presence and activity of inflammation and osteomyelitis, evaluation of mastoid extension in middle ear cholesteatoma, and evaluation of facial neuritis and labyrinthitis. Apparent diffusion coefficient derived from diffusion-weighted imaging is useful for differential diagnosis and treatment response of head and neck infections in various anatomical sites. Dynamic contrast-enhanced MRI perfusion may be useful in assessing the activity of skull base osteomyelitis. MR bone imaging may be of additional value in evaluating bony structures of the skull base and jaw. Dual-energy CT is helpful in reducing metal artifacts, evaluating deep neck abscess, and detecting salivary stones. Subtraction CT techniques are used to detect progressive bone-destructive changes and to reduce dental amalgam artifacts. This article provides a region-based approach to the imaging evaluation of head and neck infections, using both conventional and advanced imaging techniques.

Quality of Life Assessment of Chronic Otitis Media Patients Following Surgery

Chronic otitis media (COM) is a persistent inflammation of the middle ear. COM often requires surgical management and represents one of the most disabling pathologies in the field of otolaryngology, not only due to hearing loss but also because recurrent otorrhea seriously affects the quality of life (QoL) of patients. The COMOT-15 questionnaire is a reliable, valid and sensitive tool for measuring the QoL of patients with COM. The aim of this study was to evaluate QoL by using the Italian version of the COMOT-15 in COM patients undergoing surgery based on age and different operation techniques. This observational retrospective study involved fifty-two consecutive patients undergoing surgical treatment for COM according to Nadol criteria. Preoperatively (T0) and 12 months after surgery (T1) patients underwent clinical examination, imaging, the Italian version of the COMOT-15 and pure tone audiometry. After surgery, we observed an improvement of QoL in 84.6% of the population. The COMOT-15 overall score, ear symptoms and hearing subscores showed significantly better ratings after surgery in the whole analyzed group. However, the separate analysis of patients operated with open techniques and closed techniques showed a significant improvement in ear symptoms subscore in both groups and a significant improvement in hearing subscore and mental health subscore only in patients operated on with closed techniques. Moreover, we observed a positive correlation between age and Δ-COMOT. This study shows the crucial role of a reliable and suitable questionnaire such as the COMOT-15 in evaluating COM patients, including clinical symptoms, functional and psychological impairments and highlighting a positive correlation between age and COMOT-15 results.

Performance of 2D BLADE turbo gradient- and spin-echo diffusion-weighted imaging in the quantitative diagnosis of recurrent temporal bone cholesteatoma

BACKGROUND

Diffusion-weighted imaging (DWI) has become an important tool for the detection of cholesteatoma. The purpose of this study was to explore the value of 2D BLADE turbo gradient- and spin-echo imaging (TGSE BLADE) DWI in the quantitative diagnosis of recurrent temporal bone cholesteatoma (CS).

METHODS

From March 2018 to October 2021, 67 patients with suspected recurrence of temporal bone CS after assessment by clinical otorhinolaryngologists who had undergone previous ear surgery for CS were prospectively evaluated by magnetic resonance imaging (MRI). Two radiologist assessed images independently. Quantitative parameters such as signal intensity ratio (SIR) calculated using, as a reference, the inferior temporal cortex (SIRT) and the background noise (SIRN), apparent diffusion coefficient (ADC) value, and ADC ratio (with pons as reference) measured on TGSE BLADE sequences were assessed. Using receiver operating characteristic (ROC) curve analysis, the optimal threshold and diagnostic performance for diagnosing recurrent CS were determined. Pair-wise comparison of the ROC curves was performed using the area under the ROC curve (AUC).

RESULTS

Finally, 44 patients were included in this study, including 25 CS and 19 non-cholesteatoma (NCS). Mean SIRT and mean SIRN on TGSE BLADE DWI were significantly higher for CS than NCS lesions (p < 0.001). Meanwhile, mean ADC values and mean ADC ratios on ADC maps were significantly lower in the CS group than in the NCS group (p < 0.001). According to ROC analysis, the diagnostic efficacy of quantitative parameters such as SIRT (AUC = 0.967), SIRN (AUC = 0.979), ADC value (AUC = 1.0), and ADC ratio (AUC = 0.983) was significantly better than that of qualitative DWI (AUC = 0.867; p = 0.007, 0.009, 0.011 and 0.037, respectively).

CONCLUSIONS

Residual/recurrent temporal bone CS can be accurately detected using quantitative evaluation of TGSE BLADE DWI.

Accuracy of 2D BLADE Turbo Gradient- and Spin-Echo Diffusion Weighted Imaging for the Diagnosis of Primary Middle Ear Cholesteatoma

OBJECTIVE

To evaluate the diagnostic accuracy of 2D BLADE turbo gradient- and spin-echo diffusion weighted imaging (TGSE BLADE DWI) for primary middle ear cholesteatoma diagnosis, using qualitative and quantitative methods.

STUDY DESIGN

Retrospective case series.

SETTING

University hospital.

PATIENTS

Participants included those with suspected primary middle ear cholesteatoma after assessment by clinical otorhinolaryngologists combined with magnetic resonance imaging (MRI) examination. Finally, of the 85 ears from 65 patients enrolled in the study, 73 had cholesteatoma, and 12 had otitis media.

INTERVENTION

Two radiologists independently assessed images and measured apparent diffusion coefficient (ADC) values. Sensitivity, specificity and accuracy were evaluated. Kappa (k) statistics, the intraclass correlation coefficient (ICC), the Kolmogorov-Smirnov normality test, the independent t test, and receiver operating characteristic (ROC) analysis were used for statistical analysis. Pair-wise comparison of the area under the ROC curve (AUC) was also performed using the Delong test.

MAIN OUTCOME MEASURES

Imaging and histopathologic findings.

RESULTS

The mean ADC value of cholesteatoma group (mean, 0.923 ± 0.246 × 10 -3 mm 2 /s) was significantly lower than that of noncholesteatoma group (mean, 1.744 ± 0.205 × 10 -3 mm 2 /s; p < 0.001). In ≤3 mm cholesteatoma group, the AUC of qualitative DWI was 0.846; the sensitivity, specificity, and accuracy for diagnosing cholesteatoma were 69.23%, 100%, and 84%, respectively; while the AUC of quantitative diagnosis was significantly increased to 1.0 ( p = 0.0209); and based on the optimal threshold of ADC, ≤1.352 × 10 -3 mm 2 /s, the sensitivity, specificity and accuracy improved to 100%. For >3 mm cholesteatoma group, there were no significant differences in diagnostic performance. Excellent interobserver agreement and ICC for the qualitative and quantitative evaluations (k = 0.90 and ICC = 0.80, respectively) was noted between reviewers.

CONCLUSION

TGSE BLADE DWI is useful for the detection of primary middle ear cholesteatomas, especially ≤3 mm lesions.

Computed-Tomography-Structured Reporting in Middle Ear Opacification: Surgical Results and Clinical Considerations From a Large Retrospective Analysis

Purpose: The aim of the study is to compare the accuracy of unstructured preoperative Computed Tomography (CT) reports from non-tertiary diagnostic centers with intraoperative findings in a large cohort of patients with Chronic Otitis Media (COM) undergone surgery.

Methods: From 2012 to 2019, a total number of 301 patients were considered for our purposes. All patients with clinical evidence of COM had preoperative non-contrast high resolution CT scan of the temporal bone in non-tertiary diagnostic centers, performed within 3 months before surgery.

Results: The accuracy of CT reports was analyzed in terms of nature, anatomical site, disease extension, bony erosion, vascular structures abnormalities relevant to surgical planning, and Eustachian tube patency. Compared to post-surgical findings, CT reporting critical analysis revealed a tendency to overestimation of bony erosion, coupled to underestimated description of facial canal/lateral semi-circular canal, vascular structures, and Eustachian tube.

Conclusion: Discrepancies between CT reports and surgical findings in middle ear opacification can be at least in part due to limited expertise of general radiologists in ENT neuroimaging. To limit this lack of information and the limited accuracy of middle ear structures depiction, here we propose a structured checklist to adopt in the case of a temporal bone CT scan for COM, in order to optimize the communication with surgeons and provide all the crucial information for an accurate surgical planning.

Surgical Guidance for Removal of Cholesteatoma Using a Multispectral 3D-Endoscope

We develop a stereo-multispectral endoscopic prototype in which a filter-wheel is used for surgical guidance to remove cholesteatoma tissue in the middle ear. Cholesteatoma is a destructive proliferating tissue. The only treatment for this disease is surgery. Removal is a very demanding task, even for experienced surgeons. It is very difficult to distinguish between bone and cholesteatoma. In addition, it can even reoccur if not all tissue particles of the cholesteatoma are removed, which leads to undesirable follow-up operations. Therefore, we propose an image-based method that combines multispectral tissue classification and 3D reconstruction to identify all parts of the removed tissue and determine their metric dimensions intraoperatively. The designed multispectral filter-wheel 3D-endoscope prototype can switch between narrow-band spectral and broad-band white illumination, which is technically evaluated in terms of optical system properties. Further, it is tested and evaluated on three patients. The wavelengths 400 nm and 420 nm are identified as most suitable for the differentiation task. The stereoscopic image acquisition allows accurate 3D surface reconstruction of the enhanced image information. The first results are promising, as the cholesteatoma can be easily highlighted, correctly identified, and visualized as a true-to-scale 3D model showing the patient-specific anatomy.

Malignant Otitis External: Our Experience and Literature Review

BACKGROUND Malignant external otitis (MEO) is an invasive infection that can involve the external auditory canal and the skull base up to the contiguous soft tissues. Considering the changing face of MEO, we reviewed cases of MEO treated in our Ear Nose Throat (ENT) clinic - University Federico II of Naples between 2018 and 2019 to evaluate the current epidemiology of the condition and to assess the state of art on diagnosis, therapeutic and follow-up management in our patients. CASE REPORT We present the cases of three male patients with Type 2 diabetes mellitus who complained of long-lasting otorrhea and pain, with clinical suspicion of MEO. In all cases, ear swab was positive for Pseudomonas aeruginosa. All our patients received a 6-week course of intravenous ciprofloxacin, piperacillin, and tazobactam, with rapid clinical symptoms improvement and complete recovery at 1-year follow-up. CONCLUSIONS MEO is difficult to treat due to the lack of standardized care guidelines. Patients with MEO often present with severe otalgia, edema, otorrhea, and facial nerve paralysis. Clinicians must suspect MEO in elderly diabetic and immunocompromised patients with persistent otalgia after external otitis. Imaging (computed tomography and magnetic resonance imaging) can play synergistic roles in the management of MEO. To evaluate eradication of the disease, clinicians have to assess clinical symptoms and signs as well as radiological imaging and inflammatory markers.

Skull Base Fungal Osteomyelitis: A Case Report and Review of the Literature

Skull base osteomyelitis (SBO) is an invasive infection refractory to therapy, closely linked with malignant otitis externa (MOE). It is characterized by a mild clinical presentation that can delay cross-sectional imaging considered as the key to revealing it. Skull base osteomyelitis typically affects elderly diabetics and immunocompromised patients (>70 years). It most commonly has an otogenic origin due to an extension of MOE. The prognosis can be very poor without the administration of adequate and timely therapy at an early disease stage. Nowadays, Pseudomonas aeruginosa remains the most common pathogen associated with SBO. Fungi are a rare cause of MOE. This report documents a rare case of otogenic SBO caused by Candida parapsilosis in a diabetic patient, with persistent otologic symptoms as clinical onset and resistance to medical treatment. Fungal MOE has more subtle symptoms and is more aggressive than its bacterial counterpart. When MOE is resistant to antibacterial drugs, this should raise the suspicion of a fungal etiology of MOE. The current guidelines do not exhaustively describe the diagnosis, antifungal drugs of choice, and optimum duration of treatment. The description of these rare clinical cases should help with the multidisciplinary management of this disease in order to optimize the diagnosis and therapeutic protocol.