Detection of postoperative relapsing/residual cholesteatomas with diffusion-weighted echo-planar magnetic resonance imaging

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.

Cost-comparison analysis of diffusion weighted magnetic resonance imaging (DWMRI) versus second look surgery for the detection of residual and recurrent cholesteatoma

Background

Cholesteatoma is a destructive, erosive growth of keratinizing squamous epithelium in the middle ear cleft. Following treatment with a canal wall-up (CWU) tympanomastoidectomy, surveillance of residual and recurrent disease has traditionally been achieved through a second look tympanotomy following the initial procedure. Historically, MRI sequences have been inadequate at differentiating between granulation tissue, inflammation, and cholesteatoma. Recent literature has shown diffusion-weighted magnetic resonance imaging (DWMRI) to be a viable alternative to second look surgery for the detection of residual or recurrent disease. The goal of the present study was to perform a cost analysis of DWIMRI versus second look surgery in the detection of residual or recurrent cholesteatoma following combined approach tympanomastoidectomy.

Methods

A probabilistic decision tree model was generated from a literature review to compare traditional second look surgery with DWMRI. Cost inputs were obtained from the Ontario Case Costing Initiative, the Ontario Health Insurance Plan (OHIP) schedule of benefits. Costs were reported in Canadian dollars and a payer perspective was adopted. A probabilistic sensitivity analysis was performed.

Results

According to the probabilistic sensitivity analysis, mean cost difference of traditional second look tympanotomy versus echo planar imaging (EPI) DWMRI was $180.27CAD, 95%CI [$177.32, $188,32] in favour of second-look tympanotomy. However, mean cost difference of traditional second look tympanotomy versus non-EPI DWMRI was $390.66CAD, 95%CI [$381.52, $399.80] in favour of non-EPI DWMRI.

Conclusions

Diffusion-weighted MRI, specifically non-EPI sequences, are a viable cost-saving alternative to second-look tympanotomy in the setting of detecting residual or recurrent cholesteatoma.

MRI as an Alternative to Second Look Mastoid Surgery

The main goal of surgery of cholesteatoma is eradication of the disease and revision surgery is indicated when a dry and safe ear has not been achieved. Residual cholesteatoma usually occurs at the sites that are difficult to reach with an operating microscope, such as posterior tympanum and anterior epitympanic recess. Computed tomography can be performed to delineate the extent of disease. High-resolution computed tomography scanning is important for planning for surgery and is indicated for all revision mastoid operations. Magnetic resonance imaging is superior to computed tomography in tissue characterization for diagnosis of recurrent cholesteatoma. To evaluate the cases of recurrent cholesteatoma comparing the intraoperative surgical findings with the preoperative MRI radiological findings and if the preoperative MRI can replace the second look surgery for cholesteatoma. This study was applied on 60 patients that have a recurrent cholesteatoma after previous mastoid surgery. A preoperative radiological evaluation was done by Magnetic resonance, surgical management was done by canal wall up or canal wall down mastoidectomy to exclude residual disease. Then, radiological, and surgical findings correlation was done. Diffusion-weighted MRI successfully detected 42 cases out of the 45 cases of surgically proved cholesteatoma, it has accuracy 95%, sensitivity 93.33%, specificity 100%, PPV 100% and NPV 83.33%. MRI is better than CT in tissue characterization for diagnosis of recurrent cholesteatoma, and can replace the unnecessary second look surgery of cholesteatoma.

Posterior canal wall reposition for management of cholesteatoma: Technique and results

OBJECTIVE

The main goal of surgery in acquired middle ear cholesteatomas is the complete eradication of the disease with an ear free of discharge. This can be performed either by open or closed techniques with their benefits and drawbacks. We present the technique of reposition of the posterior canal wall for the management of cholesteatoma cases and its results and outcome.

PATIENTS AND METHODS

This study included 31 patients with primary acquired middle ear cholesteatoma. The surgical technique included complete cortical mastoidectomy, wide posterior tympanotomy, dividing the bony posterior meatal wall with a micro-sagittal saw and its removal, dissection and eradication of cholesteatoma, and repositioning the canal wall segment in its anatomical site.

RESULTS

No significant intraoperative complication occurred. An injury to the dura occurred in one patient. Damage of the bony posterior canal wall occurred in two patients during saw cutting. Residual cholesteatoma was found in two patients. No dislocation or necrosis of the reconstructed posterior canal wall was noted and the new reconstructed external ear canal appeared to be of near normal size, shape, and contour.

CONCLUSION

This technique provides optimal surgical exposure and access to areas that are difficult to reach by CWU approach, allows removal of the cholesteatoma without intraoperative complications, decreases the rate of residual cholesteatoma, restores near-normal anatomy of the external auditory canal, and avoids the sequelae of the open mastoid cavity. Therefore, it would be a feasible alternative to the standard CWU and CWD procedures.

The accuracy and sensitivity of diffusion-weighted magnetic resonance imaging with Apparent Diffusion Coefficients in diagnosis of recurrent cholesteatoma

OBJECTIVE

To evaluate the accuracy and sensitivity of diffusion-weighted magnetic resonance imaging with ADC value combined with MDCT in evaluating recurrent cholesteatoma.

PATIENTS

Thirty patients (20 females and 10 males), their age ranged from 10 to 40years, had undergone a tympanomastoid surgery for a cholesteatoma of the middle ear underwent MDCT and MR DWI examination before second- or third-look surgery from May 2015 to October 2016.

RESULTS

CT showed partial opacification of the tympanomastoid cavity in 10 ears and complete opacification in 21 ears. CT detects 10 cases out of 20 cases of recurrent cholesteatoma with sensitivity 47.6%, specificity 100%, and NPP 47.6%. DWI depicted 21 out of 20 cases proved cholesteatoma patients (sensitivity 100%, specificity 90%, PPV 95.2% and P value is 0.001). All MRI of patients without cholesteatoma were correctly interpreted as showing negative findings for cholesteatoma (specificity = 100%). The ADC of cholesteatoma group (21 ears) were ranged from 553 to 759 × 10-3 mm2/s and the ADCs of non cholesteatoma group (10 ears) was ranged from 1495.8 to 1766.8 × 10-3 mm2/s. Cut off value of cholesteatoma is ≤759 × 10-3 mm2/s.

CONCLUSION

MR DWI with ADC combined with MDCT has high sensitivity, specificity, accuracy in detecting recurrent cholesteatoma.

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.

Diagnostic accuracy of diffusion-weighted MR imaging versus delayed gadolinium enhanced T1-weighted imaging in middle ear recurrent cholesteatoma: A retrospective study of 39 patients

OBJECTIVE

MR imaging using diffusion-weighted (DW) images and delayed gadolinium-enhanced T1-weighted images is evolving into an alternative to second look surgery in detection of recurrent cholesteatomas. The aim of this study was to retrospectively compare the DW images, the post-gadolinium T1-weighted images and the combination of both methods in this indication.

PATIENTS AND METHODS

We retrospectively evaluated the MR examination of 39 patients clinically suspected for a recurrent cholesteatoma. Patients in the study underwent DW sequences, delayed gadolinium enhanced T1-weighted sequences as well as standard uninjected protocol using T1 and T2 sequences. Three blinded radiologists evaluated three data sets: a set of post-gadolinium T1-weighted images, a set of DW images and a set of the combination of both methods. The interobserver agreement was evaluated and the diagnostic accuracy of each method was described by sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The performances of the three techniques were also evaluated using ROC curves, from which the AUC were compared. Results were compared with surgical results or a two-year follow-up.

RESULTS

The overall sensitivity and specificity were respectively 63% and 71% for the post-gadolinium T1-weighted images, 88% and 75% for the DW images and 84% and 75% for the combined images. The PPV and NPV were respectively 89% and 33% for the post-gadolinium T1-weighted images, 93% and 62% for the DW images and 93% and 55% for the combined images. The sensitivity and the NPV were significantly different between the three methods (P<0.0001 and P=0.027). There was no statistically significant difference in specificity or PPV between the three methods (P=0.931 and P=0.650). The diagnostic accuracy evaluated with the AUC showed no statistically significant difference between the DW images and the combined images (P=0.433).

CONCLUSION

MR imaging reliably identifies those patients suspected for recurrent cholesteatoma who require a surgical second look by using DW MR imaging. The combination with delayed gadolinium enhanced T1-weighted sequences does not significantly increase the diagnostic accuracy of the examination.

Correlation of computed tomography, echo-planar diffusion-weighted magnetic resonance imaging and surgical outcomes in middle ear cholesteatoma

CONCLUSION

Echo-planar diffusion-weighted magnetic resonance imaging (DW MRI) is more reliable than high-resolution computed tomography (HRCT) in predicting the presence and localization of cholesteatoma before tympanomastoid surgery.

OBJECTIVES

To evaluate the diagnostic accuracy of HRCT and echo-planar DW MRI in the detection and localization of cholesteatoma.

METHODS

Fifty-nine patients were prospectively included in this study. Patients with suspected primary cholesteatoma were evaluated by HRCT and echo-planar DW MRI before tympanomastoid surgery. Radiological findings were correlated with intraoperative findings.

RESULTS

HRCT and echo-planar DW MRI accurately predicted the presence or absence of cholesteatoma in 40/59 (67.8%) and 52/59 (88.1%) patients, respectively. The sensitivity, specificity, and positive and negative predictive values of HRCT were 68.97%, 66.67%, 66.67%, and 68.97%, respectively. However, sensitivity, specificity, and positive and negative predictive values of echo-planar DW MRI were 85.71%, 90.32%, 88.89%, and 87.50%, respectively.

Magnetic resonance imaging at one year for detection of postoperative residual cholesteatoma in children: Is it too early?

OBJECTIVE

To compare the residual cholesteatoma detection accuracy of diffusion-weighted (DW) and T1 delayed sequences for magnetic resonance at one year postoperative with second-look surgery in pediatric patients who have undergone primary middle ear surgery for cholesteatoma.

METHODS

This was a prospective monocentric consecutive study conducted in a tertiary academic referral center. Children were referred for MR imaging (MRI) one year after surgery. A 1.5T MRI was utilized, using nonecho-planar DW images and delayed gadolinium-enhanced T1-weighted images. Accuracy of magnetic resonance imaging was assessed by two radiologists before surgery. Interobserver and intraobserver agreements were assessed using the κ test. Magnetic resonance imaging data were compared with surgery, which was considered as the gold standard.

RESULTS

Twenty-four consecutive unselected pediatric patients were included. Sensitivity, specificity, positive predictive value, and negative predictive value for the first observer were of 40%, 86%, 67%, and 67%, respectively, and those for the second observer were 30%, 86%, 60%, and 63%, respectively. The only two cholesteatoma with a size superior to 3mm were diagnosed before surgery, but the majority of small cholesteatoma were not detected.

CONCLUSIONS

MRI is a key examen to diagnosed the residual cholesteatoma but is limited by the size of the lesion under 3mm. Delaying the realization of MRI during follow-up could increase sensitivity, thus avoiding misdiagnosis as well as unnecessary second look surgery.

Canal wall reconstruction in cholesteatoma surgeries: rate of residual

To evaluate the rates of residual and recurrent cholesteatoma following canal wall reconstruction (CWR) tympano-mastoidectomy with mastoid obliteration, for the treatment of chronic otitis with cholesteatoma. Consecutive cohort study. We included patients following surgical cholesteatoma removal by CWR tympano-mastoidectomy with hydroxyapatite mastoid obliteration from 2008 to 2012. We analyzed audiometric and postoperative radiologic data. We determined the rates of residual disease and recurrence, and evaluated postoperative complications. Thirty-six ears were included in this study. The mean follow-up after surgery was 24 months (range 12.3-51.4 months). The recurrence rate was 3.1% (one case) and the rate of residual disease was 6.2% (two cases including one of iatrogenic cholesteatoma). No canal-wall-down tympanoplasty was required. Local infection was detected in 33% of cases and was successfully treated with appropriate antibiotics. Postoperative audiometry showed no impairment of the cochlear reserve. No postoperative facial palsy or deafness was observed. CWR permits well exposure of the lesion, making complete excision of the cholesteatoma possible. This study showed a decreasing of the rate of residual cholesteatoma and must be confirmed with further studies. CWR makes it possible to use hearing aids for auditory rehabilitation.

High-resolution three-dimensional diffusion-weighted imaging of middle ear cholesteatoma at 3.0 T MRI: usefulness of 3D turbo field-echo with diffusion-sensitized driven-equilibrium preparation (TFE-DSDE) compared to single-shot echo-planar imaging

OBJECTIVE

To prospectively evaluate the usefulness of a newly developed high-resolution three-dimensional diffusion-weighted imaging method, turbo field-echo with diffusion-sensitized driven-equilibrium (TFE-DSDE) in diagnosing middle-ear cholesteatoma by comparing it to conventional single-shot echo-planar diffusion-weighted imaging (SS-EP DWI).

MATERIALS AND METHODS

Institutional review board approval and informed consent from all participants were obtained. We studied 30 patients with preoperatively suspected acquired cholesteatoma. Each patient underwent an MR examination including both SS-EP DWI and DSDE-TFE using a 3.0 T MR scanner. Images of the 30 patients (60 temporal bones including 30 with and 30 without cholesteatoma) were reviewed by two independent neuroradiologists. The confidence level for the presence of cholesteatoma was graded on a scale of 0-2 (0=definite absence, 1=equivocal, 2=definite presence). Interobserver agreement as well as sensitivity, specificity, and accuracy for detection were assessed for the two reviewers.

RESULTS

Excellent interobserver agreement was shown for TFE-DSDE (κ=0.821) whereas fair agreement was obtained for SS-EP DWI (κ=0.416). TFE-DSDE was associated with significantly higher sensitivity (83.3%) and accuracy (90.0%) compared to SS-EP DWI (sensitivity=35.0%, accuracy=66.7%; p<0.05). No significant difference was found in specificity (96.7% for TFE-DSDE, 98.3% for SS-EP DWI) CONCLUSION: With increased spatial resolution and reduced susceptibility artifacts, TFE-DSDE improves the accuracy in diagnosing acquired middle ear cholesteatomas compared to SS-EP DWI.

Contemporary non-echo-planar diffusion-weighted imaging of middle ear cholesteatomas

Middle ear cholesteatoma is a common inflammatory disease that requires surgery due to potentially serious intracranial complications. Diagnosis of cholesteatoma is mainly clinical, with computed tomography (CT) used to evaluate disease extension before surgery. Certain patterns of bone erosion are specific, but CT attenuation does not allow differentiation from other inflammatory middle ear diseases. With its high tissue discrimination and contrast resolution, magnetic resonance imaging is valuable in diagnosis of cholesteatomas. Absent enhancement at delayed postcontrast imaging has been used for diagnosis. Diffusion-weighted imaging (DWI) is highly specific due to the high keratin content of cholesteatomas. New non-echo-planar DWI sequences, such as periodically rotated overlapping parallel lines with enhanced reconstruction, are superior to conventional echo-planar DWI, since they minimize susceptibility artifacts at the skull base and increase sensitivity for detection of lesions as small as 2 mm. This technique is indicated when clinical diagnosis is difficult and high tissue specificity is necessary, as in congenital, temporal bone, or atypical acquired middle ear cholesteatomas and residual or recurrent disease after surgery. Non-echo-planar DWI has been proposed for screening of postsurgical (residual or recurrent) cholesteatomas, thus obviating many second-look revision surgeries, especially after more conservative canal wall up surgery.

Diagnostic accuracy of non-echo-planar diffusion-weighted MRI versus other MRI sequences in cholesteatoma

INTRODUCTION

Non-echo-planar imaging (EPI) MRI has been recently introduced to improve the detection of small-sized cholesteatoma and decrease different artefacts occurring in the EPI-diffusion-weighted (DW) technique. This technique is also time saving in comparison to delayed post-contrast imaging. We prospectively assessed the diagnostic accuracy of MRI including delayed post-contrast standard MRI, EPI and non-EPI-DW sequences in the detection of middle ear cholesteatoma.

METHODS

We evaluated 35 patients suspected of having cholesteatoma who underwent MRI including delayed post-contrast MRI, EPI and non-EPI-DW sequences prior to their planned surgery, and the MR findings were compared with surgical findings. Two experienced radiologists reported the images. Sensitivity, specificity and predictive values of MRI were estimated.

RESULTS

We detected 26 cases of cholesteatoma at surgery. Sensitivity and specificity of delayed post-contrast MRI, EPI DW and non-EPI DW were 73.1 and 77.8%, 61.5 and 88.9%, and 96.2 and 100%, respectively, as interpreted by the first radiologist. Sensitivity and specificity of delayed post-contrast MRI, EPI-DW sequence and non-EPI-DW sequence were 84.6 and 88.9%, 50 and 88.9%, and 92.3 and 100%, respectively, as interpreted by the second radiologist.

CONCLUSION

The non-EPI MRI technique is a more accurate method in detecting middle ear cholesteatoma in comparison to other conventional sequences.

Detection of recurrent and primary acquired cholesteatoma with echo-planar diffusion-weighted magnetic resonance imaging

Objective:

To evaluate the diagnostic value of echo-planar diffusion-weighted magnetic resonance imaging in pre-operative detection of suspected primary acquired, residual and/or recurrent cholesteatoma.

Materials and methods:

Fifty-eight chronic otitis media patients with suspected cholesteatoma were thus evaluated two weeks pre-operatively, and divided into group one (41 patients, no previous surgery, suspected primary acquired cholesteatoma) and group two (17 patients, previous surgery, scheduled ‘second-look’ or revision surgery for suspected residual or recurrent cholesteatoma). Patients' operative, histopathology and radiological findings were compared.

Results:

Cholesteatoma was found in 63 per cent of group one patients and 58 per cent of group two patients at surgery. Histopathological examination of surgical specimens indicated that imaging accurately predicted the presence or absence of cholesteatoma in 90 per cent of group one (37/41; 23 true positives, 14 true negatives) and 76 per cent of group two (13/17; seven true positives, six true negatives). Three patients in both groups were false negative diagnoses and one patient in both groups was a false positive. The sensitivity, specificity, and positive and negative predictive values of echo-planar diffusion-weighted magnetic resonance imaging of cholesteatoma were respectively 88, 93, 95 and 82 per cent in group one and 70, 85, 87 and 66 per cent in group two.

Conclusion:

Echo-planar diffusion-weighted magnetic resonance imaging is a valuable technique with high sensitivity and specificity for cholesteatoma imaging.

A systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma

OBJECTIVE

A systematic review to determine whether the diffusion-weighted (DW) magnetic resonance imaging scan can reliably detect residual or recurrent cholesteatoma after mastoid surgery.

DESIGN

A systematic review.

DATA SOURCES

Databases including EMBASE, MEDLINE, CINAHL, Web of Science, and Cochrane Review were searched for studies published without language restriction from the start of the databases. Additional studies were identified from cited references.

SELECTION CRITERIA

Initial search identified 402 publications, of which 16 studies met the inclusion criteria for the systematic review. The DW imaging (DWI) scan was used to detect residual or recurrent cholesteatoma and subsequent second-look surgery was performed to correlate the findings.

REVIEW METHODS

Studies were assessed for their selection of patients for radiologic investigations, imaging parameters, and subsequent surgery. Outcome measures included sensitivity, specificity, positive and negative predictive values of the DWI, and the incidence and size of residual or recurrent cholesteatoma.

RESULTS

Two different modalities of DWI sequences have been described. Eight studies with 225 patients analyzed echo-planar imaging (EPI) and 8 studies with 207 patients described the "non-EPI" scanning techniques. Non-EPI parameters are more reliable in identifying residual or recurrent cholesteatoma with sensitivity, specificity, and positive and negative predictive values of 91%, 96%, 97%, and 85%, respectively.

CONCLUSION

The available evidence suggests that non-EPI such as half-Fourier acquisition single-shot turbo spin echo sequences are more reliable in identifying residual or recurrent cholesteatoma. This is a promising radiologic investigation; however, we think further studies are required with more patients and long-term results to establish its place as an alternative to a second-stage surgery after canal wall up surgery.

Role of magnetic resonance imaging in cholesteatoma: the Indian experience

The objectives are to evaluate role of magnetic resonance imaging (MRI) in diagnosis of cholesteatoma and correlate imaging findings with intraoperative findings, and to emphasize of role of imaging in the follow-up of postoperative patients for differentiating residual/recurrent cholesteatoma from granulation/inflammatory tissue. In this prospective study, 31 patients were evaluated with a specific MRI protocol and high resolution computed tomography of the temporal bones. These included patients with a strong suspicion of having a cholesteatoma on clinical examination and postoperative cases on clinical follow up. Based on specific MRI findings, presence of cholesteatoma was reported in 17 out of 31 patients. All 31 patients underwent surgery and 19 patients had confirmed intraoperative cholesteatoma. This study shows high sensitivity of a specific sequence based MRI examination in detection of cholesteatoma and in differentiating cholesteatoma from postoperative inflammatory/granulation tissue. To the best of the author's knowledge, this is the first such study performed in the Indian Asian population.

Predictive validity of MRI in detecting and following cholesteatoma

High recurrence rate of the middle ear cholesteatoma requires regular postoperative follow-up. This study evaluated data from the patients investigated with DW MRI to ascertain (1) the strength of the technique in detecting primary, and residual recurrent cholesteatoma, and (2) its accuracy in differentiating cholesteatoma from postoperative tissue changes. The diagnostic accuracy of two different DW imaging (EPI and non-EPI) techniques was evaluated. The data have been collected prospectively from 33 consecutive patients with either primary cholesteatoma, or with suspicious symptoms for potential cholesteatoma recurrence. The findings from non-EPI (HASTE) DW MR and EPI DW MR images were blindly compared with those obtained during a primary or secondary surgery. Preoperative non-EPI (HASTE) DWI pointed to a cholesteatoma in 25 out of 33 patients. In this subgroup, cholesteatoma were confirmed also by the surgery. In five cases, the non-EPI (HASTE) DWI did not show a cholesteatoma in the temporal bone, which agreed with the surgical findings. Three misclassifications were made by non-EPI (HASTE) DWI, all in the subgroup of patients indicated for primary surgery. The resulting pooled sensitivity of non-EPI (HASTE) DW imaging for diagnosing cholesteatoma in our study amounted to 96.15% (95% confidence interval (CI) 80.36-99.9), specificity was 71.43% (95% CI 29.04-96.33). Positive predictive value was 92.59% (95% CI 75.71-99.09) and negative predictive value 83.33% (95% CI 35.88-99.58). In conclusion, we recommend the non-EPI (HASTE) DW MRI as a valid method for diagnosing cholesteatoma and follow-up after cholesteatoma surgery.

Detection of middle ear cholesteatoma by diffusion-weighted MR imaging: multishot echo-planar imaging compared with single-shot echo-planar imaging

BACKGROUND AND PURPOSE

Previous reports have shown that DWI is useful in detecting cholesteatoma. SS-EPI is the most widely used DWI technique. However, SS-EPI may have susceptibility artifacts due to field inhomogeneity in the imaging of the temporal bone region. Our purpose was to prospectively evaluate the advantage of MS-EPI for the diagnosis of middle ear cholesteatoma by comparing it with SS-EPI.

MATERIALS AND METHODS

We studied 29 patients with preoperatively suspected acquired cholesteatoma. Each patient underwent an MR imaging examination including both SS-EPI and MS-EPI by using a 1.5T MR imaging scanner. Images of the 29 patients (58 temporal bones including 30 with and 28 without cholesteatoma) were reviewed by 2 independent neuroradiologists. The confidence level for the presence of cholesteatoma was graded on a scale of 0-2 (0 = none, 1 = equivocal, 2 = definite). Interobserver agreement as well as sensitivity, specificity, and accuracy were assessed for the 2 readers.

RESULTS

Excellent interobserver agreement was shown for both MS-EPI (κ = 0.856) and SS-EPI (κ = 0.820). MS-EPI was associated with higher sensitivity (76.7%) and accuracy (87.9%) than SS-EPI (sensitivity = 50.0%, accuracy = 74.1%) (P < .05), while both methods showed 100% specificity.

CONCLUSIONS

Compared with SS-EPI, MS-EPI improves the accuracy of the diagnosis of acquired middle ear cholesteatomas.

Imaging of postoperative middle ear cholesteatoma

Cholesteatoma is often treated surgically using canal wall-preserving techniques. Clinical and otoscopic diagnosis of residual or recurrent disease after this form of surgery is unreliable and thus radiological imaging is often used prior to mandatory "second-look" surgery. Imaging needs to be able to differentiate residual or recurrent disease from granulation tissue, inflammatory tissue or fluid within the middle ear cavity and mastoid cavity. High-resolution computed tomography (HRCT), conventional magnetic resonance imaging (MRI), and delayed contrast MRI have all been used in detecting postoperative cholesteatoma. Although delayed contrast MRI performs better than HRCT and conventional MRI, the sensitivities and specificities of these different imaging methods are relatively poor. Diffusion-weighted MRI (DWI and, in particular, non-echo planar DWI) has been shown to have a high sensitivity and specificity for detecting recurrent cholesteatoma. In this review we provide examples of postoperative imaging appearances following cholesteatoma surgery and we review the relevant literature with an emphasis on studies evaluating the diagnostic accuracy of DWI.

HASTE diffusion-weighted 3-Tesla magnetic resonance imaging in the diagnosis of primary and relapsing cholesteatoma

OBJECTIVE

To evaluate the value of half-Fourier acquisition single-shot turbo-spin-echo diffusion-weighted magnetic resonance imaging (HASTE DW MRI) using a 3-Tesla (3T) unit in the diagnosis of primary and relapsing cholesteatoma.

STUDY DESIGN

Retrospective observational investigation.

SETTING

Tertiary referral center.

PATIENTS

Seventeen patients suspected of having a primary cholesteatoma without clear clinical evidence of the lesion, and 13 patients who were candidates to a second-stage tympanoplasty to rule out a relapsing cholesteatoma or reconstruct the ossicular chain were investigated.

INTERVENTION

All patients were scanned in a 3T scanner with a 4-channel head coil using T2 HASTE DW MRI technique sequences in axial and coronal planes covering the middle ear and mastoid regions.

MAIN OUTCOME MEASURE

Images were considered positive for cholesteatoma in the presence of a hyperintense, patchy-like lesion in the petrous bone.

RESULTS

Images showed a high signal intensity suggestive of primary cholesteatoma in 10 of 17 patients and of relapsing cholesteatoma in 7 of 13 patients. Of the 17 subjects, 15 with positive MRI findings were operated on, and the presence of cholesteatoma (ranging from 2 to 20 mm in size) was confirmed at surgery. Of the 13 subjects shown to be negative on HASTE DW MRI for cholesteatoma, 11 were operated on and were all confirmed to be cholesteatoma-free.

CONCLUSION

Half-Fourier acquisition single-shot turbo-spin-echo diffusion-weighted magnetic resonance imaging technique, using a 3T unit, may be a diagnostic tool for a rapid and highly reliable discrimination between cholesteatomatous and noncholesteatomatous tissue in the middle ear, with 100% of positive and negative predictive values.

The diagnostic value of diffusion-weighted magnetic resonance imaging in detecting a residual cholesteatoma

In this evidence-based case report, we address the following clinical question: What is the predictive value of diffusion-weighted magnetic resonance imaging (DW MRI) for detecting a residual cholesteatoma in patients with chronic otitis media with cholesteatoma who have previously undergone a canal-wall-up procedure? We searched for relevant synonyms for the determinant, MRI, and for the outcome, cholesteatoma, and retrieved relevant publications in Embase, PubMed, Cinahl, and Web of Science by using search terms in the title and abstract fields. The search yielded 683 records, of which 11 were relevant and valid for our clinical question. We pooled the data of the MRI findings of the included studies by adding the two-by-two tables of the individual studies. For the eight echo planar imaging (EPI) DW MRI studies, this resulted in a pooled sensitivity, specificity, positive predictive value, and negative predictive value of 68 percent, 87 percent, 81 percent, and 78 percent, respectively. For the three non-echo planar (non-EPI) DW MRI studies, the sensitivity, specificity, positive predictive value, and negative predictive value were 97 percent, 97 percent, 97 percent, and 97 percent, respectively. DW MRI, especially the non-EPI DW MRI, appears to be a rather accurate method, as opposed to a standard second-look operation, for the follow-up of patients who have undergone a canal-wall-up procedure for a chronic otitis media with cholesteatoma and who have no clinical signs of recurrent cholesteatoma.

Detecting cholesteatoma with non-echo planar (HASTE) diffusion-weighted magnetic resonance imaging

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging (DWMRI) in the detection of cholesteatoma.

STUDY DESIGN

Prospective blinded comparative study.

SETTING

London teaching hospital.

SUBJECTS AND METHODS

Subjects comprised 32 consecutive patients with suspected primary or residual cholesteatoma. HASTE DWMRI was performed on all patients an average of three months before mastoid surgery and evaluated for the presence of cholesteatoma. Radiological findings were correlated with intraoperative findings.

RESULTS

HASTE DWMRI accurately predicted the presence or absence of cholesteatoma in 30 of 32 patients. Residual cholesteatoma was correctly diagnosed by DWMRI in 12 of 14 cases and correctly excluded in six, with two false-negative results caused by movement artifact and keratin pearls less than 2 mm. All primary cholesteatomas were correctly identified. Sensitivity and specificity were 0.93 (95% confidence interval [CI] 0.75-0.99) and 1.00 (95% CI 0.54-1.0), respectively, whereas positive and negative predictive values were 1.00 (95% CI 0.86-1.00) and 0.75 (95% CI 0.35-0.97), respectively.

CONCLUSION

Our study supports the increasing but small body of evidence that non-echo-planar imaging (i.e., HASTE) DWMRI performs well in the detection of cholesteatoma. We propose that HASTE DWMRI should be performed on all patients before their second-look surgery to provide valuable information to the operating surgeon.

Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging--value in detection

PURPOSE

To retrospectively compare non-echo-planar (non-EP) diffusion-weighted (DW) imaging, delayed gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging, and the combination of both techniques in the evaluation of patients with cholesteatoma.

MATERIALS AND METHODS

This institutional review board-approved study, for which the need to obtain informed consent was waived, included 57 patients clinically suspected of having a middle ear cholesteatoma without a history of surgery and 63 patients imaged before "second-look" surgery. Four blinded radiologists evaluated three sets of MR images: a set of delayed gadolinium-enhanced T1-weighted images, a set of non-EP DW images, and a set of both kinds of images. Overall sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV), as well as intra- and interobserver agreement, were assessed and compared among methods. To correct for the correlation between different readings, a generalized estimating equations logistic regression model was fitted. Results were compared with surgical results, which were regarded as the standard of reference.

RESULTS

Sensitivity, specificity, NPV, and PPV were significantly different between the three methods (P < .005). Sensitivity and specificity, respectively, were 56.7% and 67.6% with the delayed gadolinium-enhanced T1-weighted images and 82.6% and 87.2% with the non-EP DW images. Sensitivity for the combination of both kinds of images was 84.2%, while specificity was 88.2%. The overall PPV was 88.0% for delayed gadolinium-enhanced T1-weighted images, 96.0% for non-EP DW images, and 96.3%for the combination of both kinds of images. The overall NPV was 27.0% for delayed gadolinium-enhanced T1-weighted images, 56.5% for non-EP DW images, and 59.6% for the combination of both kinds of images.

CONCLUSION

MR imaging for detection of middle ear cholesteatoma can be performed by using non-EP DW imaging sequences alone. Use of the non-EP DW imaging sequence combined with a delayed gadolinium-enhanced T1-weighted sequence yielded no significant increases in sensitivity, specificity, NPV, or PPV over the use of the non-EP DW imaging sequence alone.

Diffusion-weighted magnetic resonance imaging of the temporal bone

This paper summarizes the value of diffusion-weighted magnetic resonance imaging in the evaluation of temporal bone pathology. It highlights the use of different types of diffusion-weighted magnetic resonance imaging in the different types of cholesteatoma, prior to first stage surgery and prior to second look surgery. The value of diffusion-weighted magnetic resonance imaging in the evaluation of pathology of the apex of the petrous bone and the cerebellopontine angle is also discussed.

The utility of diffusion-weighted imaging for cholesteatoma evaluation

DWI is a useful technique for the evaluation of cholesteatomas. It can be used to detect them when the physical examination is difficult and CT findings are equivocal, and it is especially useful in the evaluation of recurrent cholesteatoma. Initial DWI techniques only detected larger cholesteatomas, >5 mm, due to limitations of section thickness and prominent skull base artifacts. Newer techniques allow detection of smaller lesions and may be sufficient to replace second-look surgery in patients with prior cholesteatoma resection.

Neuroradiology of cholesteatomas

The relevant aspects of cholesteatomas are reviewed with the emphasis on their diagnosis by using cross-sectional imaging. The indications and limitations of CT and MR imaging and the use of novel MR imaging techniques in the diagnosis of cholesteatomas are described. HRCT of the temporal bone has an excellent spatial resolution, thus even small soft-tissue lesions can be accurately delineated (high sensitivity). However, CT has poor specificity (ie, soft-tissue structures cannot be differentiated). MR imaging with the conventional sequences (T1WI, T2WI, postcontrast T1WI) provides additional information for distinguishing different pathologic entities and for accurately diagnosing primary (nonsurgical) and residual/recurrent (surgical) cholesteatomas. Higher diagnostic specificity is achieved by introducing DW-EPI, delayed postcontrast imaging, DW-non-EPI, and DWI-PROPELLER techniques. Studies using DW-non-EPI and DWI-PROPELLER sequences show promising results related to improved diagnostic sensitivity and specificity for even small (<5 mm) cholesteatomas, thus allowing avoidance of second-look surgery in the future.

Preliminary outcomes of cholesteatoma screening in children using non-echo-planar diffusion-weighted magnetic resonance imaging

OBJECTIVE

Diffusion-weighted (DW) MRI imaging is evolving into an alternative to second look surgery in detection of cholesteatoma recurrence. Insights into the DW MRI appearances of postoperative or inflammatory mucosal changes have recently described using non-echo-planar, turbo spin-echo (TSE) DW MRI which reliably distinguishes between postoperative changes and cholesteatoma. We investigated the use of TSE DW MRI in our pediatric population in order to validate a rapid and cost-effective MRI sequence that can be used to screen for cholesteatoma.

METHODS

Prospective comparative study with adult and pediatric patients at a tertiary referral centre. Patients in the study underwent TSE DW MRI prior to second look or revision surgery for cholesteatoma. A Siemens 1.5 T scanner was employed, using the HASTE sequence (EPI DW MRI) as well as standard echo-planar DWI, T1 and T2 sequences. The MRI findings were then correlated with the intraoperative findings at surgery 9-15 months after primary surgery, or of revision surgery in the cases that were referred from other centres. Detection and localisation of cholesteatoma on TSE DW MRI were compared with the findings at second surgery, long considered the gold standard for detection of residual or recurrent disease. Scanning time between the TSE sequence and the standard planar DW MR were also compared.

RESULTS

In a cohort of 92 patients, 21 pediatric patients were identified. 15 patients have had their 15 second look or revision procedures and DW MRI prior to their surgery. TSE DW MRI detected cholesteatoma and reliably identified the location of the cholesteatoma in 2 patients whom all had disease confirmed at surgery. The 13 cases with negative preoperative DW MRI for cholesteatoma were all confirmed to be disease free at surgery. Scanning time of the TSE sequence takes 100 s as opposed to 20 min using standard echo-planar DW MRI techniques without the requirement of a contrast agent and without the need for a general anaesthetic for any of the children.

CONCLUSION

TSE (HASTE) DW MRI is emerging as a cost effective, noninvasive alternative to second look surgery for detection and screening for cholesteatoma in pediatric patients.

Diffusion-weighted MR imaging for evaluation of pediatric recurrent cholesteatomas

OBJECTIVE

To compare the efficiency of diffusion-weighted MR imaging (MRI) vs. high resolution CT in predicting recurrent or residual cholesteatoma in children who underwent prior middle ear surgery.

DESIGN

Prospective study.

SETTING

Tertiary care university hospital.

PATIENTS

Seventeen patients (4 with 2 recurrences) aged 5-17 years (mean 11.4) previously surgically treated for a cholesteatoma of the middle ear, were included for follow-up with systematic CT scan and MRI, between 2005 and 2007.

METHODOLOGY

CT scan was performed on a Siemens Somaton 64 (0.5/0.2 mm slices reformatted in 0.5/0.3 mm images), parallel and perpendicular to the lateral semi-circular canal for each ear (100 mmx100 mm FOV). MRI was undertaken on a Siemens Avanto 1.5 T unit, with an adapted protocol for young children. Diagnosis of recurrent cholesteatoma was based on the evidence of a hyperintense image at B1000 on diffusion-weighted images. Results of CT scan and MRI were compared with operative diagnosis.

RESULTS

Nine patients had a positive MRI, among which 8 had cholesteatoma confirmed during revision surgery. In the 12 negative MRI cases, 5 were positive on revision surgery. None of these lesions was over 3mm. Two of them were diagnosed on the CT scan. CT scan alone had a positive predictive value of 75%, and a negative predictive value of 58%.

CONCLUSION

Diffusion-weighted MRI is associated with a high positive predictive value for the detection of recurrent cholesteatoma. CT scan remains the first choice imaging technique. In case of doubtful CT scan, diffusion-weighted MRI could confirm a recurrence or, when negative, avoid second-look surgery.

Imaging of inflammatory and infectious diseases in the temporal bone

Inflammatory and infectious diseases of the temporal bone are a major indication to perform high-resolution CT and MR imaging studies. Such studies allow one to evaluate the extent of the disease in the soft tissues and in the bony structures of the temporal bone. On these same imaging studies the possible extension of the infection to surrounding regions is visualized. In this article a segmental approach is used, focusing on four structures in the temporal bone: the external ear, the otomastoid and petrous apex, the inner ear, and the facial nerve. For each of the four sections imaging findings are described and illustrated, and if relevant a differential diagnostic approach is highlighted.

Diffusion-weighted magnetic resonance imaging: its uses in otolaryngology

Over recent years, there has been an increase in otolaryngology publications concerning diffusion-weighted magnetic resonance imaging. The aims of this review paper are to summarise the basic principles of diffusion-weighted magnetic resonance imaging, and to provide an overview of current otolaryngological applications and areas of research. Diffusion-weighted magnetic resonance imaging is a radiological technique which has shown promising results in various areas of otolaryngology. However, studies of diffusion-weighted magnetic resonance imaging are difficult to compare, as different imaging parameters and techniques have been used. The role of this imaging modality within otolaryngology is yet to be fully elucidated. Diffusion-weighted magnetic resonance imaging may prove to be a useful adjunct in both the pre- and post-operative care of otolaryngology patients.

Diffusion-weighted magnetic resonance imaging in the management of cholesteatoma

Diffusion-weighted (DW) MRI has recently increasingly gained popularity in the diagnosis of post-operative cholesteatoma. The aim of this study is to prospectively evaluate the usefulness of echo-planar imaging (EPI) for the diagnosis of residual cholesteatoma. Fifty patients underwent DW-EPI before surgery. Fifteen patients had a scan before their first surgery and 35 patients underwent neuroimaging prior to their second look surgery. In the first preoperative group of 15 patients, DW-EPI confirmed cholesteatoma in all the patients. In the post-operative group DW-EPI identified or excluded cholesteatoma correctly in 29 out of 35 patients. Our study has demonstrated a sensitivity of 83% and specificity of 82% of DW-EPI for the diagnosis of residual cholesteatoma. DW-EPI can be a value imaging modality and may help the surgeon in selecting patients for revision surgery.

Acquired Atresia of the External Auditory Canal: Recurrence and Long-Term Results

Objectives:

I describe the clinical symptoms and signs of acquired atresia of the external auditory canal (EAC) and the technique used to manage it.

Methods:

Forty-one consecutive patients affected by acquired atresia of the EAC were assessed by otoscopy, pure tone audiometry, computed tomography, and traditional and echo-planar diffusion-weighted magnetic resonance imaging. The anatomic and functional hearing results were evaluated.

Results:

At surgery for acquired atresia of the EAC, an EAC cholesteatoma was found in 3 of the 41 patients. Twenty-three of the 41 patients were followed for at least 5 years. Recurrence was seen in 9 of the 25 ears (36%) over the entire period of observation. Twenty-one, 23, and 22 of the patients had a normal or nearly normal contour and size of the ear canal at 6 months, 1 year, and 5 years, respectively. The results were similar for the air-bone gap.

Conclusions:

The main complication following surgery was recurrence. There was recurrence at 6 months in 4 patients (16%). Recurrence was seen in 12% of the cases at the 5-year follow-up. Similar findings were clear on evaluation of the hearing results. This result demonstrates that the surgical procedure, even when performed correctly, did not afford a stable, long-lasting outcome in a cohort of patients.

Postoperative non-echo-planar diffusion-weighted magnetic resonance imaging changes after cholesteatoma surgery: implications for cholesteatoma screening

OBJECTIVES

Diffusion-weighted (DW) magnetic resonance imaging (MRI) is emerging as an alternative to second-look surgery in ruling out residual or recurrent disease after cholesteatoma eradication. However, the DW MRI appearances of postoperative or inflammatory mucosal changes have not been well investigated, thus rendering the interpretation of postoperative DW MRI difficult in the presence of mucosal reactions. We investigated the turbo-spin echo (TSE) DW MRI changes of the middle ear and mastoid mucosa after cholesteatoma surgery and compared these with the TSE DW MRI features of cholesteatoma with an aim to identify a rapid and cost-effective purely DW MRI sequence that can be used to screen for cholesteatoma.

STUDY DESIGN

A prospective comparative study.

SETTING

A tertiary referral center in Western Australia.

PATIENTS

Patients undergoing revision or second-look cholesteatoma surgery.

INTERVENTION

Patients underwent 3 to 6 monthly half-Fourier-acquisition single-shot turbo-spin-echo TSE DW MRI before their second surgery. The MRI findings were then correlated with the intraoperative findings at second-look surgery 6 to 17 months after primary surgery or of revision surgery in the cases that were referred from other centers.

MAIN OUTCOME MEASURE

Detection of cholesteatoma and noncholesteatoma mucosal changes on TSE DW MRI, compared with the gold standard of findings at second surgery.

RESULTS

Twenty-two patients underwent 23 second-look or revision procedures. All patients had DW MRI before their "second-look" or revision surgery. TSE DW MRI detected cholesteatomas in 7 patients whom all had disease confirmed at second-look or revision surgery. In 16 cases shown to be negative on DW MRI for cholesteatoma, all were confirmed to be disease-free on second-look surgery. Cholesteatomas were shown to produce a TSE DW MRI signal clearly distinct from the spectrum of imaging findings encountered in postoperative mucosal changes.

CONCLUSION

TSE DW MRI holds great promise in screening for cholesteatoma as an alternative to exploratory second-look surgery.

The role of magnetic resonance imaging in the postoperative management of cholesteatomas

Conventional CT and MRI scans have low specificity when it comes to differentiating granulation tissue from relapsing cholesteatoma.

Aim

this paper aims to analyze the use of DWI and delayed post-contrast T1-weighed imaging in the detection of recurring cholesteatomas.

Materials and method

this is a cross-sectional prospective study that looked at 17 cholesteatoma patients postoperatively. All patients underwent diffusion magnetic resonance imaging at 1.5T, T1, T2, and delayed post-contrast T1 and images were produced from both coronal and axial planes. Two radiologists assessed the images and decided consensually that the presence of hyperintensive signal in DWI on T2, iso/ hypointensive signal on T1, and absence of contrast uptake were indicative of relapsing cholesteatoma. Surgical review findings were compared to DWI scans.

Results

eleven of the twelve cases of recurring cholesteatoma presented hyperintensive signal in the DWI scans. None of the patients with granulation tissue in the surgical wound presented hyperintensive signal in the DWI scans. A patient with an abscess in the internal acoustic meatus also presented a hyperintensive signal in the DWI scans. Sensibility, specificity, positive predictive value and negative predictive value were 91.6%, 60.0%, 84.6%, and 75.0%, respectively.

Conclusion

DWI combined with delayed post-contrast T1 SE sequence proved to be useful in the differential diagnosis of granulation tissue and recurring cholesteatoma.

Comparison of echo-planar diffusion-weighted imaging and delayed postcontrast T1-weighted MR imaging for the detection of residual cholesteatoma

BACKGROUND AND PURPOSE

Echo-planar diffusion-weighted imaging (DWI) and delayed postcontrast T1-weighted MR imaging (DPI) have been proposed in previous studies to detect residual middle ear cholesteatomas, with varying results. We assessed and compared these 2 techniques in patients with canal wall-up tympanoplasty.

MATERIALS AND METHODS

This was a prospective cohort study. Patients who underwent surgery for middle ear cholesteatoma had CT scanning 9 months after the surgery. If opacity was observed (64%) on CT scans, DWI and DPI were performed before second-look surgery. CT, MR imaging, and surgical data were available for 31 patients. Charts were reviewed independently by 3 blinded examiners. Interobserver agreement for MR imaging was calculated (Cohen kappa). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for these techniques: 1) alone or in association, and 2) according to the residual cholesteatoma size measured during surgery.

RESULTS

Interobserver agreement was better for DWI (kappa = 0.81) than for DPI (kappa = 0.51). Sensitivity, specificity, PPV, and NPV values were 60%, 72.73%, 80%, and 50%, respectively, with DWI; and 90%, 54.55%, 78.26%, and 75%, respectively, with DPI. With cholesteatomas >5 mm, the sensitivity and specificity of DWI reached 100% and 88%, respectively, with values for DPI reaching 100% and 80%, respectively. The association of both techniques only allowed improvements in the specificity for lesions >5 mm.

CONCLUSIONS

Both techniques gave acceptable results for residual cholesteatoma detection. DWI is more specific but less sensitive than DPI. Their concurrent use may benefit patients by avoiding undue surgery.