Computed tomography in suppurative ear disease: does it influence management?

Correlation of Preoperative 'HRCT Temporal Bone' Findings with 'Surgical Findings' in Unsafe CSOM

To assesses the usefulness of a preoperative HRCT temporal bone and establish HRCT as an efficacious tool for diagnosis of the extent and involvement of adjacent structures by Cholesteatoma. The study group includes 52 patients with Unsafe CSOM (atticoantral), who presented to the ENT OPD at a tertiary care centre in Central India over a period of 18 months, who underwent HRCT temporal bone followed by surgical exploration of middle ear and or mastoid, for the removal of Cholesteatoma. From the observation and results obtained from this study, we can conclude that the HRCT can be used as a standard radiological imaging modality for the evaluation of temporal Bone pathology. Despite its pitfalls such as more radiation exposure and higher cost, delineates the location and extent of the disease and provides critical information regarding anatomical variations and complications. It serves as a roadmap to assist the surgeon during surgery.

Revisiting Correlation Between Pre Operative High Resolution Computed Tomography and Operative Findings in Attico Antral Disease

(1) To correlate the findings of high resolution computed tomography (HRCT) scans with operative findings in chronic otitis media (attico antral disease). (2) To assess the role of HRCT in chronic otitis media (attico antral disease). This prospective observational study undertaken at a tertiary level teaching hospital included 50 patients of chronic otitis media (attico antral disease) who underwent pre-operative HRCT scanning and the findings were compared with the operative findings and correlation between the two was assessed with appropriate statistical methods. HRCT findings correlated well for the status of malleus and incus, facial nerve canal, lateral semicircular canal, and sinus plate but were less accurate for stapes and tegmen plate. As for disease extent and prediction of cholesteatoma the degree of correlation was site dependent being greater in mastoid air cell system and epitympanum and lesser in mesotympanum and hypotympanum. HRCT despite of its value in management of chronic otitis media has its drawbacks and limitations. CT's accuracy of prediction in some aspects of the disease varies with the site of pathology and this point must always be kept in mind by the operating surgeon. We suggest that each health care centre should establish their own correlative indices for HRCT temporal bone imaging in COM. HRCT cannot be entirely relied upon in management of chronic otitis media patients. However against the backdrop of improved radiological skills in interpreting temporal bone ct images, improved CT machines and importantly the growing concern over medicolegal issues, the role of pre operative CT scan in COM is much more than what was thought previously. Undoubtedly, it is a very useful 'aid' to management BUT a well-trained, experienced and alert surgeon is the key for an accurate diagnosis and successful management of chronic otitis media (attico-antral disease).

Chronic Draining Ear and Cholesteatoma Recidivism: A Retrospection from Clinical, Imaging, and Surgical Perspectives

Objective

To evaluate the reasons for persistent draining ear and cholesteatoma recidivism following canal wall down (CWD) tympanomastoidectomy by studying the sensitivity of high-resolution computed tomography (HRCT) scanning in different potential etiologies, corroborating through appropriate surgical intervention, and thereby, to suggest proper preventive measures.

Methods

In this observational study, 32 chronic, refractory draining ears were subjected to revision surgery following a radical or a modified radical mastoidectomy. Besides disease (cholesteatoma/granulations) eradication, pitfalls of the primary surgeries were addressed. Data were interpreted for studying the epidemiologic profile, the clinical presentation at recurrence, the type of primary surgery, the sites of recidivism, the probable causes, and the best possible management at revision.

Results

Of the 32 patients/ears, 23 had residual/recurrent cholesteatoma. Major reasons were inadequate disease clearance, contracted/inadequate conchomeatoplasty, no cavity obliteration, and inappropriate bone work. HRCT predicted persistent bridge and lateral semicircular canal dehiscence with 100%, and ossicular integrity and bony overhang with >80% sensitivity. Sinus tympani and oval window niche were the commonest sites of recurrence. At revision, radical/modified radical mastoidectomies were associated with cavity obliteration and appropriate revision of conchomeatoplasty in 28 patients.

Conclusion

Recurrence of cholesteatoma/granulations is an important cause for chronic drainage from post-CWD cavities. Revision surgery explores the surgical pitfalls, and ensures clearance of disease from hidden areas, adequate bone work, and optimum conchomeatoplasty following cavity obliteration to provide a safe, dry ear with hearing improvement whenever feasible.

Is HRCT Temporal Bone Necessary in All Cases of Active Squamous Chronic Otitis Media?

To assess the usefulness of high resolution computed tomography (HRCT) temporal bones in cases of active squamous chronic otitis media (COM). Comparison of HRCT findings with operative findings. A prospective study of 104 clinically diagnosed patients with COM were included. Each patient was subjected to full clinical evaluation and HRCT temporal bone was done. Preoperative HRCT finding were correlated with surgical findings. The sensitivity of HRCT temporal bone in detecting cholesteatoma was 91.81%. However it could not differentiate cholesteatoma from other soft tissue density like granulation or hypertrophic mucosa or discharge, but soft tissue attenuation content with bone erosion was considered as hallmark of cholesteatoma. The sensitivity and specificity of HRCT for detecting malleus, incus and stapes erosion was 71.5 and 88.5%, 86.3 and 95% and 53.1 and 64.7% respectively. The sensitivity and specificity for detecting erosion of lateral semicircular canal (LSCC) was 77.78 and 98.2%. The sensitivity and specificity for facial canal was 80 and 100%. HRCT gives excellent details about the extent of cholesteatoma with reasonable accuracy in expert hands. It helps to warn the surgeon about anatomical variations preoperatively and detects complications if any. It effectively depicts integrity or erosion of dural plate, sinus plate, LSCC, facial nerve. Malleus and incus are seen reasonably well but status of stapes are not recorded effectively.

Is Routine Use of High Resolution Computerized Tomography of Temporal Bone in Patients of Atticoantral Chronic Suppurative Otitis Media without Intracranial Complications Justified?

Role of high resolution computerized tomography (HRCT) of temporal bone is established in cases of atticoantral chronic suppurative otitis media (CSOM) with intracranial complications. Routine use of HRCT in management of patients of atticoantral CSOM without intracranial complications has been an issue of debate. The aim of this study was to evaluate the routine use of HRCT of temporal bone in such cases. This study was a prospective study done at LG hospital, AMC MET Medical College, Ahmedabad to evaluate and compare the temporal bone findings in HRCT and intraoperative findings in 100 patients with atticoantral CSOM. All patients underwent HRCT screening followed by surgical exploration of middle ear cleft. In extent of disease HRCT showed very high sensitivity and specificity for epitympanum (100, 94%) and mesotympanum (98, 98%) areas. It gave valuable information of disease extent in hidden areas like sinus tympani and facial recess of mesotympanum. HRCT satisfactorily delineated malleus and incus erosion but had 75% sensitivity for detecting erosion of stapes suprastructure, though specificity was of 97%. For bony anatomical landmarks HRCT showed very high sensitivity and specificity for detecting erosion of lateral semicircular canal, tegmen tympani and sinus plate. Detection of facial canal erosion on HRCT had moderate sensitivity of 75%. We concluded that routine use of HRCT is justified as a reliable preoperative tool in patients with atticoantral CSOM without intracranial complications and it helps to plan type of surgical intervention. HRCT has limited role to distinguish between granulations and cholesteatoma and also to delineate stapes supra structure and facial nerve canal.

Extensive Acquired Cholesteatoma in Children: When the Penny Drops

Objectives:

To determine the factors associated with the diagnosis of acquired cholesteatoma (AC) in children, we performed a retrospective chart review at a tertiary care center.

Methods:

We reviewed children with a diagnosis of AC that extended beyond the mesotympanum in the presence of a nonintact tympanic membrane who underwent surgical treatment over a 14-year period.

Results:

There were 116 children (78 male, 38 female) between 3 and 18 years of age (mean, 9.5 years). Their average period of management in a specialist otolaryngology clinic before the diagnosis of cholesteatoma was made was 3.2 years, and 68% of the children had previously undergone insertion of tympanostomy tubes. Symptoms and signs included chronic otorrhea (59%), recurrent acute otitis media (58%), and conductive hearing loss (51%). The diagnosis of AC was eventually made after office otoscopy (26%), temporal bone computed tomography (24%), or examination under anesthesia (17%). In 33% of children, the diagnosis was made only after surgical exploration of the middle ear and mastoid.

Conclusions:

Our data underscore the importance of maintaining a high index of suspicion for AC in managing children with long-standing otologic symptoms, and considering otomicroscopy, computed tomographic scanning, or tympanomastoid exploration if medical treatment fails.

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.

Pre-operative high resolution computed tomography scans for cholesteatoma: has anything changed?

OBJECTIVE

CT temporal bone scans are often performed to aid in surgical planning and management of cholesteatomas. With improvements in the resolution of CT scans today, it is now possible to obtain more information from these scans than before. The aim of this study is to compare findings on high resolution CT (HRCT) temporal bone scans to intra-operative findings, so as to determine how well various middle ear structures are assessed by HRCT scanning.

STUDY DESIGN

Retrospective study.

SETTING

Otology clinic of a tertiary otolaryngology centre.

SUBJECTS AND METHODS

32 mastoidectomies performed by a single otologist for clinically confirmed cholesteatoma were included. Correlation of CT and intra-operative findings on the status of structures including the ossicles, semicircular canals, facial canal and tegmen was analysed using kappa and AC1 statistics.

RESULTS

In all patients, a soft tissue mass with bony erosion in keeping with a cholesteatoma was seen on CT. Radiosurgical agreement was excellent for the presence of semicircular canal erosion (k=0.89, AC1=0.96), facial canal dehiscence (k=0.74, AC1=0.76), tegmen erosion (k=0.76, AC1=0.92) and malleus erosion (k=0.76, AC1=0.85). It was good for incus erosion (k=0.71, AC1=0.92) and stapes erosion (k=0.63, AC1=0.73).

CONCLUSION

There was good to excellent radiosurgical agreement in the assessment of the status of various middle ear structures. Improvement in radiosurgical agreement from existing studies in the literature was noted. This was especially true for features such as facial canal dehiscence. With technological advancements, CT temporal bone scans appear even more valuable for evaluation of patients prior to cholesteatoma surgery.

[Clinical and roentgenological diagnostics of the severity of mucositis in the patients presenting with chronic suppurative otitis media]

The objective of the present study was to determine the prevalence of mucositis and its roentgenological manifestations in the patients presenting with chronic suppurative otitis media (CSOM). A total of 390 patients with CSOM (mesotympanitis) and 85 ones suffering CSOM with concomitant mucositis were available for the observation. The signs of mucositis were evaluated based on the patients' complaints, results of otomicroscopy, and computed tomography (CT) of the temporal bones. This randomized clinical study involving 390 patients presenting with CSOM revealed the signs of mucositis in 44.6% of the cases. Analysis of the results of temporal bone CT performed in 85 patients with CSOM and mucositis in the absence exacerbation has demonstrated the possibility of detecting mucositis and evaluating its severity from the changes in the airness of the tympanic cavity, attics, and antrum due to the presence of the pathological substrate in these regions.

An audit of ‘dead ear’ after ear surgery

Introduction:

‘Dead ear’ is a rare and serious complication of ear surgery. This paper presents an audit of this complication.

Method:

Over 6 years, data for all 617 middle-ear operations performed under the care of a single consultant were recorded for the International Otology Audit. All cases of dead ear were identified and assessed.

Results:

A post-operative dead ear occurred in 6 cases (approximately 1 per cent). No cases of post-operative dead ear occurred following the 83 otosclerosis operations and the 62 children's procedures. Amongst 187 adult patients undergoing mastoid surgery for cholesteatoma, there were 5 cases of post-operative dead ear (2.7 per cent of cases).

Conclusion:

The occurrence of dead ear after cholesteatoma surgery in adults is less rare than previously thought. This has implications for the surgical consenting process. The current series suggests that, whilst dead ear is often avoidable, it is sometimes inevitable.

Evaluation of temporal bone cholesteatoma and the correlation between high resolution computed tomography and surgical finding

BACKGROUND

Acquired cholesteatomas are commonly seen in patients less than 30 years. There is a typical history of recurrent middle ear infections with tympanic membrane perforation. The diagnosis of cholesteatoma is usually made on otologic examination.

OBJECTIVE

The aim of the work was to study the role of high resolution computed tomography (HRCT) in detecting, evaluating, and diagnosing middle ear cholesteatoma.

PATIENTS AND METHODS

This was a prospective study that included 56 consecutive patients with chronic suppurative otitis media, unsafe type cholesteatomas. Each patient was subjected to full clinical evaluation, and HRCT examination. Intravenous contrast media was used in some patients with suspected intracranial complication. Preoperative radiological data were correlated with data related to surgical findings.

RESULTS

The study showed that a high incidence of cholesteatoma in the third decade of life. The scutum and lateral attic wall were the most common bony erosions in the middle ear bony wall (64.3%), and the incus was the most eroded ossicle in the middle ear (88.2%). Sclerosing of mastoid air cells were encountered in 60.7% of patients and the lateral semicircular canal was affected in 9%, while facial canal erosion was found in 21.4%. Temporal bone complications are more common than intracranial complications. HRCT findings were compared with operative features; the comparative study included the accuracy and sensitivity of HRCT in detecting cholesteatoma (92.8%), its location and extension (96.4%), ossicular chain erosion (98%), labyrinthine fistula and intracranial complications (100%).

CONCLUSION

The important role of HRCT scannig lies on the early detection of cholesteatoma, and more conservative surgical procedures can be used to eradicate the disease.

The value of preoperative CT scan of tympanic facial nerve canal in tympanomastoid surgery

CONCLUSIONS

The combined analysis of axial, coronal, and sagittal planes can increase the positive rate of diagnosis for dehiscence of the facial nerve canal.

OBJECTIVE

The aim of this study was to evaluate the diagnostic value of high resolution computed tomography (HRCT) scanning of the condition of the tympanic portion of the facial nerve canal in patients with chronic otitis media.

METHODS

A total of 76 ears of 72 inpatients with chronic suppurative otitis media and with cholesteatoma or granulation tissues in the attic were examined by routine HRCT. The condition (including dehiscence) of the tympanic portion of the facial nerve canal observed by CT on multi-planar images and surgical findings were recorded.

RESULTS

The condition of the tympanic portion of the facial nerve canal observed by CT could be confirmed by surgical findings in 67/76 ears, but was not confirmed in 9/76 ears. Axial-transverse images could clearly show the position and length of dehiscence on the lateral wall of the facial nerve, while coronal images were superior to axial-transverse images in showing the bony circumference of the facial nerve, and sagittal images could show the inferior wall of the facial nerve canal more clearly than images on the former planes.

An evaluation of preoperative computed tomography on patients with chronic otitis media

This study aimed to compare the veracity of computed tomography findings on patients undergoing surgery for chronic otitis media (COM) with the surgical findings, and to determine to what extent the preoperative computerized tomography (CT) findings are useful to the surgeon. A series of 56 patients with COM undergoing preoperative CT scanning followed by surgical exploration of the middle ear and mastoid. Operative notes were recorded and data collected on the nature of soft tissue masses, the status of the ossicles, presence or absence of facial canal dehiscence and semicircular canal (SCC) dehiscence and the presence or absence of dural plate erosion, and sigmoid sinus thrombosis. Fifty-six patients were recruited in the study, 30 males and 26 females. The age range was from 16 to 67 years with a mean of 26.51 ± 1.4 years. The preoperative CT scan imaging in cases of cholesteatoma, ossicular chain erosion and SCC dehiscence have good correlation with the intraoperative findings. The specificity of preoperative CT scan in detecting facial canal dehiscence, dural plate erosion and sigmoid sinus thrombosis in patient of COM were weak. Preoperative computed tomography evaluation is fairly useful especially in cases of cholesteatoma. According to the results of this study, CT is of value particularly in the definition of cholesteatoma, and in determining ossicular chain erosion and semicircular canal fistula.

The value of scutum erosion in the diagnosis of temporal bone cholesteatoma

CONCLUSIONS

Scutum erosion has an important role in the diagnosis of attic cholesteatoma, but it does not appear in other types of cholesteatoma in temporal bone. Without scutum erosion, the existence of cholesteatoma cannot be excluded.

OBJECTIVE

To evaluate the value of scutum erosion in the diagnosis of cholesteatoma in temporal bone and its limitations.

SUBJECTS AND METHODS

CT scanning and otoscopy were used in all patients who were suspected of developing, or were probably diagnosed with, cholesteatoma in temporal bone. The condition of the scutum was recorded by otoscopy, CT scanning and surgical findings in all patients with cholesteatomas.

RESULTS

Scutum erosion can be shown in attic retraction with cholesteatoma at an early stage, but not in marginal perforation or with posterior retraction with cholesteatoma, or in central perforation or intact tympanic membrane with cholesteatoma, even in relatively late stages.

The role of preoperative CT scan in patients with chronic otitis media

Chronic otitis media may be due to chronic mucosal disease or cholesteatoma. Differentiating the two is usually achieved by clinical examination. The computed tomography (CT) scan is the standard imaging technique for the temporal bone, but its exact role in the preoperative assessment of patients with chronic otitis media is controversial. In this retrospective study we compared preoperative CT results with operative findings in 50 patients who had scan between January 2003 and December 2007. We analyzed the clinical presentation and checked if CT scan confirmed or excluded the presence of cholesteatoma and if this was affected by previous surgery. We concluded that CT scan could not be relied on to differentiate cholesteatoma from chronic mucosal disease. It should be used selectively in the preoperative preparation only if complications of the disease suspected.

Diagnosis of the pathological exposure of the mastoid portion of the facial nerve by CT scanning

CONCLUSIONS

High resolution CT imaging can provide useful information about the pathological exposure of the mastoid portion of the facial nerve before mastoid surgery and can assess the injury site of the facial nerve after operation.

OBJECTIVES

To evaluate the diagnostic value of high resolution CT scanning of pathological exposure of the mastoid portion of facial nerve and provide valuable information for otologic surgery, and to analyse the cause of facial nerve paralysis after operation.

MATERIALS AND METHODS

Routine CT scanning was used to examine patients with chronic suppurative otitis media and external auditory canal cholesteatoma preoperatively by axial-transverse and coronal views. If there was any pathological exposure of the mastoid portion of the facial nerve on CT imaging, then this was compared with intraoperative findings. In addition, one patient who had suffered postoperative facial nerve paralysis was also examined by CT scanning to determine whether any pre-existing pathological exposure of facial nerve could be found.

RESULTS

Through routine CT scanning six patients with chronic suppurative otitis media and three patients with external auditory canal cholesteatoma were found to have pathological exposure of the mastoid portion of the facial nerve. Coronal views could more clearly show the size and the position of the exposure; the corresponding surgical findings (pathological exposure) for the facial nerve could be confirmed in all nine patients. CT imaging could also show that the patient who had suffered postoperative facial nerve paralysis did indeed have pre-existing pathological exposure of the mastoid portion of the facial nerve.