F benoudiba jl sarrazin chronic otitis and cholesteatoma jfim 2014
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1. Chronic otitis and cholesteatoma occur when a retraction pocket in the middle ear develops and cannot self-clean, allowing keratin and skin debris to accumulate and form a cholesteatoma. 2. Imaging plays a key role in diagnosing and managing cholesteatoma. CT scan is usually the first choice to assess for cholesteatoma and complications prior to surgery. MRI can also be used and provides additional information. 3. Post-operatively, imaging is used to detect residual or recurrent cholesteatoma and assess complications. CT scan and MRI are both used depending on the clinical scenario and findings. Close monitoring is required after surgery.
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F benoudiba jl sarrazin chronic otitis and cholesteatoma jfim 2014
- 3. Retraction pocket § Mesotympanic pocket retraction uncontrollable and no self cleaning § (accumulation of epidermal scales Precholesteatoma state
- 4. Acquired cholesteatoma u Aetiology Pocket retraction or marginal perforation with malpighian epithelium migration coming from the external cavity u 80% of cholesteatoma
- 6. Imaging § CHOLESTEATOMA IS A CLINICAL DIAGNOSIS § Modern imaging plays a key role in management of cholesteatoma: § In pre operative § In post operative : minimally invasive supervision (avoid surgical 2nd look) § Technical imaging: ú CT scan (+++) ú MRI : growing up Essentially in post operative Before surgery when complications
- 7. Imaging § Which imaging technique: ú CT scan without enhancement: first choice modality To assess the diagnosis when otoscopy is inclonclusive (closed tympanic membran) To screen for complications For the staging Anatomical assessment of the tympanomastoid cavity Surgical approach Choice
- 8. Imaging semiology § Nodular tisssular mass ú Convex, rounded, polycyclic ú location : Prussak’s space (External attical wall) ú Attical extension § Mass effect on ossicular chain
- 9. Imaging semiology § Bone erosion ú Erosion of the external epitympanic wall (scutum): early sign ú Ossicular erosion: 70% ú Not specific Long process of incus Incus body Head of malleus
- 10. Imaging semiology § Mastoid antrum extension § Enlargement of additus § Disappearance of mastoid cell trabeculation
- 11. Imaging semiology § Exceptionally, the tissular mass may be absent § It has been removed by the ENT physician just before the CT scan § Empty pocket
- 12. Congenital cholesteatoma § Unusual § Pathogenetic explanation: persistence of residual squamous cells usually existing in embryo between the 10th and the 30th week of gestation (Mickaels’ theory).
- 13. Congénital Cholesteatoma § Petrous apex § EAC § Hypotympanum § Petrous pyramid
- 14. Complications § Erosion of the LSCC (rarely the posterior) § Tegmen destruction § Carotid canal erosion Erosion of the facial canal
- 15. Complications § Intralabyrinthine Extension (MRI+++) § Intra cranial extension § Cerebral infection
- 17. CAUTION § Prolapsed and superficial sigmoid sinus § Jugular vein § Emissary vein § Intrapetrous carotid
- 24. Cholesteatoma: post operative following § Imaging of post operative cholesteatoma ú To assess a residual cholesteatoma ú Staging (extension/complications) if residual or recurrent cholesteatoma. ú Post operative hearing loss without explanation ú Best choice of imaging: depends on the situation
- 25. MRI: u Technical MRI T2 HR T1 SE Diffusion non EPI or SE +/- T1 with contrast enhancement
- 26. MRI: results T1 T2 b1000 ADC T1 Gado Cholesteatoma Fibrosis granuloma abcess Thiriat S Am J Neuroradiol 2009
- 27. MRI diffusion: False positive § Cerumen § Sebaceous cyst § Cholesterol Granuloma
- 28. How to avoid the false positive § Well located the lesion ú Correlate different sequences and the CT scan § Correlate non Epi and ADC § Cholesteatoma: decrease ADC § T1 WI without contrast: ú hyperintense: It’s not a cholesteatoma
- 32. Children § Avoid iterative CT scan (radiation) § Prefer MRI diffusion § 1 month after surgery § No injection § Binary response: chole + or chole – ú Chole + : surgery (+/- CT) ú Chole – : MRI (1 month later)
- 33. Adult § Good audition , no otorrhea: 1 question ú Residual Cholesteatoma? § Conductive hearing loss or mixed: 2 questions ú Residual Cholesteatoma? ú Functional evaluation
- 34. Clinical No opacity Audition OK Hearing loss CT Partial opacity Total opacity Post operative monitoring Dubuous image No doubt Residual No residual Audition OK Hearing loss surgery Surgery Ossicular rehabilita tion CT Ossicular rehabilitation CT CT or MRI MRI 12 months 12,24 months 12 ,24months 12 ,24months
- 35. Post operative hearing loss § Failure : persistence or recurrence of conductive hearing loss § Complication : occured of a sensorineural hearing loss
- 37. Asensorineural hearing loss Labyrinthitis ossificant
- 38. Conclusion § Major role of imaging for the diagnosisof pre operative cholesteatoma § Systematic in pre operative: the first modality imaging is CT scan without contrast § CT may be supplemented by MRI if complications (labyrinthine fistula or extension, tegmen erosion, intra cranial extension, meningocele)