Cholesteatoma

Kenneth C. Iverson
University of South Carolina
School of Medicine
Class of 2007
Case Study
8 year old female
History of chronic Eustachian tube
dysfunction
Recurrent acute otitis media since age 3
Multiple failed audiograms at school due to
fluid in the ears
History of recent bloody otorrhea
No facial palsy, vertigo, or ear surgery
Case Study
Physical exam

Cholesteatoma
Trapped keratinizing squamous epithelium
Temporal bone
Middle ear
Mastoid
Bony erosion of surrounding structures
Direct pressure inducing remodeling
Enzymatic activity at margins
Epidemiology
Exact prevalence is unknown

Incidence estimated between 3 and 12.6
per 100,000


Types and Etiologies
Congenital

Primary acquired

Secondary acquired
Pathogenesis
Clinical manifestations
Common
Painless otorrhea
Refractory/recurrent ear infections
Conductive hearing loss
Uncommon
Vertigo/Sensorineural
Facial nerve paralysis
CNS infections
Brain herniation/CSF leak
Pneumocephalus
Diagnosis
Imaging
Purpose:
Diagnosis
Determining extent
Risk assessment

Modalities:
Plain film
Computed tomography scans
Magnetic Resonance imaging
Dr. Hendrik Willem Stenvers (1889-1973)
Utrecht, Niederlande, Neurologe.


Pionierarbeiten auf
dem Gebiet der
Neuroradiologie,
insbesondere der
Aufnahmetechnik
des Felsenbeins.
High Resolution CT Imaging
Coronal sections
512 matrix
250 mm field of view
1.5 mm contiguous slices
25 slices per exam
0.017 mSv per slice
(Yates et al, 2002)
Goals of CT Imaging
Middle ear ventilation
Ossicular destruction
Epitympanum access
Mastoid cortex
Tegmen integrity
Labyrinth involvement
Facial nerve involvement
Surgical changes
(Yates et al, 2002)


Differential Diagnosis
Chronic serous otitis media
Jugulotympanic paragangliomas
Cholesterol granulomas
Neurofibromas
Hemangiomas
Arachnoid cyst



CT Disadvantages
Granulation tissue vs. cholesteatoma
Specific soft tissue problems
Dural involvement
Abscess
Brain herniation
Labyrinth involvement
Sigmoid sinus thrombosis
MRI needed
MR Imaging
Hypointense on T1
Isointense to brain
Intermediate on T2
Nonenhancing
Granulation tissue does enhance
Recurrence detection
Lesions >2mm
90% sensitive, 100% specificity
(Ayache et al, 2005)
MR Imaging
T2 Delayed contrast T1
MR Imaging DW Fast SE
DW b factor = 0/mm
2








100% Sensitive
DW b factor = 800/mm
2











(Debrulle et al, 2006)
Treatment
Surgery

Mastoidectomy

Residual 13-36%

Recurrence 5-13%


References
Ayache D, et al. Usefulness of Delayed Postcontrast Magnetic Resonance
Imaging in the Detection of Residual Cholesteatoma after Canal Wall-Up
Tympanoplasty: Laryngoscope 115: 607-610, 2005
Chakers DW, et al. Epitympanic Cholesteatoma Head and Neck Case 102:
American College of Radiology Learning Files: 1996
Cummings CW, et al: Otolaryngology: Head and Neck Surgery, 4
th
ed.
Philadelphia: Elsevier, 2005
Debrulle F, et al. Diffusion-weighted MR Imaging Sequence in the Detection
of Postoperative Recurrent Cholesteatoma: Radiology 238 (2): 604-610,
2006
El-Bitar MA, et al. Congenital middle ear cholesteatoma: need for early
recognition role of computed tomography scan: Int J of Ped
Otolaryngology 67: 231-235, 2003
Grainger, et al. Grainger & Allisons Diagnostic Radiology: A Textbook
of Medical Imaging, 4
th
ed. Churchill Livingstone, 2001.
Grossman RI and Yousem DM. Neuroradiology, 2
nd
ed. Philadelphia:
Mosby, 2003
Yates PD, et al. CT scanning of middle ear cholesteatoma: what does the
surgeon want to know?: British J of Radiology 75: 847-852, 2002
Questions?