F benoudiba jl sarrazin chronic otitis and cholesteatoma jfim 2014

CHRONICOTITISANDCHOLESTEATOMA

F.Benoudiba,JlSarrazinServicedeNeuroradiologieCHUKremlinBicêtre

JFIMBARCELONAnov2014

Cholesteatoma

Chronicotitis

Cholesteatoma Nocholesteatoma

Retractionpocketprecholesteatoma

state

AcquiredCholesteatoma

Retractionpocket§  Mesotympanic pocket

retraction uncontrollable and no self cleaning

§  (accumulation of epidermal scales

Precholesteatoma state

Acquiredcholesteatoma

u Aetiology Pocket retraction or marginal perforation with malpighian epithelium migration coming from the external cavity

u 80% of cholesteatoma

Fromapocketretraction…tocholesteatoma

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

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

Imagingsemiology§  Nodular tisssular mass

ú  Convex, rounded, polycyclic

ú  location : Prussak’s space (External attical wall)

ú  Attical extension

§  Mass effect on ossicular chain

Imagingsemiology

§  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

Imagingsemiology

§  Mastoid antrum extension §  Enlargement of additus §  Disappearanceofmastoid

celltrabeculation

Imagingsemiology

§  Exceptionally, the tissular mass may be absent

§  It has been removed by the ENT physician just before the CT scan

§  Empty pocket

Congenitalcholesteatoma

§  Unusual §  Pathogenetic explanation:

persistence of residual squamous cells usually existing in embryo between the 10th and the 30th week of gestation (Mickaels’ theory).

CongénitalCholesteatoma§  Petrous apex

§  EAC

§  Hypotympanum

§  Petrous pyramid

Complications§  Erosion of the

LSCC (rarely the posterior)

§  Tegmen destruction

§  Carotid canal erosion

Erosion of the facial canal

Complications§  Intralabyrinthine

Extension (MRI+++)

§  Intra cranial extension

§  Cerebral infection

Surgicalapproach§  Canalwallupwithtympanoplasty

CAUTION§  Prolapsedandsuperficialsigmoidsinus

§  Jugularvein

§  Emissaryvein

§  Intrapetrouscarotid

CAUTION§  ProlapsedTegmen

§  Temporalmeningocele

Surgicalapproach§  Canalwalldownmastoidectomy

Hearingrehabilitation

KurzTTPVario(Collin)

Universalprosthesistitane(Xomed-Medtronic)

Spiggle&TheisTitaniummiddleearpartial-totalimplant(PouretMédical)

Ossicularprosthesis

II

III

ProsthesisPORP TORP

Rehabilationprosthesis

TORP

PORP

Doubletraytympanoplasty

Incustransposition

Cholesteatoma:postoperativefollowing§  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

MRI:u Technical MRI T2 HR T1 SE Diffusion non EPI or SE +/- T1 with contrast

enhancement

MRI:results

T1 T2b1000 ADC T1Gado

Cholesteatoma

Fibrosis

granuloma

abcess

Thiriat S Am J Neuroradiol 2009

MRIdiffusion:Falsepositive

§  Cerumen

§  Sebaceouscyst

§  CholesterolGranuloma

Howtoavoidthefalsepositive§  Welllocatedthelesion

ú  CorrelatedifferentsequencesandtheCTscan

§  CorrelatenonEpiandADC§  Cholesteatoma:decreaseADC

§  T1WIwithoutcontrast:ú  hyperintense:It’snotacholesteatoma

Residualcholesteatoma

Residualcholesteatoma

Imagefusion:anatomicallocation

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)

Adult

§  Good audition , no otorrhea: 1 question ú  Residual Cholesteatoma?

§  Conductive hearing loss or mixed: 2 questions ú  Residual Cholesteatoma? ú  Functional evaluation

Clinical

No opacity

Audition OK Hearing loss

CT

Partial opacity Total opacity

Postoperativemonitoring

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

Postoperativehearingloss

§  Failure : persistence or recurrence of conductive hearing loss

§  Complication : occured of a sensorineural hearing loss

Failureofrehabilitation

Incustranspositiondisplacement

PORPdislocation

A sensorineural hearing loss

Labyrinthitisossificant

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)