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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN.

, 2005 Mohsen & El-Kashef


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!E "OLE O# !I$! "E%OLUION &OM'UED OMO$"A'!( )!"&*
IN EVALUAION O# &!OLE%EAOMA+
"ADIO%U"$I&AL &O""ELAION
By
*Adel MS Mohsen and **Yehia MS El-Kashif.
Departments of *Radiodiagnosis and **EN
El-Minia !a"#lty of Medi"ine
AB%"A&,
Objective and aim of the work: $holesteatoma is "ommon pro%lem and its proper
diagnosis needs "lini"al effort for early dete"tion of "ompli"ations. Early diagnosis
and management "an a&oid permanent hearing loss 'hi"h is "ommon se(#elae. he
ad&ent of )R$ fa"ilitates diagnosis of temporal %one* mastoid and inner ear
pathologies. he st#dy aimed to e&al#ate the role of )R$ in diagnosis of
"holesteatoma* its "ompli"ations and mat"hing the res#lts s#rgi"al findings. Subjects
& methods: he present 'or+ in"l#ded ,- patients 'ithin the period from Septem%er
-..- to De"em%er -../. hey 'ere randomly sele"ted from the Radiology and EN
Departments in El M0N0A 1ni&ersity hospital. heir ages ranged from 2. to 34 years
5-/.66 7 2/.,8. All patients presented 'ith "lini"al pi"t#re of "holesteatoma s#"h as
"hroni" ear dis"harge* hearing loss 'ith or 'itho#t signs of in"reased intra"ranial
press#re or fa"ial palsy. horo#gh EN "lini"al and otos"opi" e9aminations at the
EN Department 'ere done. :atients presented 'ith &ertigo are e9amined for the
presen"e of la%yrinthine fist#la %y fist#la test. )R$ e9aminations 'ere done to all
patients #sing 5;E $< :R=S:EED :>1S ?er../... S"anner* 'ith 42- elements* -43
9 -43 matri9. S"anning 'as done to 528 Define type* lo"ation and e9tent of
"holesteatoma* 5-8 :resen"e of %ony erosions in middle ear 'alls* 5,8 E&al#ate the
integrity of the ossi"#lar "hain and fa"ial ner&e %ony "anal 5/8 0n&ol&ement of hidden
areas* la%yrinth and other ear* and 548 o e&al#ate the ear follo'ing s#rgery for the
dete"tion of possi%le resid#al* re"#rren"e or post operati&e "ompli"ations. Results:
$om%ined pars fla""ida and pars tensa "holesteatomas 'as the most "ommon type
dete"ted in 5,@.4A8. he atti" "holesteatoma 'as the most fre(#ently site seen
5,2.-4A8. he s"#t#m* lateral atti" 'all erosion B eroded KornerCs sept#m 'ere the
most "ommon findings seen in 543.,A8. $omplete erosion of ossi"les 'as seen in
543.,A8* in&ol&ement of sin#s tympani 5)idden areas8 'as seen in 5,/./A8 and
s"leroti" mastoid "ells in 543.,A8. >a%yrinthine fist#la 'as seen in 526.6A8 of "ases
and eroded fa"ial ner&e "anal in -4A of "ases. Diseased other ear 'as seen in 2.
"ases 5,2.,A8 'ith "holesteatoma seen in 53.,A8 of s#"h "ases. emporal %one
"ompli"ations 'ere the most pre&alent "ompli"ations 54.A8 'ith "ond#"ti&e hearing
loss 'as manifested in /3.DA of "ases* mean'hile intra"ranial "ompli"ations 'ere
seen only in / "ases 52-.4A8. )R$ sho'ed 2..A sensiti&ity in diagnosis of soft
tiss#e mass* %ony erosion* la%yrinthine fist#la* dehis"ent fa"ial ner&e "anal and
intra"ranial "ompli"ations. 0t sho'ed less a""#ra"y in diagnosis of eroded fa"ial "anal
5D3./A8* in"#s erosion 5D3./A8 and tegmen erosion 5D/./A8. Conclusion: )R$ is
#ni(#e in its a%ility to display not only the internal %one ar"hite"t#re of middle ear
and mastoid %#t also presen"e of soft tiss#e massE that a negati&e s"an effe"ti&ely
e9"l#des possi%ility of "holesteatoma. 0t is also &al#a%le in &is#aliFation of hidden
areas s#"h as sin#s tympani and fa"ial re"ess %eyond otos"opi" e9amination 'hi"h is
important %efore de"ision of s#rgi"al strategy. Early #se of )R$ in "ases of
"holesteatoma "an sa&e hearing and impro&e mor%idity.
,.
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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KE( -O"D%,
$hroni" otits media $holesteatoma0n"#s =ssi"les
Mastoid >a%yrin time fist#la egmen
IN"ODU&ION,
$holesteatoma of the middle
ear is "ommon pro%lem as se(#elae of
"hroni" otitis media. Be"a#se )R$
"o#ld assess this area 'ith #npre"e-
dented a""#ra"y* the radiologists
%e"ame more familiar 'ith the etiology
and potential "ompli"ations of this
disorder.
2
A"(#ired "holesteatoma
a""o#nt for D6A of all "holesteatoms
arising either from the pars fla""ida or
pars tensa portion of the tympani"
mem%rane in patients 'ith or 'itho#t
history of otitis media. hey may %e
s#%di&ided into primary a"(#ired 5no
history of otitis media* #s#ally pars
fla""ida8 and se"ondary a"(#ired
5history of pre&io#s infe"tion8.
-
A "holesteatoma is a sa" of
stratified s(#amo#s epitheli#m filled
'ith a""#m#lation of e9foliated +eratin
that is trapped and gro'n 'ithin the
middle ear spa"e or other pne#matiFed
areas of the petro#s %one or more
simpleE Gs+in in 'rong pla"eG.
-
he term G"holesteatomaG is
misnomer that 'as "oined %y Hohannes
M#ller in 26,6* %e"a#se it is a"t#ally
not a t#mor and some a#thors prefer
the term G+eratomaG.
-
A./ of 0he 1o23,
he aim of this 'or+ is to emphasiFe
the role* &al#e and impa"t of )R$ in
diagnosis of "holesteatoma* its "ompli-
"ations 'ith "orrelation st#dy 'ith
operati&e data.
'AIEN% AND ME!OD%,
'a0.en0s,
his 'or+ in"l#ded ,- patients
'ithin the period from Septem%er -..-
to De"em%er -../. hey 'ere rando-
mly sele"ted from the Radiology and
EN departments in El-Minia 1ni&er-
sity hospital. !ifteen patients 'ere
males and 2@ 'ere females* their ages
ranged from 2. to 34 years 5-/.66 7
2/.,8. All patients presented 'ith
"lini"al pi"t#re s#ggesting "holestea-
toma s#"h as "hroni" ear dis"harge
'ith or 'itho#t hearing loss and 'ith
or 'itho#t manifestations of in"reased
intra"ranial press#re or fa"ial palsy.
Me0ho4s,
E&ery patient 'as s#%Ie"ted to the
follo'ing st#diesJ
- !#ll history ta+ing in"l#ding history
of "hroni" ear dis"harge* "ond#"ti&e
hearing loss* symptoms of in"reased
intra"ranial tension 5!e&er* heada"he*
&omiting8 and fa"ial palsy.
- )istory of pre&io#s middle ear
operation-if present- 'as also ta+en.
- horo#gh EN "lini"al and otos"opi"
e9aminations at the EN Department
'ere done. :atients presented 'ith
&ertigo are e9amined for the presen"e
of la%yrinthine fist#la %y fist#la test
5Nystagm#s eli"ited %y the appli"ation
of positi&e or negati&e press#re to the
e9ternal "anal in positi&e "ases8.
-

!"& e5a/.na0.on,
he st#dy 'as done to all
patients #sing 5;E $ < :R=S:EED
:>1S ?er../... S"anner8 'ith 42-
elements* -43 9 -43 matri9. Kooming
and magnifi"ation 'ere done for the
petro#s %one on ea"h side. he )R$
s"an proto"ol in"l#des the follo'ing
fa"torsJ
K?LLLLLLLLLLLL...2-.
MALLLLLL.LLLLLL.-..
S"an timeLLLLLLLL...2.4 Se"
Sli"e thi"+nessLLLLLLL. 2 mm
,2
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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Se"tion spa"ing 50nter&al8LLL.2mm
!ield of &ie' 5small8LLLL.. -4"m
ModeLLLLLL...Bone Algorithm
Mindo' 'idth 5e9tended8 L./... )1
Mindo' le&el LLLLLLL...,...
$ollimationLLLLLLLL2.4mm
:i9elsLLLLLLLLL....-4mm
-

S"anning 'as done in the dire"t a9ial
and "oronal planes for optimal demon-
stration of temporal %one str#"t#res.
)a* A5.al )!o2.6on0al 72o8e90.on*,
S"o#t &ie' 'as o%tained and
se"tions 'ere performed parallel to the
anthropologi" line 5plane interse"ting
the inferior or%ital rim and the s#perior
margin of the e9ternal a#ditory "anal8.
he se"tions 'ere ta+en at 2mm
in"rements %eginning at the le&el of the
floor of the hypo-tympan#m and
I#g#lar fossa and e9tending
"ephali"ally to the le&el of the ar"#ate
eminen"e #sing line for lo"aliFation.
):* &o2onal )f2on0al* 72o8e90.on,
Mith the ne"+ f#lly e9tended* a
lateral s"o#t &ie' 'as performed and
se"tions performed nearly parallel to
the ram#s of the mandi%le. he gantry
of the s"anner 'as tilted 24
N
--.
N
to
"ompensate for an in"omplete e9ten-
sion of the ne"+. Se"tions 'ere ta+en
from the %ony E#sta"hian t#%e
anteriorrly* e9tended posteriorly to the
posterior 'all of the mastoid %one. he
"oronal proIe"tion 'as not done in
patients s#ffering from head tra#ma
and o%ese patient 'ith short ne"+. he
"oronal s"anning also "an %e done 'ith
the patient s#pine 'ith hypere9tended
ne"+.

)R$ images 'ere interpreted
in details to define 528 he type*
lo"ation and e9tent of "holesteatoma
5-8 Bony erosions of middle ear %ony
'alls 5,8 he integrity of the ossi"#lar
"hain* fa"ial ner&e "anal and la%yrinth
5/8 0n&ol&ement of hidden area*
mastoid air "ell system and "ondition
of the other ear* and 548 o e&al#ate the
ear follo'ing s#rgery for the dete"tion
of possi%le resid#al* re"#r-ren"e or post
operati&e "ompli"ations.
&on02as0 enhan9e/en0,
No "ontrast enhan"ement 'as
#sed* #nless there 'as s#spe"ted
&as"#lar mass or s#spe"ted intra"ranial
"ompli"ations. 0ntra&eno#s inIe"tion of
4.ml 1ro&ideo @4A 'as gi&en.
S"anning of the %rain in these "ases
'as done pre and post intra&eno#s
"ontrast media.
%a;.00al 2efo2/a0,
Sagittal reformatting 'as done
in some "ases to define the mastoid
segment* fa"ial ner&e "anal and stylo-
mastoid foramen.
he hall/a23s of 9holes0ea0o/a on &
are %ased primarily on the presen"es of
one or more of the follo'ing "riteriaE
528 A non-dependent soft tiss#e density
mass 5-8 ypi"al lo"ation in 5atti"*
meso-tympan#m or antr#m8 asso"iated
'ith 5,8 %ony erosion of the middle ear
%ony 'alls 5i.e. S"#t#m* lateral atti"
'all* anterior tympani" 'all* tegmen*
sigmoid sin#s plate* KornerCs sept#m*
posterior and s#perior metal 'all8*
erosion of the ossi"les* s"alloping of
the mastoid* erosion of the semi"ir-
"#lar "anal and fa"ial ner&e "anal
5tympani" and mastoid segments8 may
%e present.
,*/* 4* 3

"E%UL%,
his st#dy in"l#ded ,- 524
males B 2@ females8 patients ha&ing
"lini"al pi"t#re of "holesteatoma. he
high age in"iden"es 'ere in the ,
rd
B
/
th
de"ades* 'hile the lo' in"iden"e
'as in -
nd
B 3
th
de"ades. !emales
54,.2A8 'ere more affe"ted than males
5/3.DA8. See ta%le 0.
,-
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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$hroni" ear dis"harge 'ith
partial or "omplete "ond#"ti&e hearing
loss 'as the main "lini"al presentation
54,.2A8 follo'ed %y "hroni" dis"harge
524.38* "hroni" dis"harge 'ith signs of
in"reased intra"ranial tension 52-.4A8
and those 'ith &ertigo and sensori-
ne#ral hearing loss 'ere 52-.4A8. See
ta%le 00.
a:le )I*, Age B se9 distri%#tion of the st#died patients 'ith "holesteatoma
A;e .n
<ea2s
%e5
o0al
Male #e/ale
No. = No. = No. =
2.- 2 3.3@ 2 4.D - 3.-4
-.- , -... 6 /@.2 22 ,/./
,.- / -3.@ 4 -D./ D -6.2
/.- , -... 2 4.D / 2-.4
4.- , -... 2 4.D / 2-.4
3.- 2 3.3@ 2 4.D - 3.-4
o0al 15 1> ?2 100
a:le )II*, $lini"al presentations of the st#died patients 'ith "holesteatoma
&l.n.9al 72esen0a0.on No. of 7a0.en0s =
$hroni" ear dis"harge 'itho#t hearing loss 4 24.3,
$hroni" dis"harge 'ith hearing loss 2@ 4,.2
$hroni" dis"harge 'ith signs of in"reased 0.$. / 2-.4
$hroni" dis"harge 'ith fa"ial paresis - 3.-4
$hroni" dis"harge 'ith &ertigo and SN)> / 2-.4
Re"#rrent "holesteatoma - 3.-4
o0al ?2 100
SN)>J Sensorine#ral hearing loss 0.$.J 0ntra"ranial tension.
!"& 92.0e2.a of 0he s0@4.e4 ;2o@7,
he )R$ findings are presented in
ta%les 000 to ta%le O00.
<7e of 9holes0ea0o/a :
$om%ined pars fla""ida and
pars tensa "holesteatomas 'ere the
mostly en"o#-ntered type dete"ted in
5,@.4A8 and then %oth pars fla""ida B
pars tensa "holesteatomas in 5,2.-4A8.
See !igs. 50 B 008 B 5ta%le 0008.
Lo9a0.on & e50en0 of 9holes0ea0o/a,
he atti" "holesteatoma 'as most
fre(#ently seen in 5,2.-4A8 follo'ed
%y e9tensi&e holo-tympani" a"(#ired
"holesteatoma 5-6.2A8 and atti"o-
antral "holesteatoma in 5-4A8 of "ases.
!igs. 000P ? B 5ta%le 0?8
Bon< e2os.ons of 0he /.44le ea2 :on<
1alls,
he s"#t#m and lateral atti"
'all erosion 'as the most "ommon
finding 543.,A8 and eroded KornerCs
sept#m 543.,A8 follo'ed %y thinning
tegmen 5,2.,A8 and the least "ommon
'as the eroded sigmoid sin#s plate
52-.4A8. 5!ig. 000* 0?8 B 5ta%le ?8.
,,
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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In0e;2.0< of 0he oss.9@la2 9ha.n,
he ossi"les 'ere a%sent or
"ompletely eroded in 543.,A8 of "ases*
the in"#s 'as the most "ommonly
affe"ted 5-2.DA8* follo'ed %y malle#s
erosion 5D./A8. he ossi"les 'ere
displa"ed 'itho#t erosion only in
52-.4A8 of "ases. 5ta%le 0?8 5!ig. 0?8
InAolAe/en0 of h.44en a2ea,
he in&ol&ement of the sin#s
tympani 'as dete"ted in 5,/./A8 and
the fa"ial re"ess in&ol&ement 'as
en"o#ntered in 5,2.,A8. 5!ig. ?8 B
5a%le ?008
Mas0o.4 a.2 9ell s<s0e/,
he s"leroti" mastoid 'as the
most "ommon finding 543.,A8
follo'ed %y a#tomastoide"tomy in
5,2.,A8* lateral mastoid 'all fist#la in
526.6A8 and mastoid a%s"ess in 5D./A8
of "ases 'ith infe"ted "holesteatoma.
(!ig. ?08 5a%le ?0008.
he la:<2.n0h,
he lateral semi"ir"#lar "anal
fist#la 'as the most "ommon finding
526.6A8* follo'ed %y eroded 'hole
str#"t#res in 5,.2A8* and eroded "anal
in 5D./A8. 5!igs. ?0* ?0008 B 5ta%le 0O8
In0e;2.0< of 0he fa9.al ne2Ae 9anal,
he fa"ial ner&e "anal 'as inta"t
in 536.6A8* eroded in 5-4A8 and
dehis"ent in 53.,A8 of "ases. he 'hole
segments 'ere e(#ally affe"ted in
53.-4A8 of "ases. 5!ig. ?08 B 5ta%le O8.
&on4.0.on of 0he o0he2 ea2,
he other ear 'as normal in
536.6A8 and diseased in 5,2.,A8*
"hroni" s#p-p#rati&e otitis 'as en"o#n-
tered in 5-4..A8 and %ilateral "holes-
teatoma in 53.,A8. 5a%le O08
a:le )III*, ype of "holesteatomas
<7e of 9holes0ea0o/a No. of 7a0.en0s =
:ars fla""ida
"holesteatoma
2. ,2.-4
:ars tensa "holesteatoma 2. ,2.-4
$om%ined
"holesteatoma
2- ,@.4
o0al ?2 100
a:le )1V*, >o"ation B e9tent of "holesteatoma
Lo9a0.on & e50ens.on No. of
7a0.en0
=
Atti" 2. ,2.-4
Atti"o-antral 6 -4..
Mesotympan#m 4 24.3
E9tensi&e 5holotympani"8 e9tended to mastoid antr#m D -6.2
o0al ?2 100

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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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)A* )B*
#.;@2e 0J Early "holesteatoma pars fla""ida 5A8 A9ial epitympani" and 5B8 $oronal
anterior tympani" se"tions thro#gh the left petro#s %one sho'ed lo"aliFed tiss#e
density mass 5arro'8 filling the :r#ssa+Cs spa"e lateral to head and ne"+ of malle#s
and medial to the %l#nted s"#t#m. he ossi"#lar "hain is displa"ed medially. Normally
aerated remaining left middle ear "a&ity. EA$ 5e9ternal a#ditory "anal8
)A* )B*
#.;@2e II, Early $holesteatoma pars tensa 5A8 A9ial midtympani" se"tion of the left
petro#s %one sho'ed lo"aliFed tiss#e density mass seen filling the fa"ial re"ess and
o&erlying the pyramidal eminen"e. >a%eled str#"t#res in"l#deE :EQ pyramidal
eminen"e* SQ sin#s tympani* BQ %asal t#rn of the "o"hlea* ?Q &esti%#le* RMNQ
ro#nd 'indo' ni"he* $AQ "o"hlear a(#ed#"t 5B8 $oronal mid-tympani" se"tion
sho'ing a soft tiss#e density mass mostly in&ol&ing the pars tensa of the tympani"
mem%rane* eroding the in"#s lenti"#lar pro"ess 5arro'8. Note the opa"ified meso-
tympan#m and inta"t in"#s %ody. >a%eled str#"t#res in"l#deE MQ tympani"
mem%rane* 0BQin"#s %ody* SS$Q s#perior and >S$Q lateral semi"ir"#lar "anal* 0A$
Q internal a#ditory "anal.
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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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a:le )V* Middle ear %ony 'all erosion
*More
than one
finding may %e
present in the
same patient
a:le )VI*, 0ntegrity of the ossi"#lar "hain
In0e;2.0< of 0he oss.9les No. of
7a0.en0
=
$ompletely eroded 5no ossi"les8 26 43.,
Eroded malle#s only , D./
Eroded in"#s only @ -2.D
Displa"ed inta"t ossi"les / 2-.4
o0al ?2 100.0
,3
Bon< 1all e2os.onB No. of
7a0.en0s
=
Bl#nted s"#t#m 4 24.3
Eroded s"#t#m B lateral atti" 'all 26 43.,
Eroded tegmen 4 24.3
hinning of the tegmen 2. ,2.,
Eroded sigmoid sin#s plate / 2-.4
Eroded s#perior B posterior meatal 'all 4 24.3
Eroded KRrnerCs sept#m 26 43.,
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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)A* )B*
)&* )D*
)&* )D*
#.;@2e III, Atti" $holesteatoma. 5A8 A9ial se"tion 0A$ le&el* 5B8 A9ial se"tion lateral
semi"ir"#lar "anal le&el* 5$8 $oronal anterior tympani" and 5D8 $oronal midtympani"
le&el of the right petro#s %one sho'ing a 'ell defined* ro#nded tiss#e density mass
filling the anterior part of the atti" e9tended to midtympani" region. he lesion erodes
the s"#t#m and malle#s head and ne"+. Note the normal appearan"e of the adit#s
denoting that the lesion is lo"aliFed 'ithin the atti" 'ith no antral e9tension. >a%eled
str#"t#res in 5A8 in"l#deE MassQ "holesteatoma mass* :EQpyramidal eminen"e*
SQsin#s tympani and 0A$Qinternal a#ditory. >a%eled str#"t#res in 5B8 in"l#de* E:0
$Q epitympani" "a&ity* AD01SQ adit#s ad antr#m* MAQ Mastoid antr#m* >S$Q
lateral semi"ir"#lar "anal and ?AQ &esti%#lar a(#ed#"t. >a%eled str#"t#res in 5$8
in"l#deE MassQ "holesteatoma mass* Q tegmen tympani* ;;Q geni"#late ganglion*
$=$)Q "o"hlea and $$Q "arotid "anal 5&erti"al segment8. >a%eled str#"t#res in 5D8
in"l#deE MQmass* EA$Qe9ternal a#ditory "anal* 0A$Qinternal a#ditory "anal and
Q tegmen tympani.
,@
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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)A* )B*

#.;@2e IV, Right atti"o-antral "holesteatoma pars fla""ida 5A8 A9ial se"tion lateral
semi"ir"#lar "anal le&el and 5B8 $oronal midtympani" se"tion thro#gh the right
petro#s %one sho'ing a 'ell defined* soft tiss#e density mass filling the atti"* 'iden
the adit#s and e9tended to the mastoid antr#m. he mass erodes the s"#t#m and
s#pero-posterior meatal 'all* KornerCs sept#m and sigmoid sin#s plate. he tympani"
mem%rane is thi"+ened and retra"ted. Note that the "holesteatoma mass a%#tting the
anterior lim% of the lateral semi"ir"#lar "anal* 'hi"h is seen inta"t in a9ial se"tion.
>a%eled str#"t#res in 5A8 in"l#desE $Q "holesteatoma mass and SS:Q eroded sigmoid
sin#s plate. >a%eled str#"t#res in 5B8 in"l#deE E$Q posterior part of the epitympani"
"a&ity* MQ the thi"+ened retra"ted tympani" mem%rane and >S$Q lateral
semi"ir"#lar "anal.
a:le )VII*, he in&ol&ement of hidden areas 5anterior Bposterior tympan#m8
!.44en a2ea .nAolAe4 No. of 7a0.en0s =
:osterior tympan#m
Sin#s tympani
!a"ial re"ess
22
2.
,/./
,2.,
Anterior tympan#m 3 26.6
a:le )VIII*, 0ntegrity of mastoid air "ell system
Mas0o.4 s0a0eB No. of
7a0.en0s
=
S"leroti" 26 43.,
A#to-mastoide"tomy 2. ,2.,
>ateral mastoid 'all %ony fist#la 3 26.6
Mastoid a%s"ess , D./
*More than one finding may %e present in the same patient
,6
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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)A* )B*
#.;@2e V, E9tensi&e "holesteatoma in&ading the anterior epi-tympan#m 5hidden area8
5A8 $oronal anterior tympani" and 5B8 $oronal mid-tympani" o&al 'ido' le&el
thro#gh the left petro#s %one. A large "holesteatoma mass fills the middle ear "a&ity
in&ol&ing the anterior atti" 'ith erosion of the lateral atti" 'all* tegmen tympani and
the posteros#perior meatal 'all. he la%eled str#"t#res in"l#deE $=$)Q "o"hlea*
?$$Q &erti"al segment of the "arotid "anal and the "holesteatomas* SS$ and >S$Q
s#perior and lateral semi"ir"#lar "anal* Q eroded tegmen tympani* 0A$Q internal
a#ditory "anal and EA$:Q e9ternal a#ditory "anal polyp.
a:le )IC*, 0ntegrity of the inner ear
Inne2 ea2 s0a0e No. of
7a0.en0s
=
0nta"t inner ear str#"t#res -, @2.D
>ateral semi"ir"#lar "anal 5>S$8 fist#la 3 26.6
Eroded inner ear str#"t#res 5"o"hlea*
&esti%#le B semi"ir"#lar "anals8
2 ,.2
Eroded 0nternal A#ditory $anal 50A$8 , D./
*More than one finding may %e present in the same patient
a:le )C*, 0ntegrity of the fa"ial ner&e "anal
#a9.al Ne2Ae &anal s0a0e )#N&* No. of 7a0.en0s =
0nta"t !N$ -- 36.6
Dehis"ent !N$ - 3.,
Eroded !N$J
:ro9imal tympani" segment
Distal tympani" segment
All tympani" 5horiFontal8 segment
?erti"al segment
6
-
-
-
-
-4..
3.-4
3.-4
3.-4
3.-4
o0al ?2 100.0
,D
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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a:le )CI*, he "ondition of the other ear
O0he2 ea2 No. of
7a0.en0s
=
Normal other ear -- 36.6
Diseased
$hroni" s#pp#rati&e otitis media
Bilateral $holesteatoma
2.
6
-
,2.,
-4..
3.,
o0al ?2 100
)A* )B*
#.;@2e VI, E9tensi&e "holesteatoma. 5A8 A9ial lateral semi"ir"#lar "anal se"tion 5B8
$oronal I#g#lar foramen and posterior middle ear se"tions thro#gh the right petro#s
%one. A large "holesteatoma mass fills the 'hole middle ear "a&ity eroding the lateral
semi"ir"#lar "anal 'ith s#%se(#ent la%yrinthine fist#la and the mastoid air "ells 'ith
s#%se(#ent a#tomastoide"tomy. >a%eled str#"t#res in"l#deE $Q "holesteatoma mass*
>S$ !Q lateral semi"ir"#lar "anal fist#la* ?Q &esti%#le* 0A$Q internal a#ditory "anal*
:S$Qposterior semi"ir"#lar "anal* MAQ mastoid antr#m* D!N$Q des"ending fa"ial
ner&e "anal and the H!Q I#g#lar foramen.
&o/7l.9a0.ons of &holes0ea0o/a, 5see
ta%le O008. emporal %one "ompli-
"ations 'ere pre&alent more than those
of intra"ranial one. he ossi"#lar dest-
r#"tion 'as the mostly en"o#ntered
"ompli"ation 54.A8* follo'ed %y "ond-
#"ti&e hearing loss 5/3.DA8* a#to-
mastoide"tomy 5,2.,A8* la%yrinthine
fist#la 526.6A8* post a#ri"#lar a%s"ess
526.6A8* sigmoid sin#s plate erosion
524.3A8 and the least "ompli"ation 'as
the sensori-ne#ral hearing loss 53.4-A8.
Regarding intra"ranial "ompli"ations*
the "ere%ellar* "ere%ral e9trad#ral a%s"e-
sses and otiti" hydro"ephal#s 'ere
e(#ally en"o#ntered in 5,.2A8 of "ases.
/.
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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a:le CII, emporal %one and intra"ranial "ompli"ations in patients 'ith $holesteatoma
&o/7l.9a0.onsB No. of
7a0.en0s
=
e/7o2al :one 9o/7l.9a0.ons
$omplete ossi"#lar destr#"tion
A#tomastoide"tomy
Mastoid 'all fist#la
$ond#"ti&e hearing loss
otal hearing loss
>S$ fist#la
Mastoid a%s"ess
:ost a#ri"#lar B Fygomati" a%s"ess
Eroded sigmoid sin#s plate
23
2.
3
24
-
3
2
3
4
4....
,2.,
26.6
/3.D
3.4-
26.@4
,.2
26.6
24.3
In02a92an.al 9o/7l.9a0.ons
$ere%ellar a%s"ess
$ere%ral a%s"ess
E9trad#ral a%s"ess
=titi" hydro"ephal#s
2
2
2
2
,.2
,.2
,.2
,.2
*More than one finding may %e present in the same patient
)A*
)B*
#.;@2e VII, 0nfe"ted "holesteatoma 'ith a%s"ess formation 5A8 A9ial lateral and
s#perior semi"ir"#lar "anal se"tions thro#gh the right petro#s %one sho'ing diff#se
soft tiss#e density mass filling the mastoid antr#m 5MA8 and eroding the sigmoid
sin#s plate 5SS:8. 5B8 A9ial enhan"ed $ se"tion of the %rain sho'ing e9trad#ral
a%s"ess 5EDA8 and Fygomati" a%s"ess 5KA8.
/2
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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)A* )B* )&*
#.;@2e VIII, E9tensi&e "holesteatoma eroding the petro#s pyramid and osseo#s
la%yrinth 5A8 A9ial inferior tympani" se"tion and 5B8 $oronal anterior tympani"
se"tion of the right petro#s %one sho'ed middle ear "a&ity tiss#e density mass
eroding the lateral atti" 'all* s"#t#m and ossi"les and %ony la%yrinth 5long 'hite B
%la"+ arro's8* the tegmen is thinned 5short %la"+ arro'8.he lesion erodes the
la%yrinthine and tympani" segments of the fa"ial ner&e "anal. he atti"* adit#s and
mastoid antr#m are opa"ified 'ith tiss#e density and the mastoid air "ells are
s"leroti".5$8 A9ial se"tion thro#gh the posterior fossa in the same patient 'ith
"ontrast sho'ed right "ere%ellar a%s"ess.

/-
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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E2os.on of 0he 0e;/en 0</7an.,
he tegmen is &is#aliFed in
"oronal se"tions* appears as a thin
%ony plate o&erlying the epitympan#m
and antr#m. here 'as agreement in
5D/./ A8 %et'een the preoperati&e $
s"an and operati&e feat#res. =ne "ase
'as diagnosed as eroded tegmen and
the operati&e feat#res sho'ed only
dehis"en"e of the tegmen 'ith no d#ral
e9pos#re.
In0e;2.0< of 0he fa9.al ne2Ae 9anal,
0n this st#dy* $ s"ans fo#nd
agreement a%o#t fa"ial ner&e "anal
integrity in -- patients 536.6A8 and
s#rgery. =#t of 6 patients 'ith s#rgi"al
"onfirmation of eroded fa"ial ner&e
"anal* $ "o#ld dete"t @ patients in the
present st#dy. $ is agreed 'ith
operati&e feat#res regarding - patients
'ith fa"ial "anal dehis"en"e.
In0e;2.0< of 0he s.;/o.4 s.n@s 7la0e,
!o#r patients of sigmoid sin#s
plate erosion 'ere diagnosed a""#r-
ately %y preoperati&e $ s"ans.
In02a92an.al 9o/7l.9a0.ons,
!i&e patients 'ith intra"ranial "ompli-
"ations in"l#ding "ere%ellar "ere%ral*
e9trad#ral a%s"esses and otiti" hydro-
"ephal#s 'ere diagnosed a""#rately %e
preoperati&e $ s"ans.
a:le CIII, $orrelation %et'een $ findings and operati&e feat#res
#ea0@2es #.n4.n;
.n &
O7e2a0.Ae
#ea0@2es
#alse
Ne;a0.Ae
#alse
'os.0.Ae
A99@2a9< %ens.0.A.0<
iss#e mass -3 -3 . . 2.. 2..
ypi"al lo"ation -@ -@ . . 2.. 2..
Bony erosions ,- ,- . . 2.. 2..
0n"#s erosion -4 -3 2 . D3./ D3.2
Malle#s erosion 26 26 . . 2.. 2..
>S$ fist#la 3 3 . . 2.. 2..
egmen erosion 4 / . 2 D/./ 2..
!a"ial "anal
0nta"t
Eroded
Dehis"ent
--
6
-
--
D
-
.
2
.
.
.
.
2..
D3./
2..
2..
6,.,
2..
Eroded SS: 4 4 . . 2.. 2..
Eroded KS 26 26 . . 2.. 2..
0ntra"ranial
"ompli"ations
/ / . . 2.. 2..
>S$J lateral semi"ir"#lar "anal SS:J Sigmoid sin#s plate.
KSJ KornerCs sept#m


/,
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
DI%&U%%ION
//
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
in 24.DA of "holesteatoma ears prior to
s#rgery.
!"& fea0@2es of 9holes0ea0o/a of
0he s0@4.e4 7a0.en0s,
0n the present st#dy* and
a""ording to the "riteria of
,*/*4*3
* 'e
fo#nd that se"ondary a"(#ired "holes-
teatoma 'ere most often lo"aliFed to
the atti" and antr#m* some e9tended to
the meso-tympan#m and some are
holotympani". Atti" "holesteatoma 'as
dete"ted in 2. patients 5,2.-4A8*
atti"o-antral "holesteatoma in 6
patients 5-4A8* meso-tympani" "holes-
teatoma dete"ted in 4 patients 524.3A8
and e9tensi&e holo-tympani" "holes-
teatoma in D patients 5-6.2A8.
Regarding the type of "holesteatoma*
2. patients o#t of ,- patients sho'ed
$ feat#res of pars fla""ida
"holesteatoma 5,2.-4A8* 2. patients
o#t of ,- 'ere of pars tensa
"holesteatoma 5,.-4A8 and "om%ined
types "holesteatomas in 2- patients
5,@.4A8. 0f :r#ssa+Cs spa"e is "lear and
there is no pars fla""ida retra"tion* 'e
pres#med "holesteatoma to arise from
the pars tensa.
>i# and Bergeron 2D6D
3
stated
that $ is a #ni(#e in its a%ility to
display not only the internal %ony
ar"hite"t#re of the temporal %one %#t
also to e&al#ate the soft tiss#e
"omponents asso"iated 'ith a
pathologi" pro"ess. hereforeE one of
its maIor "ontri%#tions to the otologist
dealing 'ith "holesteatoma is the
preoperati&e lo"aliFation of the "holes-
teatomato#s sa"* a detail not only
determine the type of s#rgi"al
approa"h %#t may also alert the
s#rgeon to possi%le intra-operati&e as
'ell postoperati&e "ompli"ations.
)R$ "an early dete"t "holesteatoma
asso"iated 'ith s#%tle %ony erosion or
ossi"#lar displa"ement. his early
dete"tion %y )R$ 'ith the #se of
simple non in&asi&e s#rgi"al te"hni(#e
5as deli&ery or atti"otomy8 'ill prese-
r&e hearing.
0n the "#rrent st#dy* small atti"
and meso-tympani" "holesteatoma
'ere demonstrated in 2. patients o#t of
,- patients. Early :r#ssa+Cs spa"e
"holesteatoma 'as dete"ted in -
patients as a lo"aliFed small soft tiss#e
density mass slightly eroding the
s"#t#m in one patient and displa"es the
ossi"les medially in the other patient.
Early meso-tympani" "holesteatoma
e9tending from a postero-s#perior
retra"tion related to the fa"ial re"ess
and sin#s tympani dete"ted in ,
patients asso"iated 'ith slightly eroded
in"#s long and lenti"#lar pro"ess. he
remaining - patients sho'ed lo"aliFed
atti" "holesteatoma asso"iated 'ith
erosion of the s"#t#m* malle#s head
and ne"+ 'ith slight e9tension to'ards
the adit#s.
:helps and >loyd 52DD.8
2@

stated that* demonstration of small
"holesteatoma in the middle ear "a&ity
%y $ depends on t'o fa"torsJ the first
is the %one erosion of lateral atti" 'all
and s"#t#m and<or displa"ement of the
ossi"les and the se"ond fa"tor is the
morphology of a soft tiss#e mass*
'hi"h is typi"ally seen in the atti" and
e9tends do'n to the isthm#s of the
middle ear. he ossi"#lar "hain is
normally e(#idistant from the medial
and lateral 'alls of the epi-tympan#m.
he ossi"#lar displa"ement in either
dire"tion often is an early sign of
"holesteatoma. :ars fla""ida "holes-
teatomas #s#ally displa"e the ossi"#lar
"hain medially* and pars tensa
"holesteatoma displa"e it laterally.
26


Mafee et al.* 52D668
26
and
Da&id et al.* 52D6D
82D
des"ri%ed the
"riteria indi"ating "holesteatoma in the
atti" as follo'sJ destr#"tion of the
lateral sp#r of %one formed %y the
I#n"tion of the lateral atti" 'all and
/4
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
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roof of the e9ternal a#ditory "anal
5s"#t#m8. Bl#nting of the s"#t#mCs
5normally sharp tip8 is the earliest sign
of atti" "holesteatoma. Erosion of the
anterior tympani" spine 5'hi"h is %est
seen in sagittal s"ans8* is another sign
indi"ating "holesteatoma in the atti".
Bone destr#"tion of the lateral atti"
'all "a#sing 'idening of the adit#s
'ith loss of the Sfig#re-of-eightT
pattern 5formed %y narro' isthm#s of
the adit#s %et'een the radiol#"en"ies
of the epitympan#m and antr#m8
#s#ally signifies that "holesteatoma has
e9tends into the antr#m. Dehis"en"e of
the tegmen and erosion of the medial
atti" 'all are less "ommon than lateral
'all erosion and may lead to
in&ol&ement of the fa"ial ner&e "anal
'ith paralysis and in&asion of the
lateral semi"ir"#lar "anal 'ith &ertigo
or s#dden sensorine#ral hearing loss.
$holesteatoma in the mastoid
antr#m is "hara"teriFed %y a smooth
"a&ity that is #s#ally larger than
normal o'ing to %one erosion. Mhen
the air "ells appear "lo#dy %#t maintain
their irreg#lar tra%e"#llar pattern or
'hene&er there is o%literation of the
mastoid antr#m and peripheral air "ells
%y rea"ti&e ne' %one formation*
"hroni" mastoiditis 'itho#t "holes-
teatoma is indi"ated. Another sign of
"holesteatoma in the antr#m is erosion
or a%sen"e of the %ony partition +no'n
as KRrnerCs sept#m. So* it is mandatory
to "ompare %oth ears* %e"a#se of the
normal anatomi" &ariations among
indi&id#als. Destr#"tion and s"alloping
of the mastoid air "ells 5a#to-
mastoide"tomy8* dehis"en"e or erosion
of the sigmoid sin#s plate 'ith or
'itho#t &eno#s sin#s throm%osis
represents the "ompli"ations of antral
"holesteatoma.
26
!.44en 9holes0ea0o/a,
he anatomy of the posterior
tympan#m is (#ite "omple9. he pyra-
midal eminen"e from 'hi"h the
stapedial tendon arises is the most
prominent str#"t#res on the posterior
tympani" 'all. 0t is %ordered medially
%y the sin#s tympani and laterally %y
the fa"ial re"ess. hey are important in
that* "holesteatoma material may lie
'ithin and %e hidden from &ie' d#ring
s#rgery. Dete"tion of hidden "holestea-
toma 'ithin the posterior or the
anterior tympan#m %y )R$ ma+es it
the method of "hoi"e.
-.

0n the present st#dyE $ s"an
demonstrate the in&ol&ement of poste-
rior tympani" re"esses 5sin#s tympani
and fa"ial re"ess8 %y "holesteatoma
mass in -2 o#t of ,- patients 534.3A8*
the anterior tympa-n#m in&ol&ed in 3
patients 526.6A8. his is "onsistent
'ith res#lts of )asso et al.* 52D668
-2B--

and Mafee 52D668
26
'ho mentioned
that $ "o#ld demonstrate "holes-
teatomas in hidden areas s#"h as the
posterior tympani" re"esses* 'hi"h
"o#ld not %e dete"ted %y the otologi"al
e9amination. E&al#ation of these
re"esses of the tympani" "a&ity is
essential prior to s#rgery sin"e the
s#rgi"al approa"h may %e altered %y
the presen"e of inflammatory disease
medial to ossi"#lar "hain. he anterior
epi-tympan#m "orresponds to the
ossi"#lar spa"e and is &ery diffi"#lt to
&ie' 'ith operating mi"ros"ope e&en
after remo&al of the head of malle#s.
hese des"ri%ed hidden areas gi&e a
%ad rep#tation of re"#rren"e of "holes-
teatoma.
E50ens.Ae holo-0</7an.9 9holes0ea0o/a,
0n this st#dy D patients o#t of
,- 5-6.2A8 presented 'ith e9tensi&e
"holesteatoma that filling the 'hole
tympani" "a&ity and e9tended to mas-
toid antr#m. he diagnosis depends on
that* the "holesteatoma had a
propensity for %ony erosions of the
middle ear %ony %o#ndaries and
mastoid and did not gra&itate 5non
/3
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
dependent8 in a9ial and "oronal
se"tions. hese feat#res are "onsistent
'ith* ?oorhees et al.* 52D6,8
-,
and
Ha"+ler et al.* 52D6/8
-/
'ho depended
mainly on the %ony erosion not the $
n#m%ers in the diagnosis of holo-
tympani" "holesteatoma.

Sara* 52DD28
-4
and Mafee et al.*
52D668
26
reported that 'hereas $ s"an
prod#"es e9"ellent soft tiss#e reso-
l#tion* the differentiation of patho-
logi"al pro"esses on the %ases of $
n#m%ers pro&ed to %e #ns#""essf#l*
%e"a#se a"(#ired "holesteatoma*
gran#lation tiss#e and middle ear
eff#sion* all share similar $ n#m%ers.
hereforeE se"ondary findings and
"lini"al information m#st %e relied
#pon to ma+e a definiti&e diagnosis.
Complications of cholesteatoma:
?irt#ally all "ompli"ations of
the "holesteatoma are related to
osseo#s destr#"tion. he a%ility to
destroy %one may lead to serio#s
intra"ranial "ompli"ations. Altho#gh
these "ompli"ations may prod#"e
o%&io#s signs and symptoms* they may
%e s#%tle and #nre"ogniFed 'itho#t $
s"an.
4* -3

In02a-0e/7o2al 9o/7l.9a0.ons,
0n the present st#dyE "ond#"ti&e
hearing loss is a "ommon "ompli"ation
of "holesteatoma as ossi"#lar "hain
erosion o""#rred in as many as 4. A of
patients. SadU et al.* 52D6-8
-@

"on"l#ded that ossi"#lar "hain erosion
o""#rs in ,.A of patient 'ith "holes-
teatoma. Erosion of the lenti"#lar
pro"ess and stapes s#perstr#"t#re may
prod#"e a "ond#"ti&e hearing loss.
$om%ined sensorine#ral and "ond#-
"ti&e hearing loss dete"ted in t'o
patients ha&ing e9tensi&e "holestea-
toma eroding the middle ear str#"t#res
and in&ading the osseo#s la%yrinth.
he presen"e of sensorine#ral hearing
loss may indi"ate in&ol&ement of the
la%yrinth.
-@

La:<2.n0h.ne f.s0@la,
0t is en"o#ntered in 3 of
patients 'ith "holesteatoma. =ne of
these patients presented 'ith &ertigo
and sensorine#ral hearing loss as 'ell
as positi&e fist#la test. he other 4
patients 'ere dis"o&ered a""identally
%y )R$ s"an 'ith no symptoms of
la%yrinthine fist#la. Sil&er et al.* 2D6@
-6
stated that patients 'ith &ertigo and
"hroni" middle ear disease may ha&e a
"holesteatoma 'ith a Gfist#laG %et'een
the middle and inner ear. Altho#gh the
fist#la #s#ally in&ol&es the lateral
semi"ir"#lar "anal* the "holesteatoma
may in&ade the o&al 'indo'. :al&a
2DD.
-D
"on"l#ded that the la%yrinthine
fist#la may o""#r in 2.A of patients
'ith "holesteatoma. A fist#la sho#ld %e
s#spe"ted in patients 'ith longstanding
disease and ha&e sensorine#ral hearing
loss and<or &ertigo ind#"ed %y noise or
press#re "hanges in the middle ear.
)R$ s"an of the temporal %one
sho#ld %e o%tained to "onfirm the
diagnosis.
#a9.al ne2Ae 7a2es.s 'as dete"ted in
t'o patients 'ith "holesteatoma
eroding the horiFontal portion of the
fa"ial ner&e "anal. he paresis
de&eloped slo'ly from "hroni"
e9pansion of the "holesteatoma. )R$
of the temporal %one helps to lo"aliFe
the site of in&ol&ement.
In02a-92an.al 9o/7l.9a0.ons,
0n the present st#dy intra"ranial
"ompli"ations 'ere en"o#ntered in /
patients 52/.-6A8. he "ere%ellar
a%s"ess 'as a se(#el of in&asi&e
"holesteatoma eroding the sigmoid
sin#s plate. he e9trad#ral a%s"esses
'ere dete"ted in one patient ha&ing
infe"ted "holesteatoma eroding
sigmoid sin#s plate and the tegmen
mastoidi#m. =titi" hydro"ephal#s 'as
/@
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
dete"ted in one patient "omplaining of
intermittent heada"he. $ s"an
e9"l#des the presen"e of "ere%ral
a%s"ess and sho'ed atten#ated
&entri"#lar system.
E>-Essa'y et al.* 52DD-8
,.
in a
series of 5,- "ases8 "on"l#ded that* the
temporal %one "ompli"ations in"l#ding
%one erosion and "a&ity formation
'ere seen in all patients 'ith "holes-
teatoma 52..A8* s"lerosis of the
mastoid and ossi"#lar destr#"tion in ,.
patients 5D,.6A8. he intra"ranial
"ompli"ations represented in 5-2.@A8
in the ,- ears d#e to negligen"e of
treatment and delayed operati&e
interferen"e in addition to #n-
a'areness of the &al#e of $ in
dete"tion of these "ompli"ations.
Value of preoperative HRCT in
patients with cholesteatoma:
he a%sol#te indi"ations for
preoperati&e )R$ in "hroni" otitis
media 'ere des"ri%ed %y !al"ioni et
al.* 5-..-8
,2
'hi"h in"l#deJ do#%tf#l
diagnosis* s#spe"ted malformations*
diffi"#lt mi"ros"opy e&al#ation* s#spe-
"ted petro#s ape9 "holesteatoma*
s#spe"ted intra"ranial "ompli"ations*
and re&ie' of "ases that did mastoid-
e"tomy %efore. he s"an aids in
alerting s#rgeon to the presen"e of
anatomi"al &ariations 5s#"h as a high
riding I#g#lar %#l%* prominent laterally
pla"ed sigmoid sin#s* a%errant "arotid
artery8* and potential s#rgi"al haFards
that may arise from destr#"ti&e nat#re
of the disease 5s#"h as la%yrinthine
dehis"en"e8.
,-

Correlation between HRCT findins
and operative data:
)R$ findings of la%yrinthine
fist#la 'ere "ompared 'ith operati&e
feat#res and fist#la test. $ findings
'ere "oin"ident 'ith operati&e data for
all st#died parameters and the least one
is the integrity of the fa"ial ner&e
"anal.
hirty one patients o#t of ,-
'ith "holesteatoma a""#rately
diagnosed 'ith )R$ s"an 5D3./A8*
only one patient 'ith diff#se tiss#e
density in the atti" and meso-
tympan#m asso"iated 'ith eroded
in"#s long pro"ess 'as diagnosed as
a"(#ired mesotympani" "holesteatoma*
%#t the s#rgery sho'ed diff#se
gran#lation tiss#e 'ith eroded in"#s
long pro"ess. his "oin"ides 'ith
Mafee et al.* 52D668
26
'ho reported that
5D3A8 of "ases 'ere diagnosed
"orre"tly 'ith the preoperati&e $
s"an.
$hee B an* -..2
,-
"on"l#ded
that 5D/./A8 of "ases had at least - of the
, "riteria of $ feat#res of "holes-
teatoma. Both Ha"+ler et al.* 52D6/8
-/

and =CDonogh#e et al.* 52D6@8
,,
* fo#nd
"holesteatoma presents in 6.A of the
"ases e9plored. =CReilly et al.* 52DD28
,/

dete"ted -, o#t of -D "ases 5@DA8 of
"holesteatoma. )R$ images may
infl#en"e the de"ision and timing of
s#rgi"al e9ploration. $ s"an e&iden"e
of "holesteatoma 'ith signifi"ant %ony
destr#"tion or other "ompli"ations "o#ld
prompt the s#rgeon to operate earlier*
parti"#larly if polyps or a tort#o#s %ony
"anal o%s"#res &is#aliFation of the
tympani" mem%rane and hinders "lini"al
diagnosis.
,-

Oss.9@la2 9ha.n e2os.on,
Bone resorption of the ossi"les
depends on the origin and mode of
spread of "holesteatoma.
/*4*,-
0n the
present st#dy* radio-s#rgi"al "orre-
lation for the middle ear ossi"#lar
erosion 'as 5D3./A8 for the in"#s
erosion and 52..A8 for the malle#s
erosion. hese feat#res are mat"hed
'ith a st#dy made %y $hee B an*
5-..28
,-
'ho fo#nd that* o#t of ,2
/6
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
in"#s* fo#nd at s#rgery to %e erodedE
,. 'ere demonstrated %y $ s"an 'ith
a""#ra"y 5D3.6A8 and o#t of the 24
malle#s* 2/ 'ere seen %y the s"an 'ith
a""#ra"y 5D3.6A8. 0n a st#dy that done
%y Mafee et al.* 2D66
5268
the radio-
s#rgi"al "orrelation 'as 5D/A8 for the
in"#s and 56DA8 for the malle#s
erosions. )assman et al.* 5-..,8
,4
in a
series of 3. ears operated %et'een
2D66--..2 reported that there is good
"orrelation %et'een $ finding and
operati&e feat#res in "holesteatoma for
most middle ear str#"t#res e9"ept for
the integrity of in"#s long pro"ess.
=n the other hand* =CReilly et
al.* 52DD28
,/
'ere a%le to "orre"tly
predi"t an inta"t ossi"#lar "hain in only
54.A8 of "ases. =CDonogh#e et al.*
52D6@8
,,
reported that erosion of the
long pro"ess of the in"#s dete"ted in
53@A8 of the s"anned "ases. :helps and
Mright 2DD.
,3
stated that the error in
all "ases to demonstrate the ossi"#lar
"hain relia%ility 'as d#e to the "om%i-
nation of partial &ol#me a&eraging and
tiss#e silho#etting.
Mhile prior +no'ledge of the
state of the ossi"les is not "riti"al as the
operati&e ris+ is "on"erned* it has
%earing on the li+elihood of hearing
preser&ation that "an %e a"hie&ed after
s#rgery. !or e9ample* the hearing
o#t"omes in patients 'ith an inta"t
stapes tend to %e %etter than those
'here the stapes s#per-str#"t#re is
a%sent. :re-s#rgi"al +no'ledge of the
stat#s of the ossi"#lar "hain 'o#ld
allo' the s#rgeon to %etter ad&ise the
patient on the degree of hearing
attaina%le after s#rgery.
,@

La:<2.n0h.ne f.s0@la,
0n the present st#dy only 3
patients 'ith lateral semi"ir"#lar "anal
fist#las* 'ere diagnosed. he )R$
findings 'ere "orrelated 'ith fist#la
tests as 'ell as operati&e data. A
la%yrinthine fist#la is "a#sed %y resor-
ption of the %one of the oti" "aps#le %y
the a"tion of enFymes asso"iated 'ith
"holesteatoma or "hroni" a"ti&e
s#pp#rati&e osteitis. he most "ommon
site for a fist#la is the lateral
semi"ir"#lar "anal. )o'e&er* any of
the "anals may %e in&ol&ed and a
"o"hlear fist#la may o""#r in the
middle ear or epi-tympan#m. hese
res#lts 'ere in agreement 'ith those of
Mafee et al.* 52D668
26
and $hee B an
5-..28.
,-
B#sa%a* 52DDD8
,6
mentioned
that the la%yrinthine fist#la 'as
dete"ted radiologi"ally in /-A of
patients. )e "on"l#ded that in "hroni"
otitis media* la%yrinthine fist#las
o""#rred almost e9"l#si&ely in the
presen"e of "holesteatoma and the
postoperati&e hearing o#t"ome "orre-
lated 'ith the siFe of the fist#la and the
presen"e of gran#lation tiss#e in&ading
the la%yrinth.
Menif et al.* 5-...8
,D
stated
thatE )R$ s"an assessment of
osseo#s la%yrinthine fist#la "oin"ided
'ith the s#rgi"al findings 52/ "ases of
la%yrinthine fist#la s#spe"ted %y $
'as s#rgi"ally "onfirmed8. :helps and
Mright 52DD.8
,3
ad&o"ated s"anning in
%oth a9ial and "oronal planes 'hen
&esti%#lar symptoms 'ere present.
Mafee et al.*
26
stated that* a9ial se"tions
may gi&e a false impression of lateral
semi"ir"#lar fist#la and another plane
5"oronal or sagittal8 sho#ld %e
o%tained. Ha"+ler et al.* 52D6/8
-/

reported that the most "ommon "anal
affe"ted %y fist#la is the lateral
semi"ir"#lar "anal and relian"e on
"oronal se"tions alone may lead to a
54.A8 false positi&es rate of
dehis"en"e d#e to the artifa"t of partial
&ol#me a&eraging. E&en 'ith the
addition of a9ial s"ans* min#te fist#la
may still %e missed and the "aref#l
disse"tion of the "holesteatoma matri9
/D
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
o&er the dome of the lateral
semi"ir"#lar "anal re&ealed a tiny %ony
"anal fist#la.
he a9ial s"ans are more
satisfa"tory %e"a#se they depi"ted the
lateral semi"ir"#lar "anal in its entirety
and 'ere less li+e to prod#"e false
positi&es* %#t #sef#l information "o#ld
%e gained from the "oronal s"ans. Me
re"ommended %oth planes for a""#rate
diagnosis.
Malshe et al.* 5-..-8
/.
stated
that* there may %e a medi"o-legal role
for ro#tine $ %efore mastoid s#rgery.
!or e9ample* erosion of the lateral
semi"ir"#lar "anal %y "holesteatoma in
the a%sen"e of &ertigo is pres#ma%ly
d#e to "holesteatoma sealing the
defe"t. Mhen remo&ed at mastoid-
de"tomy* s#"h a patient may 'ell
%e"ome &ertigino#s. Mith e&iden"e of
erosion in the preoperati&e )R$* any
a""#sation of iatrogeni" damage "o#ld
%e ref#ted.
e;/en e2os.on,
egmen tympani represent the
roof of the middle ear "a&ity. Erosion
of the tegmen is 'ell seen on "oronal
imaging. 0n this st#dy tegmen erosion
'as dete"ted in 4 patients 'ith
a""#ra"y D/./A. =ne "ase 'as
diagnosed as eroded tegmen and the
operati&e feat#res sho'ed only
dehis"en"e of the tegmen 'ith no d#ral
e9pos#re. Mafee et al.* 52D668
26
had
similar res#lts as $ findings mat"hed
'ith operati&e data regarding tegmen
erosion 'ere seen in D/A of "ases.
Also the a""#ra"y in a st#dy made %y
$hee B an
,-
'as D/.4A.
#a9.al 9anal .n0e;2.0<,
=#t of D patients 'ith s#rgi"ally
"onfirmed fa"ial "anal erosion* 6
patients dete"ted %y $ 'ith a""#ra"y
5D3./A8 and sensiti&ity 56,.,A8. 0n a
st#dy made %y Mafee et al.* 52D668*
26

they diagnosed normal fa"ial "anal in
/2 patients 564A8. hey also reported
that to f#lly &is#aliFe the &erti"al
segment of the "anal* one m#st #tiliFe
the sagittal plane* 'hi"h is not
a&aila%le in all $ s"anners. Mhen the
middle ear is normal* the thin lateral
%ony 'all of the fallopian "anal is easy
to &is#aliFe on $ s"ans against its
%la"+ radiol#"ent %a"+gro#nd. B#t
'hen pathologi" soft tiss#e a%#ts the
tympani" portion of the "anal* it may
%e diffi"#lt to determine 'hether
"holesteatoma has eroded the "anal or
merely lies adIa"ent to "ongenital
defe"t.
26

he pro%lem 'ith partial
&ol#me a&eraging artifa"t is e&ident as
the fallopian "anal "an %e so thin e&en
in non-pathologi"al ears to appear
dehis"en"e in $ s"an. Also &is#ali-
Fing the tympani" portion of the fa"ial
"anal is diffi"#lt 'hen there is an
adIa"ent pathologi" soft tiss#e mass in
the meso-tympan#m.
-/*26

Recurrent cholesteatoma:
he diagnosis of re"#rrent
"holesteatoma depends on the presen"e
of ne' %one erosion not dete"ted in the
preoperati&e e&al#ation* the presen"e
of tiss#e density mass 'ith 'ell
defined %orders and an air spa"e
%et'een the mass and 'alls of the
tympani" "a&ity noted* e9pansion of
the mastoide"tomy "a&ity and thinning
of its 'alls. Resid#al "holesteatoma is
"onsidered if the "holesteatoma matri9
or sa" is retained o&er e9posed d#ra*
lateral sin#s* fa"ial ner&e or
la%yrinthine fist#la.
/-
he present st#dy sho'ed that
- patients had lo"aliFed middle ear
tiss#e density mass 'ith 'ell-defined
margin. =ne of them diagnosed as
re"#rrent "holesteatoma and the other
as resid#al "holesteatoma sa" left
aro#nd the o&al 'indo'.
4.
EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef
___________________________________________________________________________________
he diagnosis of re"#rrent
"holesteatoma depends on the %one
erosions in the form of eroded tegmen
and anterior epi-tympani" 'all* 'hi"h
not dete"ted in preoperati&e $ and
operati&e data. his finding is
"oin"ides 'ith ;rist'ood B ?ena%les
52DD.8
/,
'ho stated that the in"iden"e
of re"#rrent or resid#al "holesteatoma
in patients ha&e #ndergone mastoide-
"tomy ranges from 4A to 42A. 0n
another st#dy made %y >ino et al.*
2DD6
5//8
the rate of resid#al < re"#rrent
"holesteatoma after an a&erage of 2.
years from the initial s#rgery 5"anal
'all do'n8 &aried from 3A to ,6A.
he ris+ fa"tors do"#mented are poor
"a&ity &entilation and asso"iated otitis
media 'ith eff#sion
.//
ierney et al.* 52DDD8
/4
re&ealed
that the sensiti&ity of $ s"an in
diagnosing resid#al or re"#rrent
"holesteatoma 'as /-.DA 'ith a
spe"ifi"ity of /6.,A and a predi"ti&e
&al#e of -6.3A. hese res#lts
e9plained %y the fa"t that it is radiolo-
gi"ally diffi"#lt to differentiate
%et'een re"#rren"e* s"ar tiss#e or fl#id
'ith )R$ s"an.
:rimary petro#s ape9
"holesteatoma 'as s#ggested %y the
site and e9panding nat#re as 'ell as
the e9tension of the lesion thro#gh the
petro#s pyramid and these findings
'ere aided %y "lini"al presentation
5fa"ial palsy8.
/3*/@

)R$ s"an "o#ld not differentiate
%et'een primary petro#s ape9 "holes-
teatoma and the possi%le petro#s ape9
gran#loma* so MR0 is re"ommended to
sol&e the pro%lem. hese findings are
mat"hed 'ith res#lts of ?al&assori*
52DD,8
/6
'ho stated that the first sign
of primary petro#s ape9 "holesteatoma
is often fa"ial paralysis of slo' onset
follo'ed %y sensorine#ral hearing loss
"a#sed %y erosion of the la%yrinth
'hile the middle ear "a&ity may %e
normal. )R$ sho'ed e9pansile
lesion in the ape9.
&ON&LU%ION,
0n "holesteatoma )R$ is
#ni(#e in its a%ility to display not only
the internal %one ar"hite"t#re of middle
ear and mastoid %#t also presen"e of
soft tiss#e massE that a negati&e s"an
effe"ti&ely e9"l#des possi%ility of
"holesteatoma. 0t is also &al#a%le in
&is#aliFation of hidden areas s#"h as
sin#s tympani and fa"ial re"ess %eyond
otos"opi" e9amination that is important
%efore de"ision of s#rgi"al strategy.
Early #se of )R$ in "ases of "holes-
teatoma "an sa&e hearing and impro&e
mor%idity.
"E#E"EN&E%,
2- Bea#mont ;DJ GRadiology in
the management of "hroni" s#pp#rati&e
otitis media.G A#stralia Radiol 52D6.8E
-/J-,6--/4.
-- :aparella MM* ;oy"oolea M?.J
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$lini"s 0nternational &ol#me 00.
M0>>0AMS B M0>K0NS Baltimore<
>ondonE 52D6-8* $hapter 24JD4-2.-.
,- ?al&assori ;E* B#"+ingham
RA* $arter B>* )anafee MN* Mafee
M! 5eds.8J GRadiology of the temporal
%oneG. 0nJ )ead and Ne"+ 0maging.
hieme Medi"al :#%lishers 0n"* Ne'
Yor+* 52D668E 2-2@-.
/- S'artF HDJ G0maging of the
temporal %one. A te9t<Atlas. hiem
Medi"al :#%lishers 0n"* Ne' Yor+*
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4- S'artF HD.J G$holesteatoma of
the middle earJ Diagnosis* etiology and
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3- >i# D:$ and Bergeron R.J
G$ontemporary radiolgi" imaging in the
e&al#ation of middle ear-atti"o antral
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@- Maran A;D.J GDisease of
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th
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2.- Kemppainen )=* :#ha++a )H*
>aippala :HJ GEpidemiology and etio-
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