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$holesteatoma is "ommon pro%lem and its proper diagnosis needs "lini"al effort for early dete"tion of "ompli"ations. He ad&ent of )R$ fa"ilitates diagnosis of temporal %one mastoid and inner ear pathologies.
$holesteatoma is "ommon pro%lem and its proper diagnosis needs "lini"al effort for early dete"tion of "ompli"ations. He ad&ent of )R$ fa"ilitates diagnosis of temporal %one mastoid and inner ear pathologies.
$holesteatoma is "ommon pro%lem and its proper diagnosis needs "lini"al effort for early dete"tion of "ompli"ations. He ad&ent of )R$ fa"ilitates diagnosis of temporal %one mastoid and inner ear pathologies.
___________________________________________________________________________________ !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 ___________________________________________________________________________________ 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 ___________________________________________________________________________________ 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 ___________________________________________________________________________________ $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 ___________________________________________________________________________________ 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
)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. ,4 EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef ___________________________________________________________________________________ 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 ___________________________________________________________________________________ )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 ___________________________________________________________________________________ )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 ___________________________________________________________________________________ )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 ___________________________________________________________________________________ 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 ___________________________________________________________________________________ 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 ___________________________________________________________________________________ )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 ___________________________________________________________________________________ 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 ___________________________________________________________________________________ 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 G$lini"al pro%lems in otitis media and 0nno&ations in S#rgi"al =tolgy. Ear $lini"s 0nternational &ol#me 00. M0>>0AMS B M0>K0NS Baltimore< >ondonE 52D6-8* $hapter 24JD4-2.-. ,- ?al&assori ;E* B#"+ingham RA* $arter B>* )anafee MN* Mafee M! 5eds.8J GRadiology of the temporal %oneG. 0nJ )ead and Ne"+ 0maging. hieme Medi"al :#%lishers 0n"* Ne' Yor+* 52D668E 2-2@-. /- S'artF HDJ G0maging of the temporal %one. A te9t<Atlas. hiem Medi"al :#%lishers 0n"* Ne' Yor+* 52D638E 2-2@- 4- S'artF HD.J G$holesteatoma of the middle earJ Diagnosis* etiology and "ompli"ations.G Rad. $lin. North. Am. 52D6/8E --J24-,3. 3- >i# D:$ and Bergeron R.J G$ontemporary radiolgi" imaging in the e&al#ation of middle ear-atti"o antral "omple9 "holesteatoma. =tolaryngol. $lin. North Am. 52D6D8E --J 6D@. 42 EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef ___________________________________________________________________________________ @- Maran A;D.J GDisease of hroat* Nose and EarG 2. th ed* MR0;) 52D668* "h. ,.6J ,./-,23. 6- S'artF HD* )arns%erger )RJ Ghe middle ear and mastoid.G in 0maging of the temporal %one. , rd
edition. hieme 52DD68E /@-23D. D- Sa&i" D* Hso&i" A* DIeri" D.J he &al#e of "omp#ted tomography 5$8 in the e&al#ation of the anatomi" str#"t#res of the atti". H. >aryngol. =tology 52D6@8E 2.2J2226-22-/. 2.- Kemppainen )=* :#ha++a )H* >aippala :HJ GEpidemiology and etio- logy of middle ear "holesteatoma.G A"ta =tolaryngol* 52DDD8E 22D548J 436-@-. 22- BanerIee A* !lood >M* Yates :* $lifford K.J G$omp#ted tomography in s#pp#rati&e ear diseaseJ Does it infl#en"e managementV.G H >aryngol =tol 5-..,8 H#neE 22@538J /4/-6. 2-- ?eit"h D* Bro"+%an+ M* Mhittet ).J GA#ral polyps B "holes- teatoma.G $lin. =tolaryngol. 52D668E 2,J ,D4J,D@. 2,- Milliams SR* Ro%inson :H* Bright'ell A:.J GManagement of the inflamematory a#ral polyp.G H. >aryngol. =tol. 52D6D8E 2.,J2./.- 2./-. 2/- ;li+li"h RE* $#nningham MH B Roland D.J Ghe "a#se of a#ral polyp in "hildren.G Ar"h =tolaryngol. 52DD,8E 22DJ33D-3@2. 24- $ha+eres DM* Kapila A B >a Masters D.J GSoft tiss#e a%normalities of the e9ternal a#ditory "analJ S#%Ie"t re&ie' of $ findings.G Radiology 52D648E 243J2.4-2.D. 23- Da&id Mhite presentationJ A"(#ired middle ear "holesteatoma "ompli"ated %y ossi"#lar erosion and >SS$ fist#la. Milford )all Medi"al $entral Reso#r"e* /<D<2DD@. 2@- :helps :D* >loyd ;AS.J GDiagnosti" imaging of the earG. - nd
edition >ondon Berlin )eidel%erg Ne' Yor+ 2DD.. 26- Mafee M!* >e&in B$* Apple%a#m E>* $ampos M and Hames $!.J G$holesteatoma of the middle ear and mastoid. A "omparison of $ s"an and operati&e findingsG =tolaryngol. $lin North Am. 52D668E -2* No.-J -43- -D,. 2D- Da&id :.$* homas R. Bergeron M.J G$ontemporary radio- logi" imaging in the e&al#ation of middle ear atti"antral "omple9 "holes- teatomas.G =tolaryngol. $lin. North Am.52D6D8E --J6D@-D.D. -.- S'artF HDJ G)igh resol#tion "omp#ted tomography of the Middle Ear and Mastoid.G :art 2J Normal anat- omy in"l#ding normal &ariations. Radiology* 52D6,8E 2/6J//D-4/. -2- )asso AN* ?igna#d H.* De Smedt E.J GNormal anatomy of the temporal %one and mastoid. 0n Ne'ton )* )asso AN* Dilon M: 5eds8J $omp#ted tomography of the head and ne"+. Ra&en :ress* Ne' Yor+. 52D66* a8E $hap./J 2--,. --- )asso AN* ?igna#d >H and Bird $R.J G:athology of the temporal %one and mastoid. 0n Ne'ton )* )asso AN* Dillon M: 5eds8J $omp#ted tomography of the )ead and Ne"+. Ra&e :ress* Ne' Yor+. 52D66 %8E $hap.4J 2-/4. -,- ?oorhees R* Hohnson D >#f+in R* et al.*J G)igh resol#tion $ s"anning for dete"tion of "holestea- toma and "ompli"ations in post operati&e Ear.G >aryngos"ope* 52D6,8E D,J4D6-4D4. -/- Ha"+ler RK.* Dillon M:.* S"hindler RA.J G$omp#ted tomography in s#pp#rati&e ear diseaseJ a "orrelation of s#rgi"al and radiographi" findings.G >aryngos"ope 52D6/8E D/J@/3-@4-. -4- Sara .J G$omp#teriFed omographyJ its role in the assessment of ear disease. GRadiography today May 52DD28E 4@J----3. -3- Sam#el* H. et al.*J G=togeni" "ompli"ations 'ith an inta"t tympani" mem%rane*G >aryngo"ope* No&em%er* 52DD48* 2,6@-2,D.. 4- EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef ___________________________________________________________________________________ -@- SadeWH* Ber"o E* B#yano&er D. et al.*J G=ssi"#lar damage in "hroni" middle ear inflammation.G 0n Sade H 5ed8. $holesteatoma and mastoid s#rgery. Amsterdam* K#gler :#%li"a- tions $o.* 52D6-8E ,/@J ,46. -6- Sil&er AH* MaFen H* )ilal S* R#tledge HN.J G$ompli"ated $holesteatomaJ $ findings in inner ear "ompli"ations of middle ear "holes- teatomas.GRadiology52D6@8E23/J/@-42. -D- :al&a .J She pathogenesis and treatment of "holesteatomaT. A"ta =tolaryngol. 52DD.8E 2.DJ ,-,-,,.. ,.- El-Essa'y S* El-Nahas M* El-She'ahy )* ;honiem MR.J G$ompli"ated middle ear "holestea- toma* A $ st#dy.G Egyp. H. Radiol. B N#"l. Med.* 52DD-8E -, 528J 232-2@.. ,2- !al"ioni M.* ai%ah A.* De Donato ;.J G:reoperati&e imaging in "hroni" otitis s#rgery.G A"ta =torhino- laryngol 0tal.8-..-8E -- 528J 2D--@. ,-- $hee NM$ and an Y.J Ghe ?al#e of :reoperati&e )igh Resol#tion $ S"ans in $holesteatoma S#rgery.G Singapore Med H* 5-..28E ?ol. /-5/8244-24D. 5,,8 =CDonogh#e ;M* Bates ;H* Anslo' :* Rothera M:.J Ghe predi"ti&e &al#e of high - resol#tion "omp#teriFed tomography in "hroni" s#pp#rati&e ear disease.G $lini"al =tolaryngology* 52D6@8E 2-E 6D-D3. ,/- =CReilly BH* Mylie 0* ha++er $* B#tter :* Sathanathan N and Kenyon ;S.J Ghe &al#e of s"anning in "hroni" s#pp#rati&e otitis media.G H. >aryngol B =tology*52DD28E 2.4JDD.-DD/. ,4- )assman E:* ;os"i+ E* Shotni"+a B.J G$omp#teriFed omo- graphy in preoperati&e imaging of the middle ear "holesteatoma.G =tolar- yngol :ol. 5-..,8E 4@J-/,-D. ,3- :helps :D* Mright A.J G0maging "holesteatoma.G $lini"al Radiology* 52DD.8E /2J243-23-. ,@- $oo+ HA* Krishnan S* !agan :A.J G)earing res#lt follo'ing modified radi"al &ers#s "anal 'all #p mastoide"tomy.G Ann =tol. Rhinol >aryngol 52DD38E 2.4 548J ,@D-6,. ,6- B#sa%a NY.J G$lini"al prese- ntation and management of la%yri- nthine fist#la "a#sed %y "hroni" otitis media. GAnn =tol Rhinol >aryngol 52DDD8E /,4-/,D. ,D- Menif E* )emaied E* Ba""ar A* Kamo#n S* Ben Messao#d M* Slim R* Bes%es ;* )a"hi"ha S.J G:re- operati&e $ and MR e&al#ation of trans-la%yrinthine in&asi&e "holes- teatoma.G 5-...8E #nis < N. /.- Malshe :* Malsh R* Brennan :* Malsh M.J Ghe role of "omp#- teriFed tomography in the preoperati&e assessment of "hroni" s#pp#rati&e otitis media.G $lin. =tolaryngol. 5-..-8E -@JD4-D@. /2- Sade H.J GS#rgi"al planning of the treatment of "holesteatoma and postoperati&e follo' #p.G Ann =tol Rhinol >aryngol 5-...8E 2.DJ ,@--,@3. /-- De la $r#F A* !ayad HN.J GDete"tion and management of "hild- hood "holesteatoma.G :ediatr. Ann* 52DDD8E H#nE -6538J ,@.-,. /,- ;rist'ood RE* ?ena%les MN.J G!a"tors infl#en"ing the pro%a- %ility of resid#al "holesteatoma.G Ann =tol Rhinol >aryngol 52DD.8E DDJ2-.- 2-,. //- >ino Y* 0mam#ra Y* KoIima $* a+egoshi S*J GRis+ fa"tors for re"#rrent and resid#al "holesteatoma in "hildren determined %y se"ond stage operation.G 0nt H :ediatr =torhino- laryngol 52DD68E /3-34. /4- ierney :A* :ra"y :* Blaney S:J GAn assessment of the &al#e of the preoperati&e "omp#ted tomography s"ans prior to otoendos"opi" Xse"ond loo+X in inta"t "anal 'all mastoid s#rgery.G $lin =tolaryngol 52DDD8E A#gE -/5/8J -@/-3. /3- M#+herIi SK* Man"#so AA* KotF#r 0M* Slattery M)* S'artF HD* art R: and Nall A.J G$ of temporal %oneE !indings after mastoide"tomy* 4, EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef ___________________________________________________________________________________ =ssi"#lar re"onstr#"tion* and other "o"hlear implantationG Am. H. Roentog.* 52DD/8E 23,J2/3@-2/@2. /@- S'artF HD* ;oodman RS* R#ssell KB* >adenheim SE and Molfson RH.J G)igh resol#tion $omp#ted omo- graphy of the Middle Ear and Mastoid. :art 000 S#rgi"ally Altered Anatomy B pathology.G Radiology* A#g#st 52D6,8E 2/6J/32-/3/. /6- ?al&assori ;E.J G0maging St#dies of the emporal Bone. )ead and Ne"+ S#rgeryG. =tolaryngology* edited %y Byron H. Bailey. H.B. >ippin"ott $ompany* :hiladelphia* 52DD,8. 4/ EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005 Mohsen & El-Kashef ___________________________________________________________________________________ D ) ( !" #) ($% &'(! )! *! +, - D
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