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CHRONICOTITISANDCHOLESTEATOMA
F.Benoudiba,JlSarrazinServicedeNeuroradiologieCHUKremlinBicêtre
JFIMBARCELONAnov2014
Cholesteatoma
Chronicotitis
Cholesteatoma Nocholesteatoma
Retractionpocketprecholesteatoma
state
AcquiredCholesteatoma
Retractionpocket§ Mesotympanic pocket
retraction uncontrollable and no self cleaning
§ (accumulation of epidermal scales
Precholesteatoma state
Acquiredcholesteatoma
u Aetiology Pocket retraction or marginal perforation with malpighian epithelium migration coming from the external cavity
u 80% of cholesteatoma
Imaging
§ CHOLESTEATOMA IS A CLINICAL DIAGNOSIS § Modern imaging plays a key role in management of
cholesteatoma: § In pre operative § In post operative : minimally invasive supervision
(avoid surgical 2nd look) § Technical imaging:
ú CT scan (+++) ú MRI : growing up
Essentially in post operative Before surgery when complications
Imaging § Which imaging technique:
ú CT scan without enhancement: first choice modality To assess the diagnosis when otoscopy is
inclonclusive (closed tympanic membran) To screen for complications For the staging Anatomical assessment of the tympanomastoid cavity Surgical approach Choice
Imagingsemiology§ Nodular tisssular mass
ú Convex, rounded, polycyclic
ú location : Prussak’s space (External attical wall)
ú Attical extension
§ Mass effect on ossicular chain
Imagingsemiology
§ Bone erosion ú Erosion of the external
epitympanic wall (scutum): early sign
ú Ossicular erosion: 70% ú Not specific
Long process of incus Incus body Head of malleus
Imagingsemiology
§ Mastoid antrum extension § Enlargement of additus § Disappearanceofmastoid
celltrabeculation
Imagingsemiology
§ Exceptionally, the tissular mass may be absent
§ It has been removed by the ENT physician just before the CT scan
§ Empty pocket
Congenitalcholesteatoma
§ Unusual § Pathogenetic explanation:
persistence of residual squamous cells usually existing in embryo between the 10th and the 30th week of gestation (Mickaels’ theory).
Complications§ Erosion of the
LSCC (rarely the posterior)
§ Tegmen destruction
§ Carotid canal erosion
Erosion of the facial canal
Hearingrehabilitation
KurzTTPVario(Collin)
Universalprosthesistitane(Xomed-Medtronic)
Spiggle&TheisTitaniummiddleearpartial-totalimplant(PouretMédical)
Cholesteatoma:postoperativefollowing§ Imaging of post operative cholesteatoma
ú To assess a residual cholesteatoma ú Staging (extension/complications) if residual or
recurrent cholesteatoma. ú Post operative hearing loss without explanation
ú Best choice of imaging: depends on the situation
MRI:results
T1 T2b1000 ADC T1Gado
Cholesteatoma
Fibrosis
granuloma
abcess
Thiriat S Am J Neuroradiol 2009
Howtoavoidthefalsepositive§ Welllocatedthelesion
ú CorrelatedifferentsequencesandtheCTscan
§ CorrelatenonEpiandADC§ Cholesteatoma:decreaseADC
§ T1WIwithoutcontrast:ú hyperintense:It’snotacholesteatoma
Children
§ Avoid iterative CT scan (radiation) § Prefer MRI diffusion § 1 month after surgery § No injection § Binary response: chole + or chole –
ú Chole + : surgery (+/- CT) ú Chole – : MRI (1 month later)
Adult
§ Good audition , no otorrhea: 1 question ú Residual Cholesteatoma?
§ Conductive hearing loss or mixed: 2 questions ú Residual Cholesteatoma? ú Functional evaluation
Clinical
No opacity
Audition OK Hearing loss
CT
Partial opacity Total opacity
Postoperativemonitoring
Dubuous image No doubt Residual No
residual
Audition OK Hearing loss
surgery Surgery Ossicular rehabilita
tion CT Ossicular
rehabilitation CT CT or MRI
MRI
12 months
12,24 months 12 ,24months 12 ,24months
Postoperativehearingloss
§ Failure : persistence or recurrence of conductive hearing loss
§ Complication : occured of a sensorineural hearing loss
Conclusion
§ Major role of imaging for the diagnosisof pre operative cholesteatoma
§ Systematic in pre operative: the first modality imaging is CT scan without contrast
§ CT may be supplemented by MRI if complications (labyrinthine fistula or extension, tegmen erosion, intra cranial extension, meningocele)