Surgical mapping of middle ear cholesteatoma with fusion of computed tomography and diffusion-weighted magnetic resonance images: Diagnostic performance and interobserver agreement.

OBJECTIVE: To assess the diagnostic performance in detecting primary cholesteatoma at various anatomical subsites using Computed Tomography (CT), Diffusion-weighted Magnetic Resonance Imaging (DWMRI) and Fusion of CT and DWMRI (Fusion CT-MRI) images. STUDY DESIGN: A retrospective study of 22 children identified from a prospective database of surgically treated cholesteatoma cases over a five year period. All cases underwent pre-operative CT, non-echo planar DWMRI and Fusion CT-DWMRI, and with clearly documented surgical findings. For each imaging modality, two radiologists scored for the presence or absence of cholesteatoma with confidence levels at different anatomical subsites. The radiologists were blinded to the surgical findings to which their findings were compared. SETTING: Large Teaching Hospital in London. PATIENTS: 22 children with cholesteatoma confirmed surgically. INTERVENTION: CT, DWMRI imaging and fusion CT-MRI. MAIN OUTCOME MEASURE: Diagnostic performance of subsite localisation of cholesteatoma by CT, DWMRI and fusion CT-MRI imaging with intra-operative findings. RESULTS: Twenty-two patients were included (12 women and 10 men). The median age of patients was 11 years. When considering all subsites combined, the result for all imaging methods suggested 'good' agreement between both observers. When all subsites were examined together, all methods had relatively high sensitivity values (87% for CT vs 84% for DWMRI vs 85% for fusion CT-DWMRI). Specificity was highest with fusion CT-DWMRI (46% for CT vs 76% for DWMRI vs 97% for fusion CT-DWMRI), as was accuracy (66% for CT vs 80% for DWMRI vs 91% for fusion). CONCLUSIONS: Our study has demonstrated that fusion CT-DWMRI is superior to DWMRI or CT separately in localizing cholesteatoma at various middle ear cleft subsites and bony relations, making it a valuable tool for surgical planning.

Skull base anatomy and surgical safety in isolated and CHARGE-associated bilateral choanal atresia.

INTRODUCTION: Bilateral choanal atresia (BCA) is associated with a high incidence of congenital abnormalities that include skull base anomalies and defects. Surgical repair of BCA is necessary in the early neonatal period and any altered anatomy of the adjacent skull base will heighten the risk of intracranial injury. This risk may be further increased in patients with CHARGE syndrome. OBJECTIVES: To measure surgically relevant nasal and skull base dimensions in neonates with BCA in order to determine whether any difference exists between isolated and CHARGE syndrome associated subgroups, thereby optimizing the safety of surgical repair. METHODS: A retrospective review of medical charts and computed tomography was undertaken at a tertiary pediatric hospital of all neonates diagnosed with BCA between 2004 and 2016. Isolated and CHARGE syndrome subgroups of BCA were identified from clinical records and CT data was analyzed and compared between the two. The skull base parameters measured were choanal width, choanal height, mid-nasal skull base height and skull base slope. RESULTS: Of the 13 patients included, 3 had CHARGE syndrome and 10 had isolated BCA. Whilst the difference in mid-nasal height approached significance for the two groups, numbers were too small for a statistical difference to be identified. The mean value for choanal width in the isolated BCA group was significantly less the largest series of normative data available in the literature for comparison (p < 0.001). No skull base anomalies were noted in either group. CONCLUSION: While this is a small study with limited numbers, it is the first that has attempted to identify and measure the posterior nasal and skull base anatomy most pertinent to avoiding skull base injury in the surgical management of BCA.

Pharmaco-management of inhalation injuries for burn survivors.

BACKGROUND: Burn injury is exacerbated by inhalation injury, causing higher morbidity and mortality rates compared to those with a comparable burn injury alone. The complex pathophysiology of inhalation injury is well described, but analysis of treatment is a mammoth task and requires individual focus on a number of components of management. In this case, the focus of the review is treatment of inhalation injury using pharmacological means. It provides a concise overview of the disease process and a summary of the evidence for specific manipulation of various disease pathways. METHODS: A literature search through PubMed was completed and all links and bibliography reference articles were explored. RESULTS: A total of 47 papers matched the search terms. Of these, one was a comparative study with historical controls, 2 were retrospective case series, 2 studies reported a single human case series, 34 were examinations in animals, and 8 were expert opinion or reviews. CONCLUSION: The literature illustrates the complicated immunobiochemical pathways that have conflicting roles and importance, complicating integrated understanding. Secondly, there is an almost complete absence of high quality data from humans. Clinical use of pharmaco-therapies for inhalation injuries is further limited by the lack of commercial availability.