[Specialist consensus on endoscopic surgery of the middle ear mastoid].

This article discusses otoscopic middle ear mastoid surgery from multiple perspectives. Firstly, it discusses the indications and contraindications for surgery from the nature of the lesion and the imaging manifestations; secondly, it recommends the applicable equipment and describes the surgical approach in detail; finally, it summarizes the principles of the management of the operative cavity of the mastoid process in the middle ear from the perspectives of function and reconstruction. The purpose of this article is to illustrate otoscopic middle ear mastoid surgery with the aim of providing reference or guidance for performing related surgeries.

Congenital cholesteatoma: what radiologists need to know.

Congenital cholesteatoma is a rare, non-neoplastic lesion that causes conductive hearing loss in children. It is underrecognized and often diagnosed only when there is an established hearing deficit. In the pediatric population, hearing deficiency is particularly detrimental because it can impede speech and language development and, in turn, the social and academic well-being of affected children. Delayed diagnosis leads to advanced disease that requires more extensive surgery and a greater chance of recurrence. A need to promote awareness and recognition of this condition has been advocated by clinicians and surgeons, but no comprehensive imaging review dedicated to this entity has been performed. This review aims to discuss the diagnostic utility of high-resolution computed tomography and magnetic resonance imaging in preoperative and postoperative settings in congenital cholesteatoma. Detailed emphasis is placed on the essential preoperative computed tomography findings that facilitate individualized surgical management and prognosis in the pediatric population.

Proto-oncogene mutations in middle ear cholesteatoma contribute to its pathogenesis.

BACKGROUND: Chronic inflammation causes bone destruction in middle ear cholesteatomas (MECs). However, the causes of their neoplastic features remain unknown. The present study demonstrated for the first time that neoplastic features of MEC are based on proto-oncogene mutations. RESULTS: DNA was extracted from MEC and blood samples of five patients to detect somatic mutations using depth-depth exome sequencing. Exons with somatic variants were analyzed using an additional 17 MEC/blood test pairs. Variants detected in MECs but not in blood were considered pathogenic variant candidates. We analyzed the correlation between proto-oncogene (NOTCH1 and MYC) variants and the presence of bone destruction and granulation tissue formation. MYC and NOTCH1 variants were detected in two and five of the 22 samples, respectively. Two of the NOTCH1 variants were located in its specific functional domain, one was truncating and the other was a splice donor site variant. Mutations of the two genes in attic cholesteatomas (n = 14) were significantly related with bone destruction (p = 0.0148) but not with granulation tissue formation (p = 0.399). CONCLUSIONS: This is the first study to demonstrate a relationship between neoplastic features of MEC and proto-oncogene mutations.

High-Resolution Computed Tomography in Middle Ear Cholesteatoma: How Much Do We Need It?

Background and Objectives: The diagnosis of cholesteatoma is usually clinic, and the only efficient treatment is surgical. High-resolution computed tomography (HRCT) is not considered absolutely necessary for the management of an uncomplicated cholesteatoma, but unsuspected situations from a clinical point of view can be discovered using the scans, warning the surgeon. Our objective is to compare HRCT scan information with intraoperative findings in patients with cholesteatoma and analyze the usefulness of a preoperative HRCT scan from a surgical point of view. Materials and Methods: This is a prospective descriptive study conducted in the Department of Otolaryngology, Victor Babes University of Medicine and Pharmacy Timisoara, Romania, from May 2021 to April 2022. It was carried out on 46 patients with a clinical diagnosis of cholesteatoma who were consequently operated on in our department. All patients received full clinical and audiological examinations. In all cases, an HRCT scan was performed preoperatively as a mandatory investigation. Preoperative HRCT scans were analyzed, and their findings were compared to the intraoperative notes. The two sets of observations were analyzed using standard statistical methods. Results: Extensive cholesteatoma was the most common type of disease, involving 46% of the patients, followed by pars flaccida cholesteatoma (35%) and pars tensa cholesteatoma (19%). Eroded scutum was the most frequent lesion involving 70% of the patients, followed by incus erosion (67%). Comparison of the HRCT and intraoperative findings revealed a very good correlation for tegmen tympani erosion, sigmoid plate erosion, scutum and malleus erosion, and a moderate-to-good correlation for lateral semicircular canal erosion, incus and stapes erosion, and fallopian canal erosion. Conclusions: HRCT is a valuable tool in the preoperative assessment of cholesteatoma, helping in making surgical decisions. It can accurately predict the extent of disease and is helpful for detecting unapparent dangerous situations. However, it is not very accurate in detecting fallopian canal and stapes erosion.

Expression of MMP-14 and its role in bone destruction in middle ear cholesteatoma: A prospective observational study.

Cholesteatoma is a noncancerous cystic lesion caused by an abnormal growth of keratinizing squamous epithelium which is invasive and capable of destroying structures. A prospective study on the expression of membrane type1-matrix metalloproteinases (MMP-14) and its related influencing factors in middle ear cholesteatoma was conducted to fully understand the pathogenesis of cholesteatoma in the molecular level. We examined the expression of MMP-14 by immunohistochemical staining 39 middle ear cholesteatoma specimens and 10 external auditory meatus epithelial cell specimens. The cholesteatoma specimens were divided into 4 groups according to the degree of destruction of the ossicles during surgery. The associated factors affecting MMP-14 expression were analyzed using statistical methods; The positive expression of MMP-14 in the epithelium of the external auditory canal was significantly different between middle ear cholesteatoma and normal patients (P < .05); Gender, age, and the degree of hearing loss had no statistically significant effect on MMP-14 expression (P > .05); The expression of MMP-14 was positively correlated with the severity of bone destruction (R = 0.535, P < .05); MMP-14 plays an important role in the pathological development of the epithelium of cholesteatoma; MMP-14 expression in middle ear cholesteatoma tissue was not strongly correlated with the level of hearing loss, age or gender, but was positively correlated with the degree of middle ear bone destruction.

The Hyperproliferation Mechanism of Cholesteatoma Based on Proteomics: SNCA Promotes Autophagy-Mediated Cell Proliferation Through the PI3K/AKT/CyclinD1 Signaling Pathway.

Cholesteatoma is a chronic inflammatory ear disease with abnormal keratinized epithelium proliferation and tissue damage. However, the mechanism of keratinized epithelium hyperproliferation in cholesteatoma remains unknown. Hence, our study sought to shed light on mechanisms affecting the pathology and development of cholesteatoma, which could help develop adjunctive treatments. To investigate molecular changes in cholesteatoma pathogenesis, we analyzed clinical cholesteatoma specimens and paired ear canal skin with mass spectrometry-based proteomics and bioinformatics. From our screen, alpha-synuclein (SNCA) was overexpressed in middle ear cholesteatoma and might be a key hub protein associated with inflammation, proliferation, and autophagy in cholesteatoma. SNCA was more sensitive to lipopolysaccharide-induced inflammation, and autophagy marker increase was accompanied by autophagy activation in middle ear cholesteatoma tissues. Overexpression of SNCA activated autophagy and promoted cell proliferation and migration, especially under lipopolysaccharide inflammatory stimulation. Moreover, inhibiting autophagy impaired SNCA-mediated keratinocyte proliferation and corresponded with inhibition of the PI3K/AKT/CyclinD1 pathways. Also, 740Y-P, a PI3K activator reversed the suppression of autophagy and PI3K signaling by siATG5 in SNCA-overexpressing cells, which restored proliferative activity. Besides, knockdown of SNCA in RHEK-1 and HaCaT cells or knockdown of PI3K in RHEK-1 and HaCaT cells overexpressing SNCA both resulted in attenuated cell proliferation. Our studies indicated that SNCA overexpression in cholesteatoma might maintain the proliferative ability of cholesteatoma keratinocytes by promoting autophagy under inflammatory conditions. This suggests that dual inhibition of SNCA and autophagy may be a promising new target for treating cholesteatoma.

Imaging guidance for cholesteatoma surgery using tissue autofluorescence.

Significance: Cholesteatoma is an expansile destructive lesion of the middle ear and mastoid, which can result in significant complications by eroding adjacent bony structures. Currently, there is an inability to accurately distinguish cholesteatoma tissue margins from middle ear mucosa tissue, causing a high recidivism rate. Accurately differentiating cholesteatoma and mucosa will enable a more complete removal of the tissue. Aim: Develop an imaging system to enhance the visibility of cholesteatoma tissue and margins during surgery. Approach: Cholesteatoma and mucosa tissue samples were excised from the inner ear of patients and illuminated with 405, 450, and 520 nm narrowband lights. Measurements were made with a spectroradiometer equipped with a series of different longpass filters. Images were obtained using a red-green-blue (RGB) digital camera equipped with a long pass filter to block reflected light. Results: Cholesteatoma tissue fluoresced under 405 and 450 nm illumination. Middle ear mucosa tissue did not fluoresce under the same illumination and measurement conditions. All measurements were negligible under 520 nm illumination conditions. All spectroradiometric measurements of cholesteatoma tissue fluorescence can be predicted by a linear combination of emissions from keratin and flavin adenine dinucleotide. We built a prototype of a fluorescence imaging system using a 495 nm longpass filter in combination with an RGB camera. The system was used to capture calibrated digital camera images of cholesteatoma and mucosa tissue samples. The results confirm that cholesteatoma emits light when it is illuminated with 405 and 450 nm, whereas mucosa tissue does not. Conclusions: We prototyped an imaging system that is capable of measuring cholesteatoma tissue autofluorescence.

Is pre-operative audiometry a reliable predictor of ossicular chain condition?

OBJECTIVE: Investigation of ossicular chain (OC) status before surgery is important for preoperative patient consultation. This research aimed to investigate the relationship between pre-operative audiometric values and intra-operative OC condition in a relatively large population of chronic otitis media (COM) surgeries. METHODS: In this descriptive-analytic cross-sectional study, we evaluated 694 patients who underwent COM surgeries. We analyzed pre-operative audiometric data and intraoperative findings including ossicular anatomy, ossicular mobility, and the condition of middle ear mucosa. RESULTS: The optimal cut-off values of pre-operative speech reception threshold (SRT), mean air-conduction (AC), and mean air-bone gap (ABG) for predicting OC discontinuity were 37.5 dB, 37.2 dB, and 28.4 dB, respectively. For the prediction of OC fixation, the optimal cut-off points of SRT, mean AC, and mean ABG were 37.5 dB, 40.3 dB, and 32.8 dB, respectively. The computing of Cohen's d (95 % confidence interval) demonstrated the greater mean ABG in ears with OC discontinuity in comparison with ears with normal ossicles in all types of pathologies. There was a descending trend of Cohen's d from cholesteatoma to tympanosclerosis and then to granulation tissue and hypertrophic mucosa. There was a substantial relation between the type of pathology and OC status (P < 0.001). Ears with tympanosclerosis plaque had the most fixed OC among all types of pathologies (40 ears, 30.8 %), and ears with no pathology had the most normal OC (135 ears, 83.3 %). CONCLUSIONS: The results supported the view that pre-operative hearing is a key determining factor for the prediction of OC status.

The impact of fusion imaging technique on middle ear cholesteatoma surgery: a prospective comparative study.

BACKGROUND: The fusion of computed tomography images with non-echo planner diffusion-weighted magnetic resonance images may overcome the limitations of each individual modality. OBJECTIVES: This study aimed to assess the ability of the 'fusion' technique to predict the location of middle ear cholesteatoma by evaluating Its impact on preoperative surgical planning and postoperative results. METHODOLOGY: Eighty-three adults with cholesteatoma underwent preoperative CT scans and non-EPI-DW-MRI with or without the 'fusion' technique. We evaluated cholesteatoma localization in both groups, selecting the most appropriate surgical technique, and correlating it with the intraoperative findings. Both groups were compared in terms of residual/recurrent cholesteatoma at one, six and twelve months after surgery. RESULTS: The 'fusion' technique's sensitivity, specificity, and accuracy in predicting the location of cholesteatoma were 97.5. 97.4, and 97.5%, respectively, versus 97.59, 57.69, and 73.21% of CT alone. There was a total operators agreement after the evaluation of the 'fusion' images with the adopted surgical technique. A statistically significant decrease in residual and recurrence cholesteatoma rates was found in group A. CONCLUSIONS: The 'fusion' technique provides the surgeon with the precise cholesteatoma location, guiding him in making the correct surgical decision, contributing to the decrease in postoperative residual and recurrence rates.

Morphopathogenesis of Adult Acquired Cholesteatoma.

Background and Objectives. The aim of this study was to compare the distribution of proliferation markers (Ki-67, NF-κß), tissue-remodeling factors (MMP-2, MMP-9, TIMP-2, TIMP-4), vascular endothelial growth factor (VEGF), interleukins (IL-1 and IL-10), human beta defensins (HßD-2 and HßD-4) and Sonic hedgehog gene protein in cholesteatoma and control skin. Methods. Nineteen patient cholesteatoma tissues and seven control skin materials from cadavers were included in the study and stained immunohistochemically. Results. Statistically discernible differences were found between the following: the Ki-67 in the matrix and the Ki-67 in the skin epithelium (p = 0.000); the Ki-67 in the perimatrix and the Ki-67 in the connective tissue (p = 0.010); the NF-κß in the cholesteatoma matrix and the NF-κß in the epithelium (p = 0.001); the MMP-9 in the matrix and the MMP-9 in the epithelium (p = 0.008); the HßD-2 in the perimatrix and the HßD-2 in the connective tissue (p = 0.004); and the Shh in the cholesteatoma's perimatrix and the Shh in the skin's connective tissue (p = 0.000). Conclusion. The elevation of Ki-67 and NF-κß suggests the induction of cellular proliferation in the cholesteatoma. Intercorrelations between VEGF, NF-κß and TIMP-2 induce neo-angiogenesis in adult cholesteatoma. The similarity in the expression of IL-1 and IL-10 suggests the dysregulation of the local immune status in cholesteatoma. The overexpression of the Sonic hedgehog gene protein in the cholesteatoma proves the selective local stimulation of perimatrix development.

Experimental cholesteatoma: a comparison between spontaneous and induced models.

OBJECTIVE: To compare the incidence and the histopathological aspect of spontaneous and two induced Mongolian gerbils' models of cholesteatoma: External Auditory Canal (EAC) obliteration model and the Auditory Tube (AT) cauterization model. METHODS: Fifty-four ears of 27 animals were divided into EAC obliteration, AT cauterization, and control groups and histologically assessed for cholesteatoma incidence and classification at intervals of 2, 4, 8, and 16 weeks. RESULTS: Cholesteatoma was diagnosed in 30 of the 53 ears evaluated with a significantly higher incidence in groups that received some type of intervention (p<0.0001). It was not possible to histologically distinguish cholesteatomas of the same stage between the study groups. CONCLUSION: Although we observed a significant increase in cholesteatoma incidence with the two methods used when compared to the control group, all developed cholesteatomas were apparently identical from a histological point of view.

A micro-computed tomography study of the sinus tympani variation in humans.

BACKGROUND: The posterior part of the tympanic cavity comprises a depression called the sinus tympani (ST). The said structure is of outmost importance, e.g. in surgical procedures involving the middle ear, as a pathology (microbial biofilm or cholesteatoma) present in this difficult to access location might hinder its effective treatment. The aim of the study was to evaluate anatomical variants of the ST in human adult petrous bones. For this purpose, three-dimensional (3D) models of the ST were recreated from micro-computed tomography (CT) scans of 44 dry petrous bone samples (19 female, 25 male), applying 3D Slicer, Meshmixer and MeshLab software. MATERIALS AND METHODS: Anatomical variants of the ST were classified in terms of both shape and surface configuration. The internal configuration of the ST was classified as heterogeneous - containing small bony trabeculae and crests up to 1.0 mm in size, contrasting to homogeneous ST that characterizes a relatively smooth interior, or mere presence of minor depressions and mild folds. Female STs were more bowl-shaped (57.9%) than saccular (42.1%), and had heterogeneous surface configuration (52.6%) compared to homogeneous (47.4%). On the contrary, male STs were more saccular (52.0%) rather than bowl-shaped (48.0%), and predominantly had a heterogeneous surface (84.0%) over homogeneous (16.0%). RESULTS AND CONCLUSIONS: A complex combination of ST features comprised of a saccular shape and heterogeneous surface occurred in 52.0% of males and in 15.8% of females (a statistically significant difference; p = 0.0254, Fisher's exact test) seems to be clinically important because of its potential negative implication on health outcomes after surgery in the case of, for example, cholesteatoma, and it may also favour chronic pathological processes.

Clinical Analysis of 85 Cases of External Auditory Canal Cholesteatoma Surgery under Specialized Endoscopy.

Objective: To investigate the clinical characteristics, surgical experience, and surgical outcomes of external auditory canal cholesteatoma (EACC) surgery under endoscopic otolaryngoscopy. Methods: A retrospective analysis of 85 EACC cases admitted to the Department of Otolaryngology, Renji Hospital, Shanghai Jiaotong University School of Medicine, from January 2016 to February 2021 was performed, followed by retrospective analysis of clinical data to explore the feasibility and clinical characteristics of all-oral endoscopic EACC surgery. A total of 85 EACC patients (90 ears) with a mean age of 49.93 ± 14.87 years were included in the study. According to Udayabhanu staging, 43 ears (47.78%) were stage I, 40 ears (44.44%) were stage II, and 7 ears (7.78%) were stage III. All patients underwent transendoscopic surgery. Results: 79 ears (87.78%) underwent endoscopic EACC resection alone (+external auditory canal tumor resection/tympanostomy tube insertion), 9 ears (10%) underwent endoscopic EACC resection+tympanostomy+tympanoplasty, 1 ear (1.11%) underwent endoscopic EACC resection+tympanoplasty, and 2 ears (2.22%) underwent EACC resection+otolaryngotomy+tympanoplasty+auditory chain reconstruction endoscopically. Of these, 7 ears (7.78%) underwent auricular cartilage-chondroplasty and 2 ears (2.22%) underwent auricular cartilage membrane repair. All patients were reviewed at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year postoperatively. One patient with stage II external auditory atresia had a recurrence after 6 months and underwent endoscopic ear surgery (ESS) again. One patient with stage 2 atresia recurred after 1 year and again underwent endoscopic ear surgery. The rest of the patients recovered well after the surgery, and the grafts healed well. Conclusion: EACC surgery through the external ear canal under a dedicated endoscope is a safe, reliable, and effective method. Patients with stage I and II external auditory canal cholesteatoma surgery under endoscopy have a rapid postoperative recovery with significant hearing improvement, and stage IIIA patients can also achieve good results under strict evaluation of indications.

Review of potential medical treatments for middle ear cholesteatoma.

Middle ear cholesteatoma (MEC), is a destructive, and locally invasive lesion in the middle ear driven by inflammation with an annual incidence of 10 per 100,000. Surgical extraction/excision remains the only treatment strategy available and recurrence is high (up to 40%), therefore developing the first pharmaceutical treatments for MEC is desperately required. This review was targeted at connecting the dysregulated inflammatory network of MEC to pathogenesis and identification of pharmaceutical targets. We summarized the numerous basic research endeavors undertaken over the last 30+ years to identify the key targets in the dysregulated inflammatory pathways and judged the level of evidence for a given target if it was generated by in vitro, in vivo or clinical experiments. MEC pathogenesis was found to be connected to cytokines characteristic for Th1, Th17 and M1 cells. In addition, we found that the inflammation created damage associated molecular patterns (DAMPs), which further promoted inflammation. Similar positive feedback loops have already been described for other Th1/Th17 driven inflammatory diseases (arthritis, Crohn's disease or multiple sclerosis). A wide-ranging search for molecular targeted therapies (MTT) led to the discovery of over a hundred clinically approved drugs already applied in precision medicine. Based on exclusion criteria designed to enable fast translation as well as efficacy, we condensed the numerous MTTs down to 13 top drugs. The review should serve as groundwork for the primary goal, which is to provide potential pharmaceutical therapies to MEC patients for the first time in history. Video Abstract.

Middle ear cholesteatoma (MEC) is a destructive and locally invasive ulcerated lesion in the middle ear driven by inflammation which occurs in 10 out of 100,000 people annually. Surgical extraction/excision is the only treatment strategy available and recurrence is high (up to 40% after ten years), therefore developing the first pharmaceutical treatments for MEC is desperately required. This review is focused on the connections between inflammation and MEC pathogenesis. These connections can be used as attack points for pharmaceuticals. For this we summarized the results of research undertaken over the last 30 + years. MEC pathogenesis can be described by specific inflammatory dysregulation already known from arthritis, Crohn's disease or multiple sclerosis. A hallmark of this dysregulation are positive feedback loops of the inflammation further amplifying itself in a vicious circle-like manner. We have identified over one hundred drugs which are already used in clinic to treat other inflammatory diseases, and could potentially be repurposed to treat MEC. To improve and expedite clinical success rates, we applied certain criteria based on our literature searches and condensed these drugs down to the 13 top drugs. We hope the review will serve as groundwork for the primary goal, which is to provide potential pharmaceutical therapies to MEC patients for the first time in history.

Residual Cholesteatoma After Endoscopic-Assisted Canal Wall-Up Tympanomastoidectomy: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to determine the effectiveness of using endoscopes in reducing recidivism secondary to residual cholesteatoma after canal wall-up tympanomastoidectomy. STUDY DESIGN: Randomized clinical trial. SETTING: Tertiary referral center. PATIENTS: Patients with cholesteatoma, aged 7 to 70 years. INTERVENTIONS: Subjects were randomly allocated into two groups: endoscopic-assisted canal wall-up (EACWU; group 1) and conventional canal wall-up (CWU; group 2) techniques. Pars flaccida and pars tensa subgroups were analyzed according to the anatomic location of cholesteatoma origin. MAIN OUTCOME MEASURES: Presence or absence of residual cholesteatoma, based on second look surgery, diffusion-weighted magnetic resonance imaging, or video-otoscopy at 12 and 18 months after surgery. RESULTS: In total, 57 ears were analyzed: 29 in group 1 and 28 in group 2. Group 1 revealed residual disease in 17.2% of ears, whereas group 2 had residual disease in 35.7% (p > 0.05) of the ears. In the pars tensa cholesteatoma subgroup, the incidence of residual disease was 13.3% for EACWU and 47.1% for the CWU technique (p < 0.05). A tendency of reduced incidence was observed for cholesteatoma due to residual disease using EACWU. In addition, a statistically significant reduction in the residual disease was observed in the subgroup of pars tensa cholesteatomas. In this subgroup, the relative risk was 0.28, and the number needed to treat was 4.6. CONCLUSION: The use of the endoscope reduces the incidence of recidivism secondary to residual disease in pars tensa cholesteatomas. Endoscopic-assisted surgery may be useful in cases with an indication for canal wall-up tympanomastoidectomy. LEVEL OF EVIDENCE: 1b.

Surgical treatment of middle ear cholesteatoma using an oral approach in 2 dogs.

Middle ear cholesteatoma is caused by the formation of epidermoid cysts that result in distention and enlargement of the tympanic bulla with subsequent destruction of surrounding tissues. We report treatment of middle ear cholesteatoma in 2 dogs, via an oral surgical approach. Abnormal tympanic bulla contents and the wall compressing the pharynx were successfully removed in both cases. Computed tomography imaging, surgical findings, and histopathology results were consistent with middle ear cholesteatoma in both cases. The outcomes in both cases suggest that an oral surgical approach may be an alternative treatment for middle ear cholesteatoma in dogs. Key clinical message: Despite the limited number of cases described herein, our report indicates that the direct oral approach for canine cholesteatoma may be and alternative approach.

Traitement chirurgical du cholestéatome de l'oreille moyenne par approche orale chez deux chiens. Le cholestéatome de l'oreille moyenne est causé par la formation de kystes épidermoïdes qui entraînent une distension et l'élargissement de la bulle tympanique avec destruction subséquente des tissus environnants. Nous rapportons le traitement d'un cholestéatome de l'oreille moyenne chez deux chiens, via une chirurgie par approche buccale. Le contenu anormal de la bulle tympanique et la paroi comprimant le pharynx ont été enlevés avec succès dans les deux cas. L'imagerie par tomodensitométrie, les résultats chirurgicaux et les résultats histopathologiques étaient compatibles avec un cholestéatome de l'oreille moyenne dans les deux cas. Les résultats dans les deux cas suggèrent qu'une approche chirurgicale orale peut être un traitement alternatif pour le cholestéatome de l'oreille moyenne chez le chien.Message clinique clé :Malgré le nombre limité de cas décrits ici, notre rapport indique que l'approche orale directe pour le cholestéatome canin peut être une approche alternative.(Traduit par Dr Serge Messier).

Accuracy of 2D BLADE Turbo Gradient- and Spin-Echo Diffusion Weighted Imaging for the Diagnosis of Primary Middle Ear Cholesteatoma.

OBJECTIVE: To evaluate the diagnostic accuracy of 2D BLADE turbo gradient- and spin-echo diffusion weighted imaging (TGSE BLADE DWI) for primary middle ear cholesteatoma diagnosis, using qualitative and quantitative methods. STUDY DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: Participants included those with suspected primary middle ear cholesteatoma after assessment by clinical otorhinolaryngologists combined with magnetic resonance imaging (MRI) examination. Finally, of the 85 ears from 65 patients enrolled in the study, 73 had cholesteatoma, and 12 had otitis media. INTERVENTION: Two radiologists independently assessed images and measured apparent diffusion coefficient (ADC) values. Sensitivity, specificity and accuracy were evaluated. Kappa (k) statistics, the intraclass correlation coefficient (ICC), the Kolmogorov-Smirnov normality test, the independent t test, and receiver operating characteristic (ROC) analysis were used for statistical analysis. Pair-wise comparison of the area under the ROC curve (AUC) was also performed using the Delong test. MAIN OUTCOME MEASURES: Imaging and histopathologic findings. RESULTS: The mean ADC value of cholesteatoma group (mean, 0.923 ± 0.246 × 10 -3 mm 2 /s) was significantly lower than that of noncholesteatoma group (mean, 1.744 ± 0.205 × 10 -3 mm 2 /s; p < 0.001). In ≤3 mm cholesteatoma group, the AUC of qualitative DWI was 0.846; the sensitivity, specificity, and accuracy for diagnosing cholesteatoma were 69.23%, 100%, and 84%, respectively; while the AUC of quantitative diagnosis was significantly increased to 1.0 ( p = 0.0209); and based on the optimal threshold of ADC, ≤1.352 × 10 -3 mm 2 /s, the sensitivity, specificity and accuracy improved to 100%. For >3 mm cholesteatoma group, there were no significant differences in diagnostic performance. Excellent interobserver agreement and ICC for the qualitative and quantitative evaluations (k = 0.90 and ICC = 0.80, respectively) was noted between reviewers. CONCLUSION: TGSE BLADE DWI is useful for the detection of primary middle ear cholesteatomas, especially ≤3 mm lesions.

Esterified Hyaluronic Acid Placed in the Middle Ear Does Not Improve Outcomes in Cholesteatoma Surgery.

BACKGROUND: The aim of this article is to assess the efficacy of esterified hyaluronic acid as a barrier to formation of adhesions and improvement of tympanomastoid ventilation. METHODS: A prospective cohort analysis was performed at a tertiary referral centre. 126 ears were analysed in children with cholesteatoma. Esterified hyaluronic acid was placed on the promontory of 63 ears at primary canal wall intact surgery for cholesteatoma. No esterified hyaluronic acid was used in 63 control ears. Cholesteatoma recurrence, histopathological analysis of scar tissue following second-stage procedure, and middle ear pressure were the main outcome measures. RESULTS: At 5 years, esterified hyaluronic acid (7%) and non-esterified hyaluronic acid (10%) did not differ in cholesteatoma recurrence (Kaplan- Meier log rank analysis, P=.52). Esterified hyaluronic acid (n=11) and non-esterified hyaluronic acid (n=2) ears formed scar at the site of packing material (n=11) (Fisher's exact test, P=.04). Foamy histiocytes/macrophages were found in esterified hyaluronic acid (n=15) and non-esterified hyaluronic acid ears (n=1) (Fisher's exact test, P-125 daPa) in 44% (14/32) esterified hyaluronic acid ears and 42% (15/36) non-esterified hyaluronic acid ears (P=1.0, Fisher's exact test). CONCLUSIONS: We have discontinued the use of esterified hyaluronic acid in cholesteatoma surgery due to lack of detectable benefit. Esterified hyaluronic acid in the middle ear neither reduces cholesteatoma recurrence nor appears to improve the ventilation of the middle ear. Furthermore, esterified hyaluronic acid alters the inflammatory process within the middle ear, the significance of which remains unclear.

"Transcanal view" computed tomography reformat: Applications for transcanal endoscopic ear surgery.

PURPOSE: Transcanal endoscopic ear surgery (TEES) is an increasingly used surgical approach for otologic surgeries, but no en face preoperative imaging format currently exists. We aim to assess the utility of a transcanal high resolution computed tomography (HRCT) reformat suitable for TEES preoperative planning. MATERIALS AND METHODS: Preoperative HRCTs of patients with middle ear pathologies (cholesteatoma, otosclerosis, and glomus tympanicum) who underwent TEES were obtained. Axial image series were rotated and reformatted -90 or +90 degrees for left and right ear surgeries, respectively, where additional rotation along the left-right axis was performed to align the transcanal series with the plane of the external auditory canal. Quantitative measurements of middle ear structures were recorded. Consecutive transcanal reformatted sections were then reviewed to identify critical middle ear anatomy and pathology with corresponding TEES cases. RESULTS: The aforementioned methodology was used to create three transcanal view HRCTs. The mean left-right axis degree of rotation was 4.0 ± 2.2 degrees. In the cholesteatoma transcanal HRCT, areas of cholesteatoma involvement in middle ear compartments (e.g. epitympanum) and eroded ossicles were successfully identified in the corresponding case. In the otosclerosis transcanal HRCT, areas for potential otosclerotic involvement were visualized such as the round window as well as a low-hanging facial nerve. In the glomus tympanicum transcanal HRCT, the span of the glomus tympanicum was successfully visualized in addition to a high riding jugular bulb. CONCLUSION: A transcanal HRCT reformat may aid preoperative planning for middle ear pathologies. This novel reformat may help highlight patient-specific anatomy.

Determinants influencing cholesteatoma recurrence in daily practice: a retrospective analysis.

BACKGROUND: Cholesteatoma is a benign but destructive epithelial lesion in the middle ear and/or mastoid. It is hard to translate data from previous research to daily clinical practice. In this study, factors influencing recurrence rates in daily clinical practice were identified. METHOD: The study included 67 patients who were treated for a cholesteatoma with combined approach tympanoplasty. The average follow-up time was 35 months. RESULTS: The recurrence rate was 23.3 per cent in adults and 45.5 per cent in children. Predictors of recurrence were younger age and a low tegmen. A cholesteatoma in a child and the simultaneous presence of a low tegmen led to recurrence in 82.8 per cent of the patients. CONCLUSION: Patients - especially children - with a low tegmen have an increased risk of recurrence. It is recommended that ENT surgeons be aware of recurrence in children, particularly in the case of a low tegmen.