Reliability of diffusion-weighted magnetic resonance imaging in differentiation of recurrent cholesteatoma and granulation tissue after intact canal wall mastoidectomy

ObjectiveTo assess the reliability of diffusion-weighted magnetic resonance imaging in differentiating recurrent cholesteatoma from granulation tissue after intact canal wall mastoidectomy.MethodsA prospective study was conducted of 56 consecutive patients with suspected cholesteatoma recurrence after intact canal wall mastoidectomy who underwent diffusion-weighted imaging and delayed contrast magnetic resonance imaging of the temporal bone. The final diagnosis was recurrence in 38 patients and granulation tissue in 18 patients.ResultsCholesteatoma detection on diffusion-weighted imaging based on two sets of readings had sensitivity of 94.7 and 94.7 per cent, specificity of 94.4 and 88.9 per cent, and accuracy of 94.6 and 92.8 per cent, with good intra-observer agreement (Κ = 0.72, p = 0.001). Cholesteatoma detection on delayed contrast magnetic resonance imaging had sensitivity of 81.6 and 78.9 per cent, specificity of 77.8 and 66.7 per cent, and accuracy of 80.4 and 75.0 per cent, with fair intra-observer agreement (Κ = 0.57, p = 0.001). The mean cholesteatoma diameter on diffusion-weighted imaging was 7.7 ± 1.8 and 7.9 ± 1.8 mm, with excellent intra-observer agreement (Κ = 0.994, p = 0.001).ConclusionDiffusion-weighted imaging is a reliable method for differentiating recurrent cholesteatoma and granulation tissue after intact canal wall mastoidectomy.

Gradenigo's syndrome in a four-year-old patient: a rare diagnosis in the modern antibiotic era

ObjectiveThis study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically.MethodThis study presents a case report and review of the literature.ResultsA four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms.ConclusionThis study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.

Utility of Non-EPI DWI MRI in the Management of Pediatric Cholesteatoma

Introduction Cholesteatoma in children can be acquired or congenital and is generally extensive. The most commonly used technique for the removal of cholesteatoma is intact canal wall mastoidectomy. This invariably leads to second-look surgery to assess for recurrence or residual cholesteatoma. Magnetic resonance imaging (MRI) with non–echo-planar imaging (non-EPI) diffusion-weighted imaging (DWI) is an accurate noninvasive imaging option that can be used in diagnosing primary cholesteatoma. This can also be used to diagnose residual or recurrent cholesteatoma in patients who have undergone intact canal wall mastoidectomy. Case Report A 7-year-old male patient presented with a 1-week history of foul-smelling discharge from the right ear. On examination, a polypoidal mass with keratinized debris was seen. A diagnosis of cholesteatoma of right ear was made. Imaging with high-resolution computed tomography (HRCT) of the temporal bone and non-EPI DWI MRI confirmed the same. The child underwent an intact canal wall mastoidectomy and was followed up at 2 years with non-EPI DWI MRI to monitor any residual or recurrent cholesteatoma. Conclusion Non-EPI DWI MRI provides a convenient, accurate, and noninvasive method of evaluating and monitoring for residual or recurrent cholesteatoma and thus helps avoid unnecessary second-look surgery.

Outcome of intact canal wall mastoidectomy in limited attic cholesteatoma

<p class="abstract"><strong>Background:</strong> Surgery for cholesteatoma has evolved over the years in terms of efficacy and patient compliance and better life. Intact canal wall technique is best in terms of normalization of the physiology of the ear along with eradication of disease. Hence this study is undertaken to evaluate a technique of intact canal wall mastoidectomy for limited attic cholesteatoma and to study practical considerations during surgery.</p><p class="abstract"><strong>Methods:</strong> Any person undergoing surgery for attic cholesteatoma has to be thoroughly examined during surgery and decision for doing a canal wall up (CWP) surgery will be taken on the operating table. The patients were regularly followed up and microscopic, otoendoscopic and audiological assessments done at regular intervals. Revision surgery was done only if there were signs of recidivism or if ossiculoplasty was planned for second stage or placement of prosthesis later was considered. </p><p class="abstract"><strong>Results:</strong> Out of 100 cholesteatoma surgeries, 22 cases found suitable for the CWU technique. Only 1 out of 22 patients required revision surgery due to recurrence. Rest of the patients maintained healthy middle ear for more than a year. Prevention of medialization of attic cartilage piece was found to be a very important consideration.</p><p><strong>Conclusions:</strong> The CWU technique is a reliable method of management for limited attic cholesteatoma. Selection of subjects should be very meticulous. </p>