上海市第六人民医院 shanghai sixth people’s hospital cholesteatoma shankai yin prof dept...
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上海市第六人民医院Shanghai Sixth People’s Hospital
Cholesteatoma
Shankai Yin Prof Dept of Otolaryngology, the sixth hospital affiliated to Shanghai jiaotong university
Otolaryngology institute at Shanghai jiaotong university
上海市第六人民医院Shanghai Sixth People’s Hospital
Epidemiology
Exact prevalence is unknown
Incidence estimated between 3 and 12.6
per 100,000
上海市第六人民医院Shanghai Sixth People’s Hospital
Classification
Congenital
Acquired
Primary acquired (retraction pocket)
Secondary acquired
上海市第六人民医院Shanghai Sixth People’s Hospital
Pathogenesis
Congenital Arise from embryonal rests of epithelial cells Location (petrous pyramid, mastoid and
middle ear cleft) Levenson criteria
White mass medial to normal TM Normal pars flaccida and tensa No history of otorrhea or perforations No prior otologic procedures Prior bouts of otitis media not grounds for exclusion
上海市第六人民医院Shanghai Sixth People’s Hospital
Theories
“Acquired” inclusion theory - Tos
Epidermal rest theory- Teed Michael
上海市第六人民医院Shanghai Sixth People’s Hospital
Congenital cholesteatoma
上海市第六人民医院Shanghai Sixth People’s Hospital
Primary acquired Eustachian tube dysfunction Poor aeration of the epitympanic space Retraction of the pars flaccida Normal migratory pattern altered Accumulation of keratin, enlargement of
sac
上海市第六人民医院Shanghai Sixth People’s Hospital
Primary acquired cholesteatoma
上海市第六人民医院Shanghai Sixth People’s Hospital
Secondary acquired Implantation – surgery, foreign body, blast
injury Metaplasia – transformation of cuboidal
epithelium to squamous epithelium from chronic infection
Invasion/Migration – medial migration along permanent perforation of TM
Papillary ingrowth – intact pars flaccida, inflammation in Prussack’s space, break in the basal membrane, cords of epithelium migrate inward
上海市第六人民医院Shanghai Sixth People’s Hospital
上海市第六人民医院Shanghai Sixth People’s Hospital
Clinical manifestations
Common Painless otorrhea Refractory/recurrent ear infections Conductive hearing loss
Uncommon Vertigo/Sensorineural Facial nerve paralysis CNS infections Brain herniation/CSF leak Pneumocephalus
上海市第六人民医院Shanghai Sixth People’s Hospital
history Physical Examination
Otomicroscopy Posterosuperior retraction pocket with
squam Granulation from diseased bone Aural polyps Pneumatic otoscopy – positive fistula
response suggests erosion into labyrinth Cultures should be obtained in infected ears
Diagnosis
上海市第六人民医院Shanghai Sixth People’s Hospital
Audiology usually conductive loss, may vary greatly;
confirm with tuning forks
Imaging CT temporal bone – definitely obtain for
revision cases, complications of chronic suppurative otitis media, sensorineural hearing loss, vestibular symptoms, other complications of cholesteatoma
上海市第六人民医院Shanghai Sixth People’s Hospital
Imaging Purpose Diagnosis Determining extent Risk assessment
Modalities Plain film Computed tomography scans Magnetic Resonance imaging
上海市第六人民医院Shanghai Sixth People’s Hospital
Goals of CT Imaging
Middle ear ventilation Ossicular destruction Epitympanum access Mastoid cortex Tegmen integrity Labyrinth involvement Facial nerve involvement Surgical changes
上海市第六人民医院Shanghai Sixth People’s Hospital
上海市第六人民医院Shanghai Sixth People’s Hospital
上海市第六人民医院Shanghai Sixth People’s Hospital
上海市第六人民医院Shanghai Sixth People’s Hospital
CT disadvantages
Granulation tissue vs. cholesteatoma Specific soft tissue problems
Dural involvement Abscess Brain herniation Labyrinth involvement Sigmoid sinus thrombosis
MRI needed
上海市第六人民医院Shanghai Sixth People’s Hospital
MR Imaging
Hypointense on T1 Isointense to brain
Intermediate on T2 Nonenhancing Granulation tissue does enhance Recurrence detection
Lesions >2mm 90% sensitive, 100% specificity
上海市第六人民医院Shanghai Sixth People’s Hospital
T2 Delayed contrast T1
上海市第六人民医院Shanghai Sixth People’s Hospital
Differential Diagnosis Chronic serous otitis media Jugulotympanic paragangliomas Cholesterol granulomas Neurofibromas Hemangiomas Arachnoid cyst Jugular bulb anomalies Tympanosclerosis encephalocele
上海市第六人民医院Shanghai Sixth People’s Hospital
Treatment
Create a “dry and safe” ear
上海市第六人民医院Shanghai Sixth People’s Hospital
Non-surgical
Treat the Infection – Floxin Otic Drops Decrease the inflammation – Topical
steroids Debridement of the external canal
上海市第六人民医院Shanghai Sixth People’s Hospital
Surgical
Atticotomy Radical Mastoidectomy Bondy Modified Radical
(Canal wall down) mastoidectomy
Tympanoplasty and canal wall up mastoidectomy
上海市第六人民医院Shanghai Sixth People’s Hospital
Prognosis
Residual or recurrent cholesteatoma over 5 years – 15 to 40% Reported to be up to 67% in the pediatric
population
Close follow - up Regular examinations needed - 6 months
上海市第六人民医院Shanghai Sixth People’s Hospital
Complications
Dural tear - CSF leak Fistula of the horizontal semicircular canal
(vertigo) – Up to 10% Facial nerve injury Injury to the sigmoid sinus / jugular bulb Otitic Hydrocephalus Hearing loss
30% have conductive loss pre-operatively Postoperatively, an additional 30% have worsening or
onset of hearing loss due to extent of disease
Infection – Meningitis, Abscess, lateral sinus thrombosis – Up to 1%
上海市第六人民医院Shanghai Sixth People’s Hospital
Predisposing factors
Virulent organisms Cholesteatoma and bone erosion Presence of a congenital dehiscence
(e.g.dehiscent facial canal) or a preformed pathway (e.g. skull base fracture)
Obstruction of drainage e.g. by a polyp. Low resistance of the patient
上海市第六人民医院Shanghai Sixth People’s Hospital
Pathways of infection
The commonest way for extension of infection is by bone erosion due to a cholesteatoma.
Vascular extension (retrograde
thrombophlebitis). Extension along preformed pathways as
– Congenital dehiscences, fracture lines, round window membrane, the labyrinth,
– Dehiscences due to previous surgery.
上海市第六人民医院Shanghai Sixth People’s Hospital
Classification
Cranial complications
Extra-cranial complications
Intra-cranial complications
上海市第六人民医院Shanghai Sixth People’s Hospital
Cranial complications
Acute mastoiditis and mastoidabscesses (most common complication). Petrositis. Labyrinthitis. Facial paralysis. Osteomyelitis of the temporal bone
上海市第六人民医院Shanghai Sixth People’s Hospital
Extra-cranial complications
External otitis Cervical lymphadenitis Retropharyngeal Parapharyngeal abscesses
上海市第六人民医院Shanghai Sixth People’s Hospital
Intracranial complications
Extradural abscess (commonest intracranial complication).
Subdural abscess. Meningitis. Brain abscess:
Temporal lobe abscess. Cerebellar abscess.
Lateral sinus thrombosis. Otitic hydrocephalus.
上海市第六人民医院Shanghai Sixth People’s Hospital
Potentially life threatening Suppurative otorrhea, chronic headache,
pain, fever – impending intracranial complication
Mental status changes, nuchal rigidity, cranial neuropathies require neurosurgical consult
上海市第六人民医院Shanghai Sixth People’s Hospital
上海市第六人民医院Shanghai Sixth People’s Hospital
上海市第六人民医院Shanghai Sixth People’s Hospital
Brain Abscess
上海市第六人民医院Shanghai Sixth People’s Hospital
Questions?