Predictive validity of MRI in detecting and following cholesteatoma

Abstract

High recurrence rate of the middle ear cholesteatoma requires regular postoperative follow-up. This study evaluated data from the patients investigated with DW MRI to ascertain (1) the strength of the technique in detecting primary, and residual recurrent cholesteatoma, and (2) its accuracy in differentiating cholesteatoma from postoperative tissue changes. The diagnostic accuracy of two different DW imaging (EPI and non-EPI) techniques was evaluated. The data have been collected prospectively from 33 consecutive patients with either primary cholesteatoma, or with suspicious symptoms for potential cholesteatoma recurrence. The findings from non-EPI (HASTE) DW MR and EPI DW MR images were blindly compared with those obtained during a primary or secondary surgery. Preoperative non-EPI (HASTE) DWI pointed to a cholesteatoma in 25 out of 33 patients. In this subgroup, cholesteatoma were confirmed also by the surgery. In five cases, the non-EPI (HASTE) DWI did not show a cholesteatoma in the temporal bone, which agreed with the surgical findings. Three misclassifications were made by non-EPI (HASTE) DWI, all in the subgroup of patients indicated for primary surgery. The resulting pooled sensitivity of non-EPI (HASTE) DW imaging for diagnosing cholesteatoma in our study amounted to 96.15% (95% confidence interval (CI) 80.36-99.9), specificity was 71.43% (95% CI 29.04-96.33). Positive predictive value was 92.59% (95% CI 75.71-99.09) and negative predictive value 83.33% (95% CI 35.88-99.58). In conclusion, we recommend the non-EPI (HASTE) DW MRI as a valid method for diagnosing cholesteatoma and follow-up after cholesteatoma surgery.

Use of Non-Echo-Planar Diffusion-Weighted MR Imaging for the Detection of Cholesteatomas in High-Risk Tympanic Retraction Pockets

“…The usefulness of non-EP DWI for detecting patients with incipient disease has been less well-studied. Although excellent previous reports by Pizzini et al, 23 De Foer et al, 26 Profant et al, 27 and Ilıca et al 34 have included primary cholesteatomas among their cases, our research differs in that this was a prospective study that included only retraction pockets with suspicion of cholesteatoma after evaluation by an expert otologic committee. All patients had surgical confirmation, and the data did not include other groups such as recurrent disease.…”

“…12 Several studies have been published since 2006 showing promising results for this technique. [18][19][20][21][22][23][24][25][26][27][28] Recently, Li et al 29 summarized these findings in a meta-analysis including 10 articles (342 patients), reporting an overall sensitivity of 94% and specificity of 94%. False-negatives are rare, often caused by motion artifacts or self-evacuating "mural" cholesteatomas, and false-positives are very infrequent.…”

Value of Echo-Planar Diffusion-Weighted Magnetic Resonance Imaging for Detecting Tympanomastoid Cholesteatoma

“…Similarly, Profant et al [18] accurately showed residual cholesteatoma in 12 of 14 patients with EP-DWI. In our study, 12 patients with suspected residual/ recurrent cholesteatoma had undergone second-look surgery.…”

Diffusion-Weighted Intensity Magnetic Resonance in the Preoperative Diagnosis of Cholesteatoma

“…Therefore, the clinical research was directed towards alternative imaging modalities for a better discrimination between various types of tissue that may be present in the middle ear [16,22], and specifically it was noted that the classical MR with contrast medium can have validity because the cholesteatoma, which is poorly vascularized, shows hypointensity unlike the granulation tissue, which is usually highly vascularized. …”

“…Actually, the DWI-MR shows the Brownian motion [11,12,13,14] of water molecules within the scanned tissue without contrast medium. The speed of the spread movement of water molecules is markedly reduced in cholesteatoma producing a characteristic hyperintensity - obtained by a b factor of 800 or 1,000 s/mm 2 [15] - which is not found in cases where the chronic inflammatory process is represented exclusively from granulation tissue [14,16,17] or a cholesterol granuloma [6]. Such hyperintensity can also be quantified using an objective parameter called ADC (apparent diffusion coefficient), calculated for each pixel of the image until obtaining a map of the lesion [6].…”