B. De Foer

MRI screening for acoustic neuroma without gadolinium: value of 3DFT-CISS sequence

Abstract To evaluate the efficacy of a gradient-echo sequence (3DFT-CISS) in the diagnosis of acoustic neuromas, two independent observers twice reviewed the images of the temporal bones of 83 patients. Contrast-enhanced T1-weighted spin echo images were used as the reference, showing 18 acoustic neuromas, including 5 purely intracanalicular and one intralabyrinthine tumours. High sensitivity (89-94 %), specificity (94–97 %) and accuracy (94–95 %) were found. Intraobserver (kappa 0.93–1) and interobserver (kappa 0.83–0.84) reproducibility were very good. The smallest intracanalicular tumour was overlooked twice by both observers; the intralabyrinthine tumour once by one observer. All tumours were detected with a less stringent decision criterion, at the expense of lower specificity.

Diffusion-weighted magnetic resonance imaging of the temporal bone.

This paper summarizes the value of diffusion-weighted magnetic resonance imaging in the evaluation of temporal bone pathology. It highlights the use of different types of diffusion-weighted magnetic resonance imaging in the different types of cholesteatoma, prior to first stage surgery and prior to second look surgery. The value of diffusion-weighted magnetic resonance imaging in the evaluation of pathology of the apex of the petrous bone and the cerebellopontine angle is also discussed.

Imaging features in 35 cases of submucosal laryngeal mass lesions

We evaluated he clinical and radiological findings in 35 patients with submucosal laryngeal masses. The presenting symptoms were hoarseness, stridor, dysphagia and external neck mass. In 20 cases an important delay between the onset of symptoms and direct laryngoscopy was found. There was a considerable delay between laryngoscopy and definitive diagnosis in 13 cases due to repeated negative biopsies. Computed tomography pointed out the location and extension of the masses in all cases. In 27 mass lesions CT allowed correct prediction of the malignant or benign character of the lesion. In 6 cases no reliable differentiation could be made. The lesion was mischaracterised in 2 cases. Magnetic resonance imaging was also performed in 4 patients, and showed the extent of the lesion better; in 1 case MRI narrowed the differential diagnosis. In the case of a negative biopsy result, radiological findings should incite further investigation, reducing the possible delay between the onset of symptoms and definitive diagnosis.

The Bony Obliteration Tympanoplasty in Pediatric Cholesteatoma: Long-term Safety and Hygienic Results

Objective: To present the safety and hygienic results of a 5-year longitudinal study in a pediatric population undergoing surgery for extensive cholesteatoma using a canal wall up approach with bony obliteration of the mastoid and epitympanic space. Study Design: Retrospective consecutive study. Patients: Thirty-three children (⩽18 yr) undergoing surgery for cholesteatoma (34 ears) between 1997 and 2009. Interventions: Therapeutic. Setting: Tertiary referral center. Main Outcome Measures: 1) Residual and recurrent cholesteatoma rates at 5-year postsurgery, 2) postoperative waterproofing and hygienic status of the ear, and 3) required operation rate to achieve the safety and hygienic goals. Results: At 5 years no patients were lost in follow-up. This consecutive series design is rare in chronical otitis media treatment reporting. The standard residual rate at 5 years was 5.8%, representing two residual cholesteatomas in the middle ear. The standard recurrence rate at 5 years was 2.9%, representing one recurrent cholesteatoma. At 5-year follow-up all ears were free of otorrhea and waterproof and all external ear canals were patent and self-cleaning. The operation rate to reach this safety and hygienic status was 1.5 operations per ear at 5-year follow-up. Conclusion: The use of a canal wall up approach with obliteration of the mastoid cavity and epitympanic space to surgically treat cholesteatoma in children results in low residual and recurrence rates and a high rate of trouble-free ears in the long term.

Late-onset Bochdalek hernia with a rare postoperative complication: Case report

We report a case of a 7-year-old-girl with a late-presenting Bochdalek hernia. The postoperative course was complicated by splenic torsion and subsequent total splenic infarction. Total splenic infarction due to splenic torsion has been reported in children with “wandering spleen” and in incarcerated Bochdalek hernias, but to our knowledge, not as a postoperative complication of Bochdalek hernia repair.

Long-term Results of Troublesome CWD Cavity Reconstruction by Mastoid and Epitympanic Bony Obliteration (CWR-BOT) in Adults.

Objective: To present the long-term surgical outcome of the bony mastoid and epitympanic obliteration technique with canal wall reconstruction (CWR-BOT) in adults with an unstable cavity after previous canal wall-down surgery for extensive cholesteatoma. Study Design: Retrospective study. Interventions: Therapeutic. Setting: Tertiary referral center. Patients: Fifty consecutive adult patients undergoing a CWR-BOT between 1998 and 2009. Main Outcome Measure(s): (A) Recurrence and residual rates of cholesteatoma, (B) postoperative hygienic status of the ear, including postoperative aspect of the tympanic membrane and external ear canal integrity (EAC), (C) functional outcome, and (D) long-term safety issues. Results: (A) The percentage of ears remaining safe without recurrent or residual disease after CWR-BOT was 96% after a mean follow-up time of 101.8 months. Recurrent cholesteatoma occurred in 2% (n = 1) and a residual cholesteatoma was detected in 2% (n = 1) of the patients. (B) A safe dry, and trouble-free graft and selfcleaning EAC was achieved in 94%

Partielle Obliteration von Ohr-Radikalhöhlen

Die moderne operative Therapie des Mittelohrcholesteatoms hat sich von der fruheren, fast dogmatischen Anwendung entweder der 2-Wege Technik oder der Radikalhohlenoperation zu einer individualisierten Technik gewandelt, in Kenntnis der Pathomechanik (Entwicklung des Cholesteatoms aus einer Retraktionstasche) und den vielfaltigen zuverlassigen Einsatzmoglichkeiten einer Knorpelrekonstruktion der Gehorgangswande. In der modernen Ohrchirurgie kommt daher in der Mehrzahl die sogenannte Verfolgungstechnik (die transmeatale Exposition des Cholesteatomsackes ohne zwingende Mastoidektomie mit anschliesender Rekonstruktion der Gehorgangswand durch Knorpelplatten) zum Einsatz. Nur in seltenen Fallen ist noch die sogenannte 2-Wege Technik (mit Mastoidektomie) oder die Anlage einer Radikalhohle erforderlich. Auch hier hat ein Umdenken stattgefunden in Anbetracht der unertraglich hohen Rezidivraten bei der 2-Wege Technik: Sowohl die hohe Zahl der Residualcholesteatome (typischerweise im Schatten der stehengelassenen hinteren Gehorgangswand) als auch die rekurrenten Rezidive (Einsenken einer neuen Retraktion in die vormals ausgebohrte Mastoidhohle) lassen dieses Verfahren nur noch fur sehr gut pneumatisierte und mit reizloser, gasproduzierender Schleimhaut ausgekleidete Mittelohren als erfolgsversprechend erscheinen. Bei der klassischen Radikalhohlentechnik besteht trotz ihrer geringeren Rezidivrate als groser Nachteil das chronische Ohrenlaufen aufgrund der standig feuchten Hohle. Ursachlich und schon lange bekannt ist das ungunstige Beluftungsverhaltnis der hautausgekleideten grosen Hohle (zu kleine Offnung des Gehorgangs im Verhaltnis zum grosen Hohenvolumen). Eine stabile Verkleinerung der Hohle mit deutlicher Verringerung der Rezidivrate ist mit korpereigenem Knochenmehl und luckenloser Knorpelplattenabdeckung (aus dem Cavum conchae) moglich. In dem Video wird das Prinzip der Knochenmehl- und Knorpelplattenobliteration mit unserer in Dresden entwickelten Technik dargestellt und es werden einige Tipps zur Erzielung einer stabilen Hohle gegeben.

Congenital Malformations of the Temporal Bone

Computed tomography is the technique of choice to study the malformations of the auricle, external auditory canal (EAC) and middle ear. The best image quality with the lowest radiation dose can be achieved when high-end Cone Beam CT scanners are used. The 125 μm spatial resolution images they provide are crucial in the detection of subtle ossicular and oval/round window malformations. Knowledge of the embryology helps to understand which malformations can be found and atresia and stenosis of the EAC are the most frequently found malformations of the outer ear. First Branchial Cleft Anomalies are rare and are best studied using MR. Middle ear malformations can develop in association with or in the absence of EAC deformities. Anomalies of the ossicles, facial nerve, oval window, round window, etc., can all be studied in detail with CT. However, MR is needed for the detection of congenital middle ear cholesteatomas and for cholesteatomas which are caused by congenital middle ear malformations and their resulting bad middle ear aeration. Inner ear malformations normally are not associated with middle and outer ear anomalies and high-resolution MR is the best adapted technique to detect vestibular, cochlear and cochleovestibular nerve malformations. New classifications of the labyrinthine malformations and VIIIth nerve malformations are used and their goal is to warn the surgeon for potential hazards during surgery and especially when cochlear implantation is considered. Finally the outer, middle and inner ear can be involved together in syndromes and therefore both MR and CT are often required in these patients. In this chapter the embryology and most frequent malformations of the outer, middle and inner ear will be discussed as well as the contemporary imaging techniques that should be used.