Ravi K. Lingam

Detecting cholesteatoma with non-echo planar (HASTE) diffusion-weighted magnetic resonance imaging

Objective: The purpose of this study was to evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging (DWMRI) in the detection of cholesteatoma. Study Design: Prospective blinded comparative study. Setting: London teaching hospital. Subjects and Methods: Subjects comprised 32 consecutive patients with suspected primary or residual cholesteatoma. HASTE DWMRI was performed on all patients an average of three months before mastoid surgery and evaluated for the presence of cholesteatoma. Radiological findings were correlated with intraoperative findings. Results: HASTE DWMRI accurately predicted the presence or absence of cholesteatoma in 30 of 32 patients. Residual cholesteatoma was correctly diagnosed by DWMRI in 12 of 14 cases and correctly excluded in six, with two false-negative results caused by movement artifact and keratin pearls less than 2 mm. All primary cholesteatomas were correctly identified. Sensitivity and specificity were 0.93 (95% confidence interval [CI] 0.75-0.99) and 1.00 (95% CI 0.54-1.0), respectively, whereas positive and negative predictive values were 1.00 (95% CI 0.86-1.00) and 0.75 (95% CI 0.35-0.97), respectively. Conclusion: Our study supports the increasing but small body of evidence that non–echo-planar imaging (i.e., HASTE) DWMRI performs well in the detection of cholesteatoma. We propose that HASTE DWMRI should be performed on all patients before their second-look surgery to provide valuable information to the operating surgeon.

Pleomorphic adenoma (benign mixed tumour) of the salivary glands: its diverse clinical, radiological, and histopathological presentation

Pleomorphic adenoma is the single most common salivary gland tumour. It has a diverse histological presentation because of varying proportions of different epithelial and mesenchymal elements, and presents clinically and radiologically in various ways as it occurs at many different sites in the head and neck region. The choice of imaging is influenced by its site and size, and a range of options for treatment includes both operation and radiotherapy. The tumour can also present in various ways if it is not removed or treated successfully.

The value of non-echo planar HASTE diffusion-weighted MR imaging in the detection, localisation and prediction of extent of postoperative cholesteatoma

Clin. Otolaryngol. 2011, 36, 306–312

Apparent Diffusion Coefficients for Detection of Postoperative Middle Ear Cholesteatoma on Non–Echo-planar Diffusion-weighted Images

PURPOSE To determine whether there is a difference between the apparent diffusion coefficients (ADCs) of postoperative middle ear cleft cholesteatoma and noncholesteatomatous tissue on half-Fourier acquisition single-shot turbo spin-echo diffusion-weighted (DW) images and to determine, with interobserver agreement, a predictive accuracy for diagnosis of postoperative middle ear cleft cholesteatoma. MATERIALS AND METHODS Patients who underwent DW magnetic resonance (MR) examination before repeat explorative surgery for postoperative cholesteatoma were included in this study. There were 72 patient episodes and 56 patients. DW MR images were acquired with b values 0 and 1000 sec/mm(2) and 2-mm section thicknesses. Two observers assessed images qualitatively for presence of cholesteatoma and recorded ADCs. Surgery with histologic confirmation established final diagnosis of abnormal middle ear cleft soft tissue. ADCs between cholesteatoma and noncholesteatomatous tissue were compared with Mann-Whitney test. Effects of ADCs and confidence intervals to indicate presence of cholesteatoma were examined by using receiver operating characteristic (ROC) curve analysis, logistic regression analysis, and interobserver agreement. RESULTS Forty-six patients had cholesteatoma and 25 patients did not; sensitivity and specificity were 0.91 and 0.88, respectively, for the qualitative diagnosis of postoperative cholesteatoma by using a five-point confidence scale. ADC of cholesteatoma (median, 707 × 10(-6) mm(2)/sec; interquartile range, 539-858 × 10(-6) mm(2)/sec; P < .001) was significantly lower than that of noncholesteatomatous tissue (median, 1849 × 10(-6) mm(2)/sec; interquartile range, 1574-1982 × 10(-6) mm(2)/sec; P < .001). There was good accuracy (area under the ROC curve, 0.97) and interobserver agreement for detecting postoperative cholesteatoma with ADC threshold less than 1300 × 10(-6) mm(2)/sec. CONCLUSION The ADC value of postoperative middle ear cleft cholesteatoma is significantly lower than that of noncholesteatomatous tissue and has good accuracy for detecting cholesteatoma.

Staging primary middle ear cholesteatoma with non-echoplanar (half-Fourier-acquisition single-shot turbo-spin-echo) diffusion-weighted magnetic resonance imaging helps plan surgery in 22 patients: Our experience

Dear Editor, A middle ear cholesteatoma is a non-neoplastic lesion that is characterised histologically by desquamated debris surrounded by layers of keratinising squamous epithelium. It is essentially a clinical diagnosis and treated by surgery where possible. High-resolution computed tomography (CT) of the temporal bones is used to assess the extent of primary cholesteatoma, evaluate for complications (bony and ossicular erosion) and provide local anatomical information to plan surgery. Where the middle ear cleft is not completely opacified, the true extent of cholesteatoma may be defined on CT and this may be sufficient for precise surgical planning. However, in cases where the middle ear cleft is completely opacified on CT, it is not possible to determine the true extent of cholesteatoma because of poor ability of CT to differentiate between cholesteatoma and coexisting inflammatory tissue or fluid. Diffusion-weighted magnetic resonance imaging (DWI), in particular non-echoplanar half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) DWI, has been shown to have high diagnostic performance in the detection of recurrent and residual cholesteatoma by exploiting the unique nature of the cholesteatoma itself, restricted diffusion and T2 shine through effect, that gives it a high signal on b1000 images relative to brain tissue and a corresponding low signal on the apparent diffusion coefficient (ADC) map. There is also a good correlation with size and location of recurrent and residual cholesteatoma between HASTE DWI and surgery. We aim to evaluate the performance of non-echoplanar HASTE DWI in staging the extent of primary cholesteatoma when CT demonstrates complete (or almost complete) soft tissue opacification of the middle ear cleft.

Analysing lateral soft tissue neck radiographs.

A lateral soft tissue neck radiograph is a useful adjunct in diagnosing and managing the patient presenting with upper airway symptoms but is often inadequately reviewed. We present some common findings and robust systems to improve analysis of these radiographs.

CT arteriography and venography in the evaluation of Pulsatile tinnitus with normal otoscopic examination.

Our retrospective study aims to assess the ability of computed tomography arteriography and venography (CT A/V) to detect various findings that suggest a potential cause of pulsatile tinnitus and to examine the association between these findings and the side of pulsatile tinnitus.Objectives/Hypothesis Our retrospective study aims to assess the ability of computed tomography arteriography and venography (CT A/V) to detect various findings that suggest a potential cause of pulsatile tinnitus and to examine the association between these findings and the side of pulsatile tinnitus. Study Design A retrospective review of CT arteriography and venography of 32 patients with established pulsatile tinnitus and normal otoscopic examination was performed. The scans were performed using a 64-slice multidetector scanner and were reviewed to look for findings that are known to cause pulsatile tinnitus. Results One or more findings that are known to cause pulsatile tinnitus were detected on the symptomatic side in 30 patients; on the asymptomatic side in 3 patients, one patient with bilateral pulsatile tinnitus showed a potential cause of symptoms only on one side, and in one patient no potential cause could be identified. There is a significant association seen between the side of pulsatile tinnitus and various potential causes of pulsatile tinnitus detected (P < 0.001), between the side of pulsatile tinnitus and various potential venous cause detected (P < 0.001), and between the side of pulsatile tinnitus and the side of dominant venous system (P = 0.02). Conclusion CT arteriography and venography is a useful tool in detecting many described potential causes of pulsatile tinnitus. Significant association is demonstrated between the side of pulsatile tinnitus and the potential causes of pulsatile tinnitus detected by CT arteriography and venography when the otoscopic examination is normal. Level of Evidence 4. Laryngoscope, 125:979–984, 2015

The role of imaging in the diagnosis and management of otosclerosis.

Objective To examine the evidence for the role of radiologic imaging in the diagnosis and management of otosclerosis. Data Sources A review of contemporary (1990 to present) English medical literature via MedLine using the terms imaging, otosclerosis, otospongiosis, stapes surgery, computed tomography, magnetic resonance, CT, and MRI was performed. Study Selection Abstracts were reviewed independently by 2 authors and relevant articles were then evaluated. Exclusion criteria included editorials, non-English language, comments, and letters. Data Extraction Level of evidence was assigned in accordance with the Oxford Centre for Evidence-based Medicine guidance (Levels I–V). Results Thirty-seven articles met the inclusion criteria, of which, 11 were of Level III, 22 of Level IV, and 4 of level V evidence. High-resolution computed tomography (CT) of the temporal bones is the imaging technique of choice in the diagnosis of otosclerosis with newer multidetector scanners demonstrating a sensitivity and specificity in excess of 90%. There is Level III evidence that CT densitometry and extent of disease on CT correlates with hearing thresholds. Extensive and multifocal disease on CT has a poorer prognosis (Level III/IV). The potential use of CT in staging classifications, surgical planning, predicting surgical outcomes and risk of complications has also been described and evaluated. Conclusion This systematic review indicates that imaging has a useful role in both the diagnosis and management of otosclerosis, supported principally by Level III/IV evidence.

A Meta-analysis on the Diagnostic Performance of Non-echoplanar Diffusion-weighted Imaging in Detecting Middle Ear Cholesteatoma: 10 Years On

OBJECTIVE To describe via a meta-analysis of the published literature, the performance of non-echo-planar diffusion weighted imaging (DWI) in detecting middle ear cholesteatoma. METHODOLOGY A systematic review of the published literature was performed to identify original studies evaluating the diagnostic performance of non-echo-planar DWI in detecting middle ear cholesteatoma. Only studies with surgical correlation were included. A bi-variate meta-analysis and hierarchical summary receiver operating characteristic model was performed. RESULTS A total of 26 studies (1,152 patient episodes) were included. Pooled sensitivity and specificity of 0.91 (95% CI: 0.87-0.95) and 0.92 (95% CI: 0.86-0.96), respectively were obtained. Separate subgroup analysis performed for primary cholesteatoma, postoperative cholesteatoma, pediatric cases, and adult cases all showed high sensitivities (range, 0.86-0.93) and specificities (0.88-0.97). There was a statistically significant degree of heterogeneity in terms of sensitivity between all studies (I value 46%) and in the pediatric subgroup (I value 78%). There was no evidence of significant heterogeneity between the specificity measurements. CONCLUSIONS Non-echo-planar DWI is highly sensitive and specific in detecting cholesteatoma. A large prospective multicentre randomized controlled study could validate the findings and evaluate the cost-effectiveness of DWI as an alternative for second-look surgery (control arm) in managing cases of postoperative cholesteatoma.

Monitoring Progression of 12 Cases of Non-Operated Middle Ear Cholesteatoma With Non-Echoplanar Diffusion Weighted Magnetic Resonance Imaging: Our Experience.

Aim: The aim of this study is to gain insight into the disease progression and behavior of primary cholesteatoma in a cohort of patients who did not have surgery using non-echoplanar diffusion-weighted magnetic resonance imaging (DW MRI) serial monitoring. Methods: Retrospective longitudinal observational study of 12 cases of middle ear cleft cholesteatoma diagnosed between 2009 and 2014 where surgery was not performed for various reasons. All cases were monitored radiologically with non-echoplanar half-Fourier acquisition single-shot turbo spin-echo diffusion weighted imaging annually for a median period of 23 months (between 11 and 45 mo) to evaluate for changes in disease volume and direction of growth. Results: Of the 12 cases, there was one outlier where the cholesteatoma growth was disproportionately high compared with the rest of the cases outside the standard deviation range. A third of the cases had radiological evidence of cholesteatoma growth. The mean growth was about 11.9% of the initial disease volume per year. Seven out of the 12 cases had radiological evidence of cholesteatoma regression in terms of size, with three cases having negative follow-up DW-MRI scans as early as 17 months. The mean regression rate was much higher than the mean growth rate at 54.3% of the initial disease volume per year. The direction of greatest growth is craniocaudally. Conclusion: Within the limits of our longitudinal study, we have shown that by monitoring with non-echoplanar diffusion weighted imaging, cholesteatoma can progress or regress when left untreated by surgery. The greatest progression was recorded in the craniocaudal direction.