Cirugía endoscópica de oído para el manejo del colesteatoma atical / Endoscopic ear surgery approach for attic cholesteatoma treatment

RESUMEN El colesteatoma es la presencia de epitelio plano queratinizado en zonas neumatizadas del hueso temporal, cuya ubicación más frecuente es el ático. En la década de los noventa, se inicia el desarrollo de la cirugía endoscópica de oído, ofreciendo una nueva perspectiva en el tratamiento del colesteatoma. Se presentan dos casos clínicos de pacientes con colesteatoma atical. Se realiza abordaje endoscópico transcanal con resección macroscópica completa del colesteatoma. Audiometría posoperatoria evidencia mejoría de hipoacusia de conducción.

ABSTRACT The cholesteatoma is the presence of keratinized squamous epithelium in pneumatized areas of the temporal bone, its most frequent location is the attic. In the 1990s the development of the ear endoscopic surgery begins, offering a new perspective for cholesteatoma treatment. Two clinical cases of patients who present attic cholestatoma are described. A transcanal endoscopic approach with complete macroscopic resection was accomplished. Post-surgical audiometry shows improvement of the conductive hearing loss.

Hearing loss assessment in primary and secondary acquired cholesteatoma, / Potenciais evocados auditivos de longa latência com verbais e não verbais

ABSTRACT INTRODUCTION: Acquired middle ear cholesteatoma can be classified as primary or secondary. Although both can result in hearing loss, it is still controversial whether there is an association between the type of cholesteatoma and the degree of hearing loss. OBJECTIVE: To analyze the association between hearing loss and the type of acquired cholesteatoma, and the status of the ossicular chain. METHODS: This was a cross-sectional historical cohort study involving patients diagnosed with acquired cholesteatoma who were surgically treated. Air and bone conduction thresholds, air-bone gaps and the status of the ossicular chain were analyzed for both types of cholesteatoma. RESULTS: Eighty patients aged 5-57 were included in the study. Fifty-one patients had primary cholesteatoma and 29 had secondary cholesteatoma. Both types of cholesteatoma determined greater air-bone gaps at 0.5 kHz. Secondary cholesteatoma determined greater hearing loss in all analyzed frequencies and higher air conduction and air-bone gap means. CONCLUSION: There was association between hearing loss and the type of cholesteatoma. Secondary cholesteatoma resulted in greater hearing impairment.

RESUMO INTRODUÇÃO: O colesteatoma adquirido de orelha média pode ser classificado como primário e secundário. Ambos podem ocasionar perda de audição, mas ainda há controvérsia quanto à relação dos tipos de colesteatoma com a perda auditiva. OBJETIVO: Analisar a relação dos tipos de colesteatoma e da erosão da cadeia ossicular com a perda auditiva. MÉTODO: Estudo de coorte histórica com corte transversal, envolvendo pacientes que receberam o diagnóstico de colesteatoma adquirido e foram submetidos à cirurgia otológica. Foram analisados os limiares ósseos, aéreos e a diferença aéreo-óssea, e suas associações com os tipos de colesteatoma e com a presença de erosão na cadeia ossicular. RESULTADOS: No estudo foram incluídos oitenta pacientes, com idade entre 5 e 57 anos, sendo 51 com colesteatoma primário e 29 com colesteatoma secundário. Ambos os tipos de colesteatoma determinaram maior diferença aéreo-óssea na frequência de 0,5 kHz. O colesteatoma secundário determinou uma perda auditiva maior em todas as frequências analisadas, e maiores médias do limiar aéreo e da diferença aéreo-óssea. CONCLUSÃO: Houve associação entre o tipo de colesteatoma e a perda de audição. O colesteatoma secundário determinou maior comprometimento da audição.

Uso de resonancia magnética con secuencia de difusión no-ecoplanar para la detección de colesteatoma en pacientes con cirugía de oído previa: presentación de 4 casos / Use of non-echo-planar diffusion-weighted magnetic resonance imaging for the detection of cholesteatoma in patients with previous ear surgery: presentation of 4 cases

El diagnóstico de colesteatoma es fundamentalmente clínico, pudiendo ser complementado con imágenes. Últimamente, el uso de resonancia magnética con secuencia HASTE ha surgido como herramienta diagnóstica sensible y específica para colesteatoma, permitiendo diferenciar éste del tejido inflamatorio-fibrótico presente en pacientes que han sido sometidos a cirugía de oído previa. En este trabajo se presentan cuatro casos de pacientes con antecedente de cirugía de oído y sospecha de colesteatoma en el mismo oído operado, realizándose RM HASTE y cirugía posterior. Obtuvimos una alta correlación entre la imagen y resultado quirúrgico. Se requiere mayor número de pacientes para determinar la sensibilidad y especificidad en el diagnóstico de colesteatoma en pacientes con cirugía de oídos previa.

The diagnosis of cholesteatoma is mainly established by clinical signs, and can be improved by radiological imaging. Recently, the use of magnetic resonance imaging (MRI) with HASTE sequence has emerged as a sensitive and specific diagnostic tool for cholesteatoma, which allows differentiating it from inflammatory-fibrotic tissue present in patients who have undergone previous surgery ear. Here, we present four cases of patients with a history of ear surgery and a suspected cholesteatoma in the same ear, performing HASTE MRI and subsequent surgery, presenting a high correlation between MRI and surgical outcome. More patients are needed to determine the sensitivity and specificity in the diagnosis of cholesteatoma inpatients with previous ear surgery.

Colesteatoma: utilidade da sequência de difusão sem echo-planar / Cholesteatoma: utility of non-echo-planar diffusion-weighted imaging

Colesteatomas são lesões císticas congênitas ou adquiridas que acometem as orelhas e que podem apresentar padrões típicos aos estudos de tomografia computadorizada, em função de suas características expansivas e tendência a promover erosão óssea. Entretanto, particularmente nos casos de resíduo ou recorrência pós-cirúrgica, a distinção entre colesteatoma e tecido inflamatório pode ser bastante difícil e, não raro, impossível com base somente nos achados tomográficos. A avaliação por ressonância magnética pode ser útil, particularmente neste contexto, uma vez que as sequências pós-contraste obtidas tardiamente e a difusão podem demonstrar padrões distintos nestas duas situações. Os artefatos condicionados pela interface ar/osso na região das mastoides podem limitar bastante a utilização da sequência de difusão echo-planar. A sequência de difusão sem echo-planar é uma alternativa na solução deste problema por estar menos sujeita a este tipo de artefato, fornecendo ainda imagens com maior resolução espacial e com espessuras de corte mais finas, as quais permitem a detecção de colesteatomas de pequenas dimensões.

Cholesteatomas are cystic lesions which may be either congenital or acquired, affecting the ears and presenting typical imaging patterns at computed tomography because of its expansile nature and tendency to erode bone. However, particularly in cases of lesion residue or recurrence after surgery, the distinction between cholesteatoma and inflammatory tissue based solely on computed tomography findings may be quite difficult, if not impossible. Magnetic resonance imaging might be very useful, particularly in such a context, since delayed postcontrast and diffusion-weighted images can demonstrate different imaging patterns in these two situations. Artifacts related to air-bone interface in the mastoid region may represent a relevant limitation to the utilization of echo-planar diffusion-weighted imaging. Non-echo-planar diffusion‑weighted imaging represents an alternative to resolve this problem, once this method is less subject to this type of artifact, besides offering images with higher spatial resolution and thinner slice thickness, allowing the detection of small-sized cholesteatomas.

Resonancia magnética cerebral con secuencia difusión - HASTE en la evaluación clínica del colesteatoma / Cerebral magnetic resonance with diffusion - HASTE sequence for clinical evaluation of cholesteatoma

El diagnóstico del colesteatoma de oído es eminentemente clínico y su estudio complementario con imágenes se realiza con tomografía computarizada de cortes finos. En casos seleccionados de colesteatomas es necesario realizar un estudio con resonancia magnética (RM), utilizando habitualmente las secuencias T1 con gadolinio y T2. Se ha reportado alta especificidad y sensibilidad diagnóstica para colesteatoma con técnicas de difusión (DWI) en RM. Estas técnicas pueden ser montadas sobre secuencias no echo planares y rápidas, como la secuencia HASTE (Half Fourier Single Shot Turbo-spin Echo), que permiten obtener imágenes sin artefactos de susceptibilidad magnética en la interface entre el hueso y lóbulo temporal. En este trabajo se presenta una revisión de la literatura y cuatro casos clínicos evaluados en nuestro hospital en los que se utilizó la RM con secuencia DWI - HASTE. Se concluye que la RM con secuencia DWI - HASTE es una herramienta que permite tomar decisiones clínicas en un grupo seleccionado de pacientes con colesteatoma.

The diagnosis of ear cholesteatoma is done by clinical evaluation and its imaging study is performed mainly by computed tomography. In selected cases, it is necessary to consider a magnetic resonance imaging (MRI) in the evaluation of cholesteatoma, usually using gadolinium T1 and T2 sequences. It has been reported that MRI diffusion techniques (DWI) have high specificity and sensitivity results for the diagnostic of cholesteatoma. These techniques can be mounted on non-echo planar fast sequences, such as the HASTE sequence (Half Fourier Single-Shot Turbo Spin Echo), which allows the acquisition of images without any magnetic susceptibility artifacts at the interface between bone and the temporal lobe. This paper presents a literature review on the topic, and four clinical cases evaluated in our hospital, where MRI was used with DWI - HASTE sequence. We conclude that MRI with DWI - HASTE sequence is a useful tool for making clinical decisions in the assessment of a selected group of patients with cholesteatoma.

Doenças inflamatórias da orelha média / Inflammatory diseases of the middle ear

OBJETIVO: Determinar as alterações tomográficas mais frequentes na doença inflamatória da orelha média e comparar os achados da tomografia computadorizada e da ressonância magnética com os dados otológicos e cirúrgicos. MATERIAL E MÉTODO: Foram comparados os resultados dos examesde imagem, clínico e cirúrgico de 95 pacientes (95 tomografias computadorizadas e uma ressonânciamagnética). RESULTADOS: Em 52 casos os resultados dos exames de imagem foram normais. Dos 43 pacientes com alterações radiológicas, a comparação com os achados dos exames de imagem, otolaringológico e histopatológico demonstrou: otomastoidite aguda em 2 (4,6%) pacientes, otomastoidite crônica unilateral em 9 (21,0%), otomastoidite crônica bilateral em 2 (4,6%), colesteatoma unilateral em 26 (60,5%) e colesteatoma bilateral em 4 (9,3%). CONCLUSÃO: A tomografia computadorizada foi capaz de definir as características das lesões e as complicações existentes na maioria dos casos e foi necessário o uso da ressonância magnética em um dos 43 pacientes com alterações radiológicas, para definir o tipo de material presente na orelha média. O conhecimento dos dados clínicos e do exame otológico permitiu a interpretação dos achados de imagem mais apropriada para cada caso.

OBJECTIVE: To determine the aspects and frequency of middle ear alterations at computed tomography and magnetic resonance imaging in patients with clinical suspicion for middle ear inflammatory disease. MATERIAL AND METHOD: Imaging examination resultsof 95 patients (95 computed tomography and 1 magnetic resonanceimaging) were compared with the results of otology, imaging and surgical findings. RESULTS: Fifty-two patients had normal imaging results. Forty-three patients had radiologic alterations compared to the physical, otology and hystopathologic exams: acute otomastoiditis in 2 patients (4.6%), unilateral chronic otomastoiditis in 9(21.0%), bilateral chronic otomastoiditis in 2 (4.6%), unilateral cholesteatoma in 26 (60.5%), and bilateral cholesteatoma in 4 (9.3%).CONCLUSION: Computed tomography was able to demonstrate the characteristics of the lesions and found complications in majority of the cases. Magnetic resonance imaging was used only in one patient to rule out scar and cholesteatoma. The knowledge of theclinical and otologic data enables the radiologist to elaborate a more appropriate interpretation of the imaging findings.

Colesteatoma asociado a secuencia de labio y paladar hendidos / Cholesteatoma associated with a sequence of cleft lip and palate

El colesteatoma adquirido asociado a secuencia de labio y paladar hendidos constituye una secuela común en los niños como consecuencia de una función anormal de la trompa de Eustaquio. Se presenta el cuadro clínico-otológico, la otomicroscopia y la eficacia del tratamiento quirúrgico en una paciente de 9 años, afecta de labio y paladar hendido y colesteatoma en el oído derecho complicado con meningitis. Se destaca el riesgo de complicaciones de la otitis media con derrame crónico y la importancia de su diagnóstico precoz, en estadios previos a la formación del colesteatoma.

The cholesteatoma acquired associated with the sequence of cleft lip and palate is a common sequel in children as a result of a malfunction of the Eustachian tube. The clinical-otological picture, the otomicroscopy and the efficiency of the surgical treatment in a 9-year-old patient with cleft lip and palate and cholesteatoma on the right ear complicated with meningitis are presented. The risk for complications of otitis media with chronic effusion and the importance of its early diagnosis in stages previous to the formation of cholesteatoma are stressed.

Resultados auditivos posaticoantrostomía con antroexclusión / Audiologic results post attico antrostomy with antrum exclusion

Introducción: Las intervenciones quirúrgicas del oído medio por colesteatoma tienen por objetivo prioritario la erradicación de la enfermedad, logrando en ocasiones conservar o mejorar la audición de estos pacientes. La aticotomía con antroexclusión es una cirugía conservadora que permite la eliminación de un colesteatoma atical manteniendo una anatomía cercana a la normal. Objetivo: Este trabajo busca determinar los cambios auditivos en pacientes sometidos a este procedimiento quirúrgico. Material y método: Se realiza un estudio transversal con audiometrías a pacientes sometidos a aticoantrostomía con antroexclusión entre los años 2000 y 2005. Se registran datos individuales, hallazgos intraoperatorios y valores audiométricos pre y posoperatorios. Resultados: Se incluyen 18 pacientes, edad promedio de 48 años, 61 por ciento de sexo femenino. La diferencia ósea-aérea preoperatoria promedio es de 38 dB (10-51 dB), mientras la posoperatoria es de 33 dB (18-50 dB). El 50 por ciento de los pacientes obtiene un cierre posoperatorio inferior a 30 dB. No existen cambios significativos con respecto a umbrales de vías óseas o aéreas. Conclusiones: La aticoantrostomía es un procedimiento quirúrgico que permite erradicarla enfermedad y preservar la audición de los pacientes. En nuestra serie existe una conservación de la audición, lo que constituye una ventaja con respecto a otras alternativas quirúrgicas.

Introduction. The primary aim of middle ear surgical intervention due to cholesteatoma is the elimination of the disease, while conserving or in some cases improving the patient's hearing ability. Atticostomy with antrum exclution is a conservative surgery that allows attic cholesteatoma removal, maintaining a relatively normal anatomy. Aims. The main goal of this study is to characterize the audiological changes in patients that underwent this surgical procedure. Material and methods. Audiometries were performed to patients that had atticostomy with antrum exclution, between years 2000 and 2005. Individual data, intra-surgery findings, and audiometric data prior and post surgery were recorded. Results. Results from 18 patients, average age 48 years old, 61% females, are presented. Pre surgical average difference between air and bone conduction was 38dB (10-51 dB), whereas post surgical difference was 33 dB (18-50). Fifty percent of patients reached a post surgical level lower than 30 dB. There were no significant changes related to air or bone conduction thresholds. Conclusions. Atticoantrostomy is a surgical procedure that allows both disease elimination and hearing preservation. In our series, hearing was preserved, which represents an advantage over other surgical alternatives.

Surgery for otitis media with cholesteatoma: canal up versus canal down procedures

To compare and evaluate the results of surgery for Otitis Media with cholesteatoma by canal up versus canal down techniques in our set up. A descriptive study. Ear Nose Throat Department, Liaquat University Hospital, Hyderabad from January 2000 to December 2001. This study included 80 cases of otitis media with cholesteatoma. Patient were aged between 05 to 45 years. All cases operated under Zeiss microscope adopting two surgical techniques, i.e. canal up and canal down. The cases followed'up till 02 years for the recurrence of disease and any complication. Majority of cases were male adults belonging to rural areas. In patients, operated with canal up procedure, high risk of disease recurrence and complications was seen as compared to the patients operated with canal down procedure. In closed or canal-up procedures, there is more risk of recurrence of disease. Cholesteatoma has a tendency to recur if it is not properly eradicated. The canal down procedure are more reliable and safe for the patients irrespective of their age. Moreover, for follow-up the response by patients is poor due to lack of health awareness and facilities in the rural areas.. Thus, no chance should be given to the disease to recur in any case of otitis media with cholesteatoma

A retrospective study on cholesteatoma otitis media coexisting with cholesterol granuloma / 华中科技大学学报（医学）（英德文版）

To investigate the etiology and pathogenesis of cholesteatoma otitis media accompanied by cholesterol granuloma and the relationship between cholesteatoma and cholesterol granuloma, 63 cases of middle ear cholesterol granuloma treated in our hospital during the period from March 1988 to May 2000 were retrospectively reviewed. All cases were surgically and pathologically verified. 15 cases of cholesteatoma coexisting with cholesterol granuloma were found among the 63 patients. All 15 cases had a long-term history of otitis media, such as otorrhea (sanguine purulent otorrhea and bloody otorrhea in 8 cases) and perforation of the eardrum (perforation of pars flaccida in 8 cases). Temporal bone CT scans showed cholesteatoma in 11 cases. All patients were treated surgically, and cholesteatoma and cholesterol granuloma were found coexisting alternately, the latter lying mainly in the tympanic antrum, attic and mastoid air cells. Chocolate-colored mucus was accumulated in well-developed mastoid air cells, and glistening dotty cholesterol crystals were also found. In most cases, enlarged aditus, destruction of lateral attic wall, erosion of ossicular chain, exposure of horizontal segment of facial nerve and tegmen of attic were observed. Occlusion of Eustachian tube was noted in 6 cases, and occlusion of tympanic isthmus was revealed in all cases. A post-operative dry ear was achieved in all patients, and hearing improvement was achieved in all 12 cases following tympanoplasty. Cholesteatoma and cholesterol granuloma in middle ear may share a common pathophysiological etiology: occlusion of ventilation and disturbance of drainage. The diagnosis should be considered when patients presented with chronic otitis media with bloody otorrhea. CT and magnetic resonance imaging are useful for the diagnosis before operation. The surgical approach depends on the location, extension and severity of the lesion. The purpose of surgery is to remove the lesion and create an adequate drainage.

Lesiones más frecuentes del oído. Análisis retrospectivo del uso de la tomografía axial computada como método de diagnóstico / Most frequent ear lesions. A retrospective analysis of the use of computer axial tomography as diagnostic method

Antecedentes: en la actualidad la tomografía axial computada ofrece una de las herramientas más útiles en el diagnóstico de las lesiones del oído externo, medio o interno. Objetivo: determinar el padecimiento más frecuente del oído mediante la tomografía axial computada. Material y métodos: en el Hospital Regional 1§ de Octubre del ISSSTE se realizó un estudio retrospectivo de cuatro años (del 1 de enero de 1994 al 31 de diciembre de 1997) que incluyó a 130 pacientes a quienes se hizo estudio de tomografía axial computada de oído con cortes axiales y coronales y con filtro soft, y target-bony. Resultados: el rango de edad fue de 21 a 75 años de edad, con promedio de 40-50 años, sin predominio de sexo. Las afecciones más frecuentes fueron: la otitis media crónica (35 por ciento, n = 28), el colesteatoma (26 por ciento, n = 21), la otoesclerosis (21 por ciento, n = 17), otomastoiditis (14 por ciento, n = 11) y malformaciones (4 por ciento, n = 3). Conclusiones: los resultados de la literatura mundial son muy similares a los nuestros. Se muestra la alta especificidad y sensibilidad de la tomografía para la detección de los diferentes padecimientos del oído.

Perla de colesteatoma gigante / Giant cholesteatoma perl

Se presenta el caso de un paciente quien presento como complicación de una timpanoplastia, la formación de una gran perla de colesteatoma a nivel del neotimpano. Se revisa el caso, los estudios escanográficos, el tratamiento y la literatura pertinente

Colesteatoma epitimpânico anterior: apresentaçäo de um caso com paralisia facial / Anterior epitympanic cholesteatoma: report of case with facial palsy

Um caso de colesteatoma epitimpânico anterior com paralisia facial periférica levou o autor a destacar o diagnóstico diferencial (neuromas, hemangiomas, meningeomas, carcinomas etc.) e definir a importância do tratamento cirúrgico precoce.

Otitis media crónica y colesteatoma en Risaralda / Chronic middle otitis and cholesteatoma in Risaralda

La revisión de 900 historias clinicas correspondientes a tratamientos quirúrgicos de oído medio realizados por el autor entre 1981 y 1992, (que constituyeron el 97 por ciento de las cirugías de esta clase efectuadas en Risaralda, Colombia, en dicho periodo), mostró que tales operaciones fueron, en su mayoria, para pacientes de escasos recursos, afectados principalmente por Otitis Media Crónica (OMC) y Colesteatoma (C). En la población descrita, tales enfermedades se presentaron desde edades inusualmente tempranas (2 1/2 años); el 50 por ciento de los casos se concentró en el rango de 20 a 40 años; no se encontró diferencia significativa en cuanto al oído afectado, ni predominanda de sexo o raza. Las caracteristicas de la población estudiada permiten pensar que la pobreza y la ignorancia pudieron influir, no só1o en la frecuenda de tales patologías, si no tambien en la gravedad que estas alcanzaron en muchos pacientes