上海交通大学耳鼻咽喉科学英文版课件 cholesteatoma

CholesteatomaShankaiYinProfDeptofOtolaryngology,thesixthhospitalaffiliatedtoShanghaijiaotonguniversityOtolaryngologyinstituteatShanghaijiaotonguniversityCholesteatomaShankaiYinProEpidemiologyExactprevalenceisunknownIncidenceestimatedbetween3and12.6per100,000EpidemiologyExactprevalenceiClassificationCongenitalAcquiredPrimaryacquired(retractionpocket)SecondaryacquiredClassificationCongenitalPathogenesisCongenitalArisefromembryonalrestsofepithelialcellsLocation(petrouspyramid,mastoidandmiddleearcleft)LevensoncriteriaWhitemassmedialtonormalTMNormalparsflaccidaandtensaNohistoryofotorrheaorperforationsNopriorotologicproceduresPriorboutsofotitismedianotgroundsforexclusionPathogenesisCongenitalTheories

“Acquired”inclusiontheory -TosEpidermalresttheory-TeedMichaelTheories“Acquired”inclusiCongenitalcholesteatomaCongenitalcholesteatomaPrimaryacquiredEustachiantubedysfunctionPooraerationoftheepitympanicspaceRetractionoftheparsflaccidaNormalmigratorypatternalteredAccumulationofkeratin,enlargementofsacPrimaryacquiredPrimaryacquiredcholesteatomaPrimaryacquiredcholesteatomaSecondaryacquiredImplantation–surgery,foreignbody,blastinjuryMetaplasia–transformationofcuboidalepitheliumtosquamousepitheliumfromchronicinfectionInvasion/Migration–medialmigrationalongpermanentperforationofTMPapillaryingrowth–intactparsflaccida,inflammationinPrussack’sspace,breakinthebasalmembrane,cordsofepitheliummigrateinwardSecondaryacquired上海交通大学耳鼻咽喉科学英文版课件cholesteatomaClinicalmanifestationsCommonPainlessotorrheaRefractory/recurrentearinfectionsConductivehearinglossUncommonVertigo/SensorineuralFacialnerveparalysisCNSinfectionsBrainherniation/CSFleakPneumocephalusClinicalmanifestationsCommonhistoryPhysicalExaminationOtomicroscopyPosterosuperiorretractionpocketwithsquamGranulationfromdiseasedboneAuralpolypsPneumaticotoscopy–positivefistularesponsesuggestserosionintolabyrinthCulturesshouldbeobtainedininfectedearsDiagnosishistoryDiagnosisAudiologyusuallyconductiveloss,mayvarygreatly;confirmwithtuningforksImaging

CTtemporalbone–definitelyobtainforrevisioncases,complicationsofchronicsuppurativeotitismedia,sensorineuralhearingloss,vestibularsymptoms,othercomplicationsofcholesteatomaAudiologyImagingPurposeDiagnosisDeterminingextentRiskassessmentModalitiesPlainfilmComputedtomographyscansMagneticResonanceimagingImagingPurpose

GoalsofCTImagingMiddleearventilationOssiculardestructionEpitympanumaccessMastoidcortexTegmenintegrityLabyrinthinvolvementFacialnerveinvolvementSurgicalchangesGoalsofCTImagingMiddleear上海交通大学耳鼻咽喉科学英文版课件cholesteatoma上海交通大学耳鼻咽喉科学英文版课件cholesteatoma上海交通大学耳鼻咽喉科学英文版课件cholesteatomaCTdisadvantagesGranulationtissuevs.cholesteatomaSpecificsofttissueproblemsDuralinvolvementAbscessBrainherniationLabyrinthinvolvementSigmoidsinusthrombosisMRIneededCTdisadvantagesGranulationtiMRImagingHypointenseonT1IsointensetobrainIntermediateonT2NonenhancingGranulationtissuedoesenhanceRecurrencedetectionLesions>2mm90%sensitive,100%specificityMRImagingHypointenseonT1T2DelayedcontrastT1T2DelayedcontrastT1DifferentialDiagnosisChronicserousotitismediaJugulotympanicparagangliomasCholesterolgranulomasNeurofibromasHemangiomasArachnoidcystJugularbulbanomaliesTympanosclerosisencephaloceleDifferentialDiagnosisChronicTreatmentCreatea“dryandsafe”ear

TreatmentCreatea“dryandsaf

Non-surgicalTreattheInfection–FloxinOticDropsDecreasetheinflammation–TopicalsteroidsDebridementoftheexternalcanalNon-surgicalTreattheInfectiSurgicalAtticotomyRadicalMastoidectomyBondyModifiedRadical(Canalwalldown)mastoidectomyTympanoplastyandcanalwallupmastoidectomySurgicalAtticotomyPrognosisResidualorrecurrentcholesteatomaover5years–15to40%Reportedtobeupto67%inthepediatricpopulationClosefollow-up

Regularexaminationsneeded-6monthsPrognosisResidualorrecurrentComplicationsDuraltear-CSFleakFistulaofthehorizontalsemicircularcanal(vertigo)–Upto10%FacialnerveinjuryInjurytothesigmoidsinus/jugularbulbOtiticHydrocephalusHearingloss30%haveconductivelosspre-operativelyPostoperatively,anadditional30%haveworseningoronsetofhearinglossduetoextentofdiseaseInfection–Meningitis,Abscess,lateralsinusthrombosis–Upto1%ComplicationsDuraltear-CSFPredisposingfactorsVirulentorganismsCholesteatomaandboneerosionPresenceofacongenitaldehiscence(e.g.dehiscentfacialcanal)orapreformedpathway(e.g.skullbasefracture)Obstructionofdrainagee.g.byapolyp.LowresistanceofthepatientPredisposingfactorsVirulentoPathwaysofinfectionThecommonestwayforextensionofinfectionisbyboneerosionduetoacholesteatoma.Vascularextension(retrogradethrombophlebitis).Extensionalongpreformedpathwaysas–Congenitaldehiscences,fracturelines,roundwindowmembrane,thelabyrinth,–Dehiscencesduetoprevioussurgery.PathwaysofinfectionThecommoClassificationCranialcomplicationsExtra-cranialcomplicationsIntra-cranialcomplicationsClassificationCranialcomplicaCranialcomplicationsAcutemastoiditisandmastoidabscesses(mostcommoncomplication).Petrositis.Labyrinthitis.Facialparalysis.OsteomyelitisofthetemporalboneCranialcomplicationsAcutemasExtra-cranialcomplicationsExternalotitisCervicallymphadenitisRetropharyngealParapharyngealabscessesExtra-cranialcomplicationsExtIntracranialcomplicationsExtraduralabscess(commonestintracranialcomplication).Subduralabscess.Meningitis.Brainabscess:Temporallobeabscess.Cerebellarabscess.Lateralsinusthrombosis.Otitichydrocephalus.IntracranialcomplicationsExtPotentiallylifethreateningSuppurativeotorrhea,chronicheadache,pain,fever–impendingintracranialcomplicationMentalstatuschanges,nuchalrigidity,cranialneuropathiesrequireneurosurgicalconsultPotentiallylifethreatening上海交通大学耳鼻咽喉科学英文版课件cholesteatoma上海交通大学耳鼻咽喉科学英文版课件cholesteatomaBrainAbscessBrainAbscessQuestions?Questions?CholesteatomaShankaiYinProfDeptofOtolaryngology,thesixthhospitalaffiliatedtoShanghaijiaotonguniversityOtolaryngologyinstituteatShanghaijiaotonguniversityCholesteatomaShankaiYinProEpidemiologyExactprevalenceisunknownIncidenceestimatedbetween3and12.6per100,000EpidemiologyExactprevalenceiClassificationCongenitalAcquiredPrimaryacquired(retractionpocket)SecondaryacquiredClassificationCongenitalPathogenesisCongenitalArisefromembryonalrestsofepithelialcellsLocation(petrouspyramid,mastoidandmiddleearcleft)LevensoncriteriaWhitemassmedialtonormalTMNormalparsflaccidaandtensaNohistoryofotorrheaorperforationsNopriorotologicproceduresPriorboutsofotitismedianotgroundsforexclusionPathogenesisCongenitalTheories

“Acquired”inclusiontheory -TosEpidermalresttheory-TeedMichaelTheories“Acquired”inclusiCongenitalcholesteatomaCongenitalcholesteatomaPrimaryacquiredEustachiantubedysfunctionPooraerationoftheepitympanicspaceRetractionoftheparsflaccidaNormalmigratorypatternalteredAccumulationofkeratin,enlargementofsacPrimaryacquiredPrimaryacquiredcholesteatomaPrimaryacquiredcholesteatomaSecondaryacquiredImplantation–surgery,foreignbody,blastinjuryMetaplasia–transformationofcuboidalepitheliumtosquamousepitheliumfromchronicinfectionInvasion/Migration–medialmigrationalongpermanentperforationofTMPapillaryingrowth–intactparsflaccida,inflammationinPrussack’sspace,breakinthebasalmembrane,cordsofepitheliummigrateinwardSecondaryacquired上海交通大学耳鼻咽喉科学英文版课件cholesteatomaClinicalmanifestationsCommonPainlessotorrheaRefractory/recurrentearinfectionsConductivehearinglossUncommonVertigo/SensorineuralFacialnerveparalysisCNSinfectionsBrainherniation/CSFleakPneumocephalusClinicalmanifestationsCommonhistoryPhysicalExaminationOtomicroscopyPosterosuperiorretractionpocketwithsquamGranulationfromdiseasedboneAuralpolypsPneumaticotoscopy–positivefistularesponsesuggestserosionintolabyrinthCulturesshouldbeobtainedininfectedearsDiagnosishistoryDiagnosisAudiologyusuallyconductiveloss,mayvarygreatly;confirmwithtuningforksImaging

CTtemporalbone–definitelyobtainforrevisioncases,complicationsofchronicsuppurativeotitismedia,sensorineuralhearingloss,vestibularsymptoms,othercomplicationsofcholesteatomaAudiologyImagingPurposeDiagnosisDeterminingextentRiskassessmentModalitiesPlainfilmComputedtomographyscansMagneticResonanceimagingImagingPurpose

GoalsofCTImagingMiddleearventilationOssiculardestructionEpitympanumaccessMastoidcortexTegmenintegrityLabyrinthinvolvementFacialnerveinvolvementSurgicalchangesGoalsofCTImagingMiddleear上海交通大学耳鼻咽喉科学英文版课件cholesteatoma上海交通大学耳鼻咽喉科学英文版课件cholesteatoma上海交通大学耳鼻咽喉科学英文版课件cholesteatomaCTdisadvantagesGranulationtissuevs.cholesteatomaSpecificsofttissueproblemsDuralinvolvementAbscessBrainherniationLabyrinthinvolvementSigmoidsinusthrombosisMRIneededCTdisadvantagesGranulationtiMRImagingHypointenseonT1IsointensetobrainIntermediateonT2NonenhancingGranulationtissuedoesenhanceRecurrencedetectionLesions>2mm90%sensitive,100%specificityMRImagingHypointenseonT1T2DelayedcontrastT1T2DelayedcontrastT1DifferentialDiagnosisChronicserousotitismediaJugulotympanicparagangliomasCholesterolgranulomasNeurofibromasHemangiomasArachnoidcystJugularbulbanomaliesTympanosclerosisencephaloceleDifferentialDiagnosisChronicTreatmentCreatea“dryandsafe”ear

TreatmentCreatea“dryandsaf

Non-surgicalTreattheInfection–FloxinOticDropsDecreasetheinflammation–TopicalsteroidsDebridementoftheexternalcanalNon-surgicalTreattheInfectiSurgicalAtticotomyRadicalMastoidectomyBondyModifiedRadical(Canalwalldown)mastoidectomyTympanoplastyandcanalwallupmastoidectomySurgicalAtticotomyPrognosisResidualorrecurrentcholesteatomaover5years–15to40%Reportedtobeupto67%inthepediatricpopulationClosefollow-up

Regularexaminationsneeded-6monthsPrognosisResidualorrecurrentComplicationsDuraltear-CSFleakFistulaofthehorizontalsemicircularcanal(vertigo)–Upto10%FacialnerveinjuryInjurytothesigmoidsinus/jugularbulbOtiticHydrocephalusHearingloss30%haveconductivelosspre-operativelyPostoperatively,anadditional30%haveworseningoronsetofhearinglossduetoextentofdiseaseInfection–Meningitis,Abscess,lateralsinusthrombosis–Upto1%ComplicationsDuraltear-CSFPredisposingfactorsVirulentorganismsCholesteatomaandboneerosionPresenceofacongenitaldehiscence(e.g.dehiscentfacialcanal)orapreformedpathway(e.g.skullbasefracture)Obstructionofdrainagee.g.byapolyp.LowresistanceofthepatientPredisposingfactorsVirulentoPathwaysofinfectionThecommonestwayforextensionofinfectionisbyboneerosionduetoacholesteatoma.Vascularextension(retrograde