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1、Cholesteatoma,Shankai Yin Prof Dept of Otolaryngology,the sixth hospital affiliated to Shanghai jiaotong university Otolaryngology institute at Shanghai jiaotong university,Epidemiology,Exact prevalence is unknownIncidence estimated between 3 and 12.6 per 100,000,Classification,CongenitalAcquiredPri
2、mary acquired(retraction pocket)Secondary acquired,Pathogenesis,CongenitalArise from embryonal rests of epithelial cellsLocation(petrous pyramid,mastoid and middle ear cleft)Levenson criteriaWhite mass medial to normal TMNormal pars flaccida and tensaNo history of otorrhea or perforationsNo prior ot
3、ologic proceduresPrior bouts of otitis media not grounds for exclusion,Theories,“Acquired”inclusion theory-Tos,Epidermal rest theory-Teed Michael,Congenital cholesteatoma,Primary acquiredEustachian tube dysfunctionPoor aeration of the epitympanic spaceRetraction of the pars flaccidaNormal migratory
4、pattern alteredAccumulation of keratin,enlargement of sac,Primary acquired cholesteatoma,Secondary acquiredImplantation surgery,foreign body,blast injuryMetaplasia transformation of cuboidal epithelium to squamous epithelium from chronic infectionInvasion/Migration medial migration along permanent p
5、erforation of TMPapillary ingrowth intact pars flaccida,inflammation in Prussacks space,break in the basal membrane,cords of epithelium migrate inward,Clinical manifestations,CommonPainless otorrheaRefractory/recurrent ear infectionsConductive hearing lossUncommonVertigo/Sensorineural Facial nerve p
6、aralysisCNS infectionsBrain herniation/CSF leakPneumocephalus,historyPhysical ExaminationOtomicroscopyPosterosuperior retraction pocket with squamGranulation from diseased boneAural polypsPneumatic otoscopy positive fistula response suggests erosion into labyrinthCultures should be obtained in infec
7、ted ears,Diagnosis,Audiology usually conductive loss,may vary greatly;confirm with tuning forksImaging CT temporal bone definitely obtain for revision cases,complications of chronic suppurative otitis media,sensorineural hearing loss,vestibular symptoms,other complications of cholesteatoma,Imaging,P
8、urposeDiagnosisDetermining extentRisk assessmentModalitiesPlain filmComputed tomography scansMagnetic Resonance imaging,Goals of CT Imaging,Middle ear ventilationOssicular destructionEpitympanum accessMastoid cortexTegmen integrityLabyrinth involvementFacial nerve involvementSurgical changes,CT disa
9、dvantages,Granulation tissue vs.cholesteatomaSpecific soft tissue problemsDural involvementAbscessBrain herniationLabyrinth involvementSigmoid sinus thrombosisMRI needed,MR Imaging,Hypointense on T1Isointense to brainIntermediate on T2NonenhancingGranulation tissue does enhanceRecurrence detectionLe
10、sions 2mm90%sensitive,100%specificity,T2,Delayed contrast T1,Differential Diagnosis,Chronic serous otitis mediaJugulotympanic paragangliomasCholesterol granulomasNeurofibromasHemangiomasArachnoid cystJugular bulb anomaliesTympanosclerosisencephalocele,Treatment,Create a“dry and safe”ear,Non-surgical
11、,Treat the Infection Floxin Otic DropsDecrease the inflammation Topical steroidsDebridement of the external canal,Surgical,Atticotomy Radical MastoidectomyBondy Modified Radical(Canal wall down)mastoidectomyTympanoplasty and canal wall up mastoidectomy,Prognosis,Residual or recurrent cholesteatoma o
12、ver 5 years 15 to 40%Reported to be up to 67%in the pediatric populationClose follow-up Regular examinations needed-6 months,Complications,Dural tear-CSF leakFistula of the horizontal semicircular canal(vertigo)Up to 10%Facial nerve injuryInjury to the sigmoid sinus/jugular bulbOtitic HydrocephalusH
13、earing loss30%have conductive loss pre-operativelyPostoperatively,an additional 30%have worsening or onset of hearing loss due to extent of diseaseInfection Meningitis,Abscess,lateral sinus thrombosis Up to 1%,Predisposing factors,Virulent organismsCholesteatoma and bone erosionPresence of a congeni
14、tal dehiscence(e.g.dehiscent facial canal)or a preformed pathway(e.g.skull base fracture)Obstruction of drainage e.g.by a polyp.Low resistance of the patient,Pathways of infection,The commonest way for extension of infection is by bone erosion due to a cholesteatoma.Vascular extension(retrograde thr
15、ombophlebitis).Extension along preformed pathways as Congenital dehiscences,fracture lines,round window membrane,the labyrinth,Dehiscences due to previous surgery.,Classification,Cranial complicationsExtra-cranial complicationsIntra-cranial complications,Cranial complications,Acute mastoiditis and m
16、astoidabscesses(most common complication).Petrositis.Labyrinthitis.Facial paralysis.Osteomyelitis of the temporal bone,Extra-cranial complications,External otitisCervical lymphadenitisRetropharyngeal Parapharyngeal abscesses,Intracranial complications,Extradural abscess(commonest intracranial compli
17、cation).Subdural abscess.Meningitis.Brain abscess:Temporal lobe abscess.Cerebellar abscess.Lateral sinus thrombosis.Otitic hydrocephalus.,Potentially life threateningSuppurative otorrhea,chronic headache,pain,fever impending intracranial complicationMental status changes,nuchal rigidity,cranial neuropathies require neurosurgical consult,Brain Abscess,Questions?,
