The accuracy and sensitivity of diffusion-weighted magnetic resonance imaging with Apparent Diffusion Coefficients in diagnosis of recurrent cholesteatoma

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The accuracy and sensitivity of diffusion-weighted magnetic resonance imaging with Apparent Diffusion Coefficients in diagnosis of recurrent cholesteatoma Nasr Mohamed M. Osman, Ahmed Abdel Rahman, Moustafa Talaat Abdel Hakim Ali European Journal of Radiology Open Volume 4, Pages 27-39 (January 2017) DOI: 10.1016/j.ejro.2017.03.001 Copyright © 2017 The Authors Terms and Conditions

Fig. 1 Recurrent cholesteatoma in the right middle ear of 45y old woman who underwent CWU middle ear surgery. (A and B) Axial and coronal CT cuts showed complete opacification of the right middle ear cleft by tissue density lesion associated with eroded ossicular chain and bulging tympanic membrane outwards. (C) Axial T1WI, (D) Axial CISS and (E) Coronal T2W conventional non contrast MRI showed a soft tissue lesion in the right middle ear cleft of hypointense signal at T1WI and high signal intensity in T2WI and CISS. (F, G) Coronal and axial diffusion-weighted fast SE image obtained with a b factor of 1000s/mm2 showed high signal intensity of the cholesteatoma. (H) ADC (mean 561.75×10−3mm2/s). The lesion size is 1.5cm at CT and 1cm at DWI. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 2 Recurrent cholesteatoma in the left middle ear of a 50y old woman who underwent CWD ear surgery. (A and B) Axial and coronal CT cuts revealed complete opacification of the right middle ear cleft, absent ossicules. (C) Axial T1WI, (D) Axial CISS and (E) Coronal T2W MRI sequences showed a soft tissue lesion in the right middle ear cleft of hypointense signal at T1WI and high signal intensity at T2WI and CISS (Red arrow). (F) Coronal DWI fast SE image obtained with a b factor of 1000s/mm2 showed markedly high signal intensity of the cholesteatoma (yellow arrow). (G) ADC (mean 566×10−3mm2/s), (green arrow). The lesion size is 2cm at CT and 1cm at DWI. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 3 Recurrent cholesteatoma in the left middle ear of a 38years old man who underwent canal wall up middle ear surgery. (A–C) Axial and Coronal CT cuts showed complete opacification of the left middle ear cleft (red arrow) with absent ossicles. (D) Axial T1WI, (E) Coronal T2W and axial (F) CISS MRI sequences showed a soft tissue lesion in the left middle ear cleft of low signal at T1WI and high signal intensity at T2WI and CISS (red arrow). (G) Axial DWI obtained with a b factor of 1000s/mm2 showed high signal intensity of the cholesteatoma (red arrow). (I) ADC (mean 575×10−3mm2/s). The lesion size 16mm, 9mm. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 4 Recurrent cholesteatoma in the left middle ear of a 12y boy who underwent ICW middle ear surgery. (A and B) Axial and coronal CT cuts showed complete opacification of the left middle ear cleft by tissue density lesion associated with erosion of the ossicular chain. (C, D) Axial T1WI, axial CISS showed a soft tissue lesion in the left middle ear cleft of low signal in T1WI and high signal intensity in T2WI (red arrow). (E, F) Axial DWI obtained with a b factor of 1000s/mm2 showed markedly high signal intensity of the cholesteatoma (red arrow). (G) ADC (mean 584×10−3mm2/s). The size of the lesion is 15mm at CT and 10mm at MRD. The right ear showed CSOM. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 5 Bilateral recurrent cholesteatoma of a 33y old woman who underwent CWU middle ear surgery at both sides. (A and B) Axial and coronal CT cuts showed opacified attic on both sides by non-dependent tissue density lesion associated with absent ossicles (red arrow). (C) Axial T1WI right and (D) left ear, (E) Axial CISS and (F) Coronal T2W SE showed a soft tissue lesion in the middle ear cleft of both ears of low signal in T1WI and high signal intensity in T2WI and CISS (red arrow). (G) Axial DWI fast SE image obtained with a b factor of 1000s/mm2 showed markedly high signal intensity of the cholesteatoma on both sides (red arrow).(H) ADC (mean 759, 724×10−3mm2/s). European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 6 Recurrent cholesteatoma in the left middle ear with CSOM at the right of a 38years old man who underwent CWU middle ear surgery. (A and B) Axial and coronal CT cuts showed complete opacification of the right middle ear cleft by tissue density lesion associated with eroded ossicular chains (red arrow). (C) Axial T1WI, (D) Coronal T2W SE and (E) Axial CISS showed a soft tissue lesion in the right middle ear cleft of low signal at T1WI and high signal intensity at T2WI and CISS. (G) Axial DWI obtained with a b factor of 1000s/mm2 showed high signal intensity of the cholesteatoma (red arrow) at the left with no abnormal signal at T2WI. The size of the lesion is 18mm at CT and 11mm at DWI. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 7 Left CSOM without cholesteatoma in of a 21 years old man who underwent left CWU middle ear surgery. (A and B) Axial and coronal CT cuts showed complete opacification of the left middle ear cleft by tissue density lesion associated with intact ossicular chain. (C) Axial T1WI, (D) Coronal T2WI, and (E) Axial CISS showed a soft tissue density lesion in the left middle ear cleft of low signal in T1WI and high signal intensity in T2WI and CISS (green arrows). (F) Axial DWI obtained with a b factor of 1000s/mm2 showed no high signal intensity at the left middle ear cleft. (G) ADC (mean 1.746.85×10−3mm2/s). European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 8 Recurrent cholesteatoma in the left middle ear of a 12y old woman who underwent CWU middle ear surgery. (A and B) Axial and coronal CT cuts showed complete opacification of the left middle ear cleft by tissue density lesion associated with eroded malleus head and incus body (blue arrow). (C) Axial T2WI, (D) Coronal T2W SE and (E) Axial CISS showed a soft tissue lesion in the left middle ear cleft of high signal intensity at T2WI and CISS. (F) Multiple coronal DWI obtained with a b factor of 1000s/mm2 showed high signal intensity of the cholesteatoma (blue arrow). (G) ADC=595.6385×10−3mm2/s. The size of the lesion is 15mm at CT and 10mm at DWI. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 9 False positive case of recurrent cholesteatoma in the left middle ear of a 17y old man who underwent left middle ear surgery for a large cholesteatoma complicated by LSC fistula 3years ago. (A and B) Axial and coronal CT cuts showed complete opacification of the right middle ear cleft by large tissue density lesion associated with eroded LSC and tympanic segment of the facial nerve canal (small arrow). (C) Coronal T2WI, (D) Axial CISS showed a soft tissue lesion in the left middle ear cleft of high signal intensity. (E) Axial DWI obtained with a b factor of 1000s/mm2 showed small high signal intensity area at the middle ear cleft (red arrow) proved as bone graft sealing LSC fistula. ADC could not measure. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 10 Recurrent cholesteatoma MDCT of 25years old man who underwent CWD of the right middle ear surgery. (A) Axial and (B) Coronal CT cuts showed non-dependent tissue density lesion seen extended along the medial wall of the right middle ear cavity with small part of the ossicles engulfed by the lesion which extended through the oval window. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions

Fig. 11 Flow diagram for description the participants. European Journal of Radiology Open 2017 4, 27-39DOI: (10.1016/j.ejro.2017.03.001) Copyright © 2017 The Authors Terms and Conditions