0:01

So this was an example of a case of a soft tissue mass

0:05

involving the left middle ear cavity.

0:10

And there's a soft tissue mass right here that's involved in the middle ear

0:13

cavity.

0:15

And one of the things that we see here is that we do not see the

0:19

normal appearance, uh, of the ossicles.

0:23

So when we start, sorry about that. Let's get this about, uh, there.

0:28

Yeah. So when we see this area, this is the classic ice cream cone,

0:33

which is ahead of the malus and the short process of the Incas.

0:37

And you can see the soft tissue thickening here involving the epit temp of them.

0:41

You can also see soft tissue thickening here involving the mastoid aero cells.

0:45

Now what I want you to do is keep your eye on this because this is the famous

0:49

ice cream cone. And then on the, on the right hand screen,

0:52

hopefully this OBRA link will, will work, um, is,

0:56

I'm gonna mag that up and then you should be able to landmark it on the,

1:00

on the left side you can see which way we're going.

1:03

And as we come more inferiorly, we can see the two dot appearance here.

1:08

So this is part of the malus and this is part of the inus.

1:11

But what I want you to do is keep your eye on those dots. And as we get lower,

1:14

notice how we just see the malus here, the manu of the mal is here,

1:18

but we're losing the long process of the Incas.

1:22

So instead of having two dots, we're only seeing one dot.

1:25

And then once we get down to the level of the oval window,

1:29

we can see that there's soft tissue thickening here,

1:32

and we don't see the normal stape superstructure.

1:36

So what I'm gonna do now is I'm going to juxtapose this on

1:41

this image. This is the patient's opposite side.

1:45

And then when we look at the opposite side,

1:50

what we can see is,

1:55

okay, do you see, uh, the, the mally short process, the incus?

1:59

And as we come down, we can see the two dots here. See, I see the two dots here.

2:04

And then what we actually see is this horseshoe right here,

2:08

see the inverted horseshoe. And this is the staes foot plate,

2:12

and this is what you should normally see.

2:15

So the way to make this diagnosis is that anytime that you have a focal soft

2:18

tissue mass involving the middle ear cavity, that's associated with,

2:23

um, ossicular erosion that we make the diagnosis of cholesteatoma.

2:28

So let me stop there for this case before I go on and show a couple slides. So,

2:33

um,

2:34

cholesteatomas were actually first described in 1683 by

2:39

Joseph Char Duverney. Okay, that tells you, again, a boring life.

2:43

I went and found these people and this was an anatomist.

2:46

He was actually a French anatomist.

2:48

And the term keitt was actually coined in 1838.

2:53

And that was created by Johan Muer, who's an anatomist.

2:57

So koma is actually a, um,

3:00

misnomer because choli means fat, and oma means tumors.

3:05

So the actual or origin is actually fatty tumor, and that's not correct.

3:10

So what cholesteatoma is,

3:12

is izing debris that arises from the desquamation of the epithelial lining.

3:16

And that's corn of like the, the classic, the uh, classic definition.

3:22

But in actuality, chot just means skin growing in the wrong place.

3:27

And there's different types of cholesteatoma. There's a, uh,

3:30

congenital versus acquired.

3:33

So this is one way we classify congenital versus acquired,

3:37

but it's also classified based on the relationship with the membrane.

3:41

So there's the attic cholesteatomas, there's a middle ear cholesteatomas,

3:45

there's cholesteatomas involved in the external auditory canal,

3:48

and then there's mi cholesteatomas.

3:51

So a congenital cholesteatoma is an embryonic rest of

3:56

epithelial tissue that does not have any history of a typa membrane perforation.

4:01

And when the surgeons look in,

4:03

what they see is this purley white mass that's located behind the typa membrane.

4:07

So that's classic. To make the diagnosis of a genital cholesteatoma,

4:12

you have to have a focal mass that's located behind the membrane

4:17

and you shouldn't have any history of chronic otitis media.

4:20

Notice how these air cells are very well aerated. Okay?

4:24

So this is a small little epithelial, uh, soft tissue. Excuse me.

4:28

This is the small classic cholesteatoma that's located in the middle ear cavity.

4:35

Now what about acquired cholesteatomas?

4:38

So acquired cholesteatomas have different ways that you,

4:41

they can arise and there are different ways of that's been attributed

4:46

to cholesteatomas. So first is this invagination theory,

4:50

and this was this, and this is always associated with Alexander Prussack.

4:55

So what happens in Cholesteatomas is that you end up having eustachian tube

4:59

dysfunction.

5:00

And remember the eustachian tube provides air to the middle ear cavity.

5:04

So it allows aeration of that middle ear.

5:07

Now what ends up happening is that if you have chronic ear disease,

5:11

this eustachian tube becomes dysfunctional.

5:14

So instead of the air coming in and kind of having positive vectors and trying

5:18

to move this stuff out, the the debris outside,

5:22

you end up having negative vectors. And that ends up, uh,

5:25

sucking up to the typa membrane.

5:28

So the typa membrane has this tense part here and it has a flacid part up here.

5:34

So what ends up happening is as these vectors switch,

5:36

you end up having this earliest little retraction here and that's

5:41

what's referred to as retraction pocket.

5:44

And as you end up having debris in the retraction pocket,

5:47

then you end up having a klut that's located within the attic.

5:51

And this is sometimes called an attic koma.

5:55

And this is what's associated with prosac space.

6:00

Now, if you can, this is just an example of a traction pocket.

6:03

This is an attic cholesteatoma.

6:05

So this was actually path proven and this is that classic attic cholesteatoma.

6:11

Now another type of uh, cholesteatoma is the pars tena cholesteatoma.

6:16

And this is felt to be due to the migration theory in which you have small

6:20

little perforations involved within typa membrane.

6:24

So what you end up having is this little epithelial debris that extend up

6:27

transgressing the typa membrane at the level of the meso tum.

6:32

So in unlike attic cholesteatomas,

6:35

which are located more superiorly in the middle ear cavity,

6:39

these tend to be more in the mid portion of the middle ear cavity.

6:43

And here we can see erosion of the long process of the inus.

6:48

And this is an example of a mural cholesteatoma.

6:51

So a mural cholesteatoma really is a more descriptive cholesteatoma.

6:55

So these are large cholesteatomas that have extensive erosion that eventually

7:00

evacuate.

7:01

And it gives you this term that's referred to as an auto mastoidectomy.

7:06

So this was a case that was given to me by one of my colleagues.

7:08

This was back in 2014 on a head ct.

7:11

There was a small little soft tissue mass that, you know,

7:14

wasn't commented on 'cause it was part of a head ct.

7:17

And then about seven years later, this thing expanded and completely ero uh,

7:22

extended into the middle ear cavity and the mastoid air cells and actually

7:26

resulted in a fistula right here of the lateral semicircle canal. But over time,

7:31

that cholesteatoma actually underwent evacuation. And um,

7:36

central, I don't don't wanna necessarily want to use the term necrosis,

7:39

but e evacuation.

7:41

And notice how now you have this appearance that the patient appears to have

7:45

undergone a mastoidectomy. They really haven't.

7:47

This was just the extent of bone erosion of the chot and then it's centrally

7:52

evacuated.

7:53

So this is what's referred to as a neuro cholesteatoma giving you the auto

7:57

mastoidectomy appearance. One last comment is,

8:01

at least the surgeons that I work with, that I talk to,

8:03

they tend not to separate between parse, tensor, chot and parse.

8:07

They just call 'em all cholesteatomas.

8:09

And so really our job is to define the extent of it.

8:12

So let me stop there and take any questions.

8:15

Um, Dr. Suez,

8:16

I have seen the masking answer you mentioned about the cholesteatoma can

8:21

extend into the mask for acls. Mm-hmm. And sometimes people,

8:26

some people with resection or the media oma,

8:29

they have residual in the mastoid air cells.

8:33

Yes. Um, and that's a really, really good point. Um,

8:37

what I have seen is that I have seen a run of cholesteatomas

8:43

that are actually in the mastoid air cells. So they've undergone a,

8:46

a total irregular resection, but um, they end years later,

8:51

they end up having cytomas involved in the distal portion of the mastoid air

8:54

cells. From a radiological standpoint,

8:56

the only way we can make that differentiation is that if you just see mucosal

9:01

thickening involved in the mastoid air cells and the little bony structures are

9:06

intact,

9:07

then all you can say is that there's either a fusion or just mucosal thickening.

9:12

But if you see, uh,

9:14

a soft tissue mass that actually is associated with the bone erosion,

9:18

then you can suggest cholesteatoma. Now in this particular case,

9:22

this patient was febrile and had clinical symptoms of a mastoiditis.

9:26

So in this case this was coalescent mastoiditis.

9:29

But let's say the patient had no clinical symptoms,

9:32

they had a conductive hearing loss, they didn't have a fever,

9:35

and then you see all of this stuff here with the bone erosion,

9:39

then you can suggest that this is actually colome involving the mastoid air

9:43

cells.

9:44

So, uh, when, when can, uh, when can uh,

9:47

confidently say that there is a step is erosion or,

9:52

or it it just covered by the soft tissue?

9:55

Yeah, that's a great question. Um, so I'll put it this way, Ashish,

9:59

is that if you have mucosal thickening involve the middle ear cav and the middle

10:03

ear cavities will pacify,

10:05

you lose the ability to normally see the normal staes.

10:09

So what I've learned over the years is that if I just have, um,

10:13

a soft tissue in the middle ear cavity and I see the malus and the,

10:18

and all the parts of the malice and all the parts of the incus and I'm,

10:23

I just don't see the stape as well compared to the opposite side,

10:26

I'm a little bit more reluctant to call cholesteatoma,

10:29

especially if the middle ear C is completely opacified.

10:34

But if I do see a focal mass, um,

10:38

and there is absence of the staes, if, if it's focal,

10:42

then I'm more apt to call it cholesteatoma. Now one thing that I do as well too,

10:46

and this is something I learned, you know, back when I was a fellow,

10:50

is that in my report,

10:52

komas that erode the obstacles are typically associated with a 30 decibel

10:56

hearing loss.

10:57

So I would typically say that if I am considering a ctet,

11:02

especially on the ones that I'm not as sure of,

11:05

I'll just go and say that these findings should be correlated with a 30 decibel

11:08

conductive hearing loss.