耳鼻咽喉科学英文版课件 cholesteatoma.ppt

1、上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalCholesteatomaShankaiShankai Yin Yin Prof Dept of Otolaryngology, the sixth hospital affiliated to Shanghai jiaotong university Otolaryngology institute at Shanghai jiaotong university上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalEpidemiologyo Exact

2、 prevalence is unknowno Incidence estimated between 3 and 12.6 per 100,000上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalClassificationo Congenitalo Acquiredn Primary acquired (retraction pocket)n Secondary acquired上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalPathogenesiso Congenitaln Arise fr

3、om embryonal rests of epithelial cellsn Location (petrous pyramid, mastoid and middle ear cleft)n Levenson criteria White mass medial to normal TM Normal pars flaccida and tensa No history of otorrhea or perforations No prior otologic procedures Prior bouts of otitis media not grounds for exclusion上

4、海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalnTheories “Acquired” inclusion theory - TosEpidermal rest theory- Teed Michael 上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalCongenital cholesteatoma上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospitalo Primary acquiredn Eustachian tube dysfunctionn Po

5、or aeration of the epitympanic spacen Retraction of the pars flaccidan Normal migratory pattern alteredn Accumulation of keratin, enlargement of sac上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalPrimary acquired cholesteatoma上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospitalo Secondary acquiredn Im

6、plantation surgery, foreign body, blast injuryn Metaplasia transformation of cuboidal epithelium to squamous epithelium from chronic infectionn Invasion/Migration medial migration along permanent perforation of TMn Papillary ingrowth intact pars flaccida, inflammation in Prussacks space, break in th

7、e basal membrane, cords of epithelium migrate inward上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospital上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalClinical manifestationso Commonn Painless otorrhean Refractory/recurrent ear infectionsn Conductive hearing losso Uncommonn Vertigo/Sensorineural n Fa

8、cial nerve paralysisn CNS infectionsn Brain herniation/CSF leakn Pneumocephalus 上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospitalo historyo Physical Examinationn Otomicroscopyn Posterosuperior retraction pocket with squamn Granulation from diseased bonen Aural polypsn Pneumatic otoscopy positive fis

9、tula response suggests erosion into labyrinthn Cultures should be obtained in infected earsDiagnosis上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospitalo Audiology n usually conductive loss, may vary greatly; confirm with tuning forkso Imaging n CT temporal bone definitely obtain for revision cases, co

10、mplications of chronic suppurative otitis media, sensorineural hearing loss, vestibular symptoms, other complications of cholesteatoma上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalImagingo Purposen Diagnosisn Determining extentn Risk assessmento Modalitiesn Plain filmn Computed tomography scansn

11、Magnetic Resonance imaging上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospitalp Goals of CT Imagingn Middle ear ventilationn Ossicular destructionn Epitympanum accessn Mastoid cortexn Tegmen integrityn Labyrinth involvementn Facial nerve involvementn Surgical changes上海市第六人民医院上海市第六人民医院Shanghai Sixth Peo

12、ples Hospital上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospital上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospital上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalCT disadvantageso Granulation tissue vs. cholesteatomao Specific soft tissue problemsn Dural involvementn Abscessn Brain herniationn Labyrin

13、th involvementn Sigmoid sinus thrombosiso MRI needed上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalMR Imagingo Hypointense on T1n Isointense to braino Intermediate on T2o Nonenhancingo Granulation tissue does enhanceo Recurrence detectionn Lesions 2mmn 90% sensitive, 100% specificity上海市第六人民医院上海市第六

14、人民医院Shanghai Sixth Peoples Hospitalo T2o Delayed contrast T1上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalDifferential Diagnosiso Chronic serous otitis mediao Jugulotympanic paragangliomaso Cholesterol granulomaso Neurofibromaso Hemangiomaso Arachnoid cysto Jugular bulb anomalieso Tympanosclerosi

15、so encephalocele上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalTreatmentCreate a “dry and safe” ear上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospitalp Non-surgicaln Treat the Infection Floxin Otic Dropsn Decrease the inflammation Topical steroidsn Debridement of the external canal上海市第六人民医院上海市第六人民医院

16、Shanghai Sixth Peoples Hospitalp Surgicaln Atticotomy n Radical Mastoidectomyn Bondy Modified Radical (Canal wall down) mastoidectomyn Tympanoplasty and canal wall up mastoidectomy上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalPrognosiso Residual or recurrent cholesteatoma over 5 years 15 to 40%n

17、Reported to be up to 67% in the pediatric populationo Close follow - up n Regular examinations needed - 6 months上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalComplicationso Dural tear - CSF leako Fistula of the horizontal semicircular canal (vertigo) Up to 10%o Facial nerve injuryo Injury to the

18、sigmoid sinus / jugular bulbo Otitic Hydrocephaluso Hearing lossn30% have conductive loss pre-operativelynPostoperatively, an additional 30% have worsening or onset of hearing loss due to extent of diseaseo Infection Meningitis, Abscess, lateral sinus thrombosis Up to 1%上海市第六人民医院上海市第六人民医院Shanghai Si

19、xth Peoples HospitalPredisposing factorso Virulent organismso Cholesteatoma and bone erosiono Presence of a congenital dehiscence (e.g.dehiscent facial canal) or a preformed pathway (e.g. skull base fracture)o Obstruction of drainage e.g. by a polyp.o Low resistance of the patient上海市第六人民医院上海市第六人民医院S

20、hanghai Sixth Peoples HospitalPathways of infectiono The commonest way for extension of infection is by bone erosion due to a cholesteatoma.o Vascular extension (retrograde thrombophlebitis).o Extension along preformed pathways as Congenital dehiscences, fracture lines, round window membrane, the la

21、byrinth, Dehiscences due to previous surgery.上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalClassificationo Cranial complicationso Extra-cranial complicationso Intra-cranial complications上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalpCranial complicationsn Acute mastoiditis and mastoidabscesses

22、 (most common complication).n Petrositis.n Labyrinthitis.n Facial paralysis.n Osteomyelitis of the temporal bone上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalpExtra-cranial complicationso External otitiso Cervical lymphadenitiso Retropharyngeal o Parapharyngeal abscesses上海市第六人民医院上海市第六人民医院Shanghai

23、 Sixth Peoples Hospitalp Intracranial complicationsn Extradural abscess (commonest intracranial complication).n Subdural abscess.n Meningitis.n Brain abscess: Temporal lobe abscess. Cerebellar abscess.n Lateral sinus thrombosis.n Otitic hydrocephalus.上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospital

24、o Potentially life threateningo Suppurative otorrhea, chronic headache, pain, fever impending intracranial complicationo Mental status changes, nuchal rigidity, cranial neuropathies require neurosurgical consult上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospital上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples Hospital上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalBrain Abscess上海市第六人民医院上海市第六人民医院Shanghai Sixth Peoples HospitalQuestions?