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Postoperative Diffusion TSE of residual cholesteatoma

Case Study
Verbist, Berit, M.D., Ph.D. Leiden University Medical Centre • Netherlands

Patient history

A 44-year-old male was operated on for recurrent cholesteatoma after previous ear surgeries. Due to the extent of the disease and the patient’s wish to preserve hearing, the cholesteatoma could not be completely removed.

Postoperative MRI was ordered to evaluate the residual disease.

MR examination

The MRI exam was performed at Leiden University Medical Center using Achieva 3.0T with
the 32-channel SENSE Head coil.

Images

 Preoperative CT<br>
Preoperative CT
 T2 weighted<br>
T2 weighted
 Diffusion TSE<br>
Diffusion TSE
 ADC<br>
ADC
 T1 weighted<br>
<br><br>
T1 weighted


Preoperative CT images show a large, expansive mass extending along the posterior border of the temporal bone towards the superior semicircular canal (SSCC) (arrows).

 

Coronal T2-weighted images show hyperintense signal medial to the SSCC (arrow) as well as lateral to the vestibular system (asterisk).

 

On Diffusion TSE (non-EPI DWI, pixels 1.79 x 2.32 mm, scan time 4:20 min.) hyperintense signal is present medial to the SSCC, with low signal intensity on the corresponding ADC mapping. This restricted diffusion is compatible with residual cholesteatoma.

 

Contrast-enhanced T1-weighted images (pixels 0.47 x 0.59 mm, 3:47 min.) confirm the presence of non-enhancing cholesteatoma (arrows) medial to the SCC, whereas the mastoid cavity is filled with enhancing granulation tissue (asterisk).

Diagnosis

Residual cholesteatoma was found in this patient.

Clinical impact of using Diffusion TSE

The contrast-enhanced images were acquired 30-45 minutes after contrast administration to be able to distinguish the slowly enhancing granulation tissue from cholesteatoma, putting a strain on the workflow, whereas Diffusion TSE is quick and easy to obtain. In this case it has been shown to have a high sensitivity and specificity for detection of cholesteatoma.

 

In head/neck imaging the motion and the susceptibility can distort standard EPI diffusion images enormously, so we need a method that is less prone to susceptibility artifacts. In addition, we need very thin slices, and it shouldn’t take too long. Diffusion TSE solves this by providing high quality images in a short acquisition time.

 

There are several indications for Diffusion TSE in head and neck, such as otology and oncology. I’ve been using it a lot to help in assessment for cholesteatoma, which can result after chronic infection in the middle ear. Usually when patients have surgery for this condition, they will have another surgery about a year later to look for residual disease, but when we are able to visualize recurrent or residual disease with Diffusion TSE, we can make a better selection of the patients who will undergo a second operation.



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Jun 24, 2014

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Case Study
Ingenia 3.0T
Release 4
cholesteatoma, Diffusion TSE, DWI, ear, Head, Neuro, SENSE Head coil
 

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