Efficacy of added Diffusion sequences to the enhanced Magnetic Resonance imaging (MRI) in the diagnosis of pre and postoperative cases of cholesteatoma

Efficacy of added Diffusion sequences to the enhanced Magnetic Resonance imaging (MRI) in the diagnosis of pre and postoperative cases of cholesteatoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of added Diffusion sequences to the enhanced Magnetic Resonance imaging (MRI) in the diagnosis of pre and postoperative cases of cholesteatoma Mohamed Salah Elfeshawy, Ahmed Nabil Elsamanody This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3931242/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background We aimed to assess the efficacy of added diffusion to Magnetic resonance Imaging (MRI) with contrast injection for early and accurate cholesteatoma detection by comparing the radiological findings with operative and histopathological data and in the postoperative patients to differentiate between operative bed granulation tissue from the residual/recurrent cholesteatoma. Methods We assessed 40 patients using HRCT and specific MRI protocol for imaging temporal bones. The patient selection was based on clinical examination and follow-up of postoperative pathologically proven cases. In view of diffusion and MRI findings, cholesteatoma was diagnosed in 28 out of 40 cases. All 40 cases had surgery, and 30 patients had been proven during the operation as cholesteatoma. Results The study revealed the high sensitivity and specificity of the added diffusion study to MRI with contrast in diagnosing cholesteatoma and differentiating between operative bed granulation tissue and the residual/recurrent cholesteatoma. Conclusions The MRI examination plays precious role in detecting cholesteatoma, in pre and postoperative conditions. A combination of diffusion sequences, T1, T2 and T1 delayed post-contrast Weighted Images (WIs) are helpful for the early detection of cholesteatoma and for discriminating operative bed granulation tissue from the residual/recurrent cholesteatoma. Cholesteatoma High resolution computed tomography Magnetic resonance imaging Diffusion-weighted imaging Figures Figure 1 Figure 2 Figure 3 Background Cholesteatoma is composed of keratinizing squamous epithelium and resembles the epidermoid cyst histologically. They might be asymptomatic or manifest with otorrhea, conductive type of hearing loss, or dizziness. It occur at different locations along the petrous temporal bone, either in the external auditory canal, middle ear, apex petrous bone, or mastoid [ 1 ]. Cholesteatomas are locally aggressive, potentially dangerous diseases, and surgical removal is the only treatment. HRCT is considered the first radiological tool in the diagnosis and assessment of the primary site, extension, bone destruction, and possible intracranial extension [ 2 ]. High-resolution computed tomography (HRCT) cannot differentiate between operative bed granulation tissue and residual/recurrent cholesteatoma [ 3 ]. In order to properly analyse soft tissue abnormalities undetermined in the HRCT examination, diffusion WI and MRI are important in diagnosing cholesteatomas in pre- and postoperative situations. Diffusion WI and magnetic resonance imaging enable the radiologist to differentiate between granulation tissue and residual/recurrent cholesteatoma [ 4 ]. In addition, diffusion WI and magnetic resonance imaging easily assess the possible complications, like sinus thrombosis and intracranial abscess [ 5 ]. Methods Study Design It was a prospective study using HRCT and MRI radiological evaluation of the temporal bone. The study was carried out over a period of 18 months between February 2021 and August 2022. Written consent approval to participate in this study was taken. Inclusion Criteria: Clinically suspected patients referred from the Otorhinolaryngology department, faculty of medicine, Al Azhar university, Cairo, Egypt. Previous surgical intervention for histopathologically proven cholesteatoma. Exclusion Criteria: Patients have metallic implants/prosthesis incompatible with MRI machine. Claustrophobic patients. Imaging Technique 1. MRI MRI with special reference to the temporal bone using Philips Achieva 1.5 T (Philips, Netherlands). The ideal MRI scan would be short in duration and nonstrenuous for the patient and technician. For pediatric patients, we used sedation or general anesthesia. For neuro-otologic MRI examinations, multichannel coils enabled parallel imaging of both temporal bone and brain stem were targeted. Standard MRI protocol is: T1WI axial and coronal images without contrast: TR (Time of Repetition): 750 msec. TE (Time to Echo): 12.2 msec.FOV (Field Of View): 22 mm. The thickness of the slices: 2 mm. Matrix: 288/224, NEX: 6. T2WI in the coronal plane: TR: 3640 ms. TE: 85 ms. The thickness of the slices: 2 mm. FOV: 22 mm. Matrix: 320x256, NEX: 4. Single shot turbo spin echo diffusion-weighted (SS TSE DW), (non-echoplanar; non-EP), axial plane: TR: 6250 msec. TE: 126 msec. FOV: 24 mm. b factor 0, 800 and 1000 mm 2 /s. The thickness of the slices: 2 mm. 3D Fast Imaging Employing Steady-state Acquisition, (FIESTA): TR: 8 msec. TE: 4 msec. Slice thickness: 1 mm. Matrix: 512 ×512. FOV: 160x160 mm. T1WI coronal delayed post contrast-enhanced images after Dotarem (gadoterate meglumine) IV injection by about 45 minutes (the dose was 0.1 mmol/ kg). Coronal images had fewer artifacts than axial images. 2. HRCT All patients were examined by Multidetector computed tomography (MDCT) scanning using CT machines, 160 slices, Toshiba Medical Systems, and Aquilion Prime (Made in Japan). Image parameters Slice thickness: 0.75mm, slice interval: 0.25mm, rotation time: 0.6 second, tube voltage: 135 KV, tube current 160 mA, Field of View (FOV): 250 mm, matrix: 725 x 725, window level (WL): 600 and window width (WW): 3000. The scan area extends from the posterior cranial fossa above to mastoid air cells below, parallel to the infra-canthomeatal line alignment in the axial image. Results Forty cases (22 male and 18 female) age vary from 10–50 years, with a mean age of 30 years). Twenty-two patients had no previous surgical history, and 18 patients underwent surgery for cholesteatoma. Using Single shot turbo spin echo (SS TSE) DWI sequence, the study was positive for cholesteatoma if we found a hyper-intense lesion in DWI and low signal in the Apparent diffusion coefficient (ADC) (restricted diffusion pattern), and it correlates with abnormal findings in remaining MRI sequences and high-resolution CT images. Average ADC value for cholesteatomas was 859,4 × 10 − 6 mm 2 /s (range 1545 × 10 − 6 mm 2 /s; IQR = 362 × 10 − 6 mm 2 /s; σ = 276,3 × 10 − 6 mm 2 /s), while for non-cholesteatomatous inflammatory lesions, it was 2216,3 × 10 − 6 mm 2 /s (range 1015 × 10 − 6 mm 2 /s; IQR = 372,75 × 10 − 6 mm 2 /s; σ = 225,6 × 10 − 6 mm 2 /s). In the MRI study, cholesteatoma displays a low to intermediate signal in T1WI, bright signal in the T2WI, and no or minimal peripheral post-contrast enhancement in 45 minutes delayed post-contrast images. In CT, cholesteatoma displays ill-defined tissue density with or without bone destruction. Figure 1 reveals typical CT and MRI findings of cholesteatoma. Absent corresponding abnormal signal in diffusion study was seen in non-cholesteatomatous lesions (inflammatory tissue and postoperative granulation tissue). Non-cholesteatomatous lesions reveal homogeneous enhancement in delayed post-gadolinium T1W images. Non-cholesteatomatous lesions show a non-specific CT soft tissue opacification. In our study, we clarify radiological findings positive and other negative for cholesteatoma. In addition, we reported the presence or absence of coexistence of the inner ear and intracranial complication. We calculated and compared the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) results of our radiological findings with the most recent studies. SS TSE DWI showed a restricted diffusion pattern of cholesteatoma in 28 patients. Yet, we found 30 cases of cholesteatoma intraoperatively. TSE DWI showed two false negative cases; the first case was postoperative because of movement artifact, and the other was primary acquired cholesteatoma, which was smaller than the used slice thickness. No false positive cases were found in our study. Cholesteatoma displays either an intermediate or low signal in T1WI and a bright signal in T2WI. The bright T2WI signal is much less bright than the high T2 signal in inflammatory lesions. Table 3 shows a signal pattern of MRI that can differentiate inflammatory/granulomatous lesions from cholesteatoma. Discussion The HRCT of the petrous is considered the first radiological tool in diagnosing cholesteatoma accurately; assessing its site, extension, and coexisting complications. HRCT is limited in postoperative cases and cannot differentiate inflammatory/granulation tissue from recurrent or residual cholesteatoma [ 10 , 11 ]. MRI is helpful in the diagnosis of cholesteatomas in pre and postoperative cases. Moreover, MRI with diffusion and delayed enhanced images can strongly differentiate postoperative granulation/inflammatory tissue from cholesteatoma [ 12 ]. Fan X et al. [ 13 ] use the EP DW (Echo-Planar Diffusion-Weighted ) technique to diagnose and differentiate middle ear inflammation from acquired cholesteatoma. The technique of DWI measures the water molecules' random motion in tissues. We used the diffusion coefficient of water as a reference for comparison with other diffusion coefficient values of different tissue types [ 14 ]. For example, cholesteatomas show high signals in DWI and restricted diffusion patterns [ 15 ]. There are two techniques for DW imaging: Echo-Planar (EP) and non-echo planar single-shot turbo spin echo (SS TSE) DWI. Few comparative studies between the two techniques of DWI in the diagnosis of cholesteatoma were carried out [ 16 ]. Fewer susceptibility artifacts are seen in the non-echo planar SS TSE DWI, thus it is better than the EP DWI to avoid the pitfalls of the high signal at the interface between the bone and brain as well as the air, which could be misdiagnosed for high diffusion signal of cholesteatoma [ 17 ]. Furthermore, the non-echo planar SS TSE DW sequence has better contrast and spatial resolution than the EP DWI, enabling early detection of tiny cholesteatomas equal to or more than 2.5 mm [ 18 ]. Our study used non-echo planar SS TSE DWI; DWI is specifically sensitive for diagnosing cholesteatoma and epidermoid cysts because cholesteatoma and epidermoid cysts have similar histopathology [ 19 ]. Khemani S et al. [ 20 ] use delayed post-contrast T1WI, 45 minutes after intravenous gadolinium injection to diagnose postoperative residual cholesteatoma and differentiate it from the inflammatory and/or scar tissue. The residual/recurrent cholesteatoma showed non or marginal delayed post-contrast enhancements, while the inflammatory and/or scar tissue showed delayed homogeneous enhancement. We reported either no or delayed marginal enhancement in cases of cholesteatoma, while the inflammatory and/or scar tissue showed delayed homogeneous enhancement. MRI can detect the associated inner ear and/or intracranial complications [ 8 ]. De Foer et al. [ 7 ] declared the MRI accuracy in the detection of the inner ear and/or intracranial complications such as labyrinthine fistula and intracranial extension through tegmen tympani erosions. Limitations : The diffusion MRI sequences are not accurate as HRCT in bone visualization. False-negative results in DWI are seen in small or evacuated pockets of cholesteatoma < 5mm in size [ 21 ]. False positive displays in DWI are seen in cases of previous surgical intervention and the presence of Silastic sheet material, displays a false high signal in DWIs. Detailed surgical history should be available for radiologists [ 22 ]. For the long examination period, we need 45 minutes after contrast injection in addition to the time of pre-contrast examination. Moreover, there are some general drawbacks such as the relatively high cost of MRI imaging with contrast and diffusion study, the requirement of a high magnetic failed MRI machine (At least 1.5 tesla), general anesthesia in very young children and uncooperative patients. It is obligatory to have temporal bone HRCT for all patients for better osseous assessment [ 23 ]. Conclusion The early clinical and radiological diagnosis yields a better prognosis and good surgical outcome, interfering with potential complications. The availability of HRCT machines enables radiologists to better assess petrous bone, early cholesteatoma detection, and assess potential complications preoperatively. HRCT can still not discriminate among variable pathologies of the petrous bone, especially in postoperative conditions. The MRI examination plays a crucial role in detecting cholesteatoma, in pre and postoperative conditions. A combination of diffusion sequences, T1, T2, and T1 delayed post-contrast WIs are very helpful for the early detection of cholesteatoma and for differentiating operative bed granulation tissue from the residual/recurrent cholesteatoma. List Of Abbreviations 3D-FIESTA WI Three-dimensional fast imaging employing steady-state acquisition ADC Apparent diffusion coefficient DWI Diffusion-weighted imaging EP Echo- planar HRCT High-resolution computed tomography MRI Magnetic Resonance Imaging SS TSE Single shot turbo spin echo Declarations Ethics approval and consent to participate : All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent for publication was taken from all patients. Availability of data and materials : yes Competing interests : The authors declare that they have no conflicts of interest. Funding : Nil Authors' contributions : both authors share in collecting, analysis and revising the study data. Acknowledgements : Department of Diagnostic and Interventional Radiology, AL Hussein Hospital, Faculty of Medicine (for boys). Al-Azhar University, Cairo. Egypt. Author Contribution Elfeshawy and Elsamanody wrote the main manuscriptElfeshawy prepared figures.Elfeshawy and Elsamanody wrote the result , Disscusion and conclusion. References Manik S, Dabholkar Y, Bhalekar S, Velankar H, Chordia N, Saberwal A. Sensitivity and specificity of high-resolution computed tomography (HRCT) of temporal bone in diagnosing cholesteatoma and its correlation with intraoperative findings. Indian J Otolaryngol Head Neck Surg. 2021;73:25–9. https://doi.org/10.1007/s12070-12020-01892-z . Beig S, Sharma S, Khalid M. (2019) Revisiting correlation between pre operative high resolution computed tomography and operative findings in attico antral disease. Indian J Otolaryngol Head Neck Surg 71:1351–1356. https://doi:1310.1007/s12070-12018-11419-z. Park SY, Kim MJ, Sikandaner H, Kim D-K, Yeo SW, Park SN. (2016) A causal relationship between hearing loss and cognitive impairment. Acta Otolaryngol 136:480–483. https://doi:410.3109/00016489.00012015.01021931. Benson J, Carlson M, Lane J. (2021) Non-EPI versus multishot EPI DWI in cholesteatoma detection: correlation with operative findings. AJNR Am J Neuroradiol 42:573–577. https://doi:510.3174/ajnr.A6911. Kavanagh RG, Liddy S, Carroll AG et al. (2020) Rapid diffusion-weighted MRI for the investigation of recurrent temporal bone cholesteatoma. Neuroradiol J 33:210–215. https://doi:210.1177/1971400920920784. Khan S, Rowlands R, Benjamin E, Abramovich S. (2008) Accuracy of diffusion-weighted magnetic resonance imaging in the diagnosis of cholesteatoma: Abstracts of the Otorhinolaryngological Research Society Meeting Autumn Meeting 26th September 2008, UCL Ear Institute, Gray's Inn Road, London. Clin Otolarngol 33:643–643. https://doi.org/610.1007/s12070-12011-10360-12071. De Foer B, Vercruysse J-P, Pilet B, et al. Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma. Am J Neuroradiol. 2006;27:1480–2. Vaid S, Kamble Y, Vaid N et al. (2013) Role of magnetic resonance imaging in cholesteatoma: the Indian experience. Indian J Otolaryngol Head Neck Surg 65:485–492. https://doi:410.1007/s12070-12011-10360-12071. Aikele P, Kittner T, Offergeld C, Kaftan H, Huttenbrink K-B, Laniado M. (2003) Diffusion-weighted MR imaging of cholesteatoma in pediatric and adult patients who have undergone middle ear surgery. Am J Roentgenol 181:261–265. https://doi:210.2214/ajr.2181.2211.1810261. Corrales CE, Blevins NH. (2013) Imaging for evaluation of cholesteatoma: current concepts and future directions. Curr Opin Otolaryngol Head Neck Surg 21:461–467. https://doi:410.1097/MOO.1090b1013e328364b328473. Xia X, Bai Y, Zhou Y et al. (2017) Effects of 10 Hz repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex in disorders of consciousness. Front Neurol 8:182. https://doi:110.3389/fneur.2021.615356. Choi DL, Gupta MK, Rebello R, Archibald JD. Cost-comparison analysis of diffusion weighted magnetic resonance imaging (DWMRI) versus second look surgery for the detection of residual and recurrent cholesteatoma. J Otolaryngol Head Neck Surg. 2019;48:1–7. https://doi:10.1186/s40463-40019-40384-40461 . Fan X, Liu Z, Ding C, Chang Z, Ma Q. (2019) The value of turbo spin-echo diffusion-weighted imaging apparent diffusion coefficient in the diagnosis of temporal bone cholesteatoma. Clin Radiol 74:977. e971-977. e977. https://doi:910.1016/j.crad.2019.1008.1016. Özgen B, Bulut E, Dolgun A, Bajin MD, Sennaroğlu L. (2017) Accuracy of turbo spin-echo diffusion-weighted imaging signal intensity measurements for the diagnosis of cholesteatoma. Diagn Interv Radiol 23:300. https://doi:310.5152/dir.2017.16024. Lingam RK, Nash R, Majithia A, Kalan A, Singh A. (2016) Non-echoplanar diffusion weighted imaging in the detection of postoperative middle ear cholesteatoma: navigating beyond the pitfalls to find the pearl. Insights into imaging 7:669–678. https://doi:610.1007/s13244-13016-10516-13243. Suzuki H, Sone M, Yoshida T et al. (2014) Numerical assessment of cholesteatoma by signal intensity on non-EP-DWI and ADC maps. Otol Neurotol 35:1007–1010. https://doi:1010.1097/MAO.0000000000000360. van Egmond SL, Stegeman I, Grolman W, Aarts MC. (2016) A systematic review of non-echo planar diffusion-weighted magnetic resonance imaging for detection of primary and postoperative cholesteatoma. Otolaryngol Head Neck Surg 154:233–240. https://doi:210.1177/0194599815613073. Evlice A, Tarkan Ö, Kiroğlu M et al. (2012) Detection of recurrent and primary acquired cholesteatoma with echo-planar diffusion-weighted magnetic resonance imaging. J Laryngol Otol 126:670–676. https://doi:610.1017/S0022215112000679. Muzaffar J, Metcalfe C, Colley S, Coulson C. (2017) Diffusion-weighted magnetic resonance imaging for residual and recurrent cholesteatoma: a systematic review and meta‐analysis. Clin Otolaryngol 42:536–543. https://doi:510.1111/coa.12762. Khemani S, Singh A, Lingam R, Kalan A. (2011) Imaging of postoperative middle ear cholesteatoma. Clin Radiolog 66:760–767. https://doi:710.1016/j.crad.2010.1012.1019. Elefante A, Cavaliere M, Russo C et al. (2015) Diffusion weighted MR imaging of primary and recurrent middle ear cholesteatoma: an assessment by readers with different expertise. Biomed Res Int 2015: https://doi:10.1155/2015/597896 . Cavaliere M, Di Lullo AM, Cantone E et al. (2018) Cholesteatoma vs granulation tissue: a differential diagnosis by DWI-MRI apparent diffusion coefficient. Eur Arch Otorhinolaryngol 275:2237–2243. https://doi:2210.1007/s00405-00018-05082-00405. Gulati M, Gupta S, Prakash A, Garg A, Dixit R. HRCT imaging of acquired cholesteatoma: a pictorial review. Insights into imaging. 2019;10:1–8. https://doi:10.1186/s13244-13019-10782-y . Tables Table 1 The sensitivity, specificity, PPV, and NPV of DWI techniques for the diagnosis of acquired cholesteatoma in the current study compared to prior studies: Study Number of Cases DWI Technique Sensitivity Specificity PPV NPV Khan et al. [ 6 ] 51 EP 83 100 - - De Foer et al. [ 7 ] 57 TSE 82.6 87.2 96 56.5 Sanjay et al. [ 8 ] 20 TSE 92.86 100 100 85 Current study 22 TSE 90.9 100 100 83 Using SS TSE DWI for acquired cholesteatoma, the sensitivity is 90.9%, the specificity is 100%, the PPV is 100%, and NPV is 83% (Table 1 ). Table 2 The sensitivity, specificity, PPV, and NPV of DWI in the diagnosis of postoperative residual /recurrent cholesteatoma in the current study compared to prior studies: Study Number of Cases Sensitivity Specificity PPV NPV Aikele et al. [ 9 ] 22 77 100 100 75 De Foer et al. [ 7 ] 32 90 100 100 96 Sanjay et al. [ 8 ] 11 80 100 100 85.71 Current study 18 66.6 100 100 85 Using SS TSE DWI for postoperative cases, the sensitivity is 66.6%, the specificity is 100%, the PPV is 100%, and the NPV is 85% (Table 2 ). Table 3 Signal pattern of MRI enables the differentiation between cholesteatoma and inflammatory lesions: Sequence Cholesteatoma Inflammatory tissue T1WI Iso intense to low Iso intense to low T2WI Iso intense to high High TSE DWI Restricted diffusion. Free diffusion. Delayed post-contrast T1WI No or marginal contrast enhancement Homogeneous contrast enhancement Table 3 shows a signal pattern of MRI that can differentiate inflammatory/granulomatous lesions from cholesteatoma. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3931242","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":271152097,"identity":"1d1db354-a48f-4a58-9036-1342e1596d4e","order_by":0,"name":"Mohamed Salah Elfeshawy","email":"data:image/png;base64,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","orcid":"","institution":"Al Azhar University","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"Salah","lastName":"Elfeshawy","suffix":""},{"id":271152098,"identity":"9f7f53db-005c-42c8-8e1a-48d8091bfba3","order_by":1,"name":"Ahmed Nabil Elsamanody","email":"","orcid":"","institution":"Al Azhar University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Nabil","lastName":"Elsamanody","suffix":""}],"badges":[],"createdAt":"2024-02-05 14:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3931242/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3931242/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50751880,"identity":"b3bb2036-230c-45b1-bc79-79ff86a1ed82","added_by":"auto","created_at":"2024-02-06 17:40:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":531549,"visible":true,"origin":"","legend":"\u003cp\u003eThe selected CT and MRI Images showing typical MRI signals of cholesteatoma: (A) Axial HRCT. (B) Coronal HRCT. (C) T2 WI Coronal. (D) T2 high-resolution Axial. (E) DWI. (F) ADC (G) T1WI without contrast coronal. (H) Delayed T1WI post-contrast coronal.\u003c/p\u003e\n\u003cp\u003e(A \u0026amp; B) show opacification of the left petrous bone with iso density seen obliterating the right petrous bone with bony erosive changes including scutum, ossicular chain, the tympanic segment of facial nerve bony canal, and tegmen tympani.\u003c/p\u003e\n\u003cp\u003e(C through H) demonstrate a high signal in T2 WI, a bright signal in DWI, and dark in the ADC (restricted diffusion), a low signal in T1WI without contrast and delayed marginal contrast enhancement, exerting labyrinthine fistula, eroding the tympanic bony canal of the facial nerve and tegmen tympani with dural enhancement, but there is no intracranial extension.\u003c/p\u003e\n\u003cp\u003egadolinium T1W images. Non-cholesteatomatous lesions show a non-specific CT soft tissue opacification.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3931242/v1/19b613a3adf985c580a0151e.png"},{"id":50751876,"identity":"72cc1805-add1-4c7f-904b-82a3c3b3d631","added_by":"auto","created_at":"2024-02-06 17:40:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":509929,"visible":true,"origin":"","legend":"\u003cp\u003eSelected CT and MRI Images showing signal of postoperative recurrent/residual cholesteatoma, and this was confirmed during surgery: (A) Axial HRCT, (B) Coronal HRCT, (C) Coronal T2, (D) Axial T2 high resolution, (E) DWI, (F) ADC, (G) Delayed T1WI post-contrast Axial, and (H) Delayed T1WI post-contrast coronal.\u003c/p\u003e\n\u003cp\u003eThe A and B sections show postoperative change related to the right side of mastoidectomy, with granulation tissue of iso density seen obliterating the right petrous bone. (C through F) demonstrate opacified mastoid antrum with soft tissue signal lesion, display bright signal in T2, lows signal in T1 with restricted diffusion pattern (high in DWI and low in ADC), and marginal non-uniform post-contrast enhancement. Moreover, there is no intracranial extension.\u003c/p\u003e\n\u003cp\u003einflammatory/granulomatous lesions from cholesteatoma.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3931242/v1/a53ce663e6b4c6466282eecc.png"},{"id":50751879,"identity":"a26bea78-fbcd-4792-80d5-e98205cc8955","added_by":"auto","created_at":"2024-02-06 17:40:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":416974,"visible":true,"origin":"","legend":"\u003cp\u003eMRI Images showing left petrous cholesteatoma extending to the petrous apex. MRI Images show typical MRI signal of cholesteatoma: (A) coronal T2 WI, (B) axial T2 high resolution, (C) DWI, (D) ADC, (E) Coronal T1 without contrast, (F) Coronal T1 post-contrast. The delayed image shows a bright T2WI signal, restricted diffusion, and low signal in T1 without contrast with delayed marginal contrast enhancement, extending to the petrous apex with dural enhancement, but there is no intracranial extension.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3931242/v1/d2d50ce4a274f8fa255e7b23.png"},{"id":50897069,"identity":"99c861c1-0bc0-40c7-9525-17efdbf7187a","added_by":"auto","created_at":"2024-02-09 06:59:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1642704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3931242/v1/db725713-9fa6-4980-9eb5-723a44d967c5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of added Diffusion sequences to the enhanced Magnetic Resonance imaging (MRI) in the diagnosis of pre and postoperative cases of cholesteatoma","fulltext":[{"header":"Background","content":"\u003cp\u003eCholesteatoma is composed of keratinizing squamous epithelium and resembles the epidermoid cyst histologically. They might be asymptomatic or manifest with otorrhea, conductive type of hearing loss, or dizziness. It occur at different locations along the petrous temporal bone, either in the external auditory canal, middle ear, apex petrous bone, or mastoid [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Cholesteatomas are locally aggressive, potentially dangerous diseases, and surgical removal is the only treatment. HRCT is considered the first radiological tool in the diagnosis and assessment of the primary site, extension, bone destruction, and possible intracranial extension [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHigh-resolution computed tomography (HRCT) cannot differentiate between operative bed granulation tissue and residual/recurrent cholesteatoma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In order to properly analyse soft tissue abnormalities undetermined in the HRCT examination, diffusion WI and MRI are important in diagnosing cholesteatomas in pre- and postoperative situations. Diffusion WI and magnetic resonance imaging enable the radiologist to differentiate between granulation tissue and residual/recurrent cholesteatoma [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In addition, diffusion WI and magnetic resonance imaging easily assess the possible complications, like sinus thrombosis and intracranial abscess [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eIt was a prospective study using HRCT and MRI radiological evaluation of the temporal bone.\u003c/p\u003e \u003cp\u003eThe study was carried out over a period of 18 months between February 2021 and August 2022.\u003c/p\u003e \u003cp\u003eWritten consent approval to participate in this study was taken.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eClinically suspected patients referred from the Otorhinolaryngology department, faculty of medicine, Al Azhar university, Cairo, Egypt.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrevious surgical intervention for histopathologically proven cholesteatoma.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExclusion Criteria:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients have metallic implants/prosthesis incompatible with MRI machine.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClaustrophobic patients.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eImaging Technique\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1. MRI\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMRI with special reference to the temporal bone using Philips Achieva 1.5 T (Philips, Netherlands).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe ideal MRI scan would be short in duration and nonstrenuous for the patient and technician.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFor pediatric patients, we used sedation or general anesthesia.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFor neuro-otologic MRI examinations, multichannel coils enabled parallel imaging of both temporal bone and brain stem were targeted.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStandard MRI protocol is:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eT1WI axial and coronal images without contrast: TR (Time of Repetition): 750 msec. TE (Time to Echo): 12.2 msec.FOV (Field Of View): 22 mm. The thickness of the slices: 2 mm. Matrix: 288/224, NEX: 6.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eT2WI in the coronal plane: TR: 3640 ms. TE: 85 ms. The thickness of the slices: 2 mm. FOV: 22 mm. Matrix: 320x256, NEX: 4.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSingle shot turbo spin echo diffusion-weighted (SS TSE DW), (non-echoplanar; non-EP), axial plane: TR: 6250 msec. TE: 126 msec. FOV: 24 mm. b factor 0, 800 and 1000 mm\u003csup\u003e2\u003c/sup\u003e /s. The thickness of the slices: 2 mm.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e3D Fast Imaging Employing Steady-state Acquisition, (FIESTA): TR: 8 msec. TE: 4 msec. Slice thickness: 1 mm. Matrix: 512 \u0026times;512. FOV: 160x160 mm.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eT1WI coronal delayed post contrast-enhanced images after Dotarem (gadoterate meglumine) IV injection by about 45 minutes (the dose was 0.1 mmol/ kg). Coronal images had fewer artifacts than axial images.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2. HRCT\u003c/h2\u003e \u003cp\u003eAll patients were examined by Multidetector computed tomography (MDCT) scanning using CT machines, 160 slices, Toshiba Medical Systems, and Aquilion Prime (Made in Japan).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eImage parameters\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSlice thickness: 0.75mm, slice interval: 0.25mm, rotation time: 0.6 second, tube voltage: 135 KV, tube current 160 mA, Field of View (FOV): 250 mm, matrix: 725 x 725, window level (WL): 600 and window width (WW): 3000.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe scan area extends from the posterior cranial fossa above to mastoid air cells below, parallel to the infra-canthomeatal line alignment in the axial image.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eForty cases (22 male and 18 female) age vary from 10\u0026ndash;50 years, with a mean age of 30 years).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTwenty-two patients had no previous surgical history, and 18 patients underwent surgery for cholesteatoma.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eUsing Single shot turbo spin echo (SS TSE) DWI sequence, the study was positive for cholesteatoma if we found a hyper-intense lesion in DWI and low signal in the Apparent diffusion coefficient (ADC) (restricted diffusion pattern), and it correlates with abnormal findings in remaining MRI sequences and high-resolution CT images.\u003c/p\u003e \u003cp\u003eAverage ADC value for cholesteatomas was 859,4 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s (range 1545 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s; IQR\u0026thinsp;=\u0026thinsp;362 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s; σ\u0026thinsp;=\u0026thinsp;276,3 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s), while for non-cholesteatomatous inflammatory lesions, it was 2216,3 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s (range 1015 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s; IQR\u0026thinsp;=\u0026thinsp;372,75 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s; σ\u0026thinsp;=\u0026thinsp;225,6 \u0026times; 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e mm\u003csup\u003e2\u003c/sup\u003e/s).\u003c/p\u003e \u003cp\u003eIn the MRI study, cholesteatoma displays a low to intermediate signal in T1WI, bright signal in the T2WI, and no or minimal peripheral post-contrast enhancement in 45 minutes delayed post-contrast images. In CT, cholesteatoma displays ill-defined tissue density with or without bone destruction. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e reveals typical CT and MRI findings of cholesteatoma.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAbsent corresponding abnormal signal in diffusion study was seen in non-cholesteatomatous lesions (inflammatory tissue and postoperative granulation tissue). Non-cholesteatomatous lesions reveal homogeneous enhancement in delayed post-gadolinium T1W images. Non-cholesteatomatous lesions show a non-specific CT soft tissue opacification.\u003c/p\u003e \u003cp\u003eIn our study, we clarify radiological findings positive and other negative for cholesteatoma. In addition, we reported the presence or absence of coexistence of the inner ear and intracranial complication.\u003c/p\u003e \u003cp\u003eWe calculated and compared the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) results of our radiological findings with the most recent studies.\u003c/p\u003e \u003cp\u003eSS TSE DWI showed a restricted diffusion pattern of cholesteatoma in 28 patients. Yet, we found 30 cases of cholesteatoma intraoperatively.\u003c/p\u003e \u003cp\u003eTSE DWI showed two false negative cases; the first case was postoperative because of movement artifact, and the other was primary acquired cholesteatoma, which was smaller than the used slice thickness. No false positive cases were found in our study.\u003c/p\u003e \u003cp\u003eCholesteatoma displays either an intermediate or low signal in T1WI and a bright signal in T2WI. The bright T2WI signal is much less bright than the high T2 signal in inflammatory lesions. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows a signal pattern of MRI that can differentiate inflammatory/granulomatous lesions from cholesteatoma.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThe HRCT of the petrous is considered the first radiological tool in diagnosing cholesteatoma accurately; assessing its site, extension, and coexisting complications. HRCT is limited in postoperative cases and cannot differentiate inflammatory/granulation tissue from recurrent or residual cholesteatoma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003eMRI is helpful in the diagnosis of cholesteatomas in pre and postoperative cases. Moreover, MRI with diffusion and delayed enhanced images can strongly differentiate postoperative granulation/inflammatory tissue from cholesteatoma [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFan X et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] use the EP DW (Echo-Planar Diffusion-Weighted ) technique to diagnose and differentiate middle ear inflammation from acquired cholesteatoma.\u003c/p\u003e \u003cp\u003eThe technique of DWI measures the water molecules' random motion in tissues. We used the diffusion coefficient of water as a reference for comparison with other diffusion coefficient values of different tissue types [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For example, cholesteatomas show high signals in DWI and restricted diffusion patterns [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are two techniques for DW imaging: Echo-Planar (EP) and non-echo planar single-shot turbo spin echo (SS TSE) DWI. Few comparative studies between the two techniques of DWI in the diagnosis of cholesteatoma were carried out [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFewer susceptibility artifacts are seen in the non-echo planar SS TSE DWI, thus it is better than the EP DWI to avoid the pitfalls of the high signal at the interface between the bone and brain as well as the air, which could be misdiagnosed for high diffusion signal of cholesteatoma [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, the non-echo planar SS TSE DW sequence has better contrast and spatial resolution than the EP DWI, enabling early detection of tiny cholesteatomas equal to or more than 2.5 mm [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study used non-echo planar SS TSE DWI; DWI is specifically sensitive for diagnosing cholesteatoma and epidermoid cysts because cholesteatoma and epidermoid cysts have similar histopathology [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKhemani S et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] use delayed post-contrast T1WI, 45 minutes after intravenous gadolinium injection to diagnose postoperative residual cholesteatoma and differentiate it from the inflammatory and/or scar tissue. The residual/recurrent cholesteatoma showed non or marginal delayed post-contrast enhancements, while the inflammatory and/or scar tissue showed delayed homogeneous enhancement.\u003c/p\u003e \u003cp\u003eWe reported either no or delayed marginal enhancement in cases of cholesteatoma, while the inflammatory and/or scar tissue showed delayed homogeneous enhancement.\u003c/p\u003e \u003cp\u003eMRI can detect the associated inner ear and/or intracranial complications [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. De Foer et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] declared the MRI accuracy in the detection of the inner ear and/or intracranial complications such as labyrinthine fistula and intracranial extension through tegmen tympani erosions. \u003cb\u003eLimitations\u003c/b\u003e: The diffusion MRI sequences are not accurate as HRCT in bone visualization. False-negative results in DWI are seen in small or evacuated pockets of cholesteatoma\u0026thinsp;\u0026lt;\u0026thinsp;5mm in size [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. False positive displays in DWI are seen in cases of previous surgical intervention and the presence of Silastic sheet material, displays a false high signal in DWIs. Detailed surgical history should be available for radiologists [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the long examination period, we need 45 minutes after contrast injection in addition to the time of pre-contrast examination. Moreover, there are some general drawbacks such as the relatively high cost of MRI imaging with contrast and diffusion study, the requirement of a high magnetic failed MRI machine (At least 1.5 tesla), general anesthesia in very young children and uncooperative patients. It is obligatory to have temporal bone HRCT for all patients for better osseous assessment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eThe early clinical and radiological diagnosis yields a better prognosis and good surgical outcome, interfering with potential complications. The availability of HRCT machines enables radiologists to better assess petrous bone, early cholesteatoma detection, and assess potential complications preoperatively. HRCT can still not discriminate among variable pathologies of the petrous bone, especially in postoperative conditions.\u003c/p\u003e\u003cp\u003eThe MRI examination plays a crucial role in detecting cholesteatoma, in pre and postoperative conditions. A combination of diffusion sequences, T1, T2, and T1 delayed post-contrast WIs are very helpful for the early detection of cholesteatoma and for differentiating operative bed granulation tissue from the residual/recurrent cholesteatoma.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003e3D-FIESTA WI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThree-dimensional fast imaging employing steady-state acquisition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eADC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eApparent diffusion coefficient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDWI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiffusion-weighted imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eEP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEcho- planar\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHRCT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHigh-resolution computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMRI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSS TSE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSingle shot turbo spin echo\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eConsent for publication was taken from all patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: yes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: both authors share in collecting, analysis and revising the study data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Department of Diagnostic and Interventional Radiology, AL Hussein Hospital, Faculty of Medicine (for boys). Al-Azhar University, Cairo. Egypt.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElfeshawy and Elsamanody wrote the main manuscriptElfeshawy prepared figures.Elfeshawy and Elsamanody wrote the result , Disscusion and conclusion.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eManik S, Dabholkar Y, Bhalekar S, Velankar H, Chordia N, Saberwal A. Sensitivity and specificity of high-resolution computed tomography (HRCT) of temporal bone in diagnosing cholesteatoma and its correlation with intraoperative findings. Indian J Otolaryngol Head Neck Surg. 2021;73:25\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12070-12020-01892-z\u003c/span\u003e\u003cspan address=\"10.1007/s12070-12020-01892-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeig S, Sharma S, Khalid M. (2019) Revisiting correlation between pre operative high resolution computed tomography and operative findings in attico antral disease. Indian J Otolaryngol Head Neck Surg 71:1351\u0026ndash;1356. https://doi:1310.1007/s12070-12018-11419-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark SY, Kim MJ, Sikandaner H, Kim D-K, Yeo SW, Park SN. (2016) A causal relationship between hearing loss and cognitive impairment. Acta Otolaryngol 136:480\u0026ndash;483. https://doi:410.3109/00016489.00012015.01021931.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenson J, Carlson M, Lane J. (2021) Non-EPI versus multishot EPI DWI in cholesteatoma detection: correlation with operative findings. AJNR Am J Neuroradiol 42:573\u0026ndash;577. https://doi:510.3174/ajnr.A6911.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKavanagh RG, Liddy S, Carroll AG et al. (2020) Rapid diffusion-weighted MRI for the investigation of recurrent temporal bone cholesteatoma. Neuroradiol J 33:210\u0026ndash;215. https://doi:210.1177/1971400920920784.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan S, Rowlands R, Benjamin E, Abramovich S. (2008) Accuracy of diffusion-weighted magnetic resonance imaging in the diagnosis of cholesteatoma: Abstracts of the Otorhinolaryngological Research Society Meeting Autumn Meeting 26th September 2008, UCL Ear Institute, Gray's Inn Road, London. Clin Otolarngol 33:643\u0026ndash;643. https://doi.org/610.1007/s12070-12011-10360-12071.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Foer B, Vercruysse J-P, Pilet B, et al. Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma. Am J Neuroradiol. 2006;27:1480\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaid S, Kamble Y, Vaid N et al. (2013) Role of magnetic resonance imaging in cholesteatoma: the Indian experience. Indian J Otolaryngol Head Neck Surg 65:485\u0026ndash;492. https://doi:410.1007/s12070-12011-10360-12071.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAikele P, Kittner T, Offergeld C, Kaftan H, Huttenbrink K-B, Laniado M. (2003) Diffusion-weighted MR imaging of cholesteatoma in pediatric and adult patients who have undergone middle ear surgery. Am J Roentgenol 181:261\u0026ndash;265. https://doi:210.2214/ajr.2181.2211.1810261.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorrales CE, Blevins NH. (2013) Imaging for evaluation of cholesteatoma: current concepts and future directions. Curr Opin Otolaryngol Head Neck Surg 21:461\u0026ndash;467. https://doi:410.1097/MOO.1090b1013e328364b328473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXia X, Bai Y, Zhou Y et al. (2017) Effects of 10 Hz repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex in disorders of consciousness. Front Neurol 8:182. https://doi:110.3389/fneur.2021.615356.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi DL, Gupta MK, Rebello R, Archibald JD. Cost-comparison analysis of diffusion weighted magnetic resonance imaging (DWMRI) versus second look surgery for the detection of residual and recurrent cholesteatoma. J Otolaryngol Head Neck Surg. 2019;48:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1186/s40463-40019-40384-40461\u003c/span\u003e\u003cspan address=\"https://doi:10.1186/s40463-40019-40384-40461\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan X, Liu Z, Ding C, Chang Z, Ma Q. (2019) The value of turbo spin-echo diffusion-weighted imaging apparent diffusion coefficient in the diagnosis of temporal bone cholesteatoma. Clin Radiol 74:977. e971-977. e977. https://doi:910.1016/j.crad.2019.1008.1016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;zgen B, Bulut E, Dolgun A, Bajin MD, Sennaroğlu L. (2017) Accuracy of turbo spin-echo diffusion-weighted imaging signal intensity measurements for the diagnosis of cholesteatoma. Diagn Interv Radiol 23:300. https://doi:310.5152/dir.2017.16024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLingam RK, Nash R, Majithia A, Kalan A, Singh A. (2016) Non-echoplanar diffusion weighted imaging in the detection of postoperative middle ear cholesteatoma: navigating beyond the pitfalls to find the pearl. Insights into imaging 7:669\u0026ndash;678. https://doi:610.1007/s13244-13016-10516-13243.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuzuki H, Sone M, Yoshida T et al. (2014) Numerical assessment of cholesteatoma by signal intensity on non-EP-DWI and ADC maps. Otol Neurotol 35:1007\u0026ndash;1010. https://doi:1010.1097/MAO.0000000000000360.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Egmond SL, Stegeman I, Grolman W, Aarts MC. (2016) A systematic review of non-echo planar diffusion-weighted magnetic resonance imaging for detection of primary and postoperative cholesteatoma. Otolaryngol Head Neck Surg 154:233\u0026ndash;240. https://doi:210.1177/0194599815613073.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvlice A, Tarkan \u0026Ouml;, Kiroğlu M et al. (2012) Detection of recurrent and primary acquired cholesteatoma with echo-planar diffusion-weighted magnetic resonance imaging. J Laryngol Otol 126:670\u0026ndash;676. https://doi:610.1017/S0022215112000679.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuzaffar J, Metcalfe C, Colley S, Coulson C. (2017) Diffusion-weighted magnetic resonance imaging for residual and recurrent cholesteatoma: a systematic review and meta‐analysis. Clin Otolaryngol 42:536\u0026ndash;543. https://doi:510.1111/coa.12762.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhemani S, Singh A, Lingam R, Kalan A. (2011) Imaging of postoperative middle ear cholesteatoma. Clin Radiolog 66:760\u0026ndash;767. https://doi:710.1016/j.crad.2010.1012.1019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElefante A, Cavaliere M, Russo C et al. (2015) Diffusion weighted MR imaging of primary and recurrent middle ear cholesteatoma: an assessment by readers with different expertise. Biomed Res Int 2015: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1155/2015/597896\u003c/span\u003e\u003cspan address=\"https://doi:10.1155/2015/597896\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavaliere M, Di Lullo AM, Cantone E et al. (2018) Cholesteatoma vs granulation tissue: a differential diagnosis by DWI-MRI apparent diffusion coefficient. Eur Arch Otorhinolaryngol 275:2237\u0026ndash;2243. https://doi:2210.1007/s00405-00018-05082-00405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGulati M, Gupta S, Prakash A, Garg A, Dixit R. HRCT imaging of acquired cholesteatoma: a pictorial review. Insights into imaging. 2019;10:1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1186/s13244-13019-10782-y\u003c/span\u003e\u003cspan address=\"https://doi:10.1186/s13244-13019-10782-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe sensitivity, specificity, PPV, and NPV of DWI techniques for the diagnosis of acquired cholesteatoma in the current study compared to prior studies:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDWI Technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKhan et al.\u003c/b\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDe Foer et al.\u003c/b\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSanjay et al.\u003c/b\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent study\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eUsing SS TSE DWI for acquired cholesteatoma, the sensitivity is 90.9%, the specificity is 100%, the PPV is 100%, and NPV is 83% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe sensitivity, specificity, PPV, and NPV of DWI in the diagnosis of postoperative residual /recurrent cholesteatoma in the current study compared to prior studies:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAikele et al.\u003c/b\u003e [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDe Foer et al.\u003c/b\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSanjay et al.\u003c/b\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent study\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eUsing SS TSE DWI for postoperative cases, the sensitivity is 66.6%, the specificity is 100%, the PPV is 100%, and the NPV is 85% (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSignal pattern of MRI enables the differentiation between cholesteatoma and inflammatory lesions:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSequence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholesteatoma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInflammatory tissue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT1WI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIso intense to low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIso intense to low\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT2WI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIso intense to high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTSE DWI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRestricted diffusion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFree diffusion.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelayed post-contrast T1WI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo or marginal contrast enhancement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHomogeneous contrast enhancement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable 3 shows a signal pattern of MRI that can differentiate inflammatory/granulomatous lesions from cholesteatoma.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cholesteatoma, High resolution computed tomography, Magnetic resonance imaging, Diffusion-weighted imaging","lastPublishedDoi":"10.21203/rs.3.rs-3931242/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3931242/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe aimed to assess the efficacy of added diffusion to Magnetic resonance Imaging (MRI) with contrast injection for early and accurate cholesteatoma detection by comparing the radiological findings with operative and histopathological data and in the postoperative patients to differentiate between operative bed granulation tissue from the residual/recurrent cholesteatoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe assessed 40 patients using HRCT and specific MRI protocol for imaging temporal bones. The patient selection was based on clinical examination and follow-up of postoperative pathologically proven cases. In view of diffusion and MRI findings, cholesteatoma was diagnosed in 28 out of 40 cases. All 40 cases had surgery, and 30 patients had been proven during the operation as cholesteatoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study revealed the high sensitivity and specificity of the added diffusion study to MRI with contrast in diagnosing cholesteatoma and differentiating between operative bed granulation tissue and the residual/recurrent cholesteatoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe MRI examination plays precious role in detecting cholesteatoma, in pre and postoperative conditions. A combination of diffusion sequences, T1, T2 and T1 delayed post-contrast Weighted Images (WIs) are helpful for the early detection of cholesteatoma and for discriminating operative bed granulation tissue from the residual/recurrent cholesteatoma.\u003c/p\u003e","manuscriptTitle":"Efficacy of added Diffusion sequences to the enhanced Magnetic Resonance imaging (MRI) in the diagnosis of pre and postoperative cases of cholesteatoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-06 17:40:32","doi":"10.21203/rs.3.rs-3931242/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d70e244-67da-4c48-ab13-fd496ae780b8","owner":[],"postedDate":"February 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-09T06:59:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-06 17:40:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3931242","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3931242","identity":"rs-3931242","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}