- Pictorial Review
- Open Access
Non-echoplanar diffusion weighted imaging in the detection of post-operative middle ear cholesteatoma: navigating beyond the pitfalls to find the pearl
© The Author(s) 2016
- Received: 18 May 2016
- Accepted: 4 August 2016
- Published: 24 August 2016
Non-echoplanar diffusion weighted magnetic resonance imaging (DWI) has established itself as the modality of choice in detecting and localising post-operative middle ear cleft cholesteatoma. Despite its good diagnostic performance, there are recognised pitfalls in its radiological interpretation which both the radiologist and otologist should be aware of. Our article highlights the various pitfalls and provides guidance for improving radiological interpretation and navigating beyond many of the pitfalls. It is recommended radiological practice to interpret the diffusion weighted images together with the ADC map and supplement with the corresponding T1 weighted and T2 weighted images, all of which can contribute to and enhance lesion localisation and characterisation. ADC values are also helpful in improving specificity and confidence levels. Given the limitation in sensitivity in detecting small cholesteatoma less than 3 mm, serial monitoring with DWI over time is recommended to allow any small residual cholesteatoma pearls to grow and become large enough to be detected on DWI. Optimising image acquisition and discussing at a joint clinico-radiological meeting both foster good radiological interpretation to navigate beyond the pitfalls and ultimately good patient care.
• Non-echoplanar DWI is the imaging of choice in detecting post-operative cholesteatoma.
• There are recognised pitfalls which may hinder accurate radiological interpretation.
• Interpret with the ADC map /values and T1W and T2W images.
• Serial DWI monitoring is of value in detection and characterisation.
• Optimising image acquisition and discussing at clinico-radiological meetings enhance radiological interpretation.
- Diffusion weighted imaging
Since it was first described in 2006 for the detection of cholesteatoma [1, 2], non-echoplanar diffusion weighted magnetic resonance imaging (DWI) has now firmly established its role as the imaging modality of choice in detecting post-operative cholesteatoma [3–7]. It has superseded CT, echoplanar DWI and delayed contrast MRI by virtue of its superior diagnostic performance [3–8]. Non-echoplanar DWI is capable of acquiring thin slices (as thin as 2 mm) and generating a high resolution matrix, and hence can detect cholesteatoma as small as 2 mm [3–5]. It also has the advantage of not requiring intravenous gadolinium contrast, which is implicated with nephrogenic systemic fibrosis  and intracerebral deposition . It also does not require delayed scans as with delayed contrast MRI . Even though echoplanar DWI has a shorter acquisition time, non-echoplanar DWI performs better than its echoplanar counterpart primarily due to the lack of air-bone susceptibility artefact and distortion at the temporal bones [3, 6]. It offers the potential to reduce the number of mandatory second-look (or re-look) surgery in detecting residual or recurrent disease [3, 5, 7]. However, the limitations of the technique still need to be considered as part of a safer and cost-effective work-up strategy. This article aims to highlight pitfalls of radiological interpretation and empower the reader with necessary approaches to navigate beyond the pitfalls.
Typically, two b values are sufficient to generate the ADC map, which is reconstructed following acquisition of the scans . More b values can be used to strengthen further the ADC map, but would incur a longer scanning time and a higher risk of patient movement during scanning and image misregistration. Crucially, for non-multidirectionally acquired sequences (such as HASTE), which require separate acquisitions for each b value, the measurement parameters and the slice positions for the various b values have to be identical (copy-referenced) to promote better image registration and generation of the ADC map. Getting the patient to co-operate by keeping still during DWI scanning is vital for achieving good slice registration and image quality.
Following canal wall up mastoidectomy, a mandatory second-look surgery is performed 9–12 months later to detect residual disease. This is because the current literature suggests that canal wall up procedures are associated with rates of residual and recurrent disease of anything up to 36 and 18 %, respectively [3, 27, 28].
There are many studies to date that have evaluated the performance of non-echoplanar DWI in detecting post-operative cholesteatoma [2, 8, 12–23, 25, 29–39]. They are all observational studies with some studies having mixed post-operative and primary cholesteatoma cases in their study samples. The studies include both prospective cohort and retrospective studies, with sample sizes up to 158 patients . The vast majority of the studies demonstrate a sensitivity and specificity between 80 and 100 % in detecting middle ear cholesteatoma. A previous meta-analysis of 10 studies in 2013 reported a sensitivity and specificity of 94 % in detecting middle ear cholesteatoma .
The high diagnostic performance of DWI in detecting post-operative cholesteatoma lends support for a non-invasive alternative for reliably detecting post-operative disease. Apart from detecting post-operative cholesteatoma, DWI has also been shown to correlate well with surgery in depicting size and location of the disease . It therefore provides useful information for both operative planning and patient counselling. Despite its high diagnostic performance, the technique is associated with some pitfalls in image interpretation attributed by limitations in the technique, variability in the nature and behaviour of cholesteatoma and characteristics and complexity of the reconstructed post-operative anatomy.
CWU surgery is preferred in children because it obviates the potential requirement for lifelong ear care, improves the fitting of hearing aids when required, and is less likely to lead to otorrhoea associated with swimming . Cholesteatoma in children, however, is more aggressive than adult disease and has a higher rate of recurrent and residual disease post-operatively  and the otologist is more inclined to perform mandatory second-look surgery to detect disease. Having said this, a recent large prospective observational study comparing 154 adult cases with 54 paediatric cases in detecting post-operative disease, showed similar good diagnostic performance between the two groups . Hence, clinically, DWI can be considered effective in a paediatric setting as in an adult setting, in which many otologists will have more experience. By avoiding radiation exposure and administration of intravenous contrast medium, DWI is especially attractive for imaging children. However, children are less likely to be tolerant of MRI scanning and may require sedation. In our experience, successful scanning can be achieved without the need for sedation, if the clinician explained the essentials of the procedure to the parent and child beforehand.
Even though non-echoplanar DWI has a high diagnostic performance in detecting post-operative cholesteatoma, it is not without limitations. The pitfalls of image interpretation need to be recognised and managed appropriately by both radiologists and otologists for it to contribute to effective and safer patient care.
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