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Original Investigation |

Fusion of Computed Tomography and PROPELLER Diffusion-Weighted Magnetic Resonance Imaging for the Detection and Localization of Middle Ear Cholesteatoma ONLINE FIRST

Garrett D. Locketz, BSc1; Peter M. M. C. Li, MD1; Nancy J. Fischbein, MD1,2; Samantha J. Holdsworth, PhD2; Nikolas H. Blevins, MD1
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
2Department of Radiology, Stanford University, Stanford, California
JAMA Otolaryngol Head Neck Surg. Published online July 14, 2016. doi:10.1001/jamaoto.2016.1663
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Importance  A method to optimize imaging of cholesteatoma by combining the strengths of available modalities will improve diagnostic accuracy and help to target treatment.

Objective  To assess whether fusing Periodically Rotated Overlapping Parallel Lines With Enhanced Reconstruction (PROPELLER) diffusion-weighted magnetic resonance imaging (DW-MRI) with corresponding temporal bone computed tomography (CT) images could increase cholesteatoma diagnostic and localization accuracy across 6 distinct anatomical regions of the temporal bone.

Design, Setting, and Participants  Case series and preliminary technology evaluation of adults with preoperative temporal bone CT and PROPELLER DW-MRI scans who underwent surgery for clinically suggested cholesteatoma at a tertiary academic hospital. When cholesteatoma was encountered surgically, the precise location was recorded in a diagram of the middle ear and mastoid. For each patient, the 3 image data sets (CT, PROPELLER DW-MRI, and CT-MRI fusion) were reviewed in random order for the presence or absence of cholesteatoma by an investigator blinded to operative findings.

Main Outcomes and Measures  If cholesteatoma was deemed present on review of each imaging modality, the location of the lesion was mapped presumptively. Image analysis was then compared with surgical findings.

Results  Twelve adults (5 women and 7 men; median [range] age, 45.5 [19-77] years) were included. The use of CT-MRI fusion had greater diagnostic sensitivity (0.88 vs 0.75), positive predictive value (0.88 vs 0.86), and negative predictive value (0.75 vs 0.60) than PROPELLER DW-MRI alone. Image fusion also showed increased overall localization accuracy when stratified across 6 distinct anatomical regions of the temporal bone (localization sensitivity and specificity, 0.76 and 0.98 for CT-MRI fusion vs 0.58 and 0.98 for PROPELLER DW-MRI). For PROPELLER DW-MRI, there were 15 true-positive, 45 true-negative, 1 false-positive, and 11 false-negative results; overall accuracy was 0.83. For CT-MRI fusion, there were 20 true-positive, 45 true-negative, 1 false-positive, and 6 false-negative results; overall accuracy was 0.90.

Conclusions and Relevance  The poor anatomical spatial resolution of DW-MRI makes precise localization of cholesteatoma within the middle ear and mastoid a diagnostic challenge. This study suggests that the bony anatomic detail obtained via CT coupled with the excellent sensitivity and specificity of PROPELLER DW-MRI for cholesteatoma can improve both preoperative identification and localization of disease over DW-MRI alone.

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Figure 1.
Operative Diagram

AE indicates anterior epitympanum; AM, anterior mesotympanum; H, hypotympanum; MA, mastoid/antrum; PE, posterior epitympanum; and PM, posterior mesotympanum.

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Figure 2.
Computed Tomographic (CT) Scan, PROPELLER Diffusion-Weighted Magnetic Resonance Image (DW-MRI), and Fused Images for a Man With High-Frequency Sensorineural Hearing Loss and Tinnitus

A, The CT scan shows nonspecific opacification of mastoid air cells and hypotympanum. B, PROPELLER DW-MRI shows foci of high intensity in the expected region of the hypotympanum (yellow arrowhead), and a second focus of uncertain location posteriorly (white arrowhead). C, The CT-MRI fusion clearly localizes both foci. The hypotympanic signal was related to a cholesteatoma, whereas the extratemporal focus was presumed to be a clinically insignificant lymph node. This illustrates CT-MRI fusion’s capacity for both improved diagnostic and avoidance of a false-positive result seen on MRI alone.

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Figure 3.
Computed Tomographic (CT) Scan, PROPELLER Diffusion-Weighted Magnetic Resonance Image (DW-MRI), and Fused Images for a Man With Progressive Hearing Loss

A, The CT scan shows nonspecific opacification of the anterior epitympanum and mastoid air cells. B, PROPELLER DW-MRI shows multiple heterogeneous nonspecific signal foci through the middle ear and epitympanum. C, The CT-MRI fusion demonstrates a focus of hyperintensity in the anterior epitympanum, which was confirmed to be cholesteatoma at the time of surgery (arrowhead).

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