1. Jalal jalal shokouhi-MD DIFFUSION IMAGING OF CHOLESTEATOMAS

2. cholesteatomas Epidermoid inclusion cyst Cystic creatinin-filled mass Lined by stratified squamous epithelium Common in frontal bone and ear Cause: secondary to trauma and implanted inner table, outer table jalaljalalshokouhi@hotmail.com www.medimage.ir

3. Mucoid like content DDx with mucocele Fat content of cholestrol T1-MR signal T2 Intermediate high jalaljalalshokouhi@hotmail.com www.medimage.ir

4. Acquired cholesteatoma  Expansile concentrically enlarging collection of exfoliated keratin lined by keratinizing stratified squamous epithelium  Not neoplasm  May or may not contain cholesterol crystals  Congenital (epidermoid) 2%  Acquired in middle ear 98% jalaljalalshokouhi@hotmail.com www.medimage.ir

5. Frontal chole.

6. jalaljalalshokouhi@hotmail.com www.medimage.ir Frontal chole.

7. jalaljalalshokouhi@hotmail.com www.medimage.ir Frontal chole.

8. Acquired: Pars flexia (attic) -> prussak`s space -> mastoid Pars tensa Acquired: Primary acquired (no infection) Secondary acquired (infection) Etiology: retraction*, papillary proliferation, immigration, metplasia jalaljalalshokouhi@hotmail.com www.medimage.ir

9. prussak`s space- pars flexida

10. jalaljalalshokouhi@hotmail.com www.medimage.ir prussak`s space- pars flexida

11. jalaljalalshokouhi@hotmail.com www.medimage.ir

13. Petrosal cholesteatoma -> Apex jalaljalalshokouhi@hotmail.com www.medimage.ir

14. Petrosal chole. APEX

15. jalaljalalshokouhi@hotmail.com www.medimage.ir Pars tensa

16. jalaljalalshokouhi@hotmail.com www.medimage.ir Pars tensa

17. jalaljalalshokouhi@hotmail.com www.medimage.ir Pars tensa

18. jalaljalalshokouhi@hotmail.com www.medimage.ir Pars tensa and tegmental erosion

19. jalaljalalshokouhi@hotmail.com www.medimage.ir Ossicular erosion

20. jalaljalalshokouhi@hotmail.com www.medimage.ir Facial canal erosion

21. jalaljalalshokouhi@hotmail.com www.medimage.ir Acquired cholesteatoma

22. jalaljalalshokouhi@hotmail.com www.medimage.ir Acquired cholesteatoma

23. jalaljalalshokouhi@hotmail.com www.medimage.ir Acquired cholesteatoma

24. jalaljalalshokouhi@hotmail.com www.medimage.ir Auto mastoidectomy

25. jalaljalalshokouhi@hotmail.com www.medimage.ir Auto mastoidectomy

26. Imaging: X-ray CT  bone destruction, soft tissue demo. And complications, uncommon granulation tissue MR spine-echo  non-specific signal  moderately Hyperintense (better for tegmen tympani and sinus) exclude facial nerve involvement GD  for granulation tissue versus non-enhancing cholesteatoma jalaljalalshokouhi@hotmail.com www.medimage.ir

27. Epidermoid

28. jalaljalalshokouhi@hotmail.com www.medimage.ir Epidermoid

29. jalaljalalshokouhi@hotmail.com www.medimage.ir Epidermoid

30. jalaljalalshokouhi@hotmail.com www.medimage.ir EAC chol. with no atresia

31. jalaljalalshokouhi@hotmail.com www.medimage.ir EAC chol. with no atresia

32. jalaljalalshokouhi@hotmail.com www.medimage.ir Cholesteatoma of EAC with atresia

33. CH. In vestibula

34. jalaljalalshokouhi@hotmail.com www.medimage.ir Boney sequestra Ossicular

35. jalaljalalshokouhi@hotmail.com www.medimage.ir Chole. In EAC

36. jalaljalalshokouhi@hotmail.com www.medimage.ir Large Chole. In EAC

37. jalaljalalshokouhi@hotmail.com www.medimage.ir Chole. In middle ear and EAC

38. jalaljalalshokouhi@hotmail.com www.medimage.ir Osteopetrosis

39. In location of geniculate ganglion

40. Diffusion-weighted imaging Cholesteatoma is bright means restricted diffusion and (T2 shine through)  Please be aware eddy current artifacts, susceptibility artifacts, ghosting artifacts, chemical shift and motion artifacts all are prevalent  Higher magnetic fields increase potential of these artifacts in echo-planar DWI  Turbo spin-echo DWI in known to limit, these distortions  Multi shot fast spin-echo periodically rotated overlapping parallel lines with enhanced reconstructions (PROPELLER) DWI= enhanced detection of the lesion (and limiting artifact in high fields) jalaljalalshokouhi@hotmail.com www.medimage.ir

41. If there is no middle ear surgery positive predictive value is 93% and negative predictive value is 100% Sensitivity and specificity 91-100% DW FAST-SPIN-ECHO Factor 14 Matrix of resolution: 192 x 256 “a” “b” factor 800 second/mm2 1.5 tesla 9 sections in 2.5 mm 3’ 38” FOV= 230mm RSNA 2005

42. DW non-echoplanar DW of middle ear cholesteatoma differ from abscess and infected cholesteatoma AJNR DW for post-operative recurrent JU-radiology jalaljalalshokouhi@hotmail.com www.medimage.ir

43. T2 left recurrent cholesteatoma-Right granulation tissue GD T1 enhanced right-non-enhanced left DW ab factor: 0 - 2.5 mm both  DW ab factor: 800-2.5 mm right  left 

44. All complications related to bone destruction (mechanical) C.O.M., vertigo, labyrinthin fistula(more morbidity) in lat. Semicircular canal (18-49) Facial nerve palsy or paresis (1%) jalaljalalshokouhi@hotmail.com www.medimage.ir