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Objective: To analyze the time trends of recidivism of acquired cholesteatoma using the Kaplan-Meier method., Study Design: We conducted a retrospective, observational study of 256 patients having their first cholesteatoma surgery. The cumulative recidivism-free rate was calculated using Kaplan-Meier survival analysis related to the follow-up period, pathophysiology, the extent of the disease, and recidivism pathologies., Results: Pars flacida cholesteatoma with tympanic cavity progression had a high likelihood of recurrence disease. Pars tensa cholesteatoma led to more recurrence of the disease than the residual disease. In both pars flacida and pars tensa cholesteatoma, the incidence of disease recurrence increased even 3 years after surgery. On the contrary, the incidence of residual disease peaked within 3 years after surgery, and thereafter, the incidence of residual disease tended to be small. In particular, pars flacida cholesteatoma extending into the mastoid cavity or tympanic cavity tended to recur up to 5 years postoperatively., Conclusions: We calculated the cumulative recidivism-free rates of 256 patients with cholesteatoma using Kaplan-Meier survival analysis. These results can lead to better estimates of the length of the follow-up period., Level of Evidence: Level IV evidence from case-control studies., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: Cholesteatoma is occasionally accompanied by excessive calcification and presumably has different osteogenic dynamics compared to noncholesteatomous chronic otitis media. Cholesteatoma-related sclerotic lesions through the temporal bone can pose manipulatory difficulties, possibly leading to worse surgical outcomes or complications. Therefore, we compared surgical outcomes of cholesteatomas with and without sclerotic lesions., Study Design: Retrospective cohort study., Setting: Tertiary academic medical center., Patients: Consecutive ears with acquired cholesteatomas requiring primary resection between January 2009 and December 2019. The ears followed up for <1 year were excluded., Interventions: Tympanoplasty with/without mastoidectomy., Main Outcome Measures: Prevalence and location of sclerotic lesion, comorbid fistulae, postoperative air-bone gap, recidivism, and complications., Results: Overall, 19 (6.4%) of 299 ears had sclerotic lesions. More than two-thirds (68.4%) of sclerotic lesions were located adjacent to the lateral semicircular canal (LSC). Among ears with sclerotic lesions adjacent to the LSC, 46.2% had a comorbid fistula in the LSC. The prevalence of labyrinth fistula was significantly greater in ears with sclerotic lesions (42.1%) than in ears without sclerotic lesions (5.0%) (p < 0.0001, Fisher's exact test). Sensorineural hearing deterioration was significantly higher in ears with sclerotic lesions than in ears without (p = 0.0004, Fisher's exact test). Multivariate logistic regression analysis demonstrated that the presence of sclerotic lesions was a significant prognostic factor for residual disease (odds ratio [95% confidence interval]: 6.820 [2.055-22.633], p = 0.0017)., Conclusions: Surgeons should be conscious of preoperative identification of sclerotic lesions adjacent to one of the semicircular canals, possibly leading to postoperative sensorineural hearing deterioration or residual cholesteatoma., Competing Interests: The authors disclose no conflicts of interest. The authors alone are responsible for the content and writing of the manuscript., (Copyright © 2022, Otology & Neurotology, Inc.)

Background: Mastoid development, tympanic sinus depth, and residual disease after surgery for congenital cholesteatoma are probably related, but these relationships have not been examined in detail. Aims/objectives: This study aimed to clarify the relationships between the abovementioned factors. Materials and Methods: The subjects were 31 patients with congenital cholesteatoma (stage III or IV in Potsic's staging system) that underwent mastoidectomy. The cross-sectional area of the mastoid air cells was measured as described previously. Tympanic sinus depth was classified into A-C using Marchioni et al.'s system. Results: Patients with deep tympanic sinuses or residual disease exhibited significantly greater mastoid air cell development. However, little residual disease was found in the mastoid air cells. Conversely, residual disease was observed more frequently in the patients with deep tympanic sinuses. Conclusions and significance: After surgery for congenital cholesteatoma, residual disease is more likely to occur in patients with marked mastoid growth, possibly because they have deep tympanic sinuses. Cases in which congenital cholesteatoma spreads to the mastoid air cells are classified as stage IV in Potsic's system, but our findings indicate that invasion into a deep tympanic sinus is more important than invasion into the mastoid air cells.

Introduction: Partial epithelial-mesenchymal transition (p-EMT) is a process by which epithelial cells partially lose their intercellular adhesion and change to obtain migration ability. The transcription factor p63 regulates the expression of cadherin family and induces epithelial cell proliferation. In this study, we hypothesized that p-EMT under p63 expression may be a key factor in epithelial cell growth in middle ear cholesteatoma., Methods: Specimens were surgically excised from patients with congenital cholesteatoma (CC) (n = 48), acquired middle ear cholesteatoma (AC) (n = 120), and normal skin tissue (n = 34). We analyzed immunohistochemically for the EMT marker (N-cadherin), adherence junction marker (E-cadherin), and tight junction marker (claudin-1, claudin-4, occludin). We also examined the labeling index (LI) of p63 and Proliferating cell nuclear antigen (PCNA) (late S phase marker), and Snail expression as a mobility marker., Results: The expression of p63 (CC 51.0 ± 7.4%, AC 50.0 ± 5.9%) was significantly higher in the thickened epithelium of CC and AC compared with normal skin tissue (p < 0.0001). The loss of E-cadherin was observed (CC 50.0%, AC 55.8%) but the expression patterns in the tight junction were almost normal. N-cadherin was partially detected in the basal and upper layer of epithelium in CC and AC. In contrast to that of normal skin tissue, the LI of PCNA was significantly higher in AC (p < 0.0001). The positive rate of Snail was significantly higher in CC (p < 0.0001)., Conclusion: This study indicates that p-EMT via the p63 signaling pathway might plays an essential role in epithelial growth in AC and CC formation, although tight junction formation and terminal differentiation were not affected in those processes.

Background: The mastoid air cells are considered to develop better in children with congenital cholesteatoma but only a few quantitative studies have examined. Aims/objectives: The present study was undertaken in order to clarify the relationships between the development of the mastoid air cells in children with congenital cholesteatoma and clinical factors. Materials and methods: Mastoid air cell development was evaluated in 53 children with congenital cholesteatoma. The sizes of the mastoid air cells were measured on computed tomography scans of the temporal bone, and clinical factors, including age, the extent of invasion, and whether it was located close to the eustachian tube were evaluated. Results: The cross-sectional area of the mastoid air cells was significantly smaller on the affected side than on the unaffected side, especially in the older patients. The cases involving invasion into the mastoid portion also had smaller mastoid cells. Whether the cholesteatoma was located close to the eustachian tube had no effect. Conclusions and significance: The mastoid air cells on the affected side were less well developed. Our findings indicate that a high age and the presence of cholesteatoma in the mastoid region might be associated with suppressed mastoid pneumatization.

Cholesteatoma is a progressive middle ear disease that can only be treated surgically but with a high recurrence rate. Depending on the extent of the disease, a surgical approach, such as microsurgery with a retroarticular incision or transcanal endoscopic surgery, is performed. However, the current examination cannot sufficiently predict the progression before surgery, and changes in approach may be made during the surgery. Large amounts of data are typically required to train deep neural network models; however, the prevalence of cholesteatomas is low (1-in-25, 000). Developing analysis methods that improve the accuracy with such a small number of samples is an important issue for medical artificial intelligence (AI) research. This paper presents an AI-based system to automatically detect mastoid extensions using CT. This retrospective study included 164 patients (80 with mastoid extension and 84 without mastoid extension) who underwent surgery. This study adopted a relatively lightweight neural network model called MobileNetV2 to learn and predict the CT images of 164 patients. The training was performed with eight divided groups for cross-validation and was performed 24 times with each of the eight groups to verify accuracy fluctuations caused by randomly augmented learning. An evaluation was performed by each of the 24 single-trained models, and 24 sets of ensemble predictions with 23 models for 100% original size images and 400% zoomed images. Fifteen otolaryngologists diagnosed the images and compared the results. The average accuracy of predicting 400% zoomed images using ensemble prediction model was 81.14% (sensitivity = 84.95%, specificity = 77.33%). The average accuracy of the otolaryngologists was 73.41% (sensitivity, 83.17%; specificity, 64.13%), which was not affected by their clinical experiences. Noteworthily, despite the small number of cases, we were able to create a highly accurate AI. These findings represent an important first step in the automatic diagnosis of the cholesteatoma extension. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Disturbed perilymph behind a labyrinth fistula can lead to hearing deterioration; thus, delicate manipulation is required during surgery for cholesteatomatous fistulae with matrix extension to the perilymphatic space (EPS). However, it remains challenging to identify the EPS preoperatively. This study aimed to evaluate the diagnostic value of computed tomography (CT) for preoperative prediction of the EPS of cholesteatomatous fistulae. Study Design: Retrospective study. Methods: We included serial high‐resolution CT images showing a cholesteatomatous bone defect in the lateral semicircular canal (LSC) requiring mastoidectomy. CT and intraoperative findings were analyzed retrospectively. Using axial CT planes, we evaluated the length and angle between the margins of bone defects. Receiver operating characteristic (ROC) curves were constructed to determine the cutoff points. Results: We extracted data from 30 bone defects, of which six (20.0%) showed EPS intraoperatively. Bone defects with EPS (n = 6) had significantly greater length and angle values than those without EPS (n = 24) (P <.001 for both, Wilcoxon rank sum test). For length and angle, the area under the curve was 0.944 (95% confidence interval [CI]: 0.858‐1.000) and 0.951 (95% CI: 0.875‐1.000), respectively, according to the ROC analysis, and the optimal cutoff values were 3.65 mm and 71.6°, respectively, with 100% sensitivity and 91.67% specificity for both. Conclusions: Results demonstrated that a length >3.65 mm and an angle >71.6° for LSC bone defects on axial CT images are reliable diagnostic markers of EPS. Preoperative high‐resolution CT analysis can provide surgeons with a more conscientious preparation for handling deeper labyrinth fistulae. Level of Evidence: 4 Laryngoscope, 131:E1301–E1307, 2021 [ABSTRACT FROM AUTHOR]

Objective: The aeration status of the middle ear is presumed to be one of the factors affecting the outcome in acquired cholesteatoma. The present study investigated the impact of postoperative middle ear aeration on hearing and recurrence after intact canal wall tympanoplasty.Methods: We conducted a retrospective chart review of 127 pars flaccida cholesteatoma patients who underwent primary intact canal wall tympanoplasty at a tertiary academic medical center. We collected data on clinical characteristics, including extent of cholesteatoma, surgical procedure, pre- and postoperative middle ear aeration, hearing level, and recurrence. The aeration was measured before and at one year after operation on two axial computed tomography (CT) planes: at the lateral semicircular canal (mastoid cavity) and at the oval window (tympanic cavity). Based on the postoperative air-bone gap (ABG), patients were categorized into two groups: the successful hearing (ABG ≤15 dB) group and the unsuccessful hearing (ABG >15 dB) group. We used aeration ratio to assess the relationship between postoperative aeration improvement and hearing outcome or recurrence. Multivariate logistic regression analysis was used to identify the factors associated with hearing outcome.Results: At one year after operation, aeration ratio in both mastoid and tympanic cavities was significantly improved than the preoperative status (p < 0.001, p < 0.001, respectively, Wilcoxon signed-rank test). The positive correlation was found between postoperative aeration ratios of mastoid cavity and tympanic cavity (r = 0.348, p < 0.001, Spearman's rank-correlation coefficient). In mastoid and tympanic cavities, the postoperative aeration ratio in successful hearing group (n = 57) was significantly higher than that in the unsuccessful hearing group (n = 45) at one year after operation (p < 0.001, p = 0.028, respectively, Mann-Whitney U test). Multivariate logistic regression analysis demonstrated that postoperative aeration ratio in mastoid cavity and preoperative ABG were significant independent prognostic factors for successful hearing (odds ratio [95% confidence interval]: 2.630 [0.985 - 7.024], p = 0.045; 0.891[0.840 - 0.944], p < 0.001, respectively). However, postoperative aeration ratios did not significantly differ between with (n = 14) and without recurrence (n = 113) groups in both cavities.Conclusion: Our results suggest that better postoperative aeration in mastoid cavity is independently associated with satisfactory hearing outcome after intact canal wall tympanoplasty in pars flaccida cholesteatoma. However, no significant differences were observed between middle ear aeration at one year after operation and recurrence. [ABSTRACT FROM AUTHOR]

Background: The Japan Otology Society (JOS) proposed the classification and staging system for middle ear cholesteatoma. However, there was little analysis of the pathology of cholesteatoma using this staging system. Aims/objectives: To analyze the pathology of pars flaccida cholesteatoma using the staging system by JOS. Material and methods: A total of 183 cases of fresh pars flaccida cholesteatoma treated between January 2009 and December 2015 were included. We used the staging system recommended by JOS (2015). The association of the following variables in each stage of pars flaccida cholesteatoma was examined: age, gender, preoperative hearing level, staging, statuses of mastoid cell growth and stapes, tympanic sinus invasion. Results: Stage II disease showed the highest degree of progression, and peak incidence was observed in the third and fourth decades of life. Stage III significantly increased after the age of 40 years. The progression of the disease stage was significantly associated with deterioration of hearing level. Cholesteatoma invasion to tympanic sinus was recognized in 14.2% of cases. The state of the stapes is increasingly likely be to fracture as stage progresses. Conclusions: The JOS Staging System appropriately reflects the disease state, and it was found to be clinically meaningful in this study. [ABSTRACT FROM AUTHOR]

Objectives: A broad mastoid extension limits cholesteatoma resection via a transmeatal approach including endoscopic ear surgery. Therefore, a preoperative diagnosis of mastoid extension is a the most critical factor to determine whether to perform mastoidectomy. The purpose of this study was to assess the efficacy of non-echoplanar diffusion-weighted imaging (non-EPI DWI) and T1-weighted imaging in the evaluation of mastoid extension in cholesteatomas of the middle ear.Methods: Patients who underwent magnetic resonance imaging (MRI) for pretreatment evaluation before primary surgery for pars flaccida or tensa cholesteatoma, which revealed a high-signal intensity in the mastoid on T2-weighed imaging were retrospectively evaluated. Two board-certified radiologists retrospectively evaluated the extent of cholesteatomas on MRI with non-EPI DWI, non-EPI DWI- and T1-weighted axial imaging. The presence of a high signal intensity on non-EPI DWI or low or high signal intensity on T1-weighted imaging in the mastoid was evaluated. All cases were subclassified as M+ (surgically mastoid extension-positive) or M- (surgically mastoid extension-negative).Results: A total of 59 patients with middle ear cholesteatoma were evaluated. There were 37 M+ cases and 22 M- cases. High-signal intensity on non-EPI DWI exhibited a sensitivity of 0.89 and specificity of 0.82, whereas partial low-signal intensity on T1-weighted imaging exhibited a sensitivity of 0.84 and specificity of 0.91 for detecting mastoid involvement. Complete high-signal intensity on T1-weighted imaging exhibited a sensitivity of 0.73 and specificity of 0.89 for detecting non-involvement of the mastoid. The sensitivity (0.92) and specificity (0.96) of combined non-EPI DWI and T1-weighted imaging evaluation were higher than those of with non-EPI DWI or T1-weighted imaging alone. The interobserver agreement for the presence of high-signal intensity in the mastoid cavity on non-EPI DWI was very good at 0.82, that of a partial low-signal intensity area in the mastoid cavity lesions on T1-weighted imaging was good, at 0.76 and that of complete high-signal intensity in the mastoid cavity lesions on T1-weighted imaging was good, at 0.67.Conclusions: The signal intensity on non-EPI DWI and T1-weighted imaging of the mastoid could be used to accurately assess the extent of middle ear cholesteatoma, which could facilitate surgical treatment planning. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to clarify the usefulness of high-resolution computed tomography (HRCT) and establish HRCT criteria for presurgical assessment of the mastoid extension in pars flaccida cholesteatomas of the middle ear.Methods: Retrospective observational study. Patients who underwent primary surgery for pars flaccida cholesteatoma and those who underwent temporal bone HRCT for pretreatment evaluation were reviewed. The distance in the anterior-most portion of the mastoid sinus on HRCT was measured, and the presence of surgically verified mastoid extension of cholesteatoma was evaluated. All cases were subclassified as M+ (surgically mastoid extension-positive) or M- (surgically mastoid extension-negative).Results: A total of 107 patients with pars flaccida cholesteatoma were included. The distance in the M+ cases was significantly longer than that in the M- cases, and the cutoff value was 3.6 mm. The difference between the ipsilateral/diseased-side distance and the contralateral/evaluable side (difference value) in M+ cases was larger than that in M- cases, with a cutoff value of 0.6 mm. The inter-rater reliability of this distance measurement was excellent, regardless of imaging experience.Conclusions: The cutoff values of the distance and the difference value can be used for pretreatment HRCT evaluation of mastoid extension in middle ear cholesteatoma with relatively high accuracy, regardless of the experience and skill levels of the evaluator. [ABSTRACT FROM AUTHOR]