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The aim of this study was to investigate both the microbial composition and absolute abundance of clinically relevant bacteria in tissue specimens from patients with chronic suppurative otitis media with cholesteatoma (CSOM with cholesteatoma). Mastoid mucosa and cholesteatoma tissue from eleven subjects with CSOM with cholesteatoma, and mastoid mucosa from ten controls were examined using standard hospital culture swabs, Gram staining, bacterial 16S rRNA gene sequencing, Droplet Digital PCR (ddPCR), and multiplex PCR. Positive results from culture swabs were reported in half the CSOM with cholesteatoma samples and 1 control sample. In contrast, ddPCR detected bacterial genes copies in all 11 mucosa and cholesteatoma of CSOM subjects and 3 control samples. The average bacterial gene copies in tissue samples with CSOM with cholesteaotoma (1.6 ± 0.7 log10) was significantly higher compared to healthy controls (0.3 ± 1.6). These results were corroborated with Gram-staining that identified the large presence of Gram-positive cocci cells in the cholesteatoma tissue of CSOM subjects which were not seen in the mucosa of controls. The most abundant genus detected by sequencing in the mucosa and cholesteatoma of CSOM samples was Anaerococcus (93.5 % of all reads), and genus Meiothermus (0.9 %) in the control sample. The 3 samples with the highest sequencing reads (>300) were further analysed using multiplex PCR to identify the dominant Anaerococcus species. Anaerococcus hydrogenalis was the dominant species identified in these samples. In contract, commonly named ear pathogens, genera Staphylococcus and Pseudomonas, were detected in low numbers (<0.001 % of all sequencing reads) and low prevalence (2/16 samples) in the tissue samples of this study. The results show that culture severely underestimated the bacterial diversity in CSOM samples and investigating tissue rather than standard culture swabs might be advantageous to understanding the disease process. The high abundance of bacteria and the large presence of Gram-positive cells detected in the cholesteatoma tissue of CSOM compared to mucosa of CSOM or controls could be members from the genus Anaerococcus. Anaerococcus may well be a pathogen in CSOM with cholesteatoma, but their role in this condition requires further investigation., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Kristi Biswas reports financial support was provided by Garnett Passe and Rodney Williams Memorial Foundation. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To evaluate if fusion computed tomography-diffusion-weighted magnetic resonance imaging may have a role in the pre-operative assessment of congenital middle-ear cholesteatoma., Methods: A retrospective chart review of surgically treated congenital middle-ear cholesteatoma patients over a 2-year timespan was conducted. Pre-operative staging was performed on computed tomography and fusion computed tomography-diffusion-weighted magnetic resonance imaging based on extension of the disease according to the ChOLE classification system and the Potsic classification system. Intra-operative staging was compared to imaging findings to evaluate accuracy of the two imaging modalities in predicting congenital middle-ear cholesteatoma extent., Results: Computed tomography was able to correctly predict congenital middle-ear cholesteatoma extent in three out of six cases according to the ChOLE classification system, all of which were staged as Ch1a and Ch1b on pre-operative computed tomography. Cases in which computed tomography was not able correctly to determine congenital middle-ear cholesteatoma extent were staged as Ch3 on pre-operative computed tomography. Fusion scans correctly determined congenital middle-ear cholesteatoma extent in all cases according to the ChOLE classification., Conclusions: Fusion computed tomography-diffusion-weighted magnetic resonance imaging may be helpful in cases of congenital middle-ear cholesteatoma where pre-operative computed tomography shows mastoid and antrum opacification, in which computed tomography alone may overestimate cholesteatoma extension beyond the level of the lateral semi-circular canal.

Purpose: To investigate the rate of residual disease in the Potsic staging system for congenital cholesteatomas., Methods: A protocol registration was published on PROSPERO (CRD42022383932), describing residual disease as a primary outcome and hearing improvement as secondary. A systematic search was performed in four databases (PubMed, Embase, Cochrane Library, Web of Science) on December 14, 2022. Articles were included if cholesteatomas were staged according to the Potsic system and follow-up duration was documented. Risk of bias was evaluated using the Quality In Prognosis Studies (QUIPS) tool. In the statistical synthesis a random effects model was used. Between-study heterogeneity was assessed using I 2 ., Results: Thirteen articles were found to be eligible for systematic review and seven were included in the meta-analysis section. All records were retrospective cohort studies with high risk of bias. Regarding the proportions of residual disease, analysis using the χ 2 test showed no statistically significant difference between Potsic stages after a follow-up of minimum one year (stage I 0.06 (confidence interval (CI) 0.01-0.33); stage II 0.20 (CI 0.09-0.38); stage III 0.06 (CI 0.00-0.61); stage IV: 0.17 (CI 0.01-0.81)). Postoperative and preoperative hearing outcomes could not be analyzed due to varied reporting. Results on cholesteatoma location and mean age at staging were consistent with those previously published., Conclusion: No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging system's applicability for outcome prediction could not be proven based on the available data. Targeted studies are needed for a higher level of evidence., (© 2024. The Author(s).)

Transcanal endoscopic ear surgery is a minimally invasive procedure that allows a clear visualization of the middle ear. Recently, indications for endoscopic surgery have been expanding. We performed combined underwater endoscopic and microscopic surgery for external auditory canal cholesteatoma, the computer tomography of which indicates the possibility of cholesteatoma not only in the canal wall but also in the mastoid. The 30° endoscope and underwater technique makes the surgical view clear, and we could remove the cholesteatoma without canalplasty. To the best of our knowledge, no case of external auditory canal cholesteatoma treated with underwater endoscopic and microscopic surgery has been previously reported. This case indicates that the procedure could be a good indication for external auditory canal cholesteatoma., Competing Interests: Declaration of Conflicting InterestsThe author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Pediatric cholesteatoma is an aggressive disease which requires long-term evaluation to assess management strategies. The objective was to determine optimal follow-up duration in pediatric cholesteatoma to detect residual and recurrent diseases., Methods: This cohort study was set in a tertiary referral center. All consecutive patients with a minimum 5-year follow-up were included. Medical history, initial extension, surgical procedures, and follow-up were collected. The main outcome measure were Kaplan-Meier survival curves of residual and recurrence cumulative incidence., Results: Totally 239 ears with the first tympanoplasty between 2008 and 2014 were studied including 25% congenital. At first surgery (S1), mean age was 8.4 years and mean follow-up time 7.9 years. Mastoidectomy was performed in 69% and stapes was absent in 38% of cases. Notably, 83% (199 ears) had a second procedure (S2) of which 186 were planned. After S1, maximum cumulated incidence of residual was 45% [95%CI, 38%; 52%] at 74 months, with probability of residual of 39% at 3 years. After S2 (n = 199), maximum cumulated residual incidence was 21% [95%CI, 12%; 32%] at 62 months and 16% at 3 years. Concerning recurrence, maximum cumulated incidence after S1 (n = 239) was reached at 98 months with 21% [95%CI, 12%; 32%], 13% at 3 years and 16% at 5 years. Congenital disease had significantly less residuals after S1 (p = 0.02), but similar recurrence rate (p = 0.66) compared with acquired., Conclusions and Relevance: We recommend MRI follow-up of at least 5 years after the last surgery for residual disease and clinical follow-up of at least 10 years to detect recurrence., Level of Evidence: 4 Laryngoscope, 134:4789-4798, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The pathophysiology of cholesteatoma is not precisely understood, and research on the associated microRNAs (miRNAs) is also deficient. We demonstrated the expression of miRNA in normal skin and middle ear cholesteatoma by next-generation sequencing (NGS) technology. The profiles of miRNA and relevant molecular interaction pathways were investigated., Study Design: Case-control experimental study., Methods: Middle ear cholesteatoma and post-auricular skin tissue specimens were collected from 13 adult patients. Total RNA was extracted, and miRNA expression profiles were analyzed by NGS technology. Functional gene classification to predict target genes and relevant biological pathways was performed using DIANA-microT-CDS and the Kyoto Encyclopedia Gene and Genome database (KEGG) pathways., Results: The expression of 2588 miRNAs from middle ear cholesteatoma and skin tissue samples was analyzed. The expression of 76 upregulated and 128 downregulated miRNAs was identified in the cholesteatoma samples compared to normal skin (FC ≥2 and p < 0.05). Ninety-nine differentially expressed miRNAs (FC ≥4 and p < 0.05) were used to explore the biological pathways involved in the etiopathogenesis of cholesteatoma. The most predicted pathway in cholesteatoma in the upregulated miRNA group was the ErbB signaling pathway and it was extracellular matrix (ECM)-receptor interaction in the downregulated miRNA group., Conclusions: This was the first study investigating small miRNAs in human acquired cholesteatoma using NGS technique. We were able to identify new miRNAs and pathways related to cholesteatoma. The results of this study are expected to be helpful in revealing new pathophysiologies of cholesteatoma., Level of Evidence: N/A Laryngoscope, 134:4374-4382, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Congenital cholesteatoma is a rare, non-neoplastic lesion that causes conductive hearing loss in children. It is underrecognized and often diagnosed only when there is an established hearing deficit. In the pediatric population, hearing deficiency is particularly detrimental because it can impede speech and language development and, in turn, the social and academic well-being of affected children. Delayed diagnosis leads to advanced disease that requires more extensive surgery and a greater chance of recurrence. A need to promote awareness and recognition of this condition has been advocated by clinicians and surgeons, but no comprehensive imaging review dedicated to this entity has been performed. This review aims to discuss the diagnostic utility of high-resolution computed tomography and magnetic resonance imaging in preoperative and postoperative settings in congenital cholesteatoma. Detailed emphasis is placed on the essential preoperative computed tomography findings that facilitate individualized surgical management and prognosis in the pediatric population., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Cholesteatoma is a rare disease characterized by the accumulation of keratinized squamous epithelial cells in the middle ear or mastoid cavity. Vertigo and facial palsy, which are rare complications, may indicate erosion into the semicircular canals or the fallopian canal., Patient Concerns: A 40-year-old woman presented to our clinic with progressive right-sided hearing loss over 5 years (primary concern). Approximately 10 years ago, the patient had developed acute right-sided facial weakness with no additional symptoms. A neurologist at another hospital had diagnosed her condition as Bell's palsy and treated it accordingly., Diagnosis: Adult-onset congenital cholesteatoma in the hypotympanum., Intervention: Combined endoscopic and microscopic removal of the cholesteatoma., Outcomes: Physical examination revealed slight improvement in right-sided peripheral facial palsy., Lesson: Routine eardrum examination is recommended for patients presenting with isolated peripheral facial palsy. If necessary, a patient should be referred to an otologist for further evaluation and treatment., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To evaluate the diagnostic efficacy of multishot echo-planar imaging (EPI) [RESOLVE (RS)] and non-EPI (HASTE) diffusion-weighted imaging (DWI) in detecting cholesteatoma (CHO), and to explore the role of signal intensity (SI) ratio measurements in addressing diagnostic challenges., Methods: We analyzed RS-EPI and non-EPI DWI images from 154 patients who had undergone microscopic middle ear surgery, with pathological confirmation of their diagnoses. Two radiologists, referred to as Reader A and Reader B, independently reviewed the images without prior knowledge of the outcomes. Their evaluation focused on lesion location, T1-weighted (T1W) signal characteristics, and contrast enhancement in temporal bone magnetic resonance imaging. Key parameters included lesion hyperintensity, size, SI, SI ratio, and susceptibility artifact scores across both imaging modalities., Results: Of the patients, 62.3% (96/154) were diagnosed with CHO, whereas 37.7% (58/154) were found to have non-CHO conditions. In RS-EPI DWI, Reader A achieved 89.6% sensitivity, 79.3% specificity, 87.8% positive predictive value (PPV), and 82.1% negative predictive value (NPV). Non-EPI DWI presented similar results with sensitivities of 89.6%, specificities of 86.2%, PPVs of 91.5%, and NPVs of 83.3%. Reader B’s results for RS-EPI DWI were 82.3% sensitivity, 84.5% specificity, 89.8% PPV, and 74.2% NPV, whereas, for non-EPI DWI, they were 86.5% sensitivity, 89.7% specificity, 93.3% PPV, and 80% NPV. The interobserver agreement was excellent (RS-EPI, κ: 0.84; non-EPI, κ: 0.91). The SI ratio measurements were consistently higher in non-EPI DWI (Reader A: 2.51, Reader B: 2.46) for the CHO group compared with RS-EPI. The SI ratio cut-off (>1.98) effectively differentiated hyperintense lesions between CHO and non-CHO groups, demonstrating 82.9% sensitivity and 100% specificity, with an area under the curve of 0.901 (95% confidence interval: 0.815–0.956; P < 0.001). Susceptibility artifact scores averaged 1.18 ± 0.7 (Reader A) and 1.04 ± 0.41 (Reader B) in RS-EPI, with non-EPI DWI recording a mean score of 0., Conclusion: Both RS-EPI and non-EPI DWI exhibited high diagnostic accuracy for CHO. While RS-EPI DWI cannot replace non-EPI DWI, their combined use improves sensitivity. SI ratio measurement in non-EPI DWI was particularly beneficial in complex diagnostic scenarios., Clinical Significance: This study refines CHO diagnostic protocols by showcasing the diagnostic capabilities of both RS-EPI and non-EPI DWI and highlighting the utility of SI measurements as a diagnostic tool. These findings may reduce false positives and aid in more accurate treatment planning, offering substantial insights for clinicians in managing CHO., Competing Interests: Conflict of interest disclosure: The authors declared no conflicts of interest.

Objective: To determine the predictive factors for residual disease occurring after surgical removal of congenital cholesteatomas and whether these predictive factors differ between microscopic ear surgery (MES) using data from the literature and transcanal endoscopic ear surgery (TEES) using data from our own institution., Methods: Twenty-three patients with a congenital cholesteatoma who underwent surgical treatment at Yamagata University Hospital between December 2011 and December 2017 were retrospectively investigated. We divide TEES into three different approaches: non-powered TEES, powered TEES and dual MES/TEES. Main outcome measures were Potsic stage, closed or open congenital cholesteatoma type, TEES surgical approach, appearance of residual disease, tympanoplasty type and hearing outcome., Results: A logistic regression analysis was conducted on the Potsic stage, closed or open type, TEES surgical approach and age to obtain the odds ratio for residual disease. The chance of residual disease significantly increased in the presence of an open-type congenital cholesteatoma (odds ratio: 30.82; 95 % confidence interval: 1.456-652.3; p = 0.0277), but not for any of the other factors including Potsic stage. The timing of the confirmation of residual disease after ossicular chain reconstruction was analyzed using a Kaplan-Meier analysis. The residual disease rate was significantly higher with an open-type congenital cholesteatoma (log-rank test, p < 0.05). In addition, all residual disease occurred within three years after surgery., Conclusions: Our results showed that an open-type congenital cholesteatoma is the strongest predictive factor for residual disease when removing a congenital cholesteatoma by TEES., Competing Interests: Declaration of Interest statement The authors have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier B.V.)

Patients with petrous bone cholesteatoma most commonly present with hearing loss and facial paralysis. Other clinical presentations can include otorrhea, tinnitus, aural fullness, otalgia, and dizziness. Here, we report a patient with petrous bone cholesteatoma who presented with cerebrospinal fluid rhinorrhea. This patient was initially misdiagnosed with rhinogenic cerebrospinal fluid leakage, and was finally diagnosed with the supralabyrinthine type of petrous bone cholesteatoma. During the surgical repair through the transmastoid trans-superior semicircular canal approach, the fistula was found in the superior wall of the internal auditory canal. He had satisfactory outcomes after the surgery, with no recurrent cerebrospinal fluid rhinorrhea., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Purpose: Intracranial epidermoids temporal bone cholesteatomas, and head and neck epidermal inclusion cysts are typically slow-growing, benign conditions arising from ectodermal tissue. They exhibit increased signal on DWI. While much of the imaging literature describes these lesions as showing diffusion restriction, we investigated these qualitative signal intensities and interpretations of restricted diffusion with respect to normal brain structures. This study aimed to quantitatively evaluate the ADC values and histogram features of these lesions., Materials and Methods: This retrospective study included children with histologically confirmed diagnoses of intracranial epidermoids, temporal bone cholesteatomas, or head and neck epidermal inclusion cysts. Lesions were segmented, and voxelwise calculation of ADC values was performed along with histogram analysis. ADC calculations were validated with a second analysis software to ensure accuracy. Normal brain ROIs-including the cerebellum, white matter, and thalamus-served as normal comparators. Correlational analysis and Bland-Altman plots assessed agreement among software tools for ADC calculations. Differences in the distribution of values between the lesions and normal brain tissues were assessed using the Wilcoxon rank sum and Kruskal-Wallis tests., Results: Forty-eight pathology-proved cases were included in this study. Among them, 13 (27.1%) patients had intracranial epidermoids 14 (29.2%) had head and neck epidermal inclusion cysts, and 21 (43.7%) had temporal bone cholesteatomas. The mean age was 8.67 (SD, 5.30) years, and 27 (56.3%) were female. The intraclass correlation for absolute agreement for lesional ADC between the 2 software tools was 0.997 (95% CI, 0.995-0.998). The intracranial epidermoid head and neck epidermal inclusion cyst, and temporal bone cholesteatoma median ADC values were not significantly different (973.7 versus 875.7 versus 933.2 × 10 -6 mm 2 /s, P = .265). However, the ADCs of the 3 types of lesions were higher than those of 3 normal brain tissue types (933 versus 766, × 10 -6 mm 2 /s, P < .001)., Conclusions: The ADC values of intracranial epidermoids, temporal bone cholesteatomas, and head and neck epidermal inclusion cysts are higher than those of normal brain regions. It is not accurate to simply classify these lesions as exhibiting restricted diffusion or reduced diffusivity without considering the tissue used for comparison. The observed hyperintensity on DWI compared with the brain is likely attributable to a relatively higher contribution of the T2 shinethrough effect., (© 2024 by American Journal of Neuroradiology.)

Competing Interests: Competing interests:: None declared.

Objective: Cholesteatoma secondary to tympanic perforation, known as "secondary acquired cholesteatoma" may progress slower than a retraction pocket cholesteatoma, with less bone destruction and fewer intracranial complications. However, complete surgical removal remains difficult because the pathological epithelium on the marginal side of the extension is not covered by the subepithelial layer of the cholesteatoma matrix, making the boundary with the middle ear mucosa difficult to identify. Therefore, considering the pathophysiology of secondary acquired cholesteatoma, suitable preoperative evaluation and surgical techniques are required. In this study, we aimed to evaluate (i) the extension of secondary acquired cholesteatoma according to the size and location of tympanic membrane perforation; and (ii) the microscopic surgical outcomes, including the rate of residual cholesteatoma, requirement for specialized surgical management, and changes in hearing., Methods: This retrospective study included data of cases with secondary acquired cholesteatoma (n = 66; 66 ears of 64 patients, 2 patients had bilateral ear involvement), including those who underwent a staged operation (n = 25)., Results: The perforation level of the tympanic membrane was associated with the cholesteatoma extension. When the cholesteatoma extended around the stapes, staged operation was chosen. Six cases of spontaneous resolution of stapes lesions at the time of staged surgery were observed. A significant postoperative improvement in hearing was observed; however, five cases experienced sensorineural hearing loss., Conclusion: Surgery, including staged surgery of the stapes lesions, along with careful observation of the perforation, is required in secondary acquired cholesteatoma. For lesions that are visible yet challenging to remove, it is imperative to exercise prudent judgment, taking into account the possibility of spontaneous resolution., Competing Interests: Conflict of interest This work was supported by JSPSKAKENHI Grant Number JP22K16904., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: To describe a rare complication of cholesteatoma., Methods: Case report with literature review., Results: We report a case of a 37-year-old male who presented for evaluation of otorrhea, headache, and progressive left sensorineural hearing loss. Clinical and radiologic evaluation demonstrated a large recurrent attic cholesteatoma with erosion into the lateral and superior semicircular canals, and diffuse enhancement of the internal auditory canal and cerebellopontine angle suggestive of hypertrophic pachymeningitis secondary to cholesteatoma. After treatment with a course of antibiotics and canal wall down mastoidectomy surgery for cholesteatoma exteriorization, he experienced improvement of his symptoms and resolution of hypertrophic pachymeningitis., Conclusion: Hypertrophic pachymeningitis is a rarely described complication of cholesteatoma. In the context of cholesteatoma, treatment with antibiotics and surgical removal or exteriorization of cholesteatoma are effective treatments for HP., Competing Interests: Declaration of competing interest The authors declare no conflict of interests to authorship, research, or publication of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma., Methods: A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY., Results: Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations., Conclusion: Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized., Level of Evidence: V., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Middle ear cholesteatoma may lead to the erosion of the bony structures of the temporal bone, possibly causing intra- and extracranial complications. Surgical treatment is mandatory, and due to possible residual/recurrent disease, the use of reliable diagnostic methods is essential. Our study aimed to evaluate the reliability of non-EPI DW-MRI for the follow-up of cholesteatoma after surgery., Methods: In a study group including 53 consecutive patients who underwent surgery for cholesteatoma at a tertiary university hospital, an imaging protocol was applied, including non-echo planar diffusion-weighted imaging magnetic resonance (MR) at 1 month after surgery and then at 6 and 12 months after surgery. Based on the combination of preoperative assessment and intraoperative findings, the study group was divided into 3 subgroups: petrous bone (PB) cholesteatoma, complicated cholesteatoma and uncomplicated cholesteatoma. PB cholesteatoma patients were treated by a subtotal petrosectomy, whereas complicated and uncomplicated cholesteatoma patients were treated either by a canal wall up procedure or a retrograde (inside-out) canal wall down technique with bone obliteration technique (BOT)., Results: The results show that patients who had positive findings on non-EPI DW-MRI scans 1 month after surgery consequently underwent revision surgery during which residual cholesteatoma was noted. All the patients who displayed negative findings on non-EPI DWI-MRI scan at 1 month after surgery did not show the presence of a lesion at the 6- and 12-month evaluations. The 6 patients who displayed residual cholesteatoma at the 1-month follow-up presented dehiscence/exposure of the facial nerve canal at the primary surgery, mostly at the level of the labyrinthine segment., Conclusion: Non-EPI DW-MRI is a useful and reliable tool for follow-up cholesteatoma surgery, and when applied early, as was done in the protocol proposed in the present study, this tool may be used to detect the presence of residual cholesteatoma in some patients, prompting the planning of early revision surgery., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The present study aims to identify the differential miRNA expression profile in middle ear cholesteatoma and explore their potential roles in its pathogenesis., Methods: Cholesteatoma and matched normal retroauricular skin tissue samples were collected from patients diagnosed with acquired middle ear cholesteatoma. The miRNA expression profiling was performed using small RNA sequencing, which further validated by quantitative real-time PCR (qRT-PCR). Target genes of differentially expressed miRNAs in cholesteatoma were predicted. The interaction network of 5 most significantly differentially expressed miRNAs was visualized using Cytoscape. Further Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genome (KEGG) pathway enrichment analyses were processed to investigate the biological functions of miRNAs in cholesteatoma., Results: The miRNA expression profile revealed 121 significantly differentially expressed miRNAs in cholesteatoma compared to normal skin tissues, with 56 upregulated and 65 downregulated. GO and KEGG pathway enrichment analyses suggested their significant roles in the pathogenesis of cholesteatoma. The interaction network of the the 2 most upregulated (hsa-miR-21-5p and hsa-miR-142-5p) and 3 most downregulated (hsa-miR-508-3p, hsa-miR-509-3p and hsa-miR-211-5p) miRNAs identified TGFBR2, MBNL1, and NFAT5 as potential key target genes in middle ear cholesteatoma., Conclusions: This study provides a comprehensive miRNA expression profile in middle ear cholesteatoma, which may aid in identifying therapeutic targets for its management., (© 2024. The Author(s).)

Competing Interests: The authors disclose no conflicts of interest.

Purpose: This study aimed to explore the ability of fusion images of non-echo planar diffusion-weighted magnetic resonance imaging (non-EPI-DWI MRI) and computed tomography (CT) to accurately locate cholesteatoma and plan the surgical approach., Methods: In the first part, 41 patients were included. Their CT images and non-EPI DWMRI images were fused. The scope of cholesteatoma in the fusion image was compared with that in the surgical video to evaluate the capability to locate cholesteatoma. A total of 229 patients were included in the second part, and they were divided into 2 groups. We chose the surgical approach for the CT group and the fusion group, and compared the accuracy of surgical approaches in the CT group and the fusion group using the surgical records., Results: The location of cholesteatoma shown in the fusion images was almost identical to that observed during the operation (kappa = .862). The overall specificity and sensitivity of the fusion images in locating cholesteatoma were 94.12% and 93.06%, respectively. The accuracy of surgical approach selection based on the fusion images (99.02%) was higher than that of surgical approach selection based on the CT images (85.83%)., Conclusion: It is recommended that the fusion images be used to locate the range of the cholesteatoma before operation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives : Petrous bone cholesteatoma (PBC) is a rare condition of the petrous portion of the temporal bone. Treatment of choice consists of radical surgical removal, paying attention to protect the facial nerve and inner ear as far as possible. The aim of the present study was to evaluate the efficacy of modified translabyrinthine techniques in preserving hearing function and the use of the adjuvant endoscopic techniques in a group of PBC patients. Methods : This study comprised 16 cases of PBCs surgically treated in our Department. Pre- and post-operative hearing status was assessed with pure tone audiometry and speech discrimination and graded according to the Gardner- Robertson classification system. Facial function was based on the House Brackman (HB) classification. PBCs were grouped using Sanna's classification. The choice of surgical technique was based on the above findings together with preoperative evidence. Post-operative follow-up ranged from 1 to 10 years and also included Computed Tomography and Magnetic Resonance Imaging assessment. Results : PBCs were classified as follows: 37.5% infralabyrinthine; 43.75% supralabyrinthine; and 18.75% massive. Preservation of the bone conduction threshold was feasible in 62.5% of patients. For supralabyrinthine PBCs a subtotal petrosetomy was performed in all cases and hearing preservation was possible in 57% of them: an adjuvant endoscopic approach was performed in 43%. Infralabyrinthine PBCs were treated using a modified translabyrinthine approach with preservation of bone conduction in 83% of patients; an adjuvant endoscopic approach was performed in 50% cases. One patient with a massive cholesteatoma was treated by modified translabyrinthine approach, preserving a serviceable level of hearing. In all massive cases, an adjuvant endoscopic approach was performed. In 2 patients with preoperative palsy, facial nerve function showed an improvement. The follow-up period revealed evidence of limited recurrence at CT imaging in 2 patients. Conclusions : The introduction of modified surgical approaches, able to preserve the anatomical-functional structures, have shown an improvement of post-operative hearing outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objective: Atticotomy represents an essential surgical step within the management of attical cholesteatoma during endoscopic ear surgery. The aim of the present study was to evaluate the safety and functional results of an endoscopic atticotomy performed with piezosurgery, in terms of audiological outcomes and tissue's healing., Methods: This is an observational retrospective study on patients with attical cholesteatoma who underwent endoscopic ear surgery with piezoelectric atticotomy and subsequent scutum reconstruction either with tragal cartilage or temporalis muscle fascia. Scutumplasty's status was evaluated via scheduled outpatient controls through an endoscopic check and classified as stable or unstable at least 10 months after surgery. A pre- and postoperative audiometric examination was performed in each patient., Results: Eighty-four patients were enrolled. In 50 out of 84 patients (59.52%), an exclusive endoscopic procedure was performed, whereas in 34 patients (40.48%) a combined microscopic/endoscopicapproach was adopted. In 72 cases (85.71%), scutum's reconstruction appeared to be normally positioned, whereas 12 patients developed a retraction pocket, which was self-cleaning in 8 of them and non-self-cleaning in the remaining 4. In 17 patients, a slight sensorineural hearing loss (between 5 and 15 dBHL) was observed, and in 2 patients, the loss was greater than 15 dBHL. Overall, no significative differences between pre- and postoperative pure-tone average bone thresholds resulted (p = 0.4983), though a mild significant hearing deterioration was detected by the specific analysis at 4000 Hz (p = 0.0291)., Conclusion: Piezosurgery represents an extremely useful tool in performing atticotomy during endoscopic tympanoplasties. Our data seem to support the safety of its usage in this specific step, as it did not lead to any significant sensorineural damage on overall pure-tone average. Moreover, satisfactory tissue healing in regard to scutum reconstruction was observed., Competing Interests: The authors have no conflicts of interest to declare. The authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: The retrospective cohort study aimed to determine the safety and efficacy of TruBlue laser application in cholesteatoma surgeries., Methods: All cholesteatoma surgeries conducted from January 2018 to January 2022 in two tertiary referral hospitals in Hong Kong, with and without use of TruBlue laser, were included. Pure tone audiogram was done pre- and post-operatively to assess hearing. Disease extent was graded with ChOLE score and ChOLE staging. Residual disease was determined clinically, radiologically, or surgically with second look operation., Results: One hundred twenty cholesteatoma cases were identified. There are 39.2% (n = 47) of the cholesteatoma surgeries that utilized TruBlue laser, while 60.8% (n = 73) did not. Overall follow-up duration was 21 ± 12.4 months, ranging from 2 to 47 months. Both groups were similar in demographics, pre-operative hearing and ChOLE staging. The length of stay was comparable in both groups (2 ± 2 days in nonlaser, 1 ± 1 day in laser, p = 0.31). There was no facial nerve injury related to surgery in both groups, and overall complication rates were similar (4.1% in nonlaser, 4.3% in laser, p = 0.97). The postoperative hearing was comparable with good hearing preservation in both groups. Residual cholesteatoma occurred in 17.8% (n = 13) in nonlaser group, and 21.3% (n = 10) in laser group, which was not statistically significant (p = 0.64). Seventy percent of the cholesteatoma residual in laser group occurred at area that TruBlue LASER cannot be applied., Conclusion: TruBlue LASER was safe in cholesteatoma surgeries, though no added benefits were shown in reducing cholesteatoma residual rate. A larger controlled study is warranted to discern the true effect of TruBlue LASER., Level of Evidence: Level 3., Competing Interests: Conflicts of Interest and Source of Funding: Part of the data had been submitted as abstract and presented in the 2022 Annual Scientific Meeting of The Hong Kong College of Otorhinolaryngologist and 8th World Chinese Otorhinolaryngology, Head and Neck Surgery Conference, otherwise no work resembling the enclosed article had been published elsewhere. There are no other conflict of interests to declare regarding the contents and publication of this manuscript. There are no financial disclosures., (Copyright © 2024, Otology & Neurotology, Inc.)

Background: Mastoiditis frequently occurs in children as they are more susceptible to middle ear infections, but infrequently occurs in adults. A rare complication that results from mastoiditis and an obstructing cholesteatoma is a Bezold's abscess, of which there are less than 100 reported cases in literature to date., Case Presentation: Here, we present a case of a 72-year-old Caucasian man who has had no history of prior ear infections and was found to have a cholesteatoma and advanced acute coalescent mastoiditis complicated by a Bezold's abscess., Conclusions: Bezold's abscess is a rare entity infrequently encountered in the modern era, likely owing to more prompt treatment of otitis media. Cholesteatoma poses a great risk for both the development of otitis media and further progression to mastoiditis and its associated complications, such as Bezold's abscess. Knowledge of said abscess is crucial; without prompt recognition, further spread of infection can occur with vascular or mediastinal involvement., (© 2024. The Author(s).)

Objective: To investigate the changes in hearing threshold of the acquired primary cholesteatoma of the middle ear with different degrees of eustachian tube dysfunction after balloon eustachian tuboplasty. Methods: This retrospective study included forty cases with middle ear cholesteatoma and eustachian tube dysfunction who underwent open mastoidectomy + tympanoplasty + balloon eustachian tuboplasty were enrolled. All patients were admitted from November 2020 to April 2022. The preoperative eustachian tube score of 0-2 were defined as the lower group, and the scores of 3-5 were defined as the higher group. Pure tone audiometry was measured preoperatively and 1, 3, 6 and 12 months postoperatively. The average value of bone conduction threshold and air conduction threshold of 250-4 000 Hz were calculated, and the air-bone gap was calculated simultaneously. SPSS 25.0 was used for statistical analysis. P <0.05 was considered statistically significant. Results: In the lower group, the air conduction threshold and air-bone gap at 3 months postoperatively were significantly decreased in comparison with those preoperatively（ P <0.05），as was the air-bone gap at 6 months postoperatively（ P <0.05）. In the higher group, the air conduction threshold and air-bone gap were significantly decreased at 3, 6 and 12 months postoperatively（ P <0.05）. Conclusion: The air conduction threshold and air-bone gap of patients with the acquired primary cholesteatoma of the middle ear and eustachian tube dysfunction were significantly decreased after eustachian tube balloon dilatation. Hearing improvement lasted longer in patients with slight eustachian tube dysfunction., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)