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ORIGINAL ARTICLE

Correlation of highresolution computed

tomography temporal bone findings with
intraoperative findings in patients with
cholesteatoma
Sonika Kanotra, Rohan Gupta, Nitika Gupta, Rashmi Sharma1, Saurabh Gupta1,
Sunil Kotwal
Department of ENT and Head and Neck Surgery, SMGS Hospital, Government Medical College, 1Department of
Radiodiagnosis and Imaging, Government Medical College, Jammu, Jammu and Kashmir, India

Aim: To evaluate the role of highresolution computed tomography(HRCT) temporal bone in patients with active
Abstract
squamosal chronic otitis media(COM). Materials and Methods: Totally, 47patients with active squamosal
COM underwent preoperative HRCT temporal bone followed by surgery. Their intraoperative findings were
considered as the gold standard and were compared and correlated with the radiological findings, to calculate
the sensitivity, specificity, positive and negative predictive value of HRCT temporal bone. Results: According
to the present study, HRCT was highly sensitive for detecting mastoid pneumatization, soft tissue extension,
ossicular erosion, tegmen and sigmoid sinus erosion, and less sensitive for fallopian canal erosion and lateral
sinus fistula. It was specific for all these parameters. Conclusion: The present study concludes that HRCT can
be recommended not only in cases suspected with potential complications but also in all cases of COM to
know the extent of disease, varied pneumatization, and the presence of anatomical variations, which should
alert the clinician and guide in surgical approach and treatment plan.

Keywords: Cholesteatoma, Highresolution computed tomography, Intraoperative, Temporal bone

Introduction ear cholesteatoma can be made simply by an otoscopic

Cholesteatoma, an inflammatory disease of the temporal
bone, generally develops in the middle ear[1] and is the result
of the formation of keratinized squamous epithelium in the
middle ear.[2] The clinical manifestations of cholesteatoma
are quite variable, ranging from an asymptomatic phase to
lifethreatening complications.[3] The diagnosis of middle
Address for correspondence: Dr.Rohan Gupta,
Department of ENT and Head and Neck Surgery, SMGS Hospital,
Government Medical College, Shalamar Road, Jammu180001,
Jammu and Kashmir, India.
Email:rohangupta5949@gmail.com
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examination, in addition to endoscopic and microscopic
evaluation or even surgical exploration.
Aim
The aim of the present study was to evaluate the role of high
resolution computed tomography (HRCT) temporal bone in
patients with active squamosal chronic otitis media (COM),
by comparing the preoperative HRCT temporal bone findings
with the intra operative findings (gold standard).
This is an open access article distributed under the terms of the Creative
Commons AttributionNonCommercialShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work noncommercially, as long as the
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For reprints contact: reprints@medknow.com

How to cite this article: Kanotra S, Gupta R, Gupta N,

DOI: Sharma R, Gupta S, Kotwal S. Correlation of high-resolution
10.4103/0971-7749.164550 computed tomography temporal bone findings with intra-operative
findings in patients with cholesteatoma. Indian J Otol 2015;21:280-5.

280 2015 Indian Journal of Otology | Published by Wolters Kluwer -Medknow |

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Kanotra, etal.: Correlation of HRCT with intraoperative findings in cholesteatoma
Acquired cholesteatomas are classified into two typespars
flaccida and pars tensa, they are difficult to discriminate on
computed tomography(CT), when involvement is extensive.
The vast majority are attic cholesteatomas(82%) which arise
in the Prussaks space and extend posteriorly through the
posterolateral attic and into the aditus, antrum, and mastoid
air cells. As the mass expands, in the epitympanum, the
ossicular chain is displaced medially and in more severe
cases, the ossicles may be completely eroded. In children, attic
cholesteatomas can extend inferiorly into the mesotympanum
or anteriorly into the protympanum, and in the protympanum,
the anterior portion of the horizontal facial nerve canal, like
the sinus tympani may also be the site of occult disease and
source of recurrent cholesteatoma. This information is critical
to surgical planning and approach. Pars tensa cholesteatomas
arise from the sinus tympani or posterosuperior retraction
pockets, and as these are medial to the ossicular chain, the
ossicles are displaced laterally.
Cholesteatomas have characteristics pattern of growth,
migration, and osseous erosion and are locally destructive. The
only treatment to avoid its complications and to restore the
middle ear is its full surgical removal since there is no effective
clinical treatment for eradication of the disease so far.[4]
A major advance in imaging of the ear structures has occurred
with the development of HRCT.[5,6] By means of special
algorithms, thin section HRCT allows imaging of osseous
structures up to a spatial resolution of 0.450.65mm.
HRCT findings suggesting cholesteatoma include outer attic
wall(scutum) erosion, aditus ad antrum widening, dislocation of
ossicular chain, erosion of ossicles, semicircular canal fistula, facial
nerve canal(fallopian canal) erosion, tegmen plate dehiscence,
mastoid destruction (automastoidectomy), sigmoid plate
dehiscence, and external auditory canal roof erosion and sagging.[7]
An HRCT scan is useful for planning the surgical approach,
determining the extension and site of cholesteatoma and its
sac, assessing the ossicles, evaluating the facial nerve, tegmen
and sinus plate, and determining dural, sigmoid sinus, and
jugular bulb positions.[8]
The use of CT in the preoperative evaluation of the patient
with COM is still controversial nowadays. Some otologists
use it regularly aiming to evaluate the extension of the disease,
which helps to plan the surgical strategies and helps to reduce
the postoperative risks.[9] Others reserve its utilization for
cases of suspicion of complication, recurrence or diagnostic
doubt, using the surgical indication only for the clinical profile
presented.[10]
This study assesses the usefulness of a preoperative HRCT in
depicting the status of middle ear structures in the presence
of cholesteatoma. Its aim is to correlate the preoperative
HRCT findings with the intraoperative findings and establish
Indian Journal of Otology | October 2015|Vol 21|Issue 4 |
HRCT as an efficacious tool for diagnosis of the extent and
involvement of adjacent structures by cholesteatoma.
Materials and Methods
The present study was conducted in the Department of
Otorhinolaryngology and Head and Neck Surgery, SMGS
Hospital, Government Medical College, Jammu for a period of
1year from November 1, 2012 to October 31, 2013 in which
47 patients with active squamosal COM (choleastatoma),
underwent HRCT temporal bone and subsequently,
tympanomastoidectomy in our institution. All the patients
diagnosed with active squamosal COM, on clinical examination
with otoscope and otoendoscope were included in the present
study while those with active mucosal COM, inactive mucosal
COM, inactive squamosal COM, revision surgery, congenital
ear disease, suspicion of ear pathology to be malignant, history
of fracture temporal bone, systemic disease which may affect
the ear (e.g., collagen vascular or granulomatous diseases),
and patients unfit for CT scanning and surgery(pregnancy,
ischemic heart disease, etc.) were excluded.
A thorough history and clinical examination of ear, nose, and
throat were carried out. Ear examination under microscope,
tuning fork tests, pure tone audiometry, radiological test(Xray
mastoid, Townes view), and laboratory investigation were also
performed. HRCT scan of the temporal bone was performed
before surgery in all the cases with 1mm sections in both axial
and coronal planes. Findings were recorded and tabulated.
After detailed discussion regarding the nature of the disease,
its complications, the possible outcome of surgery, and
improvement, informed consent was obtained from each
patient.
All the patients underwent mastoidectomy via postaural route,
under general anesthesia and intraoperative findings were
noted by the operating surgeon. These intraoperative findings
were considered as the gold standard and were compared
and correlated with the radiological findings, to calculate the
sensitivity, specificity, positive and negative predictive value
of HRCT temporal bone.
Statistical analysis
The apparent differences between the findings of HRCT
temporal bone and intraoperative findings were studied in
numbers and proportions, and the apparent differences between
these two categories were statistically tried using Chisquare
test to find out any statistically significant difference. Avalue
of<0.05 was taken to be statistically significant.
Results
Totally, 47patients were included in the present study with
27 (57.44%) male and 20 (42.55%) female patients with
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Kanotra, etal.: Correlation of HRCT with intraoperative findings in cholesteatoma

age ranging from 16 to 59 years and the mean age being Table 1: Pneumatization of mastoid
36.38years. Number of patients
HRCT finding Intra-operative finding
Comparison of preoperative HRCT findings with Sclerotic 47 47
intraoperative findings: Pneumatic 0 0
Sensitivity=100%, Positive predictive value=100%

Pneumatization of the mastoidMastoid was sclerotic on CT in

all the 47(100%) patients and was similar to the intraoperative Table 2: Extension of cholesteatoma
findings. Therefore, when statistically tried, the results of the Number of patients
2 categories were at par with no difference. Sensitivity and HRCT Intra-operative
positive predictive value of HRCT=100%[Table1]. finding finding
Middle ear and attic 5 5
On HRCT temporal bone, the soft tissue density(cholesteatoma) Middle ear, attic and mastoid 42 42
Sensitivity=100% Specificity=100% Positive predictive value=100% Negative predictive
involved middle ear and attic in five patients while in the value=100%
remaining 42 patients, it extended to the mastoid. Similar
findings were reported by the surgeon intraoperatively.
Table 3: Status of tegmen plate
On statistical analysis, no difference was found between
Number of patients
the two categories with the results being at par. HRCT,
HRCT finding Intra-operative finding
sensitivity = 100%, specificity = 100%, positive predictive
Tegmen erosion 5 3
value=100%, and negative predictive value=100%[Table2].
Intact tegmen 42 44
Sensitivity=100%, Specificity=95.45%, Positive predictive value=60%, Negative predictive
Erosion of tegmen plate was reported in five patients on value=95.23%

HRCT temporal bone while intraoperatively, it was present

in three patients. On statistical analysis, Chisquare with Yates Table 4: Status of sinus plate
correction=0.14(degree of freedom=1) and P =0.7116. Number of patients
Therefore, HRCT sensitivity = 100%, specificity = 95.45%, HRCT finding Intra-operative finding
positive predictive value = 60%, and negative predictive Eroded 5 5
value=95.23%[Table3 and Figure1]. Intact 42 42
Sensitivity=100%, Specificity=100%, Positive predictive value=100%, Negative predictive
value=100%
Sigmoid sinus plate erosion was seen in five patients on
HRCT temporal bone, and the same results were found
intraoperatively. Therefore, the statistical analysis showed at Table 5: Status of lateral semi-circular canal
par results with no difference, the sensitivity, specificity, positive Number of patients
and negative predictive value of HRCT=100%[Table4]. HRCT Intra-operative
finding finding
Lateral semi-circular canal fistula 2 3
HRCT temporal bone reported the erosion of lateral
Intact lateral semi-circular canal 45 44
semicircular canal in two patients; while intraoperatively, it Sensitivity=66.66%, Specificity=95.74%, Positive predictive value=100%, Negative
was present in three patients. On statistical analysis, Chisquare predictive value=97.77%
with Yates correction = 0.00 (degree of freedom = 1) and
P=1.00. Sensitivity of HRCT=66.66%, specificity=95.74%, Stapes superstructure was reported to be eroded in nine
positive predictive value = 100%, and negative predictive patients and intact in 38 patients on HRCT temporal
value=97.77%[Table5]. bone, while intraoperatively, it was found to be eroded in
10patients and intact in rest of the 37patients. Statistical
On HRCT temporal bone, 19 cases were reported to have analysis, Chisquare = 0.07 and P = 0.7973. HRCT,
an intact malleus and 28 cases with eroded malleus, while sensitivity = 90%, specificity = 100%, positive predictive
intraoperatively, it was found to be intact in 16patients and was value=100%, and negative predictive value=97.36%[Table6
eroded in 31patients. Statistical analysis, Chisquare=0.41 and and Figure2].
P=0.522. HRCT, sensitivity=90%, specificity=100%, positive
predictive value=100%, and negative predictive value=84.21%. HRCT reported dehiscent fallopian canal in two
patients whereas it was detected in four more patients
HRCT reported incus to be intact in two cases and eroded in intraoperatively. On statistical analysis, Chisquare
45cases, while intraoperatively, it was found to be eroded with Yates correction = 1.23 and P = 0.2674. HRCT,
in all the cases. Statistical analysis, Chisquare with Yates sensitivity=33.33%, specificity=100%, positive predictive
correction=0.51 and P=0.4747. HRCT, sensitivity=95.74%, value=100%, and negative predictive value=91.11%[Table7
and positive predictive value=100%. and Figure3].

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Kanotra, etal.: Correlation of HRCT with intraoperative findings in cholesteatoma

Table 6: Ossicular status

Number of patients
HRCT Intra-operative
finding finding
Intact malleus 19 16
Eroded malleus 28 31
Intact incus 2 0
Eroded incus 45 47
Intact stapes 38 37
Eroded stapes superstructure 9 10
a b
Figure 1: High-resolution computed tomography temporal bone
(a) coronal section and (b) axial section both showing erosion of Table 7: Status of the fallopian canal
tegmen tympanum of left side with soft tissue density in left middle ear Number of patients
HRCT finding Intra-operative finding
Dehiscent fallopian canal 2 6
Intact fallopian canal 45 41
Sensitivity=33.33%, Specificity=100%, Positive predictive value=100%, Negative predictive
value=91.11%

Figure 2: High-resolution computed tomography temporal bone, both
axial sections of the same patient at different levels showing soft tissue
density replacement of middle ear air, with ossicular chain disruption
in right ear whereas we can appreciate the normal ossicular anatomy
of left ear with air surrounding them
Pneumatization of mastoid
In the present study, the sensitivity and positive predictive
value of HRCT were 100% in predicting the pneumatization
of mastoid when compared with the intraoperative results.
Similar results were reported by Jackler etal.,[10] Vlastarakos
et al.,[11] Rai[12] and Datta et al.,[13] who also found a strong
agreement between HRCT and intraoperative findings in
case of mastoid air cell complex.
Extension of soft tissue
HRCT had sensitivity = 100%, specificity = 100%, positive
predictive value=100%, and negative predictive value=100%
in predicting the extension of soft tissue mass. This finding
is in agreement with that of Walshe etal.[14] and Sirigiri and
Dwaraknath[15] who reported a sensitivity of 90% and 87.5%,
respectively.

Figure 3: High-resolution computed tomography temporal bone in a
patient of cholesteatoma formation, showing erosion of bony canal
of horizontal part of facial nerve (fallopian canal) in the medial wall of
middle ear with soft tissue density (cholesteatomatous tissue) seen
adjacent to the erosion
Discussion
HRCT temporal bone plays an important role in the assessment
of patients with suppurative COM and cholesteatoma by giving
preoperative information of the closed spaces of the middle ear.
Tegmen erosion
On comparing the HRCT findings with Intraoperative findings
in the present study, the sensitivity=100%, specificity=95.45%,
positive predictive value = 60%, and negative predictive
value = 95.23%, P = 0.7116 (insignificant) thereby implying
that there was no statistically significant difference between
the HRCT report when it was compared to the gold
standard(intraoperative findings). Asimilar specificity rate
of 95% was reported by Gerami etal.,[16] and a specificity rate of
91.93% and negative predictive value of 100% were also reported
by Prata et al.[17] and Datta et al.[13] A similar value of 100%
sensitivity, of HRCT, was also reported by Rocher etal.,[18] Zhang
et al.,[19] Alzoubi et al.,[20] and Datta et al.[13] Gerami et al.[16]
reported the sensitivity, positive and negative predictive value
to be 6%, 50%, and 60%, respectively, quite low as compared
to the present study. Apoor sensitivity rate of HRCT to detect
tegmen tympani erosion was also reported by Jackler etal.[10]
and OReilly etal.,[21] while a moderate association was seen by
Vlastarakos etal.[11] and Chee and Tan.[22]

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Kanotra, etal.: Correlation of HRCT with intraoperative findings in cholesteatoma
Sigmoid sinus plate erosions
The present study reported the sensitivity, specificity, positive
and negative predictive value to be 100%. Datta et al.[13]
reported results similar to that documented by the present
study while Rai[12] intraoperatively found sigmoid sinus plate
erosion in eight patients whereas it was reported by HRCT in
only six patients.
Lateral semicircular canal fistula
Sensitivity=66.66%, specificity=95.74%, positive predictive
value = 100%, negative predictive value = 97.77%, and
P=1.0 were reported in the present study in detecting lateral
semicircular canal fistula, thereby pointing out an insignificant
statistical difference between the HRCT temporal bone
and intraoperative findings (gold standard). Datta et al.[13]
reported 100% sensitivity, specificity, positive and negative
predictive value, values much higher than the present study.
Alzoubi etal.,[20] Chee and Tan,[22] Mafee etal.,[23] and Rocher
etal.[18] also reported HRCT to be 100% sensitive in predicting
lateral semicircular canal fistulas while Rai[12] reported it to be
only 25% sensitive. Gerami etal.[16] reported a weak correlation
between HRCT temporal bone and intraoperative findings.
Ossicular erosion
Malleus was reported to be eroded in 28patients by HRCT,
while intraoperatively, it was eroded in three more patients,
making the HRCT, sensitivity = 90%, specificity = 100%,
positive predictive value = 100%, and negative predictive
value = 84.21% in the present study. A specificity rate of
100% was also reported by Rai, [12] Rocher et al.,[18] and
Zhang etal.,[19] however, they all reported HRCT to be 100%
sensitive, which was higher as compared to the present study.
The sensitivity, specificity, and positive predictive value of
the present study were comparable to the study conducted
by Datta et al.,[13] whereas the negative predictive value of
the present study was higher 84.21% as compared to 66.66%
reported by Datta etal.[13] According to a study conducted
by Rogha etal.,[24] there is a good radiosurgical correlation
for malleus while Chee and Tan[22] reported an excellent
correlation.
Incus was observed to be eroded in 45cases on HRCT, while
intraoperatively, it was found to be eroded in all the 47cases,
therefore, HRCT was found to be 95.74% sensitive with
100% positive predictive value and P=0.4747, implying an
insignificant difference between HRCT and intraoperative
findings. Datta et al.[13] and Rai[12] also observed a positive
predictive value of 100%, but the sensitivity was slightly
low(87% and 85%, respectively) as compared to the present
study. Results comparable to the present study were also
reported by Zhang etal.[19] whereas Tok etal.[25] reported a
sensitivity rate of 84.6% and a positive predictive value of
97.1%. A good radiosurgical correlation was reported by
Rogha etal.[24] and Chee and Tan[22] for incus.
284
Stapes superstructure erosion was reported by HRCT in nine
patients, while intraoperatively, it was found in one more
patient, making HRCT, sensitivity=90%, specificity=100%,
positive predictive value = 100%, and negative predictive
value=97.36%. Rai[12] reported HRCT to be 100% specific but
less sensitive(75%) as compared to the present study, and a
similar observation was made by O Donoghue.[26] Tok etal.[25]
reported a sensitivity of 71.2%, specificity = 100%, positive
predictive value=100%, and negative predictive value=76.2%.
Chee and Tan[22] have reported a good radiosurgical correlation
for stapes while Zhang etal.[19] and Datta etal.[13] have reported
HRCT to be poor in detecting stapes.
Dehiscent fallopian canal
The present study reported 33.33% sensitivity, 100%
specificity and positive predictive value, and 91.11% negative
predictive value with a P=0.267, the value being statistically
insignificant (no statistically significant difference between
HRCT and intraoperative findings). In the present study,
HRCT reported 4 falsenegative cases for facial canal
dehiscence, making it 33.33% sensitive but 100% specific.
Similar results were also observed by Alzoubi et al.[20] and
Rai,[12] but poor and insignificant correlation between the two
was reported by Jackler etal.,[10] OReilly,[21] Rocher etal.,[18]
Chee and Tan,[22] Zhang etal.,[19] Gerami etal.[16] and Rogha
etal.[24] Mafee etal.,[23] however, reported HRCT to be 100%
accurate. Datta etal.[13] reported the specificity, positive and
negative predictive value to be comparable to the present
study but a higher sensitivity of 75%, while Magliulo etal.[27]
in their study, observed a sensitivity and specificity of 69%
and 87%, respectively.
Conclusion
The CT scan is the standard imaging technique for the temporal
bone. In the present study, HRCT has high reliability for the
parameters such as mastoid pneumatization, cholesteatoma
extension in the middle ear and mastoid, and the presence of
complications such as sigmoid sinus plate erosion and tegmen
mastoideum erosion.
Therefore, it is concluded that CT despite its pitfalls such
as more radiation exposure and higher cost delineates the
location and extent of the disease and provides information
on anatomical variations and complications. It serves as a
roadmap to assist the surgeon during surgery.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Kanotra, etal.: Correlation of HRCT with intraoperative findings in cholesteatoma
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