EL-MINIA MED., BUL., VOL. 21, NO. 1, JAN., 2010
Abdel Karim et al
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RADIOLOGICAL EVALUATION OF MIDDLE EAR
CHOLESTEATOMA OTITIS
By
Abdel. Rahim Ahmed Abdel. Karim*, Hosny Sayed Abdel Khany**,
Mohamed Abdel Motal Gomma*, Ahmed Abdel Kader El-Hene*
Ahmed Adel Sadek*
Departments of *Otorhinolaryngology and ** Radiodiagnosis
El Minia Faculty of Medicine
ABSTRACT:
Media remains a significant internat-ional health problem in terms ofprevalence, economics, and sequelae. Cholesteatoma is a cystic lesion formed from
keratinizing stratified squamous epithelium, the matrix of which is composed of
epithelium that rests on a stroma of varying thickness, the perimatrix. The resulting
hyperkeratosis and shedding of keratin debris usually results in a cystic mass with a
surrounding inflammatory reaction (Seiden et al. 2002). The ability of high-resolution
computed tomography (HRCT) to depict accurately the status of the structures of the
temporal bone represents a major advance in delineating pathology prior to surgical
exploration of the ears with cholesteatoma. This imaging technique provides
information concerning location and extent of the disease as well as possible anatomic
variations and complications that may be encountered. CT scan may also be valuable
in early diagnosis of cholesteatoma, when the disease is confined to the attic or
posterior tympanum beyond ostoscopic view. (Chee and Tan 2001).
KEY WORDS:
Ct: compnterized tomography
HRCT: High resolution compntenized tomogrophy
CSOM chronic supp.otitis media
ICC: Intra-cranial complication
AIM OF THIS WORK:
The aim of this work is to
emphasize the role, value and impact
of imaging in detecting, evaluating,
and diagnosis of middle ear
cholesteatoma.
PATIENTS AND METHODS
This
work
includes
56
consecutive patients presented within
the period from September 2007 to
February 2011. referred to Radiology
Department from our E.N.T Department, El-Minia University hospital for
CT scanning of the temporal bone.(26)
were males and (30) were females,
their ages regarded from (9) to (65)
years with the main age (25.6). All
patients were diagnosed clinically as
cholesteatoma presented with chronic
ear discharge with offensive odour,
marginal tympanic membrane perforation, conductive hearing loss some
by signs of intracranial complications
and facial palsy.
Every patient was subjected to:
1- Full history taking.
2- Clinical examination:
All patients are subjected to full ENT
examination in our ENT department.
Careful otoscopic examination. full
audiological evaluation.
3- Radiological evaluation: CT
examination: HRCT examination was
done to all patients.
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4- Operative interference and
data correlate-ion: All these patients
were carefully prepared and operative
interference is done with correlation of
operative
data
obtained
intraoperatively and those obtained from
imagine studies.
RESULTS:
This study included 56 patients
with cholesteatoma with age ranging
from 9 years to 65 years. 26 of them
were males and 30 were females. The
high incidences were in the third
decade as a complication to chronic
otitis and eustachian tube dysfunction,
while the low incidences were in six
decade. Females (30 patients/ 53.57%)
were more affected than males
(46.42%).
2- Clinical presentation (symptommatology): Chronic ear discharge with
partial or complete conductive hearing
loss was the main clinical presentation
and representing (60.71%) followed by
chronic ear discharge (17.85), chronic
ear discharge with signs of increased
intracranial tension (14.28%), facial
paresis with chronic ear discharge
(3.57%) and lastly vertigo with
sensorineural hearing loss in two
patients (3.57%).
3- CT findings of choLesteatoma:
CT
criteria
of
acquired
cholesteatoma: The hallmarks of
cholesteatoma on CT scan are based on
the presences of one more of the
following criteria;
- A non-dependent soft tissue density
mass.
- Typicallocation (attic, mesotympanum or antrum) associated with;
- Bony erosion (Yates et al; 2002)
Combined pars f1accida and
pars tensa cholesteatomas were the
mostly encountered- type detected in
(35.71%) and pars f1accida choles-
teatomas (35.71%) followed by pars
tensa cholesteatomas in (28.57%).
- The extensive holotympanic
acquired cholesteatoma was the most
common (32.14%) followed by attic
cholesteatoma in (28.57%), atticoantral cholesteatoma in (21.42%) and
mesotympanic
cholesteatoma
in
(17.85%).
- The scutum and lateral attic
wall erosion was the most common
finding encountered in (64.28%) and
eroded Korner's septum (64.28%)
followed by eroded tegmen (17.85%)
and the least common is the eroded
sigmoid sinus plate (14.28%).
- The ossicles was absent or
completely eroded in (57.14%), the
incus was the most commonly affected
of the ossicles (82.14%), followed by
malleus erosion (67.88%), the ossicles
was displaced without erosion only in
(7.1%).
- The involvement of the sinus
tympani was detected in (39.28%) and
the facial recess involvement was
encountered in (35.71%).
- The sclerotic mastoid was the
most common finding encountered in
(60.71%). Automastoiectomy was
encountered in (35.71%), lateral
mastoid wall fistula (17.85) and
mastoid abscess was detected in one
case
(3.57%)
with
infected
cholesteatoma.
- The lateral semicircular canal
fistula was the most common finding
encountered in (21.42%), eroded
cochlea, vestibule and semicircular
canals in (3.57%), and eroded IAC in
(3.57%).
- The facial nerve canal was
intact in (71.42%), eroded in (21.42%)
and dehiscent in (7.14%). The
horizontal (tympanic) segment of the
facial nerve canal was the mostly
affected segment (17:85%) and the
vertical segment was the least (3.57%).
- The other ear was normal in
(71.42%) and diseased in (28.57%),
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Abdel Karim et al
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chronic suppurative otitis was encountered in (25.0%) and bilateral cholesteatoma in (3.57%).
Compilications
of
chronic
suppurative otitis media with
cholesteatoma:
They were classified into
temporal bone complications and intracranial complications. -The temporal
bone complications were more encountered than. intracranial compli-cations
(14128%). The ossicular destruction
was the mostly encountered complication (53.57%) followed by conductive hearing loss (53.57%), automastoidectomy (35.71%), labyri-nthine
fistula (21.42%), post auricular abscess
(14.28%), sigmoid sinus plate erosion
(14.28%) and the least complication
was the sensori-neural hearing loss
(3.57%).
-Regarding
intracranial
complications, the cerebellar abscess,
cerebral abscess, extradural abscess
and otitic hydrocephalus were equally
encountered (3.57%) for each.
Correlation between ct findings and,
operative features in 56 patients with
cholesteatoma.
HRCT scans showed the
presence of a non dependent tissue
mass in 52 out of, 56 patients with
cholesteatoma (92.8%), the location of
the pathology on the scan was typical
for cholesteatoma in 54 patients
(96.4%) and in 56 patients (100%)
there was radiological evidence of
erosion or destruction of the bony
walls of the middle ear, mastoid
antrum or ossicles. All patients had at
least one of the above radiological
features, and 52 (92.8%) patients
showed all 3 features. Based on these
features 54 eats with cholesteatoma
(96.4%) were accurately diagnosed by
the HRCT scan. The accuracy and
sensitivity of CT scan were correlated
with the operative finding in all
patients of cholesteatoma undergoing
operative interference. This revealed
that the accuracy and sensitivity was
excellent regarding malleus erosion,
lateral semicircular canal fistula,
sigmoid sinus plate erosion and intracranial complications, very good'
correlation regarding sincus erosion
and the tegmen tympani erosion and
good for the facial nerve canal. -State
of the ossicles: The incus was the most
frequently eroded ossicle, followed by
the malleus. Out of the 56 patients with
incus erosion found at surgery, 50
patients were demonstrated with CT'
scan and the preoperative CT scans
agreed were surgical findings of incus
erosion in; 50 patients (96.4%). Of the
36 eroded malle of 36 were, seen by
the scan with accuracy (1.00%). The
stapes is not visualized consistently by
can and not analyzed in this study
Semicircular canal fistlila:
Cholesteatoma may occasionally erode the semicircular canals,
particularly the lateral semicircular
canal where it is exposed on the medial
wall of the epitympanum. There were
12 patients with surgically confirmed
labyrinthine fistula. Preoperative CT
Scan diagnosed all the 12 patients of
lateral semicircular canal fistulas
accurately. In the remaining cases,
there were no false positive radiographic interpretations, and thus complete agreement was obtained.
Erosion tegmen tympani:
The tegmen is visualized in
coronal sections, appears as a thin
bony plate overlying the epitympanum
and antrum. There was agreement in
(94.4 %) between the preoperative CT
scan and operative features. two cases
was diagnosed as eroded tegmen and
the operative features showed only
dehiscence of the tegmen with no dural
exposure.
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Integrity of the facial nerve canal:
In this study CT scans found
agreement about facial nerve canal
integrity in 21 patients (75%) between
the radiograph and surgery. Out of6
patients with surgical confirmation of
eroded facial nerve canal, CT could
detect 5 patients in the present study.
CT is agreed with operative features
regarding 2 patients with facial canal
dehiscence.
Integrity of the sigmoid sinus plate:
Four patients of sigmoid sinus
plate erosion were diagnosed accurately by preoperative CT scans.
Intracranial complications:
Eight patients with intracranial
complications including cerebellar
abscess, cerebral abscess extradural
abscess and otitic hydrocephalus were
diagnosed accurately be preoperative
CT scans.
DISCUSSION:
The present study included 56
patients diagnosed as acquired
cholesteatoma with age ranging from 9
years to 60 years. 26 of them were
males and 30 were females. The high
incidence was in the third decade with
a history of recurrent chronic otitis
media,
tympanic
membrane
perforation, while the low incidence
was in sixth decade. David white
(1997). Stated that acquired cholesteatoma are inflammatory lesion may
occur at any age but are more common
seen in patients less than 30 years
There is typically a history of recurrent
middle year infections, with tympanic
membrane perforation.A study made
by kemppainen et al (1999), the mean
annual inadence was 9.2 per 100.000
inhabitants and the incidence was
higher among males under the age of
50 years. The majority (72.4%) of
cholesteatoma patients had suffered
from otitis media episodes. In the
present study, ear discharge was a
constant clinical feature either alone in
10 patients (17.85%) or associated with
other clinical features such conductive
hearing loss in 34 patients (60.71%)
signs of increased intracranial tension
in 8 patients (14.28%), facial paresis in
2 patients (3.57%), vertigo and
sensneural hearing loss in 2 patients
(3.57%). These clinical features are
coincident with the presentation described in literatures. Seiden (2002) and
Balleneger (1985) reported that ear
discharge and hearing loss are the main
symptoms of patients with cholesteatoma, hearing loss vary from trivial to
sever.
CT features of cholesteatoma
patients:
Cholesteatoma can be accurately diagnosed by HRCT scan. Mafee
et al (1988) reported in his series of 48
patients with cholesteatoma that 46of
them (96%) were diagnosed correctly
with pre-operative CT scan .In the
present study 56 patients were
diagnosed as acquired cholesteatoma.
CT dignosis was based primarily on
three criteria:
1) Presence of a non dependant soft
tissue density mass.
2) A location of the pathology typical
for cholesteatoma. (i.e epitympanun. mastoid antram, mesotympanum) assoaated with
3) Bony erosion (ossicular chain,
scutum, lateral wall of the
epitympanic recess or tegmen).
Based on these citeria we found
that secondary acquired cholesteatoma were most often localized
to the attic and some are
hypotympanic.
Liu and Bergeron (1989) stated
that CT is a unique in its ability to
display not only the internal bony
architecture of the temporal bone but
also to evaluate the soft tissue
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Abdel Karim et al
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components associated with the
pathologic process .In the current study
small
attic
and
mesotympanic
cholesteatoma was detected in 12
patients. Early prussak's space cholesteatoma was detected in 4 patients as a
localized small soft tissue density mass
slightly eroding the scutum and
displace the ossicles medially.
Early mesotympanic cholesteatoma eat-ending from a posterosuperior retraction related to the facial
recess and sinus tympanic detected in
21 patients associated with slightly
eroded incus long and lenticular
process. The remaining 4 patients
showed localized attic cholesteatoma
associated with erosion of the scutum,
malleus head and neck with slight
extension towards the aditus. Joselitol
et al (2004) reported that signs
indicating cholesteatoma in the attic
include erosion or destruction of
scutum or spur (the lateral wall of the
attic). Widening of the aditus and
antrum with loss of figure of "8"
appearance.
Hidden cholesteatoma:
In the present study CT scan
demonstrate the involvement of
posterior tympanic recesses (sinus
tympanic and facial recess) by cholesteatoma mass in 22 patients of 56
patients (39.28%). The anterior tympanum involved in 12 patients
(21.4%). This is consistent with Hasso
et al (1988) and Mafee et al (1988)
who mentioned that Ct could
demonstrate cholesteatoma in hidden
areas such as post tympanic recesses,
which could not be detected by the
otologic examined examination.
Extensive cholesteatoma:
In this study 18 patient presented with extensive cholesteatoma
filling the whole tympanic cavity and
extend to mastoid antrum (32.14%).
The diagnosis of these cases depends
on that, the cholesteatoma had a
propensity for bony erosions of the
middle ear bony boundries and mastoid
and did not gravitate (non dependant)
in axial and coronal sections. These
features are consistent with Swortz et
al. (1983) and Jackler et al (1984)
depending mainly on bony erosion.
Joselito et al (2004) postulate that
unfortunately the diagnosis of extensive cholesteatoma need to differentiate it from other diffuse ear diseases
either inflammatory or neoplastic,
associated granulation tissue, mucosal
oedema and effusion may be indistinguishable on CT scanning and
magnetic resonance imaging can
differentiate.
Complications of cholesteatoma:
In the present study complications of cholesteatoma were
divided into temporal bony complications and intra cranial complications.
Cranial complications:
Conductive hearing loss is a
common complication as ossicular
chain erosion occurred in (57%) of
patients. literature presents similar
results, with sensitivity ranging from
80 to 100% (Banerjee et al 2003) The
presence of sensorineural hearing loss
may Indicate
involvement of the
labyrinth (Sade et al., 1982).
Labyrinth fistula encoutered in
20% of patients. two patients presented
with vertigo the other ten patients
discovered by HRCT. Chee et al
(2001) stated that labryrinthine fistula
can be accurately detected most of the
time when both axial and coronal
images are taken to look for erosions
of the sernicircircular canal and
reliance on coronal setions alone may
lead to 50% falsepositive rate due to
the artifact of partial volume
averaging. -palva (1990) concluded
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that the labyrinthine fistula may occur
in 10% of patients with chronic ear
infection due to cholesteatoma .
- fascial paresis detected in two
patients with cholesteatoma eroding the horizontal portion of facial
nerve canal .
- automastoidectory detected in 20
patients (35.71%) in which the
mastoid air cells were eroded .
- sigmoid sinus plate erosion was
detected in 8 patients (14.28%) .
Intra cranial complications:
The incidence of Intracranial complication is less than in preantibiotic
era. In the present study complications
were encountered in 8 patients (14.2%)
in the form of cerebeller abscess,
cerebral abscess, extradural abscess
otitic hydrocephalus.
- Graziela et al (2008) concluded in
his study that brain abscess is the
most
common
intracranial
cmplication and mostly affect the
temporal lobe and cerebellum.
- Correlation between CT finding
and operative Data: -In the
present study the correlation
between CT scan and operative
features of 56 patient with cholesteatoma depends on the accuracy
and sensitivity of HRCT scan
compared with operative data and
clinical correlation. HRCT scan
revealed the presense of tissue
density mass in 52 out of 56
patients
with
cholesteatoma
(92.8%). the location of pathology
on CT scan was typical for cholesteatoma in 54 patients (96.4%). in
56 patients (100%) the radioloyical
evidence of bony erosion either of
the middle ear structures, mastoid
or ossicular chin noted. All patients
with cholesteatoma had at least one
of the CT criteria indicating
cholesteatoma and 54(92.8%)
patients showed all the 3 featurs.
-
54 patients accurately diagnosed
with HRCT scan.
This coincides with mafee et al
(1988) who repoted in his series
(48 patients) with cholesteatoma
that 46 of them (96%) were
diagnosed correctly with pre
operative.CT. -Joselito et al (2004)
who reporte in his series of (64)
patients the analysis of pre.
operative HRCT scan correlated
with the surgical finding and
histopathologic reports with ahigh
degree of accuracy (96.8%) .
Ossicular chain erosion:
In the present study, radio.
surgical correlation for the middle ear
ossicular erosion was (96.4%) for the
incus erosion and (100%) for the
malleus erosion. there fetures are
mtched with study made by chee et al
who found that out of 31 incus which
were found at surgery to be eroded 30
were demonstrated by CT scan with
accuracy (96.8%) and of the 15
malleus 14 were seen by the scan with
accuracy (96.8%) In the study. -In the
study for joslito et al (2004) the radio –
surgical correlation was (94%) for
malleulus and (96%) for incus. Hassman et al (2003) in aseries of 60
patients reported that there is good
correlation between CT finding and
operative features in cholesteatoma for
most middle ear structures.
- Labyrinthine fistula: In the present
study 12 patients with later semicircular canal fistulas, were diagnosed
accurately by operative CT scan in
both axial and coronal planes. A study
mode by joselito et al (2004) in a series
of 64 patients there were 4 case
(6.25%) that had labyrinthin fistula in
HRCT but only 3(4.69%) were in
agreement with surgical finding. Anelise et al (2010) state that in his
series the lateral semicircular canal
erosion was present in two cases and
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was correctly
Operative CT.
identified
by
pre.
Tegmen erosion: Tegmen tympani
represent the roof the middle ear cavity
. Erosion of the tegmen is well seen on
coronal imaging. In this study Tegmen
erosion was detected in 10 patients
with accuracy (94.4%). One case was
dignosed as eroded tegmen and the
operative feature showed only dehiscence of the tegmen with no dural
exposure. Mafee et al (1988) had
similar results as CT findings matched
with operative data regarding tegmen
erosion in 94%. Also the accuracy in a
study made by chee et al (2001) was
(94.5%).
Facial canal integrity: Out of 12
patients with surgically confirmed
.fascial canal erosion. 10 patients
detected by CT with accuracy (96.4%)
and sensitivity (83.3%). joselito et al
(2004) state that pre. Operative
demonstration of .facial nerve canal
involvement was often difficult not
only because of its small size but due
to its oblique orientation and the
presense of developmental dehiscence,
particularly when obutted by the soft
tissue.
Value of pre. Operative CT in
patients with cholesteatoma:CT
offers
high-resolution
images with a section thickness of
approximately 1 mm, which allows for
good visualization of the bony
anatomy, ossicular, and inner ear
anatomy. On CT scan, good contrast is
demonstrated for bone, soft tissue, and
air. CT scan is the preferred method for
evaluating chronic middle ear disease,
including acquired cholesteatoma,
because of its ability to demonstrate
bony destruction.
CT scanning is used to
establish the surgical procedure needed
in each patient. CT helps in
determining the extent of the
cholesteatoma; the location and size of
the sac; the status of the ossicular
chain; the integrity of the facial canal,
tegmen, and sinus plate; and the
position of the dura, sigmoid sinus, and
jugular bulb.
Cholesteatoma has a tendency
to reside in hidden ares such as the
sinus tympani and the anterior epitympaum. CT finding determine the choice
of surgical approach and is of most
value when the otologist can be
flexible in surgical technique, tailoring
it to imaging finding (Banerjee et al
2003). The absolute indication for
preoperative CT in chronic otitis media
were described by Falcioni et al (2002)
which include: doubtful diagnosis, suspected malformations, difficult microscopy evaluation, suspected petrous
apex cholesteatoma, suspected intracranial complications.
CONCLUSIONS:
From the study we conclude that:
1- cholesteatoma remins asignificant
health problem. The early detection
and effective managment may
overcome or redue the incidence of
complications.
2- the patient with cholesteatoma
should be scanned in both axial and
coronal planes as may relevant
structures are best seen in only one
of these planes.
3- CT scan is a unique method in
detecting early cholesteatoma as
well as detecting cholesteatoma In
hidden areas.
4- CT scan serves as aroad map assist
the surgeon during surgery more
limited and more directed procedures can be done with preserving
function.
Recommendation
HRCT is Recommended in chonic
suppurative otitis media with choles-
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teatoma for: -Early detection, Localization and extension, Detection of
cholesteatoma in hidden areas.
Detection the subtle bony defects: as
scutal erosion, labyrinthine fistula,
defect in tegmen, details of ossicular
involuement, details of ossicular
erosion or discontinuity, anomalies,
erosion or invasion of facial nerve
canal . Intra cranial complications .
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Otolaryngology, the Essential, Text,
thieme New York; 2002; 44-58.
26. Swartz
JD(1984).
Cholesteatoma of the middle ear,
diagnosis, etiology and complications.
Radiol clin North Am. 1984; 22-15.
27. Tony W and peter V (2008).
the anatomy and embriology of the
external and middle ear. In: scott.
Brown's otolaryngology Head and
neck surgey 7th edition. Butterworth
Heinemann oxford. G.B., Cropter 225.
28. Valvassori GE, Buckingham
RA, Carter BL, Hanafee WN, Mafee
MF (eds.) (1988).
29. Yates PD, Flood LM, Banerjee
et al (2002) ctscanning of middle ear
cholesteatoma. What does the surgeon
want to know? B, J Radiol 75: 847852.
‫‪EL-MINIA MED., BUL., VOL. 21, NO. 1, JAN., 2010‬‬
‫‪Abdel Karim et al‬‬
‫___ _______________________________________________________________________________‬
‫الملخص العربي‬
‫التقييم اإلشعاعي لاللتهاب الصديدي اللؤلؤى لألذن الوسطى‬
‫‬‫‬‫‪-‬‬
‫‬‫‪-‬‬
‫‬‫‬‫‬‫‪-‬‬
‫‬‫‪-‬‬
‫تعتبر الكوليستياتوما (االلتهاب الصديدي اللؤلؤي ) من األمررا الطييررو والمردمرو لر ن‬
‫الوسيى لما لها من مضاعفات طييرو من طالل تأكل العظمة الصدغية ‪.‬‬
‫وتنقسم الكوليستي اتوما إلى كوليسرتياتوما طلقيرة و كوليسرتياتوما مكتسربة واألطيررو تنقسرم إلرى‬
‫أولية وثانوية ‪.‬‬
‫وتعتمررد علررى ت ررطيل الكوليسررتياتوما علررى الفكررل الكلينيكررل ‪ .‬ولكررن نظرررا لتيررور علررم‬
‫األ عة فل السنوات األطيرو تيورا م هالً واستطدام األ عة المقيعيرة برالكمبيوتر منر ميلر‬
‫السبعينيات فل فكول األ عة على مطتلف أجزاء الجسم وساعد لك فل ت طيل كثيرا من‬
‫األمرا بكفاءو عالية وكان من ه ه التيبيقات استطدامه ب كل طال فل ت طيل أمرا‬
‫األ ن ومجمرررل أمررررا العظرررم الصرررترو ومررر التيرررور الميررررد ظهرررر اسرررتطدام األ رررعة‬
‫المقيعية عالية التمييز كأهم التيبيقات لقردرتها فرل ت رطيل األمررا بدمرة متناهيرة كترى‬
‫التل يصل كجمها إلى أكل من سنتيمتر ‪.‬‬
‫وكان الهدف من ه ا البكث هو تقيريم دور األ رعة المقيعيرة برالكمبيوتر عاليرة التمييرز فرى‬
‫ت طيل و تقييم كاالت االلتهاب الصديدي اللؤلؤي " الكوليستياتوما " ‪.‬‬
‫ومد أجريت ه ه الدراسة على ‪ 56‬مري يعرانون مرن الكوليسرتياتوما أوليرة مكتسربة تررددوا‬
‫على العيادو الطارجية لقسم األنف واأل ن والكنجرو بمست فى المنيا الجرامعل فرل الفتررو مرن‬
‫‪ . 2011-2007‬وتراوكررت أعمررارهم مررن ‪ 65-9‬سررنة وكرران مررن بررين هررؤالء ثالثررون مررن‬
‫السرريدات وسررتة وع رررون مررن الرجررال وتررم فكررل جمي ر الكرراالت فكصررا إكلينيكيررا ررمل‬
‫األعررررا المصررراكبة لكررراالت التهررراب األ ن الوسررريى والفقرررد الجز رررل أو الكلرررى للسرررم‬
‫التوصررريفل ر ارتفرررا درجرررة الكررررارو ر و رررعور المرررري بالصررردا ال رررديد أو الررردوار أو‬
‫لل العصب الساب ‪.‬‬
‫أعرا‬
‫ثررم إجررراء األ ررعة المقيعيررة عاليررة التمييررز علررى العظررم الصرردغل لجمي ر الكرراالت الوض ر‬
‫المكوري والتراجى بالضرافة إلرى فكرل المرا لبيران المضراعفات المصراكبة ‪ .‬ومرد اسرتطدم‬
‫وسيي التباين فل بع الكاالت المصكوبة بالمضاعفات‪.‬‬
‫وتمت مقارنرة النترا ا الناتجرة عرن الفكرل ال رعاعل بالنترا ا الترل ترم الكصرول عليهرا مرن‬
‫التدطل الجراكل لهؤالء المرضى‪.‬‬
‫تمت مقارنة ه ه النتا ا التل تم التوصل إليها فل ه ا البكث م نتا ا األبكراث األطررو فرل‬
‫ه ا المجال ‪.‬‬
‫وتبين انه فى كاالت االلتهاب الصرديدي اللؤلرؤي " الكوليسرتياتوما" أثبترت األ رعة المقيعيرة‬
‫أنها الفكل األمثل فرل تقيريم تلرك الكراالت بثقرة متناهيرة وك رف الصرابة المبكررو ‪ .‬وكر لك‬
‫توضيح وجود المر بالفجوات والدهاليز باأل ن الوسيى بعيدا عن مجرال الرؤيرة بمنظرار‬
‫األ ن وك لك أظهرت األ عة المقيعية مكان الصابة بدمة ويريق ومدو انت ارها ‪.‬‬
‫دورا ها ًمرا فرل تقيريم الكراالت مبرل الجراكرة ورسرم اليريقرة المثلرى للجراكرة‬
‫كما أن ل عة ً‬
‫المناسبة للمري ‪.‬‬
‫ومد تم تزويد الرسالة بعدد وافر من الصور التوضيكية وتم اطتيار أكثر من مثرال للتوضريح‬
‫‪.‬‬