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Otosclerosis: Incidence of Positive Findings on High-Resolution Computed Tomography and Their Correlation to Audiological Test Data

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Otosclerosis: Incidence of Positive Findings on High-Resolution Computed Tomography and Their Correlation to Audiological Test Data Annals of Ololcgy. Rhinology & Laryngology 1 !4(9):7O9-7I6. © 2(KI5 Annals Publishing Company. All rights reserved. Otosclerosis: Incidence of Positive Findings on High-Resolution Computed Tomography and Their Correlation to Audiological Test Data Ilka C. Naumann, MD; Beat Porcellini, MD; Ugo Fisch, MD Objectives: Computed tomographic (CT) scanning with slices of 1 mm or more has not been sufficient to demonstrate otosclerotic foci in most cases to date. Methods: We investigated the validity of CT scans with a 0.5-mm cubical scan technique, with and without planar reconstruction, and correlated these findings with audiologicai data. Forty-four temporal bone CT scatis from 30 patients with conductive or mixed hearing loss were evaluated. Results: Otosclerotic foci were visualized in 74% of the cases. With reconstruction at the workstation, the sensitivity increased to 8,^%. Whereas in fenestral otosclerosis a correlation was found between the size of the focus and the air- bone gap, no correlation was seen between the size of the focus and bone conduction thresholds with cochlear involvement. Otosclerotic foci in patients treated with sodium fluoride were smaller than those in patients without treatment. This finding may indicate a beneficial effect of sodium fluoride on otosclerotic growth. Conclusions: High-resolution CT scans are a valid tool that can be used to confirm, localize, and determine the size of clinically suspected otosclerotic foci. Key Words: audiometry, computed tomography, otosclerosis. INTRODUCTION foci, and also to determine whether there is a corre- Although otoscierosis has ati estimated prevalence lation between the extent of otosclerosis and the de- of 10% iti the Caucasian population and was de- gree of hearing loss (conductive and sensorineural). scribed histopathologically nearly 250 years ago, its diagnosis is, to this day, made clinically. A suspicion METHODS of otosclerosis is evoked by a combination of the Between May 2001 and May 2003, we collected history and audiometric findings (conductive hearing data on consecutive patients with normal findings loss, absent stapedial reflexes, Carhart's notch, and on otoscopic examination and long-standing progres- type Atympanogram). Confirmation of the diagnosis sive unilateral or bilateral hearing loss suggestive of typically requires surgical middle ear exploration. otosclerosis. Both genders and all age groups were Fine-cut computed tomographic (CT) images have included in the study after informed consent was ob- been proven to demonstrate otosclerotic foci around tained. Patients with congenital malformations, a his- the oval and round windows, as well as the otic cap- tory of chronic ear infections, previous surgery, or sule. So far, the clinical role of CT scanning in oto- sudden hearing loss of the affected ear were excluded. sclerosis remains controversial. The differential diag- The initial workup for hearing loss included otos- nosis of otosclerosis is extensive and encompasses copy, audiometry (pure tone and speech), a tympan- entities from ossicular discontinuity to congenital fix- ogram, and stapedial refiex testing. The preoperative ation. High-resolution CT (HRCT) scanning may be air and bone conduction thresholds for the speech helpful in differentiating these middle ear disorders frequencies of 500, 1,000, 2,000. and 4,000 Hz were and confirming the diagnosis of otosclerosis before recorded, and the air-bone gap (preoperative values) operative treatment, thereby helping in surgical plan- was calculated. All tests, including the HRCT scan- ning and patient counseling. ning, were timed closely together. A total of 44 HRCT This study was intended to determine the accuracy scans, with each ear counted as a single scan, from of fine-cut CT scanning in identifying otosclerolic 30 patients were studied; because of the above-men- From the Deparlmeni of Otolaryngology-Head and Neck Surgery. Indiana University. Indianapolis, Indiana (Naumann), and the Depanmeni of Radiology (Porceilini) and the ORL Zenlrum (Fisch), Klinik Hirsianden. Zurich. Switzerland. Presented at the meeting of the Politzer Society, Saas Fee, Switzerland, April 22-25, 2004. Correspondence: Ugo Fisch. MD. ORL-Zentrum Klinik Hirsianden. Witellikerstr40. Zurich 8029. Switzerland. 709 710 Naumann el al. High-Resolution Computed Tomographx in Otoavierosis Fig 1. Size of fenestral otosclerotic foci withotii cochlear involvement. A) Group I. otospongiosis limited tofissula ante fencstram. B) Group 2. otospongiosis is half of di- ameter of oval window niche and/or cochleariform pro- cess. C) Group 3. otospongiosis extends over entire diam- eter of oval window niche. tioned exclusioti criteria, only 44 HRCT scatis, iti- detector row helical HRCT scanner with a 2 x 0.^- stead of 60, were analyzed. The CT scans were ob- mm collimation. Thin-section images were created tained with identical protocols in all patients, and in any desired plane from the initial axial cut on a the images were read by the same experienced neu- computer workstation. Images were produced with roradiologist in a single-blinded study design. a high-resolution bone algorithm and read with a win- dow width of 4,000 Hounsfield units. Eighteen ot the 30 patients, who entered the .study from November 2002 onward, had their HRCT scans Initially, all 44 temporal bone HRCT scans from read at an imaging computer workstation, as well as the 30 patients were read from printed films. Patients by printed films. The direct visualization of all three with positive results were divided into 3 groups de- dimensions, as well as the free rotation of the image pending on the size of the otosclerotic focus. In fe- at the time of the reading, allowed a more accurate nestral otosclerosis, group 1 included patients with measurement of the extent of the otosclerotic foci. small foci or visible otospongiosis limited to the fis- The results of the readings of the printed images and sula ante fenestram. The foci of the group 2 patients of the workstation-based images were compared. reached at least half of the diameter of the oval win- When abnormalities other than otosclerosis were de- dow niche and/or the cochlearifonn process. Group tected on HRCT scanning, patients were excluded 3 contained patients with large otosclerotic foci ex- from the study. The HRCT scanner model used was tending over the entire diameter of the ova! window an MX 8000 (Picker/Marconi, Cleveland, Ohio) 4- niche {Fig 1). Naumann et al. High-Resolution Computed Tomography in Otosclerosis 711 Fig 2. Extent of cochtear otosclerotic involvement. A) Group I. otospongiosis not exceeding diameter of one cochlear turn. B) Group 2. otospongiotic focus larger than one cochlear turn but not involving entire otic capsule. C,D) Group 3. spongiotic involvement of entire otic capsule. For cochlear involvemetit, the otosclerotic foci were Germany) for at least 6 months before our investiga- divided in a similar tnanner. Group 1 patients had a tion. singular spongiotic focus not exceeding the diameter of one cochlear turn. Group 3 patients presented with For statistical analysis, we used nonparametric tests, a spongiotic involvement of the entire otic capsule, including Mann-Whitney, Kruskal-Wallis, Pearson, and group 2 patients had an involvement of the co- and Spearman p correlation tests. chlea with an extent between those of groups I and 3 (Fig 2). RESULTS Twenty-seven scans from 18 patients underwent Radiologic Findings. Of the 30 patients included additional reading and measurements on a computer in this study, 20 were female and 10 male. The mean workstation. The obtained results were compared age, independent of gender, was 49 years (range, 9 with those of the printed films (Fig 3). to 72 years). Sodium fluoride therapy was offered as a medical A well-defined focus of otosclerosis was seen ra- treatment option to patients with a sensorineural hear- diologicaily on 70.3% of the printed HRCT films (31 ing loss component. Eleven patients had received 40 of 44); no otosclerotic foci were identified in the other mg of sodium fluoride (Ossin, Grunenthal, Aachen. 29.3% (13 of 44). The Table shows the classification 712 Naumann etal. High-Resolution Computed Tomography in Otosrierosis Fig 3. Computer-aided analysis of sizeof otosclerotic focus. A) In fenestral otosclerosi.s (largest extension. 3.2 mm). B) In cochlear involvement (8 mm). of the otosclerotic foci and the corresponding pure logically visible cochlear involvement, but received tone averages. There was a significant correlation (p an initial diagnosis of mild audiological cochlear in- = .005) between the size of the fenestral otosclerotic volvement (group 1). Another 3 of 7 cases, previously focus and the air-bone gap (Figs 1, 4, and 3), but no read as negative from the printed film, did show a correlation (p > . 1) between the extent of cochlear fenestral otosclerotic focus at the workstation. Three involvement and the bone or air conduction levels of 18 HRCT scans negative for cochlear involvement (Figs 2 and 6). The size of the fenestral otosclerotic were shown to have visible cochlear involvement. focus had no influence on the bone conduction levels All patients with cochlear involvement had fenestral otosclerotic foci. The detection rate for otosclerotic changes increased by 11% (from 74% to 83% for Toevaluatethereliability of the printed images in fenestral involvement and from 33% to 44% for co- comparison to the reconstructed data in the computer chlear involvement) when a computer-aided analysis system, we compared 27 HRCT scans of the 18 pa- was used instead of manual reading of the film. The tients from whom images were also available in a measurements at the workstation showed 0.3-mm to digitized format. Digital data were not available from 10-mm foci in all patients, whereas 16 cases had foci all patients. By excluding the older HRCT scans (non- as large as 2.3 mm and 3 cases as large as 3.3 mm digitized), we decreased the number of ears analyzed (Fig 3). There was a very high correlation (p = 1.3E- from 44 to 27.
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