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Imaging for evaluation of cholesteatoma: current
concepts and future directions
C. Eduardo Corrales and Nikolas H. Blevins

Purpose of review
To examine the rationale and utility of imaging in patients with known or suspected cholesteatoma, with
emphasis on high-resolution computed tomography (HRCT) and diffusion-weighted MRI (DW-MRI).
Recent findings
The initial diagnosis of cholesteatoma is largely based on patient history and clinical findings. HRCT scan
can be a useful adjunct to define the presence of pathologic soft tissue in the temporal bone, and the extent
of bony erosion, and inform the otologic surgeon about expected findings at the time of surgery. Although
MRI has not traditionally been used in the evaluation of cholesteatoma given its poor resolution of bone
anatomy, recent advances in DW-MRI sequences allow for high sensitivity and specificity in identifying the
presence of cholesteatoma. More specifically, non-echo-planar DW-MRI is superior in the detection of
residual or recurrent cholesteatoma compared to delayed-contrast MRI and echo-planar DW-MRI.
HRCT and DW-MRI offer complementary anatomic information that can be used effectively in the
management of cholesteatoma. DW-MRI imaging has proven to be a reliable method for detecting residual
or recurrent cholesteatomas down to 3 mm in size, and allows radiologic differentiation between
cholesteatoma and other soft tissue. As more centers implement DW-MRI imaging for detecting residual or
recurrent cholesteatoma, there will likely be less need for second-look surgery, thereby potentially
decreasing associated morbidity and surgical costs.
cholesteatoma, computed tomography, diffusion-weighted imaging, magnetic resonance imaging

Cholesteatoma has long presented otologists
with many diagnostic and therapeutic challenges.
Although cholesteatoma is usually readily identified
based on history and otoscopic examination, its
presence and extent may not always be entirely
clear. This is particularly the case in postoperative
ears, in which recurrent or residual disease may
present in areas hidden from direct examination.
The considerable variability of the size and location
of cholesteatoma can have considerable impact on
surgical approach and expectations. Similarly, the
potential involvement of vital adjacent structures
can also present hidden risks. For these reasons, the
efficient use of imaging can be a valuable adjunct
to the clinical management of these patients.
Since its introduction in the early 1980s, highresolution computed tomography (HRCT) has been
the gold standard for imaging in cholesteatoma
[1–3]. HRCT remains the best modality for defining
the bony anatomy, including the ossicles, delicate
bony trabeculations, patterns of pneumatization,

and the presence or absence of aeration. As a result,
HRCT can be quite helpful in identifying the presence
and extent of cholesteatoma, as such epithelial cysts
are characterized by the presence of abnormal soft
tissue with associated bony erosion.
Still, HRCT is limited in its ability to differentiate
soft tissue in the temporal bone from other fluid
or tissues commonly seen in chronic otitis media.
Recent refinements of diffusion-weighted MRI (DWMRI) have greatly improved in this regard, providing
the ability to accurately identify the presence of
small collections of keratin debris within an ear that
would otherwise be impossible to differentiate from
Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
Correspondence to Nikolas H. Blevins, MD, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine,
801 Welch Road, Stanford, CA 94305, USA. Tel: +1 650 725 6500; fax:
+1 650 725 8502; e-mail:
Curr Opin Otolaryngol Head Neck Surg 2013, 21:461–467

1068-9508 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

posterior. Reformatting can be performed at arbitrary planes from the original dataset in cases in which planar views in nonstandard orientations may be helpful.  DW-MRI will likely decrease the quantities of secondlook surgeries. A. HRCT is also very useful in identifying the geometry and location of adjacent vital structures. fluid or edematous mucosa on HRCT. anterior. The tegmen (T) is dehiscent and low-lying. When ossicular or mastoid bony erosion is seen with a soft tissue density. T. HRCT can identify cholesteatoma with specificity between 80–90% [4.  DW-MRI has shown the highest sensitivity and specificity in detecting recidivistic cholesteatoma. Chorda tympani. revealing the pathway of ingrowth of epithelium from the pars flaccida into the epitympanum (Fig. scar tissue. There is tympanosclerosis medial to the ossicular chain (TS). HIGH-RESOLUTION COMPUTED TOMOGRAPHY With present CT scanner technology. affording minimal surgical access to the epitympanum. Similarly. scar. eroded. . tympanosclerosis.) contrast. tegmen. is shown to be dehiscent adjacent to the oval window on the coronal image. FN. C. ChT. The subtle flattening over the lateral semicircular canal seen on the coronal image () is also indicative of progressive expansion. P. In this way. usually occurring in pneumatized regions of the temporal bone. and sagittal (c) orientations show diagnostic and therapeutic findings. The strength of HRCT is its ability to image bone. Cholesteatoma. facial nerve. sigmoid sinus. decreasing patient morbidity and surgical costs. and fibrosis. loss of the normal bone overlying any of these structures may give a valuable warning of involvement by cholesteatoma. Useful in the postoperative period.Otology and neuro-otology KEY POINTS  HRCT scan provides a fast and reliable method for evaluating temporal bone anatomy and provides invaluable information for primary cases of cholesteatoma. O. Adjacent ossicles may be absent.5]. Axial (a). The scutum is often eroded. scutum erosion (S) and a demineralized ossicular chain (O).com Volume 21  Number 5  October 2013 Copyright © Lippincott Williams & Wilkins. The inner ear. L. fibrosis. A cholesteatoma appears as abnormal appearance of soft tissue. HRCT has proven to be a method with high negative predictive value when it shows a well aerated middle ear with no (c) FIGURE 1. demonstrating scalloped edges. Patients may still require second-look surgery to address reconstruction of the conductive hearing mechanism of the middle or fluid [6–8]. including: a sclerotic mastoid with an erosive cholesteatoma (C). and carotid artery can all be seen quite readily on the same sequence given their interface with bone. left. mucosal edema. Unauthorized reproduction of this article is prohibited. A careful study of the HRCT can reveal anatomic variations that may impact surgery. and the chorda tympani can be seen on the sagittal reconstruction. coronal (b). R.  Cholesteatomas of size 3 mm or larger can be detected by DW-MRI and differentiated from granulation tissue. 462 www. scutum.  Low-risk patients for developing residual or recurrent cholesteatomas can be stratified for serial DW-MRI and potentially avoid additional surgery. HRCT has proven unreliable in differentiating residual or recurrent cholesteatoma from granulation tissue. cholesterol granuloma. with high negative predictive value when it shows a disease-free middle ear and mastoid. The facial nerve (FN). In the postoperative period. ossicles. or demineralized. S. 1: coronal). TS. The normal aeration is lost and the surrounding bone often shows evidence of erosion with smooth or scalloped margins. the selective use of HRCT and DW-MRI can provide complementary information that can guide the otologic surgeon in the management of cholesteatoma. Cone beam computed tomography scans of a patient with left cholesteatoma.v. tegmen.6 mm slice thickness (a) (b) can be performed in about 40 s with minimal discomfort and no need for intravenous (i. However. a volumetric HRCT of temporal bone with 0. right. facial nerve.

24. although it does require longer acquisition times compared to HRCT. and a predictive value of 28% of detecting residual or recurrent cholesteatoma [8.6%. and produces a high signal intensity compared to brain or other surrounding soft tissues. In contrast. Two distinct DWI algorithms can be used for detection of residual or recurrent cholesteatoma: echo-planar and non-echo-planar DW-MRI. cone-beam imaging systems can be installed in clinic rooms with little need for specialized shielding. 1). The radiation dose of these scans is reported to be 60% of a conventional CT scanner when evaluating middle ear structures [12–14]. and thus produce a hypointense signal on DWI.25 . .18–20]. early acquisition of images may lead to false positives. Disadvantages of using delayedcontrast MRI include: the cost and potential morbidity associated with the need for i. which is restricted in certain pathologic conditions. including ischemia. De Foer et al. silicone/plastic (Silastic. Unauthorized reproduction of this article is prohibited. and the need for immobilization may make it difficult to obtain in young children. selected MRI techniques can provide valuable information regarding the presence. MRI has the advantage of not requiring exposure to radiation. which results in enhancement of inflammatory mucosa. Middle and inner ear bony structures are equally seen in both CBCT and conventional HRCT scanners [13] (Fig. The keratin debris associated with cholesteatomas predictably restricts water diffusion.17 . The first algorithm developed was the echo-planar (EPI) DW imaging.10]. 463 Copyright © Lippincott Williams & Wilkins.7 and 67. T1-images are obtained in 30–45 min after i. delayed-contrast MRI for detecting residual or recurrent cholesteatoma is not routinely used. Absence of contrast enhancement in a lesion suggests cholesteatoma. The high signal intensity return in regions where the diffusion of water is impeded is termed diffusion restriction [6. USA) sheets and calcified scars can mimic nonperfused cholesteatoma. On traditional MRI sequences. bright on T2-weighted images. Over the last decade. requires expert interpretation of results. In this setting. As a result of their relatively low radiation production and small size. cannot give the bony definition that can provide a geometric framework for surgical planning. specificity of 42–51%. Molecular diffusion refers to the haphazard movement of water molecules.Imaging for evaluation of cholesteatoma Corrales and Blevins evidence of soft tissue densities [4. and the presence of keratin debris as seen in cholesteatoma [22 ]. especially in children who may be more susceptible to radiation effects. One limitation of in-office CBCT is the limited field of view. [19] reported sensitivity and specificity for delayedcontrast MRI in detecting cholesteatoma as 56. and do not take up i. Delayed-contrast MRI has been used to better detect recurrent cholesteatoma by taking advantage of the fact that other tissue will often take up more contrast given sufficient time [17 . Non-EPI DWI consists 1068-9508 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins & && & & && & www.21].26. For this reason.v.6.9]. A disadvantage of HRCT is its need for ionizing radiation. and its inherent potential for inducing malignancy [15. and sedation or general anesthesia is required for children because of the prolonged time required for image acquisition. the relevance of bony erosion is lost as it is impossible to differentiate between surgical changes from pathological bony destruction due to cholesteatoma. retained secretions. One mechanism to circumvent this limitation has been through the use of delayed-contrast techniques. neoplasia. MRI Although MRI.28 . the clinician should always be judicious in its use. Overall positive predictive value (PPV) was 88% and negative predictive value was 27% in the particular population studied. scar. Diffusion-weighted imaging (DWI) is a variation of the conventional MRI sequences relying on the principles of molecular diffusion or Brownian motion [21]. However. HRCT has a sensitivity of 43%. Dow Corning. respectively. The advent of in-office cone-beam CT (CBCT) imaging has further improved the availability and convenience of imaging for cholesteatoma [11].29–31].v. the X-ray beam forms a cone-shaped geometry between the imaging source (apex of the cone) and the detector (base of the cone).27. In this technique. cholesteatomas appear dark on T1-weighted images. unlike HRCT. or fibrosis. This makes them indistinguishable from much of the other soft tissue present in a chronic ear. contrast. and approximate location of cholesteatoma that may not be available on HRCT imaging. in patients who have undergone previous tympanomastoidectomy.16]. Michigan. contrast. can not detect cholesteatomas smaller than 3 which means inner ear or more distal disease in the mastoid may be missed.22 .v. granulation tissue. the use of diffusionweighted sequences has provided considerable improvement in the diagnosis of cholesteatoma. which consists of single-shot spin echo pulse sequences. As a result. conventional scanners have a fan beam geometry [12]. Many articles have described its use in detecting cholesteatomas [7. paramagnetic contrast administration (gadolinium). In data acquisition via CBCT scanners. Granulation tissue.18–21. size. fibrosis and mucosal edema have less restriction diffusion for water molecules.

Unauthorized reproduction of this article is prohibited. the patient cost generated in an MRI is approximately double that of an HRCT [32]. the benefits gained in selected patients by avoiding needless surgery. Surgeons should always be diligent about reviewing imaging studies themselves. Some otologists routinely obtain imaging whenever cholesteatoma is either seen or suspected. HRCT can be very helpful prior to revision surgery. Although difficult to assess completely. which could serve as a warning to potential hazards during dissection. abscess. Similarly. as could exposure of the carotid artery or jugular bulb. cholesterol granuloma. . An HRCT study can reveal specific patterns of pneumatization and aeration or variability on the position of the sigmoid sinus or tegmen. Although the clinician should consider this additional economic impact. as are almost all facial nerve dehiscences. DW-MRI can provide additional information in primary cases in which clinical information is limited. whereas others use imaging only with great reservation. In the meta-analysis. have evaluated DW-MRI for the detection of residual and recurrent cholesteatomas. 464 www. the diagnosis is not in doubt. Surgeons should carefully consider the benefits they receive from imaging in their particular practice. it causes local distortions in the magnetic field.23.24.30]. Despite MRI’s superior ability to identify cholesteatoma and differentiate it from other soft tissues. can potentially justify its use on economic grounds.24. The great majority of times. 25 . obvious ossicular abnormalities may predict the need for ossicular reconstruction. which cause image distortion. or the otoscopic examination is inconclusive (Fig. becomes considerably more useful in assessing the potential for postoperative recurrence of disease. Additionally. the mastoid and middle ear produce susceptibility artifacts due to natural air–bone interfaces. deep to reconstructive materials. Preoperative assessment The benefits of knowing potential challenges. False-positives reported in this study were due to susceptibility artifacts. Most agree that imaging is indicated in revision cases and those with intracranial or intratemporal complications. DWMRI. including a recent meta-analysis [28 ]. Some semicircular canal dehiscence can be clinically silent [34]. including the mastoid cavity.25 . and growing around adjacent structures in which the furthest extent of cholesteatoma may have been missed on Volume 21  Number 5  October 2013 Copyright © Lippincott Williams & Wilkins.30]. These magnetic susceptibility artifacts correspond to the magnetization of adjacent tissues as a result of an external magnetic field. However. however. warranting a planned canal-wall-down procedure? Erosion of the Fallopian canal may be suggested. In revision cases.23. Germany)].co-otolaryngology. and thus non-EPI DWI has become the standard for MRI imaging of cholesteatoma. limiting the utility of normal surgical landmarks and presenting unexpected challenges. especially when the surgeon did not perform the initial procedure. thus preoperative knowledge of these findings may alert the surgeon to areas that warrant extra intraoperative attention. One limitation of DWI is that it can yield artifacts at the interface of varied anatomic tissues. the overall sensitivity for this imaging modality was 94% with a specificity of 94%. however. which may affect surgical access to disease.Otology and neuro-otology of either single-shot turbo-spin sequences (HASTE: Half Fourier Acquisition Single Shot Turbo Spin Echo. and having a roadmap for surgical planning is particularly helpful in teaching settings in which expectations for the case can be reviewed preoperatively. it is seldom helpful in the preoperative setting in primary cases. and HRCT is superior in providing information on salient anatomic geometry. or by preventing a delay in diagnosis. BLADE (Siemens Systems. Various recent studies [22 . non-EPI DWI to be superior to EPI DWI in detecting recurrent or residual cholesteatoma [22 . (Siemens Systems. Studies have also shown newer. 2). Germany) or multishot turbo-spin sequences [Periodically Rotated Overlapping ParallEL Lines with Enhanced Reconstruction (PROPELLER). This has been shown in multiple studies. The majority of false-negatives reported were due to cholesteatoma pearls less than 3 mm in size. In such cases. cholesteatoma may appear in unexpected areas inaccessible to clinical otomicroscopy.26. or bone powder. or can the disease be adequately accessed transcanal? Is there likely to be adequate space to access disease while leaving the canal wall up. HRCT can also demonstrate unexpected and potentially unrelated anatomic variation such as anomalous facial nerve patterns [35]. as even the best radiology report will rarely convey the subtleties that affect surgery. When two tissues with different magnetic susceptibilities are juxtaposed. which have demonstrated its inability to detect cholesteatomas smaller than 5 mm [6]. anatomy may be considerably altered. && & && & & Indications for imaging Experts may disagree about the indications of imaging and the extent to which it assists in treatment decisions [33]. Is a mastoidectomy needed. and regularly reevaluate these indications as they gain experience and modify their surgical techniques. or is the mastoid sclerotic and contracted.

and supports the diagnosis of cholesteatoma.9.6. (b) Diffusion-weighted (DW)-MRI of the same patient. The patient’s tympanic cavity showed no evidence of disease on otoscopy. in an early postoperative (a) ear. it is rare that an HRCT study will be entirely without some suspicious soft tissue. it is impossible to distinguish this from other soft tissues seen in chronic otitis media. This provides complementary information to the anatomic detail seen on CT. Unfortunately. fluid. as cholesterol granuloma may appear similar to recidivistic cholesteatoma (Fig. (a) Diffusionweighted (DW)-MRI shows a high signal lesion in the mastoid.28 . the use of other MRI sequences may be very useful to predict the diagnosis. After 9–12 months. Also. the primary procedure (Fig. If an HRCT shows no abnormal soft tissue at 6 or 9 months following the initial stage. In other areas. 1068-9508 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins www. The high signal results from restricted diffusion of water within the keratin debris.24. Axial images of a recurrent cholesteatoma (arrows) eroding the mastoid tip air cells 25 years following a prior canal-wall-up tympanomastoidectomy. (b) high-resolution computed tomography (HRCT) confirms an erosive soft tissue lesion with loss of bone over the sigmoid sinus (s) and posterior fossa dura. In some areas. Unauthorized reproduction of this article is prohibited.33]. one cannot use bone erosion to help differentiate the soft tissue from scar.25 . Although this finding is consistent with cholesteatoma. Note the bright area in the epitympanum () that corresponds to the soft tissue seen on the CT. 3).com 465 Copyright © Lippincott Williams & Wilkins. not all high-signal intensites on DW-MRI are cholesteatomas. or edema. 4). a recurrent cyst of this size can usually be readily such as at the mastoid cavity. Postoperative surveillance It is compelling to look for alternatives to secondlook surgery. most persistent cholesteatomas will be larger than 3 mm and therefore should be apparent on DW-MRI [22 . The surgeon needs to make the judgment based on the likely area of involvement on whether a recurrence of 3 mm or greater is unacceptably large. and provide the surgeon and patient with expectations for treatment. A negative DW-MRI study may avoid the expense and morbidity associated with a negative second look. Conversely. consistent with cholesteatoma. . In these cases. This is likely the situation in which DW-MRI is most useful in imaging cholesteatoma.23. showing soft tissue on the epitympanum (). (a) Axial high-resolution computed tomography (HRCT) scans of a patient with a primary left cholesteatoma. one may feel comfortable holding off on a second look [4.Imaging for evaluation of cholesteatoma Corrales and Blevins (a) (b) FIGURE 2. such as the sinus tympani or on the stapes footplate.30]. a cholesteatoma of && & & (b) FIGURE 3.

In routine cases. It is important to note that such restricted diffusion can occur in disease other than cholesteatoma. the need for second-look surgery to evaluate for the presence of residual or recurrent disease will likely reduce and even replace surgery. MRI is best suited for defining intracranial complications such as perimeningeal spread of infection. & CONCLUSION HRCT scan and DW-MRI have proven to be complementary scanning modalities and reliable methods for detecting and characterizing cholesteatoma. HRCT still provides a useful roadmap 466 www. Dobben GD. Lemmerling MM. the surgeon should use his or her clinical judgment as to whether another scan is needed at a later date. J Otolaryngol 1983. Computerized tomography of the temporal bone. Kassel EE. Conflicts of interest The authors have no relevant financial disclosures or conflict of interest. the clinician may wish to obtain both HRCT and MRI studies. in which recidivistic disease is likely to occur in the middle ear or mastoid. If this is the case. 15:723– 753. Volume 21  Number 5  October 2013 Copyright © Lippincott Williams & Wilkins. 3. As more centers implement DW-MRI for detecting residual or recurrent cholesteatoma. as demonstrated here. REFERENCES AND RECOMMENDED READING Papers of particular interest. If a DW-MRI study is negative at 9–12 months postoperatively. Imaging of the opacified middle ear. No funding to disclose. thereby decreasing patient morbidity and surgical costs. 36. mucosal edema or scar. and proceeding directly with a second-look procedure is very reasonable. suggesting the diagnosis of cholesterol granuloma. Jazrawy H. Axial images of a cholesterol granuloma presenting as an expansile mastoid lesion (arrows) 6 years following tympanomastoid surgery for cholesteatoma. such as the jugular foramen or petrous apex. petrous apex or jugular foramen are best identified by HRCT. 1.37]. 66:363–371. (a) Diffusion-weighted (DW)-MRI showing heterogeneous high signal on a PROPELLER DWI sequence. et al. By correlating this with the image shown in (b). brain abscess. Valvassori GE. It also provides adequate differentiation between cholesteatoma and other soft tissue densities including granulation tissue.30. 2. VandeVyver V. Current literature suggests DW-MRI to have a high sensitivity and specificity in detecting cholesteatoma down to 3 mm in . however. Otolaryngol Clin North Am 1982. imaging is almost always indicated [17 . as both may offer valuable insights with diagnostic and therapeutic implications. there is concern for persistence in areas that are inherently more difficult to assess. Mafee MF. a single scan may well be sufficient. Acknowledgements for surgery which can help guide the surgeon to more safe and effective management.18. Eur J Radiol 2008. 3 mm may present a prohibitively greater surgical challenge. another scan obtained a year later is a reasonable option. 4. Laryngoscope 1982. Wortzman G. have been highlighted as: & of special interest && of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. the lesion is seen to have inherently high signal on T1-weighted sequences (unlike the low signal expected for cholesteatoma). Mafee MF.Otology and neuro-otology (a) (b) FIGURE 4. and the patient can be followed clinically. Intratemporal complications with facial paralysis. Noyek AM. or sinus thrombosis. foregoing imaging. Dobben GD. If. 510). Unauthorized reproduction of this article is prohibited. Computed tomography of the temporal bone. extension into the labyrinth. Valvassori GE. published within the annual period of review. The role of radiology in surgery of the ear and skull base. De Foer B. 12:37–44. 92:562–565. Cholesteatoma complications In patients with complications of cholesteatoma. fibrosis. However in the majority of complications.

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