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Recurrent cholesteatoma

Case contributed by Dr Erik Ranschaert


38-year old female with history of previous middle-ear surgery for cholesteatoma

Modality: MRI
Modality: CT

Case Discussion:

Conventional MR imaging with diffusion-weighted imaging is recommended in patients with a suspicion of cholesteatoma recurrence or residual tumor tissue who have undergone middle ear surgery. On the DWI images with b-value =1000 s/mm2 a cholesteatoma becomes apparent as a hyperintense area. On the ADC-map these foci should show a low signal, confirming the presence of diffusion-restriction in these areas. Differential diagnosis can be made with cholesterol granuloma or inflammation, that show high signal on the ADC map. With these findings recurrent cholesteatoma can be detected with 100% specificity. Cholesteatoma's up to a size of 2mm can be detected with this technique. CT-scan should be added in case a cholesteatoma is detected for preoperative planning and to exclude perforation of the bony tegmen.

Further differential diagnosis is to be made with cerumen, which shows similar image characteristics to cholesteatoma but is located in the external ear. Abscess formation in the middle ear can also show similar imaging findings but has a completely  different clinical appearance.

Further reading: 

B. De Foer et al, Middle Ear Cholesteatoma: Non–Echo-planar Diffusion-weighted MR Imaging versus Delayed Gadolinium-enhanced T1-weighted MR Imaging—Value in Detection

Radiology June 2010 255:866-872; doi:10.1148/radiol.10091140

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