Recurrent cholesteatoma

Case contributed by Erik Ranschaert


History of previous middle-ear surgery for cholesteatoma.

Patient Data

Age: 40 years
Gender: Female

T2 imaging is routinely performed for detection of cholesteatoma in the middle ear. In this patient a hyperintense signal is demonstrated in the previous resection area and left middle ear, suggesting the presence of inflammation or tumor (cholesteatoma, cholesterol granuloma).

TSE DWI imaging (b-value 1000) shows hyperintense foci in the left middle ear and resection area, which is suggestive of cholesteatoma. These findings are to be correlated with the ADC map.
The TSE DWI is more time consuming than the EPI DWI but is much less susceptible to artifacts and allows detection of cholesteatomas as small as 2 mm.

Image fusion of both the T2 and DWI sequences allows for a more precise anatomic description of the recurrent cholesteatoma. The largest lesion is proximate to the tegmen.


CT scan of the middle ear was performed to allow for preoperative planning. Perforation of the tegmen tympani in the (old) resection area is demonstrated.

Case Discussion

Conventional MRI 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 DWI, on images with b-value =1000 s/mm2, a cholesteatoma becomes apparent as a hyperintense focus. 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. Cholesteatomas up to a size of 2 mm 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 canal. Abscess formation in the middle ear can also show similar imaging findings but has a completely different clinical appearance.


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