The Role of Imaging Methods in Diagnostic and Therapeutic Management of Middle Ear Cholesteatoma

Authors: T. Bakaj 1;  L. Bakaj Zbrožková 2;  R. Salzman 1;  M. Heřman 2;  I. Stárek 1
Authors‘ workplace: Otolaryngologická klinika LF UP a FN Olomouc 1;  Radiologická klinika LF UP a FN Olomouc 2
Published in: Otorinolaryng. a Foniat. /Prague/, 65, 2016, No. 3, pp. 173-178.
Category: Review Article


At the present time a closed operational technique (canal wall up – CWU) or an open technique (canal wall down – CWD with canal wall reconstruction or mastoid cavity obliteration in the treatement of middle ear cholesteatoma is preferred. Due to relatively high risk of residual and/or reccurent disease, a control, second-look operation is indicated. Majority of patients are yet free of the disease, and thus exposed to unnecessary operational risks. Therefore, less invasive imaging methods for the detection of recidivous cholesteatoma are investigated.

Lately, magnetic resonance (MR) with high predictive value has overcome previously used high resolution computed tomography (HRCT).

This paper presents a brief review of imaging methods possibilities in the diagnosis of primary cholesteatoma, as well as its postoperative recidivism. The abilities of HRCT and especially importance of new MR methods, like delayed postcontrast imaging (DPI), convetional echo- planar diffusion-weighted imaging (DWI) and non-echo-planar diffusion-weighted imaging (non-EPI DWI) are discussed.

Non-EPI DWI technique has the main contribution in assesement of postoperative changes and potentional cholesteatoma recidivism, thereby is preferred nowadays.

cholesteatoma, middle ear, MR, non-EPI DWI


1. Aikele, P., Kittner, T., Offergeld, C. et al.: Diffusion-weighted MR imaging of cholesteatoma in pediatric and adult patients who have undergone middle ear surgery. AJR Am. J. Roentgenol., 181, 2003, 1, s. 261-265.

2. Akkari, M., Gabrillargues, J., Saroul, N. et al.: Contribution of magnetic resonance imaging to the diagnosis of middle ear cholesteatoma: analysis of a series of 97 cases. Eur Ann. Otorhinolaryngol. Head Neck Dis., 131, 2014, 3, s. 153-158.

3. Alvo, A., Garrido, C., Salas, Á. et al.: Use of non-echo-planar diffusion-weighted MR imaging for the detection of cholesteatomas in high-risk tympanic retraction pockets. AJNR Am. J. Neuroradiol., 35, 2014, 9, s. 1820-1824.

4. Ayache, D., Williams, M. T., Lejeune, D. et al.: Usefulness of delayed postcontrast magnetic resonance imaging in the detection of residual cholesteatoma after canal wall-up tympanoplasty. Laryngoskope, 115, 2005, 4, s. 607-610.

5. Blaney, S. P., Tierney, P., Oyarazabal, M. et al.: CT scanning in „second look“ combined approach tympanoplasty. Rev. Laryngál. Otol Rhinol. (Bord), 121, 2000, 2, s. 79-81.

6. Brown, J. S.: A ten year statistical follow-up of 1142 consecutive cases of cholesteatoma: the closed vs. the open technique. Laryngoskope, 92, 1982, 4, s. 390-396.

7. De Foer, B., Vercruysse, J. P., Bernaerts, A. et al.: Detection of postoperative residual cholesteatoma with non-echo-planar diffusion-weighted magnetic resonance imaging. Otol. Neurotol., 29, 2008, 4, s. 513-517.

8. De Foer, B., Vercruysse, J. P., Bernaerts, A. et al.: Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging–value in detection. Radiology, 255, 2010, s. 866-872.

9. Deveze, A., Rameh, C., Puchol, M. S. et al.: Rehabilitation of canal wall down mastoidectomy using a titanium ear canal implant. Otol. Neurotol., 31, 2010, 2, s. 220-224.

10. Dhepnorrarat, R. C., Wood, B., Rajan, G. P.: Postoperative non-echo-planar diffusion-weighted magnetic resonance imaging changes after cholesteatoma surgery: implications for cholesteatoma screening. Otol. Neurotol., 30, 2009, 1, s. 54-58.

11. Dodson, E. E., Hashisaki, G. T., Hobgood, T.C. et al.: Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoskope, 108, 1998, 7, s. 977-983.

12. Dornhoffer, J. L.: Retrograde mastoidectomy with canal wall reconstruction: a follow-up report. Otol. Neurotol., 25, 2004, 5, s. 653-660.

13. Dubrulle, F., Souillard, R., Chechin, D. et al.: Diffusion-weighted MR imaging sequence in the detection of postoperative recurrent cholesteatoma. Radiology, 238, 2006, 2, s. 604-610.

14. Emonot, G., Richard, C., Dumollard, J. M. et al.: Contribution of MRI to diagnosis of residual cholesteatoma. Fr. ORL, 94, 2008, s. 366-374.

15. Fitzek, C., Mewes, T., Fitzek, S. et al.: Diffusion-weighted MRI of cholesteatomas of the petrous bone. J. Magn. Reson Imaging, 15, 2002, 6, s. 636-641.

16. Ganaha, A., Outa, S., Kyuuna, A. et al.: Efficacy of diffusion-weighted magnetic resonance imaging in the diagnosis of middle ear cholesteatoma. Auris Nasus Larynx, 38, 2011, 3, s. 329-334.

17. Garrido, L., Cenjor, C., Montoya, J. et al.: Diagnostic capacity of non-echo planar diffusion-weighted MRI in the detection of primary and recurrent cholesteatoma. Acta Otorrinolaringol. Esp., 66, 2015, 4, s. 199-204.

18. Gomaa, M. A., Abdel Karim, A. R., Abdel Ghany, H. S. et al.: Evaluation of temporal bone cholesteatoma and the correlation between high resolution computed tomography and surgical finding. Clin. Med. Insights Ear Nose Throat, 23, 2013, 6, s. 21-28.

19. Hatano, M., Ito, M., Yoshizaki, T.: Retrograde mastoidectomy on demand with soft-wall reconstruction in pediatric cholesteatoma. Acta Otolaryngol., 130, 2010, 10, s. 1113-1118.

20. Huins, C. T., Singh, A., Lingam, R. K. et al.: Detecting cholesteatoma with non-echo planar (HASTE) diffusion-weighted magnetic resonance imaging. Otolaryngol. Head Neck Surg., 143, 2010, 1, s. 141-146.

21. Hulka, G. F., McElveen, J. T. Jr.: A randomized, blinded study of canal wall up versus canal wall down mastoidectomy determining the differences in viewing middle ear anatomy and pathology. Am. J. Otol., 19, 1998, 5, s. 574-578.

22. Chee, N. W., Tan, T. Y.: The value of pre-operative high resolution CT scans in cholesteatoma surgery. Singapore Med. J., 42, 2001, 4, s. 155-159.

23. Chrobok, V., Pellant, A., Profant, M.: Cholesteatom spánkové kosti, Havlíčkův Brod, Tobiáš, 2008, s. 70-79.

24. Jindal, M., Riskalla, A., Jiang, D. et al.: A systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma. Otol. Neurotol., 32, 2011, s. 1243-1249.

25. Khemani, S., Lingam, R. K., Kalan, A. et al.: The value of non-echo planar HASTE diffusion-weighted MR imaging in the detection, localisation and prediction of extent of postoperative cholesteatoma. Clin. Otolaryngol., 36, 2011, 4, s. 306-312.

26. Khemani, S., Singh, A., Lingam, R. K. et al.: Imaging of postoperative middle ear cholesteatoma. Clin. Radiol., 66, 2011, 8,, s. 760-767.

27. Kerckhoffs, K. G., Kommer, M. B., Van Strien, T. H. et al.: The disease recurrence rate after the canal wall up (CWU) or canal wall down (CWD) technique in adults. Laryngoskope, 25, 2005.

28. Koval, J.: Chirurgická liečba chronického stredoušného zápalu, Bratislava, USPO, 1998, s. 81-90.

29. Lehmann, P., Saliou, G., Brochart, C. et al.: 3T MR imaging of postoperative recurrent middle ear cholesteatomas: value of periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted MR imaging. AJNR Am. J. Neuroradiol., 30, 2009, 2, s. 423-427.

30. Li, P. M., Linos, E., Gurgel, R. K. et al.: Evaluating the utility of non-echo-planar diffusion-weighted imaging in the preoperative evaluation of cholesteatoma: a meta-analysis.Laryngoscope, 123, 2013, 5, s. 1247-1250.

31. Martin, N., Sterkers, O., Nahum, H.: Chronic inflammatory disease of the middle ear cavities: Gd-DTPA-enhanced MR imaging. Radiology, 176,1990, 2, s. 399-405.

32. Más-Estellés, F., Mateos-Fernández, M., Carrascosa-Bisquert, B. et al.: Contemporary non-echo-planar diffusion-weighted imaging of middle ear cholesteatomas.Radiographics, 32, 2012, 4, s. 1197-1213.

33. Mateos-Fernández, M., Mas-Estellés, F., de Paula-Vernetta, C. et al.: The role of diffusion-weighted magnetic resonance imaging in cholesteatoma diagnosis and follow-up. Study with the diffusion PROPELLER technique. Acta Otorrinolaringol. Esp., 63, 2012, ec, 6, s. 436-442.

34. Mokbel, K. M., Khafagy, Y. W.: Single flap with three pedicles, bone paté and split-thickness skin graft for immediate mastoid obliteration after canal wall down mastoidectomy. Eur Arch. Otorhinolaryngol., 269, 2012, 9, s. 2037-2041.

35. Nash, R., Wong, P. Y., Kalan, A. et al.: Comparing diffusion weighted MRI in the detection of post-operative middle ear cholesteatoma in children and adults. Int. J. Pediatr. Otorhinolaryngol., 79, 2015, 12, s. 2281-2285.

36. Neudert, M., Lailach, S., Lasurashvili, N. et al.: Cholesteatoma recidivism: comparison of three different surgical techniques. Otol. Neurotol., 35, 2014, 10, s. 1801-1808.

37. Ng, J. H., Zhang, E. Z., Soon, S. R. et al.: Pre-operative high resolution computed tomography scans for cholesteatoma: has anything changed? Am. J. Otolaryngol., 35, 2014, 4, s. 508-513.

38. Osborn, A. J., Papsin, B. C., James, A. L.: Clinical indications for canal wall-down mastoidectomy in a pediatric population. Otolaryngol. Head Neck Surg., 147, 2012, 2, s. 316-322.

39. Pizzini, F. B., Barbieri, F., Beltramello, A. et al.: HASTE diffusion-weighted 3-Tesla magnetic resonance imaging in the diagnosis of primary and relapsing cholesteatoma. Otol. Neurotol., 31, 2010, 4, s. 596-602.

40. Plouin-Gaudon, I., Bossard, D., Fuchsmann, C. et al.: Diffusion-weighted MR imaging for evaluation of pediatric recurrent cholesteatomas. Int. J. Pediatr. Otorhinolaryngol., 74, 2010, 1, s. 22-26.

41 Prata, A. A. S, Antunes, M. L., de Abreu, C. E. C. et al.: Comparative study between radiological and surgical findings of chronic otitis media. Intl. Arch. Otorhinolaryngol, 15, 2011, 1, s. 72-78.

42. Profant, M., Sláviková, K., Kabátová, Z. et al.: I. Predictive validity of MRI in detecting and following cholesteatoma. Eur Arch. Otorhinolaryngol., 269, 2012, 3, s. 757-765.

43. Rajan, G. P., Ambett, R., Wun, L. et al.: Preliminary outcomes of cholesteatoma screening in children using non-echo-planar diffusion-weighted magnetic resonance imaging. Int. J. Pediatr. Otorhinolaryngol., 74, 2010, 3, s. 297-301.

44. Stasolla, A., Magliulo, G., Cortese, A. et al.: Preoperative imaging assessment of chronic otitis media: what does the otologist need to know? Radiol. Med., 116, 2011, 1, s. 114-124.

45. Swartz, J. D., Goodman, R. S., Russell, K. B. et al.: High-resolution computed tomography of the middle ear and mastoid. Part III: Surgically altered anatomy and pathology. Radiology, 148, 1983, 2, s. 461-464.

46. Tatlipinar, A., Tuncel, A., Öğredik, E. A. et al.: The role of computed tomography scanning in chronic otitis media. Eur Arch. Otorhinolaryngol., 269, 2012, 1, s. 33-38.

47. Tierney, P. A., Pracy, P., Blaney, S. P. et al.: An assessment of the value of the preoperative computed tomography scans prior to otoendoscopic ‚second look‘ in intact canal wall mastoid surgery. Clin. Otolaryngol. Allied Sci., 24, 1999, 4, s. 274-276.

48. Tomlin, J., Chang, D., McCutcheon, B. et al.: Surgical technique and recurrence in cholesteatoma: a meta-analysis. Audio. Neurootol., 18, 2013, 3, s. 135-142.

49. Tomura, N., Sashi, R., Kobayashi, M. et al.: Normal variations of the temporal bone on high-resolution CT: their incidence and clinical significance. Clin. Radiol.. 50, 1995, 3, s. 144-148.

50. Van Egmond, S. L., Stegeman, I., Grolman, W. et al.: A systematic review of non-echo planar diffusion-weighted magnetic resonanceiImaging for detection of primary and postoperative cholesteatoma. Otolaryngol. Head Neck Surg., 2015, 2. pii: 0194599815613073.

51. Venail, F., Bonafe, A., Poirrier, V. et al.: Comparison of echo-planar diffusion-weighted imaging and delayed postcontrast T1-weighted MR imaging for the detection of residual cholesteatoma. AJNR, Am. J. Neuroradiol., 29, 2008, 7, s. 1363-1368.

52. Verbist, B. M., Mancuso, A. A., Antonelli, P. J. et al.: Chronic otomastoiditis and acquired cholesteatoma. Head and neck radiology. Philadelphia, Lippincott Williams & Wilkins, 2011, s. 756-776.

53. Vercruysse, J. P., De Foer, B., Pouillon, M. et al.: The value of diffusion-weighted MR imaging in the diagnosis of primary acquired and residual cholesteatoma: a surgical verified study of 100 patients. Eur Radiol., 16, 2006, 7, s. 1461-1467.

54. Von Kalle, T., Amrhein, P., Koitschev, A.: Non-echoplanar diffusion-weighted MRI in children and adolescents with cholesteatoma: reliability and pitfalls in comparison to middle ear surgery. Pediatr. Radiol., 45, 2015, 7, s. 1031-1038.

55. Walshe, P., McConn Walsh, R., Brennan, P. et al.: The role of computerized tomography in the preoperative assessment of chronic suppurative otitis media. Clin. Otolaryngol. Allied Sci., 27, 2002, 2, s. 95-97.

56. Williams, M. T., Ayache, D., Alberti, C. et al.: Detection of postoperative residual cholesteatoma with delayed contrast-enhanced MR imaging: initial findings. Eur Radiol., 13, 2003, 1, s. 169-174.

Audiology Paediatric ENT ENT (Otorhinolaryngology)
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account