REVIEW

URRENT
C
OPINION

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.
Summary
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.
Keywords
cholesteatoma, computed tomography, diffusion-weighted imaging, magnetic resonance imaging

INTRODUCTION
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
[13]. 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: nblevins@stanford.edu
Curr Opin Otolaryngol Head Neck Surg 2013, 21:461467
DOI:10.1097/MOO.0b013e328364b473

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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. Useful in the postoperative period,
with high negative predictive value when it shows a
disease-free middle ear and mastoid.
 DW-MRI has shown the highest sensitivity and
specificity in detecting recidivistic cholesteatoma.
 Cholesteatomas of size 3 mm or larger can be detected
by DW-MRI and differentiated from granulation tissue,
scar, and fibrosis.
 Low-risk patients for developing residual or recurrent
cholesteatomas can be stratified for serial DW-MRI and
potentially avoid additional surgery.
 DW-MRI will likely decrease the quantities of secondlook surgeries, decreasing patient morbidity and
surgical costs. Patients may still require second-look
surgery to address reconstruction of the conductive
hearing mechanism of the middle ear.

fluid or edematous mucosa on HRCT. In this

way, the selective use of HRCT and DW-MRI can
provide complementary information that can
guide the otologic surgeon in the management of
cholesteatoma.

HIGH-RESOLUTION COMPUTED
TOMOGRAPHY
With present CT scanner technology, a volumetric
HRCT of temporal bone with 0.6 mm slice thickness

(a)

(b)

can be performed in about 40 s with minimal discomfort and no need for intravenous (i.v.) contrast.
Reformatting can be performed at arbitrary planes
from the original dataset in cases in which planar
views in nonstandard orientations may be helpful.
The strength of HRCT is its ability to image
bone. A cholesteatoma appears as abnormal appearance of soft tissue, usually occurring in pneumatized
regions of the temporal bone. The normal aeration is
lost and the surrounding bone often shows evidence
of erosion with smooth or scalloped margins.
Adjacent ossicles may be absent, eroded, or demineralized. The scutum is often eroded, revealing
the pathway of ingrowth of epithelium from the
pars flaccida into the epitympanum (Fig. 1: coronal).
HRCT is also very useful in identifying the
geometry and location of adjacent vital structures.
The inner ear, facial nerve, tegmen, sigmoid sinus,
and carotid artery can all be seen quite readily on
the same sequence given their interface with bone.
A careful study of the HRCT can reveal anatomic
variations that may impact surgery. Similarly, loss
of the normal bone overlying any of these structures
may give a valuable warning of involvement by
cholesteatoma.
When ossicular or mastoid bony erosion is
seen with a soft tissue density, HRCT can identify
cholesteatoma with specificity between 8090%
[4,5]. However, HRCT has proven unreliable in
differentiating residual or recurrent cholesteatoma
from granulation tissue, cholesterol granuloma,
mucosal edema, fibrosis, scar tissue, or fluid [68].
In the postoperative period, 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. Cone beam computed tomography scans of a patient with left cholesteatoma. Axial (a), coronal (b), and sagittal
(c) orientations show diagnostic and therapeutic findings, including: a sclerotic mastoid with an erosive cholesteatoma (C),
demonstrating scalloped edges, scutum erosion (S) and a demineralized ossicular chain (O). The subtle flattening over the
lateral semicircular canal seen on the coronal image () is also indicative of progressive expansion. The tegmen (T) is
dehiscent and low-lying, affording minimal surgical access to the epitympanum. There is tympanosclerosis medial to the
ossicular chain (TS). The facial nerve (FN), is shown to be dehiscent adjacent to the oval window on the coronal image, and
the chorda tympani can be seen on the sagittal reconstruction. A, anterior; C, Cholesteatoma; ChT, Chorda tympani; FN,
facial nerve; L, left; O, ossicles; P, posterior; R, right; S, scutum; T, tegmen; TS, tympanosclerosis.
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Imaging for evaluation of cholesteatoma Corrales and Blevins

evidence of soft tissue densities [4,6,9]. However,

in patients who have undergone previous tympanomastoidectomy, the relevance of bony erosion is
lost as it is impossible to differentiate between
surgical changes from pathological bony destruction due to cholesteatoma. In this setting, HRCT
has a sensitivity of 43%, specificity of 4251%, and
a predictive value of 28% of detecting residual or
recurrent cholesteatoma [8,10].
The advent of in-office cone-beam CT (CBCT)
imaging has further improved the availability and
convenience of imaging for cholesteatoma [11]. As a
result of their relatively low radiation production
and small size, cone-beam imaging systems can
be installed in clinic rooms with little need for
specialized shielding. In data acquisition via CBCT
scanners, the X-ray beam forms a cone-shaped
geometry between the imaging source (apex of
the cone) and the detector (base of the cone).
In contrast, conventional scanners have a fan beam
geometry [12]. The radiation dose of these scans is
reported to be 60% of a conventional CT scanner
when evaluating middle ear structures [1214].
Middle and inner ear bony structures are equally
seen in both CBCT and conventional HRCT scanners [13] (Fig. 1). One limitation of in-office CBCT is
the limited field of view, which means inner ear or
more distal disease in the mastoid may be missed.
A disadvantage of HRCT is its need for ionizing
radiation, and its inherent potential for inducing
malignancy [15,16]. For this reason, the clinician
should always be judicious in its use, especially
in children who may be more susceptible to radiation effects.

MRI
Although MRI, unlike HRCT, cannot give the bony
definition that can provide a geometric framework
for surgical planning, selected MRI techniques
can provide valuable information regarding the
presence, size, and approximate location of cholesteatoma that may not be available on HRCT
imaging. MRI has the advantage of not requiring
exposure to radiation, although it does require
longer acquisition times compared to HRCT, and
the need for immobilization may make it difficult
to obtain in young children.
On traditional MRI sequences, cholesteatomas
appear dark on T1-weighted images, bright on
T2-weighted images, and do not take up i.v. contrast. This makes them indistinguishable from much
of the other soft tissue present in a chronic ear. One
mechanism to circumvent this limitation has been
through the use of delayed-contrast techniques.
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 ,1820]. In this
technique, T1-images are obtained in 3045 min
after i.v. paramagnetic contrast administration
(gadolinium), which results in enhancement of
inflammatory mucosa, granulation tissue, scar,
or fibrosis. Absence of contrast enhancement in a
lesion suggests cholesteatoma. De Foer et al. [19]
reported sensitivity and specificity for delayedcontrast MRI in detecting cholesteatoma as
56.7 and 67.6%, respectively. Overall positive
predictive value (PPV) was 88% and negative
predictive value was 27% in the particular population studied. Disadvantages of using delayedcontrast MRI include: the cost and potential
morbidity associated with the need for i.v. contrast;
retained secretions, silicone/plastic (Silastic, Dow
Corning, Michigan, USA) sheets and calcified scars
can mimic nonperfused cholesteatoma; early acquisition of images may lead to false positives; can not
detect cholesteatomas smaller than 3 mm; requires
expert interpretation of results; and sedation or
general anesthesia is required for children because
of the prolonged time required for image acquisition. As a result, delayed-contrast MRI for detecting residual or recurrent cholesteatoma is not
routinely used.
Over the last decade, the use of diffusionweighted sequences has provided considerable
improvement in the diagnosis of cholesteatoma.
Diffusion-weighted imaging (DWI) is a variation
of the conventional MRI sequences relying on the
principles of molecular diffusion or Brownian
motion [21]. Molecular diffusion refers to the
haphazard movement of water molecules, which
is restricted in certain pathologic conditions, including ischemia, neoplasia, and the presence of keratin
debris as seen in cholesteatoma [22 ]. The high
signal intensity return in regions where the diffusion of water is impeded is termed diffusion
restriction [6,21]. The keratin debris associated with
cholesteatomas predictably restricts water diffusion,
and produces a high signal intensity compared to
brain or other surrounding soft tissues. Granulation
tissue, fibrosis and mucosal edema have less restriction diffusion for water molecules, and thus produce
a hypointense signal on DWI.
Two distinct DWI algorithms can be used for
detection of residual or recurrent cholesteatoma:
echo-planar and non-echo-planar DW-MRI. The first
algorithm developed was the echo-planar (EPI) DW
imaging, which consists of single-shot spin echo
pulse sequences. Many articles have described its
use in detecting cholesteatomas [7,17 ,1821,22 ,
23,24,25 ,26,27,28 ,2931]. Non-EPI DWI consists

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Otology and neuro-otology

of either single-shot turbo-spin sequences (HASTE:

Half Fourier Acquisition Single Shot Turbo Spin
Echo, (Siemens Systems, Germany) or multishot
turbo-spin sequences [Periodically Rotated Overlapping ParallEL Lines with Enhanced Reconstruction (PROPELLER); BLADE (Siemens Systems,
Germany)].
One limitation of DWI is that it can yield
artifacts at the interface of varied anatomic tissues.
These magnetic susceptibility artifacts correspond
to the magnetization of adjacent tissues as a result of
an external magnetic field. When two tissues with
different magnetic susceptibilities are juxtaposed,
it causes local distortions in the magnetic field.
Unfortunately, the mastoid and middle ear produce
susceptibility artifacts due to natural airbone interfaces, which cause image distortion. This has been
shown in multiple studies, which have demonstrated its inability to detect cholesteatomas smaller
than 5 mm [6]. Studies have also shown newer,
non-EPI DWI to be superior to EPI DWI in detecting
recurrent or residual cholesteatoma [22 ,23,24,
25 ,26,30], and thus non-EPI DWI has become the
standard for MRI imaging of cholesteatoma.
Additionally, the patient cost generated in an
MRI is approximately double that of an HRCT
[32]. Although the clinician should consider this
additional economic impact, the benefits gained
in selected patients by avoiding needless surgery,
or by preventing a delay in diagnosis, can potentially justify its use on economic grounds.
Various recent studies [22 ,23,24,25 ,30], including a recent meta-analysis [28 ], have evaluated
DW-MRI for the detection of residual and recurrent
cholesteatomas. In the meta-analysis, the overall
sensitivity for this imaging modality was 94% with
a specificity of 94%. The majority of false-negatives
reported were due to cholesteatoma pearls less
than 3 mm in size. False-positives reported in
this study were due to susceptibility artifacts,
cholesterol granuloma, abscess, or bone powder.
&&

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Indications for imaging

Experts may disagree about the indications of
imaging and the extent to which it assists in treatment decisions [33]. Some otologists routinely
obtain imaging whenever cholesteatoma is either
seen or suspected, whereas others use imaging only
with great reservation. Most agree that imaging
is indicated in revision cases and those with intracranial or intratemporal complications. Surgeons
should carefully consider the benefits they receive
from imaging in their particular practice, and
regularly reevaluate these indications as they gain
experience and modify their surgical techniques.
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Surgeons should always be diligent about

reviewing imaging studies themselves, as even
the best radiology report will rarely convey the
subtleties that affect surgery.
Preoperative assessment
The benefits of knowing potential challenges,
and having a roadmap for surgical planning is
particularly helpful in teaching settings in which
expectations for the case can be reviewed preoperatively. Similarly, HRCT can be very helpful
prior to revision surgery, especially when the
surgeon did not perform the initial procedure.
In revision cases, anatomy may be considerably
altered, limiting the utility of normal surgical
landmarks and presenting unexpected challenges.
An HRCT study can reveal specific patterns of
pneumatization and aeration or variability on the
position of the sigmoid sinus or tegmen, which may
affect surgical access to disease. Is a mastoidectomy
needed, or can the disease be adequately accessed
transcanal? Is there likely to be adequate space to
access disease while leaving the canal wall up, or is
the mastoid sclerotic and contracted, warranting a
planned canal-wall-down procedure? Erosion of the
Fallopian canal may be suggested, as could exposure
of the carotid artery or jugular bulb, which could
serve as a warning to potential hazards during
dissection. Some semicircular canal dehiscence
can be clinically silent [34], as are almost all facial
nerve dehiscences, thus preoperative knowledge
of these findings may alert the surgeon to areas that
warrant extra intraoperative attention. Although
difficult to assess completely, obvious ossicular
abnormalities may predict the need for ossicular
reconstruction. HRCT can also demonstrate unexpected and potentially unrelated anatomic variation such as anomalous facial nerve patterns [35].
Despite MRIs superior ability to identify cholesteatoma and differentiate it from other soft tissues,
it is seldom helpful in the preoperative setting in
primary cases. However, DW-MRI can provide
additional information in primary cases in which
clinical information is limited, or the otoscopic
examination is inconclusive (Fig. 2). The great
majority of times, however, the diagnosis is not
in doubt, and HRCT is superior in providing
information on salient anatomic geometry. DWMRI, however, becomes considerably more useful
in assessing the potential for postoperative recurrence of disease. In such cases, cholesteatoma
may appear in unexpected areas inaccessible to
clinical otomicroscopy, including the mastoid
cavity, deep to reconstructive materials, and growing around adjacent structures in which the furthest
extent of cholesteatoma may have been missed on
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Imaging for evaluation of cholesteatoma Corrales and Blevins

(a)

(b)

FIGURE 2. (a) Axial high-resolution computed tomography (HRCT) scans of a patient with a primary left cholesteatoma,
showing soft tissue on the epitympanum (). Although this finding is consistent with cholesteatoma, it is impossible to
distinguish this from other soft tissues seen in chronic otitis media. (b) Diffusion-weighted (DW)-MRI of the same patient. Note
the bright area in the epitympanum () that corresponds to the soft tissue seen on the CT. The high signal results from restricted
diffusion of water within the keratin debris, and supports the diagnosis of cholesteatoma. This provides complementary
information to the anatomic detail seen on CT.

the primary procedure (Fig. 3). Conversely, not all

high-signal intensites on DW-MRI are cholesteatomas, as cholesterol granuloma may appear similar to
recidivistic cholesteatoma (Fig. 4). In these cases, the
use of other MRI sequences may be very useful to
predict the diagnosis, and provide the surgeon and
patient with expectations for treatment.
Postoperative surveillance
It is compelling to look for alternatives to secondlook surgery. If an HRCT shows no abnormal
soft tissue at 6 or 9 months following the initial
stage, one may feel comfortable holding off on a
second look [4,6,9,33]. Unfortunately, it is rare that
an HRCT study will be entirely without some
suspicious soft tissue. Also, in an early postoperative

(a)

ear, one cannot use bone erosion to help differentiate the soft tissue from scar, fluid, or edema. This is
likely the situation in which DW-MRI is most useful
in imaging cholesteatoma.
After 912 months, most persistent cholesteatomas will be larger than 3 mm and therefore should
be apparent on DW-MRI [22 ,23,24,25 ,28 ,29,30].
A negative DW-MRI study may avoid the expense
and morbidity associated with a negative second
look. 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. In some areas, such as at the mastoid cavity,
a recurrent cyst of this size can usually be readily
resected. In other areas, such as the sinus tympani
or on the stapes footplate, a cholesteatoma of
&&

&

&

(b)

FIGURE 3. Axial images of a recurrent cholesteatoma (arrows) eroding the mastoid tip air cells 25 years following a prior
canal-wall-up tympanomastoidectomy. The patients tympanic cavity showed no evidence of disease on otoscopy. (a) Diffusionweighted (DW)-MRI shows a high signal lesion in the mastoid, consistent with cholesteatoma. (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.
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Otology and neuro-otology

(a)

(b)

FIGURE 4. Axial images of a cholesterol granuloma presenting as an expansile mastoid lesion (arrows) 6 years following
tympanomastoid surgery for cholesteatoma. (a) Diffusion-weighted (DW)-MRI showing heterogeneous high signal on a
PROPELLER DWI sequence. It is important to note that such restricted diffusion can occur in disease other than cholesteatoma,
as demonstrated here. By correlating this with the image shown in (b), the lesion is seen to have inherently high signal on
T1-weighted sequences (unlike the low signal expected for cholesteatoma), suggesting the diagnosis of cholesterol granuloma.

3 mm may present a prohibitively greater surgical

challenge. If this is the case, foregoing imaging, and
proceeding directly with a second-look procedure
is very reasonable. If a DW-MRI study is negative at
912 months postoperatively, the surgeon should
use his or her clinical judgment as to whether
another scan is needed at a later date. In routine
cases, in which recidivistic disease is likely to occur
in the middle ear or mastoid, a single scan may
well be sufficient, and the patient can be followed
clinically. If, however, there is concern for persistence in areas that are inherently more difficult
to assess, such as the jugular foramen or petrous
apex, another scan obtained a year later is a reasonable option.
Cholesteatoma complications
In patients with complications of cholesteatoma,
imaging is almost always indicated [17 ,18,30,
36,37]. MRI is best suited for defining intracranial
complications such as perimeningeal spread of
infection, brain abscess, or sinus thrombosis.
Intratemporal complications with facial paralysis,
extension into the labyrinth, petrous apex or jugular
foramen are best identified by HRCT. However in
the majority of complications, the clinician may
wish to obtain both HRCT and MRI studies, as both
may offer valuable insights with diagnostic and
therapeutic implications.
&

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
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for surgery which can help guide the surgeon to

more safe and effective management. Current literature suggests DW-MRI to have a high sensitivity
and specificity in detecting cholesteatoma down
to 3 mm in size. It also provides adequate differentiation between cholesteatoma and other soft tissue
densities including granulation tissue, fibrosis,
mucosal edema or scar. As more centers implement
DW-MRI for detecting residual or recurrent cholesteatoma, the need for second-look surgery to evaluate for the presence of residual or recurrent disease
will likely reduce and even replace surgery, thereby
decreasing patient morbidity and surgical costs.
Acknowledgements
None.
Conflicts of interest
The authors have no relevant financial disclosures or
conflict of interest.
No funding to disclose.

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