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Cholesteatoma occurs more often in children than in adults and is more aggressive, often resulting in ossicular erosion and marked conductive loss, amongst other more serious possibilities. Recurrence happens in all three methods used, namely canal wall up, canal wall down and canal wall down with obliteration of the mastoid cavity. It is therefore crucial that recurrence of cholesteatoma is not missed. With the advent of diffusion-weighted MRI at the turn of the century, there has been increasing reliance on this rather than on ‘second look’ operations, thus saving children the morbidity of the latter. In this retrospective study comprising 36 non-planar DW MRI, the authors assessed reliability of this method in 29 ears. Out of 18 images reported positive, there were 13 true positive and five false positives, noted at the time of surgery. Out of 16 images reported negative, four were surgically confirmed negative and nine did not undergo surgery because clinically they were not suspected to have cholesteatoma. However, three cases had surgically confirmed cholesteatoma, i.e. these were false positive on DW MRI. Reasons for false positives have been cited as cartilage graft material, cerumen, fluid, adhesions and debris-filled retraction pocket. The sensitivity of DW MRI was 81% and specificity 72%. The positive predictive and negative predictive values were 72% and 81% respectively. False negatives have been attributed to small size of cholesteatoma - less than 3mm. Non-planar DW MRI has been recommended instead of second-look surgery. However, it is advised that all patients, even with negative DW MRI, should be closely followed up and the threshold for surgical intervention should be low if there is a clinical suspicion of cholesteatoma, regardless of the imaging results.

Diffusion-weighted magnetic resonance imaging for diagnosis of post operative paediatric cholesteatoma.
McCallum R, Coleman H, Pervaiz H, et al.
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Madhup K Chaurasia

Mid and South Essex NHS Foundation Trust, UK.

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