Best of five
- A. Residual or recurrent cholesteatoma requiring specialist revision planning
- B. Ossicular discontinuity alone
- C. Postoperative granulation tissue
- D. Cholesterol granuloma
- E. Observe without further review
FRCS (ORL-HNS) · SECTION 1 SBA
Recurrent cholesteatoma after canal-wall-up surgery
A 34-year-old has progressive conductive hearing loss three years after canal-wall-up cholesteatoma surgery. Otoscopy shows a reconstructed intact tympanic membrane. Diffusion-weighted MRI shows a 7 mm focus of restricted diffusion in the epitympanum. What is the most appropriate interpretation?
A. Residual or recurrent cholesteatoma requiring specialist revision planning
Non-echo-planar diffusion restriction at this size is strongly suspicious for keratin debris; operative anatomy, hearing and disease extent determine revision strategy.
Why every option is right or wrong
A. Residual or recurrent cholesteatoma requiring specialist revision planning: Non-echo-planar diffusion restriction at this size is strongly suspicious for keratin debris; operative anatomy, hearing and disease extent determine revision strategy.
B. Ossicular discontinuity alone: It may explain conductive loss but not a focal restricted-diffusion lesion.
C. Postoperative granulation tissue: Granulation commonly enhances but does not usually show the characteristic marked non-EPI diffusion restriction.
D. Cholesterol granuloma: This is typically intrinsically T1 hyperintense rather than defined by focal diffusion restriction.
E. Observe without further review: A convincing postoperative lesion needs otology review because silent progression can threaten hearing, facial nerve and labyrinth.
What if the scenario changed?
If the focus were 2 mm and equivocal, interval non-EPI diffusion MRI rather than immediate surgery could be the better next step.
Independent Clinora preparation material; not official JCIE content, an accredited programme or a substitute for local policy and specialist judgement.
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