FRCS (ORL-HNS) · SECTION 1 SBA

Cholesteatoma follow-up strategy

After canal-wall-up surgery for extensive cholesteatoma, otoscopy is reassuring but the epitympanum is not fully visible. What follow-up principle best detects residual disease?

CHOOSE ONE ANSWER

Best of five

  1. A. Discharge after a normal six-week otoscopy
  2. B. Use plain skull radiographs
  3. C. Planned non-echo-planar diffusion-weighted MRI and/or staged surgical surveillance
  4. D. Rely on symptoms alone
  5. E. Order annual PET-CT
ANSWER AND REASONING

C. Planned non-echo-planar diffusion-weighted MRI and/or staged surgical surveillance

Residual cholesteatoma may be hidden after canal-wall-up surgery. Non-EPI diffusion-weighted MRI is useful for surveillance, with timing and second-look surgery individualised to disease extent and reconstruction.

Why every option is right or wrong

A. Discharge after a normal six-week otoscopy: A hidden residual matrix may not be visible.

B. Use plain skull radiographs: They cannot sensitively detect small residual cholesteatoma.

C. Planned non-echo-planar diffusion-weighted MRI and/or staged surgical surveillance: Residual cholesteatoma may be hidden after canal-wall-up surgery. Non-EPI diffusion-weighted MRI is useful for surveillance, with timing and second-look surgery individualised to disease extent and reconstruction.

D. Rely on symptoms alone: Residual disease can remain asymptomatic until advanced.

E. Order annual PET-CT: PET is not the standard surveillance test and adds unnecessary radiation.

What if the scenario changed?

If an open cavity allowed complete clinical inspection and remained healthy, imaging requirements could differ.

EDUCATIONAL USE

Independent Clinora educational preparation material; not official JCIE content, an accredited programme, clinical advice, or a substitute for current guidance, local policy and specialist judgement.

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