The British Journal of Radiology, 75 (2002), 847–852 E 2002 The British Institute of Radiology

Pictorial review
CT scanning of middle ear cholesteatoma: what does
the surgeon want to know?
1
P D YATES, FRCS, 1L M FLOOD, FRCS, 1A BANERJEE, FRCS and 2K CLIFFORD, FRCR
1
Department of Otolaryngology, North Riding Infirmary, Newport Road, Middlesbrough TS1 5JE and
2
Department of Radiology, South Cleveland Hospital, Middlesbrough, UK

Abstract. The history of surgery for middle ear cholesteatoma is of an evolution of techniques to
meet the challenges of inaccessible disease and of post-operative cavity management. The concept
has traditionally been of exploration guided by awareness and anticipation of all, possibly
asymptomatic, complications. Modern imaging reliably demonstrates surgical anatomy, dictating
the ideal approach, forewarns of complications and may reveal the extent of disease. An apparent
resistance amongst otologists to universal CT scanning prior to mastoidectomy contrasts with the
enthusiasm of skull base surgeons or rhinologists for appropriate imaging.

A cholesteatoma is a collection of keratinizing patient prone, without intravenous contrast and

squamous epithelium in the middle ear cleft
associated with bone resorption, which may be
congenital or acquired. It is accepted that most
acquired cholesteatomas develop in a retraction
pocket in the tympanic membrane, usually in the
thinner pars flaccida, superiorly. Keratin squames
normally migrate from the tympanic membrane
along the ear canal to the external auditory mea-
tus. The presence of a retraction pocket disturbs
this clearance mechanism and leads to keratin
accumulation in an expanding and destructive
‘‘pearl’’. Other mechanisms, such as implantation,
migration through a perforation or even squam-
ous metaplasia of middle ear mucosa, may be
implicated.
The hazards of uncontrolled cholesteatoma
demand a surgical approach in all but the worst
anaesthetic candidates. The difficulty of eradicat-
ing this invasive disease in the complex anatomy
of the temporal bone has inspired a variety of
surgical approaches, each with its own propo-
nents. The choice of technique has traditionally
been determined by personal preference with pre-
operative investigations limited to otoscopy and
pure tone audiometry.
applying the following parameters: 512 matrix;
250 mm field of view, or zoom; 4 s scan time (the
maximum available); 1.5 mm contiguous slices;
1 H filter (edge enhancement); 120 kV, 100 mA
exposure; 1.5 mm table index (to give contiguous
slices); fast scan mode; beam hardening correction
switched on; approximately 25 slices performed
per examination.
Radiation dosage
Calculated from a head phantom, using the
above factors, the effective dose was found to be
2.319 mSv for 136 slices. Average dose per slice is
therefore equal to 0.017 mSv. This is about the
same dose as one chest X-ray. Therefore for 25
slices the total dose is 0.43 mSv.
The typical effective dose of a standard CT
brain scan is, in comparison, over four times
greater at 2 mSv. In practice, coronal scanning of
the temporal bone produces minimal irradiation
of the most sensitive target tissue, the lens of the
eye, and the theoretical risk of cataract formation
is far greater in CT scanning of the paranasal
sinuses.

Imaging protocol
Imaging
In our practice [1], routine CT scanning of the
middle ear has required coronal scans with the
Interpretation of scans (Figures 1–4)
The radiologist should provide the following
clinically valuable information from the images
obtained:

Received 20 June 2001 and in revised form 15 November (1) Degree of ventilation/opacification of middle
2001, accepted 14 February 2002. ear cleft from the Eustachian tube to the
Address correspondence to L M Flood, Consultant mastoid tip.
Otolaryngologist. (2) Erosion of ossicular chain.

The British Journal of Radiology, October 2002 847


(3) Access to the epitympanum as determined by
the level of the dura laterally.
(4) Development/cellularity/sclerosis of the mas-
toid cortex.
(5) Dehiscence of the tegmen.
(6) Erosion of the labyrinth, especially the lateral
semicircular canal.
(7) Status of the facial nerve
(8) Alterations in anatomy secondary to previous
surgery.
Discussion
CT imaging of the paranasal sinuses has been
accepted as an essential investigation in the pre-
operative planning of endoscopic sinus surgery. It
has not, however, gained wide acceptance as an
essential aid to planning surgery for cholestea-
toma. Most otologists reserve scans for selected
cases:
(1) Complications of chronic suppurative otitis
media (CSOM).
(2) Suspected congenital abnormalities.
(3) Loss of landmarks owing to previous surgery.
Routine CT scanning prior to all surgery of
cholesteatoma can only be justified if it can be
shown that clinical management is influenced.
Cooperation between radiologist and an otolo-
gist sufficiently flexible to tailor surgical manage-
ment according to radiological findings is the
ideal. Advantages of scanning will then include:
(1) A visual aid to pre-operative counselling of
the patient.
(2) Avoidance of unnecessary surgery owing to its
high degree of sensitivity/specificity for middle
ear disease.
(3) A prediction of the anatomy, ease of surgical
access and extent of disease, all of which guide
surgical approach.
(4) Anticipation of complications of chronic
suppurative otitis media.
The lack of effective, non-surgical management
for cholesteatoma, and the potential complica-
tions if untreated, require surgical eradication.
The earliest technique, a radical mastoidectomy,
converted the external canal and middle ear into a
large, empty cavity devoid of ossicles or tympanic
membrane. Poor epithelialization generally caused
a chronic discharging cavity. The later modified
radical mastoidectomy aimed to preserve the
tympanic membrane, thereby sealing off the
Eustachian tube from the cavity. The open
mastoid bowl is still associated with discharge
and a need to regularly attend an out-patient
clinic for suction clearance.
Subsequent development of the intact canal
848
P D Yates, L M Flood, A Banerjee and K Clifford
wall technique, the combined approach tympano-
plasty, allowed access through an intact bony
canal and separately through a transmastoid
approach to the facial recess and middle ear
(Figure 5). Unfortunately the prospect of preser-
ving relatively normal anatomy, avoiding cavity
problems and producing better hearing results,
did not entirely stand the test of time. Residual
cholesteatoma, i.e. failure to eradicate the disease,
occurs in 13–36% of cases, and recurrent choles-
teatoma in 5–13% of cases, following this
procedure [2]. The high incidence of residual or
recurrent cholesteatoma in relatively inaccessible
sites, such as the stapes or sinus tympani makes a
re-exploration, or ‘‘second look tympanotomy’’,
mandatory after 1 year.
Relevance of anatomy
The intact canal wall and ‘‘open’’ canal wall
down techniques both have their proponents.
Some otologists argue that a single stage canal
wall down procedure (modified radical mastoi-
dectomy) provides maximum long-term patient
benefit. Others argue that even in difficult cases
where more than two stages are required to
eradicate disease, combined approach tympano-
plasty is preferable to modified radical mastoi-
dectomy. Ideally the otologist will employ both
techniques, the choice being influenced by radio-
logical anatomy. The closed, intact canal wall
approach requires wide access, ideally through a
large cellular mastoid, whilst the canal wall down
approach is preferable in the small sclerotic
system (Figure 6), which is commonly associated
with cholesteatomas in adults. Open exploration
will then produce only a small cavity with better
prospects for epithelialization. The modified radi-
cal cavity in a large cellular system holds poorer
prospects for healing. Equally, the intact canal
wall technique in tiny mastoid cavity is technically
difficult because of poor access. Similarly, fore-
knowledge of the extent of the disease and
mastoid system may determine whether drilling
starts at the outer attic wall, proceeding poster-
iorly, in a small system or starts with a direct
approach to the antrum through a well pneuma-
tized mastoid. Low lying dura lateral to the attic
is also a potential hazard (Figure 3a).
Prediction of complications
Studies of sensitivity/specificity of CT in
detecting asymptomatic complications prior to
surgical exploration may reflect earlier techniques,
e.g. axial imaging, but false negatives are inevi-
table. The wise surgeon will always approach
danger areas, such as the lateral semicircular
canal, the facial nerve and stapes footplate, with
The British Journal of Radiology, October 2002
Pictorial review: CT scanning of cholesteatoma
caution. However, one can only detect bone
erosion and abnormal exposure by dissection of
cholesteatoma from these structures, with obvious
hazards. If forewarned, the operator may decide
to leave cholesteatoma matrix as a protective
cover, which becomes harmless once exteriorized.
Interpretation of CT scans obviously requires
an otologist prepared to benefit from the knowl-
edge of an expert radiologist. With time, surgeon
and radiologist gain increased experience of
correlating CT with eventual surgical findings.
Coronal scans are also relatively easily under-
stood by the patient. A few minutes discussion of
the images, demonstrating the course of the facial
nerve, the relationship of the inner ear and the
damage to the ossicles, can be of great help in pre-
operative counselling. Such scans can illustrate
both the need, but also the hazards, of surgery
(Figure 7). Imaging can also enhance the trainee’s
knowledge of surgical anatomy. Although a
relatively minor consideration as yet, any pre-
operative documentation of disease can be of
medicolegal value.
Clinical examination and otoscopy are used
to diagnose cholesteatoma. CT can determine its
extent by revealing the combination of a soft
tissue mass and bone erosion with 80% specificity
[3, 4]. Unfortunately, cholesteatoma sac, asso-
ciated granulation tissue, mucosal oedema and
effusion may be indistinguishable on CT [5, 6].
Although cholesteatoma is said to show a lower
attenuation than granulation tissue, the difference
The British Journal of Radiology, October 2002
is subtle and enhanced MRI may be more reliable
in differentiation [7].
Complications of cholesteatoma are related to
bone erosion, limiting the value of MRI. MRI
can confirm suspicion of defects in the tegmen
tympani or dural plate on CT, and is of especial
value in diagnosing cerebral herniation [8, 9]. It
can exclude dual pathology in patients presenting
with facial nerve palsy or sudden sensorineural
hearing loss, associated with cholesteatoma. MRI
also reliably detects disease extension to the
petrous apex, lateral sinus thrombosis or intra-
cranial sepsis [10].
Few authors recommend scanning as routine
prior to all mastoid surgery [11], but with
improving resolution, and therefore sensitivity,
this may evolve. In planning revision surgery,
especially after intact canal wall procedures,
residual diseased air cells in the sinodural angle,
tegmen, mastoid tip and petrous apex, together
with recurrent cholesteatoma, can be demon-
strated [12].
Few intratemporal complications of CSOM
require such immediate surgery as to prevent
radiology. The direst emergency, intracranial
sepsis, will certainly require neuroradiology but
sophisticated imaging of the temporal bone may
well have to be sacrificed.
In our practice, CT evaluation has become the
norm prior to the majority of mastoid surgery,
and is the subject of a prospective study of its
clinical relevance.
Figure 1. An ideal coronal CT scan with the external
and internal auditory canal simultaneously displayed.
The scutum is intact (arrow). The stapes suprastruc-
ture and incus body (arrowhead) are preserved but
the long process of incus has been eroded. The tym-
panic membrane is retracted onto the stapes head but
the middle ear is ventilated.
849
 P D Yates, L M Flood, A Banerjee and K Clifford

(a) (b)
Figure 2. (a) The scutum is eroded (white arrow) with an attic opacity eroding the malleus head. Medially the
cochlea is intact with the labyrinthine and horizontal portions of the facial nerve displayed (black arrow). (b)
More posteriorly the middle ear connects with a well preserved, opaque and very extensive cellular mastoid;
potentially a huge cavity with a modified radical mastoidectomy.

(a) (b)

Figure 3. (a) Laterally there is a very low lying dura

(open arrow), which would restrict surgical access to
the opaque attic. Erosion of the scutum is again
demonstrated. (b) Posteriorly the arch of the lateral
semicircular canal is eroded causing an asymptomatic
fistula (arrow). (c) Ultimately the cholesteatoma
extends into a small, dense, sclerotic mastoid cavity.
The canal of the descending portion of the facial
nerve is intact (black arrow).
(c)
850 The British Journal of Radiology, October 2002
Pictorial review: CT scanning of cholesteatoma

(a) (b)

(c) (d)

Figure 4. A woman with history of right total hearing loss after radical mastoidectomy who developed a mild
hearing loss in her left, only hearing, ear. She also had a temporary left facial weakness, initially attributed to a
Bell’s palsy. CT scans confirmed the otoscopically apparent cholesteatoma, with (a) erosion of the scutum and
malleus head (arrow). (b) Despite lack of vertigo there is a fistula of the lateral semicircular canal (arrow) and
attenuated tegmen. Exposure of the fistula at surgery risked a profound bilateral sensorineural hearing loss in the
only functioning ear, so the keratin matrix was preserved. (c) CT of the contralateral ear demonstrates the open
mastoid cavity but also the unsuspected fistula of this lateral canal that had resulted in destruction of cochlear
function at operation. This defect compares with (d) the intact dome of the semi-circular canal in another, simi-
lar, mastoid cavity.

The British Journal of Radiology, October 2002 851


Figure 5. Axial scan through a healthy middle ear
cleft and descending facial nerve. The arrow demon-
strates the transmastoid, intact canal wall, approach
to the facial recess. Medially, the descending facial
nerve (arrowhead) is marked by the pyramidal emi-
nence, the origin of the Stapedius tendon. Further
medially is a second cleft, the relatively inaccessible
sinus tympani.
Figure 7. Extensive cholesteatoma with tegmen ero-
sion and dural exposure. Long neglected erosion into
the labyrinth produced a profound sensorineural loss
and ultimately, the bony sclerosis obliterating the coil
of the cochlea (arrow). Compare with Figures 2a and
4a.
References
1. Watts S, Flood LM, Clifford K. A systematic
approach to interpretation of computed tomogra-
phy scans prior to surgery of middle ear cholestea-
toma. J Laryngol Otol 2000;114:248–53.
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P D Yates, L M Flood, A Banerjee and K Clifford
Figure 6. Coronal scan centred on the stylomastoid
foramina (arrows). The patient’s healthy ventilated,
extensive, cellular, left mastoid system contrasts with
the sclerotic bone and the tiny antral cavity, pro-
duced by cholesteatoma, on their right.
2. Mills RP. Management of chronic suppurative otitis
media. In: Kerr A, Booth JB, editors. Scott Brown’s
Otolaryngology (6th edn). Oxford, UK: Butter-
Heinemann, 1997.
3. O’Donoghue GM, Bates GJ, Anslow P, Rothera
MP. The predicitive value of high resolution
computed tomography in chronic suppurative ear
disease. Clin Otol 1987;12:89–96.
4. O’Reilly BJ, Chevretton EB, Wylie I, Thakker C,
Butler P, Sathuanathan N, et al. The value of CT
scanning in suppurative otitis media. J Laryngol
Otol 1991;105:990–4.
5. Phelps PD, Wright A. Imaging cholesteatoma. Clin
Radiol 1990;41:156–62.
6. Jackler RK, Dillon WP, Schindler RA. Computed
tomography in suppurative ear disease: a correla-
tion of surgical and radiographic findings.
Laryngoscope 1984;94:746–52.
7. Martin N, Sterkers O, Nahum H. Chronic
inflammatory disease of the middle ear cavities, Gd
DTPA enhanced MR imaging. Radiology 1990;176:
399–405.
8. Bowes AK, Wiet PJ, Monsell SM. Brain herniation
and space-occupying lesions eroding the tegmen
tympani. Laryngoscope 1987;97:1172–5.
9. Martin N, Sterkers O, Murat M, Nahum N. Brain
herniation into the middle ear cavity; MR imaging.
Neuroradiology 1989;31:184–6.
10. Swartz JD, Harnsberger HR. The Middle ear and
mastoid. In: Swartz J and Harnsberger H, editors.
Imaging of the Temporal Bone (3rd edn). New
York, NY: Thieme, 1998.
11. Blevins NH, Carter BL. Routine preoperative
imaging in chronic ear surgery. Am J Otol 1998;
19:527–38.
12. Campbell JP, Pillsbury HC 3rd. The use of
computerized tomographic imaging in revision
mastoid surgery for chronic otitis media. Am J
Otol 1990;11:387–94.
The British Journal of Radiology, October 2002