Case III: cholesteatoma (L) - axial view

Case description

A 52-year-old male patient with previous surgery for cholesteatoma (Ch) in his right ear was brought in for follow-up imaging and a hyperintensity was noted in the diffusion-weighted magnetic resonance image (MRI) in his left, unoperated ear. Upon endoscopic examination of the left ear, the tympanic membrane (TM) with flares of keratin debris at the pars flaccida (PF) revealing the early stages of an attic cholesteatoma. In the endoscopic image, the malleus (M) handle and umbo (U) are clearly visible, and the posterosuperior aspect of the tympanic membrane (TM) is bulging out. The patient has also developed a moderate conductive hearing loss in his left ear as shown in the audiogram.

Diagnostic imaging

(click image to enlarge)

otoscopic image
audiogram
CT (axial view)
OCT (3D view)
case3-coronal
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case3-sagittal
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case 3 axial CT/OCT fused

Clinical findings

The OCT, CT and fused coronal views along with the axial view image all show clear evidence of tympanic membrane (TM) thickening and retraction and of the contact between the TM and the inflamed mucosa over the cochlear promontory (CP). The keratinous outer layers of the cholesteatoma (Ch)visible from the ear canal create a hyper-reflective layer overlaying a less reflective inner layer. This has previously been reported as a distinctive feature of cholesteatoma (Ch)in OCT imaging that can be used to differentiate cholesteatoma (Ch)from inflamed mucosa. Additionally, comparison between the OCT and CT images and allow us to see that the OCT image delineates the inferior edge of the cholesteatoma (Ch)sac in the mesotympanum. The OCT image shows a region of inflamed mucosa superior to the TM with a uniform appearance distinct from the more irregular intensity distribution of the cholesteatoma (CH). The most inferior portion of the TM is of normal thickness with no evidence of inflammation. Mucosal inflammation can also be seen near the facial nerve (FN).