Learning Objectives: 1. Correlate histopathologic evidence to predict clinical location of cholesteatoma. 2. Appreciate new real-time imaging modalities to optimize complete removal of cholesteatoma while preserving normal structures. 3. Understand the utility of MR imaging in the management of cholesteatoma.

Surgical extirpation of cholesteatoma must be adequate to negate recurrent or recidivistic disease but maintain as much hearing function as possible in a healthy mucosalized space. A thorough understanding of patterns of growth of various types of cholesteatoma enables the otologic surgeon to accomplish this. As the ‘something old’ we have access to temporal bone histopathologic specimens that show us the usual path of an atticoantral cholesteatoma vs. a tubotympanic one. Studying otopathologic slides allows for such in-depth understanding that it becomes second nature to the surgeon to anticipate the location of disease. The ‘something new’ involves optical imaging with high resolution microendoscopes, multiwavelength fluorescent otoscopes, and multicolor reflectance imaging of middle ear pathology in vivo. Use of these methods should allow the surgeon to remove all disease while maintaining the integrity of the normal or near-normal adjacent mucosa, at the time of initial surgery, preventing recidivism and potentially preventing repeat otologic surgical interventions. ‘Something borrowed’ is using new magnetic resonance imaging (MRI) techniques from radiology to image either nascent cholesteatomas or to use MRI as the ‘second look’ procedure. The goal is to enable miminally invasive techniques of complete cholesteatoma removal while preserving hearing function either naturally or by immediate reconstruction, and avoiding ‘clean’ second look surgeries. Details of using all of these techniques, including pitfalls that should be avoided, will be discussed.