Learning Objectives: to establish realistic expectations in pediatric cholesteatoma in the era of non-EPI-diffusion weighted MRI.

Introduction: Cholesteatoma is a struggle for a safe and convenient condition with the least possible surgeries in the presence of a disease that tends to re-create after complete removal due to the compromised ME physiology, as well as the possibility of residual disease.

Methods: Data collected from consecutive pediatric cholesteatoma surgeries performed by a single surgeon (ML) between 2001 and 2005 and between 2011 and 2015. Type and number of surgeries performed in each group over the follow up period before (2001 and 2005) and after (2011 and 2015) the introduction of non-EPI-diffusion weighted MRI were compared. Revision surgery was also performed in both groups at any point when recurrent cholesteatoma is detected by routine follow-up otoscopy (4–6 weeks, 3 m, and every 6 m thereafter).

Results: There were no significant medical or surgical complications in either group. 54.5% of the children operated between 2001–2005 ended with a CWD mastoidectomy condition (radical cavity) after a mean follow up of 5.8 ± 3.8. None of the children operated during 2011–2015, after the introduction of routine periodic post -operative non-EPI diffusion MRI follow-up ended at this point or expected to have at any point a radical mastoidectomy.

Conclusions: Currently, radical mastoidectomy with meatoplasty should not be used as one of the routine surgical options in pediatric cholesteatoma. Follow up (clinical and imaging) after cholesteatoma is absolutely mandatory, without it, children with cholesteatoma are exposed to a very significant and unnecessary risk. In cases of repeated, de-novo re-creation of cholesteatoma, or repeated infection in an existing radical cavity, a CWD mastoidectomy with blind sac obliteration of the EEC and the ME cleft is also a very practical option in certain cases, as it eliminates de-novo re-creation of cholesteatoma.