Learning Objectives: 1) Understand the rationale of DW MRI for identifying presence of cholesteatoma 2) Understand the limits of DW MRI for identifying presence of cholesteatoma 3) Understand the accuracy and utility of DW MRI in determining the presence of cholesteatoma in children.

Cholesteatoma has a significant rate of recidivism. Children in particular are at higher risk of residual disease due to the aggressive nature of congenital cholesteatomas as well as recurrent disease due to ongoing Eustachian tube dysfunction. As a result, historically, “second look” procedures were routinely performed and considered standard of care. Recently, obligate planned revision tympanomastoidectomy procedures have become challenged due to concerns of repeated risks of anesthesia and surgery as well as added health care costs. While the diagnosis of cholesteatoma is primarily made clinically, imaging, particularly computed tomography, has been used as a tool to assist in confirming the diagnosis and determining the extent of the disease. In patients who have previously undergone primary cholesteatoma surgery, diffusion weighted magnetic resonance imaging (DW MRI) has become a useful imaging modality to assist in deciphering the presence of cholesteatoma vs. mere fluid or inflammation in the middle ear and mastoid. Since 2012, we have performed nearly 100 DW MRI studies in children to determine the presence of cholesteatoma. The results of these studies in comparison to subsequent surgical findings will be presented to review the accuracy of DW MRI in identifying cholesteatoma in our pediatric patient population.