The imaged "decisional line" for cholesteatoma surgical approach

Background: Cholesteatoma (CHO) is a pathological condition in which an epidermal cyst grows within the petrous pyramid. As it progresses, CHO can erode the ossicles and bony walls, leading to complications such as hearing loss, vertigo, and facial nerve palsy. Surgery is the gold standard treatment for CHO, with various surgical approaches differing in invasiveness. When choosing which surgical approach is most appropriate for the patient, surgeons must balance the necessary radicality of treatment with the invasiveness of their chosen surgical approach. Objective: This study aims to provide objective radiological criteria for localizing cholesteatoma and guiding the selection of the most appropriate surgical approach. Methods: Patients with CHO underwent high-resolution CT scans and non-EPI DWI MRI. A spatial quadrant was arbitrarily drawn and used to map the CHO location within the petrous bone, delineating 4 anatomical quadrants. Results: By using image fusion techniques and objective markers, the preoperatively planned canal-wall-up (CWU) approach was modified for 75% of the cases. At the 1-year follow-up, non-EPI DWI MRI was performed, and 20% of the patients who underwent the canal wall-up (CWU) technique showed cholesteatoma recurrence. Among patients whose surgical approach was modified on the basis of preoperative fusion imaging, 10% experienced CHO recurrence. Conclusions: Accurate preoperative CHO localization through image fusion appears useful for staging the disease, preserving the surrounding structures and achieving the best excision results.