Managing postoperative cholesteatoma: second-look surgery or surveillance with diffusion-weighted magnetic resonance imaging

Objective: To compare second-look surgery with surveillance using serial nonechoplanar diffusion-weighted imaging to detect residual cholesteatoma after canal wall-up mastoidectomy. Methods: This was a longitudinal observational study. A prospectively collected database was searched for patients who underwent canal wall-up mastoidectomy and had an initial negative diffusion-weighted imaging scan 9-12 months after the surgery. A total of 34 patients were included; 13 patients subsequently underwent second-look surgery, and 21 patients were monitored with serial diffusion-weighted imaging for at least 3 years. Results: Of the 13 patients who underwent second-look surgery, 11 (85%) had no residual cholesteatoma, but 2 (15%) had residual disease. A total of 3 patients (23%) developed postsurgical complications after the second-look surgery. Of the 21 patients who were planned for serial monitoring with diffusion-weighted imaging, 3 (14%) were lost to follow-up after the first year. Of the remaining 18 patients, the second diffusion-weighted imaging (performed 2 years after surgery) was positive for cholesteatoma in 2 patients (11%). On the third diffusion-weighted imaging (3 years after surgery), 12 of the 16 patients (75%) remained negative, and the other 4 (25%) were lost to follow-up. Conclusion: If one elects not to perform second-look surgery, a diffusion-weighted imaging surveillance program is necessary to detect residual disease. Surveillance should be for a minimum of 3 years after the initial surgery, and there is a real risk of losing patients to follow-up.