Cholesteatoma is a benign but locally destructive lesion characterized by abnormal proliferation of keratinizing squamous epithelium within the middle ear cleft and/or mastoid air cells. Although often colloquially referred to as "skin in the wrong place," the term is a misnomer, as the lesion neither contains cholesterol crystals nor exhibits neoplastic behavior.[1] Histopathologically, cholesteatoma comprises a keratinizing epithelial matrix surrounding a central core of desquamated keratin debris. It exerts a mass effect and promotes enzymatic bone resorption, frequently leading to erosion of adjacent osseous structures. Cholesteatoma is often linked to chronic suppurative otitis media (CSOM) and can gradually damage the small bones in the ear, causing problems with hearing.[2] If left untreated, the disease may lead to serious complications such as sensorineural hearing loss, facial nerve paralysis, labyrinthine fistula, and even life-threatening intracranial infections, including meningitis and brain abscess.[3] Therefore, early diagnosis and timely surgical intervention are vital to prevent long-term morbidity. The incidence of chronic otitis media (COM) ranges from 0.5% to 2% in developed countries, while in developing regions, it varies significantly from 3% to 57%.[4] The prevalence is especially high in lower socioeconomic populations, likely due to factors such as malnutrition, overcrowding, poor hygiene, limited healthcare access, and recurrent upper respiratory tract infections.[5] According to Gupta A, et al. [6], the prevalence of cholesteatoma in complicated COM cases in India is approximately 65–75%. Kumari MS, et al. (2016) reported that squamous-type CSOM was the most common variant (47.3%), followed by mucosal CSOM (18.5%), acute suppurative otitis media (17.6%), and otitis media with effusion (16.6%).[7] A recent meta-analysis by Bhatia R, et al. (2023) further highlighted the high prevalence of CSOM among Indian children compared to other forms of otitis media.[8] These findings emphasize the need for early diagnosis and prompt surgical management, particularly in suspected cases of cholesteatoma where mastoid exploration is often warranted. Historically, cholesteatoma diagnosis relied on clinical evaluation, otomicroscopy, and conventional imaging such as plain radiographs of the mastoid.[9] However, these modalities have limited sensitivity and are inadequate for assessing soft tissue involvement, lesion size, and concealed spaces like the sinus tympani and facial recess. Consequently, high-resolution computed tomography (HRCT) of the temporal bone has become integral in the preoperative evaluation and surgical planning for cholesteatoma.[10] HRCT offers superior anatomical resolution, enabling accurate visualization of bony erosions, ossicular chain integrity, and disease extent. It plays a pivotal role in surgical decision-making by helping anticipate intraoperative findings and tailoring surgical approaches accordingly. [10–12] However, radiological findings do not always perfectly correlate with intraoperative observations. Establishing a reliable correlation between HRCT and surgical findings is crucial for both otologic surgeons and radiologists to ensure optimal surgical planning and avoid unforeseen complications. [10–12] In this context, the present study aims to evaluate the correlation between pre-operative HRCT findings and intra-operative observations in patients diagnosed with cholesteatoma.

This cross-sectional, observational study was conducted in the Department of ENT at a tertiary care hospital. Written informed consent was obtained from all participants for clinical procedures and inclusion in the study. Ethical clearance was obtained from the Institutional Ethics Committee (IEC) prior to data collection. Patient data were documented using a pre-designed, pre-tested questionnaire. Inclusion criteria consisted of patients clinically diagnosed with chronic otitis media with cholesteatoma presenting with chronic scanty ear discharge and conductive hearing loss. Only those who provided written informed consent were included. Exclusion criteria included patients with a history of prior ear surgery, head trauma, known sensorineural hearing loss, systemic diseases affecting the ear (e.g., collagen vascular or granulomatous diseases), malignancies of the temporal bone/skull base, or history of head and neck radiotherapy. A total of 104 patients fulfil the inclusion and exclusion criteria were enrolled. Diagnosis was established through clinical and radiological evaluation, including a detailed history, otoscopic examination, and relevant laboratory and imaging investigations. Statistical analysis: In the present study, statistical analysis was performed using descriptive and inferential methods. Categorical variables such as age group, gender distribution, and anatomical structures involved were expressed as frequencies and percentages. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of HRCT were calculated by comparing preoperative imaging findings with intraoperative observations, which served as the gold standard. Data were tabulated and analyzed using Microsoft Excel and SPSS software (version 20). Correlation between HRCT and intraoperative findings for various anatomical sites was assessed to determine diagnostic validity. A p-value of less than 0.05 was considered statistically significant wherever applicable.

In the present study, a total of 104 participants were included, with an average age of 36.87 ± 13.70 years, as represented in Table 1. Table no. 1: Demographic and Clinical Profile of Patients with Cholesteatoma Age ( in years) Mean ± SD 36.87 ± 13.70 Gender Male 60 (57.69%) Female 44 (42.31%) Complains Hearing Loss (Total) 95 (91.34%) Ear Discharge 98 (94.23%) Tinnitus 21 (20.19%) Ear Ache 49 (47.11%) Vertigo 26 (25.00%) Facial nerve palsy 4 (3.80%) The above Table 1 shows the demographic and clinical profile of patients with cholesteatoma. The study included 104 patients with a mean age of 36.87 ± 13.70 years and a male predominance (57.69%). Table no. 2: Correlation of Ossicular Erosion on HRCT with Intraoperative Findings in Patients Ossicle Finding CT Intraoperative P value Malleus Eroded 83 90 0.26 Not eroded 21 14 Undefined 0 0 Incus Eroded 90 97 0.16 Not eroded 14 7 Undefined 0 0 Stapes Eroded 14 45 0.01 Not eroded 48 59 Undefined 42 0 According to Table 2, Malleus and incus erosion were identified in 83 and 90 cases on HRCT, which closely matched the intraoperative findings of 90 and 97 cases respectively, showing no significant difference (p = 0.26 and 0.16). Table no. 3: Correlation of HRCT Findings with Intraoperative Observations of Middle Ear Structures in Cholesteatoma Finding HRCT Findings Intraoperative Findings Kappa Coefficient P-value Eroded Superior and Posterior Meatal Wall 17 16 0.891 0.86 Scutum erosion 41 42 0.959 0.91 Tegmen Tympanic erosion 18 17 0.896 0.86 Facial Canal involvement 22 29 0.72 0.32 Lateral Semicircular Canal Erosion 15 21 0.69 0.31 Prussak’s space involvement 86 87 0.902 0.93 In this study, HRCT showed excellent agreement with intraoperative findings for scutum erosion (κ = 0.959, p = 0.91), Prussak’s space involvement (κ = 0.902, p = 0.93), and tegmen tympani erosion (κ = 0.896, p = 0.86). Good correlation was also noted for meatal wall erosion (κ = 0.891). Moderate agreement was observed for facial canal (κ = 0.72) and lateral semicircular canal erosion (κ = 0.69), where HRCT tended to slightly underreport findings, as represented in Table 3. Table no. 4: Comparison of Soft Tissue Involvement on HRCT and Intraoperative Findings in Cholesteatoma Structure Involved HRCT (%) Intraoperative (%) P-value Soft tissue in attic 98 96 0.88 Soft tissue in middle year 76 74 0.87 Aditus 84 82 0.87 Mastoid Antrum and air cells 88 90 0.88 According to Table 4, the presence of soft tissue in the attic was observed in 98% of cases on HRCT and 96% intraoperatively, showing excellent agreement (p = 0.88). This indicates that HRCT reliably identifies the extent of soft tissue involvement in cholesteatoma. Table no. 5 (a): Diagnostic Accuracy of HRCT in Detecting Cholesteatoma Compared with Intraoperative Findings HRCT Impression On Report Intra Op Cholesteatoma Present Intra Op Cholesteatoma Absent Total Reported As Cholesteatoma 64 4 68 Reported As Soft Tissue Mass/ Not Labelled Cholesteatoma 30 6 36 Total 94 10 104 Table no. 5 (b): Diagnostic Accuracy Findings. Diagnostic accuracy Percentage (%) Sensitivity 68.08% Specificity 60.00% Positive Predictive Value (PPV) 94.12% Negative Predictive Value (NPV) 16.67% Accuracy 67.31% Out of 104 cases, HRCT correctly identified 64 cases as cholesteatoma and missed 30 cases, while 4 cases were falsely reported as cholesteatoma. The sensitivity and specificity of HRCT were 68.08% and 60%, respectively, with a high positive predictive value of 94.12% but a low negative predictive value of 16.67%. The overall diagnostic accuracy was 67.31%, indicating that HRCT is a reliable tool for identifying cholesteatoma preoperatively, though it may miss some cases when the disease is limited or atypical, as shown in Table 5 (a) and 5 (b).

In the present study, the highest incidence of cholesteatoma was seen among individuals with a mean age of 36.87 ± 13.70 years, indicating that the condition is most commonly encountered in early to mid-adulthood. This trend is comparable to the findings of Kumar R, et al. (2025), who reported that, 31% of cholesteatoma cases occurred between 31–40 years of age.[13] Similarly, Barati B, et al., (2023) documented a mean age of 32.2 ± 16.1 years, [14] while Rosito LP, et al., in 2017 [15] noted a mean age of 34.49 years, reinforcing that cholesteatoma predominantly affects young to middle-aged adults. A male predominance (57.69%) was observed in this study, consistent with the trends reported by Wilson E, et al., [16] (2025), Bonnard A, et al., [17] (2023), and Im GJ, et al., [18] (2020), all of whom noted a higher prevalence among males. This may be related to greater exposure to environmental or occupational risk factors or differing patterns in healthcare utilization. In terms of clinical presentation, ear discharge (94.23%) and hearing loss (91.34%) were the most frequent symptoms, followed by earache, vertigo, tinnitus, and facial nerve palsy. These findings reflect the chronic and progressive nature of cholesteatoma and align with typical symptom profiles described in earlier studies. Regarding diagnostic performance, the sensitivity and specificity of HRCT in our study were 68.08% and 60%, respectively, with a high PPV of 94.12%. Although these values are lower than the sensitivity of 85.79% and specificity of 89.34% reported in previous literature, they remain comparable to findings from Jahangeer G, et al. (2025), who noted an 80.2% detection rate, and Naveen J, et al., (2019), who reported sensitivity and specificity values of 83.3% and 58.3%.[19,20] The current results are also in agreement with observations by Thukral CL, et al., (2015) [21] and Gomaa MA, et al., (2013) demonstrating that, HRCT provides reasonably accurate preoperative information, although some cholesteatomas may still be missed.[22] Among anatomical findings, scutum erosion was frequently identified (42 cases intraoperatively), consistent with the study by Kumar RA et al., (2025), who observed ossicular erosion in 88% of cases.[13] Erosion of the incus and malleus also showed strong correlation between HRCT and intraoperative findings; however, stapes erosion was significantly underreported on HRCT (14 vs. 45 cases), echoing earlier reports such as Abele et al., (2015), which highlighted the challenge of imaging smaller ossicles.[23] Facial nerve canal involvement and lateral semicircular canal erosion showed moderate agreement between HRCT and intraoperative findings. Facial nerve canal dehiscence, noted intraoperatively in 29 cases in our study, has similarly been documented by Sayit AT et al., (2019) in 54.8% of patients, emphasizing its clinical importance.[24] HRCT demonstrated excellent agreement in assessing tegmen tympani erosion, Prussak’s space involvement, scutum erosion, and soft tissue extension, with kappa coefficients above 0.89. These results further support HRCT as a valuable preoperative tool for delineating disease extent. The diagnostic performance of HRCT in evaluating bone erosion and ossicular status, although variable, aligns with the conclusions of Stefanescu EH, et al. (2023), who emphasized the utility of HRCT in pre-surgical assessment.[25] However, certain limitations must be acknowledged. HRCT showed reduced sensitivity in detecting stapes erosion and facial canal involvement. The study was conducted at a single center with a limited sample size, and inter-observer variations in HRCT interpretation may have influenced the results. Moreover, HRCT cannot reliably differentiate cholesteatoma from granulation tissue or fibrosis, limiting its diagnostic specificity. Future research integrating advanced imaging modalities such as diffusion-weighted MRI may help overcome these limitations and further refine preoperative evaluation strategies.

This study emphasizes, HRCT as an essential preoperative tool for evaluating cholesteatoma, especially in assessing ossicular status, extent of soft tissue involvement, and bony erosions. However, limitations remain in detecting stapes erosion and differentiating cholesteatoma from granulation tissue. The moderate sensitivity and low NPV suggest that HRCT should be interpreted alongside clinical findings and otoscopic assessment. We recommended further studies related to diffusion-weighted MRI which provides superior soft tissue characterization may help overcome these limitations and improve preoperative diagnostic accuracy.

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