Cholesteatoma is a destructive lesion of the temporal bone characterized by the presence of keratinizing squamous epithelium within the middle ear and mastoid, which leads to progressive bone erosion and potentially serious complications if untreated [1–4]. Although histologically benign, cholesteatoma exhibits locally aggressive behavior, often resulting in ossicular chain erosion, labyrinthine fistula formation, facial nerve canal dehiscence, and intracranial extension [5–7,10–13,15–17,19,20]. Early and accurate diagnosis, along with appropriate surgical planning, is therefore essential to prevent morbidity and improve outcomes. Epidemiologically, cholesteatoma affects individuals across all age groups but has a predilection for young adults, with a slight male predominance and a tendency to present unilaterally [1–4,18]. The epitympanum and mastoid are the most commonly involved sites, and acquired cholesteatoma accounts for the majority of cases, followed by congenital and recurrent types [1–4,18]. Clinically, patients typically present with hearing loss, otorrhoea, otalgia, tinnitus, and, in advanced cases, facial nerve palsy or vertigo, which are indicative of complications such as labyrinthine or facial canal involvement [1–4,18–19]. High-resolution computed tomography (HRCT) of the temporal bone has become the imaging modality of choice for evaluating cholesteatoma due to its ability to accurately depict the extent of disease, assess bony erosions, and identify complications [5–7,10–13,15–17,19,20]. HRCT provides excellent visualization of ossicular chain integrity, scutum, tegmen tympani, sigmoid sinus plate, facial canal, and labyrinthine structures, thereby assisting surgeons in preoperative mapping and intraoperative decision-making. Several studies have demonstrated that HRCT has high sensitivity and specificity (80–100%) for detecting bony erosions, particularly involving the malleus, incus, scutum, and tegmen [5–7,10–13,15–17,19,20]. However, a well-recognized limitation of HRCT is its inability to reliably differentiate cholesteatoma from granulation tissue, fibrosis, or postoperative scarring, as all appear as nonspecific soft tissue densities [8–10,14,20]. In such situations, magnetic resonance imaging (MRI)—particularly non–echo-planar diffusion-weighted imaging (DWI) sequences—serves as a valuable adjunct. MRI is especially useful for detecting residual or recurrent disease and for problem-solving in equivocal cases [8–10,14,20]. Given the potentially severe complications associated with cholesteatoma, such as labyrinthine fistula, facial nerve involvement, sigmoid sinus thrombosis, meningitis, brain abscess, and other intracranial extensions, accurate preoperative imaging evaluation is indispensable [18,19]. The present study was undertaken to evaluate the demographic and clinical profile, HRCT findings,anatomical distribution, bony erosions, and complications in patients with cholesteatoma, and to comparethese results with previously published literature, with the aim of reinforcing the role of HRCT incomprehensive disease assessment and surgical planning.

This was a retrospective, observational study conducted in the Department of Radiodiagnosis, Dr. M.K. Shah Medical College, over a period of 19 months, from 1st January 2022 to 31st July 2023. A total of 50 patients with a confirmed diagnosis of cholesteatoma were included in the study. Diagnosis was established either by surgical confirmation or through clinical and radiological correlation. Demographic details (age, gender, laterality), clinical features, and HRCT findings were retrieved from hospital medical records and the Picture Archiving and Communication System (PACS). Relevant clinical information, including symptom duration, previous surgeries, and presenting complaints, was also documented. HRCT Protocol All patients underwent high-resolution computed tomography (HRCT) of the temporal bone using a standard protocol: Section thickness: < 1 mm axial slices with multiplanar reconstructions (coronal and sagittal planes). Evaluation parameters: Each HRCT scan was systematically assessed for the presence of soft tissue masses, bony erosions involving the scutum, ossicular chain, facial nerve canal, tegmen tympani, and sigmoid sinus plate, as well as mastoid changes and associated complications, including labyrinthine fistula, facial canal dehiscence, sinus thrombosis, and intracranial extension. All images were reviewed by experienced radiologists to ensure consistency in reporting.

In the present study, the age of the patients ranged from 5 to 70 years, with a mean age of 33.0 ± 15.9 years. The maximum number of cases (30%) were observed in the 21–30 years age group, followed by the 31–40 years group (20%) (Table:1). A smaller proportion of patients belonged to the extreme age groups of 0–10 years (6%) and 61–70 years (6%).Out of a total of 50 patients, 30 (60%) were male and 20 (40%) were female, indicating a male preponderance with a male-to-female ratio of 1.5:1. With respect to lesion laterality, the right ear was involved in 30 patients (60%), while the left ear was affected in 15 patients (30%). Bilateral involvement was noted in 5 patients (10%), suggesting a predominantly unilateral distribution with a right-sided dominance. Table 1. Demographic Analysis Parameters Number (%) Age Groups (years) Mean age (33.0 ± 15.9) 0-10 years 3 (6.0%) 11-20 years 7 (14.0%) 21-30 years 15 (30.0%) 31-40 years 10 (20.0%) 41-50 years 7 (14.0%) 51-60 years 5 (10.0%) 61-70 years 3 (6.0%) Gender Male 30 (60%) Female 20 (40%) Laterality of Lesion Left 15 (30%) Right 30 (60%) Bilateral 5 (10%) The most common type of cholesteatoma observed was the acquired type, accounting for 37 cases (74%), followed by congenital cholesteatoma in 11 patients (22%), and recurrent cholesteatoma in 2 patients (4%). A history of previous ear surgery was present in 13 patients (26%), whereas 37 patients (74%) were undergoing surgery for the first time. The mean duration of symptoms prior to presentation was 11.5 ± 12.2 months, with 42% of patients presenting within 6 months, 32% between 6–12 months, and 26% with a history of more than 12 months. The mean size of the cholesteatoma on HRCT was 12.8 ± 6.5 mm. Lesions measuring 10–19 mm were the most common (46%), followed by <10 mm in 38% and ≥20 mm in 16% of cases. These findings suggest that acquired cholesteatoma with relatively short symptom duration and moderate lesion size predominates, while congenital and recurrent cases are less frequent. Table 2. Clinical and HRCT Findings Parameter Category n (%) / Mean ± SD Cholesteatoma Type Acquired 37 (74%) Congenital 11 (22%) Recurrent 2 (4%) Previous Surgery Yes 13 (26%) No 37 (74%) Symptom Duration (months) Mean ± SD 11.5 ± 12.2 < 6 months 21 (42.0%) 6–12 months 16 (32.0%) > 12 months 13 (26.0%) Size (mm) Mean ± SD 12.8 ± 6.5 < 10 mm 19 (38%) 10–19 mm 23 (46%) ≥ 20 mm 8 (16%) Table 3. Anatomical Location Location Frequency (n) Percentage (%) Mesotympanum 19 38.0 Mastoid 18 36.0 Epitympanum 15 30.0 External auditory canal 15 30.0 Hypotympanum 14 28.0 The mesotympanum was the most frequently involved site, seen in 19 patients (38%). This was followed closely by mastoid involvement in 18 patients (36%), epitympanum in 15 patients (30%), external auditory canal in 15 patients (30%), and hypotympanum in 14 patients (28%). These observations indicate that multiple anatomical sites are frequently involved simultaneously, with mesotympanic and mastoid involvement being the most common. Table 4. CT Findings CT Finding Frequency (n) % Facial nerve canal dehiscence 35 70.0 Lateral semicircular canal fistula 27 54.0 Ossicular erosion 26 52.0 Soft tissue mass 24 48.0 Tegmen erosion 18 36.0 Sigmoid sinus plate erosion 18 36.0 Scutum erosion 16 32.0 Mastoid opacification 15 30.0 On HRCT evaluation, facial nerve canal dehiscence was the most frequent finding, observed in 35 patients (70%). This was followed by lateral semicircular canal fistula in 27 patients (54%), ossicular erosion in 26 patients (52%), and soft tissue mass in 24 patients (48%). Tegmen erosion and sigmoid sinus plate erosion were seen in 18 patients each (36%), while scutum erosion was noted in 16 patients (32%) and mastoid opacification in 15 patients (30%). The high frequency of facial nerve canal dehiscence and labyrinthine fistula underscores the aggressive local behavior of cholesteatoma, often causing bony erosions and complications. Table 5. Complications Complication Frequency (n) % Sigmoid sinus thrombosis 8 16.0 Labyrinthine fistula 8 16.0 Intracranial extension 7 14.0 Facial nerve involvement 6 12.0 Meningitis 6 12.0 Brain abscess 6 12.0 Ossicular erosion 6 12.0 Complications were documented in a significant number of patients. Sigmoid sinus thrombosis and labyrinthine fistula were the most commonly observed complications, each seen in 8 patients (16%). Intracranial extension was present in 7 patients (14%), while facial nerve involvement, meningitis, brain abscess, and ossicular erosion were each seen in 6 patients (12%). These data reflect the potential severity and life-threatening nature of advanced cholesteatoma, emphasizing the importance of early detection and intervention (Table 5). Table 6. Clinical Presentation Symptom n % Otalgia 26 52.0 Ear discharge 23 46.0 Tinnitus 22 44.0 Facial weakness 20 40.0 Hearing loss 19 38.0 Vertigo 15 30.0 The most common presenting symptom was otalgia, reported by 26 patients (52%), followed by ear discharge in 23 patients (46%) and tinnitus in 22 patients (44%). Facial weakness was noted in 20 patients (40%), while hearing loss and vertigo were reported in 19 patients (38%) and 15 patients (30%), respectively. This spectrum of clinical presentation is consistent with middle ear disease with possible extension to adjacent structures, often correlating with the CT findings and anatomical involvement. The demographic and clinical profile indicates a young adult male predominance with right-sided acquired cholesteatoma being the most common presentation. HRCT findings provide critical information about lesion size, extent, and complications, guiding surgical planning and prognosis.

The present study analyzed the demographic distribution, clinical features, HRCT characteristics, anatomical extent, CT findings, complications, and clinical presentation of patients with cholesteatoma, and compared the results with published literature. In our study, the mean age of presentation was 33.0 ± 15.9 years, with the 21–30 years age group being the most commonly affected. This age distribution is in concordance with earlier studies that also reported a young adult predominance [1–4,18]. A male preponderance (60%) was observed, which is consistent with prior literature, where male predominance ranged from 55% to 65% [1–4,18]. Most patients presented with unilateral disease, predominantly affecting the right ear, which aligns with previous reports [1–4,18]. The most common presenting symptoms in the present study were otalgia (52%), followed by ear discharge (46%), tinnitus (44%), facial weakness (40%), hearing loss (38%), and vertigo (30%). Similar symptom patterns have been reported in the literature, where hearing loss, otorrhoea, and otalgia were predominant, and facial nerve weakness and vertigo were often associated with advanced disease [1–4,18]. HRCT played a crucial role in evaluating disease extent and bony erosions. In the present series, epitympanum and mesotympanum were the most commonly involved sites, followed by the mastoid, external auditory canal, and hypotympanum, findings consistent with previously published data [5–7,10–13,15–17,19,20]. The majority of cases were of the acquired type (74%), with congenital (22%) and recurrent (4%) cases being less common. The mean lesion size was 12.8 ± 6.5 mm, with most lesions measuring between 10–19 mm. These findings parallel earlier studies, where acquired disease was dominant and lesions frequently involved the epitympanum and mastoid [5–7,10–13,15–17,19,20]. The most common CT finding in our study was facial nerve canal dehiscence (70%), followed by lateral semicircular canal fistula (54%), ossicular erosion (52%), soft tissue mass (48%), tegmen erosion (36%), sigmoid sinus plate erosion (36%), scutum erosion (32%), and mastoid opacification (30%). These observations are consistent with prior studies reporting facial canal dehiscence in 30–70%, ossicular erosion in 50–90%, and tegmen or sigmoid sinus plate erosion in 20–40% of cases [5–7,10–13,15–17,19,20]. Previous literature has documented that HRCT has high sensitivity and specificity (80–100%) for detecting bony erosions, particularly in the ossicular chain, scutum, tegmen, and sigmoid sinus plate [5–7,10–13,15–17,19,20]. These findings highlight the diagnostic accuracy of HRCT for preoperative assessment and surgical planning. In the present study, complications were noted in a significant number of patients. Sigmoid sinus thrombosis and labyrinthine fistula were the most common complications (16% each), followed by intracranial extension (14%), facial nerve involvement, meningitis, brain abscess, and ossicular erosion (each 12%). These findings are comparable to previous studies, which reported complication rates between 10% and 30% for extracranial and intracranial extensions in advanced disease [18,19]. Despite the high diagnostic performance of HRCT, differentiating cholesteatoma from granulation tissue or postoperative scarring remains a challenge. In such cases, MRI with diffusion-weighted imaging (DWI) serves as an essential adjunct, especially for evaluating residual or recurrent disease, and for preoperative assessment in equivocal soft tissue lesions [8–10,14,20].

The findings of the present study are consistent with published literature. Cholesteatoma typically affects young adults, with a male predominance and unilateral epitympanic/mastoid involvement. HRCT reliably identifies the extent of disease, ossicular and bony erosions, and complications, playing a critical role in surgical planning and prognosis. The addition of MRI (DWI) further enhances diagnostic confidence, especially in postoperative or ambiguous soft tissue cases.

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