From Scan to Surgery: Evaluating High-Resolution Computed Tomography (HRCT) and Diffusion-Weighted Magnetic Resonance Imaging (DWI) Accuracy in Detecting Cholesteatoma

Background Cholesteatoma is a destructive middle ear lesion that frequently leads to bone erosion and complications if not detected early. Accurate imaging is crucial for timely diagnosis and effective surgical planning. High-resolution computed tomography (HRCT) provides excellent anatomical detail, particularly for detecting bony erosions, but it is limited in differentiating cholesteatoma from granulation tissue. Diffusion-weighted magnetic resonance imaging (DWI) has emerged as a non-invasive modality with strong potential for improving diagnostic accuracy. This study aimed to assess the diagnostic performance of HRCT and DWI in identifying cholesteatoma, correlating imaging findings with histopathological examination (HPE) as the gold standard. Methods A cross-sectional study was conducted in a tertiary care hospital over 18 months, including 47 patients aged 10-60 years with suspected middle ear lesions. All patients underwent HRCT and DWI, and findings were correlated with HPE results. Clinical and demographic characteristics were analyzed, and diagnostic parameters, including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, were calculated. Results Among the 47 patients, 40 (85.1%) were confirmed to have cholesteatoma on HPE. DWI demonstrated perfect diagnostic performance, correctly identifying all 40 cholesteatoma cases and 7 non-cholesteatoma cases, with 100% sensitivity, specificity, PPV, and NPV. HRCT detected bone erosion in 37 patients (78.7%) and demonstrated high sensitivity (91.9%, 34/37) and diagnostic accuracy (80.9%), but specificity was relatively low (40%, 4/10), with moderate NPV (57.1%, 4/7). False positives on HRCT occurred in 6 non-cholesteatoma cases, highlighting its limitations in differentiating soft tissue lesions. Conclusion DWI outperformed HRCT in diagnosing cholesteatoma, accurately distinguishing it from postoperative changes and nonspecific inflammatory tissue. While HRCT remains indispensable for assessing bony involvement and surgical mapping, combining HRCT with DWI offers a comprehensive, highly accurate diagnostic approach, improving clinical decision-making, reducing unnecessary second-look surgeries, and optimizing patient outcomes.