Detection of postoperative cholesteatoma with non-echo-planar diffusion-weighted MRI: diagnostic performance and follow-up, a systematic review

Abstract

Cholesteatoma is a benign but locally destructive lesion of the middle ear and mastoid treated surgically, with a well-recognized risk of postoperative recurrence. This systematic review evaluated the diagnostic performance of non-echo-planar diffusion-weighted magnetic resonance imaging (non-EPI DWI) in detecting postoperative recurrences and assessed variability in follow-up protocols. A systematic search was conducted in Embase, Scopus, PubMed, CINAHL, the Cochrane Library, and SciELO for studies published between 2000 and November 2025, following PRISMA guidelines. Eligible studies included postoperative cholesteatoma patients undergoing follow-up with non-EPI DWI and reporting diagnostic performance and/or follow-up characteristics. Out of the 115 identified articles, 9 studies involving 931 patients met the inclusion criteria. Non-EPI DWI demonstrated high specificity (90–100%) and variable sensitivity (59–100%). Positive predictive values ranged from 93 to 100%, while negative predictive values ranged from 53 to 91.7%. Detection of cholesteatomas smaller than 2–3 mm was limited across studies. Follow-up duration varied widely from 1 to 31.6 years, and recurrences were identified both early and late, up to 7.5 years postoperatively. Marked heterogeneity was observed in imaging protocols and follow-up schedules. Non-EPI DWI demonstrates consistently high specificity and variable sensitivity for detecting postoperative cholesteatoma recurrence, particularly for lesions larger than 2–3 mm. However, substantial heterogeneity across studies limits definitive conclusions regarding optimal surveillance strategies. These findings highlight the need for standardized imaging protocols and long-term follow-up tailored to surgical technique and patient risk profile.