A Wait and Scan Protocol for Asymptomatic Post-Surgical Cholesteatoma Recurrence: A Novel Management Strategy

Objective
To evaluate the feasibility and safety of active MRI surveillance as an alternative to immediate surgical re-exploration in patients with small, asymptomatic postoperative cholesteatoma recurrence.

Study Design
Prospective single arm pilot study.

Setting
Secondary referral otology center.

Patients
Patients with prior cholesteatoma surgery demonstrating postoperative recurrence ≤5 mm on non–echo-planar diffusion-weighted MRI without otologic symptoms, suspicious findings on otoscopy for cholesteatoma or radiologic proximity to critical structures.

Intervention
Structured active surveillance with serial non–echo-planar diffusion-weighted MRI scans at 12–18 month intervals.

Main Outcome Measures
Surgery-free survival (SFS), defined as time from baseline MRI demonstrating recurrence to surgical intervention. Secondary outcome included annual lesion growth rate.

Results
Thirteen patients were included in longitudinal analysis with a mean follow-up of 43 ± 17 months. Ten patients (77%) remained surgery-free throughout surveillance. Three patients (23%) required surgical intervention due to lesion enlargement or symptom development. The mean lesion growth rate was 0.32 ± 1.0 mm/year. Three patients (23%) demonstrated spontaneous radiologic regression during follow-up. Kaplan–Meier analysis demonstrated cumulative SFS of 100% at 24 months and 91% (95% CI, 74–100) at 36 months.

Conclusions
In selected patients with small, asymptomatic postoperative cholesteatoma recurrence, active MRI surveillance may safely defer surgical re-exploration. These findings support further prospective evaluation of imaging-guided surveillance strategies for the management of MRI-detected recurrence.