A Wait and Scan Protocol for Asymptomatic Postsurgical 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- to 18-month intervals. Main outcome measures: Surgery-free survival (SFS) is defined as the time from baseline MRI demonstrating recurrence to surgical intervention. The secondary outcome included the annual lesion growth rate. Results: Thirteen patients were included in the longitudinal analysis with a mean follow-up of 43±17 months. Ten patients (77%) remained surgery-free throughout the 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.