The Role of Stepwise Imaging in the Diagnosis and Management of Cholesteatoma in a Resource-Limited Setting: A Case Report.

Background: Cholesteatoma is a non-neoplastic but destructive lesion of the temporal bone that can lead to significant complications if not accurately diagnosed and managed. While computed tomography (CT) is the standard for assessing bony erosion, its ability to differentiate cholesteatoma from inflammatory tissue is limited. Non-echo planar diffusion-weighted magnetic resonance imaging (non-EPI DWI MRI) offers high specificity for diagnosing cholesteatoma. In resource-limited settings, access to MRI is often restricted, making a stepwise, evidence-based imaging approach crucial. Case Presentation: A 26-year-old male presented with a decade-long history of chronic, foul-smelling left ear discharge and progressive hearing loss. Clinical examination was suspicious for a left-sided cholesteatoma. An initial non-contrast CT scan revealed a soft tissue mass with significant erosion of the scutum and ossicular chain. To confirm the diagnosis, a subsequent non-EPI DWI MRI was performed, which demonstrated a well-defined lesion with restricted diffusion, characteristic of cholesteatoma. The MRI also identified contralateral otomastoiditis in the right ear without evidence of cholesteatoma. Based on this definitive diagnosis, the patient underwent a left-sided canal wall down mastoidectomy. Conclusion: This case highlights the pivotal role of a stepwise imaging strategy in a resource-limited environment. While CT identified the extent of bony destruction, the selective use of non-EPI DWI MRI provided a definitive diagnosis, confidently guiding the surgical plan towards an eradicative procedure. This approach ensures appropriate management, prevents potential complications, and underscores the value of integrating advanced diagnostics judiciously when resources are scarce.