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AJR 2005; 185:788-789
© American Roentgen Ray Society

Case Report

MRI of Acquired Cholesteatoma Presenting as a Temporal Lobe Mass

Eoin C. Kavanagh1, David M. Fenton1, Donald Griesdale2 and Douglas A. Graeb1

1 Department of Neuroradiology, Vancouver General Hospital, 855 West 12th Ave., Vancouver, BC, Canada V5Z 1M9.
2 Department of Neurosurgery, Vancouver General Hospital, Vancouver, BC, Canada.

Received August 25, 2004; accepted after revision September 30, 2004.

 
Address correspondence to E. C. Kavanagh (eoinkav{at}yahoo.com).


Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Intracranial extension of acquired cholesteatoma is a rare occurrence [1, 2]. We describe a case of recurrent acquired cholesteatoma presenting as an intraaxial temporal lobe mass.



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  		Fig. 1A —65-year-old man with recurrent acquired cholesteatoma. Axial T2-weighted image shows lobulated right temporal lobe mass with whorled appearance.

 

Case Report
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 Introduction
 Case Report
Discussion
 References
 
A 65-year-old man presented with headaches and new-onset seizures. The patient had been involved in a motor vehicle accident in 1959, during which he suffered a skull base fracture. In 1985, the patient presented with hearing loss and was diagnosed with a right middle ear cholesteatoma. Radiological investigation revealed extension through the petrous apex and the patient underwent a middle fossa craniotomy with resection of the cholesteatoma. Postoperatively, the patient developed a CSF leak. In 1987, the patient underwent a complete right-sided mastoidectomy for recurrent cholesteatoma.

Investigation on this presentation included an MRI brain scan, which revealed a large right-sided intraaxial temporal lobe mass (Figs. 1A, 1B, 1C, and 1D). The mass was lobulated and of mixed signal intensity on T1- and T2-weighted sequences, with a whorled appearance. Partial enhancement was noted after administration of gadolinium. Diffusion-weighted imaging showed restricted diffusion within the tumor. The patient underwent a middle fossa craniotomy, which revealed an intraaxial temporal lobe mass with a scaly and shiny white appearance. The mass was noted to extend into the temporal horn of the right lateral ventricle. The mass was completely excised and histology revealed recurrent cholesteatoma. Postoperatively, the patient made a good recovery and remains on carbamazepine, 700 mg daily, for seizure control.



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  		Fig. 1B —65-year-old man with recurrent acquired cholesteatoma. Sagittal T1-weighted image after gadolinium administration shows partially enhancing mass in right temporal lobe.

 


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  		Fig. 1C —65-year-old man with recurrent acquired cholesteatoma. Coronal T1-weighted image after gadolinium administration shows partially enhancing mass in right temporal lobe, in direct continuity with similar-appearing tissue in right middle ear (arrow).

 


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  		Fig. 1D —65-year-old man with recurrent acquired cholesteatoma. Axial diffusion-weighted image shows restricted diffusion within tumor mass.

 

Discussion
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 Introduction
 Case Report
 Discussion
References
 
Acquired cholesteatoma consists of epithelial debris that results from ingrowth of keratinizing squamous epithelium from the external ear and outer lining of the tympanic membrane [2]. Treatment of acquired cholesteatoma is surgical. Intracranial acquired cholesteatoma can develop secondary to trauma or secondary to acquired aural cholesteatoma, extending beyond the middle ear into the middle or posterior cranial fossae, with the supratubal recess the most common site of spread [1]. Typically these tumors are extraaxial in location [2]. Diffusion-weighted MRI can be used to distinguish between recurrent cholesteatoma and granulation tissue [3]. Similar to epidermoid tumors, recurrent or residual cholesteatoma typically shows hyperintensity on diffusion-weighted imaging because of a combination of T2 shine-through and restricted diffusion [4]. The restricted diffusion occurs for unknown reasons [3].

We conclude that acquired intracranial cholesteatoma can present as an intraaxial temporal lobe mass. A whorled appearance and restricted diffusion may aid in the differential diagnosis of such tumors.


References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. Horn KL. Intracranial extension of acquired aural cholesteatoma. Laryngoscope 2000;110 : 761-772[Medline]
  2. Ishii K, Takahashi S, Matsumoto K, et al. Middle ear cholesteatoma extending into the petrous apex: evaluation by CT and MR imaging. AJNR 1991; 12:719 -724[Abstract]
  3. Aikele P, Kittner T, Offergeld C, Kaftan H, Huttenbrink B, Laniado M. Diffusion-weighted MR imaging of cholesteatoma in pediatric and adult patients who have undergone middle ear surgery. AJR2003; 181:261 -265[Abstract/Free Full Text]
  4. Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weighted MR imaging of the brain. Radiology 2000;217 : 331-345[Abstract/Free Full Text]

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