Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients

Clinical article

Restricted access

Object

The aim of this study was to report the results in a consecutive series of patients who had undergone an endoscopic endonasal approach (EEA) for drainage of a petrous apex cholesterol granuloma (CG).

Methods

Seventeen cases with a confirmed diagnosis of petrous apex CG were identified from a database of more than 1600 patients who had undergone an EEA to skull base lesions at the authors' institution in the period from 1998 to 2011. Clinical outcomes were reviewed and compared with those in previous studies of open approaches.

Results

Nine patients underwent a transclival approach and 8 patients underwent a combined transclival and infrapetrous approach. A Silastic stent was used in 11 patients (65%), a miniflap in 4 (24%), and a simple marsupialization of the cyst in 3 (18%). All symptomatic patients had partial or complete improvement of their symptoms postoperatively and at the follow-up (mean follow-up 20 months, range 3–67 months). Complications developed in 3 patients (18%) including epistaxis, chronic serous otitis media, eye dryness, and a transient sixth cranial nerve palsy. Two patients (12%) had a symptomatic recurrence of the cyst requiring repeat endoscopic endonasal drainage. There were no instances of internal carotid artery injuries, CSF leaks, or new hearing loss. The mean postoperative hospital stay was 2 days (range 0.7–4.6 days). These results were comparable with those in previous studies of open approaches to petrous apex CGs.

There was a strong correlation between the size of the cyst and the type of approach chosen (Rpb [point biserial correlation coefficient] = +0.67, p = 0.003359) and a very strong correlation between the degree of medial extension (defined by the V-angle) and the choice of approach (Rpb = +0.81, p < 0.0001). Based on these observations, the authors developed an algorithm for guiding the choice of the most appropriate route of drainage.

Conclusions

The EEA is a safe and effective alternative to traditional open approaches to petrous apex CGs.

Article Information

Address correspondence to: Alessandro Paluzzi, M.D., F.R.C.S.(SN), Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: apaluzzi@doctors.org.uk.

Please include this information when citing this paper: published online January 6, 2012; DOI: 10.3171/2011.11.JNS111077.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative pictures showing steps in an EEA for removal of a petrous apex CG. A: Transclival approach to the petrous apex. The CG is visible medial and posterior to the paraclival ICA. B: The CG has been punctured and its typical content discharged into the operating field. C: The solid wall of the “cyst” can be removed through gentle suction. D: View into the CG cavity with a 45° angled endoscope. E: A Silastic tube has been inserted into the CG cavity after drainage. F: The nasal mucoperiosteal flap has been harvested and rotated to cover the clivus; a small portion of the flap (miniflap) has been used to line the CG cavity (dotted line).

  • View in gallery

    Type A CG. A: Axial postcontrast T1-weighted MR image showing a CG. B: Axial postcontrast T1-weighted MR image showing measurement of the V-angle. The angle reflects the “aperture” of the CG as viewed from a 0° endoscope resting on the most lateral point of the pyriform aperture. C: Coronal postcontrast T1-weighted MR image showing the same CG. D: Schematic representing the Type A CG. E: Endoscopic view (0°) of a cadaveric specimen demonstrating the position of the CG in relation to the carotid artery (dotted circle). F: Postoperative CT scan with bone window showing the bone removed during the transclival approach.

  • View in gallery

    Type B CG. A: Axial CT angiogram showing a laterally located CG. B: Axial CT angiogram showing a V-angle that does not favor a simple transclival approach. C: Coronal CT reconstruction showing the CG inferior to the petrous ICA and medial to the parapharyngeal ICA. D: Schematic demonstrating a Type B CG. E: A 45° endoscopic view of the CG (dotted line) in a cadaveric specimen. F: Postoperative CT scan with bone window showing the bone removed during the transclival and infrapetrous approach without dissection of the eustachian tube.

  • View in gallery

    Type C CG. A: Axial CT angiogram demonstrating a small, very lateral CG. B: Axial CT angiogram showing a negative V-angle; the cyst is completely hidden behind the petrous horizontal ICA. C: Coronal CT reconstruction showing how close the CG is to the parapharyngeal ICA. D: Schematic showing a Type C CG. E: Endoscopic view (45°) of the lesion (dotted circle) in a cadaveric specimen. F: Postoperative CT scan with bone window obtained after an infrapetrous approach requiring eustachian tube transection, showing the extreme lateral extension of the endonasal approach.

References

1

Bockmühl UKhalil HSDraf W: Clinicoradiological and surgical considerations in the treatment of cholesterol granuloma of the petrous pyramid. Skull Base 15:2632682005

2

Bootz FKeiner SSchulz TScheffler BSeifert V: Magnetic resonance imaging—guided biopsies of the petrous apex and petroclival region. Otol Neurotol 22:3833882001

3

Brackmann DEToh EH: Surgical management of petrous apex cholesterol granulomas. Otol Neurotol 23:5295332002

4

Brodkey JARobertson JHShea JJ IIIGardner G: Cholesterol granulomas of the petrous apex: combined neurosurgical and otological management. J Neurosurg 85:6256331996

5

Cristante LPuchner MA: A keyhole middle fossa approach to large cholesterol granulomas of the petrous apex. Surg Neurol 53:64712000

6

Dhanasekar GJones NS: Endoscopic trans-sphenoidal removal of cholesterol granuloma of the petrous apex: case report and literature review. J Laryngol Otol 125:1691722011

7

Eisenberg MBHaddad GAl-Mefty O: Petrous apex cholesterol granulomas: evolution and management. J Neurosurg 86:8228291997

8

Fucci MJAlford ELLowry LDKeane WMSataloff RT: Endoscopic management of a giant cholesterol cyst of the petrous apex. Skull Base Surg 4:52581994

9

Gallia GReh D: Expanded endonasal endoscopic approach to the petrous apex. Otolaryngol Head Neck Surg 143:Suppl 2P281P2822010. (Poster) (http://oto.sagepub.com/content/143/2_suppl/P281.3.full) [Accessed November 18 2011]

10

Georgalas CKania RGuichard JPSauvaget ETran Ba Huy PHerman P: Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex. Clin Otolaryngol 33:38422008

11

Griffith AJTerrell JE: Transsphenoid endoscopic management of petrous apex cholesterol granuloma. Otolaryngol Head Neck Surg 114:91941996

12

Jaberoo MCHassan APulido MASaleh HA: Endoscopic endonasal approaches to management of cholesterol granuloma of the petrous apex. Skull Base 20:3753792010

13

Jackler RKCho M: A new theory to explain the genesis of petrous apex cholesterol granuloma. Otol Neurotol 24:961062003

14

Jaramillo MWindle-Taylor PCJ: Large cholesterol granuloma of the petrous apex treated via subcochlear drainage. J Laryngol Otol 115:100510092001

15

Mattox DE: Endoscopy-assisted surgery of the petrous apex. Otolaryngol Head Neck Surg 130:2292412004

16

Montgomery WW: Cystic lesions of the petrous apex: transsphenoid approach. Ann Otol Rhinol Laryngol 86:4294351977

17

Moore KRHarnsberger HRShelton CDavidson HC: ‘Leave me alone’ lesions of the petrous apex. AJNR Am J Neuroradiol 19:7337381998

18

Mosnier ICyna-Gorse FGrayeli ABFraysse BMartin CRobier A: Management of cholesterol granulomas of the petrous apex based on clinical and radiologic evaluation. Otol Neurotol 23:5225282002

19

Nager GTVanderveen TS: Cholesterol granuloma involving the temporal bone. Ann Otol Rhinol Laryngol 85:2042091976

20

Oyama KIkezono TTahara SShindo SKitamura TTeramoto A: Petrous apex cholesterol granuloma treated via the endoscopic transsphenoidal approach. Acta Neurochir (Wien) 149:2993022007

21

Prabhu KKurien MChacko AG: Endoscopic transsphenoidal approach to petrous apex cholesterol granulomas. Br J Neurosurg 24:6886912010

22

Presutti LVillari DMarchioni D: Petrous apex cholesterol granuloma: transsphenoid endoscopic approach. J Laryngol Otol 120:e202006

23

Sanna MDispenza FMathur NDe Stefano ADe Donato G: Otoneurological management of petrous apex cholesterol granuloma. Am J Otolaryngol 30:4074142009

24

Snyderman CHKassam ABCarrau RMintz A: Endoscopic approaches to the petrous apex. Op Tech Otolaryngol 17:1681732006

25

Zanation AMSnyderman CHCarrau RLGardner PAPrevedello DMKassam AB: Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 119:19252009

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 92 92 39
Full Text Views 197 197 13
PDF Downloads 116 116 7
EPUB Downloads 0 0 0

PubMed

Google Scholar