Primary cholesteatoma of petrous bone presenting as cervical fistula

Management of Petrous Bone Cholesteatoma: The Gruppo Otologico Experience

BACKGROUND

The term petrous bone cholesteatoma (PBC) refers to lesions extending deep to the bony labyrinth via superior, inferior, and posterior cell tracts. PBC is a rare incidence accounting for only 4-9% of petrous bone lesions. Lesions of petrous bone represent a real surgical challenge due to its complex relationship with critical neurovascular structures.

OBJECTIVE

To demonstrate our 40-plus years' experience in the management of PBC, depict the clinical features of PBC according to Sanna's Classification, evaluate the postoperative follow-up of surgically treated PBC patients, and determine the recurrence rate.

STUDY DESIGN

Retrospective medical record review.

MATERIAL AND METHODS

Medical records of 298 PBC cases operated from the year 1983 to 2024 were thoroughly evaluated.

RESULTS

A total of 298 PBC cases were surgically treated at our center. The average age at presentation in this series was 47 years. Males are more affected than females with a male-to-female ratio of 2.2:1. The most common presenting symptoms were hearing loss (84%), tinnitus (48%), and facial nerve paralysis (45%). Mixed hearing loss (41%) was the commonest audiometric pattern of hearing loss followed by conductive hearing loss (26%) and profound sensorineural hearing loss (4%) and a total of 86 (29%) had anacusis at presentation. On preoperative facial nerve function examination, 133(45%) of patients had various degrees of paresis and complete paralysis whereas 55% had normal HB-I function. The commonest degree of paresis noted was HB-III (18%) followed by HB-VI (5%). A total of 150 (50%) patients had previous otologic surgery and two-thirds of these cases had two or more prior otologic surgeries. According to Sanna's PBC Classification system, we identified that the supralabyrinthine class (44%) is the commonest of all classes followed by massive (33%), infralabyrinthine-apical (9%), infralabyrinthine(8%), and apical (5%) classes in that order. However, only ten patients had congenital type of PBC. Extension to clivus, sphenoid, nasopharynx, intradural space, and occipital condyle was found in 8, 2, 1, and 2 cases respectively. The most commonly used surgical approaches at our center were TO, MTCA with rerouting of the facial nerve, and TLAB with external auditory canal (EAC) closure. Postoperative complications were minimal and the duration of follow-up ranged from one to 458 months with a mean duration of 65 months. Residual lesions were evident in 11 cases (3.7%), with the surgical cavity, middle and posterior fossa dura, and jugular bulb being the commonest sites.

CONCLUSION

Petrous bone cholesteatoma represents diagnostically and surgically challenging lesions of temporal bone which are usually frustrating to the treating surgeon. A high index of clinical suspicion, thorough clinical evaluation examination, and preoperative radiologic evaluation make the diagnosis easier. Preoperative anatomic classification of the lesion enables the physician to choose the appropriate surgical approach. Sanna's classification is widely used to classify PBC in relation to the labyrinthine block. Radical disease removal should always come before hearing preservation. Cavity obliteration is the solution to the problems related to a large cavity. Finally, advancements in lateral skull base approaches create adequate surgical access for the complete removal of the lesion with excellent control of critical neurovascular structures.

Modified Translabyrinthine Approach for Massive Petrous Bone Cholesteatoma Removal and Cochlear Preservation Using Latent Spaces Anterior to the Cochlea

OBJECTIVE

Microsurgery is the reference standard treatment of petrous bone cholesteatoma (PBC). In most cases, radical removal of an extensive PBC can only be achieved at the cost of sacrificing the cochlea. Such treatment will result in the impossibility of future cochlear implantation for hearing rehabilitation purposes. To address this issue, a modification of the traditional translabyrinthine (TL) approach with endoscopic assistance has been developed for radical removal of extensive PBC with preservation of the cochlea.

METHODS

From June 2017 to December 2017, 3 patients with a massive PBC underwent surgical removal using the modified TL approach by the senior author in our department. We reviewed the patient characteristics and retrospectively studied the surgical outcomes and postoperative complications. In the present report, we have described our modified TL approach in detail.

RESULTS

Complete resection of the PBC and successful cochlea preservation were achieved in all 3 patients. No recurrence had developed during the follow-up period. However, various degrees of cochlear ossification were observed in 2 patients postoperatively.

CONCLUSIONS

This modified TL approach provides the possibility of fully exposing the whole petrous apex without removing the cochlea in selected cases. However, the development of long-term cochlear ossification requires further investigation to allow for successful cochlear implantation.

Clinical characteristics of petrosal cholesteatoma and value of MRI-DWI in the diagnosis

Background: Petrosal cholesteatoma is difficult to be diagnosed before operation. MRI-DWI can make the diagnosis more objective and accurate.Objective: Analysis of incidences and clinical characteristics of petrosal cholesteatoma, and the value of MRI-DWI in this disease.Materials and methods: The clinical manifestations, such as gender, hearing loss, vertigo, tinnitus, hemifacial spasm, facial paralysis, diplopia and ear leakage, and some images, such as CT and MRI of 81 patients with petrosal cholesteatoma were collected and analyzed retrospectively. And the Sanna classification of all the cases were also been analyzed.Results: There were 76 cases of hearing loss. There were 16 patients with vertigo; 12 of headache; 23 of tinnitus; 7 of hemifacial spasm; 54 of facial paralysis; 44 of homolateral ear leakage. There were 57 cases of type Supralabyrinthine, 8 of type Infralabyrinthine, 5 of type Apical, 6 of type Infralabytinthine-apical and 5 of type Massive. There were 2 cases of inconsistency between admission diagnosis and discharge diagnosis.Conclusions: The clinical manifestations of petrosal cholesteatoma are various, and sometimes it is difficult to differentiate it from other petrosal lesions. The combining with MRI-DWI and CT examination is necessary and has an advantage.

CONGENITAL CHOLESTEATOMA OF THE TEMPORAL BONE: ISSUES ASSOCIATED WITH ITS ETIOLOGY, DIAGNOSTICS AND TREATMENT (A LITERATURE REVIEW)

This article provides a brief literature review on congenital cholesteatoma of the temporal bone. Existing theories describing the development of this pathology are analysed. The diagnostic criteria of congenital cholesteatoma are presented, along with a comparative analysis of the characteristics of various instrumental research methods used in the verification of this disease. Issues involved with the surgical management of such patients are considered.

A conclusion is made that, due to the rare occurrence of the congenital cholesteatoma of the temporal bone, diverse theories of its etiology, the lack of clear criteria for its diagnostics, this pathology requires further research to elucidate the nature of the disease and identify the risk groups of its occurrence.

Conflict of interest: the authors declare no conflict of interest.

[Sanation of petrous bone cholesteatoma in the otosurgical practice]

The present article reports the clinical cases of the surgical intervention on 20 patients presenting with petrous bone cholesteatoma. We have identified several clinical variants of petrous bone cholesteatoma based on the results of multispiral computed tomography (MSCT) of the temporal bones and categorized them into the following types in accordance with the classification proposed by Moffat-Smith an M. Sanna for this pathological condition: supralabyrinthine (n=8), supralabyrinthine-apical (n=2), infralabyrinthine (n=3), infralabyrinthine-apical (n=5), massive (n=1), and massive - apical (n=1). The surgical sanation of petrous bone cholesteatoma was performed in all the 20 patients in the absence of the pronounced bone destruction in the walls of the temporal bone pyramid and of the subdural expansion of cholesteatoma. In all the cases, the trepanation cavity remained open till its complete epidermization. The follow up period was around 3 years in duration on the average. The post-surgical analysis of the clinical conditions of each of the 20 patients was performed with special reference to the surgical technique applied for the removal of petrous bone cholesteatoma and the final outcome of the radical treatment.

Surgical Strategy and Facial Nerve Outcomes in Petrous Bone Cholesteatoma

Objective: To review the classification and management of petrous bone cholesteatomas (PBCs) at our center and the outcomes of facial nerve (FN) management in these lesions. Methods: This was a retrospective study. The setting was a quaternary referral center for skull base pathology in Italy. A total of 200 patients with 201 PBCs were included in the study. All patients diagnosed radiologically with PBCs were classified according to the Sanna classification. All patients were surgically treated and followed up with radiology. The main outcome measures - classification of PBCs, the surgical approach used, disease control, and FN outcomes - were analyzed. Results: Supralabyrinthine PBCs were the most common type with 92 cases (45.8%) followed by the massive PBCs with 72 cases (35.8%). Preservation of preoperative FN function was highest in the infralabyrinthine (72.2%) and infralabyrinthine-apical (73.3%) types. The transotic approach was used in 66 cases (32.8%) in this series. The modified transcochlear approach type A was applied in 55 cases (27.3%). Active management of the nerve (rerouting, anastomosis, or grafting) was required in 53 cases (26.4%). Postoperatively, of the 116 cases with FN House-Brackmann grade I and II, 107 cases (92.2%) retained the same grade or improved. Recurrence was seen in 7 cases (3.5%). The mean duration of follow-up was 6.3 years. Conclusions: Radical disease clearance must take precedence over hearing and FN preservation in PBCs. Active FN management, including rerouting, end-to-end anastomosis, and cable nerve grafting, routinely come to play in the surgical management of PBCs, and the postoperative FN results after such interventions can be satisfactory in most cases.

Surgical management options and postoperative functional outcomes of petrous apex cholesteatoma

CONCLUSION

In cases of petrous apex (PA) cholesteatoma, radical removal should be prioritized over an unreasonable sparing of hearing or facial symmetry. Nevertheless, for patients with serviceable hearing and spared inner ear structures, conservative approaches may be applicable. Restoration of facial nerve (FN) function is achievable by reanimation procedures.

OBJECTIVES

To analyze clinical manifestations, surgical techniques, and postoperative functional results of PA cholesteatoma.

METHODS

From 1987 to 2010, 13 cases of PA cholesteatoma underwent operations. Clinical, audiological, and radiological findings, surgical approach, and postoperative functional outcomes were analyzed retrospectively.

RESULTS

The most common symptoms were hearing loss and FN paralysis. All PA cholesteatomas extended to the middle ear; 10 (76.9%) through the anterior-superior route, whereas the other 3 (23.1%) were through the posterior-superior route. In 10 patients, labyrinthectomy was inevitable because of inner ear invasion. However, three limited cholesteatomas were removable via the middle cranial fossa or transmastoid approach without changing the bone-conduction threshold. Among six cases with FN paralysis, one underwent interposition graft, two FN decompression, and the others hypoglossal-FN anastomosis. One FN decompression case recovered to House-Brackmann grade I, and all other reanimation cases finally presented with grade IV. There were no major complications or recurrences during the follow-up period.

Management of petrous bone cholesteatoma: open versus obliterative techniques

The objective of this study was to expose our results in the treatment of petrous bone cholesteatomas (PBC), paying attention to diagnosis, surgical strategy, facial management, results, and recurrences. The main objective is to compare the results of obliterative and open techniques in their management concerning the recurrence rate, due to the controversy elicited on obliterative or closed techniques in large cholesteatomas. A retrospective study was performed from July 1977 to September 2007 at the Tertiary referral cranial base center. Thirty-five patients were treated for PBC through different surgical approaches, and in 25 cases (72%) the surgical cavity was obliterated with a muscle flap. Four patients (11%) had a long-term recurrence. These patients received an open technique and after surgical re-exploration using a closed technique they had no recurrence. There were no recurrences in patients who underwent an obliterative technique and they received periodic MRI controls. The facial function after surgery was acceptable (71% of patients had House-Brackmann grades I to III). PBC is a complex pathology and presents difficulties in its diagnosis and treatment. Surgical technique should be suitable for removing the pathology and preventing damage to structures such as the facial nerve or great vessels. Obliterative techniques, where possible, are at least as safe as open cavity procedures and they have fewer postoperative complications; however, regular follow-up with CT and MRI is mandatory.