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Hanai K, Hashimoto M, Nakamura H. Unilateral expanding petrous apex cephalocele and contralateral vitreous hemorrhage in a young patient with intracranial hypertension. Am J Ophthalmol Case Rep 2022; 25:101368. [PMID: 35146212 PMCID: PMC8818526 DOI: 10.1016/j.ajoc.2022.101368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 10/29/2022] Open
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Dedhia K, Marchica C, Mattox D. Unilateral Facial Paralysis in the Pediatric Patient. Cureus 2021; 13:e12701. [PMID: 33614309 PMCID: PMC7883570 DOI: 10.7759/cureus.12701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Unilateral facial paralysis (FP) in the pediatric population is a rare entity secondary to multiple etiologies including infectious, vascular, and neoplastic. In persistent or recurrent FP, imaging can demonstrate a peripheral facial nerve (FN) lesion. Given the rarity of FN lesions, however, there is limited literature regarding optimal management. In this case series, we describe the presentation, evaluation, and management of unilateral FP in three pediatric patients along with a review of the literature. All patients presented with complete FP due to a peripheral FN lesion or compression of the FN. A combined mastoid and middle cranial fossa approach was utilized for excision in two cases, and the other child underwent a translabyrinthine approach. The pathology of the lesions revealed a meningioma, an arachnoid cyst, and a hemangioma. Presentation, evaluation, post-operative outcomes, as well as final pathologies are discussed.
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Affiliation(s)
- Kavita Dedhia
- Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, USA
| | | | - Douglas Mattox
- Otolaryngology, Emory University School of Medicine, Atlanta, USA
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Li KL, Agarwal V, Moskowitz HS, Abuzeid WM. Surgical approaches to the petrous apex. World J Otorhinolaryngol Head Neck Surg 2020; 6:106-114. [PMID: 32596655 PMCID: PMC7296478 DOI: 10.1016/j.wjorl.2019.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/27/2019] [Indexed: 11/18/2022] Open
Abstract
The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures. Petrous apex pathology ranges from extradural cholesterol granulomas, cholesteatomas, asymmetric pneumatization, and osteomyelitis to intradural meningiomas and schwannomas. Certain lesions, such as cholesterol granulomas, can be managed with drainage while neoplastic lesions must be completely resected. Surgical options use open, endoscopic, and combined techniques and are categorized into anterior, lateral, and posterior approaches. The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient. The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex, and the anatomy on which these approaches are based.
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Affiliation(s)
- Kevin L Li
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Vijay Agarwal
- Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Howard S Moskowitz
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
Case summary A 14-year-old neutered female Burmese cat was referred for investigation of a caudal oropharyngeal mass. CT showed a thin walled cyst-like structure filling and expanding from the right tympanic bulla. Histopathology showed fragments of mildly dysplastic squamous epithelium and aggregates of keratin. These findings were considered consistent with a diagnosis of cholesteatoma. Relevance and novel information To the best of our knowledge, this is the first reported case of a cholesteatoma in a cat. Cholesteatoma should be considered a differential diagnosis for cats presenting with a caudal oropharyngeal mass, a history of chronic ear disease or a history of previous, surgically managed middle ear disease. Advanced imaging and biopsies should be considered important in the diagnosis of these lesions.
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Bruchhage KL, Wollenberg B, Leichtle A. Transsphenoidal and infralabyrinthine approach of the petrous apex cholesterol granuloma. Eur Arch Otorhinolaryngol 2017; 274:2749-2756. [PMID: 28474189 DOI: 10.1007/s00405-017-4593-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
Abstract
Space-demanding or destructive changes in the petrous bone are often challenging differential diagnosis. Cholesterol granulomas of the petrous apex can clinically present in a combination of hearing loss, vertigo, tinnitus, chronic cephalgia, impairment of facial nerve function, neuralgic pain of the nervus trigeminus, or manifest diplopia by the nerve palsy of the nervus abducens. CT-morphologically cholesterol granulomas appear as soft-tissue density masses, which may display a discrete rim after intravenous administration of a contrast agent. The MRI, T1 as well as T2-weighted images show a strong signal in the area of the lesion. Depending on the individual anatomical conditions, the surgical access must be carefully chosen between transsphenoidal, transtemporal, infracochlear/-labyrinthine, or translabyrinthine. Here, we present the transsphenoidal and translabyrinthine access for the excision of cholesterol granulomas of the petrous apex. The different accesses are compared using a neuro-navigation-supported surgical technique with respect to its complications, drainage possibilities, outcomes, and recurrence of symptoms.
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Affiliation(s)
- Karl-Ludwig Bruchhage
- Department of Otolaryngology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Barbara Wollenberg
- Department of Otolaryngology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Anke Leichtle
- Department of Otolaryngology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Pross SE, Uribe Cardenas R, Ahn ES, Matthew Stewart C. Recurrent meningitis in a child with bilateral cochlear implantation associated with a petrous apex encephalocele: a case report and literature review. ACTA OTO-LARYNGOLOGICA CASE REPORTS 2016. [DOI: 10.1080/23772484.2016.1193426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Boppel T, Bendszus M, Bartsch AJ. Excavating Meckel's cave: Cavum-trigeminale-cephaloceles (CTCs). J Neuroradiol 2015; 42:156-61. [PMID: 25857688 DOI: 10.1016/j.neurad.2015.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 01/07/2015] [Accepted: 02/23/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cavum-trigeminale-cephaloceles (CTCs) are rare lesions of Meckel's cave and the petrous apex. Despite distinctive imaging features, they are frequently mistaken for other petrous apex lesions. In contrast to many of these entities, CTCs do--when asymptomatic--not require any invasive work-up or even surgical excision. Since correct diagnosis has profound impact on clinical decision-making, we report on a series of CTCs with distinct imaging features and their important differential diagnoses. MATERIAL AND METHODS We report a retrospective series of 5 patients with CTCs and the associated imaging features including the absence of diffusion restriction and solid contrast enhancement as well as their size, anatomical location with regard to adjacent structures and the remodeling or erosion of surrounding bony structures. RESULTS Our series contains the largest CTC that has, to the best of our knowledge, been reported so far. It revealed a deep cervical extension and was initially mistaken for a branchial cleft cyst. Furthermore, we show that CTCs can erode or remodel important structures such as canalis nervi hypoglossi, canalis Vidiani, foramen rotundum, ovale, lacerum and spinosum without causing clinical symptoms. CONCLUSION In contrast to previous reports in which asymptomatic CTC did not include critical structures such as the foramina rotundum, ovale, lacerum or spinosum or the hypoglossal or Vidian canal, we show that CTCs can be asymptomatic even when eroding or remodeling such clinically important structures. When extending below the skull base, CTCs are a rare differential diagnosis to cystic cervical lesions such as type II branchial cleft cysts.
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Affiliation(s)
- Tobias Boppel
- Department of Neuroradiology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Andreas J Bartsch
- Department of Neuroradiology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; FMRIB Centre, Department of Clinical Neurology, University of Oxford, Oxford, UK
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Çavusoglu M, Duran S, Hatipoglu HG, Ciliz DS, Elverici E, Sakman B. Petrous apex cephalocoele: contribution of coexisting intracranial pathologies to the aetiopathogenesis. Br J Radiol 2015; 88:20140721. [PMID: 25651410 DOI: 10.1259/bjr.20140721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to show the MRI findings of petrous apex cephalocoele (PAC) and the other intracranial pathologies that coexist with PAC, and to discuss the contribution of the co-existing pathologies to aetiopathogenesis. METHODS A retrospective analysis of our imaging archive for the period from January 2012 to October 2013 revealed 13 patients with PAC (12 females and 1 male; age range, 26-69 years). 11 patients underwent MRI examination of the cranium, and 2 patients underwent MRI examination of the sellar region. We evaluated the lesions for content, signal intensity, enhancement, relation to petrous apex and Meckel's cave. Images were also evaluated for coexisting pathologies. RESULTS The presenting symptoms included headache, vertigo, cerebrospinal fluid (CSF) leak and trigeminal neuropathy. All patients had PAC. All lesions were located posterolateral to the Meckel's cave and were isointense with CSF signal on all pulse sequences. All lesions were continuous with Meckel's cave. Coexisting pathologies included intracranial aneurysmal dilatation, empty sella, mass in hypophysis, arachnoid cyst, inferior herniation of parahippocampal gyrus and optic nerve sheath CSF distension. CONCLUSION Coexistence with other intracranial pathologies supports the possibility of CSF imbalance and/or intracranial hypertension in the aetiopathogenesis of PAC. ADVANCES IN KNOWLEDGE This study examined the contribution of the co-existing intracranial pathologies to the aetiopathogenesis of PAC.
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Affiliation(s)
- M Çavusoglu
- Department of Radiology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Razek AA, Huang BY. Lesions of the petrous apex: classification and findings at CT and MR imaging. Radiographics 2012; 32:151-73. [PMID: 22236899 DOI: 10.1148/rg.321105758] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The petrous apex is a complex region of the central skull base that is surrounded by a number of important vascular and neural structures and can be home to a wide range of disease processes. Lesions arising in or spreading to the petrous apex cause varied and occasionally severe clinical sequelae, which typically result from mass effect or direct invasion of the cranial nerves, brainstem, or internal carotid artery. Because the petrous apex is not amenable to direct examination, cross-sectional imaging with computed tomography and magnetic resonance (MR) imaging plays an important role in diagnosis and characterization of lesions occurring there. Petrous apex lesions can be classified on the basis of their origin into the following categories: developmental lesions, inflammatory lesions, benign tumors, malignant tumors, vascular lesions, and osseous dysplasias. The most common lesions arising in the petrous apex are cholesterol granulomas, which can be reliably diagnosed with MR imaging due to their high signal intensity on both T1-weighted images and T2-weighted images. In addition, one should also be familiar with anatomic variants or pseudolesions in the petrous apex that can be mistaken for pathologic conditions.
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Affiliation(s)
- Ahmed Abdel Razek
- Department of Diagnostic Radiology, Mansoura Faculty of Medicine, Mansoura, Egypt
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Goiney C, Bhatia R, Auerbach K, Norenberg M, Morcos J. Intraosseous schwannoma of the petrous apex. J Radiol Case Rep 2011; 5:8-16. [PMID: 22470769 DOI: 10.3941/jrcr.v5i11.859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Primary neoplasms of the petrous apex are rare and include eosinophilic granuloma, chondroma, chondrosarcoma, chordoma, and schwannoma. We report just the second published case of an intraosseous schwannoma of the petrous apex and are the first to describe the entity using magnetic resonance imaging. By studying the computed tomography and magnetic resonance imaging features of this rare tumor, it is possible to suggest the diagnosis preoperatively.
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Affiliation(s)
- Christopher Goiney
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA.
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González-García JA, Trinidad A, Verdaguer JM, García-Berrocal JR, Ramírez-Camacho R. [Radiological diagnostic of the non-pathological conditions of the petrous apex]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2009; 60:346-51. [PMID: 19814987 DOI: 10.1016/j.otorri.2009.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 05/07/2009] [Indexed: 11/18/2022]
Abstract
Many patients with otological symptoms are remitted to the otolaryngology outpatient clinics every day. These patients commonly undergo imaging studies, generally magnetic resonance imaging (MRI). In some cases, a positive unilateral result is found in the form of a potentially pathological signal that can be observed in the petrous apex region. We present the cases of 6 patients (aged between 26 and 62 years) with asymmetric bone marrow distribution or trapped mucous fluid secretions in the petrous apex, collected over a 6-year period. Diagnosis was made with the use of CT scans and MRI. All of the patients were referred for skull base surgery. In all cases a non-pathologic asymmetry was diagnosed in the petrous apex. Certain non-pathologic conditions of the petrous apex must be treated expectantly without any surgery.
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Affiliation(s)
- José Angel González-García
- Servicio de Otorrinolaringología, Instituto Oncológico Kutxa-Onkologikoa, San Sebastián, Guipúzcoa, España.
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González-García JÁ, Trinidad A, María Verdaguer J, García-Berrocal JR, Ramírez-Camacho R. Radiological diagnostic of the non-pathological conditions of the petrous apex. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2009. [DOI: 10.1016/s2173-5735(09)70155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Spontaneous Resolution of a Meckel's Cave Arachnoid Cyst Causing Sixth Cranial Nerve Palsy. J Neuroophthalmol 2008; 28:186-91. [DOI: 10.1097/wno.0b013e318183be6c] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leonetti JP, Anderson DE, Marzo SJ, Origitano TC, Schuman R. The Preauricular Subtemporal Approach for Transcranial Petrous Apex Tumors. Otol Neurotol 2008; 29:380-3. [DOI: 10.1097/mao.0b013e31816021a3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alkilic-Genauzeau I, Boukobza M, Lot G, George B, Merland JJ. [CT and MRI features of arachnoid cyst of the petrous apex: report of 3 cases]. ACTA ACUST UNITED AC 2007; 88:1179-83. [PMID: 17878880 DOI: 10.1016/s0221-0363(07)89930-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To describe the CT and MRI features of 3 cases of arachnoid cyst of the petrous apex. PATIENTS AND METHODS Three patients with isolated trigeminal neuralgia, trigeminal hypoesthesia, and sinusitis. Axial and coronal CT images were obtained. T1W, FSE T2W, FLAIR, T2*W and diffusion-weighted MR sequences were obtained. RESULTS In all cases, both CT and MRI showed expansile lesions eroding the petrous apex. Lesions were hypodense on CT and isointense to CSF on MRI, without contrast enhancement. In one case, the lesion was contiguous with Meckel's cave with temporal fossa and sphenoid sinus extension. CT and MR imaging features are useful to distinguish arachnoid cysts of the petrous apex from other benign lesions of the petrous apex. CONCLUSION CT and MRI imaging features allow diagnosis of arachnoid cyst of the petrous apex because its imaging features, especially on DWI, are different from other cystic lesions of the petrous apex, namely cholesteatoma. It should be considered in patients with trigeminal involvement, especially trigeminal neuralgia.
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Affiliation(s)
- I Alkilic-Genauzeau
- Service de Neuroradiologie diagnostique et interventionnelle, Hôpital Lariboisière, 2, rue Ambroise Paré, 75475 Paris Cedex 10
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Isaacson B, Kutz JW, Roland PS. Lesions of the petrous apex: diagnosis and management. Otolaryngol Clin North Am 2007; 40:479-519, viii. [PMID: 17544693 DOI: 10.1016/j.otc.2007.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Management of petrous apex pathology poses a unique challenge even to the most seasoned skull base surgeons. The central location in the skull base with adjacent critical neurovascular structures makes access to this region more than a trivial matter. Significant advances in diagnostic imaging have greatly facilitated the diagnosis of petrous apex lesions. The introduction of modern skull base surgery techniques also has provided skull base surgeons with numerous avenues to the petrous apex while significantly decreasing morbidity. The latest diagnostic and management strategies are discussed and an update of some of the more common pathologic entities is provided.
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Affiliation(s)
- Brandon Isaacson
- Department of Otolaryngology-Head and Neck Surgery, The University of Texas-Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9035, USA.
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Alorainy IA. Petrous apex cephalocele and empty sella: Is there any relation? Eur J Radiol 2007; 62:378-84. [PMID: 17306489 DOI: 10.1016/j.ejrad.2007.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 01/09/2007] [Accepted: 01/12/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To document the presence of incidental petrous apex cephalocele (PAC) in association with empty sella in a group of patients and propose an etiologic/pathologic relation between the two lesions. MATERIALS AND METHODS Retrospective review of our imaging archive for the period from October 2001 to October 2006 revealed five patients with PAC (four females and one male; age range, 25-60 years; mean, 47 years). All patients underwent enhanced MR examination of the skull base and four of them underwent CT examination. Lesions were evaluated for size, content, signal intensity, enhancement, and relation to Meckel's cave and petrous apex. Images were also evaluated for the presence of empty sella. RESULTS The presenting symptoms in all patients were not attributable to PAC. None of the patients had symptoms related to the trigeminal nerve or history of CSF leak. Four patients had bilateral PAC and one had left PAC (total nine lesions). The lesions ranged from 6 mm to 15 mm (mean 9 mm) in the maximum diameter. All lesions were centered posterolateral to Meckel's cave and had low attenuation on CT with sharply demarcated margins. No lesion reached the inner ear structures, internal auditory canal, or mastoid air cells. On MR imaging, all lesions demonstrated CSF signal intensity that is continuous with that of the Meckel's cave. Only the periphery of the lesions demonstrated mild enhancement. All patients had empty sella. One patient had small arachnoid cysts in the middle cranial fossa, bilaterally. CONCLUSION PAC and empty sella are similar mechanically in terms of CSF extension and erosion into petrous apex and sella, respectively. Both conditions are seen predominantly in females and have been reported in association with CSF leak, which raises a possibility of etiologic/pathologic relation between the two.
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Affiliation(s)
- Ibrahim A Alorainy
- Department of Radiology and Diagnostic Imaging, King Khalid University Hospital, King Saud University, PO Box: 9047, Riyadh 11413, Saudi Arabia.
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Kanzaki S, Araki Y, Okamoto Y, Kurita A, Ogawa K. Cholesterol granuloma surrounding the endolymphatic sac. Auris Nasus Larynx 2007; 34:95-100. [PMID: 16914280 DOI: 10.1016/j.anl.2006.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 05/25/2006] [Accepted: 05/26/2006] [Indexed: 11/21/2022]
Abstract
We report a unique case of cholesterol granuloma (CG) surrounding the endolymphatic sac (ES). A 49-year-old man presented with the left side of sensorineural hearing loss, tinnitus, and vertigo. Magnetic resonance and computed tomography imaging revealed a CG surrounding the left ES. The patient initially underwent left transmastoid surgical resection of the tumor. At the time of surgery, brown fluid was aspirated from the tumor, but no other tumors were found. Histopathological examination revealed that the tumor contained cholesterol crystals, confirming the diagnosis of CG. At his 12-month postoperative follow-up, there was no evidence of recurrence. We discuss the radiology, pathology, and surgical removal of CGs surrounding ES.
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Affiliation(s)
- Sho Kanzaki
- Department of Otorhinolaryngology, School of Medicine, Keio University, Shinjuku, Tokyo 160-8582, Japan.
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Isaacson B, Coker NJ, Vrabec JT, Yoshor D, Oghalai JS. Invasive Cerebrospinal Fluid Cysts and Cephaloceles of the Petrous Apex. Otol Neurotol 2006; 27:1131-41. [PMID: 17068409 DOI: 10.1097/01.mao.0000244353.26954.71] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the presentation, diagnostic evaluation, and surgical management of petrous apex cerebrospinal fluid (CSF) cysts and cephaloceles. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Six patients with symptomatic CSF cysts or cephaloceles. INTERVENTION(S) All patients underwent operative intervention. MAIN OUTCOME MEASURE(S) Presentation, imaging characteristics, operative findings, surgical approach, resolution of symptoms, and complications. RESULTS Six patients presented with various neurotologic symptoms including vertigo, otalgia, diplopia, meningitis, hearing loss, and retroorbital headaches. Four lesions were centered within the anterior petrous apex and were classified as a cephalocele originating from Meckel's cave. The remaining two lesions were arachnoid cysts that involved the posterior petrous apex. Cysts and cephaloceles both demonstrated bone erosion on computed tomography and were hyperintense on T2-weighted magnetic resonance imaging and isointense or hypointense on T1-weighted magnetic resonance imaging. A variety of surgical approaches was used to treat these lesions. Preoperative symptoms were improved in five of six cases. One patient developed a postoperative CSF leak that resolved with conservative measures. CONCLUSION Petrous apex CSF cysts and cephaloceles may present with a variety of neurotologic symptoms. Imaging often helps narrow the differential diagnosis, but these lesions can still be confused with other erosive skull base lesions such as cholesterol granulomas, epidermoids, or tumors. Optimal treatment of symptomatic posterior petrous apex CSF cysts is marsupialization via a posterior fossa approach (i.e., retrosigmoid or retrolabyrinthine). A middle fossa approach with obliteration of the anterior petrous apex may be used to treat symptomatic CSF cephaloceles arising from Meckel's cave.
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Affiliation(s)
- Brandon Isaacson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas-Southwestern, Dallas, Texas 77030, USA
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Abstract
INTRODUCTION Petrous apex fluid accumulations without evidence of acute infection are routinely managed as "leave alone lesions" without potential morbidity. Are petrous apex fluid accumulations (effusions) in the absence of acute infection always asymptomatic without the need for treatment? If petrous apex effusions can produce symptoms separate from acute infections, what are the clinical outcomes in these patients? STUDY DESIGN Retrospective clinical review. METHODS A retrospective record review of 31 patients presenting with petrous apex effusions was performed with recording of clinical characteristics, interventions, and outcomes. RESULTS Eighteen of the 31 patients had clinical symptoms referable to the petrous apex effusion with the following characteristics: indolent and previous infections (4), hearing loss (3), headache and pressure alone (8), facial spasms (1), and positional vertigo (2). Overall, 5 of 18 symptomatic patients resolved with antibiotics, steroids, or positioning maneuvers. Three of five infracochlear drainages produced symptom resolution. Three of four patients undergoing retrolabyrinthine drainage had symptom resolution, and four of seven middle fossa drainages yielded symptom resolution. In contrast, infratemporal fossa drainage procedures did not resolve the patients' symptoms. CONCLUSIONS Isolated petrous apex effusions are rare, but they can cause symptoms. If medical management fails, surgical drainage based on the location is appropriate. The surgical drainage approach selected (infracochlear, infralabyrinthine, middle fossa, and endoscopic transnasal) should be based on an anatomic consideration of the involved petrous apex air cells (superior vs. inferior) and the relative position of the carotid artery and jugular bulb.
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Affiliation(s)
- Moisés A Arriaga
- Pittsburgh Ear Associates, Hearing and Balance Center, Allegheny General Hospital, 420 E. North Avenue, Pittsburgh, PA 15212, USA.
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Batra A, Tripathi RP, Singh AK, Tatke M. Petrous apex arachnoid cyst extending into Meckel's cave. AUSTRALASIAN RADIOLOGY 2002; 46:295-8. [PMID: 12196240 DOI: 10.1046/j.1440-1673.2002.01063.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A rare case of arachnoid cyst involving the petrous apex with an unusual clinical presentation has been described with special emphasis in the imaging features and importance of accurate presurgical diagnosis. Differentiation from the other benign lesions involving the petrous apex and the role of newer MR techniques in the diagnosis of these lesions has been highlighted.
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Affiliation(s)
- Arun Batra
- Nuclear Magnetic Resonance Research Centre, Institute of Nuclear Medicine and Allied Sciences, Delhi 110054, India
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Mosnier I, Cyna-Gorse F, Grayeli AB, Fraysse B, Martin C, Robier A, Gardini B, Chelikh L, Sterkers O. Management of cholesterol granulomas of the petrous apex based on clinical and radiologic evaluation. Otol Neurotol 2002; 23:522-8. [PMID: 12170156 DOI: 10.1097/00129492-200207000-00022] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the imaging characteristics of 12 cholesterol granulomas as a function of their clinical symptoms. The results of the different surgical approaches and the management of these lesions are discussed. STUDY DESIGN Retrospective case review. SETTING Five tertiary referral centers. PATIENTS Twelve patients managed for a cholesterol granuloma of the petrous apex. INTERVENTIONS All patients were evaluated via computed tomography and magnetic resonance imaging. Eight patients required surgical drainage: through a conservative approach in seven patients (infralabyrinthine, n = 5; infracochlear, n = 2) and a transotic approach in one patient. Clinical and radiologic follow-up without surgery was the mode of treatment for four patients. The mean follow-up period was 18 months for patients who underwent operations and ranged from 6 months to 10 years for patients without operations. RESULTS Four patterns of clinical symptoms were noted: retrocochlear signs by an involvement of the internal auditory meatus (n = 8), headaches by a traction of the dura (n = 4), serous otitis media by a compression of the eustachian tube (n = 2), and asymptomatic lesions with no involvement of the adjacent structures (n = 2). Hearing and facial functions were preserved in all the cases treated by a noninvasive procedure. No recurrence or complication was reported in the patients who underwent operations. None of the noninvasively treated patients with cholesterol granulomas showed significant enlargement on follow-up imaging. CONCLUSION Clinical manifestations of cholesterol granulomas depend on their anatomic location and the involvement of the adjacent structures. Aggressive lesions in patients with residual hearing can be drained via an infralabyrinthine or an infracochlear approach with minimal morbidity. Follow-up must be preferred for patients with nonaggressive lesions. Although magnetic resonance imaging provides a specific diagnosis tool for cholesterol granulomas, computed tomography is essential for an accurate evaluation of the location of the cyst and choice of the surgical procedure.
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Affiliation(s)
- Isabelle Mosnier
- Department of Otolaryngology, Hôpital Beaujon, Faculté Xavier Bichat, Université Paris, AP-HP 100 Boulevard du Général Leclerc, F-92118 Clichy cedex, France.
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Falcioni M, Caruso A, Taibah A, De Donato G, Piccirillo E, Russo A, Sanna M. Arachnoid cysts of the petrous apex in a patient with vestibular schwannoma. Otolaryngol Head Neck Surg 2000; 123:657-8. [PMID: 11077366 DOI: 10.1067/mhn.2000.110542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M Falcioni
- Gruppo Otologico, Piacenza; and the B ENT Department, Palermo University
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27
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Pisaneschi MJ, Langer B. Congenital cholesteatoma and cholesterol granuloma of the temporal bone: role of magnetic resonance imaging. Top Magn Reson Imaging 2000; 11:87-97. [PMID: 10794198 DOI: 10.1097/00002142-200004000-00004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Magnetic resonance imaging (MRI) can be of significant benefit in characterizing expansile lesions of the petrous apex. MRI can be of particular help in distinguishing congenital cholesteatoma from cholesterol granuloma. Furthermore, with the advent of faster high-resolution scanning techniques, MRI can define precise spatial relationships of these masses with the middle and inner ear structures, internal carotid artery, jugular vein, and other structures of the skull base. MRI scanning is sensitive in detecting intracranial extension of these masses. MR angiography can provide additional information regarding the relationship of these masses with adjacent vascular structures and confirm patency of the adjacent vessels. In the postoperative period, MR scanning can help evaluate for complete removal, complication, recurrence, or formation of complicating granulation tissue.
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Abstract
Primary or secondary petrous apex cholesteatoma requires surgical management. We describe here live patients with cholesteatoma in the petrous apex on whom different surgical approaches to this region were used. Translabyrinthine transcochlear (transotic) approach with VII-XII anastomosis was used in four patients. In one patient middle fossa approach with otic capsule and facial canal leaving intact was used. All patients are without recurrence of cholesteatoma with improving of the facial nerve function in one case. We discuss specific pathologies of the petrous apex, the surgical approach to this region indicated according to the size and type of pathology diagnosed, hearing loss and facial nerve function. Possible complications of this surgical procedure and their management are also discussed.
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Affiliation(s)
- M Profant
- Department of Otolaryngology, Faculty Hospital Bratislava, Slovak Republic.
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Kacker A, Bent JP, Abbott R. Non-communicating arachnoid cyst of the temporal bone presenting as facial nerve paralysis in an infant. Int J Pediatr Otorhinolaryngol 1999; 49:151-4. [PMID: 10504022 DOI: 10.1016/s0165-5876(99)00119-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Non-communicating arachnoid cyst of the lateral temporal bone is a rare condition. We present a case of a non-communicating arachnoid cyst of the temporal bone in an infant who presented with a lower motor neuron facial nerve paralysis. The patient was treated by surgical excision of the cyst.
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Affiliation(s)
- A Kacker
- Department of Otolaryngology, Manhattan Eye, Ear, and Throat Hospital and Lenox Hill Hospital, New York, NY, USA
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