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Marchioni D, Alberti C, Bisi N, Rubini A. Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma. J Clin Med 2024; 13:2505. [PMID: 38731034 PMCID: PMC11084343 DOI: 10.3390/jcm13092505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Petrous apex cholesterol granulomas (PACGs) are benign inflammatory cystic lesions of the temporal bone. Usually, asymptomatic patients may develop symptoms as the lesions expand. The diagnosis is based on both CT and MRI scans and the management relies on "wait and scan" or surgery. This paper aims at evaluating surgical outcomes and proposing a CT-based classification and a management algorithm. Methods: Patients with PACGs who were surgically treated between 2014 and 2024 were included. Symptoms, imaging, approach type and complications were considered. CT scans were classified as Type A (preserved apex cellularity), Type B (erosion of the apex cellularity), and Type C (involvement of the noble structures bone boundaries). The possible connection of the lesion with the infracochlear, perilabyrinthine and sphenoidal cellularity was assessed. Results: Nineteen patients with symptoms like diplopia, headache and sensorineural hearing loss were included. According to our classification, 1/19 patients was Type A, 4/19 were Type B and 14/19 were Type C. Five patients underwent a total resection, seven a subtotal and seven a surgical drainage. Only two complications were recorded, and 17/19 patients showed symptom regression and stability during follow-up. Conclusions: While the management of PACGs is still controversial, according to our classification and surgical outcomes, Type A, being mostly asymptomatic, should be managed with "wait and scan", Type B should undergo surgery when symptoms are present, while Type C should always undergo surgery because of their invasiveness and potential complications. When possible, a drainage should be attempted; otherwise, a surgical resection is chosen, and its completeness depends on the preoperative general and hearing status.
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Affiliation(s)
| | | | - Nicola Bisi
- Department of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, 41125 Modena, Italy; (D.M.); (C.A.); (A.R.)
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Noy R, Bassal R, Ostrovsky D, Cohen J, Ishai R, Cohen-Vaizer M, Vaisbuch Y. Surgical Approaches to Petrous Apex Cholesterol Granulomas: A Systematic Review and Network Meta-analysis. Laryngoscope 2024; 134:1540-1550. [PMID: 37812326 DOI: 10.1002/lary.31073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/10/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE To compare the outcomes of different surgical approaches to petrous apex cholesterol granulomas (PACG). DATA SOURCES PubMed, Embase, Google Scholar, Cochrane, and Web of Science. REVIEW METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Network Meta-analyses guidelines, databases were searched from inception to November 31, 2022. Studies comparing two or more approaches were included. Reviews and population studies were excluded. The main outcome measures were the resolution of symptoms, serviceable hearing, complication, and revision rates. RESULTS The search yielded 2132 studies. After applying inclusion and exclusion criteria, 15 studies remained, consisting of 214 patients treated with lateral approaches (n = 182) or anterior endonasal approaches (n = 32). The efficacy of lateral and anterior endonasal approaches in achieving symptom resolution was comparable (73% vs. 68%, p = 0.5). Both exhibited similar rates of complications (33% vs. 37%, p = 0.3), albeit with distinct profiles. Lateral approaches were associated with higher rates of facial palsy and sensorineural hearing loss (44% vs. 18%, p = 0.03). Anterior endonasal approaches demonstrated higher rates of epistaxis and cerebrospinal fluid leak (15% vs. 1%, p = 0.001). Anterior endonasal approaches exhibited lower revision rates (OR: 0.35, 95% CI: 0.14-0.88). The placement of a stent in both approaches was associated with higher symptom resolution (OR: 5.12, 95% CI: 1.05-9.97) and lower revision rates (OR: 0.71, 95% CI: 0.33-0.92). CONCLUSIONS Anterior endonasal approaches yield lower revision rates compared to lateral approaches for PACG. Both approaches demonstrate similar effectiveness in symptom resolution and comparable rates of complications, with distinct profiles. Facial nerve and hearing status are important factors that should be addressed when selecting the approach. Stenting is beneficial. LEVEL OF EVIDENCE NA Laryngoscope, 134:1540-1550, 2024.
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Affiliation(s)
- Roee Noy
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Raghad Bassal
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Dmitry Ostrovsky
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Jacob Cohen
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Reuven Ishai
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mauricio Cohen-Vaizer
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yona Vaisbuch
- Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Characteristics and Clinical Management Strategy of Petrous Apex Cholesterol Granulomas. Cancers (Basel) 2023; 15:cancers15041313. [PMID: 36831654 PMCID: PMC9953853 DOI: 10.3390/cancers15041313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Purpose: To evaluate the clinical characteristics of petrous apex cholesterol granulomas (PACG) and assess outcomes after different treatment strategies. Method: A consecutive case series of 34 patients with a PACG. Main outcomes were PACG growth, symptoms, and the outcomes of different treatment strategies: wait-and-scan (WS) and surgical drainage. Results: Thirty-four patients were analyzed; mean follow-up time was 7.1 years. Twenty-one patients (61.7%) showed symptoms, mostly more than one. Most symptoms reported were cranial nerve palsy (58.8%) and headache (35.3%). Twenty-one patients (61.8%) received solely wait-and-scan (WS), and thirteen patients (38.2%) underwent surgery, five of whom (38.5%) after an initial WS period. In the solely WS group, one (4.8%) developed new symptoms, and two (9.5%) reported symptom progression despite a stable granuloma size. Two (9.5%) showed granuloma growth on follow-up scans without symptom progression. Surgery consisted of drainage. Eleven (84.6%) of these thirteen patients reported partial recovery; one (7.7%) reported no recovery; and one (7.7%) reported full recovery of reported symptoms related to PACG. Among the patients with cranial nerve involvement, 7.7% showed full recovery after surgery; 84.6% showed partial recovery; and 7.7% did not recover. Adverse events occurred in five out of 13 patients who underwent surgery, all with full recovery. Conclusions: This study confirms that PACG are slow-growing lesions with a low risk of adverse events. Solely using wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth.
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Gersey ZC, Zenonos GA, Gardner PA. Malignant Brain and Spinal Tumors Originating from Bone or Cartilage. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:477-506. [PMID: 37452950 DOI: 10.1007/978-3-031-23705-8_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Malignant bone tumors affecting the brain and spine are a rare and exceedingly difficult-to-treat group of diseases. Most commonly consisting of chordoma and chondrosarcoma, these tumors also include giant-cell tumors and osteosarcomas. This chapter will cover the background, epidemiology, genetics, molecular biology, histopathology, radiographic features, clinical manifestations, therapeutic approaches, and clinical management of each entity.
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Affiliation(s)
- Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul A Gardner
- UPMC Center for Cranial Base Surgery, 200 Lothrop Street, PUH B-400, Pittsburgh, PA, 15213, USA.
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Typical and Atypical Symptoms of Petrous Apex Cholesterol Granuloma: Association with Radiological Findings. J Clin Med 2022; 11:jcm11154297. [PMID: 35893388 PMCID: PMC9330305 DOI: 10.3390/jcm11154297] [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] [Received: 06/22/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 12/10/2022] Open
Abstract
Objective: Petrous apex cholesterol granuloma (PACG) is a lesion that can give rise to different symptoms, and correlations with etiopathology are ambiguous. The aim of this study is to analyze the association between PACG symptoms and radiological findings at presentation, in order to establish a reproduceable pre-operative radiological evaluation and guide the surgical indication. Methods: PACG patients were collected in two tertiary care hospitals. All cases underwent CT/MRI to evaluate the cyst localization and erosion of surrounding structures. Typical and atypical symptoms were then analyzed and compared to radiologic findings established in accordance with the literature. Results: Twenty-nine patients were recruited; the most common symptoms were headache (69%), diplopia (20.7%) and fainting (24.1%), an atypical clinical manifestation related to jugular tubercle involvement. Significant associations between symptoms and radiologic findings were noted in terms of headache and temporal lobe compression (p = 0.04), fainting and jugular tubercle erosion (p < 0.001), vestibular symptoms and internal auditory canal erosion (p = 0.02), facial paresthesia and Meckel’s cave compression (p = 0.03), diplopia and Dorello canal involvement (p = 0.001), and tinnitus and cochlear basal turn erosion (p < 0.001). All patients were treated via an endoscopic−endonasal approach, in which extension was tailored to each case. At a median follow-up of 46 months, 93.1% of patients experienced resolution of symptoms. Conclusions: This clinico-radiological series demonstrates associations between symptoms and anatomical subsites involved with PACG. Hence, it may guide the surgeon at the time of surgical decision, since it asserts that typical and atypical symptoms are actually related to PACG.
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Pochueva TV, Borisenko ON, Srebnyak IA, Merkulov AY. [Pathology of the apex of the temporal bone pyramid: cholesterol granuloma and congenital cholesteatoma]. Vestn Otorinolaringol 2021; 86:127-133. [PMID: 34269036 DOI: 10.17116/otorino202186031127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The report presents modern views on the origin and pathomorphological characteristics of the cholesterol granuloma of the petrous apex of temporal bone, its clinical comparison with congenital cholesteatoma of the same localization. The differential diagnostic features in CT and MRI scans are analyzed in detail, and the principles of surgical treatment, indications and contraindications are discussed. Also the case of atypical course of cholesterol granuloma is presented, which was difficult in the diagnostics but with a successful treatment result.
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Affiliation(s)
- T V Pochueva
- Kharkov Medical Academy of Postgraduate Education, Kharkov, Ukraine.,Kolomiychenko Institute of Otolaryngology, Kiev, Ukraine
| | - O N Borisenko
- Kharkov Medical Academy of Postgraduate Education, Kharkov, Ukraine.,Kolomiychenko Institute of Otolaryngology, Kiev, Ukraine
| | - I A Srebnyak
- Kharkov Medical Academy of Postgraduate Education, Kharkov, Ukraine.,Kolomiychenko Institute of Otolaryngology, Kiev, Ukraine
| | - A Yu Merkulov
- Kharkov Medical Academy of Postgraduate Education, Kharkov, Ukraine.,Kolomiychenko Institute of Otolaryngology, Kiev, Ukraine
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Cömert E, Cömert A. Surgical anatomy of the transcanal infracochlear approach. Eur Arch Otorhinolaryngol 2021; 279:159-168. [PMID: 33532901 DOI: 10.1007/s00405-021-06635-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/20/2021] [Indexed: 01/29/2023]
Abstract
PURPOSE The objective of this study is to describe the detailed surgical anatomy of the infracochlear approach to prevent complications and to compare the postauricular transcanal microscopic and endoscopic approaches to reach the petrous apex. METHODS Cadaver heads were dissected using a binocular surgical microscope, endoscopes, and an electric drill. The dimensions of the access field that could be reached and manipulated with surgical instruments and straight drill via postauricular transcanal microscopic and endoscopic approaches were evaluated. RESULTS Both postauricular microscopic and transcanal endoscopic approaches were considered to be inapplicable in cases with a tympanic cavity located jugular bulb closer than 3 mm to the cochlea. This relationship was seen in 3 (9%) sides of the cadavers. In 4 specimens (12%), a cochlear aqueduct with an open lumen was detected. Both postauricular microscopic and transcanal endoscopic approaches reached a nearly identic dissection area. Detailed anatomy of the approach and measurements about the topography of the third portion of the facial nerve from the tympanic cavity were presented. CONCLUSION Both traditional microscopic postauricular and endoscopic transcanal approaches provided comparable access areas to the inferior petrous apex with wide exposure, and radiologic measurements were compatible. A tympanic cavity located jugular bulb in close relation with cochlea was the only instance that restricted the applicability of this technique.
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Affiliation(s)
- Ela Cömert
- Department of Otolaryngology, Kırıkkale University School of Medicine, Ankara Yolu 7. Km, 71450, Yahşihan, Kırıkkale, Turkey.
| | - Ayhan Cömert
- Department of Anatomy, Ankara University School of Medicine, Ankara, Turkey
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Pace A, Iannella G, Riminucci M, Corsi A, Magliulo G. Tympano-Mastoid Cholesterol Granuloma: Case Report and Review of the Literature. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2020; 13:1179547620958728. [PMID: 32994699 PMCID: PMC7502992 DOI: 10.1177/1179547620958728] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022]
Abstract
Cholesterol granuloma (CG) is a rare condition histological consisting of a foreign body, giant cell reaction to cholesterol crystals and haemosiderin derived from the ruptured of the erythrocytes. A 25-year-old man came to our Department presenting signs and symptoms of tympano-mastoid cholesterol granuloma. He showed all the specific sign and symptoms of the disease. However, considering the lack of literature regarding TMCG, this study was performed with the aim of presenting the main characteristics of tympano-mastoid CG, describing the case report and reviewing the literature.
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Affiliation(s)
- Annalisa Pace
- Organi di Senso Department, Sapienza University of Rome, Rome, Italy
| | | | - Mara Riminucci
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Corsi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Magliulo
- Organi di Senso Department, Sapienza University of Rome, Rome, Italy
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Tabet P, Saydy N, Saliba I. Cholesterol Granulomas: A Comparative Meta-Analysis of Endonasal Endoscopic versus Open Approaches to the Petrous Apex. J Int Adv Otol 2020; 15:193-199. [PMID: 31287439 DOI: 10.5152/iao.2019.5859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Petrous apex cholesterol granulomas (PACG) are rare disorders that can lead to patient morbidity and must, occasionally, be drained by either endoscopic endonasal (EN) or open procedures (OP). The objective of our study was to complete a review of the literature to compare the EN and OP approaches on multiple levels, notably on safety and effectiveness. Ovid MEDLINE and Embase were used to perform a thorough literature review of all cases of PACG treated by either EN or OP dating from January 1948 to August 2017. In total, 49 articles were selected including 23 for EN (n=76) and 26 for OP (n=210). Differences were found in the incidence of preoperative hearing loss (HL) (EN 18.4%, OP 57.3%; p<0.001), headache (EN 48.7%, OP 31.2%; p=0.007), and disequilibrium (EN: 14.5%, OP 26.1%; p=0.04). Differences in lesion proximity to the sphenoid sinus (EN 23.6%, OP: 1.0%; p<0.001), clivus (EN 11.8%, OP 4.7%; p=0.03), otic capsule (EN 0.0%, OP 5.2%; p=0.03), internal auditory canal (EN 2.6%, OP 10.9%; p=0.01), and internal carotid artery (ICA) (EN 9.2%, OP 2.8%; p=0.02) were found on preoperative imaging. The EN procedure had better hearing improvement rates (EN 85.7%, OP 23.4%; p<0.001), lower complication rates (EN 7.9%, OP 17.6%; p=0.04), shorter median follow-up (EN:13.5 months, OP:37.2 months; p<0.001), and shorter time to recurrence (EN 3 months, OP 22.6 months; p=0.002) than the known OP. No differences were found in age, preoperative size, recurrence rate, operative time, stent placement, or improvement of other symptoms. Endoscopic nasal approaches, when feasible, should be favored to open procedures for PACG drainage given their better hearing improvement and less complication rates.
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Affiliation(s)
- Paul Tabet
- Division of Otorhinolaryngology Head - Neck Surgery - Otology and Neurotology, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada
| | - Nadim Saydy
- University of Montreal, Montreal, Quebec, Canada
| | - Issam Saliba
- Division of Otorhinolaryngology Head - Neck Surgery - Otology and Neurotology, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada
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Endoscopic Endonasal Approach to Selected Lesions of the Petrous Apex. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Al-Afif S, Hatipoglu Majernik G, Al Krinawe Y, Esmaeilzadeh M, Hartmann C, Krauss JK. The Role of Neurosurgery in the Treatment of Intracranial Tumor-Like Inflammatory Lesions. World Neurosurg 2018; 124:S1878-8750(18)32803-1. [PMID: 30554001 DOI: 10.1016/j.wneu.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/30/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Different inflammatory diseases can manifest as intracranial lesions. They may be indistinguishable from intracranial neoplasms in the clinical setting, imaging studies, or laboratory studies. The value of surgery in the diagnosis and the treatment of such lesions is still unclear. METHODS A total of 3066 reports of histopathologic examinations over a 10-year period were reviewed. Forty patients with an inflammatory intracranial lesion were identified. Clinical, radiologic, and follow-up data were analyzed and the diagnostic and therapeutic value of surgery was assessed. RESULTS We identified 24 women and 16 men (mean age, 47 years). The diameter of the lesion varied between 1 and 5.5 cm (mean, 2.6 cm). The location of the inflammatory lesion was intracerebral supratentorial (n = 18, 45%), intrasellar/suprasellar (n = 5, 12.5%), cerebellar (n = 5, 12.5%), in the brainstem (n = 4, 10%), in the cerebellopontine angle (n = 3, 7.5%), meningeal (n = 3, 7.5%), and at other locations (n = 6, 15%). Seventeen patients underwent surgical removal of the mass lesion, whereas in 23 patients a biopsy was taken. The lesions were classified into 7 groups: specific (infectious) granuloma (n = 10, 25%), unspecific granuloma (n = 7, 17.5%), idiopathic inflammatory pseudotumor (n = 5, 12.5%), demyelinating lesions (n = 5, 12.5%) encapsulated hematoma (n = 4, 10%), organized cerebral infarction (n = 3, 7.5%), and vasculitis (n = 4, 10%). Surgery was judged as valuable in 35 patients (87.5%). CONCLUSIONS The differential diagnosis of intracranial inflammatory lesions involves a wide spectrum. Surgery has a diagnostic and/or therapeutic value in most entities and clinical circumstances. However, attention must be taken to avoid surgery without a therapeutic or diagnostic value for the patient.
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Affiliation(s)
- Shadi Al-Afif
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany.
| | | | - Yazeed Al Krinawe
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Majid Esmaeilzadeh
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Christian Hartmann
- Department of Neuropathology, Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Institute for Pathology, Hannover Medical School, Hannover, Germany
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Liu W, Lu Y, Laurell G, Cousins V. A morphometric study of the structures bordering the infra-cochlear corridor - Relevant for endoscopic/microscopic ear surgery. J Otol 2018; 13:81-84. [PMID: 30559770 PMCID: PMC6291685 DOI: 10.1016/j.joto.2018.08.001] [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] [Received: 07/07/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 11/29/2022] Open
Abstract
Application of surgical endoscope, used alone or in combination with the surgical microscope, for the operative management of ear and temporal bone conditions may allow improved access and clearance of disease. Preservation of normal structures may also be improved. As the use of this tool is increasing, the need for better understanding of the anatomy of the ear is becoming evident. This is particularly so for endoscopic surgery aiming at removal of lesions involving the infra-cochlear corridor and/or petrous apex. Human temporal bone-derived labyrinth casts (molds), originally made for endolymphatic duct and sac analysis which genuinely represent the membranous labyrinth and its adjacent soft tissues, were morphometrically analyzed in terms of the anatomic relations between structures in and around the infra-cochlear corridor. The distance between the petrous carotid artery (PCA) and the basal turn of the cochlea, the distance between PCA and infra-cochlear vein (ICV)/cochlear aqueduct (CA), and the distance between the lower surface of basal cochlear turn and the point where the carotid artery and jugular vein (JV) meet close to the jugular foramen, were measured to be around 1.3 mm, 6 mm and 8 mm respectively, thus constituting an approximate 6 × 8 mm2 infra-cochlear corridor. This analysis and further study with larger samples might be helpful for operation via this corridor led to the petrous apex where cholesterol granuloma, cholesteatoma and other lesions are not uncommon.
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Affiliation(s)
- Wei Liu
- Department of Surgical Sciences, Section of Otolaryngology, Uppsala University Hospital, Uppsala, Sweden
| | - Yongtian Lu
- Shenzhen Second People's Hospital, Sungang West Road, Futian District, Shenzhen City, China
| | - Göran Laurell
- Department of Surgical Sciences, Section of Otolaryngology, Uppsala University Hospital, Uppsala, Sweden
| | - Vincent Cousins
- Department of Ear Nose and Throat Surgery, The Alfred Hospital, Melbourne, Australia.,Department of Surgery, Monash University, Australia
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Petrous Apex Cholesterol Granulomas: Outcomes, Complications, and Hearing Results From Surgical and Wait-and-Scan Management. Otol Neurotol 2018; 38:e476-e485. [PMID: 28984806 DOI: 10.1097/mao.0000000000001578] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE 1. To analyze the surgical outcomes in the management of petrous apex cholesterol granulomas (PACG) with a brief literature review.2. To evaluate the importance of wait-and-scan management option. STUDY DESIGN Retrospective review. SETTING Quaternary referral center for otology and skull base surgery. SUBJECTS AND METHODS Charts of 55 patients with at least 12 months of follow-up were analyzed for demographic, clinical, audiometric, and radiological features. Patients were divided into surgical group (SG) (n = 31) and wait-and-scan (n = 24) (WS) group. Surgical approach was chosen as per hearing status and PACG extension and relation to nearby neurovascular structures and included either drainage by transmastoid-infralabyrinthine approach (TM-IL)/transcanal-infracochlear approach (TC-IC) or resection by infratemporal fossa type B approach (ITF-B). The combination of ITF-B with trans-otic (TO) approach or TO approach solely was used in unserviceable hearing cases. Postoperative outcomes and complications were evaluated in SG. RESULTS Postoperative symptom relief was observed in 24 patients (77.4%). Diplopia and paresthesia recovered in each case and improvement in headache, dizziness, tinnitus, and hearing loss was observed in 87.1% cases. Serviceable hearing was preserved in 24 of 26 cases. Postoperative complication rate was 32.2% including incidences of profound hearing loss, facial nerve paresis, carotid artery injury and intraoperative CSF leaks. Revision surgery was required in 3 (9.6%) cases, after TM-IL approach. CONCLUSION Surgical drainage is preferable to more aggressive resection procedures, with the latter reserved for recurrent lesions or lesions with severe hearing loss/involvement of critical neurovascular structures. ITF-B approach provides adequate cyst and neurovascular control for resection, while avoiding brain retraction. An initial wait-and-scan approach can be used in most patients where symptoms and imaging justify so.
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Han BH, Choi IS. A Case of Cholesterol Granuloma of Maxillary Sinus Misdiagnosed as Odontogenic Cyst. JOURNAL OF RHINOLOGY 2018. [DOI: 10.18787/jr.2018.25.2.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Byung Hyun Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Inje University of College of Medicine, Ilsan Paik Hospital, Ilsan, Korea
| | - Ick Soo Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Inje University of College of Medicine, Ilsan Paik Hospital, Ilsan, Korea
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Long-term Symptom-specific Outcomes for Patients With Petrous Apex Cholesterol Granulomas: Surgery Versus Observation. Otol Neurotol 2017; 38:253-259. [PMID: 27898604 DOI: 10.1097/mao.0000000000001268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Review long-term symptom-specific outcomes for petrous apex cholesterol granulomas (PACG). STUDY DESIGN Retrospective review. SETTING Tertiary center. PATIENTS Adults with PACG were assessed from 1998 to 2015. INTERVENTION(S) Symptomatic patients were stratified into surgical and observation subgroups. MAIN OUTCOME MEASURE(S) Resolution rates of individual symptoms and chief complaints were assessed as was the impact of surgical approach and stent usage on symptom-specific outcomes. Symptom recurrence rates were tabulated. RESULTS Twenty-seven patients were included whose mean age was 44.8 ± 3.3 years. Fourteen and 13 patients stratified into the surgical and observation subgroups respectively. The surgical subgroup trended toward a longer follow-up period (mean 68.5 vs. 33.8 mo; p = 0.06). Overall, the most frequent symptoms encountered were headache (52%), aural fullness, tinnitus, and vestibular complaints (41% each). Visual complaints, retro-orbital pain, and cranial neuropathies were less common (18%, 15%, 11%). The overall symptom resolution rate was significantly higher in the surgical subgroup (48% vs. 26%, p = 0.03). In both subgroups, headache, retro-orbital pain, and visual complaints had the highest resolution rates. Vestibular complaints and tinnitus were very unlikely to resolve. Significantly more patients in the surgical group resolved their chief complaints (70% vs. 25%, p = 0.02). While approach type and stent usage did not significantly influence symptom outcomes, all patients with symptom recurrence (11%) were initially managed without stents. CONCLUSION Symptom-specific outcomes were better in patients managed surgically for PACG. Individual symptom resolution rates were highly variable. Some symptoms were refractory regardless of management strategy. Surgical approach and stent usage did not significantly influence symptom outcomes.
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Fomichev DV, Kalinin PL, Kutin MA, Sharipov OI, Chernov IV. [The extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts of the chiasmatic region]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 81:70-77. [PMID: 28914873 DOI: 10.17116/neiro201781470-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical treatment for epidermoid cysts of the chiasmatic region is a challenge because of the tendency to a massive spread of epidermoid masses through the cerebrospinal fluid pathways and a significant lesion deviation from the midline. PURPOSE To analyze capabilities of the extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts. MATERIAL AND METHODS The study included 6 patients with epidermoid cysts of the chiasmatic region who were operated on using the extended anterior endoscopic endonasal transsphenoidal approach at the Burdenko Neurosurgical Institute in the past 5 years. RESULTS Epidermoid masses were completely removed in 5 patients; in none of the cases, complete removal of the epidermoid cyst capsule was achieved. There were no cases of vision deterioration and the development of new focal neurological symptoms. One female patient developed hypopituitary disorders in the postoperative period. There was no recurrence of epidermoid cysts during follow-up. CONCLUSION Removal of epidermoid cysts of the chiasmatic region using the extended anterior endoscopic transsphenoidal approach may be an alternative to transcranial microsurgery.
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Affiliation(s)
- D V Fomichev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - P L Kalinin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - M A Kutin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - O I Sharipov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I V Chernov
- Burdenko Neurosurgical Institute, Moscow, Russia
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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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18
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Iannella G, Di Gioia C, Carletti R, Magliulo G. Tympanomastoid cholesterol granulomas: Immunohistochemical evaluation of angiogenesis. Laryngoscope 2017; 127:E283-E290. [PMID: 28158903 DOI: 10.1002/lary.26458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/06/2016] [Accepted: 11/16/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study investigates the immunohistochemical expression of vascular endothelial growth factor (VEGF) and CD34 in patients treated for middle ear and mastoid cholesterol granulomas to evaluate the angiogenesis and vascularization of this type of lesion. A correlation between the immunohistochemical data and the radiological and intraoperative evidence of temporal bone marrow invasion and blood source connection was performed to validate this hypothesis. STUDY DESIGN Retrospective study. METHODS Immunohistochemical expression of VEGF and CD34 in a group of 16 patients surgically treated for cholesterol granuloma was examined. Middle ear cholesteatomas with normal middle ear mucosa and external auditory canal skin were used as the control groups. The radiological and intraoperative features of cholesterol granulomas were also examined. RESULTS In endothelial cells, there was an increased expression of angiogenetic growth factor receptors in all the cholesterol granulomas in this study. The quantitative analysis of VEGF showed a mean value of 37.5, whereas the CD34 quantitative analysis gave a mean value of 6.8. Seven patients presented radiological or intraoperative evidence of bone marrow invasion, hematopoietic potentialities, or blood source connections that might support the bleeding theory. In all of these cases there was computed tomography or intraoperative evidence of bone erosion of the middle ear and/or temporal bone structures. The mean values of VEGF and CD34 were 41.1 and 7.7, respectively. CONCLUSIONS High values of VEGF and CD34 are present in patients with cholesterol granulomas. Upregulation of VEGF and CD34 is indicative of a remarkable angiogenesis and a widespread vascular concentration in cholesterol granulomas. LEVEL OF EVIDENCE 3b. Laryngoscope, 127:E283-E290, 2017.
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Affiliation(s)
| | - Cira Di Gioia
- Radiological, Oncological and Pathological Department, Sapienza University of Rome, Rome, Italy
| | - Raffaella Carletti
- Radiological, Oncological and Pathological Department, Sapienza University of Rome, Rome, Italy
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19
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Fomichev D, Kalinin P, Kutin M, Sharipov O. Endoscopic Endonasal Surgery of Epidermoid Cysts of the Chiasmatic Region. World Neurosurg 2016; 96:159-164. [PMID: 27601152 DOI: 10.1016/j.wneu.2016.08.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite the rarity of epidermoid cysts in the chiasmatic region, their surgical treatment is particularly complicated because of the tendency toward massive dissemination of the epidermoid masses along cerebrospinal fluid pathways and significant deviation of the tumor from the midline. OBJECTIVE The purpose of the present work is evaluation of the role of extended transsphenoidal endoscopic endonasal approaches in the surgery of epidermoid cysts. METHODS The study included 6 patients with epidermoid cysts in the chiasmatic region who were operated on at the Burdenko Neurosurgery Institute in the last 5 years using an anterior extended transsphenoidal endoscopic endonasal approach. RESULTS The epidermoid masses were totally removed in 5 patients, but in no patient was it possible to completely remove the epidermoid cyst capsule. Visual deterioration was not noted in any patient, nor did new focal neurologic symptoms appear. One of the patients developed hypopituitary disorders in the postoperative period. No recurrence of the epidermoid cysts was observed during the follow-up period. CONCLUSIONS Removal of epidermoid cysts in the chiasmatic region using an anterior extended transsphenoidal endoscopic approach may be an alternative to transcranial microsurgery operations. This technique is widely accepted as an approach to this area.
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Affiliation(s)
| | | | - Maxim Kutin
- Burdenko Neurosurgery Institute, Moscow, Russia
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20
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Yawn RJ, Sweeney AD, Carlson ML, Wanna GB. Spontaneous resolution of a petrous apex cholesterol granuloma. Am J Otolaryngol 2016; 37:452-4. [PMID: 26732999 DOI: 10.1016/j.amjoto.2015.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
Abstract
Cholesterol granuloma is the most common primary lesion of the petrous apex. Management of petrous apex cholesterol granuloma has evolved in recent years from primary surgical treatment to conservative observation. In this article, a case of spontaneous resolution of a petrous apex cholesterol granuloma is described. To the authors' knowledge, this is the first known report of spontaneous involution of a petrous apex cholesterol granuloma. Radiographic differential diagnosis of petrous apex lesions and the natural history of cholesterol granulomas are discussed.
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21
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Russo FY, De Seta D, Mosnier I, Sterkers O, Bernardeschi D. Surgical management of petrous apex cholesterol granulomas by an infralabyrinthine approach: our experience with fourteen cases. Clin Otolaryngol 2016; 42:871-875. [PMID: 27513703 DOI: 10.1111/coa.12721] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
- F Y Russo
- Department of Otology Auditory Implants and Skull Base Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,Inserm UMR-S 1159, "Minimally Invasive Robot-Based Hearing Rehabilitation", Paris, France
| | - D De Seta
- Department of Otology Auditory Implants and Skull Base Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,Inserm UMR-S 1159, "Minimally Invasive Robot-Based Hearing Rehabilitation", Paris, France
| | - I Mosnier
- Department of Otology Auditory Implants and Skull Base Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,Inserm UMR-S 1159, "Minimally Invasive Robot-Based Hearing Rehabilitation", Paris, France
| | - O Sterkers
- Department of Otology Auditory Implants and Skull Base Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,Inserm UMR-S 1159, "Minimally Invasive Robot-Based Hearing Rehabilitation", Paris, France
| | - D Bernardeschi
- Department of Otology Auditory Implants and Skull Base Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,Inserm UMR-S 1159, "Minimally Invasive Robot-Based Hearing Rehabilitation", Paris, France
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Abstract
OBJECTIVE To evaluate the clinical and radiographic characteristics of cholesterol granulomas of the petrous apex, as well as the outcomes of operative and conservative management. STUDY DESIGN Retrospective chart review. SETTING Two independent tertiary academic referral centers. PATIENTS Adult and pediatric patients with cholesterol granulomas of the petrous apex were identified from the experience of two separate centers. Patients were included after radiographic diagnosis and clinical evaluation. All patients with less than 6 months of follow-up and those with iatrogenic postoperative cholesterol granulomas were excluded. INTERVENTION Demographic information, presenting symptoms, imaging characteristics, treatment strategies, and outcomes were recorded. MAIN OUTCOME MEASURES Patients were evaluated on the basis of symptom and radiographic evolution during time, with or without operative intervention. RESULTS Ninety petrous apex cholesterol granulomas were analyzed (57.8% females, 55.6% right-sided). The average age at presentation was 43.1 years (median 42.0, range 8.0-77.0 years). The most common presenting symptom was headache (56.7%), and the average lesion size in the greatest dimension was 2.1 cm (median 1.7, range 0.7-5.0 cm). During a mean follow-up of 46.0 months, no cases of spontaneous rupture or carotid injury occurred. Twenty-three patients (25.6%) ultimately underwent surgical management, most commonly for intractable headache, and only 47.8% of these patients experienced durable symptom improvement by their last postoperative follow-up. CONCLUSION Many cholesterol granulomas of the petrous apex remain stable during time and can be safely managed with primary observation. Surgery should be reserved for lesions that are causing, or threatening, neurologic dysfunction because of mass effect or erosion of critical structures such as the otic capsule. Cranial neuropathy associated with cholesterol granuloma may improve after operative management; however, symptoms such as headache and dizziness are less likely to benefit from surgery. As a general guideline, in the presence of a radiologically stable cholesterol granuloma in the petrous apex, alternative etiologies for headache and dizziness should be considered and treated before offering surgical intervention.
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23
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Miller M, Pearl MS, Wyse E, Olivi A, Francis HW. Decompression of the Jugular Bulb for Enhanced Infralabyrinthine Access to the Petroclival Region: A Quantitative Analysis. J Neurol Surg B Skull Base 2016; 77:249-59. [PMID: 27175321 DOI: 10.1055/s-0035-1566302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 09/10/2015] [Indexed: 10/22/2022] Open
Abstract
Objectives To describe an enhanced infralabyrinthine approach to petroclival lesions with jugular bulb decompression, and to quantify surgical access using a flat-panel computed tomography image protocol. Design Retrospective case series and paired comparison of pre- versus post-dissection anatomy. Setting Tertiary academic medical center. Participants Four patients presenting with petroclival lesions. Six fresh cadaveric specimens were used for temporal bone dissection. Main Outcome Measures Axial and coronal dimensions, and access angles of the infralabyrinthine surgical corridor. Results Decompression of the jugular bulb increased the craniocaudal width of the infralabyrinthine corridor from 0.9 to 7.9 mm to 6.5 to 11.6 mm. The mean increase of 4 mm was statistically significant (t = 3.7; p < .05). There was also a significant widening of the infralabyrinthine window along the axial dimension by 0.9 to 4.5 mm or a mean of 2 mm (t = 3.7; p < .05). Angles of access to the petroclival region were wider following jugular bulb decompression, particularly in the coronal plane (mean difference 7.9 degrees; t = 5.0; p < .005) but less so in the axial plane (mean difference 4.7 degrees; t = 2.5; p = .05). Conclusions Jugular bulb decompression enhances infralabyrinthine access to petroclival lesions, permitting the removal of tissue for diagnoses or partial resection, without significant additional morbidity.
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Affiliation(s)
- Matthew Miller
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Monica S Pearl
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Emily Wyse
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Alessandro Olivi
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Howard W Francis
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, United States
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Iannella G, Stasolla A, Pasquariello B, Re M, Magliulo G. Tympanomastoid cholesterol granuloma: radiological and intraoperative findings of blood source connection. Eur Arch Otorhinolaryngol 2015; 273:2395-401. [PMID: 26521188 DOI: 10.1007/s00405-015-3820-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
The hypothesis that the close contiguity between the cholesterol granulomas and some rich blood sources provided the trigger to the aggressive nature of tympanomastoid cholesterol granulomas has been recently reported. To corroborate this new etiopathogenetic theory we retrospectively reviewed a series of 14 patients with primary middle ear and mastoid cholesterol granulomas and investigated the temporal bone marrow invasion and its hematopoietic potentialities and a possible cholesterol granulomas contiguity with relevant vascular structures such as the carotid artery, sigmoid jugular system, mastoid or dural vein. Eight cases did not show radiological sign of bone marrow invasion or hematopoietic potentialities visible in MRI. Besides no intraoperative vascular connections that could explain an initial bleeding source were found. Cholesterol granulomas bone marrow invasion was present in six patients. A bone marrow hematopoietic potentiality was showed in four of these patients, whereas, an evident anatomical contiguity of the cholesterol granuloma with some important temporal bone vascular structures was visible in five cases. Analysis of cardiovascular risk factors showed that four patients presented one or more of the risk factors analysed.
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Affiliation(s)
- Giannicola Iannella
- 'Organi di Senso' Department, 'Sapienza' University of Rome, Viale del Policlinico, 151, 00161, Rome, Italy
| | - Alessandro Stasolla
- Emergency Radiology Department, 'San Camillo' Hospital, C.ne Gianicolense 87, 00152, Rome, Italy
| | - Benedetta Pasquariello
- 'Organi di Senso' Department, 'Sapienza' University of Rome, Viale del Policlinico, 151, 00161, Rome, Italy
| | - Massimo Re
- Department of Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Giuseppe Magliulo
- 'Organi di Senso' Department, 'Sapienza' University of Rome, Viale del Policlinico, 151, 00161, Rome, Italy. .,, Via Gregorio VII n. 80, 00165, Rome, Italy.
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Eytan DF, Kshettry VR, Sindwani R, Woodard TD, Recinos PF. Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review. Neurosurg Focus 2015; 37:E14. [PMID: 25270133 DOI: 10.3171/2014.7.focus14344] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endoscopic endonasal treatment of petrous apex cholesterol granulomas allows for a natural drainage pathway into the nasopharynx. Because of the limited number of case series in the literature, there is limited evidence of recurrence rates and outcomes following endoscopic endonasal management. The purpose of this study was to determine the surgical outcomes of endoscopic endonasal approaches in the treatment of cholesterol granulomas of the petrous apex. METHODS A systematic literature review was performed using PubMed for articles published from January 1980 to April 2014 to identify all studies reporting outcomes for endoscopic endonasal surgical management of cholesterol granulomas of the petrous apex. Operative approach, use of a stent, symptom outcome, restenosis, cyst recurrence, reoperation, and complications were extracted from included studies. RESULTS A total of 53 patient cases were included from 22 relevant studies. The mean age was 41 years, and 26 patients (49%) were female. Stents were used in 45.1% of cases. Symptom resolution or improvement was seen in 98.6% of cases at follow-up (mean follow-up 20 months). Complications were reported in 13.2% of cases, with the most common complication being epistaxis. Restenosis on follow-up office endoscopic examination occurred in 9 of 45 cases (20.0%). Only 4 of these restenosis cases resulted in symptomatic cyst recurrence, resulting in an overall recurrence rate of 7.5%. The mean time from surgery to cyst recurrence was 13.5 months. The rate of symptomatic cyst recurrence was 10.7% in cases without the use of a stent compared with 4.3% in cases with stent placement (p = 0.6). CONCLUSIONS Based on current literature, endoscopic endonasal approaches result in a high rate of symptom improvement or resolution. Complication rates are lower than prior case series that have utilized open approaches. Asymptomatic restenosis can be managed conservatively, since it is associated with symptomatic cyst recurrence less than half of the time. This study revealed a nonsignificant trend toward a decrease in symptomatic cyst recurrence when a stent was used, but further work is needed to clarify its impact.
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Karligkiotis A, Bignami M, Terranova P, Ciniglio-Appiani M, Shawkat A, Verrilaud B, Meloni F, Herman P, Castelnuovo P. Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex. Int Forum Allergy Rhinol 2015; 5:747-53. [PMID: 25821119 DOI: 10.1002/alr.21521] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 01/18/2015] [Accepted: 02/17/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nowadays the endoscopic approach represents a useful alternative to traditional surgical approaches in the treatment of cholesterol granulomas (CGs) of the petrous apex (PA). Recently the nasoseptal flap (NSF) has been employed to permit long-term patency of drainage site. The purpose of this study is to report our experience with the NSF in the endoscopic management of CG and to analyze the advantages, limitations, and outcomes of the technique. METHODS A retrospective analysis was carried out on 10 patients affected by CG of the PA who had been treated endoscopically, using the NSF. RESULTS An endoscopic transpterygoid approach was used for 6 patients and the remaining 4 were treated using the transclival approach. A NSF was used in all 10 cases. In 6 cases the flap was ipsilateral to the lesion whereas in 4 it was contralateral. In 90% of our patients no evidence of disease was observed after a mean follow-up period of 35.7 months, with resolution of their symptoms. One patient presented a recurrence because of a technical error (inadequate placement of the flap in the cavity), and has been retreated endoscopically. CONCLUSION The pedicled NSF seems to be helpful in avoiding the concentric growth of the granulomatous cyst epithelium while assuring ventilation and drainage of the cyst. However, bigger studies with longer-term follow-up are needed to confirm these findings. Correct and meticulous placement of the flap inside the cystic cavity is the most critical issue for the success of the procedure.
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Affiliation(s)
- Apostolos Karligkiotis
- Division of Otorhinolaryngology, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Maurizio Bignami
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Paola Terranova
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Mario Ciniglio-Appiani
- Ear, Nose, and Throat (ENT) Section, Department of Sensory Organs, Sapienza University of Rome, Rome, Italy
| | - Abdulrahman Shawkat
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Benjamin Verrilaud
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hopitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, Equipe d'accueil (EA) Recherche Clinique Cordonnée Ville-Hôpital, Méthodologies et Société (REMES), Paris, France
| | - Francesco Meloni
- Division of Otorhinolaryngology, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Philippe Herman
- Department of Otorhinolaryngology, Lariboisière Hospital, Assistance Publique-Hopitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, Equipe d'accueil (EA) Recherche Clinique Cordonnée Ville-Hôpital, Méthodologies et Société (REMES), Paris, France
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Raghavan D, Lee TC, Curtin HD. Cholesterol Granuloma of the Petrous Apex: A 5-Year Review of Radiology Reports with Follow-Up of Progression and Treatment. J Neurol Surg B Skull Base 2015. [PMID: 26225314 DOI: 10.1055/s-0034-1396600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objectives To assess the stability and outcomes of patients with cholesterol granulomas at Brigham and Women's Hospital. Design A retrospective review of neuroradiology magnetic resonance imaging (MRI) studies was performed. The number of newly diagnosed cases of cholesterol granuloma per year was determined. Additional data included age and gender, clinical presentation if applicable, growth on imaging follow-up, and recurrence on postoperative follow-up if applicable. Participants Inclusion criteria included patients who underwent MRI studies between January 1, 2009 and July 1, 2013. Upon review of imaging of these patients, 18 patients had findings compatible with cholesterol granuloma. Results During the study period, an average of three cases of cholesterol granuloma were diagnosed on MRI per year. Three of 18 patients underwent treatment. Two underwent surgery, both of whom demonstrated recurrence on postoperative follow-up imaging. One patient who underwent computed tomography-guided percutaneous aspiration and Gelfoam (Pfizer, New York, United States) embolization had no recurrence on imaging follow-up of up to 23 months. Among the patients who were observed without intervention, growth was identified in only one patient. Conclusions Cholesterol granulomas are a rare entity; however, their appearance on imaging may be greater than previously reported. Most of the lesions demonstrate stability and can be observed.
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Affiliation(s)
- Deepak Raghavan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Thomas C Lee
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Hugh D Curtin
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States ; Department of Radiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, United States
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Cömert E, Cömert A, Çay N, Tunçel Ü, Tekdemir İ. Surgical Anatomy of the Infralabyrinthine Approach. Otolaryngol Head Neck Surg 2014; 151:301-7. [DOI: 10.1177/0194599814527725] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/21/2014] [Indexed: 11/16/2022]
Abstract
Objective The objective of this study is to demonstrate the surgical anatomy of the infralabyrinthine approach (ILA) and ways to prevent complications based on the complex anatomy. Study Design Cadaveric study. Setting Ankara University Faculty of Medicine, Department of Anatomy. Subjects and Methods Temporal bones were selected from 30 sides of 20 fixed human cadaver heads. Computed tomography (CT) scans of the heads were performed and, afterward, the cadavers were dissected using a surgical microscope and electric drill. Results An appropriate tract could be achieved in 73.3% of the dissections by applying slight pressure to the jugular bulb (JB). The narrowest portion of the ILA was defined as the inner window, which was located superior-inferiorly between the inferior border of the cochlea and the inferior wall of the petrous apex and anterior-posteriorly between the posterior wall of the carotid canal and the cochlear opening of the cochlear aqueduct. The ILA could not be performed when the distances between the facial nerve-JB and JB-cochlea were less than 2.9 mm and 2.6 mm, respectively, on CT scan. Conclusion Close attention should be paid to the access and inner window during preoperative temporal bone imaging to assess for ILA. The detailed anatomy of the route, measurements of the topography of the cochlea from the mastoid view, and angles of the route are defined to prevent complications.
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Affiliation(s)
- Ela Cömert
- Clinic of Otolaryngology, Ankara Oncology Education and Research Hospital, Ankara, Turkey
- Department of Anatomy, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Ayhan Cömert
- Department of Anatomy, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Nurdan Çay
- Department of Radiology, Ataturk Education and Research Hospital, Ankara, Turkey
| | - Ümit Tunçel
- Clinic of Otolaryngology, Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - İbrahim Tekdemir
- Department of Anatomy, Ankara University, Faculty of Medicine, Ankara, Turkey
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Minimally invasive image-guided access for drainage of petrous apex lesions: a case report. Otol Neurotol 2014; 35:649-55. [PMID: 24622019 DOI: 10.1097/mao.0000000000000328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In this case report, we present a novel, minimally invasive image-guided approach to drainage of a petrous apex lesion. PATIENT(S) A 34-year-old man diagnosed with a petrous apex lesion consistent with cholesterol granuloma. The granuloma was large and caused mild compression of the brainstem with associated neurologic symptoms and seizure-like activity. INTERVENTIONS Based on the anatomic location of the lesion, it was determined that the treatment plan would be to surgically drain the lesion via 2 linear paths-one after an infralabyrinthine approach and the other a subarcuate approach. Customized microstereotactic frames that mount on bone-implanted markers and constrain the drill along the desired path were used to accurately drill these desired paths and avoid damage to surrounding critical structures. After a simple mastoidectomy, the petrous apex was successfully reached without damage to vital adjacent structures by drilling the 2 linear channels using 2 custom microstereotactic frames. MAIN OUTCOME MEASURES Viscous brown liquid and debris was recovered by irrigating through one of the channels and suctioning through the other. RESULTS Drainage of the petrous apex was successfully performed via 2 linear channels without any complications. Custom microstereotactic frames were used to accurately drill those linear channels. Postoperative CT ensured no complications. Postoperative course of the patient was remarkable with normal hearing and normal facial nerve function. CONCLUSION We presented a successful implementation of an image-guided approach to drain petrous apex.
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Abstract
Cholesterol granulomas are the most common lesions involving the petrous apex. However, they are still an uncommon finding overall, and they often remain undiagnosed until they have become extremely large and symptomatic. Many surgical approaches to the petrous apex exist. Factors that often influence the surgical approach include the surgeon's experience, the patient's anatomy, and the patient's hearing status. The purpose of this case report—which involved a 66-year-old woman who was referred to our clinic for evaluation of severe headaches, dizziness, and left sided pulsatile tinnitus—is to demonstrate the definitive need for an extended middle fossa approach when a bilobed petrous apex mass is encountered.
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Affiliation(s)
- Aaron G. Benson
- From the Ohio Hearing and Balance Institute, Toledo
Ear, Nose and Throat, Saint Luke's Hospital, Maumee, Ohio
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Endoscopic transsphenoidal drainage of an aggressive petrous apex cholesterol granuloma: unusual complications and lessons learnt. The Journal of Laryngology & Otology 2013; 127:1230-4. [PMID: 24280098 DOI: 10.1017/s0022215113002983] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This case report describes the endoscopic transsphenoidal management of a cholesterol granuloma situated in a technically challenging part of the petrous apex, and the associated peri- and post-operative complications that arose. The literature on diagnosis and management of petrous apex cholesterol granulomas is reviewed. METHOD AND RESULTS Surgical intervention was attempted on three occasions, each time via an endoscopic, transsphenoidal approach with image guidance. The procedure was abandoned on the first occasion as there was a significant risk to the carotid artery; only a small drainage ostium was created because of the proximity of the carotid artery. The second attempt, complicated by copious bleeding from the clival venous plexus, was arrested prematurely. Successful drainage was achieved at the third attempt, but recovery was complicated by tension pneumocephalus. CONCLUSION The transnasal route is less invasive than a lateral labyrinthine or cochlear approach, and spares cochlear and vestibular function. However, this approach is not without risk. It is important to consider the natural anatomical variance of vasculature when planning surgical intervention for a lesion situated in a technically challenging part of the petrous apex. Additional magnetic resonance venography is recommended to circumnavigate the venous plexus, thereby avoiding an unexpected breach.
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Usefulness of image guidance in the surgical treatment of petrous apex cholesterol granuloma. Case Rep Otolaryngol 2013; 2013:257263. [PMID: 24251056 PMCID: PMC3819795 DOI: 10.1155/2013/257263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 09/18/2013] [Indexed: 11/18/2022] Open
Abstract
The petrous apex is a pyramid-shaped structure, located medial to the inner ear and the intrapetrous segment of the internal carotid artery. Lesions of the petrous apex can be surgically treated through different surgical routes. Because of the important neurovascular structures located inside the temporal bone, anatomical 3D knowledge is paramount. For this reason, image-guided surgery could represent a useful tool. We report the case of a young woman who came to our observation for a trigeminal neuralgia due to a petrous apex cholesterol granuloma. The lesion was treated through the placement of a drainage tube via an infracochlear approach, with the aid of neuronavigation and intraoperative MRI. Preoperative CT scan images and intraoperative MRI images were fused for surgical planning. The accuracy of the neuronavigation system has proved to be good, and the safety of the procedure was enhanced. Therefore, neuronavigation and intraoperative MRI, though not available in all neurootological centres, should be considered useful tools in these challenging procedures.
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Kusumi M, Fukushima T, Mehta AI, Cunningham CD, Friedman AH, Fujii K. Middle fossa approach for total resection of petrous apex cholesterol granulomas: use of vascularized galeofascial flap preventing recurrence. Neurosurgery 2013; 72:77-86; discussion 86. [PMID: 22986599 DOI: 10.1227/neu.0b013e3182724354] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cholesterol granulomas (CGs) of the petrous apex (PA) are rare, benign, expanding lesions. Surgical treatment is recommended for patients with symptomatic disease; however, the optimal surgical procedure is still controversial due to high recurrence rates. The main treatment strategy is divided into drainage and complete resection. OBJECTIVE We advocate radical resection of the lesion by the middle fossa approach and reconstruction with a vascularized galeofascial flap. METHODS A 10-year retrospective case review of 17 patients undergoing surgical treatment of PA CGs between 2000 and 2010 was undertaken. Operative outcomes and surgical complications were analyzed. In addition, our operative method and the related anatomy are described from cadaveric dissections. RESULTS All but 1 patient was operated on via a middle fossa approach. Using the middle fossa approach, radical resection of all PA CGs was achieved with obliteration of the cyst cavity using a vascularized flap. Important surrounding structures included the internal auditory canal, cochlea, petrous carotid artery, and abducens nerve. There was 1 death caused by internal carotid artery occlusion. No other major complications or cranial nerve deficits occurred postoperatively. Clinical recurrence occurred in 1 patient (5.9%). CONCLUSION Our technique of radical resection and reconstruction with a vascularized flap has the advantage of being less invasive with less cosmetic deformity and allows preservation of cranial nerve function with a low recurrence rate. Knowledge of the surgical anatomy and the characteristics of CG is prudent because important neurovascular structures may be exposed behind the CG wall due to bony erosion.
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Affiliation(s)
- Mari Kusumi
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA.
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Petrous apex cholesterol granuloma: pictorial review of radiological considerations in diagnosis and surgical histopathology. The Journal of Laryngology & Otology 2013; 127:339-48. [PMID: 23442366 DOI: 10.1017/s0022215113000091] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Petrous apex cholesterol granulomas are expansile, cystic lesions containing cholesterol crystals surrounded by foreign body giant cells, fibrous tissue reaction and chronic inflammation. Appropriate treatment relies on an accurate radiological diagnosis and an understanding of the distinguishing radiological features of relevant entities in the differential diagnosis of this condition. METHODS Firstly, this paper presents a pictorial review of the relevant radiological features of petrous apex cholesterol granuloma, and highlights unique features relevant to the differential diagnosis. Secondly, it reviews the histopathological and radiological findings associated with surgical drainage of these lesions. RESULTS Radiological features relevant to the differential diagnosis of petrous apex cholesterol granuloma are reviewed, together with radiological and histopathological features relevant to surgical management. Following surgical management, histopathological and radiological evidence demonstrates that the patency of the surgical drainage pathway is maintained. CONCLUSION Accurate diagnosis of petrous apex cholesterol granuloma is essential in order to instigate appropriate treatment. Placement of a stent in the drainage pathway may help to maintain patency and decrease the likelihood of symptomatic recurrence.
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Petrous apex cholesterol granuloma: maintenance of drainage pathway, the histopathology of surgical management and histopathologic evidence for the exposed marrow theory. Otol Neurotol 2012; 33:1059-65. [PMID: 22710556 DOI: 10.1097/mao.0b013e31825d63ea] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES (1) To assess the maintenance of drainage pathway patency in patients who undergo surgical management of cholesterol granulomas, (2) to review the histopathologic and radiologic changes associated with surgical drainage of petrous apex (PA) cholesterol granulomas, and (3) to provide histopathologic evidence regarding the exposed marrow theory of PA cholesterol granulomas. STUDY DESIGN Retrospective case review and histopathologic analysis. SETTING Tertiary referral center. PATIENTS Records of 17 patients with surgically managed PA cholesterol granulomas were reviewed. Histopathologic analysis was performed on temporal bones of 11 patients with PA cholesterol granulomas from the Temporal Bone repository at the House Research Institute. INTERVENTIONS Surgical drainage of PA cholesterol granulomas; follow-up radiologic imaging (computed tomography or magnetic resonance imaging), when available. MAIN OUTCOME MEASURES Primary outcome is demonstrated maintenance of a PA outflow drainage pathway after the surgical drainage procedure as assessed by radiologic imaging, available histopathology, and/or recurrence of symptoms indicating failure of maintenance. Other measures include need for revision surgery and histopathology findings. RESULTS A majority (65%) of patients exhibited maintenance of their PA drainage pathway. Histopathologic evidence suggests that the PA drainage pathway can be maintained for many years after surgical drainage. Recurrence of symptoms was related to obstruction of the drainage pathway by fibrous tissue and/or granulomatous tissue. Placement of a stent improved the patient's chance of remaining symptom-free, with recurrence of symptoms and revision surgery required in only 2 stent cases (18%) as compared with 83% of those with no stent (p ≤ 0.035). Histopathologic evidence for the exposed marrow theory of PA cholesterol granulomas was found. CONCLUSION The majority of patients who undergo surgical drainage of PA cholesterol granulomas remain symptom-free after surgical drainage. Histopathologic analysis of temporal bone specimens provides evidence supporting the exposed marrow theory of PA cholesterol granuloma formation. Loss of patency of the PA drainage pathway may be an important predictor for symptomatic recurrence of PA cholesterol granulomas. Placement of a stent may decrease the likelihood of symptomatic recurrence.
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Scopel TF, Fernandez-Miranda JC, Pinheiro-Neto CD, Peris-Celda M, Paluzzi A, Gardner PA, Hirsch BE, Snyderman CH. Petrous apex cholesterol granulomas: endonasal versus infracochlear approach. Laryngoscope 2012; 122:751-61. [PMID: 22434679 DOI: 10.1002/lary.22448] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to investigate and compare the surgical anatomy of two different routes to access and drain petrous apex (PA) cholesterol granulomas: the expanded endonasal approach (EEA) and the transcanal infracochlear approach (TICA). STUDY DESIGN Anatomic and radiologic study. METHODS The EEA and TICA to the PA were performed in 11 anatomic specimens with the assistance of imaging guidance. The PA was categorized into three zones: superior PA, anterior-inferior PA, and posterior-inferior PA. The maximum drainage window achieved by each approach was calculated using the imaging studies of each anatomic specimen. RESULTS The EEA was able to reach superior PA and anterior-inferior PA in all specimens and posterior-inferior PA in 90%. The TICA did not provide access to superior PA in any case. The TICA was suitable to reach anterior-inferior PA in 80% of specimens and posterior-inferior PA in 60%. Based on the radiologic study, the EEA provided a drainage window three times larger than the TICA. CONCLUSIONS The transnasal approach provides reliable access to the PA when combined with internal carotid artery exposure and allows for large drainage window. The transcanal approach is less versatile and more limited than the transnasal approach but provides access to the most posterior and inferior portion of the PA without Eustachian tube transection. Here we propose a new surgical classification that may help to decide the most suitable approach to the PA according to the location and extension of the lesion.
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Affiliation(s)
- Tiago Fernando Scopel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA
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Korbmacher D, Lehmann M, Gehl HB, Ebmeyer J, Sudhoff H. Petrous apex cholesterol granuloma involving the sphenoid sinus. EAR, NOSE & THROAT JOURNAL 2012; 90:E23-5. [PMID: 22109929 DOI: 10.1177/014556131109001106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Petrous apex cholesterol granulomas are slowly expanding lesions that clinically present with a variety of cranial nerve deficits. We present a case of a 40-year-old man with a right-sided, sudden-onset hearing loss. Apart from a 60-dB high-frequency sensorineural hearing loss in the right ear, all other neurotologic examinations were normal. Computed tomography revealed partial destruction of the right carotid canal, petrous apex, and clivus. Surgical treatment was performed via an endoscopic transnasal, trans-sphenoid approach using an image-guidance system. Postoperative magnetic resonance imaging showed a significant reduction in the size of the cholesterol granuloma and a stable hearing threshold.
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Affiliation(s)
- Dirk Korbmacher
- Department of Otolaryngology, Head and Neck Surgery, Bielefeld Academic Teaching Hospital, Teutoburger Str. 50, 33604 Bielefeld, Germany
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Paluzzi A, Gardner P, Fernandez-Miranda JC, Pinheiro-Neto CD, Scopel TF, Koutourousiou M, Snyderman CH. Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients. J Neurosurg 2012; 116:792-8. [DOI: 10.3171/2011.11.jns111077] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Carl H. Snyderman
- 2Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jaberoo MC, Hassan A, Pulido MA, Saleh HA. Endoscopic endonasal approaches to management of cholesterol granuloma of the petrous apex. Skull Base 2011; 20:375-9. [PMID: 21359004 DOI: 10.1055/s-0030-1253574] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cholesterol granulomas are the most common lesion of the petrous apex. Traditionally, lesions of the petrous apex have been accessible via open, infracochlear, and transtemporal approaches. We describe two cases in which the endoscopic transsphenoidal approach was used to manage this lesion. The design of this study is as a review of new endoscopic approaches. The setting of the study is a tertiary referral unit in a London teaching hospital. Case 1: A 53-year-old man diagnosed with bilateral cholesterol granulomas of the petrous apices. Case 2: A 32-year-old woman diagnosed with a right-sided cholesterol granuloma of the petrous apex. The main outcome measures were symptom resolution and postoperative complications. An endoscopic transsphenoidal approach was used in the first case. In the second case, the lesion was approached through the nasopharynx, an approach that has not been described previously. Both patients' symptoms resolved and no complications occurred. Transsphenoidal endoscopic removal of cholesterol granulomas is a recent advance in the extended applications of sinus surgery. It allows for a less invasive procedure with markedly less associated morbidity.
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Affiliation(s)
- Marie-Claire Jaberoo
- Department of Otorhinololaryngology, Charing Cross Hospital, London, United Kingdom
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Wu KC, Shu MT, Yang CC. Cholesterol granuloma of the external ear canal: A rare presentation. EAR, NOSE & THROAT JOURNAL 2011; 89:E16. [PMID: 21174266 DOI: 10.1177/014556131008901205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Almost all aural cholesterol granulomas develop in the mucosa of the middle ear. We describe the case of a 14-year-old girl who presented with an asymptomatic, nontender, dark-blue, cystic lesion in the posteroinferior portion of the left ear canal. The mass was excised via a postauricular approach. Postoperatively, the mass was identified as a cholesterol granuloma on pathologic examination. To the best of our knowledge, this is the first reported case of a human cholesterol granuloma limited to the external ear canal.
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Affiliation(s)
- Kang-Chao Wu
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Hsin-Chu City, Taiwan
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Shoman NM, Samy RN, Pensak ML. Double-barrel stenting in infracochlear approach for drainage of petroux apex cholesterol granulomas. Laryngoscope 2011; 121:574-6. [PMID: 21344437 DOI: 10.1002/lary.21420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 10/13/2010] [Indexed: 11/07/2022]
Affiliation(s)
- Nael M Shoman
- Department of Otolaryngology-Head and Neck Surgery, Division of Otology/Neurotology and Skull Base Surgery, The Neurosciences Institute, University of Cincinnati/Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Radiographic anatomy of the infracochlear approach to the petrous apex for computer-assisted surgery. Otol Neurotol 2010; 31:419-23. [PMID: 20084044 DOI: 10.1097/mao.0b013e3181c99524] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE 1) To define the surgical anatomy and dimensions of the infracochlear approach to the petrous apex through the use of high-resolution computed tomography and 2) use of digitized images of cadaveric temporal bones for computer simulation of infracochlear access using the Ohio Supercomputer Center/Ohio State University temporal bone simulator. BACKGROUND The petrous apex is a surgically challenging area to access. Many routes have been described and used successfully in clinical practice. However, these routes have not been defined with the aim of application in computer-assisted surgery. The infracochlear approach, due to its access via a transcanal route, affords the opportunity for its potential application in minimally invasive computer-assisted surgery. METHODS High-resolution computed tomographic scans were performed on 102 cadaveric skulls (204 temporal bones). Standard measurements were taken using an open-source picture archiving and communication system software of the maximum height, width, and depth of the infracochlear approach. In addition, the maximum diameter of a circular fenestration that could be created in the infracochlear space without breaching the basal turn of the cochlea, internal carotid artery, or the jugular bulb was used to simulate a drill path. In addition, 5 temporal bone specimens (3 left, 2 right) underwent high-resolution computed tomography, with the digitized images being used to create simulated temporal bones for infracochlear surgical access; the transcanal infracochlear approach was then performed by the same surgeon on the cadaveric bone. RESULTS The mean height, width, and depth of the infracochlear space in temporal bones with nonpneumatized petrous apices were 7.2 +/- 0.4, 9.4 +/- 0.8, and 17.5 +/- 1.0 mm, respectively. Corresponding dimensions in pneumatized petrous apices were 7.6 +/- 0.4, 10.1 +/- 1.1, and 18.6 +/- 0.8 mm, respectively. The mean diameter of the circular fenestra in the nonpneumatized petrous apices was 5.1 +/- 0.4 compared with 5.7 +/- 0.6 mm in pneumatized petrous pieces. This was statistically significant (unpaired t test; p value = 0.04). The time to perform a simulated infracochlear approach to the petrous apex ranged from 3.1 to 12.6 minutes (mean, 6.1 minutes). The time to perform the same approach on the cadaveric bone ranged from 4.32 to 14.1 minutes (mean, 9.3 minutes). CONCLUSION Temporal bones with pneumatized petrous apices have an overall larger infracochlear space. The mean diameter of a circular infracochlear path that would avoid damage to vital structures was sufficiently large in both pneumatized and nonpneumatized petrous apices to have a potential application as a safe approach in computer-assisted surgery. Such an application is feasible with mating of a robotic system with computed tomographic- or magnetic resonance imaging-guided imagery, which is the next phase of this study.
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Sanna M, Dispenza F, Mathur N, De Stefano A, De Donato G. Otoneurological management of petrous apex cholesterol granuloma. Am J Otolaryngol 2009; 30:407-14. [PMID: 19880030 DOI: 10.1016/j.amjoto.2008.08.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 08/03/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of the study is to review the management of petrous apex cholesterol granuloma. The surgical approaches for drainage or total removal and the wait and see policy were analyzed, and outcomes were evaluated. METHODS Retrospective charts of 27 patients managed for petrous apex cholesterol granuloma with a minimum follow-up of 12 months were analyzed in a quartenary skull base center. Presenting symptoms and signs were recorded, and radiologic imaging was evaluated. Management options included wait and see policy and surgery by several approaches. RESULTS The mean age of patients affected by the lesion was 38.8 years. The mean follow-up was 56.7 months. Patients complained of hearing loss, vertigo, tinnitus, diplopia, hemifacial spasm, trigeminal neuralgia, and facial paresthesia. Twelve patients were managed by wait and see policy, and in this category, only one lesion showed growth during the follow-up. Depending upon size and location, 15 patients were surgically treated by infralabyrinthine approach (9 patients), infratemporal type B approach (3 patients), combined infratemporal type B transotic approach (2 patients), and transotic approach (1 patient). One recurrence was recorded during the follow-up. CONCLUSIONS Radiologic evaluation is required for diagnosis and management. Patients with good hearing can be treated by infralabyrinthine approach. Infratemporal fossa type B approach is advocated in patients with extensive disease and internal carotid artery involvement. Wait and see policy is recommended for asymptomatic cases. Drainage and permanent ventilation are the goals of treatment. Complete removal is indicated in selected cases where placement of drainage tube is not feasible.
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Affiliation(s)
- Mario Sanna
- Fellow Gruppo Otologico Piacenza-Roma, Italia
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CT venography: use in selecting a surgical approach for the treatment of petrous apex cholesterol granulomas. Otol Neurotol 2009; 30:386-91. [PMID: 19318890 DOI: 10.1097/mao.0b013e31819d3355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate the use of computed tomographic (CT) venography in selecting a surgical approach for cholesterol granulomas. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Three patients presented with symptomatic petrous apex cholesterol granulomas with extensive bone erosion involving the jugular fossa. INTERVENTION(S) Computed tomographic venography was performed on each patient before selecting a surgical approach for drainage. MAIN OUTCOME MEASURE(S) Localization of the jugular bulb in relation to the petrous carotid artery and basal turn of the cochlea was ascertained in each subject. RESULTS Three patients with large symptomatic cholesterol granulomas were identified. Conventional CT demonstrated extensive bone erosion involving the jugular fossa in each patient. The location of the jugular bulb and its proximity to the petrous carotid artery and basal turn of the cochlea could not be determined with conventional temporal bone CT and magnetic resonance imaging. Computed tomographic venography provided the exact location of the jugular bulb in all 3 patients. The favorable position of the jugular bulb in all 3 cases permitted drainage of these lesions using an infracochlear approach. CONCLUSION Computed tomographic venography provided invaluable information in 3 patients with large symptomatic cholesterol granulomas. All 3 patients were previously thought to be unsuitable candidates for an infracochlear or infralabyrinthine approach because of the unknown location of the jugular bulb.
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Bilateral middle ear cholesterol granuloma in familial hypercholesterolemia. Otolaryngol Head Neck Surg 2008; 138:803-4. [DOI: 10.1016/j.otohns.2008.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 02/15/2008] [Accepted: 02/27/2008] [Indexed: 11/21/2022]
Abstract
Cholesterol granuloma (CG) is a histologic description of foreign body giant cell formation toward cholesterol crystals. The majority of temporal bone CG is unilateral and most common in the petrous apex. Middle ear CG is usually the result of underlying ear diseases. Primary middle ear CG is very rare. Most reported CG has not been associated with familial hypercholesterolemia (FH). FH, an autosomal dominant disorder, manifests as high levels of serum cholesterol and low density lipoprotein (LDL) cholesterol. We report a rare case of FH and bilateral aggressive primary middle ear CG. This publication has been approved by the IRB, Hospital Alor Setar.
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Castillo MP, Samy RN, Isaacson B, Roland PS. Petrous apex cholesterol granuloma aeration: does it matter? Otolaryngol Head Neck Surg 2008; 138:518-22. [PMID: 18359365 DOI: 10.1016/j.otohns.2007.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 11/26/2007] [Accepted: 12/11/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether aeration of surgically treated petrous apex cholesterol granulomas (PA CG) has any correlation with resolution of symptoms. STUDY DESIGN Retrospective chart review. SUBJECTS Twenty-six patients with a petrous apex cholesterol granuloma during a 16-year period were reviewed. RESULTS Seventeen of 26 (65%) patients underwent surgical intervention. Preoperative symptoms included headache, facial weakness/twitching or numbness, vertigo, hearing loss, vision changes, and tinnitus. Postoperative symptoms resolved in 9 of the 16 patients (56%). Three patients had a postoperative headache. Facial nerve dysfunction persisted or recurred in four patients. One patient was lost to follow-up. Thirteen patients had postoperative imaging. All 13 (100%) patients demonstrated stable or increased size of PA CG with no evidence of aeration. Revision surgery was performed in four patients (25%) for facial nerve symptoms or persistent headaches. CONCLUSION The extent of PA CG aeration on postoperative imaging had no correlation to symptom resolution or cyst enlargement. Revision surgery should not depend on imaging alone but primarily on patient symptoms and physical exam.
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Affiliation(s)
- Michael P Castillo
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Abstract
PURPOSE OF REVIEW This paper reviews the literature relating to the pathogenesis, diagnosis and management of petrous apex cholesterol granulomas. RECENT DEVELOPMENTS Diagnosis of cholesterol granulomas can be challenging due to the rarity of this surgical condition and similarities to other petrous apex pathology. Recent literature reports novel locations of cholesterol granulomas, provides support for a new theory of pathogenesis, describes additional cases of endoscopic approaches to excision, and evaluates the efficacy of stenting to prevent recurrence of the lesion. SUMMARY Cholesterol granulomas of the petrous apex are significant due to their similarity to other petrous apex lesions, their adverse effect on cranial nerves and their challenging surgical location. These lesions are now believed to be an inflammatory reaction to the by-products of eroded marrow cavities in the temporal bone. The ideal surgical approach takes into account the hearing status of the patient and lesion location and may include the endoscopic transsphenoid, transmastoid, infralabyrinthine, middle fossa, and transotic approaches. Lesions should be excised, drained, and stented with the largest diameter silicone stent possible.
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Affiliation(s)
- Mark C Royer
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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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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Sincoff EH, Liu JK, Matsen L, Dogan A, Kim I, McMenomey SO, Delashaw JB. A novel treatment approach to cholesterol granulomas. J Neurosurg 2007; 107:446-50. [PMID: 17695405 DOI: 10.3171/jns-07/08/0446] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ The authors report a novel technique for the treatment of cholesterol granulomas. An extradural middle fossa approach was used to access the granuloma, with drainage through silastic tubes into the sphenoid sinus via the anteromedial triangle between V1 and V2.
Cholesterol granulomas occur when the normal aeration and drainage of temporal bone air cells is occluded, resulting in vacuum formation and transudation of blood into the air cells. This process results in anaerobic breakdown of the blood with resulting cholesterol crystal formation and an inflammatory reaction. Traditional treatment of this lesion involves extensive drilling of the temporal bone to drain the granuloma cyst and establish a drainage tract into the middle ear. Such drainage procedures can be time consuming and difficult, and potentially involve structural damage to the inner ear and facial nerve. An extradural middle fossa approach provides easy access to the granuloma and anterior petrous bone entry into the granuloma for resection. Granuloma drainage is then achieved using shunt tubing in the sphenoid sinus via a small hole in the anteromedial triangle between V1 and V2.
Five patients with symptomatic cholesterol granuloma were treated without complication using this novel extradural middle fossa approach. One patient required reoperation 1-year postoperatively for cyst regrowth and occlusion of the drainage tube. At the 5-year follow-up examination, no patient reported recurrent symptoms.
Extradural middle fossa craniotomy and silastic tube drainage into the sphenoid sinus is a viable alternative method for treatment of cholesterol granuloma.
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Affiliation(s)
- Eric H Sincoff
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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