Endoscopic Endonasal Transpterygoid Approach Using Pedicled Nasoseptal Flap for Petrous Apex Cholesterol Granuloma With Intraoperative Video

Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma

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.

Contemporary surgical management of skull base chordomas - anatomical reflections on a single center experience retrospective case series

Chordoma, a rare, locally aggressive tumor can affect the central skull base, usually centered at the midline. Complete surgical resection remains mainstay of therapy in case of primary as well as recurrent tumors. Owing to their secluded location, surgical resection of skull base chordomas remains a challenge, even though the recent advancement of endoscopic endonasal approaches has had a significant positive impact on the management of these patients. Endoscopic endonasal approaches have been shown to significantly reduce surgical morbidity when compared to traditional open approaches, however the classical endoscopic transclival midline approach fails to sufficiently expose parts of many skull base chordomas. More recent refinements of the technique, such as the interdural pituitary transposition and posterior clinoidectomy, the transpterygoid plate approach and the transcondylar far medial (TFM) approach enable the surgeon the increase the resection rate in these patients. This retrospective case series focuses on anatomical aspects in the surgical management of patients with skull base chordomas. We outline the surgical anatomy of contemporary endoscopic approaches to the skull base based intraoperative illustrations as well as pre- and postoperative 3D reconstructed CT and MR images if our patients. This article should help the clinical choose the most appropriate approach and be aware of relevant anatomy as well as potential shortcomings of a given approach.