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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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Yamakami I, Kubota S, Higuchi Y, Horiguchi K, Matsuda T. Cyst-to-Mastoid Antrum Diversion as an Alternate Pathway for Management of Small Symptomatic Petrous Apex Cholesterol Granuloma Without Anteromedial Expansion Using an Extradural Middle Fossa Approach: A Technical Case Report. Oper Neurosurg (Hagerstown) 2023; 24:e126-e129. [PMID: 36637323 DOI: 10.1227/ons.0000000000000473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/19/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Cholesterol granuloma (CG) is the most common petrous apex (PA) cystic lesion. Posterolateral expansion of a PA CG (PACG) compresses the internal auditory canal (IAC), leading to vestibulocochlear (VC) and facial nerve dysfunction. Even small, symptomatic PACGs are managed surgically. The preferred strategy is not complete removal, but drainage and aeration. PACG with anteromedial expansion using an endoscopic endonasal approach provides natural drainage into the nasal sinus without risking VC and facial dysfunction. Endoscopic endonasal approach is inappropriate for small PACGs without anteromedial expansion because of potential damage to the petrous internal carotid artery. Small PACGs without anteromedial expansion are managed using extradural middle fossa (EMF) approach, which lacks a natural drainage pathway, thus necessitating an artificial drainage pathway for PACG aeration to prevent recurrence. We introduced EMF approach for CG decompression and cyst-to-mastoid antrum (MA) diversion for managing small, symptomatic PACGs without anteromedial expansion. CLINICAL PRESENTATION A 48-year-old woman presented with headache, vertigo, tinnitus, and left hemifacial spasm with preserved hearing because of IAC compression caused by a small PACG without anteromedial expansion. Using the EMF approach, the CG and IAC were safely decompressed. Effective and long-standing artificial drainage for CG aeration was established by anterior petrosectomy and silicone tubing from the CG into the MA. Surgery resolved the symptoms, which have not recurred in 3 years. CONCLUSION Granuloma decompression and cyst-to-MA diversion using silicone tubing using the EMF approach is a safe and effective surgical management for small, symptomatic PACG without anteromedial expansion.
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Affiliation(s)
- Iwao Yamakami
- Neurosurgery, Seikei-kai Chiba Medical Center, Chuo-ku, Chiba, Japan
| | - Shunsuke Kubota
- Neurosurgery, Seikei-kai Chiba Medical Center, Chuo-ku, Chiba, Japan
| | - Yoshinori Higuchi
- Neurosurgery Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Kentaro Horiguchi
- Neurosurgery Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Tatsuma Matsuda
- Neurosurgery Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
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Petrous bone lesions: surgical implementation and outcomes of extradural subtemporal approach. Acta Neurochir (Wien) 2021; 163:2881-2894. [PMID: 34420107 DOI: 10.1007/s00701-021-04962-5] [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: 05/24/2021] [Accepted: 07/31/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Petrous bone lesions (PBLs) are rare with few reports in the neurosurgical literature. In this study, the authors describe our current technique of extradural subtemporal approach (ESTA). The objective of this study was to evaluate the role and efficacy of ESTA for treatment of the PBLs. To our knowledge, this is the largest reported clinical series of using an ESTA-treated PBLs in which the clinical outcomes were evaluated. METHODS Between 1994 and 2019, 67 patients with PBLs treated by ESTA were retrospectively reviewed. Extent of resection, neurological outcomes, recurrence rate, and surgical complications were evaluated and compared with previous studies. The indications, advantages, limitations, and outcomes of ESTA were analyzed according to pathology. RESULTS This series included 7 facial nerve schwannomas (10.4%), 16 cholesterol granulomas (23.9%), 16 chordomas (23.9%), 6 chondrosarcomas (9%), 5 trigeminal schwannomas (7.5%), 9 epidermoids/dermoids (13.4%), and 8 other pathologies (11.9%). The most common location of PBLs operated with ESTA was at the petrous apex and rhomboid areas (68.7%). Gross total resection was achieved in 35 (55.6%). Symptomatic improvement occurred in 56 patients (83.6%). Complications occurred in 7 (10.4%) of cases including one mortality. Nine patients (17%) had recurrence within the mean follow-up 71 months. Compared to previous literature, our results demonstrated comparable outcomes but with higher rates of hearing and facial nerve preservation as well as minimal morbidity. From our results, ESTA is an effective therapeutic option for lesions located at the rhomboid and petrous apex, particularly when patients presented with intact facial and hearing function. CONCLUSION Our series demonstrated that ESTA provided satisfactory outcomes with excellent benefits of hearing and facial function preservation for patients with petrous bone lesions. ESTA should be considered as a safe and effective therapeutic option for selected patients with PBLs.
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Bawornvaraporn U, Zomorodi AR, Friedman AH, Fukushima T. Neurosurgical management of petrous bone lesions: classification system and selection of surgical approaches. Acta Neurochir (Wien) 2021; 163:2895-2907. [PMID: 34313854 DOI: 10.1007/s00701-021-04934-9] [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: 12/15/2020] [Accepted: 06/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgery of petrous bone lesions (PBLs) is challenging for neurosurgeons. Selection of the surgical approach is an important key for success. In this study, the authors present an anatomical classification for PBLs that has been used by our group for over the past 26 years. The objective of this study is to investigate the benefits and applicability of this classification. METHODS Between 1994 and 2019, 117 patients treated for PBLs were retrospectively reviewed. Using the V3 and arcuate eminence as reference points, the petrous bone is segmented into 3 parts: petrous apex, rhomboid, and posterior. The pathological diagnoses, selection of the operative approach, and the extent of resection (EOR) were analyzed and correlated using this classification. RESULTS This series included 22 facial nerve schwannomas (18.8%), 22 cholesterol granulomas (18.8%), 39 chordomas/chondrosarcomas (33.3%), 6 trigeminal schwannomas (5.1%), 13 epidermoids/dermoids (11.1%), and 15 other pathologies (12.8%). PBLs were most often involved with the petrous apex and rhomboid areas (46.2%). The extradural subtemporal approach (ESTA) was most frequently used (57.3%). Gross total resection was achieved in 58.4%. Symptomatic improvement occurred in 92 patients (78.6%). Our results demonstrated a correlation between this classification with each type of pathology (p < .001), selection of surgical approaches (p < 0.001), and EOR (p = 0.008). Chordoma/chondrosarcoma, redo operations, and lesions located medially were less likely to have total resection. Temporary complications occurred in 8 cases (6.8%), persistent morbidity in 5 cases (4.3%), and mortality in 1 case. CONCLUSION In this study, we proposed a simple classification of PBLs. Using landmarks on the superior petrosal surface, the petrous bone is divided into 3 parts, apex, rhomboid, and posterior. Our results demonstrated that chordoma/chondrosarcoma, redo operations, and lesions involving the tip of the petrous apex or far medial locations were more difficult to achieve total resection. This classification could help surgeons understand surgical anatomy framework, predict possible structures at risk, and select the most appropriate approach for each patient.
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Affiliation(s)
- Udom Bawornvaraporn
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
| | - Ali R Zomorodi
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Allan H Friedman
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Takanori Fukushima
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Eisenberg M, Ibn Essayed W, Al-Mefty O. Extirpation of Recurrent Petrous Apex Cholesterol Granuloma Through the Zygomatic Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E229-E230. [PMID: 34114037 DOI: 10.1093/ons/opab156] [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: 01/28/2021] [Accepted: 03/14/2021] [Indexed: 11/14/2022] Open
Abstract
Petrous apex cholesterol granulomas are believed to result from blockage of the normal aeration of the petrous air cells, resulting in a repetitive cycle of mucosal engorgement, hemorrhage, and granuloma formation.1 The lesion usually progressively expands causing compressive symptoms. The thick granulomatous wall envelopes various ages of breakdown products, including a cholesterol-containing fluid, which is typically hyperintense on T1 and T2 weighted magnetic resonance imaging. Drainage procedures, regardless of the route (endoscopic, endonasal, or transtemporal), with or without stenting or marsupialization, will only temporarily drain this cholesterol-containing fluid, with consequently frequent recurrences.2-5 A total exoneration of the granuloma and obliteration of the cavity with vascularized tissue will assure a more durable outcome.1 The extradural zygomatic/middle fossa approach provides a short distance to the petrous apex and is purely extradural. By sectioning the zygoma, temporal lobe retraction is avoided.6 We present a case of a 29-yr-old male who presented in the year 2000 with progression of a left petrous apex cholesterol granuloma despite 2 previous drainage and stenting procedures. The patient consented for surgery and photo publication. Images in video at 2:41 © JNSPG, republished from Eisenberg et al1 with permission.
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Affiliation(s)
- Mark Eisenberg
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Endoscopic Petrous Apex Surgery: The Utilization of Frontal Sinus Instrumentation. J Craniofac Surg 2021; 31:2317-2319. [PMID: 33136880 DOI: 10.1097/scs.0000000000006716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The petrous apex is a complex anatomic region for which each surgical approach each has distinct limitations. The authors describe the use of frontal sinus instrumentation for the endonasal endoscopic approach to petrous apex lesions OBJECTIVE:: To demonstrate that the angled design of frontal sinus instrumentation has pronounced clinical utility for the transsphenoidal transclival approach to the petrous apex. METHODS The authors present cases of expansile petrous apex lesions approached endoscopically via transsphenoid and transclival corridors, and highlight the technique of using curved frontal sinus instruments and angled endoscopes for posterolateral reach in the petrous apex dissection. RESULTS As demonstrated in the accompanying video, dissection with frontal sinus instrumentation allows the surgeon to navigate around the internal carotid artery. CONCLUSIONS Significant technical and technological advances have been made in the field of expanded endoscopic endonasal skull base surgery in the past 3 decades. Increasing efforts are made to push the boundaries and access more laterally located lesions, such as those in the petrous apex. Surgical trajectory or vector is paramount to safely navigate around the internal carotid artery.
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Patel CR, Snyderman CH, Fernandez-Miranda JC, Gardner PA, Wang EW. Mucosal Grafting Reduces Recurrence After Endonasal Surgery of Petrous Apex Cholesterol Granulomas. Laryngoscope 2021; 131:E2513-E2517. [PMID: 33559896 DOI: 10.1002/lary.29432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/28/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES/HYPOTHESIS The endoscopic endonasal approach (EEA) is increasingly utilized for management of petrous apex cholesterol granuloma (PACG). Surgical goals include drainage and marsupialization of the cyst. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of mucosal grafting on recurrence. STUDY DESIGN Retrospective Cohort study. METHODS Patients who underwent EEA for PACG at two tertiary care centers between 1999 and 2018 were identified and divided into two cohorts: Mucosal versus no mucosal reconstruction. Surgical approach, reconstructive method, and recurrence were recorded. Primary endpoint was symptomatic or radiographic recurrence. RESULTS Thirty-four patients were identified undergoing 37 surgeries. Four patients developed recurrences of which three elected to undergo revision. Some form of mucosa was used to line the drainage tract in 20 cases. A free mucosal graft was used in 8, and a small customized nasal septal flap (miniflap) in 12. All four recurrences occurred in cases where no mucosa was used, demonstrating decreased recurrences with mucosal reconstruction (P < .05). There was no difference found between free mucosal grafts and miniflaps. CONCLUSIONS Utilization of mucosa to partially line a circumferentially de-epithelialized drainage pathway after EEA for PACG reduce recurrence rates. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2513-E2517, 2021.
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Affiliation(s)
- Chirag R Patel
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Gulati A, Bustos R, Cai Y, Aubin-Pouliot A, Pletcher SD, Cheung SW. Giant septated petrous apex cholesterol granuloma. OTOLARYNGOLOGY CASE REPORTS 2020. [DOI: 10.1016/j.xocr.2020.100253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Mangussi-Gomes J, Alves-Belo JT, Truong HQ, Nogueira GF, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Anatomical Limits of the Endoscopic Contralateral Transmaxillary Approach to the Petrous Apex and Petroclival Region. Skull Base Surg 2020; 83:44-52. [DOI: 10.1055/s-0040-1716693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
Abstract
Objectives This study aimed to establish the anatomical landmarks for performing a contralateral transmaxillary approach (CTM) to the petrous apex (PA) and petroclival region (PCR), and to compare CTM with a purely endoscopic endonasal approach (EEA).
Design EEA and CTM to the PA and PCR were performed bilaterally in eight human anatomical specimens. Surgical techniques and anatomical landmarks were described, and EEA was compared with CTM with respect to ability to reach the contralateral internal acoustic canal (IAC). Computed tomographic scans of 25 cadaveric heads were analyzed and the “angle” and “reach” of CTM and EEA were measured.
Results Entry to the PA via a medial approach was limited by (1) abducens nerve superiorly, (2) internal carotid artery (ICA) laterally, and (3) petroclival synchondrosis inferiorly (Gardner's triangle). With CTM, it was possible to reach the contralateral IAC bilaterally in all specimens dissected, without dissection of the ipsilateral ICAs, pterygopalatine fossae, and Eustachian tubes. Without CTM, reaching the contralateral IAC was possible only if: (1) angled endoscopes and instruments were employed or (2) the pterygopalatine fossa was dissected with mobilization of the ICA and resection of the Eustachian tube. The average “angle” and “reach” advantages for CTM were 25.6-degree greater angle of approach behind the petrous ICA and 1.4-cm more lateral reach.
Conclusion The techniques and anatomical landmarks for CTM to the PA and PCR are described. Compared with a purely EEA, the CTM provides significant “angle” and “reach” advantages for the PA and PCR.
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Affiliation(s)
- João Mangussi-Gomes
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - João T. Alves-Belo
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Huy Q. Truong
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | | | - Eric W. Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C. Fernandez-Miranda
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A. Gardner
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H. Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Open and Endoscopic Skull Base Approaches. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00283-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Endoscopic Endonasal Transpterygoid Approach Using Pedicled Nasoseptal Flap for Petrous Apex Cholesterol Granuloma With Intraoperative Video. J Craniofac Surg 2020; 30:1833-1835. [PMID: 31313683 DOI: 10.1097/scs.0000000000005589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
With the development of minimally invasive endoscopic surgery and image-guided navigation systems, the endoscopic endonasal approach to petrous apex lesions has become more favorable. In this case, a petrous apex cholesterol granuloma was successfully treated with an endoscopic endonasal transpterygoid approach. A navigation system was used, and a contralateral nasoseptal flap and silicone tube stent were applied to maintain the cholesterol granuloma drainage pathway. The authors describe the endoscopic endonasal transpterygoid approach using a pedicled nasoseptal flap for petrous apex cholesterol granuloma and provide an intraoperative video and a literature review.
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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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Indications and endonasal treatment of petrous apex cholesterol granulomas. Curr Opin Otolaryngol Head Neck Surg 2019; 27:54-58. [PMID: 30507687 DOI: 10.1097/moo.0000000000000511] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Lesions of the petrous apex of the temporal bone can be challenging to access and approaches laterally through the mastoid as well as medially through an endonasal approach are utilized to access this region while preserving function of adjacent structures. Cholesterol granulomas of the petrous apex requiring surgery are marsupialized to prevent expansion of the inflamed cyst and relieve associated clinical symptoms. The endonasal approach to the petrous apex has in the past been limited to lesions medial to the internal carotid artery. RECENT FINDINGS Endoscopic approaches have been developed to expand the range of petrous apex lesions that are accessible endonasally. These endonasal corridors include a nasopharyngeal/transclival corridor, lateralization of the internal carotid artery to create an expanded medial window, a pterygopalatine infrapetrosal approach, and a contralateral maxillary approach, which allow improved access to the inferior and lateral petrous apex. Nasoseptal flaps may reduce the risk of postoperative stenosis of the drainage tract. SUMMARY Endoscopic endonasal approaches can be used safely to address both medial and lateral/inferior petrous apex lesions. Morbidity of these procedures is low and use of a nasoseptal flap may limit restenosis of the drainage pathway.
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Radonjic A, Moldovan ID, Kilty SJ, Schramm DR, Alkherayf F. Complete Recovery of Sensorineural Hearing Loss Following Endoscopic Transsphenoidal Surgery for a Petrous Apex Cholesterol Granuloma: Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:335-339. [PMID: 30867405 PMCID: PMC6429980 DOI: 10.12659/ajcr.913964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/02/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cholesterol granulomas of the petrous apex may impinge surrounding cranial nerves, leading to neurological impairments such as hearing loss. Less invasive endoscopic techniques are gaining popularity as the mainstay of therapy for this lesion. CASE REPORT We present a case of petrous apex cholesterol granuloma causing mild sensorineural hearing loss. An endoscopic endonasal transsphenoidal approach was successfully performed to partially resect and aerate the lesion. The auditory function on the affected side was completely restored after surgery. The patient experienced no post-operative complications. CONCLUSIONS This case report highlights the advantages of using an endoscopic transsphenoidal surgical approach in cases of petrous apex cholesterol granuloma, including the potential for this less invasive technique to restore sensorineural hearing loss.
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Affiliation(s)
| | - Ioana D. Moldovan
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shaun J. Kilty
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Otolaryngology – Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - David R. Schramm
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Otolaryngology – Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Fahad Alkherayf
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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16
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Negm HM, Singh H, Dhandapani S, Cohen S, Anand VK, Schwartz TH. Landmarks to Identify Petrous Apex Through Endonasal Approach Without Transgression of Sinus. J Neurol Surg B Skull Base 2018; 79:156-160. [PMID: 29868320 DOI: 10.1055/s-0037-1604388] [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: 01/15/2016] [Accepted: 06/13/2017] [Indexed: 10/19/2022] Open
Abstract
Objectives The use of nasopharyngeal landmarks to localize the petrous apex has not been previously described. We describe a purely endoscopic endonasal corridor to localize the petrous apex without transgressing any of the paranasal sinuses. Methods Anatomical dissections of four formalin preserved cadaveric heads (eight petrous apices) were performed to evaluate the feasibility of a nonsinus-based approach and illustrate the surgical landmarks and measurements that are useful for surgery in this area. Results The Eustachian tubes, fossa of Rosenmüller (FR), and posterior end of the middle and inferior turbinates are constant landmarks, which can be identified without opening any nasal sinuses. The petrous apex is located on an extended straight line connecting the upper end of the torus tubarius (TT) and the roof of the FR. The distance from upper end of TT to the roof of FR measured 9.875 (±0.99) mm, and the distance from roof of the FR to the petrous apex measured 9.75 (±1) mm. Conclusion With well-defined landmarks, the inferior, medial petrous apex can be reached using the endoscopic endonasal approach without crossing the sinus cavities.
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Affiliation(s)
- Hazem M Negm
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States.,Department of Neurosurgery, Menoufia University, Shebeen El-Kom, Egypt
| | - Harminder Singh
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Sivashanmugam Dhandapani
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States.,Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Salomon Cohen
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States.,Department of Neurosurgery, National Institute of Neurology and Neurosurgery, "Manuel Velasco Suarez," Mexico City, Mexico
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States.,Department of Otolaryngology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States.,Department of Neuroscience, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, United States
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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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18
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Komune N, Matsuo S, Miki K, Akagi Y, Kurogi R, Iihara K, Nakagawa T. Surgical Anatomy of the Eustachian Tube for Endoscopic Transnasal Skull Base Surgery: A Cadaveric and Radiologic Study. World Neurosurg 2018; 112:e172-e181. [PMID: 29325963 DOI: 10.1016/j.wneu.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach to the anatomically complex lateral skull base presents technical challenges. The use of the eustachian tube as a landmark to identify the petrous internal carotid artery has recently been reported, and this study aims to define the anatomic relationship between the eustachian tube and its surrounding structures using cadaveric dissection and radiologic analysis. METHODS To clarify the relationship of the eustachian tube with its surrounding structures, we performed endoscopic and microscopic dissection of 4 adult cadaveric heads and analyzed computed topography scans from 20 patients. RESULTS The eustachian tube is divided into the osseous and cartilaginous parts. The cartilaginous part can be further subdivided into the posterolateral, middle, and anteromedial parts, based on its relationship to the skull base. The eustachian tube is closely related to the pterygoid process of the sphenoid bone, the foramen lacerum, and the petrosal apex and is directed away from the oblique sagittal plane almost parallel to the vidian canal at 12.2° ± 6.2° (mean ± standard deviation). The relationship between the course of the vidian canal and the eustachian tube can aid the estimation of the anatomic course of the horizontal segment of the petrous carotid artery. CONCLUSIONS The eustachian tube is a useful landmark for predicting the course of the internal carotid artery when accessing the lateral skull base regions via an endonasal route. A profound understanding of the relationship between the eustachian tube and the surrounding skull base structures is important for endoscopic endonasal skull base surgeries.
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Affiliation(s)
- Noritaka Komune
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Koichi Miki
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka University, Fukuoka, Japan
| | - Yojiro Akagi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Nakagawa
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Patel CR, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Contralateral transmaxillary corridor: an augmented endoscopic approach to the petrous apex. J Neurosurg 2017; 129:211-219. [PMID: 29053078 DOI: 10.3171/2017.4.jns162483] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has been shown to be an effective means of accessing lesions of the petrous apex. Lesions that are lateral to the paraclival segment of the internal carotid artery (ICA) require lateralization of the paraclival segment of the ICA or a transpterygoid infrapetrous approach. In this study the authors studied the feasibility of adding a contralateral transmaxillary (CTM) corridor to provide greater access to the petrous apex with decreased need for manipulation of the ICA. METHODS Using image guidance, EEA and CTM extension were performed bilaterally on 5 cadavers. The anterior wall of the sphenoid sinus and rostrum were removed. The angle of the surgical approach from the axis of the petrous segment of the ICA was measured. Five illustrative clinical cases are presented. RESULTS The CTM corridor required a partial medial maxillectomy. When measured from the axis of the petrous ICA, the CTM corridor decreased the angle from 44.8° ± 2.78° to 20.1° ± 4.31°, a decrease of 24.7° ± 2.58°. Drilling through the CTM corridor allowed the drill to reach lateral aspects of the petrous apex that would have required lateralization of the ICA or would not have been accessible via EEA. The CTM corridor allowed us to achieve gross-total resection of the petrous apex region in 5 clinical cases with significant paraclival extension. CONCLUSIONS The CTM corridor is a feasible extension to the standard EEA to the petrous apex that offers a more lateral trajectory with improved access. This approach may reduce the risk and morbidity associated with manipulation of the paraclival ICA.
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Affiliation(s)
- Chirag R Patel
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric W Wang
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan C Fernandez-Miranda
- 2Neurological Surgery, University of Pittsburgh School of Medicine; and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- 2Neurological Surgery, University of Pittsburgh School of Medicine; and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Hasegawa H, Shin M, Kondo K, Hanakita S, Mukasa A, Kin T, Saito N. Role of endoscopic transnasal surgery for skull base chondrosarcoma: a retrospective analysis of 19 cases at a single institution. J Neurosurg 2017; 128:1438-1447. [PMID: 28686110 DOI: 10.3171/2017.1.jns162000] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Skull base chondrosarcoma is one of the most intractable tumors because of its aggressive biological behavior and involvement of the internal carotid artery and cranial nerves (CNs). One of the most accepted treatment strategies for skull base chondrosarcoma has been surgical removal of the tumor in conjunction with proactive extensive radiation therapy (RT) to the original tumor bed. However, the optimal strategy has not been determined. The goal of this study was to evaluate the early results of endoscopic transnasal surgery (ETS). METHODS The authors retrospectively analyzed 19 consecutive patients who underwent ETS at their institution since 2010. Adjuvant stereotactic radiosurgery (SRS) was performed only for the small residual tumors that were not resected to avoid critical neurological complications. Histological confirmation and evaluation of the MIB-1 index was performed in all cases. The Kaplan-Meier method was used to determine the actuarial rate of tumor-free survival. RESULTS The median tumor volume and maximal diameter were 14.5 cm3 (range 1.4-88.4 cm3) and 3.8 cm (range 1.5-6.7 cm), respectively. Nine patients (47%) had intradural extension of the tumor. Gross-total resection was achieved in 15 (78.9%) of the 19 patients, without any disabling complications. In 4 patients, the surgery resulted in subtotal (n = 2, 11%) or partial (n = 2, 11%) resection because the tumors involved critical structures, including the basilar artery or the lower CNs. These 4 patients were additionally treated with SRS. The median follow-up duration was 47, 28, and 27 months after the diagnosis, ETS, and SRS, respectively. In 1 patient with an anterior skull base chondrosarcoma, the tumor relapsed in the optic canal 1 year later and was treated with a second ETS. Favorable tumor control was achieved in all other patients. The actuarial tumor control rate was 93% at 5 years. At the final follow-up, all patients were alive and able to perform independent activities of daily living without continuous neurological sequelae. CONCLUSIONS These preliminary results suggest that ETS can achieve sufficient radical tumor removal, resulting in comparative resection rates with fewer neurological complications to those in previous reports. Although the follow-up periods of these cases were relatively short, elective SRS to the small tumor remnant may be rational, achieving successful tumor control in some cases, instead of using proactive extensive RT. Thus, the addition of RT should be discussed with each patient, after due consideration of histological grading and biological behavior. To determine the efficacy of this strategy, a larger case series with a longer follow-up period is essential. However, this strategy may be able to establish evidence in the management of skull base chondrosarcoma, providing less-invasive and effective options as an initial step of treatment.
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Affiliation(s)
| | | | - Kenji Kondo
- 2Otorhinolaryngology, University of Tokyo Hospital, Tokyo, Japan
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21
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Sun Z, Cao Y, Zhai LZ. Java brucea and Chinese herbal medicine for the treatment of cholesterol granuloma in the suprasellar and sellar regions: A case report and literature review. Medicine (Baltimore) 2017; 96:e5930. [PMID: 28151875 PMCID: PMC5293438 DOI: 10.1097/md.0000000000005930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 11/27/2022] Open
Abstract
RATIONALE A cholesterol granuloma (CG) is usually found in the middle ear, papilla, orbits, petrous apex, and choroid plexus, but is highly uncommon in the skull. In spite of benign clinicopathological lesions, bone erosion can be seen occasionally in the patient with CG. The optimal treatment strategy is radical surgery, but complete excision is usually impossible due to anatomical restrictions and a risk of injury to the key structures located nearby. Here, we report a patient with CGs in the suprasellar and sellar regions who was successfully treated with Java brucea and Chinese herbal medicine. PATIENT CONCERNS A 31-year-old man presenting with progressive decreased vision in both eyes was analyzed. DIAGNOSES A skull magnetic resonance imaging (MRI) scan showed a low-density tumor in the uprasellar and sellar regions and histopathological examination revealed a CG. INTERVENTIONS The patient was referred the surgery and radiotherapy. In the meantime, brucea soft capsules and herbal medicine combined were administered to him. OUTCOMES The related clinical symptoms and signs resolved significantly after several months, as his therapy progressed. The patient showed no sign of recurrence during the treatment period. Furthermore, he was still alive and disease-free at 37 months of follow-up visit. LESSONS Overall, brucea soft capsules and a Chinese herbal formula treatment combined could be beneficial in improving the patient's quality of life with CG in the skull.
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Affiliation(s)
- Zhe Sun
- First clinical medical college of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong,China
| | - Yang Cao
- Department of Oncology Center, the First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Lin-zhu Zhai
- Department of Oncology Center, the First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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22
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Endoscopic transnasal skull base surgery: pushing the boundaries. J Neurooncol 2016; 130:319-330. [DOI: 10.1007/s11060-016-2274-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/31/2016] [Indexed: 12/22/2022]
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Endoscopic transsphenoidal surgery using pedicle vascularized nasoseptal flap for cholesterol granuloma in petrous apex: A technical note. Neurol Neurochir Pol 2016; 50:504-510. [PMID: 27575680 DOI: 10.1016/j.pjnns.2016.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/20/2016] [Accepted: 08/10/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Compared with surgical resection, endoscopic transsphenoidal surgery (TSS) for cholesterol granuloma (CG) in the petrous apex (PA) is associated with local recurrence due to obstruction of the drainage route. We present a detailed procedure of an endoscopic TSS using pedicle vascularized nasoseptal flap (PVNF). METHODS A 40-year-old woman with a history of repeated surgery for left tympanitis was referred to our institution. Neurological examination revealed severe hearing loss in the left ear. Radiologic examination presented a round mass in the left PA and significant fluid collection in the mastoid air cells of the left temporal bone. CG was strongly suspected, and endoscopic TSS using PVNF was performed. Prior to endoscopic drainage, a PVNF was harvested from the mucosa of the ipsilateral nasal septum, with an attempt to preserve the sphenopalatine artery in the flap. Following this, puncture and adequate irrigation of the lesion was performed by endoscopic TSS, with neuro-navigation system assistance; the apex of PVNF was then placed into the lesion to prevent the obstruction of the drainage route. An absorbable polyglycolic acid sheet and fibrin glue were applied on the flap to prevent spontaneous deviation from the lesion. RESULTS The patient was discharged without any further neurological complications. Eight-month postoperative computed tomography images showed no recurrence; the drainage route was patent and the fluid collection in the left mastoid air cells was resolved. Moreover, hearing loss was improved. CONCLUSIONS Endoscopic TSS using PVNF may be one of available surgical options for PACG.
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Turan N, Baum GR, Holland CM, Ahmad FU, Henriquez OA, Pradilla G. Upper Nasopharyngeal Corridor for Transnasal Endoscopic Drainage of Petroclival Cholesterol Granulomas: Alternative Access in Conchal Sphenoid Patients. J Neurol Surg Rep 2015; 77:e017-22. [PMID: 26929897 PMCID: PMC4726374 DOI: 10.1055/s-0035-1567865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 09/14/2015] [Indexed: 11/25/2022] Open
Abstract
Background Cholesterol granulomas arising at the petrous apex can be treated via traditional open surgical, endoscopic, and endoscopic-assisted approaches. Endoscopic approaches require access to the sphenoid sinus, which is technically challenging in patients with conchal sphenoidal anatomy. Clinical Presentation A 55-year-old woman presented with intermittent headaches and tinnitus. Formal audiometry demonstrated moderately severe bilateral hearing loss. CT of the temporal bones and sella revealed a well-demarcated expansile lytic mass. MRI of the face, orbit, and neck showed a right petrous apex mass measuring 22 × 18 × 19 mm that was hyperintense on T1- and T2-weighted images without enhancement, consistent with a cholesterol granuloma. The patient had a conchal sphenoidal anatomy. Operative Technique Herein, we present an illustrative case of a low-lying petroclival cholesterol granuloma in a patient with conchal sphenoidal anatomy to describe an alternative high nasopharyngeal corridor for endoscopic transnasal transclival access. Postoperative Course Postoperatively, the patient's symptoms recovered and no complications occurred. Follow-up imaging demonstrated a patent drainage tract without evidence of recurrence. Conclusion In patients with a conchal sphenoid sinus, endoscopic transnasal transclival access can be gained using a high nasopharyngeal approach. This corridor facilitates safe access to these lesions and others in this location.
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Affiliation(s)
- Nefize Turan
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Griffin R Baum
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Christopher M Holland
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Faiz U Ahmad
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Oswaldo A Henriquez
- Emory University School of Medicine, Department of Otolaryngology, Head and Neck Surgery, Atlanta, GA, United States
| | - Gustavo Pradilla
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
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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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Shibao S, Toda M, Tomita T, Saito K, Ogawa K, Kawase T, Yoshida K. Petrous apex cholesterol granuloma: importance of pedicled nasoseptal flap in addition to silicone T-tube for prevention of occlusion of drainage route in transsphenoidal approach--a technical note. Neurol Med Chir (Tokyo) 2015; 55:351-5. [PMID: 25797784 PMCID: PMC4628183 DOI: 10.2176/nmc.tn.2014-0254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Recently, petrous apex cholesterol granulomas (CGs) have been treated via the endoscopic endonasal transsphenoidal approach (EEA) using a silicone tube, to prevent drainage route occlusion. Occlusion of the drainage route has led to problems with recurrence. The aim of this report is to describe the use of a surgical technique to prevent drainage route occlusion. In surgical technique, the posterolateral wall of the sphenoid sinus was opened by EEA. After cyst debridement, a vascularized nasoseptal flap with a width of approximately 4 cm was inserted into the lumen with a silicone T-tube with a diameter of 7 mm. This technique was used in two patients: the first patient during the second operation after recurrence following occlusion of the drainage route, and the second patient during the first operation. Opening of the cyst wall was confirmed endoscopically in both patients 12–24 months after surgery, even after removal of the T-tube. In conclusion, the use of a pedicled nasoseptal flap with a silicone tube is useful to prevent CG recurrence, by paranasal cavitization of the cystic cavity.
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Affiliation(s)
- Shunsuke Shibao
- Department of Neurosurgery, Head, and Neck Surgery, Keio University Graduate School of Medicine
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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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Lee TC, Raghavan D, Curtin HD. Image-guided percutaneous aspiration and gelfoam treatment of petrous apex cholesterol granuloma: a new theory and method for diagnosis and treatment. J Neurol Surg B Skull Base 2014; 74:342-6. [PMID: 24436935 DOI: 10.1055/s-0033-1345107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 02/11/2013] [Indexed: 10/26/2022] Open
Abstract
Although diagnosis of cholesterol granulomas of the skull base can be straightforward with computed tomography (CT) and magnetic resonance imaging (MRI) appearance, treatment is controversial with various skull base approaches described in the literature. This report describes a 35-year-old man who presented with a symptomatic, enlarging cystic lesion in the left petrous apex and clivus that had imaging features of a cholesterol granuloma (cholesterol cyst). Due to a prior history of treated mediastinal germ cell tumor, pathologic confirmation of the lesion was requested. A CT-guided percutaneous aspiration revealed dark used motor oil-like fluid. Continued aspiration yielded a change in the character of the fluid to marrow red. Injection of contrast revealed no communication with cerebrospinal fluid. Gelfoam (Pfizer, New York, New York, USA) was subsequently injected percutaneously into the residual cavity. Histopathology showed no evidence of malignancy and follow-up MRI at 1 month, 3 months, 6 months, and 1 year demonstrated continued decrease in size and signal of the lesion.
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Affiliation(s)
- Thomas C Lee
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Deepak Raghavan
- 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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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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Fernandez-Miranda JC, Gardner PA, Snyderman CH, Devaney KO, Mendenhall WM, Suárez C, Rinaldo A, Ferlito A. Clival chordomas: A pathological, surgical, and radiotherapeutic review. Head Neck 2013; 36:892-906. [PMID: 23804541 DOI: 10.1002/hed.23415] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/10/2013] [Accepted: 06/10/2013] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The purpose of this study was to discuss the optimal management of patients with clival chordomas and provide an up-to-date review of the field. METHODS A schematic description of the anatomy of the clivus and its surrounding structures is provided based on the modular classification of the surgical corridors used in endoscopic skull base surgery. Postoperative radiotherapy (RT) techniques are described. RESULTS The optimal treatment is gross total resection. Recent advances in endoscopic endonasal skull base surgery have allowed very high rates of macroscopic and radiographic complete tumor resection in spite of the challenging location of these lesions. When the tumor location or extension is too lateral or inferior to be effectively resected with an endoscopic approach, an open approach or a combination of endoscopic and open approaches in stages should be considered. Postoperative RT is usually indicated because the likelihood of recurrence is high in spite of complete surgical resection. The main site of recurrence is local and late recurrences are relatively common. The probability of cure is approximately 50% at 10 years and significantly increases when complete tumor resection has been achieved. CONCLUSION The preferred treatment for patients with clival chordoma is gross total resection (via endoscopic endonasal surgery when possible) followed by postoperative RT. Treatment at experienced multidisciplinary cranial base centers is key to minimize complications and to enhance the probability of total removal of the tumors.
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Affiliation(s)
- Juan C Fernandez-Miranda
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Terranova P, Karligkiotis A, Gallo S, Meloni F, Bignami M, Castelnuovo P. A novel endoscopic technique for long-term patency of cholesterol granulomas of the petrous apex. Laryngoscope 2013; 123:2639-42. [DOI: 10.1002/lary.24170] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 03/01/2013] [Accepted: 04/01/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Paola Terranova
- Department of Otorhinolaryngology; University of Insubria; Varese Italy
| | | | - Stefania Gallo
- Department of Otorhinolaryngology; University of Insubria; Varese Italy
| | - Francesco Meloni
- Department of Otorhinolaryngology; University of Sassari; Sassari Italy
| | - Maurizio Bignami
- Department of Otorhinolaryngology; University of Insubria; Varese Italy
| | - Paolo Castelnuovo
- Department of Otorhinolaryngology; University of Insubria; Varese Italy
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