Skull Base Rep 2011; 1(1): 027-032
DOI: 10.1055/s-0031-1275253
© Thieme Medical Publishers

Endoscopic Endonasal Management of Recurrent Petrous Apex Cholesterol Granuloma

Nancy McLaughlin1 , Daniel F. Kelly1 , Daniel M. Prevedello1 , Kiarash Shahlaie1 , Ricardo L. Carrau1 , Amin B. Kassam1
  • 1Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
Further Information

Publication History

Publication Date:
30 March 2011 (online)

ABSTRACT

Petrous apex cholesterol granulomas (PACG) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. A 19-year-old woman presented with a recurrent right abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom- and recurrence-free. Endoscopic endonasal surgery must be adapted to manage recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences.

REFERENCES

  • 1 Sincoff E H, Liu J K, Matsen L et al.. A novel treatment approach to cholesterol granulomas. Technical note.  J Neurosurg. 2007;  107 446-450
  • 2 Eisenberg M B, Haddad G, Al-Mefty O. Petrous apex cholesterol granulomas: evolution and management.  J Neurosurg. 1997;  86 822-829
  • 3 Griffith A J, Terrell J E. Transsphenoid endoscopic management of petrous apex cholesterol granuloma.  Otolaryngol Head Neck Surg. 1996;  114 91-94
  • 4 Brackmann D E, Toh E H. Surgical management of petrous apex cholesterol granulomas.  Otol Neurotol. 2002;  23 529-533
  • 5 Terao T, Onoue H, Hashimoto T, Ishibashi T, Kogure T, Abe T. Cholesterol granuloma in the petrous apex: case report and review.  Acta Neurochir (Wien). 2001;  143 947-952
  • 6 Thedinger B A, Nadol Jr J B, Montgomery W W, Thedinger B S, Greenberg J J. Radiographic diagnosis, surgical treatment, and long-term follow-up of cholesterol granulomas of the petrous apex.  Laryngoscope. 1989;  99 896-907
  • 7 Georgalas C, Kania R, Guichard J P, Sauvaget E, Tran Ba Huy P, Herman P. Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex.  Clin Otolaryngol. 2008;  33 38-42
  • 8 Michaelson P G, Cable B B, Mair E A. Image-guided transphenoidal drainage of a cholesterol granuloma of the petrous apex in a child.  Int J Pediatr Otorhinolaryngol. 2001;  57 165-169
  • 9 DiNardo L J, Pippin G W, Sismanis A. Image-guided endoscopic transsphenoidal drainage of select petrous apex cholesterol granulomas.  Otol Neurotol. 2003;  24 939-941
  • 10 Presutti L, Villari D, Marchioni D. Petrous apex cholesterol granuloma: transsphenoid endoscopic approach.  J Laryngol Otol. 2006;  120 e20
  • 11 Oyama K, Ikezono T, Tahara S, Shindo S, Kitamura T, Teramoto A. Petrous apex cholesterol granuloma treated via the endoscopic transsphenoidal approach.  Acta Neurochir (Wien). 2007;  149 299-302 discussion 302
  • 12 Samadian M, Vazirnezami M, Moqaddasi H, Rakhshan M, Khormaee F, Ashraf H. Endoscopic transrostral-transsphenoidal approach to petrous apex cholesterol granuloma: case report.  Turk Neurosurg. 2009;  19 106-111
  • 13 Zanation A M, Snyderman C H, Carrau R L, Gardner P A, Prevedello D M, Kassam A B. Endoscopic endonasal surgery for petrous apex lesions.  Laryngoscope. 2009;  119 19-25
  • 14 Mattox D E. Endoscopy-assisted surgery of the petrous apex.  Otolaryngol Head Neck Surg. 2004;  130 229-241

Amin B KassamM.D. F.R.C.S.C. 

The Ottawa Hospital Civic Campus, 1053 Carling Avenue

Room D733, Ottawa, Ontario, K1Y 4E9, Canada

Email: kassamab@gmail.com