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J Neurol Surg B Skull Base 2012; 73(03): 190-196
DOI: 10.1055/s-0032-1312706
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Endoscopic Endonasal Management of Recurrent Petrous Apex Cholesterol Granuloma

Nancy McLaughlin
1   Brain Tumor Center, John Wayne Cancer Institute of Saint John's Health Center, Santa Monica, California, United States
,
Daniel F. Kelly
1   Brain Tumor Center, John Wayne Cancer Institute of Saint John's Health Center, Santa Monica, California, United States
,
Daniel M. Prevedello
1   Brain Tumor Center, John Wayne Cancer Institute of Saint John's Health Center, Santa Monica, California, United States
,
Kiarash Shahlaie
1   Brain Tumor Center, John Wayne Cancer Institute of Saint John's Health Center, Santa Monica, California, United States
,
Ricardo L. Carrau
3   Department of Head and Neck Surgery, The Ohio State University, Columbus, Ohio, United States
,
Amin B. Kassam
4   Department of Surgery, Division of Neurosurgery, University of Ottawa, Ontario, Canada
› Author Affiliations
Further Information

Publication History

07 August 2010

15 November 2010

Publication Date:
17 May 2012 (online)

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Abstract

Introduction Petrous apex cholesterol granulomas (PACGs) 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.

Results A 19-year-old woman presented with a recurrent 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 sinus, 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-free and recurrence-free.

Conclusion Endoscopic endonasal surgery must be adapted to manage a recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and the use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences.

Keywords

cholesterol granuloma - petrous apex - endoscopy - transsphenoidal approach - expanded endonasal approach
 

  • References

  • 1 Sincoff EH, Liu JK, Matsen L , et al. A novel treatment approach to cholesterol granulomas. Technical note. J Neurosurg 2007; 107 (2) 446-450
    CrossrefPubMedSearch in Google Scholar
  • 2 Eisenberg MB, Haddad G, Al-Mefty O. Petrous apex cholesterol granulomas: evolution and management. J Neurosurg 1997; 86 (5) 822-829
    CrossrefPubMedSearch in Google Scholar
  • 3 Griffith AJ, Terrell JE. Transsphenoid endoscopic management of petrous apex cholesterol granuloma. Otolaryngol Head Neck Surg 1996; 114 (1) 91-94
    Search in Google Scholar
  • 4 Brackmann DE, Toh EH. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol 2002; 23 (4) 529-533
    CrossrefPubMedSearch in Google Scholar
  • 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 (9) 947-952
    CrossrefPubMedSearch in Google Scholar
  • 6 Thedinger BA, Nadol Jr JB, Montgomery WW, Thedinger BS, Greenberg JJ. Radiographic diagnosis, surgical treatment, and long-term follow-up of cholesterol granulomas of the petrous apex. Laryngoscope 1989; 99 (9) 896-907
    PubMedSearch in Google Scholar
  • 7 Georgalas C, Kania R, Guichard JP, Sauvaget E, Tran Ba Huy P, Herman P. Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex. Clin Otolaryngol 2008; 33 (1) 38-42
    CrossrefPubMedSearch in Google Scholar
  • 8 Michaelson PG, Cable BB, Mair EA. Image-guided transphenoidal drainage of a cholesterol granuloma of the petrous apex in a child. Int J Pediatr Otorhinolaryngol 2001; 57 (2) 165-169
    CrossrefPubMedSearch in Google Scholar
  • 9 DiNardo LJ, Pippin GW, Sismanis A. Image-guided endoscopic transsphenoidal drainage of select petrous apex cholesterol granulomas. Otol Neurotol 2003; 24 (6) 939-941
    CrossrefPubMedSearch in Google Scholar
  • 10 Presutti L, Villari D, Marchioni D. Petrous apex cholesterol granuloma: transsphenoid endoscopic approach. J Laryngol Otol 2006; 120 (6) e20
    CrossrefPubMedSearch in Google Scholar
  • 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 (3) 299-302 , discussion 302
    CrossrefPubMedSearch in Google Scholar
  • 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 (1) 106-111
    PubMedSearch in Google Scholar
  • 13 Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 2009; 119 (1) 19-25
    CrossrefPubMedSearch in Google Scholar
  • 14 Mattox DE. Endoscopy-assisted surgery of the petrous apex. Otolaryngol Head Neck Surg 2004; 130 (2) 229-241
    CrossrefPubMedSearch in Google Scholar