Endoscopic Endonasal Fenestration and Marsupialization of Petrous Apex Cholesterol Granulomas Using Silastic “Cigarette” Stent-Assisted Nasoseptal Flap

Background: The endoscopic endonasal approach (EEA) has become a popular approach for the treatment of petrous apex cholesterol granulomas (PACGs). Compared with open skull base approaches, such as the middle fossa approach or the infracochlear approach, the EEA offers the advantage of direct exposure of the cyst, shorter operative times, minimal bone drilling, and marsupialization into the nasal cavity. Surgical management of PACGs typically involves drainage, aeration and occasional cyst wall resection. Successful prevention of recurrence of PACGs relies on maintaining patency of the cyst fenestration.

Objective: We describe the use of an endoscopic endonasal expandable silastic “cigarette” stent-assisted nasoseptal flap technique to help maintain patency and prevent recurrence after endoscopic fenestration and drainage of PACGs. The technique and surgical outcomes are described.

Methods: A retrospective study was conducted for the treatment of PACG using the described technique. After an EEA exposure, the anterior cyst wall is opened and excised to maximize the width of the fenestration. A small nasoseptal flap is rotated into the PACG defect, lining the cyst wall. A silastic sheet is then rolled up like a cigarette and placed into the long axis of the PACG. After the stent is released, the silastic sheet uncoils and radially expands to keep the nasoseptal flap opposed to the cyst wall lining. The stent is removed 2 weeks after surgery. Serial nasal endoscopy and magnetic resonance imaging is performed to assess the patency of the PACG marsupialization.

Results: Five patients (two females, three males; mean age = 45 years) with PACG underwent the described technique. Three patients were primary cases, and two patients presented as recurrences after prior procedures (one middle fossa, one infracochlear approach). All patients experienced improvement of preoperative symptoms. There were no recurrences of PACG after a mean follow-up of 13.2 months (range: 2–48 months). There were no complications of CSF leakage, carotid injury, or infection.

Conclusions: Endoscopic endonasal fenestration and marsupialization of PACG using the silastic “cigarette” stent-assisted nasoseptal flap is a safe and effective technique for maintaining patency and preventing recurrences of cholesterol granulomas. The nasoseptal flap promotes mucosalization and marsupialization of the cyst while the silastic stent prevents migration of the nasoseptal flap. This technique helps ensure continuous drainage and aeration of the PACG.

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