DILEMMA IN THE MANAGEMENT OF MASSIVE PETROUS APEX CHOLESTEATOMAS
Background
Congenital cholesteatoma in the petrous apex is an insidious pathology that often causes sensorineural hearing loss, vertigo, and/or facial nerve paralysis. Although complete removal of the pathology is the goal of treatment, this is sometimes difficult to achieve because of its massive extension and/or anatomical complexity of the petrous apex. In this paper, dilemmas were discussed in managing the massive type of petrous apex cholesteatomas (PAC).
Case report
A 45-year-old female, who had undergone the transpetrosal (middle cranial fossa) surgery for removal of extensive PAC in another hospital seven years before, was referred to our hospital aiming a further surgery for its regrowth. She had already presented with total deafness in the left ear and with the ipsilateral House-Brackmann (H-B) grade-III facial paralysis. High-resolution CT (HRCT) and magnetic-resonance images (MRI) revealed that a huge cystic lesion in the petrous apex, devastating cochlea and labyrinth, extended to involve the internal auditory meatus (IAM) and the internal carotid artery (ICA) completely (Fig. 1). Because she desired to maintain the current facial function because of her occupation, complete removal was first attempted via the transotic approach. After extended mastoidectomy and cochleotomy, the matrices of cholesteatoma were almost removed from the ICA. However, the dura and contents of the IAM could not be identified in the cholesteatoma, and therefore the exteriorization of the lesion was finally carried out (Fig. 2). The facial nerve was left in its original position, and the post-operative grade of facial palsy was thereby unchanged.
Discussion
Congenital cholesteatoma in the petrous apex insidiously grows and sometimes extends to devastate the cochlea and labyrinth and to involve the facial nerve and ICA (Moffat-Smith’s massive labyrinthine-apical,1 Sanna’s massive complex2,3). Complete removal of cholesteatoma, regardless its size and location, is always a goal of the treatment, but this type of massive PAC is a hard object to control. A transotic approach3,4 is mainly selected for the case of PAC with profound deafness aiming preservation of the facial nerve, in which the facial nerve remains in position. On the contrary, the transcochlear approach2,5 provides better access to the petrous apex by a slight sacrifice of the facial nerve, which needs posterior rerouting or tentative transection followed by re-approximation. The latter approach, however, never results in a facial function beyond grade III.
In the present case, cholesteatoma had already destroyed the cochlea and labyrinth and extended far medially to the sphenoid sinus. Furthermore, the IAM was totally involved in the cholesteatoma mass, and so the posterior rerouting of the facial nerve could never be achieved. A fair amount of the cholesteatoma matrices must have been left on the medial wall of the IAM and on the sphenoid sinus wall, even though the transco-chlear approach with a tentative transection of the facial nerve was performed. These were the reasons that we believed the exteriorization was the best treatment choice in this case, and that we selected the transotic approach for the facial function surely to be preserved.
Fig. 1. T2-weighted MRI. A huge cholesteatoma existed in the petrous apex, extending to the sphenoid sinus and involving the internal auditory meatus (IAM) and the internal carotid artery (ICA).
Fig. 2. An intra-operative view after cochleotomy and labyrinthectomy surgery. Transotic approach was selected. The cholesteatoma matrices could not be controlled medially to the IAM.
Selection of either near-total removal followed by obliteration or exteriorization alone has always been a dilemma in the management of the massive PAC.6,7 A better solution needs to be pursued in an individual case with PAC.
Massive complex petrous apex cholesteatoma always creates a dilemma and provides us with a surgical challenge. Either transotic or transcochlear approach may have to be selected based on the patient’s background and pre-operative facial nerve function.
References
1.Moffat D, Jones S, Smith W. Petrous temporal bone cholesteatoma: a new classification and long-term surgical outcomes. Skull Base 18:107–115, 2008
2.Pandya Y, Piccirillo E, Mancini F, Sanna M. Management of complex cases of petrous bone cholesteatoma. Ann Otol Rhinol Laryngol 119:514–525, 2010
3.Sanna M, Pandya Y, Mancini F, Sequino G, Piccirillo E. Petrous bone cholesteatoma: classification, management and review of the literature. Audiol Neurootol 16:124–136, 2011
4.Aubry K, Kovac L, Sauvaget E, Tran Ba Huy P, Herman P. Our experience in the management of petrous bone cholesteatoma. Skull Base 20:163–167, 2010
5.House WF, De la Cruz A, Hitselberger WE. Surgery of the skull base: transcochlear approach to the petrous apex and clivus. Otolaryngology 86:770–779, 1978
6.Alvarez FL, Gómez JR, Bernardo MJ, Suárez C. Management of petrous bone cholesteatoma: open versus obliterative techniques. Eur Arch Otorhinolaryngol 268:67–72, 2011
7.Pyle GM, Wiet RJ. Petrous Apex Cholesteatoma: Exteriorization vs. Subtotal Petrosectomy with Obliteration. Skull Base Surg 1:97–105, 1991
Address for correspondence: Masashi Hamada, mhamada@is.icc.u-tokai.ac.jp
Cholesteatoma and Ear Surgery – An Update, pp. 267–269
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands