Endoscopic transsphenoidal drainage of an aggressive petrous apex cholesterol granuloma: unusual complications and lessons learnt

Abstract

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.

Complete Recovery of Sensorineural Hearing Loss Following Endoscopic Transsphenoidal Surgery for a Petrous Apex Cholesterol Granuloma: Case Report

“…Rather, the goal is to drain it and aerate petrous air cells to prevent recurrence [7,14]. This was traditionally done by transcranial techniques such as middle fossa, infralabyrinthine, translabyrinthine, transcanal, infracochlear, and other approaches [4]. Many of these surgical interventions operated laterally through the skull base and thus exposed delicate auditory structures to damage, making unilateral hearing loss a common complication of transcranial procedures [15].…”

“…Cysts in the petrous apex also represent a challenge for surgeons as they must diligently navigate around critical structures such as the internal auditory canal, facial nerve, and internal carotid artery [3]. Transcranial procedures have been used for treating petrous apex cholesterol granulomas in the past; however, due to inherent risks such as physical damage to auditory structures as well as difficulty observing the patient’s post-operative course, treatment has shifted to an endoscopic approach when possible [4]. This less invasive technique is particularly interesting because of its potential to preserve hearing in patients for whom restoration efforts were previously abandoned, and for those who would have suffered further auditory damage during a transcranial operation [5].…”

Application of 3‐dimensional Modeling to Plan Totally Endoscopic Per‐Meatal Drainage of Petrous Apex Cholesterol Granuloma

“…Developments in endoscopic ear surgery allow the prospect of an even less invasive per‐meatal approach to the PA than that provided by transsphenoidal surgery 1‐3 . Similarly, though, access may be restricted in children by smaller morphology, making the feasibility of this approach uncertain.…”

“…Developments in endoscopic ear surgery allow the prospect of an even less invasive per-meatal approach to the PA than that provided by transsphenoidal surgery. [1][2][3] Similarly, though, access may be restricted in children by smaller morphology, making the feasibility of this approach uncertain. Surface rendering of skull base imaging provides accurate representation 4 for preoperative evaluation (as Figure 1) but is not sufficient to predict the complex 4-dimensional interaction between movement of endoscope and instruments within the complex curvature of the ear canal.…”

Endoscopic transsphenoidal surgery using pedicle vascularized nasoseptal flap for cholesterol granuloma in petrous apex: A technical note

“…Direct resection using a middle fossa approach would yield relatively few recurrences, but it is quite invasive and has a risk of severe postoperative complications [3][4][5][6]. Recently, many reports on endoscopic transsphenoidal surgery (TSS) for PACG drainage have been published [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. Although it is a less invasive approach, the frequency of recurrence is high compared with direct resection.…”