Cholesterol Granuloma of the Petrous Apex: A 5-Year Review of Radiology Reports with Follow-Up of Progression and Treatment

Management of cholesterol granuloma due to eosinophilic otitis media using large ventilation tube

A 46-year-old man who had been diagnosed with eosinophilic otitis media (EOM) and eosinophilic chronic rhinosinusitis was referred to our department. He suffered from bilateral earache, clogged ear sensation, and otorrhea associated with EOM. He had been treated with a myringotomy and a ventilation tube (VT) insertion. However, his symptoms did not improve, and the VT repeatedly fell out. We performed canal wall down mastoidectomy via a retro-auricular incision to remove the presumed cholesterol granuloma (CG) and a long-term VT insertion. The VT fell out repeatedly. Therefore, a large VT that Komune devised was inserted. Four months after reinsertion, there was no evidence of recurrent otorrhea or fallout of a large VT. A large VT insertion could be useful in the severe case of EOM with CG.

Characteristics and Clinical Management Strategy of Petrous Apex Cholesterol Granulomas

Purpose: To evaluate the clinical characteristics of petrous apex cholesterol granulomas (PACG) and assess outcomes after different treatment strategies. Method: A consecutive case series of 34 patients with a PACG. Main outcomes were PACG growth, symptoms, and the outcomes of different treatment strategies: wait-and-scan (WS) and surgical drainage. Results: Thirty-four patients were analyzed; mean follow-up time was 7.1 years. Twenty-one patients (61.7%) showed symptoms, mostly more than one. Most symptoms reported were cranial nerve palsy (58.8%) and headache (35.3%). Twenty-one patients (61.8%) received solely wait-and-scan (WS), and thirteen patients (38.2%) underwent surgery, five of whom (38.5%) after an initial WS period. In the solely WS group, one (4.8%) developed new symptoms, and two (9.5%) reported symptom progression despite a stable granuloma size. Two (9.5%) showed granuloma growth on follow-up scans without symptom progression. Surgery consisted of drainage. Eleven (84.6%) of these thirteen patients reported partial recovery; one (7.7%) reported no recovery; and one (7.7%) reported full recovery of reported symptoms related to PACG. Among the patients with cranial nerve involvement, 7.7% showed full recovery after surgery; 84.6% showed partial recovery; and 7.7% did not recover. Adverse events occurred in five out of 13 patients who underwent surgery, all with full recovery. Conclusions: This study confirms that PACG are slow-growing lesions with a low risk of adverse events. Solely using wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth.

Malignant Brain and Spinal Tumors Originating from Bone or Cartilage

Malignant bone tumors affecting the brain and spine are a rare and exceedingly difficult-to-treat group of diseases. Most commonly consisting of chordoma and chondrosarcoma, these tumors also include giant-cell tumors and osteosarcomas. This chapter will cover the background, epidemiology, genetics, molecular biology, histopathology, radiographic features, clinical manifestations, therapeutic approaches, and clinical management of each entity.

Typical and Atypical Symptoms of Petrous Apex Cholesterol Granuloma: Association with Radiological Findings

Objective: Petrous apex cholesterol granuloma (PACG) is a lesion that can give rise to different symptoms, and correlations with etiopathology are ambiguous. The aim of this study is to analyze the association between PACG symptoms and radiological findings at presentation, in order to establish a reproduceable pre-operative radiological evaluation and guide the surgical indication. Methods: PACG patients were collected in two tertiary care hospitals. All cases underwent CT/MRI to evaluate the cyst localization and erosion of surrounding structures. Typical and atypical symptoms were then analyzed and compared to radiologic findings established in accordance with the literature. Results: Twenty-nine patients were recruited; the most common symptoms were headache (69%), diplopia (20.7%) and fainting (24.1%), an atypical clinical manifestation related to jugular tubercle involvement. Significant associations between symptoms and radiologic findings were noted in terms of headache and temporal lobe compression (p = 0.04), fainting and jugular tubercle erosion (p < 0.001), vestibular symptoms and internal auditory canal erosion (p = 0.02), facial paresthesia and Meckel’s cave compression (p = 0.03), diplopia and Dorello canal involvement (p = 0.001), and tinnitus and cochlear basal turn erosion (p < 0.001). All patients were treated via an endoscopic−endonasal approach, in which extension was tailored to each case. At a median follow-up of 46 months, 93.1% of patients experienced resolution of symptoms. Conclusions: This clinico-radiological series demonstrates associations between symptoms and anatomical subsites involved with PACG. Hence, it may guide the surgeon at the time of surgical decision, since it asserts that typical and atypical symptoms are actually related to PACG.

Rare Diseases of the Middle Ear and Lateral Skull Base

Otalgia, otorrhea and hearing loss are the most common ear-related symptoms that lead to the consultation of an otolaryngologist. Furthermore, balance disorders and affections of the cranial nerve function may play a role in the consultation. In large academic centres, but also in primary care, the identification of rare diseases of the middle ear and the lateral skull base is essential, as these diseases often require interdisciplinary approaches to establish the correct diagnosis and to initiate safe and adequate treatments. This review provides an overview of rare bone, neoplastic, haematological, autoimmunological and infectious disorders as well as malformations that may manifest in the middle ear and the lateral skull base. Knowledge of rare disorders is an essential factor ensuring the quality of patient care, in particular surgical procedures. Notably, in untypical, complicated, and prolonged disease courses, rare differential diagnoses need to be considered.

Tympano-Mastoid Cholesterol Granuloma: Case Report and Review of the Literature

Cholesterol granuloma (CG) is a rare condition histological consisting of a foreign body, giant cell reaction to cholesterol crystals and haemosiderin derived from the ruptured of the erythrocytes. A 25-year-old man came to our Department presenting signs and symptoms of tympano-mastoid cholesterol granuloma. He showed all the specific sign and symptoms of the disease. However, considering the lack of literature regarding TMCG, this study was performed with the aim of presenting the main characteristics of tympano-mastoid CG, describing the case report and reviewing the literature.

Indications and endonasal treatment of petrous apex cholesterol granulomas

PURPOSE OF REVIEW

Lesions of the petrous apex of the temporal bone can be challenging to access and approaches laterally through the mastoid as well as medially through an endonasal approach are utilized to access this region while preserving function of adjacent structures. Cholesterol granulomas of the petrous apex requiring surgery are marsupialized to prevent expansion of the inflamed cyst and relieve associated clinical symptoms. The endonasal approach to the petrous apex has in the past been limited to lesions medial to the internal carotid artery.

RECENT FINDINGS

Endoscopic approaches have been developed to expand the range of petrous apex lesions that are accessible endonasally. These endonasal corridors include a nasopharyngeal/transclival corridor, lateralization of the internal carotid artery to create an expanded medial window, a pterygopalatine infrapetrosal approach, and a contralateral maxillary approach, which allow improved access to the inferior and lateral petrous apex. Nasoseptal flaps may reduce the risk of postoperative stenosis of the drainage tract.

SUMMARY

Endoscopic endonasal approaches can be used safely to address both medial and lateral/inferior petrous apex lesions. Morbidity of these procedures is low and use of a nasoseptal flap may limit restenosis of the drainage pathway.

Endoscopic Infracochlear Approach for Drainage of Petrous Apex Cholesterol Granulomas: A Case Series

OBJECTIVE

To describe the feasibility and technical nuances of a transcanal endoscopic infracochlear approach for drainage of petrous apex cholesterol granulomas.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care university hospital.

PATIENTS

A 32-year-old man with bilateral petrous apex cholesterol granulomas and a 54-year-old man with a left-sided petrous apex granuloma each with symptoms necessitating surgical intervention.

INTERVENTIONS

Transcanal endoscopic infracochlear approach for drainage of the cholesterol granulomas.

MAIN OUTCOME MEASURES

Operation efficacy, corridor size, and perioperative morbidity.

RESULTS

All three cholesterol granulomas were successful drained without violating the cochlea, jugular bulb, or carotid artery. The dimensions of the infracochlear surgical corridor measured 5 mm × 6 mm, 3.5 mm × 3.5 mm, and 6 mm × 4 mm, respectively. All corridors facilitated visualization within the cyst and allowed lyses of adhesions for additional cyst content eradication. All patients had resolution of their acute symptoms. Two of the three subjects had serviceable hearing before and after their procedures. One patient required revision surgery 2-months after their initial procedure secondary to recurrent symptoms from acute hemorrhage within the cyst cavity. The infracochlear tract in this patient was noted to be patent.

CONCLUSIONS

A transcanal endoscopic infracochlear approach is feasible for the management of cholesterol granuloma. The surgical access was wide enough to introduce the endoscope into the petrous apex cavity in each case. Further studies are needed to compare the efficacy and perioperative morbidity versus the traditional postauricular transtemporal approaches.

Tympanomastoid cholesterol granuloma: radiological and intraoperative findings of blood source connection

The hypothesis that the close contiguity between the cholesterol granulomas and some rich blood sources provided the trigger to the aggressive nature of tympanomastoid cholesterol granulomas has been recently reported. To corroborate this new etiopathogenetic theory we retrospectively reviewed a series of 14 patients with primary middle ear and mastoid cholesterol granulomas and investigated the temporal bone marrow invasion and its hematopoietic potentialities and a possible cholesterol granulomas contiguity with relevant vascular structures such as the carotid artery, sigmoid jugular system, mastoid or dural vein. Eight cases did not show radiological sign of bone marrow invasion or hematopoietic potentialities visible in MRI. Besides no intraoperative vascular connections that could explain an initial bleeding source were found. Cholesterol granulomas bone marrow invasion was present in six patients. A bone marrow hematopoietic potentiality was showed in four of these patients, whereas, an evident anatomical contiguity of the cholesterol granuloma with some important temporal bone vascular structures was visible in five cases. Analysis of cardiovascular risk factors showed that four patients presented one or more of the risk factors analysed.