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Marchioni D, Alberti C, Bisi N, Rubini A. Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma. J Clin Med 2024; 13:2505. [PMID: 38731034 PMCID: PMC11084343 DOI: 10.3390/jcm13092505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Petrous apex cholesterol granulomas (PACGs) are benign inflammatory cystic lesions of the temporal bone. Usually, asymptomatic patients may develop symptoms as the lesions expand. The diagnosis is based on both CT and MRI scans and the management relies on "wait and scan" or surgery. This paper aims at evaluating surgical outcomes and proposing a CT-based classification and a management algorithm. Methods: Patients with PACGs who were surgically treated between 2014 and 2024 were included. Symptoms, imaging, approach type and complications were considered. CT scans were classified as Type A (preserved apex cellularity), Type B (erosion of the apex cellularity), and Type C (involvement of the noble structures bone boundaries). The possible connection of the lesion with the infracochlear, perilabyrinthine and sphenoidal cellularity was assessed. Results: Nineteen patients with symptoms like diplopia, headache and sensorineural hearing loss were included. According to our classification, 1/19 patients was Type A, 4/19 were Type B and 14/19 were Type C. Five patients underwent a total resection, seven a subtotal and seven a surgical drainage. Only two complications were recorded, and 17/19 patients showed symptom regression and stability during follow-up. Conclusions: While the management of PACGs is still controversial, according to our classification and surgical outcomes, Type A, being mostly asymptomatic, should be managed with "wait and scan", Type B should undergo surgery when symptoms are present, while Type C should always undergo surgery because of their invasiveness and potential complications. When possible, a drainage should be attempted; otherwise, a surgical resection is chosen, and its completeness depends on the preoperative general and hearing status.
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Affiliation(s)
| | | | - Nicola Bisi
- Department of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, 41125 Modena, Italy; (D.M.); (C.A.); (A.R.)
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Abouammo MD, Narayanan MS, Alsavaf MB, Alwabili M, Gosal JS, Bhuskute GS, Wu KC, Jawad BA, VanKoevering KK, Carrau RL, Prevedello DM. Contralateral Nasofrontal Trephination: A Novel Corridor for a "Dual Port" Approach to the Petrous Apex. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01097. [PMID: 38506519 DOI: 10.1227/ons.0000000000001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/13/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Expanded endonasal approaches (EEAs) have proven safe and effective in treating select petrous apex (PA) pathologies. Angled endoscopes and instruments have expanded indications for such approaches; however, the complex neurovascular anatomy surrounding the petrous region remains a significant challenge. This study evaluates the feasibility, anatomic aspects, and limitations of a contralateral nasofrontal trephination (CNT) route as a complementary corridor improving access to the PA. METHODS Expanded endonasal and CNT approaches to the PA were carried out bilaterally in 15 cadaveric heads with endovascular latex injections. The distance to the PA, angle between instruments through the 2 approach portals, and surgical freedom were measured and compared. RESULTS Three-dimensional DICOM-based modeling and visualization indicate that the CNT route reduces the distance to the target located within the contralateral PA by an average of 3.33 cm (19%) and affords a significant increase in the angle between instruments (15.60°; 54%). Furthermore, the vertical vector of approach is improved by 28.97° yielding a caudal reach advantage of 2 cm. The area of surgical freedom afforded by 3 different approaches (endonasal, endonasal with an endoscope in CNT portal, and endonasal with an instrument in CNT portal) was compared at 4 points: the dural exit point of the 6th cranial nerve, jugular foramen, foramen lacerum, and petroclival fissure. The mean area of surgical freedom provided by both approaches incorporating the CNT corridor was superior to EEA alone at each of the surgical targets (P = <.001). CONCLUSION The addition of a CNT portal provides an additional avenue to expand on the classical EEA to the PA. This study provides insight into the anatomic nuances and potential clinical benefits of a dual-port approach to the PA.
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Affiliation(s)
- Moataz D Abouammo
- Department of Otorhinolaryngology-Head and Neck Surgery, Tanta University, Tanta, Egypt
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maithrea S Narayanan
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Otolaryngology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
| | - Mohammed Alwabili
- Department of Otorhinolaryngology-Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Govind S Bhuskute
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Otolaryngology, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India
| | - Kyle C Wu
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
| | - Basit A Jawad
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
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Coutinho da Silva MB, Hernández Hernández V, Gupta P, Lavinsky J, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. Anteromedial Petrous (Gardner's) Triangle: Surgical Anatomy and Relevance for Endoscopic Endonasal Approach to the Petrous Apex and Petroclival Region. Oper Neurosurg (Hagerstown) 2024; 26:330-340. [PMID: 37856762 DOI: 10.1227/ons.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 08/13/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Triangular corridors have been used as reliable surgical entry points for open transcranial approaches to the petrous apex (PA) and petroclival region (PCR). The endoscopic endonasal approaches have grown rapidly in the last decade, and the indications have advanced. The knowledge of accurate and reliable anatomic landmarks through endoscopic endonasal route is essential and remain to be established. The purpose of this study was to describe the feasibility and surgical exposure of the anteromedial petrous (Gardner's) triangle as a novel corridor to the PA and PCR. METHODS Five anatomic specimens were dissected. The PA and PCR were accessed through endoscopic endonasal approaches and contralateral transmaxillary approach. The limits of the anteromedial petrous (Gardner's) triangle were identified and dissected and associated measurements performed. RESULTS The dissection was divided into 6 steps. The limits of the anteromedial petrous (Gardner's) triangle were identified and defined by the paraclival internal carotid artery anterolaterally, the abducens nerve posteromedially, and the petroclival synchondrosis inferiorly. Three lines were established following the limits of the triangle. The mean distance of the anterolateral limit was 10.03 mm (SD = 0.94), of the posteromedial limit was 20.06 mm (SD = 2.90), and of the inferior limit was 17.99 mm (SD = 2.99). The mean area was 87.56 mm 2 (SD = 20.06). The 3 anatomic landmarks with a critical role to safely define the triangle were the pterygosphenoidal fissure, the petrosal process of the sphenoid bone, and the petroclival synchondrosis. CONCLUSION The anteromedial (Gardner's) triangle is a well-defined bone corridor which provides access to the entire petrous bone and petroclival junction through endoscopic endonasal route. Regardless of the anatomic variations or tumor location, the landmarks of the abducens nerve, paraclival internal carotid artery, and petroclival synchondrosis are key for understanding lateral access to tumors extending from the clivus.
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Affiliation(s)
- Martin B Coutinho da Silva
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
- Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre , Rio Grande do Sul , Brazil
| | - Vanessa Hernández Hernández
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Prakash Gupta
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Joel Lavinsky
- Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre , Rio Grande do Sul , Brazil
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
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Fujiwara Y, Fujiwara K, Motegi H, Ishi Y, Morita S, Hoshino K, Fukuda A, Nakamaru Y, Homma A. Quantitative Evaluations of Vestibular Function in Patients With Petrous Apex Cholesterol Granulomas Treated With an Endoscopic Transsphenoidal Approach: A Report of Two Cases. Otol Neurotol 2023; 44:809-812. [PMID: 37464454 DOI: 10.1097/mao.0000000000003961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE We report two cases of petrous apex cholesterol granuloma (PACG) treated with an endoscopic transsphenoidal approach. Vestibular functions of the two patients were evaluated quantitatively by video Head Impulse Test (vHIT) and/or vestibular evoked myogenic potentials (VEMPs). PATIENTS Two patients with PACG who experienced episodes of dizziness are presented. INTERVENTION An endoscopic transsphenoidal approach to PACG. MAIN OUTCOME MEASURE The preoperative and postoperative vestibular functions as evaluated by vHIT and VEMP. RESULTS Two cases of PACG were treated by a transsphenoidal approach. The internal auditory canal was compressed by the PACG in both cases. The patients both experienced episodes of dizziness before surgery and preoperative vestibular testing including vHIT and VEMP indicated dysfunction of vestibular nerves. After surgery, their symptoms were completely resolved, and the vestibular testing results were improved. CONCLUSIONS This article is noteworthy for being the first to publish quantitative vestibular function testing for patients with PACG with vestibular dysfunction. PACG may show various symptoms, with dizziness being one of the most common symptoms. In cases in which the internal auditory canal is compressed by the PACG, vestibular functions should be evaluated by vHIT and VEMP. In the present cases, dizziness was found to be resolved by surgery to release the compression on internal auditory canal. Based on the present cases, the transsphenoidal approach is considered to be both safe and effective.
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Affiliation(s)
- Yuuki Fujiwara
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Keishi Fujiwara
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Hiroaki Motegi
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yukitomo Ishi
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Shinya Morita
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Kimiko Hoshino
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Atsushi Fukuda
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Yuji Nakamaru
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Akihiro Homma
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
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Porto E, Vuncannon J, Revuelta Barbero JM, Spielman DB, Barrow E, Garzon-Muvdi T, Mattox DE, Pradilla G, Solares CA. Contralateral Transmaxillary Approach to Petrous Apex Granuloma with Lateral Maxillotomy: 2-Dimensional Operative Video. World Neurosurg 2023; 169:9. [PMID: 36272728 DOI: 10.1016/j.wneu.2022.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
The endoscopic endonasal approach (EEA) has proven to be a valuable tool to access the petrous apex (PA).1 Although lesions located medial to the PA can be easily accessed through an EEA with minimal risk to the internal carotid artery (ICA), more laterally seated lesions represent a surgical challenge. The contralateral transmaxillary approach is an effective extension of the normal EEA to the PA, allowing a more lateral trajectory and thereby reducing the risks connected to paraclival ICA manipulation.2-4 This is a 47-year-old female presenting with tinnitus, hearing loss, and right facial twitching. The preoperative audiogram showed a 60 dB sensorineural hearing loss, and magnetic resonance imaging demonstrated an expansive lesion of the PA with high signal intensity in T1- and T2-weighted sequences. A high-riding jugular bulb ruled out the use of an infracochlear infralabyrinthine approach, and a middle cranial fossa approach was felt to render a high risk of recurrence due to the potential for incomplete resection. Ultimately, a contralateral transmaxillary approach was selected. Due to the extreme lateral position of the lesion, the maxillotomy was created in the lateral wall of the maxillary sinus to allow a coaxial approach to the PA. Postoperatively, the patient did not report new neurologic deficits. Anatomic pathology was consistent with cholesterol granuloma (Video 1). In the surgical management of PA granulomas, recognizing relevant anatomic structures such as the paraclival ICA, cochlea, jugular bulb, and vestibule preoperatively is of paramount importance to tailor the surgical approach and reduce its risks.
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Affiliation(s)
- Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Jackson Vuncannon
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | | | - Daniel B Spielman
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Emily Barrow
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Tomas Garzon-Muvdi
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Douglas E Mattox
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Arturo Solares
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA.
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Chowdhary S, Alexander A, Puducherry Ravichandran S, Penubarthi LK. CSF leak complicating the infralabyrinthine approach to petrous apex: lessons learnt. BMJ Case Rep 2022; 15:15/11/e252685. [DOI: 10.1136/bcr-2022-252685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Weisskopf PA, Turcotte EL, Rahme RJ, Bendok BR. Middle Fossa Approach for Resection of a Petrous Apex Cholesterol Granuloma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e322-e323. [PMID: 36103353 DOI: 10.1227/ons.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 05/24/2022] [Indexed: 11/19/2022] Open
Abstract
Cholesterol granulomas (CGs) are the most common cyst of the petrous apex.1 The management options for CG include observation and surgical resection. Surgery is complicated by the proximity of these lesions to critical neurological and vascular structures, as with many skull base lesions; however, if left untreated, their growth may lead to mass effect resulting in conductive hearing loss, cranial nerve dysfunction, tinnitus, and/or chronic headaches.2,3 In this video, we present the case of 52-year-old woman who presented with medically refractory right retro-orbital headaches. MRI revealed a large, right-sided petrous apex cystic structure consistent with a CG. Computed tomography of the head demonstrated bony remodeling. Given the large size of the cyst and the patient's symptoms, surgery was proposed, and the patient agreed. We performed a middle fossa craniotomy and elevated the dura from the floor of the middle fossa, working posteriorly from the petrous ridge and extending anteriorly. The cyst was exposed and decompressed, and its wall was then dissected off. After all cystic components were removed, the cavity was packed with abdominal fat, which is believed to prevent cyst reaccumulation. Postoperative MRI demonstrated good resection, and the patient reported complete resolution of her headaches. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication.
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Affiliation(s)
| | - Evelyn L Turcotte
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Rudy J Rahme
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
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Vinciguerra A, Turri-Zanoni M, Verillaud B, Guichard JP, Spirito L, Karligkiotis A, Castelnuovo P, Herman P. Typical and Atypical Symptoms of Petrous Apex Cholesterol Granuloma: Association with Radiological Findings. J Clin Med 2022; 11. [PMID: 35893388 DOI: 10.3390/jcm11154297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 12/10/2022] Open
Abstract
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.
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Shen M, Shou X, Zhao Y, Wang Y. How I do it? Resection of residual petrous apex chordoma with combined endoscopic endonasal and contralateral transmaxillary approaches. Acta Neurochir (Wien) 2022; 164:1967-1972. [PMID: 35616736 DOI: 10.1007/s00701-022-05243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The petrous apex is one of the most challenging areas of the skull base to access. METHOD We present a case of residual petrous apex chordoma posterolateral to the paraclival segment of the internal carotid artery (ICA) resected with combined endoscopic endonasal and contralateral transmaxillary (CTM) approaches, without lateralization of the ICA. CONCLUSION This case demonstrates the value of the CTM corridor in resecting petrous apex lesions that are posterolateral to the paraclival segment of the ICA.
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Affiliation(s)
- Ming Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Shanghai Pituitary Tumor Center, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, China
- Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences, Beijing, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Shanghai Pituitary Tumor Center, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, China
- Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences, Beijing, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Shanghai Pituitary Tumor Center, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, China
- Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences, Beijing, China
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China.
- Shanghai Pituitary Tumor Center, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, China.
- Research Units of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences, Beijing, China.
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Bawornvaraporn U, Zomorodi AR, Friedman AH, Fukushima T. Petrous bone lesions: surgical implementation and outcomes of extradural subtemporal approach. Acta Neurochir (Wien) 2021; 163:2881-94. [PMID: 34420107 DOI: 10.1007/s00701-021-04962-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/31/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Petrous bone lesions (PBLs) are rare with few reports in the neurosurgical literature. In this study, the authors describe our current technique of extradural subtemporal approach (ESTA). The objective of this study was to evaluate the role and efficacy of ESTA for treatment of the PBLs. To our knowledge, this is the largest reported clinical series of using an ESTA-treated PBLs in which the clinical outcomes were evaluated. METHODS Between 1994 and 2019, 67 patients with PBLs treated by ESTA were retrospectively reviewed. Extent of resection, neurological outcomes, recurrence rate, and surgical complications were evaluated and compared with previous studies. The indications, advantages, limitations, and outcomes of ESTA were analyzed according to pathology. RESULTS This series included 7 facial nerve schwannomas (10.4%), 16 cholesterol granulomas (23.9%), 16 chordomas (23.9%), 6 chondrosarcomas (9%), 5 trigeminal schwannomas (7.5%), 9 epidermoids/dermoids (13.4%), and 8 other pathologies (11.9%). The most common location of PBLs operated with ESTA was at the petrous apex and rhomboid areas (68.7%). Gross total resection was achieved in 35 (55.6%). Symptomatic improvement occurred in 56 patients (83.6%). Complications occurred in 7 (10.4%) of cases including one mortality. Nine patients (17%) had recurrence within the mean follow-up 71 months. Compared to previous literature, our results demonstrated comparable outcomes but with higher rates of hearing and facial nerve preservation as well as minimal morbidity. From our results, ESTA is an effective therapeutic option for lesions located at the rhomboid and petrous apex, particularly when patients presented with intact facial and hearing function. CONCLUSION Our series demonstrated that ESTA provided satisfactory outcomes with excellent benefits of hearing and facial function preservation for patients with petrous bone lesions. ESTA should be considered as a safe and effective therapeutic option for selected patients with PBLs.
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Kajal S, Thakar A, Verma H. Indications and advantages of Endoscopic Trans-sphenoid approach for petrous apex lesions: Two case reports. J Laryngol Otol 2021;:1-16. [PMID: 34583795 DOI: 10.1017/S0022215121002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Morino T, Yamamoto Y, Yamamoto K, Komori M, Asaka D, Kojima H. Management of Intractable Petrous Bone Cholesteatoma With a Combined Translabyrinthine-Transsphenoidal Approach. Otol Neurotol 2021; 42:e311-6. [PMID: 33555753 DOI: 10.1097/MAO.0000000000002952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate whether a combined translabyrinthine-transsphenoidal approach can be used to achieve adequate surgical resection of an extensive petrous bone cholesteatoma and create a debris drainage route for the residual cholesteatoma that is maintained long-term. PATIENT A 71-year-old man with residual petrous temporal bone cholesteatoma that had spread extensively to the internal carotid artery and posterior cranial fossa. INTERVENTION Surgical resection of the cholesteatoma via a translabyrinthine approach and creation of a debris drainage route into the nasopharynx via a transsphenoidal approach. MAIN OUTCOME MEASURES Control of unresectable petrous temporal bone cholesteatoma and occurrence of cholesteatoma- or surgery-related complications. RESULTS Although complete removal of the cholesteatoma was attempted via a translabyrinthine approach, this was not possible because the epithelium of the cholesteatoma was strongly attached to the internal carotid artery and posterior cranial fossa. A debris drainage route leading to the nasopharynx was created by drilling the clivus on the side of the lesion via a transsphenoidal approach. The patient has had no complications since surgery. The drainage route remains open, and the cholesteatoma has been controlled for 57 months. CONCLUSIONS A markedly advanced petrous temporal bone cholesteatoma can be managed safety and reliably by combining a translabyrinthine approach with a transsphenoidal approach. Creation of a debris drainage route into the nasopharynx can prevent isolation of the cholesteatoma and mastoid cavity problems after surgery. This one-stage surgery may be a suitable method for keeping cholesteatoma under control in patients with unresectable petrous bone cholesteatoma.
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Zheng Z, Otten ML, Bruce JN, Gudis DA. Endoscopic Petrous Apex Surgery: The Utilization of Frontal Sinus Instrumentation. J Craniofac Surg 2020; 31:2317-9. [PMID: 33136880 DOI: 10.1097/SCS.0000000000006716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The petrous apex is a complex anatomic region for which each surgical approach each has distinct limitations. The authors describe the use of frontal sinus instrumentation for the endonasal endoscopic approach to petrous apex lesions OBJECTIVE:: To demonstrate that the angled design of frontal sinus instrumentation has pronounced clinical utility for the transsphenoidal transclival approach to the petrous apex. METHODS The authors present cases of expansile petrous apex lesions approached endoscopically via transsphenoid and transclival corridors, and highlight the technique of using curved frontal sinus instruments and angled endoscopes for posterolateral reach in the petrous apex dissection. RESULTS As demonstrated in the accompanying video, dissection with frontal sinus instrumentation allows the surgeon to navigate around the internal carotid artery. CONCLUSIONS Significant technical and technological advances have been made in the field of expanded endoscopic endonasal skull base surgery in the past 3 decades. Increasing efforts are made to push the boundaries and access more laterally located lesions, such as those in the petrous apex. Surgical trajectory or vector is paramount to safely navigate around the internal carotid artery.
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Lucke-Wold B, Fleseriu C, Calcagno H, Smith T, Levy J, Ciporen J. Endoscopic transsphenoidal drainage of a petrous apex cholesterol granuloma using a frontal sinus nasal stent: a case report with long term follow up. Br J Neurosurg 2021; 35:139-144. [PMID: 32516000 PMCID: PMC8106767 DOI: 10.1080/02688697.2020.1773400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cholesterol granulomas of the petrous apex are benign cysts affecting 0.6 patients per 1 million. The pathophysiology involves cholesterol crystals and lipids that are surrounded by giant cells. The cholesterol deposits induce an inflammatory response likely from acute hemorrhage leading to the formation of a fibrous capsule. The capsule expands over time compressing nearby cranial nerves (VI-VIII), which can cause worsening symptoms. Surgical resection has been shown to provide excellent improvement in symptoms. Historically, open approaches such as the infracochlear, infralabyrinthine, and middle fossa have been used. Herein we present a case showing the feasibility and clinical utility of using an endoscopic endonasal transclival approach for treatment of these tumors. CASE A 44-year-old female presented with history of intermittent double vision, dizziness, nausea, and headaches for 3 years. She developed a partial left CN6 palsy with significant diplopia and episodes of left facial weakness. The worsening symptoms prompted presentation to the ED where MRI and CT scan revealed a left petrous apex lesion (1.8 × 1.7 cm) with hyperintensity on T1 and T2 imaging, suggestive of cholesterol granuloma. She underwent an endoscopic transclival resection of the lesion: drainage of left petrous apex cholesterol granuloma and stent placement from left petrous apex into sphenoid sinus (novel technique). This was done to allow continued communication and drainage of the tumor bed from the petrous apex into the sphenoid sinus with the intent to minimize the risk of recurrence. At the postop visit both 6th nerve palsy and diplopia had resolved. Imaging is stable 2 years after the surgery. DISCUSSION The placement of the stent in this case was done to prevent symptom recurrence. 11% of patients that do not receive a stent will have symptom recurrence within one year. From the historical literature, only 4% of patients who had stent placement developed cyst recurrence or expansion on follow-up imaging. Stent placement has been shown to prevent cyst enlargement within the first few months after surgery. We demonstrate that the endoscopic endonasal transclival approach provided good visualization of the tumor, allowed for an adequate working window for resection, and provided a sufficient approach for stent placement.
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Affiliation(s)
| | - Cara Fleseriu
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Haley Calcagno
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Smith
- Department of Otolaryngology, Oregon Health & Science University, Portland, OR, USA
| | - Joshua Levy
- Department of Otolaryngology, Oregon Health & Science University, Portland, OR, USA
| | - Jeremy Ciporen
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR, USA
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15
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Patel CR, Snyderman CH, Fernandez-Miranda JC, Gardner PA, Wang EW. Mucosal Grafting Reduces Recurrence After Endonasal Surgery of Petrous Apex Cholesterol Granulomas. Laryngoscope 2021; 131:E2513-E2517. [PMID: 33559896 DOI: 10.1002/lary.29432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/28/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES/HYPOTHESIS The endoscopic endonasal approach (EEA) is increasingly utilized for management of petrous apex cholesterol granuloma (PACG). Surgical goals include drainage and marsupialization of the cyst. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of mucosal grafting on recurrence. STUDY DESIGN Retrospective Cohort study. METHODS Patients who underwent EEA for PACG at two tertiary care centers between 1999 and 2018 were identified and divided into two cohorts: Mucosal versus no mucosal reconstruction. Surgical approach, reconstructive method, and recurrence were recorded. Primary endpoint was symptomatic or radiographic recurrence. RESULTS Thirty-four patients were identified undergoing 37 surgeries. Four patients developed recurrences of which three elected to undergo revision. Some form of mucosa was used to line the drainage tract in 20 cases. A free mucosal graft was used in 8, and a small customized nasal septal flap (miniflap) in 12. All four recurrences occurred in cases where no mucosa was used, demonstrating decreased recurrences with mucosal reconstruction (P < .05). There was no difference found between free mucosal grafts and miniflaps. CONCLUSIONS Utilization of mucosa to partially line a circumferentially de-epithelialized drainage pathway after EEA for PACG reduce recurrence rates. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2513-E2517, 2021.
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Affiliation(s)
- Chirag R Patel
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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16
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Maharaj S, Joseph J. Pediatric Petrous Apex Mass. Ear Nose Throat J 2020; 101:86-88. [PMID: 32697620 DOI: 10.1177/0145561320944057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Shivesh Maharaj
- Department of Otorhinolaryngology, University of the Witwatersrand, Johannesburg, South Africa
| | - Judith Joseph
- University of the Witwatersrand, Johannesburg, South Africa
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17
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Li KL, Agarwal V, Moskowitz HS, Abuzeid WM. Surgical approaches to the petrous apex. World J Otorhinolaryngol Head Neck Surg 2020; 6:106-114. [PMID: 32596655 PMCID: PMC7296478 DOI: 10.1016/j.wjorl.2019.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/27/2019] [Indexed: 11/18/2022] Open
Abstract
The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures. Petrous apex pathology ranges from extradural cholesterol granulomas, cholesteatomas, asymmetric pneumatization, and osteomyelitis to intradural meningiomas and schwannomas. Certain lesions, such as cholesterol granulomas, can be managed with drainage while neoplastic lesions must be completely resected. Surgical options use open, endoscopic, and combined techniques and are categorized into anterior, lateral, and posterior approaches. The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient. The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex, and the anatomy on which these approaches are based.
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Affiliation(s)
- Kevin L Li
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Vijay Agarwal
- Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Howard S Moskowitz
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
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18
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Kim JS, Kim DH, Yoon WS, Kim Y. Endoscopic Endonasal Transpterygoid Approach Using Pedicled Nasoseptal Flap for Petrous Apex Cholesterol Granuloma With Intraoperative Video. J Craniofac Surg 2019; 30:1833-5. [PMID: 31313683 DOI: 10.1097/SCS.0000000000005589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
With the development of minimally invasive endoscopic surgery and image-guided navigation systems, the endoscopic endonasal approach to petrous apex lesions has become more favorable. In this case, a petrous apex cholesterol granuloma was successfully treated with an endoscopic endonasal transpterygoid approach. A navigation system was used, and a contralateral nasoseptal flap and silicone tube stent were applied to maintain the cholesterol granuloma drainage pathway. The authors describe the endoscopic endonasal transpterygoid approach using a pedicled nasoseptal flap for petrous apex cholesterol granuloma and provide an intraoperative video and a literature review.
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20
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Choi KJ, Jang DW, Zomorodi AR, Codd PJ, Friedman A, Abi Hachem R. Novel Application of Steroid Eluting Stent in Petrous Apex Cholesterol Granuloma. J Neurol Surg B Skull Base 2019; 80:500-504. [PMID: 31534892 DOI: 10.1055/s-0038-1675751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 10/06/2018] [Indexed: 10/27/2022] Open
Abstract
Objective This study describes the safety and efficacy of mometasone furoate eluting stents in the management of petrous apex cholesterol granuloma approached through an endonasal endoscopic route and assesses the restenosis rate. Methods Consecutive patients undergoing endoscopic endonasal marsupialization of a petrous apex cholesterol granuloma at a tertiary referral center who had a mometasone furoate eluting stent placed intraoperatively were reviewed in a retrospective fashion. Postoperative endoscopy was used to determine success of surgery and stenting. Results Five patients were included in the study, three were primary cases and two patients had revision surgeries performed. The steroid eluting stent was placed successfully and safely in all patients with no dural or vascular injuries. The average follow-up duration was 10.6 months. There was no restenosis in three patients and one patient had an immediate restenosis that was debrided in clinic (revision case). This was patent at the 16 months follow-up. One patient also developed stenosis, 4 months after surgery due to sphenoid sinusitis. Conclusion Mometasone furoate eluting stents are safe and effective in the primary management of petrous apex cholesterol granuloma. Further studies are needed to assess their efficacy in revision cases and for long term results.
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Affiliation(s)
- Kevin J Choi
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina, United States
| | - David W Jang
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina, United States.,Department of Neurosurgery, Duke University, Durham, North Carolina, United States
| | - Ali R Zomorodi
- Department of Neurosurgery, Duke University, Durham, North Carolina, United States
| | - Patrick J Codd
- Department of Neurosurgery, Duke University, Durham, North Carolina, United States
| | - Allan Friedman
- Department of Neurosurgery, Duke University, Durham, North Carolina, United States
| | - Ralph Abi Hachem
- Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina, United States.,Department of Neurosurgery, Duke University, Durham, North Carolina, United States
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21
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Kohanski MA, Palmer JN, Adappa ND. Indications and endonasal treatment of petrous apex cholesterol granulomas. Curr Opin Otolaryngol Head Neck Surg 2019; 27:54-8. [PMID: 30507687 DOI: 10.1097/MOO.0000000000000511] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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22
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Radonjic A, Moldovan ID, Kilty SJ, Schramm DR, Alkherayf F. Complete Recovery of Sensorineural Hearing Loss Following Endoscopic Transsphenoidal Surgery for a Petrous Apex Cholesterol Granuloma: Case Report. Am J Case Rep 2019; 20:335-339. [PMID: 30867405 PMCID: PMC6429980 DOI: 10.12659/ajcr.913964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patient: Male, 64 Final Diagnosis: Petrous apex cholesterol granuloma Symptoms: Right ear sensorineural hearing loss Medication: — Clinical Procedure: Endoscopic endonasal transsphenoidal surgery Specialty: Neurosurgery
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Affiliation(s)
| | - Ioana D Moldovan
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shaun J Kilty
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - David R Schramm
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Fahad Alkherayf
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Giourgos G, Bizzoni A, Danesi G. Endoscopic Endonasal Approach to Selected Lesions of the Petrous Apex. Curr Otorhinolaryngol Rep 2019; 7:73-78. [DOI: 10.1007/s40136-019-00228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Di Somma A, Andaluz N, Cavallo LM, Topczewski TE, Frio F, Gerardi RM, Pineda J, Solari D, Enseñat J, Prats-Galino A, Cappabianca P. Endoscopic transorbital route to the petrous apex: a feasibility anatomic study. Acta Neurochir (Wien) 2018; 160:707-720. [PMID: 29288394 DOI: 10.1007/s00701-017-3448-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/21/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND While the subtemporal approach represents the surgical module milestone designed to reach the petrous apex, a novel ventral route, which is the superior eyelid endoscopic transorbital approach, has been proposed to access the skull base. Accordingly, we aimed to evaluate the feasibility of this route to the petrous apex, providing a qualitative and quantitative analysis of this relatively novel pathway. METHODS Five human cadaveric heads were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. After proper dissection planning, anterior petrosectomy via the endoscopic transorbital route was performed. Specific quantitative analysis, as well as dedicated three-dimensional reconstruction, was done. RESULTS Using the endoscopic transorbital approach, it was possible to reach the petrous apex with an average volume bone removal of 1.33 ± 0.21 cm3. Three main intradural spaces were exposed: cerebellopontine angle, middle tentorial incisura, and ventral brainstem. The first one was bounded by the origin of the trigeminal nerve medially and the facial and vestibulocochlear nerves laterally, the second extended from the origin of the oculomotor nerve to the entrance of the trochlear nerve into the tentorium free edge while the ventral brainstem area was hardly accessible through the straight, ventral endoscopic transorbital trajectory. CONCLUSION This is the first qualitative and quantitative anatomic study concerning details of the lateral aspect of the incisura and ventrolateral posterior fossa reached via the transorbital window. This manuscript is intended as a feasibility anatomic study, and further clinical contributions are mandatory to confirm the effectiveness of this approach, defining its possible role in the neurosurgical armamentarium.
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Affiliation(s)
- Alberto Di Somma
- Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli "Federico II", 80131, Naples, Italy.
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Comprehensive Stroke Center at UC Neuroscience Institute, Mayfield Clinic, Cincinnati, OH, USA
| | - Luigi Maria Cavallo
- Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli "Federico II", 80131, Naples, Italy
| | - Thomaz E Topczewski
- Department of Neurosurgery, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Federico Frio
- Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli "Federico II", 80131, Naples, Italy
| | - Rosa Maria Gerardi
- Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli "Federico II", 80131, Naples, Italy
| | - Jose Pineda
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Domenico Solari
- Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli "Federico II", 80131, Naples, Italy
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Paolo Cappabianca
- Division of Neurosurgery, School of Medicine and Surgery, Università degli Studi di Napoli "Federico II", 80131, Naples, Italy
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Wick CC, Hansen AR, Kutz JW Jr, Isaacson B. Endoscopic Infracochlear Approach for Drainage of Petrous Apex Cholesterol Granulomas: A Case Series. Otol Neurotol 2017; 38:876-81. [PMID: 28498267 DOI: 10.1097/MAO.0000000000001422] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Patel CR, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Contralateral transmaxillary corridor: an augmented endoscopic approach to the petrous apex. J Neurosurg 2017; 129:211-219. [PMID: 29053078 DOI: 10.3171/2017.4.jns162483] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has been shown to be an effective means of accessing lesions of the petrous apex. Lesions that are lateral to the paraclival segment of the internal carotid artery (ICA) require lateralization of the paraclival segment of the ICA or a transpterygoid infrapetrous approach. In this study the authors studied the feasibility of adding a contralateral transmaxillary (CTM) corridor to provide greater access to the petrous apex with decreased need for manipulation of the ICA. METHODS Using image guidance, EEA and CTM extension were performed bilaterally on 5 cadavers. The anterior wall of the sphenoid sinus and rostrum were removed. The angle of the surgical approach from the axis of the petrous segment of the ICA was measured. Five illustrative clinical cases are presented. RESULTS The CTM corridor required a partial medial maxillectomy. When measured from the axis of the petrous ICA, the CTM corridor decreased the angle from 44.8° ± 2.78° to 20.1° ± 4.31°, a decrease of 24.7° ± 2.58°. Drilling through the CTM corridor allowed the drill to reach lateral aspects of the petrous apex that would have required lateralization of the ICA or would not have been accessible via EEA. The CTM corridor allowed us to achieve gross-total resection of the petrous apex region in 5 clinical cases with significant paraclival extension. CONCLUSIONS The CTM corridor is a feasible extension to the standard EEA to the petrous apex that offers a more lateral trajectory with improved access. This approach may reduce the risk and morbidity associated with manipulation of the paraclival ICA.
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Affiliation(s)
- Chirag R Patel
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric W Wang
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan C Fernandez-Miranda
- 2Neurological Surgery, University of Pittsburgh School of Medicine; and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- 2Neurological Surgery, University of Pittsburgh School of Medicine; and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Departments of1Otolaryngology and.,3Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Stevens SM, Manning A, Pensak ML, Samy RN. Long-term Symptom-specific Outcomes for Patients With Petrous Apex Cholesterol Granulomas: Surgery Versus Observation. Otol Neurotol 2017; 38:253-9. [PMID: 27898604 DOI: 10.1097/MAO.0000000000001268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Review long-term symptom-specific outcomes for petrous apex cholesterol granulomas (PACG). STUDY DESIGN Retrospective review. SETTING Tertiary center. PATIENTS Adults with PACG were assessed from 1998 to 2015. INTERVENTION(S) Symptomatic patients were stratified into surgical and observation subgroups. MAIN OUTCOME MEASURE(S) Resolution rates of individual symptoms and chief complaints were assessed as was the impact of surgical approach and stent usage on symptom-specific outcomes. Symptom recurrence rates were tabulated. RESULTS Twenty-seven patients were included whose mean age was 44.8 ± 3.3 years. Fourteen and 13 patients stratified into the surgical and observation subgroups respectively. The surgical subgroup trended toward a longer follow-up period (mean 68.5 vs. 33.8 mo; p = 0.06). Overall, the most frequent symptoms encountered were headache (52%), aural fullness, tinnitus, and vestibular complaints (41% each). Visual complaints, retro-orbital pain, and cranial neuropathies were less common (18%, 15%, 11%). The overall symptom resolution rate was significantly higher in the surgical subgroup (48% vs. 26%, p = 0.03). In both subgroups, headache, retro-orbital pain, and visual complaints had the highest resolution rates. Vestibular complaints and tinnitus were very unlikely to resolve. Significantly more patients in the surgical group resolved their chief complaints (70% vs. 25%, p = 0.02). While approach type and stent usage did not significantly influence symptom outcomes, all patients with symptom recurrence (11%) were initially managed without stents. CONCLUSION Symptom-specific outcomes were better in patients managed surgically for PACG. Individual symptom resolution rates were highly variable. Some symptoms were refractory regardless of management strategy. Surgical approach and stent usage did not significantly influence symptom outcomes.
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Hernández-Estrada RA, Kshettry VR, Vogel AN, Curtis MT, Evans JJ. Cholesterol granulomas presenting as sellar masses: a similar, but clinically distinct entity from craniopharyngioma and Rathke's cleft cyst. Pituitary 2017; 20:325-332. [PMID: 27837386 DOI: 10.1007/s11102-016-0775-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Cholesterol granulomas in the sella are rare and can mimic the appearance of craniopharyngioma or Rathke's cleft cysts. Information regarding the clinical presentation, imaging characteristics, and clinical course of sellar cholesterol granulomas can help clinicians to differentiate these lesions from other sellar cystic lesions. METHODS We present three cases of sellar cholesterol granulomas. A literature review was performed for all cases of sellar cholesterol granulomas with individual patient data reported. RESULTS We identified 24 previously reported cases in addition to our three cases. Mean age was 36.6 years (range 5-68). There were 16 (59%) females. The most common (74%) presenting symptom was endocrinological deficits, typically either isolated diabetes insipidus (DI) or panhypopituitarism. Location was intrasellar in 3 (11%), suprasellar in 6 (22%), and intrasellar/suprasellar in 18 (67%) patients. Lesions were most commonly (83%) T1 hyperintense. Gross total resection was achieved in 16 (64%) and subtotal resection in 9 (36%) patients. Of the seventeen (63%) patients presenting with varying degrees of bitemporal hemianopsia, all had improvement in vision postoperatively. It is worth noting that no cases of preoperative hypopituitarism or DI improved postoperatively. Even though gross total resection was only achieved in 64%, there was only one recurrence reported. CONCLUSION Sellar cholesterol granulomas are characterized by T1 hyperintensity, younger age, and more frequent and severe endocrinological deficits on presentation. Our review demonstrates high rates of improvement of visual deficits, but poor rates of endocrine function recovery. Recurrence is uncommon even in cases of subtotal resection.
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Affiliation(s)
- Raúl A Hernández-Estrada
- Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
- Department of Neurosurgery, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Avenida Belisario Dominguez 1000, Independencia Oriented, 44340, Guadalajara, Jal., Mexico
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH, 44195, USA.
| | - Ashley N Vogel
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, 132 10th Street, Main Building Suite 262, Philadelphia, PA, 19107, USA
| | - Mark T Curtis
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, 132 10th Street, Main Building Suite 262, Philadelphia, PA, 19107, USA
| | - James J Evans
- Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
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Ishi Y, Kobayashi H, Motegi H, Endo S, Yamaguchi S, Terasaka S, Houkin K. Endoscopic transsphenoidal surgery using pedicle vascularized nasoseptal flap for cholesterol granuloma in petrous apex: A technical note. Neurol Neurochir Pol 2016; 50:504-10. [PMID: 27575680 DOI: 10.1016/j.pjnns.2016.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/20/2016] [Accepted: 08/10/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Compared with surgical resection, endoscopic transsphenoidal surgery (TSS) for cholesterol granuloma (CG) in the petrous apex (PA) is associated with local recurrence due to obstruction of the drainage route. We present a detailed procedure of an endoscopic TSS using pedicle vascularized nasoseptal flap (PVNF). METHODS A 40-year-old woman with a history of repeated surgery for left tympanitis was referred to our institution. Neurological examination revealed severe hearing loss in the left ear. Radiologic examination presented a round mass in the left PA and significant fluid collection in the mastoid air cells of the left temporal bone. CG was strongly suspected, and endoscopic TSS using PVNF was performed. Prior to endoscopic drainage, a PVNF was harvested from the mucosa of the ipsilateral nasal septum, with an attempt to preserve the sphenopalatine artery in the flap. Following this, puncture and adequate irrigation of the lesion was performed by endoscopic TSS, with neuro-navigation system assistance; the apex of PVNF was then placed into the lesion to prevent the obstruction of the drainage route. An absorbable polyglycolic acid sheet and fibrin glue were applied on the flap to prevent spontaneous deviation from the lesion. RESULTS The patient was discharged without any further neurological complications. Eight-month postoperative computed tomography images showed no recurrence; the drainage route was patent and the fluid collection in the left mastoid air cells was resolved. Moreover, hearing loss was improved. CONCLUSIONS Endoscopic TSS using PVNF may be one of available surgical options for PACG.
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Abstract
Building an endoscopic cranial base practice can be challenging and is predicated on the right team. Successful outcomes stem from an efficient and talented team that improves its skills experientially in a supportive environment. As with most new endeavors that are beyond the traditional approach, there is a great deal of up-front effort and investment required. This article explores some of the key building blocks necessary for a successful endoscopic cranial base and pituitary program and highlights some of the lessons learned during the authors' journey at the Cleveland Clinic.
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Affiliation(s)
- Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA.
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA
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Turan N, Baum GR, Holland CM, Ahmad FU, Henriquez OA, Pradilla G. Upper Nasopharyngeal Corridor for Transnasal Endoscopic Drainage of Petroclival Cholesterol Granulomas: Alternative Access in Conchal Sphenoid Patients. J Neurol Surg Rep 2015; 77:e017-22. [PMID: 26929897 PMCID: PMC4726374 DOI: 10.1055/s-0035-1567865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 09/14/2015] [Indexed: 11/25/2022] Open
Abstract
Background Cholesterol granulomas arising at the petrous apex can be treated via traditional open surgical, endoscopic, and endoscopic-assisted approaches. Endoscopic approaches require access to the sphenoid sinus, which is technically challenging in patients with conchal sphenoidal anatomy. Clinical Presentation A 55-year-old woman presented with intermittent headaches and tinnitus. Formal audiometry demonstrated moderately severe bilateral hearing loss. CT of the temporal bones and sella revealed a well-demarcated expansile lytic mass. MRI of the face, orbit, and neck showed a right petrous apex mass measuring 22 × 18 × 19 mm that was hyperintense on T1- and T2-weighted images without enhancement, consistent with a cholesterol granuloma. The patient had a conchal sphenoidal anatomy. Operative Technique Herein, we present an illustrative case of a low-lying petroclival cholesterol granuloma in a patient with conchal sphenoidal anatomy to describe an alternative high nasopharyngeal corridor for endoscopic transnasal transclival access. Postoperative Course Postoperatively, the patient's symptoms recovered and no complications occurred. Follow-up imaging demonstrated a patent drainage tract without evidence of recurrence. Conclusion In patients with a conchal sphenoid sinus, endoscopic transnasal transclival access can be gained using a high nasopharyngeal approach. This corridor facilitates safe access to these lesions and others in this location.
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Affiliation(s)
- Nefize Turan
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Griffin R Baum
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Christopher M Holland
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Faiz U Ahmad
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Oswaldo A Henriquez
- Emory University School of Medicine, Department of Otolaryngology, Head and Neck Surgery, Atlanta, GA, United States
| | - Gustavo Pradilla
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
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Carlos C, Parkes W, James AL. Application of 3-dimensional Modeling to Plan Totally Endoscopic Per-Meatal Drainage of Petrous Apex Cholesterol Granuloma. Otolaryngol Head Neck Surg 2015; 153:1074-5. [DOI: 10.1177/0194599815607851] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/02/2015] [Indexed: 11/15/2022]
Affiliation(s)
| | - William Parkes
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Adrian L. James
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Canada
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