Endoscopic Transsphenoidal Drainage of a Big Petrous Apex Cholesterol Granuloma

• Main Authors: Oberascher, Gerhard, Meco, Cem
• Format: Conference Proceeding
• Language: English
• ISSN: 1531-5010; 1532-0065
• DOI: 10.1055/s-2009-1222185

Introduction: Petrous apex cholesterol granulomas are the most commonly seen benign tumors that occur at the pneumatized cells in this region. They occur as a foreign body granulomatous reaction to cholesterol crystals, which are the end products of hemosiderin arising from erythrocyte breakdown after a local hemorrhage. Their management is principally watchful waiting, as long as they are not symptomatic. However, because of their expansive pressure on adjacent structures, giant cholesterol granulomas cause neurological symptoms, such as headache or cranial nerve deficits, rather than otologic ones. Once surgery is indicated in this difficult-to-reach area, appropriate treatment is controversial; it is a choice between traditionally used surgical drainage procedures (infralabyrinthine, infracochlear) and approaches that aim for total removal (transtemporal, extended translabyrinthine, transcochlear, transotic). These treatment modalities have, respectively, either high recurrence rates or risk high morbidity because of exposing and removing critical areas and structures. In cases with anatomical features suitable for transsphenoidal surgery, the endonasal endoscopic approach promises a reasonable and durable drainage pathway to the nasal cavity. Method: A 27-year-old man presented with headache and left-sided conductive hearing loss (pure tone average, 40 dB HL). Physical examination revealed nothing but a left-sided retracted tympanic membrane and a left-sided nasal septal deviation. High-resolution CT and MRI showed a left-sided cystic mass (3 × 2 × 2 cm) at the petrous apex, expanding from the medial side of the cochlea to the posterior wall of the sphenoid sinus. Due to suitable anatomy, transsphenoidal drainage through the endonasal endoscopic approach was performed under image guidance. Once the bony layer over the cholesterol granuloma had been drilled out, the medial cyst wall was evaporated using a carbon dioxide laser to facilitate a wide opening to the nasal cavity, which was also secured with a stent. Results: The cholesterol granuloma was successfully drained through the sphenoid sinus, diminishing the symptoms of the patient. No intraoperative or postoperative complications were encountered. Postoperative controls were very easy, and the first-year follow-up revealed a patent drainage pathway. Discussion: In selected cases where cholesterol granuloma cyst wall is in close proximity to sphenoid sinuses, the endonasal endoscopic transsphenoida