Endoscope-Assisted Middle Fossa Craniotomy for Resection of Petrous Cholesteatomas

Cholesteatomas are benign cystic expansile lesions of the petrous apex. These lesions are often clinically silent, but occasionally can present with symptoms such as facial pain, numbness, weakness, vertigo or hearing loss. A variety of skull base approaches have been utilized for the resection/drainage of cholesterol granulomas depending on location and hearing status. These approaches include transcanal infracochlear, transmastoid infralabyrinthine, translabyrinthine, transotic, middle fossa and endoscopic endonasal. The middle fossa approach is a reasonable option in supralabyrinthine lesions in patients with serviceable hearing. The limitation of this approach is its caudal visualization and reach as well as potential hearing loss due to injury to cochlea. Due to these limitations the middle fossa approach has often been limited to the resection of small lesion of the petrous apex without significant caudal extension. Endoscopes have been increasingly used as adjuncts in microsurgical procedures to improve visualization and extent of resection.

We present our series of three cases of endoscopic assisted middle fossa approaches to petrous apex cholesteatomas. In all cases a middle fossa approach was utilized with maximal resection of the lesion, followed by the introduction of an endoscope to assess the degree of resection and resect any remaining portions of the lesion. This approach not only permitted complete resection of these potentially difficult to access lesions, but also, allowed us to limit the bony resection needed for resection. Each patient in our series had improvement in their preoperative symptoms and no change in their hearing.