Clinicoradiological and Surgical Considerations in the Treatment of Cholesterol Granuloma of the Petrous Pyramid

ABSTRACT

We describe a 71-year-old woman who complained of a 1-year history of double vision when looking to the left, numbness over the right cheek, intermittent tinnitus, and gradually increasing unsteadiness when walking. Computed tomography and magnetic resonance imaging revealed a cholesterol granuloma at the right pyramidal apex anterior to the internal auditory canal and a slight compression of the brainstem on the ipsilateral side. For surgical removal we used the transtemporal approach instead of the trans-sphenoidal approach to obtain better control over the internal carotid artery. To avoid the problems of stenting, the resulting dead space was obliterated with fat. We discuss the essential preoperative imaging, controversies in choosing the appropriate surgical approach, and developments in treatment.

KEYWORDS

Cholesterol granuloma - skull base - surgical approach

REFERENCES

• 1 Chole R A. Petrous apicitis: surgical anatomy.  Ann Otol Rhinol Laryngol. 1985;  94 251-257
• 2 Moore K R, Harnsberger H R, Shelton C, Davidson H C. “Leave me alone” lesions of the petrous apex.  AJNR Am J Neuroradiol. 1998;  19 733-738
• 3 Brackmann D E, Toh E H. Surgical management of petrous apex cholesterol granulomas.  Otol Neurotol. 2002;  23 529-533
• 4 Nager G T, Vanderveen T S. Cholesterol granuloma involving the temporal bone.  Ann Otol Rhinol Laryngol. 1976;  85 204-209
• 5 Thedinger B A, Nadol Jr J B, Montogomery W W, Thedinger B S, Greenberg J J. Radiographic diagnosis, surgical treatment and long-term follow-up of cholesterol granulomas of the petrous apex.  Laryngoscope. 1989;  99 896-907
• 6 Lo W W, Solti-Bohmann L G, Brackmann D E, Gruskin P. Cholesterol granuloma of the petrous apex: CT diagnosis.  Radiology. 1984;  153 705-711
• 7 Howitz M F, Johansen C, Tos M, Charabi S, Olsen J H. Incidence of vestibular schwannoma in Denmark 1977-1995.  Am J Otol. 2000;  21 690-694
• 8 Mosnier I, Cyna-Gorse F, Grayeli A B et al.. Management of cholesterol granulomas of the petrous apex based on clinical and radiological evaluation.  Otol Neurotol. 2002;  23 522-528
• 9 Chole R A, Donald P J. Petrous apicitis. Clinical considerations.  Ann Otol Rhinol Laryngol. 1983;  92 544-551
• 10 Larson T L. Petrous apex and cavernous sinus: anatomy and pathology.  Semin Ultrasound CT MR. 1993;  14 232-246
• 11 Palacios E, Valvassori G. Petrous apex lesions: cholesterol granuloma.  Ear Nose Throat J. 1999;  78 234
• 12 Muckle R P, De la Cruz A, Lo W M. Petrous apex lesions.  Am J Otol. 1998;  19 219-225
• 13 Jaramillo M, Windle-Taylor P C. Large cholesterol granuloma of the petrous apex treated via subcochlear drainage.  J Laryngol Otol. 2001;  115 1005-1009
• 14 Michaelson P G, Cable B B, Mair E A. Image-guided transphenoidal drainage of a cholesterol granuloma of the petrous apex in a child.  Int J Pediatr Otorhinolaryngol. 2001;  57 165-169
• 15 Griffith A J, Terrell J E. Transsphenoid endoscopic management of petrous apex cholesterol granuloma.  Otolaryngol Head Neck Surg. 1996;  114 91-94
• 16 Haberkamp T. Surgical anatomy of the transtemporal approach to the petrous apex.  Am J Otol. 1997;  18 501-516
• 17 Horn K L, Hankinson H L, Erasmus M D, Beauparalant P A. The modified transcochlear approach to the cerebellopontine angle.  Otolaryngol Head Neck Surg. 1991;  104 37-41
• 18 Fong B P, Brackmann D E, Telischi F F. The long-term follow-up of drainage procedures for petrous apex cholesterol granulomas.  Arch Otolaryngol Head Neck Surg. 1995;  121 426-430
• 19 Ghorayeb B Y, Jahrsdoerfer R A. Subcochlear approach for cholesterol granulomas of the inferior petrous apex.  Otolaryngol Head Neck Surg. 1990;  103 60-65
• 20 House W F, Hitselberger W E, McElveen J T, Shelton C. The middle cranial fossa approach to lesions of the temporal bone and cerebellopontine angle. In: Wilkins RH, Rengachary SS Neurosurgery Update I. New York, NY; McGraw-Hill 1990: 321-327
• 21 Gianoli G J, Amedee R G. Hearing results in surgery for primary petrous apex lesions.  Otolaryngol Head Neck Surg. 1994;  111 250-257