Subscribe to RSS
Upper Nasopharyngeal Corridor for Transnasal Endoscopic Drainage of Petroclival Cholesterol Granulomas: Alternative Access in Conchal Sphenoid Patients
05 October 2015
14 September 2015
16 November 2015 (online)
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.
Content of this work was presented in poster presentation form at the 25th Annual North American Skull Base Society Meeting Tampa, Florida, USA, February 20–22, 2015.
- 1 Brackmann DE, Toh EH. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol 2002; 23 (4) 529-533
- 2 Isaacson B, Kutz JW, Roland PS. Lesions of the petrous apex: diagnosis and management. Otolaryngol Clin North Am 2007; 40 (3) 479-519, viii
- 3 Durgam A, Batra PS. Paranasal sinus cholesterol granuloma: systematic review of diagnostic and management aspects. Int Forum Allergy Rhinol 2013; 3 (3) 242-247
- 4 Imre A, Pinar E, Paker I, Imre SS, Duran R, Ozturkcan S. Osteoplastic flap approach versus orbitotomy in case of orbitofrontal cholesterol granuloma. J Craniofac Surg 2015; 26 (1) e36-e37
- 5 Jackler RK, Cho M. A new theory to explain the genesis of petrous apex cholesterol granuloma. Otol Neurotol 2003; 24 (1) 96-106 , discussion 106
- 6 Selman Y, Wood JW, Telischi FF, Casiano RR, Angeli SI. Development of cholesterol granuloma in a temporal bone petrous apex previously containing marrow exposed to air cells. Otol Neurotol 2013; 34 (5) 958-960
- 7 Hoa M, House JW, Linthicum Jr FH. Petrous apex cholesterol granuloma: maintenance of drainage pathway, the histopathology of surgical management and histopathologic evidence for the exposed marrow theory. Otol Neurotol 2012; 33 (6) 1059-1065
- 8 Paluzzi A, Gardner P, Fernandez-Miranda JC , et al. Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients: clinical article. J Neurosurg 2012; 116 (4) 792-798
- 9 Sade B, Batra PS, Scharpf J, Citardi MJ, Lee JH. Minimally invasive endoscopic endonasal management of skull base cholesterol granulomas. World Neurosurg 2012; 78 (6) 683-688
- 10 Gore MR, Zanation AM, Ebert CS, Senior BA. Cholesterol granuloma of the petrous apex. Otolaryngol Clin North Am 2011; 44 (5) 1043-1058
- 11 Fournier HD, Mercier P, Roche PH. Surgical anatomy of the petrous apex and petroclival region. Adv Tech Stand Neurosurg 2007; 32: 91-146
- 12 Hamid O, El Fiky L, Hassan O, Kotb A, El Fiky S. Anatomic variations of the sphenoid sinus and their impact on trans-sphenoid pituitary surgery. Skull Base 2008; 18 (1) 9-15
- 13 Fucci MJ, Alford EL, Lowry LD, Keane WM, Sataloff RT. Endoscopic management of a giant cholesterol cyst of the petrous apex. Skull Base Surg 1994; 4 (1) 52-58
- 14 Mattox DE. Endoscopy-assisted surgery of the petrous apex. Otolaryngol Head Neck Surg 2004; 130 (2) 229-241
- 15 DiNardo LJ, Pippin GW, Sismanis A. Image-guided endoscopic transsphenoidal drainage of select petrous apex cholesterol granulomas. Otol Neurotol 2003; 24 (6) 939-941
- 16 Presutti L, Villari D, Marchioni D. Petrous apex cholesterol granuloma: transsphenoid endoscopic approach. J Laryngol Otol 2006; 120 (6) e20
- 17 Prabhu K, Kurien M, Chacko AG. Endoscopic transsphenoidal approach to petrous apex cholesterol granulomas. Br J Neurosurg 2010; 24 (6) 688-691
- 18 Dhanasekar G, Jones NS. Endoscopic trans-sphenoidal removal of cholesterol granuloma of the petrous apex: case report and literature review. J Laryngol Otol 2011; 125 (2) 169-172
- 19 Jaberoo MC, Hassan A, Pulido MA, Saleh HA. Endoscopic endonasal approaches to management of cholesterol granuloma of the petrous apex. Skull Base 2010; 20 (5) 375-379
- 20 Chatrath P, Nouraei SA, De Cordova J, Patel M, Saleh HA. Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study. Clin Otolaryngol 2007; 32 (4) 255-260
- 21 Gherini SG, Brackmann DE, Lo WW, Solti-Bohman LG. Cholesterol granuloma of the petrous apex. Laryngoscope 1985; 95 (6) 659-664
- 22 Scopel TF, Fernandez-Miranda JC, Pinheiro-Neto CD , et al. Petrous apex cholesterol granulomas: endonasal versus infracochlear approach. Laryngoscope 2012; 122 (4) 751-761
- 23 Eytan DF, Kshettry VR, Sindwani R, Woodard TD, Recinos PF. Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review. Neurosurg Focus 2014; 37 (4) E14
- 24 Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope 2009; 119 (1) 19-25