Massive Petrous Apex Cholesteatomas: Surgical Aspects and Outcome

Introduction: Petrous apex cholesteatomas are rare tumors of the skull base, claiming 4 to 9% of petrous apex lesions. These tumors are locally invasive and gradually engulf the entire petrous bone by various pathways—supralabyrinthine, infralabyrinthine, infralabyrinthine apical, massive and apical. The surgical technique employed for excising these lesions should be radical while making every attempt to preserve functionality like hearing and facial nerve function if unaffected preoperatively. In this study, we present a case series of giant petrous apex cholesteatomas with emphasis on surgical technique and postoperative outcome in the form of hearing and facial nerve status.

Materials and Methods: It is a retrospective case review of four patients with giant petrous apex cholesteatomas over a period of 3 years (2014–2016).

Results: The patients were staged radiologically according to Sanna’s classification: infralabyrinthine apical (one), massive (one), supralabyrinthine (one), and supralabyrinthine apical (one). The massive petrous apex cholesteatoma fulfilled the criteria for congenital cholesteatoma. Age at presentation ranged from 18 to 46 years. Three patients had preoperative profound SNHL, one patient had moderate conductive hearing loss, grade VI facial palsy was present in three patients, and one patient had grade 5 facial palsy preoperatively. In the patient with congenital massive cholesteatoma with conductive hearing loss, a transmastoid endoscopic assisted approach was employed. Translabyrinthine approach was utilized in the rest, of which one required cavity obliteration and cul-de-sac closure of canal. We were able to preserve bone conduction thresholds in the congenital cholesteatoma patient. For facial nerve rehabilitation–facial nerve decompression was undertaken in two patients, facial–hypoglossal anastomosis in three patients, and gold weight implantation in one patient. No complications or recurrences were noted.

Conclusion: Petrous apex cholesteatomas are aggressive forms of temporal bone cholesteatoma .They pose a lot of challenge to surgeons in their quest for radical excision while salvaging hearing and facial nerve function. Translabyrinthine and transmastoid approaches provide very good exposure for all types of massive cholesteatoma with acceptable morbidity and excellent disease clearance.