scholarly journals A Case of a Nonpetrous Cholesterol Granuloma Presenting as a Temporal Mass

2020 ◽  
Vol 2020 ◽  
pp. 1-3
Author(s):  
Nathaniel Reeve ◽  
Jacob Kahane ◽  
Matthew Ng
Keyword(s):  
Temporal Bone ◽  
Cystic Mass ◽  
Petrous Apex ◽  
Literature Discussion ◽  
Cholesterol Granuloma ◽  
Middle Fossa ◽  
Review Of The Literature ◽  
Temporal Fossa ◽  
Middle Fossa Approach ◽  
Inflammatory Processes

Objective. A case of a skull base cholesterol granuloma (CG) of the squamosal temporal bone. This is the first ever reported case of CG in a well-pneumatized squamous temporal bone. Design. Case report and review of the literature. Discussion. CG is a cystic mass typically found in the petrous apex and occasionally in the paranasal sinuses and orbit. Experience with the treatment of these expansile and inflammatory processes has largely been garnered from those occurring in the petrous apex, where they are surgically drained, via a transtympanic, transmastoid, or middle fossa approach. We report a case of cholesterol granuloma situated in the temporal fossa presenting as a temporal mass. The accessible location of this particular lesion made it amenable to total excision, avoiding the need for surgical drainage and possibility for recurrence. Conclusion. This case supports the theory of pathogenesis of such lesions typically occurring where pneumatized air spaces interface with bone marrow, in this case, where the reaches of pneumatized cells in the squamous portion of the temporal bone meet diploic bone.

Combined transmastoid middle fossa approach for giant cholesterol granuloma of the petrous apex: technique for “dual exhaust” drainage

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1
Author(s):  
James K. Liu ◽  
Robert W. Jyung
Keyword(s):  
Hearing Loss ◽  
Facial Nerve ◽  
Cyst Wall ◽  
Petrous Apex ◽  
Cholesterol Granuloma ◽  
Middle Fossa ◽  
Catheter Drainage ◽  
Middle Fossa Approach ◽  
Air Cells ◽  
Cyst Cavity

Cholesterol granulomas are cystic lesions that typically arise in the petrous apex as a result of an inflammatory giant-cell reaction to cholesterol crystal deposits that are formed when normal aeration and drainage of temporal bone air cells become occluded resulting in transudation of blood into the petrous air cells. Surgical strategies include simple cyst decompression, radical excision of the cyst wall, or fenestration and drainage with silastic tubing. The authors present a giant cholesterol granuloma compressing the cerebellopontine angle and brainstem in a 35 year-old male who presented with progressive facial nerve weakness, sensorineural hearing loss, and vertigo. A combined transmastoid middle fossa extradural approach was performed to remove the cyst contents and decompress the brain-stem. A near total excision of the cyst wall was achieved with a small remnant adherent to the posterior fossa dura. Two separate silastic catheters were placed into the cyst cavity to provide “dual exhaust” drainage. One catheter drained the cyst cavity into the sphenoid sinus via a window made in the anteromedial triangle between V1 and V2. The second catheter drained the cyst cavity into the mastoidectomy cavity and middle ear. Postoperative MRI demonstrated regression of the cyst and excellent decompression of the brainstem. The patient experienced return of normal facial nerve function while hearing loss remained unchanged. He remained free of recurrence at 4 years postoperatively. The theoretical advantages of cyst wall removal combined with dual catheter drainage are longer term patency of cyst drainage and decrease of cyst recurrence. In this operative video atlas report, we describe the step-by-step technique and illustrate the operative nuances and surgical pearls to safely and efficiently perform the “dual exhaust” catheter drainage and resection of a giant cholesterol granuloma via a combined transmastoid middle fossa approach.The video can be found here: http://youtu.be/iZpYBP26ghA.

Extirpation of Recurrent Petrous Apex Cholesterol Granuloma Through the Zygomatic Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Mark Eisenberg ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Short Distance ◽  
Petrous Apex ◽  
Cholesterol Granuloma ◽  
Middle Fossa ◽  
Resonance Imaging ◽  
Endoscopic Endonasal ◽  
Middle Fossa Approach ◽  
Weighted Magnetic Resonance Imaging ◽  
Year 2000 ◽  
Air Cells

Abstract Petrous apex cholesterol granulomas are believed to result from blockage of the normal aeration of the petrous air cells, resulting in a repetitive cycle of mucosal engorgement, hemorrhage, and granuloma formation.1 The lesion usually progressively expands causing compressive symptoms. The thick granulomatous wall envelopes various ages of breakdown products, including a cholesterol-containing fluid, which is typically hyperintense on T1 and T2 weighted magnetic resonance imaging. Drainage procedures, regardless of the route (endoscopic, endonasal, or transtemporal), with or without stenting or marsupialization, will only temporarily drain this cholesterol-containing fluid, with consequently frequent recurrences.2-5 A total exoneration of the granuloma and obliteration of the cavity with vascularized tissue will assure a more durable outcome.1 The extradural zygomatic/middle fossa approach provides a short distance to the petrous apex and is purely extradural. By sectioning the zygoma, temporal lobe retraction is avoided.6 We present a case of a 29-yr-old male who presented in the year 2000 with progression of a left petrous apex cholesterol granuloma despite 2 previous drainage and stenting procedures.  The patient consented for surgery and photo publication. Images in video at 2:41 © JNSPG, republished from Eisenberg et al1 with permission.

A novel treatment approach to cholesterol granulomas

2007 ◽  
Vol 107 (2) ◽  
pp. 446-450 ◽  
Author(s):  
Eric H. Sincoff ◽  
James K. Liu ◽  
Laura Matsen ◽  
Aclan Dogan ◽  
Ilman Kim ◽  
...  
Keyword(s):  
Temporal Bone ◽  
Structural Damage ◽  
Sphenoid Sinus ◽  
Easy Access ◽  
Crystal Formation ◽  
Cholesterol Granuloma ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Patient Reported ◽  
Air Cells

✓ The authors report a novel technique for the treatment of cholesterol granulomas. An extradural middle fossa approach was used to access the granuloma, with drainage through silastic tubes into the sphenoid sinus via the anteromedial triangle between V1 and V2. Cholesterol granulomas occur when the normal aeration and drainage of temporal bone air cells is occluded, resulting in vacuum formation and transudation of blood into the air cells. This process results in anaerobic breakdown of the blood with resulting cholesterol crystal formation and an inflammatory reaction. Traditional treatment of this lesion involves extensive drilling of the temporal bone to drain the granuloma cyst and establish a drainage tract into the middle ear. Such drainage procedures can be time consuming and difficult, and potentially involve structural damage to the inner ear and facial nerve. An extradural middle fossa approach provides easy access to the granuloma and anterior petrous bone entry into the granuloma for resection. Granuloma drainage is then achieved using shunt tubing in the sphenoid sinus via a small hole in the anteromedial triangle between V1 and V2. Five patients with symptomatic cholesterol granuloma were treated without complication using this novel extradural middle fossa approach. One patient required reoperation 1-year postoperatively for cyst regrowth and occlusion of the drainage tube. At the 5-year follow-up examination, no patient reported recurrent symptoms. Extradural middle fossa craniotomy and silastic tube drainage into the sphenoid sinus is a viable alternative method for treatment of cholesterol granuloma.

Microsurgical Resection of Trigeminal Schwannomas: 3-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E18-E18
Author(s):  
Duarte N C Cândido ◽  
Marcio S Rassi ◽  
Guilherme Henrique Weiler Ceccato ◽  
Jean Gonçalves de Oliveira ◽  
Luis A B Borba
Keyword(s):  
Trigeminal Nerve ◽  
Senior Author ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
3 Dimensional ◽  
History Of ◽  
Nerve Paresis ◽  
Microsurgical Resection ◽  
The Right

Abstract Trigeminal schwannomas are benign lesions arising from the Schwann cells of the trigeminal nerve. This is an unusual tumor that accounts for less than 0.4% of intracranial pathologies, even though they are the second most frequent schwannoma after the vestibular schwannoma. The tumor spreads along the natural course of the V nerve at its cisternal portion, along the ganglion inside Meckel's cave or through its peripheral division. Even though the tumor can reach great size and become multicompartmental. We present a 51-yr-old woman, with an history of 3 mo of incapacitating facial pain, that was found on examination to be on the territory of the third division of the trigeminal nerve on the right side. The MRI depicted a large homogeneous enhancing lesion at the base of the right middle fossa with extension through the petrous apex to the most superior and medial part of the posterior fossa. The patient was operated by the senior author, through a middle fossa approach, dissecting between the two layers of the middle fossa dura (the apparent inner and the true outer layer of the cavernous sinus), the so called middle fossa “peeling”. We achieved total resection of the tumor, but the patient presented after surgery with facial nerve paresis. This is thought to be related to geniculate ganglion manipulation, as it was unprotect by bone at the middle fossa and the patient maintained lacrimal function (post-geniculate alteration). It resolved completely after 6 mo. The patient consented to publication of her images.

scholarly journals Anterior Petrosal Approach for the Resection of a Petrous Apex Meningioma with Tentorial Infiltration

2019 ◽  
Vol 80 (S 03) ◽  
pp. S304-S304
Author(s):  
Diego Mendez-Rosito
Keyword(s):  
Trigeminal Neuralgia ◽  
Free Edge ◽  
Gross Total Resection ◽  
Petrous Apex ◽  
Anatomical Landmarks ◽  
Middle Fossa ◽  
Total Resection ◽  
Middle Fossa Approach ◽  
Anterior Petrosectomy ◽  
Surgical Corridor

Objective The anterior petrosal approach is an extension of the middle fossa approach, characterized by drilling of the posteromedial triangle of the middle fossa. Drilling the Kawase's rhomboid creates a surgical corridor to the posterior fossa after splitting the tentorium. We present a case of a petrous apex meningioma invading the tentorium and causing trigeminal neuralgia. Results The patient was positioned in a Mayfield with the head rotated. A frontotemporal incision was done. A basal craniotomy was done to allow epidural dissection. The anatomical landmarks were identified. The surgical video is analyzed together with cadaveric dissections to highlight landmarks when doing an anterior petrosectomy. The tentorium was identified and the infiltrated region was coagulated and removed. The tentorium was sharply sectioned until the free edge of the tentorium was opened. The tumor in the petrous apex was identified and removed. The trigeminal nerve was decompressed and a gross total resection was achieved with resolution of the symptoms. Conclusion The anterior petrosal approach is a useful corridor to remove tumors in the petrous apex that infiltrate the tentorium. A thorough knowledge of the anatomical landmarks is crucial to identify and delineate the limits of the Kawase's rhomboid. After evaluating different surgical corridors, the anterior petrosal approach allows a gross total resection including the removal of the infiltrated tentorium and a resolution of the symptoms.The link to the video can be found at: https://youtu.be/p4KPUnM_bww.

Radiographic Anatomy of the Petrous Apex: A Study Related to the Middle Fossa Approach

2004 ◽  
Vol 131 (2) ◽  
pp. P249-P250 ◽  
Author(s):  
Aaron Gabriel Benson ◽  
Hamid R Djalilian
Keyword(s):  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach

Endoscopic Endonasal Petrosectomy for Resection of Giant Petrous Apex Cholesterol Granuloma with Posterior and Middle Fossa Extension: Case Report

Skull Base ◽  
2009 ◽  
Vol 19 (01) ◽  
Author(s):  
Juan Fernandez-Miranda ◽  
Victor Morera ◽  
Rick Madhok ◽  
Daniel Prevedello ◽  
Paul Gardner ◽  
...  
Keyword(s):  
Case Report ◽  
Petrous Apex ◽  
Cholesterol Granuloma ◽  
Middle Fossa ◽  
Endoscopic Endonasal

Middle Fossa Approach for Total Resection of Petrous Apex Cholesterol Granulomas

2013 ◽  
Vol 72 ◽  
pp. ons 77-ons 86 ◽  
Author(s):  
Mari Kusumi ◽  
Takanori Fukushima ◽  
Ankit I. Mehta ◽  
Calhoun D. Cunningham ◽  
Allan H. Friedman ◽  
...  
Keyword(s):  
Petrous Apex ◽  
Middle Fossa ◽  
Total Resection ◽  
Middle Fossa Approach

Endoscopic trans-sphenoidal removal of cholesterol granuloma of the petrous apex: case report and literature review

2010 ◽  
Vol 125 (2) ◽  
pp. 169-172 ◽  
Author(s):  
G Dhanasekar ◽  
N S Jones
Keyword(s):  
Case Report ◽  
Sphenoid Sinus ◽  
Vestibular Function ◽  
Posterior Wall ◽  
Uneventful Recovery ◽  
Petrous Apex ◽  
Cholesterol Granuloma ◽  
Alternative Route ◽  
Review Of The Literature

AbstractObjective:We report a case of cholesterol granuloma of the petrous apex which was surgically treated via an endoscopic trans-sphenoidal approach.Methods:Case report and review of the literature concerning cholesterol granulomas of the petrous apex and their management.Results:The lesion was approached endoscopically via a bilateral sphenoidotomy with removal of the vomer. A large cholesterol granuloma was evacuated and marsupialised. The patient made an uneventful recovery.Conclusion:Trans-sphenoidal access to the petrous apex represents an alternative route for the drainage and ventilation of cholesterol granulomas. This approach is the technique of choice when the cholesterol granuloma abuts the posterior wall of the sphenoid sinus. The trans-sphenoid approach, unlike other lateral approaches to the petrous apex, spares cochlear and vestibular function and allows post-operative endoscopic follow up.

scholarly journals Transzygomatic extended middle fossa approach for upper petroclival skull base lesions

2008 ◽  
Vol 25 (6) ◽  
pp. E5 ◽  
Author(s):  
Jin-cheng Zhao ◽  
James K. Liu
Keyword(s):  
Skull Base ◽  
Internal Auditory Canal ◽  
Direct Access ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Trigeminal Root ◽  
Skull Base Lesions ◽  
Anterior Petrosectomy ◽  
Surgical Corridor

Central skull base lesions in the upper retroclival and petroclival regions can be challenging to access because of their location anterior to the brainstem. Several transpetrosal approaches have been developed to access the petroclival junction, including anterior petrosal (anterior petrosectomy), posterior petrosal (retrolabyrinthine, translabyrinthine, transcochlear), and combined petrosal approaches. The anterior petrosal approach is best suited for upper petroclival lesions located anterior and superior to the internal auditory canal and superior to the inferior petrosal sinus. This approach provides direct access to the anteromedial cerebellopontine angle, petrous apex, Meckel cave, and ventrolateral brainstem between the trigeminal root and the facial nerve. The authors describe their modification of an anterior petrosal approach, the so-called transzygomatic extended middle fossa approach, which incorporates a zygomatic osteotomy, anterior mobilization of the V3, and extensive middle fossa drilling. This exposure provides a wider surgical corridor for direct view of the clivus and ventral brainstem.

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