Surgical Management of Cholesteatoma Growing Medially into the Petrous part of the Temporal Bone

In this article we describe the surgical management of petrous bone cholesteatoma, a rare form of an epidermoid cyst growing medially into the petrous part of the temporal bone. In our series of 5 patients, high resolution Computerized Tomography (CT) played an essential role in the diagnosis of this pathological entity. CT was also important in planning for the surgical access to this intricate part of the temporal bone. In all cases we performed a subtotal petrosectomy with skeletonization of the facial nerve bony canal to preserve the facial nerve function. We were able to remove totally the medially growing cholesteatoma with low morbidity. *Corresponding author: Maged B Naguib, ENT Department, University of Dammam, Dammam, Kingdom of Saudi Arabia, E-mail: [email protected] Received February 22, 2013; Accepted April 28, 2013; Published May 05, 2013 Citation: Naguib MB (2013) Surgical Management of Cholesteatoma Growing Medially into the Petrous part of the Temporal Bone. Surgery S12: 012. doi:10.4172/2161-1076.S12-012 Copyright: © 2013 Naguib MB. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Petrous bone cholesteatoma describes an epidermoid cyst affecting the petrous portion of the temporal bone. It is a rare pathological entity with a reported incidence of 4 to 9% of all lesions affecting the petrous pyramid [1,2]. Petrous bone cholesteatoma is detected in about 3% of all patients diagnosed and treated for cholesteatoma in general [3]. Contrary to the more common middle ear cholesteatoma, petrous bone cholesteatoma grows medial to the otic capsule invading the inner ear and the facial nerve early before they are diagnosed. Clinical presentation of petrous bone cholesteatoma is not only variable but may be misleading. It can present as a middle ear cholesteatoma, progressive or sudden facial nerve palsy, sensorineural hearing loss or a conductive hearing loss, secretary otitis media or intracranial complication. Moreover, managing petrous bone cholesteatoma is a surgical challenge. The tendency for medial growth renders the surgical management of petrous bone cholesteatoma a difficult task owing to the central location of the otic capsule and the facial nerve as well as the proximity of vital intracranial structures namely the internal carotid artery, the jugular bulb, the lower cranial nerves and the brain itself. An even more difficult task is to be expected with further extension of the petrous bone cholesteatoma towards the clivus, the sphenoid sinus and the rhinopharynx [3]. In this study we report on the presentation and clinical picture of our series of patients having a petrous bone cholesteatoma. The management strategy adopted to deal with this difficult and rather uncommon otologic entity is also discussed. Materials and Methods This study is a retrospective review of the charts of five patients with petrous bone cholesteatoma presented to the ENT department, Suez Canal University, Ismailia, Egypt and University of Dammam, Dammam, KSA during the period from 2005 to 2010. Charts were reviewed with particular attention to the presenting symptoms, history of the disease, condition of the facial nerve, clinical findings and audiometric results at presentation. All patients had a high resolution CT of the temporal bone for diagnosis and follow up (coronal and axial thin cuts in a bone window). Operative details were reviewed and noted with special attention to the surgical access, success in cholesteatoma exenteration and the surgical complications. CT for follow up was done every 6 months in the first year and annually in the following years for up to 3 years to detect recurrence of cholesteatoma. Results Our series of patients with petrous bone cholesteatoma comprises 5 cases; 3 males and 2 females. Their ages ranged from 18 to 50 years with an average of 30 years. Petrous bone cholesteatoma affected the right ear in 3 cases and the left ear in the remaining 2. The duration of symptoms was short and generally did not exceed 2 years. The main symptom at presentation was a gradual hearing loss reported by all patients. Four cases presented with a sensorineural hearing loss which was severe to profound. One case presented with a moderate mixed hearing loss. An ear discharge was the second most common symptom which varied from a purulent discharge to an occasional bloody discharge. Facial nerve weakness was seen in 2 (40%) of our patients at presentation; both were grade 3 on the House-Brackmann scale [4]. Vertigo and imbalance were not reported as a complaint in any of our cases. Four cases gave a history of a previous ear surgery on the same ear (80%). Based on the CT topographic location and extension and following the classification of Sanna et al. [5], our series of petrous bone cholesteatoma was classified into supralabyrinthine (2 cases), infralabyrinthine (2 cases), and infralabyrinthine apical (one case).