Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma
Abstract
:1. Introduction
2. Materials and Methods
- Selection criteria:
- Exclusion criteria:
2.1. MRI Radiological Evaluation
2.2. CT Scan Imaging Study of the Petrous Apex
- Type A cholesterol granuloma: presence of a cholesterol granuloma of the petrous apex with preserved cellularity in the absence of erosive phenomena and/or of cellular confluence.
- Type B cholesterol granuloma: presence of a cholesterol granuloma of the petrous apex with erosive phenomena and cellular confluence without any involvement of the bony limitations that cover the noble structures of the apex (otic capsule, IAC, middle and posterior cranial fossa dura, ICA, jugular bulb).
- Type C cholesterol granuloma: presence of a cholesterol granuloma of the petrous apex with erosive and cellular confluence phenomena with involvement of the bony limitations covering the noble structures of the apex (otic capsule, IAC, dura of the middle and posterior cranial fossa, ICA, jugular bulb).
- group C (Connected): when, from the CT scan study, we detected a connection between the lesion and the infracochlear/perilabyrinthine or sphenoidal cellularity.
- group D (Disconnected): when the CT scan of the apex showed an anatomical condition of disconnection between the cholesterol granuloma cyst and the infracochlear/perilabyrinthine or sphenoidal cellularity.
2.3. Signs and Symptoms
2.4. Type of Surgery
- Drainage and marsupialization of the cyst, when a connection between the pneumatized and cellular spaces of the infracochlear/perilabyrinthine area or of the sphenoid area was created.
- Complete resection of the granuloma, in which the whole cyst and its content was removed.
- Subtotal resection of the lesion, in which the cholesterol granuloma was partially removed, leaving a visible portion of the cyst with its capsule in situ, in the absence of a possible drainage route through the infracochlear/perilabyrinthine or sphenoid cellularity.
- Near-total resection, when an almost complete removal of the lesion was achieved, leaving a small part of the capsule without visible cyst content and in the absence of a possible drainage route through the infracochlear/perilabyrinthine or sphenoid cellularity.
2.5. Complications and Follow-Up
3. Results
3.1. MRI Radiological Evaluation
3.2. CT Scan Imaging Study of the Petrous Apex
3.3. Sign and Symptoms
- Eight patients first presented a palsy of the 6th cranial nerve and diplopia.
- Four patients presented temporary and/or permanent spasms or paralysis of the facial nerve.
- Four patients had a deep sensorineural hearing impairment.
- One patient presented a mixed hearing impairment with transmissive prevalence.
- Eleven patients complained about a headache.
- One patient came to our department for meningitis associated with complete facial paralysis and deep sensorineural hearing loss due to a dural interruption near the capsule of the cholesterol granuloma and to the spilling of its cystic content into the pontocerebellar angle.
- Fourteen patients presented with normoacusis, assessed on the pure tone and speech audiometry.
- One patient presented with moderate mixed hearing loss on the same side of the lesion.
- Four patients showed a pattern of profound sensorineural hearing loss on the same side of the lesion.
3.4. Type of Surgery
3.5. Complications and Follow-Up
4. Discussion
4.1. Wait and Scan
4.2. Surgical Treatment
4.2.1. Surgical Drainage
4.2.2. Complete Surgical Removal
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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Name | Sex | Age at Surgery | Symptoms | Surgical Approach | Follow Up | Complication |
---|---|---|---|---|---|---|
CM | F | 64 | Headache | Trans-sphenoidal | 1 month, no symptoms. | |
EA | M | 36 | Headache + VI cranial nerve paralysis | MCF approach | 6 months, MRI negative, no symptoms | |
FS | M | 48 | Headache + VI cranial nerve paralysis | Trans-sphenoidal | Recurrence with several surgeries following years. No symptoms at the end. | |
LLA | F | 46 | Headache | MCF approach | 6 months, MRI negative, no symptoms | |
SA | F | 15 | Recurrent facial paralysis | MCF approach | 1 year, MRI negative, no symptoms | |
TG | M | 50 | Headache + hearing loss | Transotic + IFTB | 3 years, MRI negative, no symptoms | ICA fissuration |
BG | M | 59 | VI cranial nerve paralysis | Trans-sphenoidal + MCF approach | 1 years, MRI with minimal residual, no symptoms. | |
KWK | M | 40 | Hearing loss | Transotic + IFTB | 1 month, no symptoms. | |
NPE | F | 57 | Headache | Partial removal with infracochlear approach | 3 years, MRI with stable residual | |
MM | M | 19 | VI cranial nerve paralysis | Partial removal with infracochlear approach | 3 years, MRI with stable residual | |
GL | F | 53 | VI cranial nerve paralysis | MCF approach | 6 years, MRI negative, no symptoms | |
VE | F | 11 | Headache | MCF approach | 1 year, MRI negative, no symptoms | |
MG | M | 49 | Headache + Facial nerve paralysis | MCF approach | 3 months, no symptoms | Transient facial palsy + Subdural hematoma |
BI | F | 52 | Headache + transmissive hearing loss | Infracochlear | 2 years, stable | |
GP | M | 53 | VI cranial nerve paralysis + hearing loss | Transotic + IFTB | 3 years, MRI negative, no symptoms | |
CF | F | 81 | VI cranial nerve paralysis | Trans-sphenoidal | 6 months, CT negative, no symptoms | |
AA | M | 35 | VI cranial nerve paralysis + headache | MCF approach | 1 year, MRI negative, no symptoms | |
NA | M | 35 | Facial nerve paralysis + hearing loss + Headache + vertigo + meningitis | Transcochlear | 5 years, no symptoms | |
NCK | M | 12 | Facial nerve paralysis + hearing loss | Transotic + IFTB | 6 months, MRI negative, no symptoms |
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Marchioni, D.; Alberti, C.; Bisi, N.; Rubini, A. Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma. J. Clin. Med. 2024, 13, 2505. https://doi.org/10.3390/jcm13092505
Marchioni D, Alberti C, Bisi N, Rubini A. Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma. Journal of Clinical Medicine. 2024; 13(9):2505. https://doi.org/10.3390/jcm13092505
Chicago/Turabian StyleMarchioni, Daniele, Chiara Alberti, Nicola Bisi, and Alessia Rubini. 2024. "Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma" Journal of Clinical Medicine 13, no. 9: 2505. https://doi.org/10.3390/jcm13092505