19 Petrous Apex Cholesterol Granulomas

  • Michael J. LinkEmail author
  • Daniel M. Prevedello


Traditionally, cholesterol granulomas have been treated by drainage and stent placement via an infracochlear route. Modern thinking and experience shows that while proper preoperative diagnosis remains of the utmost important, CGs may require a more extensive approach for definitive management, with at least partial resection of the cyst wall. There remains controversy on the optimal surgical approach to best address these lesions. Understanding the natural history of these lesions is essential to set realistic treatment goals, as watchful observation is usually the best strategy when CGs are discovered incidentally. However, when these lesions become symptomatic, treatment is indicated, and the only definitive treatment is aggressive surgical intervention. In 19.2, we discuss the open transcranial approaches. The endoscopic management of cholesterol granulomas located in the petrous apex has been developed and improved through the last decades. In 19.3, we discuss the three main endoscopic approaches that can be used to treat these lesions: medial transphenoidal approach, medial approach with internal carotid artery lateralization, and transpterygoid infrapetrous approach. This technique offers the possibility of reestablishing a larger and natural drainage pathway into the sinuses while avoiding the potential complications of transtemporal/transcranial approaches.


Cholesterol granuloma Anterior petrosectomy Petrous apex Open approach Cyst wall Infracochlear endoscopic approach Silastic stents Vascular pedicled nasoseptal flaps 

References (Key References Bolded)

  1. 1.
    Eisenberg MB, Haddad G, Al-Mefty O. Petrous apex cholesterol granulomas: evolution and management. J Neurosurg. 1997;86(5):822–9.CrossRefGoogle Scholar
  2. 2.
    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.CrossRefGoogle Scholar
  3. 3.
    Greenberg JJ, et al. Cholesterol granuloma of the petrous apex: MR and CT evaluation. AJNR Am J Neuroradiol. 1988;9(6):1205–14.PubMedGoogle Scholar
  4. 4.
    Leon ME, et al. Cholesterol granuloma of the maxillary sinus. Arch Pathol Lab Med. 2002;126(2):217–9.PubMedGoogle Scholar
  5. 5.
    Hoa M, House JW, Linthicum FH Jr. 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):1059–65.PubMedGoogle Scholar
  6. 6.
    Jackler RK, Parker DA. Radiographic differential diagnosis of petrous apex lesions. Am J Otol. 1992;13:561–74. Google Scholar
  7. 7.
    Kusumi M, Fukushima T, Mehta AI, Cunningham CD 3rd, Friedman AH, Fujii K. Middle fossa approach for total resection of petrous apex cholesterol granulomas: use of vascularized galeofascial flap preventing recurrence. Neurosurgery. 2013;72:77–86. Discussion 86.CrossRefGoogle Scholar
  8. 8.
    Isaacson B. Cholesterol granuloma and other petrous apex lesions. Otolaryngol Clin. 2015;North Am 48:361–73.CrossRefGoogle Scholar
  9. 9.
    Moore KR, Harnsberger HR, Shelton C, Davidson HC. Leave me alone lesions of the petrous apex. AJNR Am J Neuroradiol. 1998;19:733–8.PubMedGoogle Scholar
  10. 10.
    Eisenberg MB, Haddad G, Al-Mefty O. Petrous apex cholesterol granulomas: evolution and management. J Neurosurg. 1997;86:822–9. Google Scholar
  11. 11.
    Henry H, Schmidek DWR. Operative neurosurgical techniques. Philadelphia: Saunders; 2012.Google Scholar
  12. 12.
    Shiobara R, Ohira T, Kanzaki J, Toya S. A modified extended middle cranial fossa approach for acoustic nerve tumors. Results of 125 operations. J Neurosurg. 1988;68:358–65.CrossRefGoogle Scholar
  13. 13.
    King TT. Combined translabyrinthine-transtentorial approach to acoustic nerve tumours. Proc R Soc Med. 1970;63:780–2.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Yokoyama T, Uemura K, Ryu H, Hinokuma K, Nishizawa S, Yamamoto S, Endo M, Sugiyama K. Surgical approach to the internal auditory meatus in acoustic neuroma surgery: significance of preoperative high-resolution computed tomography. Neurosurgery. 1996;39:965–9. Discussion 969–70.PubMedGoogle Scholar
  15. 15.
    Giddings NA, Brackmann DE, Kwartler JA. Transcanal infracochlear approach to the petrous apex. Otolaryngol Head Neck Surg. 1991:29–36.Google Scholar
  16. 16.
    Brackmann DE, Toh EH. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol. 2002;23(4):529–33. Google Scholar
  17. 17.
    Thedinger BA, Nadol JB, Jr., Montgomery WW, Thedinger BS, Greenberg JJ. Radiographic diagnosis, surgical treatment, and long-term follow-up of cholesterol granulomas of the petrous apex. The Laryngoscope. 1989;896–907. Google Scholar
  18. 18.
    Cristante L, Puchner MA. A keyhole middle fossa approach to large cholesterol granulomas of the petrous apex. Surg Neurol. 2000:4–70. Discussion 70–61.Google Scholar
  19. 19.
    Terao T, Onoue H, Hashimoto T, Ishibashi T, Kogure T, Abe T. Cholesterol granuloma in the petrous apex: case report and review. Acta Neurochir. 2001:947–52.Google Scholar
  20. 20.
    Sweeney AD, Osetinsky LM, Carlson ML, Valenzuela CV, Frisch CD, Netterville JL, Link MJ, Driscoll CL, Haynes DS. The natural history and management of petrous apex cholesterol granulomas. Otol Neurotol. 2015;36:1714–9. Google Scholar
  21. 21.
    Montgomery WW. Cystic lesions of the petrous apex: transsphenoidal approach. Ann Otol Rhinol Laryngol. 1977;86:429–35.CrossRefGoogle Scholar
  22. 22.
    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;Surg 4:52–8.CrossRefGoogle Scholar
  23. 23.
    Scopel TF, Fernandez-Miranda JC, Pinheiro-Neto CD, Peris-Celda M, Paluzzi A, Gardner PA, Hirsch BE, Snyderman CH. Petrous apex cholesterol granulomas: endonasal versus infracochlear approach. Laryngoscope. 2012;122:751–61. Google Scholar
  24. 24.
    Zanation AM, Snydeman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope. 2009;119:19–25. Google Scholar
  25. 25.
    Paluzzi A, Paluzzi A, Gardner P, Fernandez-Miranda JC, Pinheiro-Neto CD, Scopel TF, Koutourousiou M, Snyderman CH. Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients: clinical article. J Neurosurg. 2012;116:792–8. Google Scholar
  26. 26.
    Karligkiotis A, Bignami M, Terranova P, Ciniglio-Appiani M, Shawkat A, Verrilaud B, Meloni F, Herman P, Castelnuovo P. Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex. Int Forum Allergy Rhinol. 2015;5:747–53. Google Scholar
  27. 27.
    Labib MA, Prevedello DM, Carrau R, Kerr EE, Naudy C, Abou Al-Shaar H, Corsten M, Kassam A. A road map to the internal carotid artery in expanded endoscopic endonasal approaches to the ventral cranial base. Neurosurgery. 2014;10:448–71.CrossRefGoogle Scholar
  28. 28.
    Mattox DE. Endoscopy-assisted surgery of the petrous apex. Otolaryngol Head Neck Surg. 2004;130:229–41.CrossRefGoogle Scholar
  29. 29.
    Brackmann DE, Toh EH. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol. 2002;230:529–33.CrossRefGoogle Scholar
  30. 30.
    Robier A, et al. Management of cholesterol granulomas of the petrous apex based on clinical and radiologic evaluation. Otol Neurotol. 2002;23:522–8.CrossRefGoogle Scholar
  31. 31.
    Georgalas C, Kania R, Guichard JP, Sauvaget E, Tran Ba Huy P, Herman P. Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex. Clin Otolaryngol. 2008;33:32–55.CrossRefGoogle Scholar
  32. 32.
    McLaughlin N, Kelly DF, Prevedello DM, et al. Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma. J Neurol Surg B Skull Base. 2012;73:190–6.Google Scholar
  33. 33.
    Terranova P, Karligkiotis A, Gallo S, Meloni F, Bignami M, Castelnuovo P. A novel endoscopic technique for long-term patency of cholesterol granulomas of the petrous apex. Laryngoscope. 2013;123:2639–42.CrossRefGoogle Scholar
  34. 34.
    Shibao S, Toda M, Tomita T, Saito K, Ogawa K, Kawase T, Yoshida K. Petrous apex cholesterol granuloma: importance of pedicled nasoseptal flap in addition to silicone T-tube for prevention of occlusion of drainage route in transsphenoidal approach-a technical note. Neurol Med Chir (Tokyo). 2015;55:351–5.CrossRefGoogle Scholar
  35. 35.
    Griffith AJ, Terrell JE. Transsphenoid endoscopic management of petrous apex cholesterol granuloma. Otolaryngol Head Neck Surg. 1996;114(1):91–4.CrossRefGoogle Scholar
  36. 36.
    Michaelson PG, Cable BB, Mair EA. Image-guided transphenoidal drainage of a cholesterol granuloma of the petrous apex in a child. Int J Pediatr Otorhinolaryngol. 2001;57(2):165–9.CrossRefGoogle Scholar
  37. 37.
    DiNardo LJ, Pippin GW, Sismanis A. Image-guided endoscopic transsphenoidal drainage of select petrous apex cholesterol granulomas. Otol Neurotol. 2003;24(6):939–41.CrossRefGoogle Scholar
  38. 38.
    Presutti L, Villari D, Marchioni D. Petrous apex cholesterol granuloma: transsphenoid endoscopic approach. J Laryngol Otol. 2006;120(6):e20.CrossRefGoogle Scholar
  39. 39.
    Oyama K, Ikezono T, Tahara S, Shindo S, Kitamura T, Teramoto A. Petrous apex cholesterol granuloma treated via the endoscopic transsphenoidal approach. Acta Neurochir. 2007;149(3):299–302.CrossRefGoogle Scholar
  40. 40.
    Samadian M, Vazirnezami M, Moqaddasi H, Rakhshan M, Khormaee F, Ashraf H. Endoscopic transrostral- transsphenoidal approach to petrous apex cholesterol granuloma: case report. Turk Neurosurg. 2009;19(1):106–11; Samadian M, Akbari Dilmaghani N, Ahmady Roozbahany N, Farzin N, Bahadoram M. Endoscopic transnasal approach for cholesterol granuloma of the petrous apex. Case Rep Neurol Med. 2015;2015:481231.
  41. 41.
    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):375–9. Scholar
  42. 42.
    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):683–8. Scholar
  43. 43.
    Tomazic PV, Nemetz U, Koele W, Walch C, Braun EM, Hammer GP, Gellner V, Clarici G, Braun H, Mokry M, Stammberger H. Cholesterol granulomas of the petrous apex; endonasal endoscopic approach. B-ENT. 2013;9(4):263–7.PubMedGoogle Scholar
  44. 44.
    Emanuelli E, Ciorba A, Bianchini C, Bossolesi P, Stomeo F, Pelucchi S. Transnasal endoscopic management of petrous apex and clivus selected lesions. Eur Arch Otorhinolaryngol. 2013;270(5):1747–50. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Departments of Neurologic Surgery and OtolaryngologyMayo ClinicRochesterUSA
  2. 2.Division of Skull Base SurgeryThe Ohio University Wexner Medical CenterColumbusUSA
  3. 3.Department of NeurosurgeryThe Ohio State UniversityColumbusUSA

Personalised recommendations