Transcanal Endoscopic Infracochlear Approach for a Petrous Apex Cholesterol Granuloma

Video Type: CVideo
  • 2-5 min videos of a particular surgery or technique. These again show major events in the surgery
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Author: Brandon Isaacson
Published:
Specialties: Endoscopy, Neurosurgery, Otolaryngology
Schools: UT Southwestern Medical Center
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Basic Info

This video demonstrates a transcanal endoscopic infracochlear approach to the petrous apex in a patient with a large cholesterol granuloma. The patient presented with a history of profound left sensorineural hearing loss, hemifacial spasm, and House Brackmann Grade 2 facial function. Preoperative imaging demonstrated a T1 and T2 hyperintense heterogenous lesion in both petrous apices with the left being larger than the right on magentic resonance imaging. A computed tomography scan (CT) of the temporal bones demonstrates extension of the left petrous apex lesion into the internal auditory canal and cochlea.

Dr. Isaacson has had 2 patients who have had significant recovery of their bone line after using an infracochlear approach. In the unlikely event that the patient experiences hearing loss in the other ear, their cochlea is preserved for a possible CI. However, the patients hearing loss is likely secondary to the 8th nerve involvement of cholesterol granuloma erosion into IAC.

The patient in this surgical video has been monitored for a year. One year postop CT shows aeration of the apex. This patient's facial spasm has resolved. Dr. Isaacson has used stents in the past, but in this case felt the opening was large enough that he could forego it. Patient did not recover their hearing.

DOI: http://dx.doi.org/10.17797/1wq11j68wa

Advanced

Procedure

Transcanal Endoscopic Infracochlear Approach for a Petrous Apex Cholesterol Granuloma

Indications

cholesterol granuloma, cholesteatoma, neoplasms of the petrous apex

Contraindications

High jugular bulb

Instrumentation

Setup

The patient is turned 180 degrees from anesthesia with the head turned with the operative ear facing the surgeon. Facial nerve monitoring is used for the case. The ear is prepped with betadine which includes getting solution into the ear canal. A four quadrant ear canal injection is performed with lidocaine or marcaine with diluted epinephrine. The ear canal hair is trimmed with curved iris scissors.

Preoperative Workup

Magnetic resonance imaging, temporal bone computed tomography, detailed cranial nerve exam

Anatomy and Landmarks

Petrous carotid artery, cochlea, jugular bulb, tympanic annulus, hypotympanum,

Advantages/Disadvantages

Advantages: minimally invasive, unparalleled wide field, magnified view, faster healing time, can examine the entire extent of the petrous apex.
Disadvantages: using one hand for dissection, lack of depth perception, more difficult to use the drill concurrent with the endoscope

Complications/Risks

vascular injury, bleeding, hearing loss, vertigo, cerebrospinal fluid leak, facial paralysis, chorda tympani nerve injury with taste disturbance, injury to the ossicular chain

Disclosure of Conflicts

vascular injury, bleeding, hearing loss, vertigo, cerebrospinal fluid leak, facial paralysis, chorda tympani nerve injury with taste disturbance, injury to the ossicular chain

Acknowledgements

References

1. Marchioni D, Alicandri-Ciufelli M, Mattioli F, et al. From external to internal auditory canal: surgical anatomy by an exclusive endoscopic approach. Eur Arch Otorhinolaryngol 2013 Mar;270(4):1267���¢�¯�¿�½�¯�¿�½1275.
2. Endoscopic transcanal corridors to the lateral skull base: Initial experiences. Marchioni D, Alicandri-Ciufelli M, Rubini A, Presutti L. Laryngoscope. 2015 Sep;125 Suppl 5:S1-S13. doi: 10.1002/lary.25203. Epub 2015 Feb 20.

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