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
Transcanal Endoscopic Infracochlear Approach for a Petrous Apex Cholesterol Granuloma
cholesterol granuloma, cholesteatoma, neoplasms of the petrous apex
High jugular bulb
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.
Magnetic resonance imaging, temporal bone computed tomography, detailed cranial nerve exam
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
vascular injury, bleeding, hearing loss, vertigo, cerebrospinal fluid leak, facial paralysis, chorda tympani nerve injury with taste disturbance, injury to the ossicular chain
vascular injury, bleeding, hearing loss, vertigo, cerebrospinal fluid leak, facial paralysis, chorda tympani nerve injury with taste disturbance, injury to the ossicular chain
N/A
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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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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Review Transcanal Endoscopic Infracochlear Approach for a Petrous Apex Cholesterol Granuloma.