Endoscopic Assisted Petrosectomy via Middle Fossa Approach for Isolated Petrous Bone Cholesteatoma

Objective This video was aimed to demonstrate the middle fossa approach for the resection of an intracanalicular vestibular schwannoma. Design Present study is a video case report. Setting The operative video is showing a microsurgical resection. Participant The patient was a 59-year-old man who presented with worsening headache and right-side hearing loss. He was found to have a right intracanalicular vestibular schwannoma. After weighing risks and benefits, he chose surgery to remove his tumor. Since his hearing remained “serviceable,” a middle fossa approach was chosen. Main Outcome Measures Pre- and postoperative patient photographs evaluated the muscles of facial expression as a marker for facial nerve preservation. Results A right middle fossa craniotomy was performed which allowed access to the floor of the middle cranial fossa. The greater superficial petrosal nerve (GSPN) and arcuate eminence were identified. Using these two landmarks, the internal acoustic canal (IAC) was localized. After drilling the petrous bone, the IAC was unroofed. The facial nerve was identified by stimulation and visual inspection and the tumor was separated from it with microsurgical dissection. In the end, the tumor was fully resected. Both the facial and cochlear nerves were preserved. Postoperatively, the patient experienced no facial palsy and his hearing is at baseline. Conclusion With radiosurgery gaining increasing popularity, patients with intracanalicular vestibular schwannomas are frequently treated with it, or are managed with observation. The middle fossa approach is therefore becoming a “lost art,” but as demonstrated in this video, remains an effective technique for tumor removal and nerve preservation.The link to the video can be found at: https://youtu.be/MD6o3DF6jYg.

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Transpetrosal approaches to the posterior fossa

Neurosurgical FOCUS ◽

10.3171/foc.2005.19.2.7 ◽

2005 ◽

Vol 19 (2) ◽

pp. 1-9 ◽

Cited By ~ 23

Author(s):

Ramachandra P. Tummala ◽

Ernesto Coscarella ◽

Jacques J. Morcos

Keyword(s):

Temporal Bone ◽

Posterior Fossa ◽

Cerebellopontine Angle ◽

Petrous Bone ◽

Middle Fossa ◽

Petroclival Region ◽

Middle Fossa Approach ◽

Petrous Temporal Bone ◽

Anterior Group ◽

Different Levels

Resection of the petrous temporal bone to various degrees provides different levels of access to lesions of the posterior fossa. Although their nomenclature can be confusing, the numerous variants of the transpetrosal approaches can be classified broadly into anterior and posterior groups. The posterior transpetrosal approaches include the retro-labyrinthine, translabyrinthine, and transcochlear, whereas the ones in the anterior group are extensions of the basic middle fossa approach. Both the anterior and posterior approaches have the potential of exposing the cerebellopontine angle and the petroclival region. The posterior approaches are based on the standard mastoidectomy and involve resection of the petrous bone to various degrees. This results in progressively increased exposure anteriorly, but comes at the expense of hearing in the translabyrinthine approach and of hearing and facial strength in the transcochlear approach. In contrast, the middle fossa approaches spare the lateral petrous bone and involve resection of the medial petrous bone to various degrees. All of the middle fossa approaches are designed to preserve hearing. Extensions of the middle fossa approaches involve resection of bone within the Kawase rhomboid and division of the tentorium to provide exposure of the posterior fossa.

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Congenital Cholesteatoma of Petrous Apex – case report and review of literature

Polski Przegląd Otorynolaryngologiczny ◽

10.5604/01.3001.0009.7991 ◽

2017 ◽

Vol 6 (1) ◽

pp. 62-67

Author(s):

Maria Makuszewska

Keyword(s):

Case Report ◽

Surgical Planning ◽

Petrous Bone ◽

Petrous Apex ◽

Review Of Literature ◽

Middle Fossa Approach ◽

Lateral Skull Base ◽

Radical Removal ◽

High Index Of Suspicion ◽

Petrous Bone Cholesteatoma

Objective: Congenital cholesteatomas of the petrous apex are rare lesions that develop insidiously, which delays diagnosis and requires a high index of suspicion. A case report of supralabyrinthine congenital petrous bone cholesteatoma and review of recent literature are presented. Methods: A 27-year-old woman presented with progressive facial palsy. Otomicroscopy did not reveal any abnormalities, and hearing was normal. Although there were no complaints of vertigo or instability, vestibular examinations indicated a non-compensated peripheral vestibular lesion. Radiological examinations revealed a lesion in the petrous apex and epitympanum that had features of a cholesteatoma. Results: To preserve normal hearing, the middle fossa approach was chosen for surgery. A damaged part of the facial nerve was reconstructed with cable graft. Conclusion: Advances in radiological imaging facilitate surgical planning, and improvements in the techniques of lateral skull base surgery enable safe and radical removal of petrous bone cholesteatomas with minimal morbidity.

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Middle Fossa Approach For Acoustic Tumor Removal

Otolaryngologic Clinics of North America ◽

10.1016/s0030-6665(20)30991-9 ◽

1992 ◽

Vol 25 (2) ◽

pp. 347-359 ◽

Cited By ~ 2

Author(s):

William F. House ◽

Clough Shelton

Keyword(s):

Middle Fossa ◽

Tumor Removal ◽

Middle Fossa Approach ◽

Acoustic Tumor

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Complications of Middle Fossa Approach

Skull Base ◽

10.1055/s-2005-916606 ◽

2005 ◽

Vol 15 (S 2) ◽

Author(s):

Emilio García-Ibánez ◽

Luis García-Ibánez ◽

Elena Hernández ◽

G. Martínez-Monche

Keyword(s):

Middle Fossa ◽

Middle Fossa Approach

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Cadaveric Study to Find a Novel Method of Identifying the Internal Acoustic Canal in the Middle Fossa Approach: The Rule of 2s

Skull Base ◽

10.1055/s-2009-1242371 ◽

2009 ◽

Vol 19 (03) ◽

Author(s):

Raghuram Sampath ◽

Chad Glenn ◽

Shashikant Patil ◽

Prasad Vannemreddy ◽

Anil Nanda ◽

...

Keyword(s):

Cadaveric Study ◽

Middle Fossa ◽

Middle Fossa Approach ◽

Novel Method ◽

Internal Acoustic Canal

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Petrous bone cholesteatoma: our experience of 20 years and management of two giant cases affecting rhinopharynx

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s00405-021-06969-1 ◽

2021 ◽

Author(s):

Ya Liu ◽

Fangyuan Wang ◽

Weidong Shen ◽

Jun Liu ◽

Hui Zhao ◽

...

Keyword(s):

Petrous Bone ◽

Petrous Bone Cholesteatoma

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The remnant of primary head sinus found in the case of dural arteriovenous fistula: A case report

Interventional Neuroradiology ◽

10.1177/1591019916641903 ◽

2016 ◽

Vol 22 (4) ◽

pp. 452-456 ◽

Cited By ~ 1

Author(s):

Katsuhiro Mizutani ◽

Takenori Akiyama ◽

Kazunari Yoshida

Keyword(s):

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Rare Condition ◽

Venous Drainage ◽

Petrous Bone ◽

Jugular Bulb ◽

Cone Beam ◽

Middle Fossa ◽

Rotational Angiography ◽

Anatomic Information

In the embryo, the primary head sinus (PHS) is the first venous drainage channel in the craniocervical region. During embryonic development, this channel regresses and usually disappears completely; accordingly, a remnant of the PHS is an extremely rare condition and has been described in only a few previous studies. Here, we report a case of remnant of the PHS with a dural arteriovenous fistula (dAVF) in an adult. The remnant of the PHS had penetrated the petrous bone to run from the middle fossa to the jugular bulb and served as a drain for the middle fossa dAVF. We used digital subtraction angiography and reconstructed cone-beam computed tomography in 3D rotational angiography to obtain detailed anatomic information about the remnant PHS and additionally scrutinised and discussed its features.

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