Eur Arch Otorhinolaryngol DOI 10.1007/s00405-017-4763-9
OTOLOGY
Endoscopic management of petrous apex cholesteatoma Hisashi Sugimoto1 · Miyako Hatano1 · Masao Noda1 · Hiroki Hasegawa1 · Tomokazu Yoshizaki1
Received: 26 June 2017 / Accepted: 4 October 2017 © Springer-Verlag GmbH Germany 2017
Abstract We describe a technique for approaching petrous apex cholesteatoma using combined lateral microscopic/ endoscopic approaches, and discuss the utility of endoscopy in managing matrix inside the petrous apex. In our two cases, total view inside the petrous apex was achieved under endoscopy without mobilizing the internal carotid artery, and the matrix was successfully removed. Neither patient has presented with postoperative recurrence thanks to the wide-angle endoscopic view inside the petrous apex. Since the number of patients was small, comparisons with microscopic treatments are not yet valid, but endoscopes could offer a helpful tool for operating inside the petrous apex. Keywords Petrous apex · Cholesteatoma · Combined lateral microscopic/endoscopic approaches
Introduction Petrous bone cholesteatoma is classified into 5 classes: Class I, supralabyrinthine; Class II, infralabyrinthine; Class III, infralabyrinthine-apical; Class IV, massive; and Class V, apical [1]. Petrous apex cholesteatoma classified as Class V is located very deep in the temporal bone, in one of the least accessible regions of the skull base. The anterior border is formed by Meckel’s cave area, the inferior border by the infralabyrinthine compartment, the posterior border by the internal carotid artery (ICA) and posterior cranial fossa, and * Tomokazu Yoshizaki [email protected]‑u.ac.jp 1
Department of Otolaryngology‑Head and Neck Surgery, Kanazawa University Hospital, Kanazawa University Graduate School of Medical Science, 13‑1 Takaramachi, Kanazawa, Ishikawa 920‑8640, Japan
the medial border by the clivus and sphenoid sinus. Securing complete visibility inside the petrous apex is difficult, because the entrance to the petrous apex is small and the deep part is large. In recent years, endoscopy has come into use for ear operations, due to improvements in endoscopic imaging technology and the development of equipment specifically for operations. Advantages of endoscopic surgery include the ability to secure a good visual field, and reduced invasiveness. The number of applications to lateral skull base surgery has also been increasing, because endoscopic surgery allows access to spaces traditionally considered difficult. Combined lateral microscopic/endoscopic approaches to the lateral skull base were advocated in 2014 [2], and such procedures have proven effective in allowing less-destructive approaches compared to exclusive microscopic procedures. We describe a technique in which we approached petrous apex cholesteatomas in two cases using combined lateral microscopic/endoscopic approaches, and discuss the utility of endoscopy in managing matrix inside the petrous apex.
Case 1 The patient was a 77-year-old man. In 2005, at 66 years old, he had presented with total facial palsy, and had undergone tympanoplasty for cholesteatoma of the middle ear at another hospital. In 2008, revision surgery had been performed for residual cholesteatoma of the petrous bone. A combined middle cranial fossa approach and transmastoid approach was applied. In 2014, residual cholesteatoma of the petrous apex had grown and the patient presented with headache. Facial palsy was classified as Grade VI using the House–Brackmann facial nerve grading system. Pure-tone audiograms showed 70 dB in the
13
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right ear and 105 dB in the left ear. The cholesteatoma was classified as apical type from computed tomography and magnetic resonance imaging (Fig. 1a, b). In July 2014, a transotic approach (necessitating sacrifice of the facial nerve) was performed for petrous apex cholesteatoma. Under microscopic visualization, the skin of the external auditory canal (EAC) and the tympanic membrane were removed, and the EAC was closed by blind sac closure. The malleus and incus were identified and removed. Mastoidectomy was performed using a canal wall-down technique and the labyrinth was removed. The facial nerve was then exposed and sacrificed, because the patient had experienced complete facial paralysis since 9 years earlier. After all the above-mentioned steps under microscopy, the endoscopic procedure was performed using a 4.0-mm endoscope. Direct endoscopic visualization of the medial surface of the carotid artery in the petrous apex was then established (Fig. 2b) and the matrix was successfully removed. As of 42 months postoperatively, no recurrences have been identified in this patient.
Fig. 1 Imaging findings in Case 1. a Results of CT. Cholesteatoma located in the petrous apex involves the internal carotid artery. b Magnetic resonance imaging
Fig. 2 Surgical findings in Case 1. a Microscopic view of the petrous apex. The viewer is blind to the medial surface of the internal carotid artery (ICA). b Endoscopic view of the petrous apex. No blind spots are seen inside the petrous apex
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Eur Arch Otorhinolaryngol
Case 2 The patient was a 36-year-old man. He had presented with facial palsy in his teens and had undergone ear surgery at another hospital. In 2007, he underwent tympanoplasty for residual cholesteatoma at another hospital. The patient was referred to our hospital in 2014 due to growth of residual cholesteatoma of the petrous apex. Facial palsy was classified as Grade VI using the House–Brackmann facial nerve grading system. Pure-tone audiograms showed scale-out in both ears. The cholesteatoma was classified as infralabyrinthine–apical type from computed tomography and magnetic resonance imaging (Fig. 3a, b). A transotic approach (with sacrifice of the facial nerve) was performed for this case. We removed the matrix in the petrous apex using endoscopy, as in Case 1 (Fig. 4b).
Discussion The petrous apex is one of the most difficult-to-access areas of the lateral skull base. Achieving a good operative field and adequate working space is essential for
Eur Arch Otorhinolaryngol Fig. 3 Imaging findings in Case 2. a CT imaging. Cholesteatoma located in the petrous apex involves the internal carotid artery. b Magnetic resonance imaging
Fig. 4 Surgical findings in Case 2. a Microscopic view. The viewer is blind to the medial surface of internal carotid artery (ICA). b Endoscopic view. No blind spots are seen inside the petrous apex
managing petrous apex disease. Several techniques have been advocated to approach these lesions. The transcochlear approach [3], modified transcochlear approach [4] and transotic approach [5] are all standard techniques to treat petrous apex cholesteatoma. Removal of the labyrinth (transcochlear, modified transcochlear, and transotic approaches), rerouting of the facial nerve (transcochlear and modified transcochlear approaches), and removal of the EAC and middle ear (modified transcochlear and transotic approaches) are important steps to approach this lesion under microscopy. We applied the transotic approach with sacrifice of the facial nerve in our two cases, because both patients presented with long histories of complete facial palsy and severe hearing loss. Despite wide bone removal and soft-tissue dissection, we could not achieve complete operative visualization of the petrous apex under microscopy (Figs. 2a, 4a). Low visibility inside the petrous apex is due to the small entrance and large deep area. The entrance to the petrous apex from the lateral temporal bone is defined by the ICA, jugular bulb and posterior cranial fossa. If the cholesteatoma involves the ICA, the medial surface of the ICA will be a blind spot. Mobilization of the ICA provides an option to obtain a surgical view of the medial surface of the ICA under
microscopy [1], but should only be performed with caution, because rupture of the ICA is fatal. In the 1990s, endoscopic techniques were introduced to visualize middle ear pathology during surgical treatment [6]. With improvements in instrumentation, technique and knowledge, endoscopic surgery is gaining importance for ontological interventions. Potential advantages of an endoscopic approach to ear surgery include the possibility of obtaining a wide view and observing areas behind the angle. In middle ear surgery, new endoscopic surgical concepts [7–12] have been introduced and endoscopy for otological surgery is gradually receiving greater attention in place of a standardized microscopic approach. Technical and surgical improvements for endoscopic approaches to the middle ear have allowed introduction of the advantages of endoscopy to the lateral skull base [13, 14] and the number of applications to the lateral skull base surgery has been increasing because of the clear advantages, including reductions in dead corners. In our two cases, an endoscopic approach was introduced and total view inside the petrous apex was achieved without mobilizing the ICA (Figs. 2b, 4b), thanks to the wide-angle endoscopic view inside the petrous apex. Since the number of patients remained small, comparisons with
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microscopic treatments cannot yet be made, but the endoscope clearly shows potential as a helpful tool for operating inside the petrous apex. Our opinion is that the key advantage of endoscopy in managing petrous apex seems to be good visualization.
Conclusion Despite wide bone removal and soft-tissue dissection, achieving a complete operative field of the petrous apex is still difficult under microscopy. Low visibility inside the petrous apex is due to the small entrance and large deep area. Use of an endoscope may resolve this problem by providing a wide-angle view inside the petrous apex. Endoscopes could offer a helpful tool for operating inside the petrous apex. Acknowledgements This study was supported by a Grant-in-Aid for Scientific Research from the Ministry of Education, Science, Sports and Culture of Japan. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval This article does not contain any studies with human participants performed by any of the authors.
References 1. Pandya Y, Piccirillo E, Mancini MF. Sanna M (2010) Management of complex cases of petrous bone cholesteatoma. Ann Otol Rhinol Laryngol 119(8):514–525
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Eur Arch Otorhinolaryngol 2. Presutti L, Alicandri-Ciufelli M, Rubini A, Gioacchini FM. Marchioni D (2014) Combined lateral microscopic/endoscopic approaches to petrous apex lesions: pilot clinical experiences. Ann Otol Rhinol Laryngol 123(8):550–559 3. House WF, Hitselberger WE (1976) The transcochlear approach to the skull base. Arch Otolaryngol 102(6):334–342 4. Sanna M, Mazzoni A, Saleh EA, Taibah AK, Russo A (1994) Lateral approaches to the median skull base through the petrous bone: the system of the modified transcochlear approach. J Laryngol Otol 108(12):1036–1044 5. Jenkins HA, Fisch U (1980) The transotic approach to resection of difficult acoustic tumors of the cerebellopontine angle. Am J Otol 2(2):70–76 6. Thomassin JM, Korchia D, Doris JM (1993) Endoscopic-guided otosurgery in the prevention of residual cholesteatomas. Laryngoscope 103(8):939–943 7. Tarabichi M (2004) Endoscopic management of limited attic cholesteatoma. Laryngoscope 114(7):1157–1162 8. Marchioni D, Alicandri-Ciufelli M, Molteni G, Artioli FL, Genovese E, Presutti L (2010) Selective epitympanic dysventilation syndrome. Laryngoscope 120(5):1028–1033 9. Marchioni D, Villari D, Alicandri-Ciufelli M, Piccinini A, Presutti L (2011) Endoscopic open technique in patients with middle ear cholesteatoma. Eur Arch Oto Rhino Laryngol 268(11):1557–1563 10. Alicandri-Ciufelli M, Marchioni D, Grammatica A, Soloperto D, Carpeggiani P, Monzani D et al (2012) Tympanoplasty: an up-todate pictorial review. J Neuroradiol 39(3):149–157 11. Marchioni D, Alicandri-Ciufelli M, Piccinini A, Genovese E, Monzani D, Tarabichi M et al (2011) Surgical anatomy of transcanal endoscopic approach to the tympanic facial nerve. Laryngoscope 121(7):1565–1573 12. Kakehata S, Watanabe T, Ito T, Kubota T, Furukawa T (2014) Extension of indications for transcanal endoscopic ear surgery using an ultrasonic bone curette for cholesteatomas. Otol Neurotol 35(1):101–107 13. Presutti L, Nogueira JF, Alicandri-Ciufelli D, Marchioni M (2013) Beyond the middle ear: endoscopic surgical anatomy and approaches to inner ear and lateral skull base. Otolaryngol Clin North Am 46(2):189–200 14. Marchioni D, Alicandri-Ciufelli M, Rubini A, Presutti L (2015) Endoscopic transcanal corridors to the lateral skull base: initial experiences. Laryngoscope 125(Suppl 5):S1-13
OTOLOGY
Endoscopic management of petrous apex cholesteatoma Hisashi Sugimoto1 · Miyako Hatano1 · Masao Noda1 · Hiroki Hasegawa1 · Tomokazu Yoshizaki1
Received: 26 June 2017 / Accepted: 4 October 2017 © Springer-Verlag GmbH Germany 2017
Abstract We describe a technique for approaching petrous apex cholesteatoma using combined lateral microscopic/ endoscopic approaches, and discuss the utility of endoscopy in managing matrix inside the petrous apex. In our two cases, total view inside the petrous apex was achieved under endoscopy without mobilizing the internal carotid artery, and the matrix was successfully removed. Neither patient has presented with postoperative recurrence thanks to the wide-angle endoscopic view inside the petrous apex. Since the number of patients was small, comparisons with microscopic treatments are not yet valid, but endoscopes could offer a helpful tool for operating inside the petrous apex. Keywords Petrous apex · Cholesteatoma · Combined lateral microscopic/endoscopic approaches
Introduction Petrous bone cholesteatoma is classified into 5 classes: Class I, supralabyrinthine; Class II, infralabyrinthine; Class III, infralabyrinthine-apical; Class IV, massive; and Class V, apical [1]. Petrous apex cholesteatoma classified as Class V is located very deep in the temporal bone, in one of the least accessible regions of the skull base. The anterior border is formed by Meckel’s cave area, the inferior border by the infralabyrinthine compartment, the posterior border by the internal carotid artery (ICA) and posterior cranial fossa, and * Tomokazu Yoshizaki [email protected]‑u.ac.jp 1
Department of Otolaryngology‑Head and Neck Surgery, Kanazawa University Hospital, Kanazawa University Graduate School of Medical Science, 13‑1 Takaramachi, Kanazawa, Ishikawa 920‑8640, Japan
the medial border by the clivus and sphenoid sinus. Securing complete visibility inside the petrous apex is difficult, because the entrance to the petrous apex is small and the deep part is large. In recent years, endoscopy has come into use for ear operations, due to improvements in endoscopic imaging technology and the development of equipment specifically for operations. Advantages of endoscopic surgery include the ability to secure a good visual field, and reduced invasiveness. The number of applications to lateral skull base surgery has also been increasing, because endoscopic surgery allows access to spaces traditionally considered difficult. Combined lateral microscopic/endoscopic approaches to the lateral skull base were advocated in 2014 [2], and such procedures have proven effective in allowing less-destructive approaches compared to exclusive microscopic procedures. We describe a technique in which we approached petrous apex cholesteatomas in two cases using combined lateral microscopic/endoscopic approaches, and discuss the utility of endoscopy in managing matrix inside the petrous apex.
Case 1 The patient was a 77-year-old man. In 2005, at 66 years old, he had presented with total facial palsy, and had undergone tympanoplasty for cholesteatoma of the middle ear at another hospital. In 2008, revision surgery had been performed for residual cholesteatoma of the petrous bone. A combined middle cranial fossa approach and transmastoid approach was applied. In 2014, residual cholesteatoma of the petrous apex had grown and the patient presented with headache. Facial palsy was classified as Grade VI using the House–Brackmann facial nerve grading system. Pure-tone audiograms showed 70 dB in the
13
Vol.:(0123456789)
right ear and 105 dB in the left ear. The cholesteatoma was classified as apical type from computed tomography and magnetic resonance imaging (Fig. 1a, b). In July 2014, a transotic approach (necessitating sacrifice of the facial nerve) was performed for petrous apex cholesteatoma. Under microscopic visualization, the skin of the external auditory canal (EAC) and the tympanic membrane were removed, and the EAC was closed by blind sac closure. The malleus and incus were identified and removed. Mastoidectomy was performed using a canal wall-down technique and the labyrinth was removed. The facial nerve was then exposed and sacrificed, because the patient had experienced complete facial paralysis since 9 years earlier. After all the above-mentioned steps under microscopy, the endoscopic procedure was performed using a 4.0-mm endoscope. Direct endoscopic visualization of the medial surface of the carotid artery in the petrous apex was then established (Fig. 2b) and the matrix was successfully removed. As of 42 months postoperatively, no recurrences have been identified in this patient.
Fig. 1 Imaging findings in Case 1. a Results of CT. Cholesteatoma located in the petrous apex involves the internal carotid artery. b Magnetic resonance imaging
Fig. 2 Surgical findings in Case 1. a Microscopic view of the petrous apex. The viewer is blind to the medial surface of the internal carotid artery (ICA). b Endoscopic view of the petrous apex. No blind spots are seen inside the petrous apex
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Eur Arch Otorhinolaryngol
Case 2 The patient was a 36-year-old man. He had presented with facial palsy in his teens and had undergone ear surgery at another hospital. In 2007, he underwent tympanoplasty for residual cholesteatoma at another hospital. The patient was referred to our hospital in 2014 due to growth of residual cholesteatoma of the petrous apex. Facial palsy was classified as Grade VI using the House–Brackmann facial nerve grading system. Pure-tone audiograms showed scale-out in both ears. The cholesteatoma was classified as infralabyrinthine–apical type from computed tomography and magnetic resonance imaging (Fig. 3a, b). A transotic approach (with sacrifice of the facial nerve) was performed for this case. We removed the matrix in the petrous apex using endoscopy, as in Case 1 (Fig. 4b).
Discussion The petrous apex is one of the most difficult-to-access areas of the lateral skull base. Achieving a good operative field and adequate working space is essential for
Eur Arch Otorhinolaryngol Fig. 3 Imaging findings in Case 2. a CT imaging. Cholesteatoma located in the petrous apex involves the internal carotid artery. b Magnetic resonance imaging
Fig. 4 Surgical findings in Case 2. a Microscopic view. The viewer is blind to the medial surface of internal carotid artery (ICA). b Endoscopic view. No blind spots are seen inside the petrous apex
managing petrous apex disease. Several techniques have been advocated to approach these lesions. The transcochlear approach [3], modified transcochlear approach [4] and transotic approach [5] are all standard techniques to treat petrous apex cholesteatoma. Removal of the labyrinth (transcochlear, modified transcochlear, and transotic approaches), rerouting of the facial nerve (transcochlear and modified transcochlear approaches), and removal of the EAC and middle ear (modified transcochlear and transotic approaches) are important steps to approach this lesion under microscopy. We applied the transotic approach with sacrifice of the facial nerve in our two cases, because both patients presented with long histories of complete facial palsy and severe hearing loss. Despite wide bone removal and soft-tissue dissection, we could not achieve complete operative visualization of the petrous apex under microscopy (Figs. 2a, 4a). Low visibility inside the petrous apex is due to the small entrance and large deep area. The entrance to the petrous apex from the lateral temporal bone is defined by the ICA, jugular bulb and posterior cranial fossa. If the cholesteatoma involves the ICA, the medial surface of the ICA will be a blind spot. Mobilization of the ICA provides an option to obtain a surgical view of the medial surface of the ICA under
microscopy [1], but should only be performed with caution, because rupture of the ICA is fatal. In the 1990s, endoscopic techniques were introduced to visualize middle ear pathology during surgical treatment [6]. With improvements in instrumentation, technique and knowledge, endoscopic surgery is gaining importance for ontological interventions. Potential advantages of an endoscopic approach to ear surgery include the possibility of obtaining a wide view and observing areas behind the angle. In middle ear surgery, new endoscopic surgical concepts [7–12] have been introduced and endoscopy for otological surgery is gradually receiving greater attention in place of a standardized microscopic approach. Technical and surgical improvements for endoscopic approaches to the middle ear have allowed introduction of the advantages of endoscopy to the lateral skull base [13, 14] and the number of applications to the lateral skull base surgery has been increasing because of the clear advantages, including reductions in dead corners. In our two cases, an endoscopic approach was introduced and total view inside the petrous apex was achieved without mobilizing the ICA (Figs. 2b, 4b), thanks to the wide-angle endoscopic view inside the petrous apex. Since the number of patients remained small, comparisons with
13
microscopic treatments cannot yet be made, but the endoscope clearly shows potential as a helpful tool for operating inside the petrous apex. Our opinion is that the key advantage of endoscopy in managing petrous apex seems to be good visualization.
Conclusion Despite wide bone removal and soft-tissue dissection, achieving a complete operative field of the petrous apex is still difficult under microscopy. Low visibility inside the petrous apex is due to the small entrance and large deep area. Use of an endoscope may resolve this problem by providing a wide-angle view inside the petrous apex. Endoscopes could offer a helpful tool for operating inside the petrous apex. Acknowledgements This study was supported by a Grant-in-Aid for Scientific Research from the Ministry of Education, Science, Sports and Culture of Japan. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval This article does not contain any studies with human participants performed by any of the authors.
References 1. Pandya Y, Piccirillo E, Mancini MF. Sanna M (2010) Management of complex cases of petrous bone cholesteatoma. Ann Otol Rhinol Laryngol 119(8):514–525
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Eur Arch Otorhinolaryngol 2. Presutti L, Alicandri-Ciufelli M, Rubini A, Gioacchini FM. Marchioni D (2014) Combined lateral microscopic/endoscopic approaches to petrous apex lesions: pilot clinical experiences. Ann Otol Rhinol Laryngol 123(8):550–559 3. House WF, Hitselberger WE (1976) The transcochlear approach to the skull base. Arch Otolaryngol 102(6):334–342 4. Sanna M, Mazzoni A, Saleh EA, Taibah AK, Russo A (1994) Lateral approaches to the median skull base through the petrous bone: the system of the modified transcochlear approach. J Laryngol Otol 108(12):1036–1044 5. Jenkins HA, Fisch U (1980) The transotic approach to resection of difficult acoustic tumors of the cerebellopontine angle. Am J Otol 2(2):70–76 6. Thomassin JM, Korchia D, Doris JM (1993) Endoscopic-guided otosurgery in the prevention of residual cholesteatomas. Laryngoscope 103(8):939–943 7. Tarabichi M (2004) Endoscopic management of limited attic cholesteatoma. Laryngoscope 114(7):1157–1162 8. Marchioni D, Alicandri-Ciufelli M, Molteni G, Artioli FL, Genovese E, Presutti L (2010) Selective epitympanic dysventilation syndrome. Laryngoscope 120(5):1028–1033 9. Marchioni D, Villari D, Alicandri-Ciufelli M, Piccinini A, Presutti L (2011) Endoscopic open technique in patients with middle ear cholesteatoma. Eur Arch Oto Rhino Laryngol 268(11):1557–1563 10. Alicandri-Ciufelli M, Marchioni D, Grammatica A, Soloperto D, Carpeggiani P, Monzani D et al (2012) Tympanoplasty: an up-todate pictorial review. J Neuroradiol 39(3):149–157 11. Marchioni D, Alicandri-Ciufelli M, Piccinini A, Genovese E, Monzani D, Tarabichi M et al (2011) Surgical anatomy of transcanal endoscopic approach to the tympanic facial nerve. Laryngoscope 121(7):1565–1573 12. Kakehata S, Watanabe T, Ito T, Kubota T, Furukawa T (2014) Extension of indications for transcanal endoscopic ear surgery using an ultrasonic bone curette for cholesteatomas. Otol Neurotol 35(1):101–107 13. Presutti L, Nogueira JF, Alicandri-Ciufelli D, Marchioni M (2013) Beyond the middle ear: endoscopic surgical anatomy and approaches to inner ear and lateral skull base. Otolaryngol Clin North Am 46(2):189–200 14. Marchioni D, Alicandri-Ciufelli M, Rubini A, Presutti L (2015) Endoscopic transcanal corridors to the lateral skull base: initial experiences. Laryngoscope 125(Suppl 5):S1-13
