Learning Objectives:

Introduction: Petrous temporal bone cholesteatoma (PTBC) poses a significant management challenge. The location and nature of the disease as well as surgery carry risks to vital anatomical structures with potential impact on quality of life. Traditionally an aggressive surgical approach has been used. We present our series of PTBC; their classification, management, hearing and facial nerve outcomes.

Method: A retrospective case note review was carried out for all petrous cholesteatomas managed by the senior authors from 2008–2016. The study was an analysis of service provision and therefore formal ethical approval was not required.

Results: 15 patients were included in the study (mean age 42y 6 m; 10 males). Using Sanna et al.'s classification there were: 4 supralabyrinthine (Class I), 3 infralabyrinthine (II), 4 labyrinthine-apical (III), 4 massive labyrinthine (IV) and 1 apical (V). Hearing loss was a presenting symptom in 80% of patients, four of which were dead ears and 40% had a degree of facial nerve palsy. Mean follow-up was 1391 days. 5/15 patients underwent otic capsule sparing surgery. Recurrence occurred in 8 patients (53%), who all underwent further surgery and are currently disease free. Post operatively 20% had worse hearing (all requiring a labyrinthectomy or transotic approach). Four patients had new or worse facial weakness post operatively and three of these have had subsequent facial reanimation surgery.

Conclusion: The aim in PTBC management is total exenteration of disease while minimizing complications. Compared to other series in the literature we have a higher residual/recurrence rate due to a more conservative surgical approach in recent years. Advances in diffusion-weighted magnetic resonance imaging enable a less aggressive initial approach and directed second stage surgery in cases with residual disease.

Learning points: Long term outcomes will determine whether a less aggressive initial surgical approach is acceptable (for managing PTBC).