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The Management of Petrous Bone Cholesteotoma: A Challenging Clinical Entity

Presenting Author: Scott Mitchell

Published online by Cambridge University Press:  03 June 2016

Scott Mitchell ,
Karamveer Narang  and
Richard Irving
Scott Mitchell
Affiliation:
University Hospitals Birmingham NHS Foundation Trust
Karamveer Narang
Affiliation:
University Hospitals Birmingham NHS Foundation Trust
Richard Irving
Affiliation:
University Hospitals Birmingham NHS Foundation Trust
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Abstract

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Learning Objectives: 1. To demonstrate that petrous bone cholesteotomas are a complex clinical entity. 2. To show that patients with this condition often present late with significant morbidity present prior to intervention 3. To describe our clinical outcomes following surgical intervention in the context of the current literature.

Introduction: Cholesteotomas occurring or extending medial to the otic capsule and labyrinth are regarded as petrous bone cholesteotomas (PBC). Important anatomical structures within this area makes the management of these cases demanding. We report our experience and outcomes following surgery.

Methods: Case notes of patients who underwent PBC surgery over an 11 year period (2003–2014) were retrospectively analysed.

Results: 23 patients were identified. Median age 50 years (range 19–81). The commonest symptom was hearing loss (78.3%) with facial nerve dysfunction (69.6%) and disequilibrium (26.1%) being experienced by many. 12 (52.2%) patients had a facial nerve palsy prior to operative intervention. 11 (47%) had previously undergone ear surgery with 7 (30.4%) being for cholesteotoma. 1 (4.3%) patient had multiple episodes of meningitis and 1 (4.3%) had developed a cerebellar abscess prior to operative intervention. Preoperatively, 6 (26.1%) had a “dead” ear with 5 (21.7%) having a profound hearing loss.

In our series, 14 (60.9%) patients had a total petrosectomy with closure of the ear canal, eustachian tube and obliteration of the cavity with an abdominal fat graft. The remaining had subtotal petrosectomy (4), revision petrosectomy (3) or a combined middle fossa and trans-mastoid approach (2). Operative findings confirmed extensive disease in most cases with facial nerve (56%), dural (39%), vestibular (26%), cochlear (21%) and carotid (13%) involvement being encountered. 9 patients had post-operative complications including: wound infections (3), post aural fistula (2), facial palsy (2) and dead ear (2). Within an average follow up period of 43 months, there was 1 (4.3%) recurrence.

Conclusion: In our series, PBC had often become advanced prior to intervention, despite advances and increased availability of imaging techniques. Extensive PBCs are difficult to “cure” by surgery but we show good control rates with little increased morbidity from intervention.