Learning Objectives:

Introduction: Cholesteatoma is one of the most frequent lesions in the petrous portion of the temporal bone. It is difficult to completely remove the lesions of the petrous apex, specifically cholesteatoma. Selection of a surgical approach is determined by the location of the cholesteatoma in the petrous bone. We report a case of an intractable petrous apex cholesteatoma, which was managed with combined surgery, involving a translabyrinthine approach and trans-sphenoidal approach.

Case report: A 71-year-old Japanese man underwent right tympanoplasty 6 years previously. He visited our hospital because of recurrent cholesteatoma. He could not hear because of obstruction of the right external auditory meatus caused by the previous surgery. Computed tomography (CT) revealed a soft tissue density lesion that extended widely from the petrous portion of the temporal bone to the sphenoid sinus. Cholesteatoma had extensively spread to the nearby carotid artery and posterior cranial fossa. It was considered difficult to completely remove this lesion. Surgery was performed via a translabyrinthine approach to remove most of the cholesteatoma. A trans-sphenoidal approach was used to create a drainage and observation hole. The postoperative course was uneventful, and the remainder of his clinical course was benign. Post-operative CT findings after 10 months revealed that the drainage route leads to the petrous portion of the temporal bone.

Conclusions: We encountered a markedly advanced, intractable petrous apex cholesteatoma. A surgical procedure, including trans-sphenoidal approach can maintain debris drainage and facilitate observation of the lesion from the sphenoid sinus. This therapy will help prevent complications in the future.