Petrosal cholesteatoma: management considerations for minimizing morbidity

Abstract

Objective: This study aimed to analyze the surgical treatment of patients presenting with petrosal cholesteatoma.

Study design: The study design was a retrospective case review.

Setting: The study was conducted at a tertiary referral center.

Patients: Patients were referred to the University Department of Otolaryngology, Manchester Royal Infirmary, with surgically confirmed petrosal cholesteatoma.

Intervention: Interventions were diagnostic and therapeutic.

Main outcome measures: Postoperative facial function, hearing loss, recurrent cholesteatoma, and petrous cavity morbidity in relation to preoperative signs, intraoperative findings, and surgical techniques were measured.

Results: Twenty-five patients were treated between 1979 and 1997. Complete preoperative facial paralysis was always associated with bony erosion around the geniculate ganglion, and facial nerve ischemia was thought to be an important factor. Resection of the ischemic nerve segment and end-to-end anastomosis over the posterior fossa dura allowed full removal of cholesteatoma matrix and reinnervation along a healthy and vascularized nerve. In five of the seven cases with recurrent disease, cholesteatoma was localized to the intrapetrous carotid or geniculate ganglion. The introduction of endoscopic techniques has allowed assessment of the full extent of disease and removal of cholesteatoma matrix missed using conventional microscopic visualization. Bipolar diathermy to areas of cholesteatoma, densely adherent to dura, is effective in destroying squamous epithelium. Patients with cavity obliteration and blind sac closure had minimal postoperative morbidity, and current magnetic resonance imaging techniques are effective in diagnosing and delineating recurrence.

Conclusions: This study illustrates a gradual change in the treatment of patients with petrosal cholesteatoma. By defining the main areas of patient morbidity and using both recent technical advances and alternative surgical techniques, further improvement in patient outcome is envisaged.