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Review
. 2020 Jun 3;6(2):106-114.
doi: 10.1016/j.wjorl.2019.11.002. eCollection 2020 Jun.

Surgical approaches to the petrous apex

Kevin L Li  1 , Vijay Agarwal  2 , Howard S Moskowitz  1 , Waleed M Abuzeid  1
Affiliations
Review

Surgical approaches to the petrous apex

Kevin L Li et al. World J Otorhinolaryngol Head Neck Surg. .

Abstract

The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures. Petrous apex pathology ranges from extradural cholesterol granulomas, cholesteatomas, asymmetric pneumatization, and osteomyelitis to intradural meningiomas and schwannomas. Certain lesions, such as cholesterol granulomas, can be managed with drainage while neoplastic lesions must be completely resected. Surgical options use open, endoscopic, and combined techniques and are categorized into anterior, lateral, and posterior approaches. The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient. The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex, and the anatomy on which these approaches are based.

Keywords: Anterior approaches; Endoscopic endonasal approach; Lateral approaches; Petrous apex; Surgical approaches.

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Conflict of interest statement

Waleed Abuzeid, MD is a consultant for Medtronic Inc. and Intersect ENT. Neither of these relationships is pertinent to the contents of this study.

Figures

Fig. 1
Fig. 1
An illustration of the various surgical approaches to the petrous apex with relevant anatomy. The sphenoid bone (yellow), temporal bone (red), and occipital bone (blue) are shaded.
Fig. 2
Fig. 2
Detailed anatomy of the petrous apex (yellow).
Fig. 3
Fig. 3
A and B are T2-weighted MRI images demonstrating a multilobulated expansile lesion in the right petrous temporal bone extending to the sphenoid bone and displacing the petrous internal carotid artery consistent with a cholesterol granuloma. C and D are non-contrast high-resolution CT images re-demonstrating the right petrous apex lesion and the associated remodeling and scalloping of surrounding bones including the clivus as well as bony dehiscence of the right petrous carotid canal.
Fig. 4
Fig. 4
Series of endoscopic images derived from the same patient. A: Initial exposure of petrous apex granuloma capsule via medial transsphenoidal approach. B: Evaluation of the expanded granuloma cavity using 30° angled endoscope demonstrating typical debris associated with this lesion within the cavity. C: View of the sphenoid and silastic stent placed across the opening into the petrous apex.
Fig. 5
Fig. 5
Transcanal infracochlear approach. A corridor is opened to the petrous apex within the space between the cochlea, internal carotid artery and jugular bulb.
See this image and copyright information in PMC

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