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Petrous cholesteatoma sample

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petrous cholesteatoma
petrous bone
petrous apex
trans mastoid approach
subtotal petrosectomy

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Petrous cholesteatoma sample

  1. 1. PETROUS CHOLESTEA TOMA DR ANUSREE A KARUN PETROUS BONE CHOLESTEATOMA Dr Anusree A Karun
  2. 2. PETROUS BONE CHOLESTEATOMA Uncommon pathologic condition(4-6% of all temporal bone lesions)used to define an epidermoid cyst of the petrous portion of the temporal bone A surgical challenge considering the complex anatomic relationship with vital intracranial structures and the risk of csf leak . Two cases of petrous bone cholesteatoma are entailed here.
  3. 3. CASE REPORT CASE1 A 49 yr old male pt came with H/O left ear discharge-since 10yrs H/O head ache-4 months Patient also had left facial palsy hard of hearing & following previous surgery for cholesteatoma k/c/o DM,HTN-1yr on treatment CASE 2 24 yr old male presented with chief complaints of Left sided headache -4mnths And Giddiness *3 mnths No h/o any comorbidities
  4. 4. PAST HISTORY CASE1 Pt underwent modified radical mastoidectomy in 2014 (for extensive cholesteatoma) Radical mastoidectomy in 2015(for recurrent cholesteatoma ) Craniotomies twice for extradural abscess and zygoma excision for zygomatic abscess in 2016 CASE2 H/O MRM 8 yrsback
  5. 5. GENERAL PHYSICAL EXAMINATION General examination: Pt GC fair Afebrile Nopallor/icterus/cyanosis/lymphadenopathy/clubbing/pedal edema CVS-s1,s2+ RS-B/L AE+ P/A-soft,no organomegaly CNS-NFND
  6. 6. ENT EXAMINATION PTA Right –wnl Left- severe mixed HL Right-wnl Left-mild CHL CASE1 CASE2 EXTERNAL EAR Preauricular region normal normal Pinna normal normal Post auricular region Left-Scar + Right -normal Left- Scar+ Right-normal EAC Left-Blind sac closure Right –normal Left-Normal Right-normal TM Left-Not seen Right-normal Left-normal Right-neotympanum Fistula sign absent absent 3 point/tragal tenderness absent absent TFT Rinne Weber ABC +ve -ve Lateralised to LEFT Not reduced +ve -ve Lateralised to LEFT Not reduced Facial nerve Grade 5 facial palsy normal Vestibular signs absent absent
  7. 7. CASE1- HRCT-craniotomy defect + large cystic destructive lesion noted in left EAC,ME cavity,squamous,temporal,m astoid and PETROUS portion and facial canal F/s/o ? recurrent cholesteatoma –with petrous bone involvement CASE2 HRCT-soft tissue opacity note in the left mastoid and extending into petrous temporal bone Middle ear appears normal,with intact ossicles
  8. 8. CASE 2-MRI-clearly demonstrates the extension of cholesteatoma into petrous apex with intact ME inner ear structures CASE1-MRI-post radical mastoidectomy status-soft tissue density noted in mastoid and middle ear extending to petrous apex,fallopian canal involvement+ RAMASAMY 49/M Temporal 2017 01 05 16 38 pm BIR 3372 R R L TR 3760 TE 89.00 ‘KK_15/150 TR 3760 TE 89.00 SP F33 5 SL 5 0/5 44 FeV 186 4s ‘KK_15/150 SP F33 5 SL 5 0/5 44 FeV 186 4s
  9. 9. DECISION CASE1 – diagnosed as massive petrous bone cholesteatoma pt taken up for trans cochlear approach(pt already had grade 5 facial nerve palsy and non serviceable hearing on left ) Case2 –provisionally diagnosed as infralabyrinthine petrous bone cholesteatoma taken up for subtotal petrosectomty in view of hearing preservation MASSIVE INFRALABYRINTHINE
  10. 10. SURGERY VIDEO
  11. 11. PETROUS BONE-RELEVANT ANATOMY Petrous bone :That part of the temporal bone medial to the middle ear cleft. Consists of base ,apex, anterior ,inferior and posterior surfaces Shaped like a pyramid, contains the semicircular canals, vestibule, cochlea, and carotid artery.
  12. 12. PETROUS APEX Petrous apex : That part of the temporal bone medial to the otic capsule, between the greater wing of sphenoid and occiput The superior surface is formed by the middle cranial fossa, Meckel cave& ICA Along inferior surface is jugular bulb and IPS
  13. 13. IAC bisects the petrous apex into a large anterior portion that typically contain bone marrow and a smaller posterior portion derived from otic capsule The petrous carotid canal and IAC are the largest channels traversing the petrous apex The Dorello canal, subarcuate canal, singular canal, and Meckel cave are smaller channels.
  14. 14. PBC-CLASSIFICATION According to Sanna et al. [1993] PBCs can be classified into five groups:  supralabyrinthine-geniculate ganglion  infralabyrinthine-hypotympanic and infralabyrinthine cells infralabyrinthine-apical-infralabyrinthine compartment extending to petrous apex Massive-otic capsule Apical-petrous apex These terms describe both the location and the extent of the lesion.
  15. 15. ROUTES OF SPREAD Extension of acquired cholesteatoma into petrous occurs in large cholesteatoma and in well pneumatized petrous bone In medial extension ,cholesteatoma follows course of least resistance & erodes thin wall of petrous air cells 1.Infralabyrinthine-below cochlea & IAC,may break into jugular fossa 2.Anterosuperior-above cochlea,involving geniculate ganglion&extending into supra meatal area of petrous bone 3.Posterosuperior-between limbs of Superior SCC to reach fundus of IAC
  16. 16. 1.Subaarcuate via arch of scc-FRECKNER 2.Retrolabyrinthine Superior to lscc & posterior to superior scc-THORNWALDT 3.Infralabyrinthine(hearing preserving) inferior to posterior scc posterior to VII nerve and superior to jugular bulb[DEARMIN &FARRIOR] 4.Subcochlear/infracochlear-(hearing preserving)hypotympanic air cell tract between ica,jugular bulb and cochlea[FARRIOR] 5/6.peritubal– b/w ica,cochlea and tegmen 5-Ramdier/lempert 6-Kopetsky/Almoor 7.Middle cranial fossa (hearing preserving) EAGLETON
  17. 17. TREATMENT PROTOCOL Main factors to be considered are (1) complete eradication of the disease (2) preservation of facial nerve function, (3) prevention of CSF leak and meningitis, (4) Cavity obliteration (5) hearing preservation whenever feasible
  18. 18.  If the patient presents with preserved hearing, four routes are possible: 1.transcanal infracochlear, 2.Transsphenoidal 3. Infralabyrinthine- but limited access, especially in patients with high jugular bulb 4.middle cranial fossa- but it does not allow a permanent drainage pathway, and some degree of temporal lobe retraction is necessary, which could result in brain injury  If hearing is not preserved, there are two more options: 1.translabyrinthine 2. transcochlear  Trans otic approach preserves facial nerve
  19. 19. TREATMENT PROTOCOL SUPRALABYRINTHINE Hearing normal sensory neural HL or No e/o fistula in cochlea e/o fistula in cochlea Middle fossa approach with subtotal petrosectomy/ Transmastoid approach enlarged translabyrinthine / transotic approach with cavity obliteration
  20. 20. Infralabyrinthine infralabyrinthine apical (hearing preservation isnt possible) N Hearing SNHL VII N normal VII N palsy Subtotal transotic transotic/ IFTB+ modified petrosectomy IFTB Transcochlear approach A
  21. 21. Massive Apical & those with extn to clivus,nasopharyn Hearing preservation not possible & sphenoid sinus VII N nrml VII N palsy hearing N SNHL SNHL+VII palsy VII n nrml VII palsy Transotic MTCA IFTB IFTB+TO IFTB+MTCA
  22. 22. CONCLUSION • With thorough pretreatment evaluation of location and extent of lesion , meticulous radiological assessment, planning and execution, the difficult terrain of petrous apex can be approached and dealt with successful results • Unlike any other lesion of the petrous apex ,cholesteatoma has the advantage of total removal and disease clearance in the hands of an experienced surgeon with meticuluos dissection ,by simply foolowing the lesion • Classification is important to decide the appropriate surgical approach. • The facial nerve requires special consideration as it gets involved in almost all the cases and is a cornerstone of management. • Radical removal takes priority over hearing preservation even in only hearing ears with the possibility of hearing rehabilitation (CI, BAHA and Soundbridge). • Regular follow-up is mandatory

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