Petrous apex cholesteatoma: Report of two cases

Two patients with extensive cholesteatoma in the petrous apex are reported. Case 1 was a 29-year-old man with left facial palsy for more than 20 years. CT and MRI examinations revealed that massive cholesteatoma in the petrous apex had expansively destroyed the internal acoustic meatus. A joint operation with a neurosurgeon was performed by both middle cranial fossa and translabyrinthine approaches. Cholesteatoma involved the middle and apical turn of the cochlea and anterior semicircular canal. The proximal portion from the geniculate ganglion of the facial nerve had disappeared and could not be identified. The dura mater in the internal acoustic foramen was penetrated and the internal carotid artery was exposed after removal of the cholesteatoma. The internal acoustic foramen was closed with the temporal fascia and the postoperative large cavity was obliterated with abdominal fat. Case 2 was a 35-year-old man with left hearing loss. CT examination revealed an attic cholesteatoma extending to the petrous apex and widely exposed middle cranial fossa dura. The exenteration of the cholesteatoma was done by both transmastoid and translabyrinthine approaches. The facial nerve was preserved and rerouted. Cerebrospinal fluid leaked out of the internal acoustic meatus upon removal of the cholesteatoma. The internal acoustic meatus was closed with the temporal fascia and the postoperative cavity was obliterated with abdominal fat. After total exenteration of massive cholesteatoma in the petrous apex, if possible, the postoperative cavity should be obliterated, in order to improve the quality of the patient's life and to shorten the duration of admission. When the cavity is obliterated, concentrative follow-up MRI study should be performed.