Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Endoscopic endonasal treatment of petrous apex cholesterol granulomas allows for a natural drainage pathway into the nasopharynx. Because of the limited number of case series in the literature, there is limited evidence of recurrence rates and outcomes following endoscopic endonasal management. The purpose of this study was to determine the surgical outcomes of endoscopic endonasal approaches in the treatment of cholesterol granulomas of the petrous apex.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A systematic literature review was performed using PubMed for articles published from January 1980 to April 2014 to identify all studies reporting outcomes for endoscopic endonasal surgical management of cholesterol granulomas of the petrous apex. Operative approach, use of a stent, symptom outcome, restenosis, cyst recurrence, reoperation, and complications were extracted from included studies.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 53 patient cases were included from 22 relevant studies. The mean age was 41 years, and 26 patients (49%) were female. Stents were used in 45.1% of cases. Symptom resolution or improvement was seen in 98.6% of cases at follow-up (mean follow-up 20 months). Complications were reported in 13.2% of cases, with the most common complication being epistaxis. Restenosis on follow-up office endoscopic examination occurred in 9 of 45 cases (20.0%). Only 4 of these restenosis cases resulted in symptomatic cyst recurrence, resulting in an overall recurrence rate of 7.5%. The mean time from surgery to cyst recurrence was 13.5 months. The rate of symptomatic cyst recurrence was 10.7% in cases without the use of a stent compared with 4.3% in cases with stent placement (p = 0.6).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Based on current literature, endoscopic endonasal approaches result in a high rate of symptom improvement or resolution. Complication rates are lower than prior case series that have utilized open approaches. Asymptomatic restenosis can be managed conservatively, since it is associated with symptomatic cyst recurrence less than half of the time. This study revealed a nonsignificant trend toward a decrease in symptomatic cyst recurrence when a stent was used, but further work is needed to clarify its impact.</jats:p></jats:sec>

ICAR: endoscopic skull‐base surgery

“…When compared to transtemporal approaches, the aggregate evidence to date suggests excellent outcomes with regard to symptomatic improvement with the endoscopic approach. In a systematic review of 53 patients, Eytan et al . reported that only 7.5% experienced recurrent symptoms.…”

Endoscopic transsphenoidal surgery using pedicle vascularized nasoseptal flap for cholesterol granuloma in petrous apex: A technical note

“…The use of silastic stent would be effective in prevention of recurrence, but its removal would need additional surgery under local anesthesia, or general anesthesia in some cases [10]. Moreover, the 13 of 14 (92.9%) reported cases of PACG treated by pedicle flap without stent did not present with recurrence [12,14,22], suggesting non-inferiority of the pedicle flap technique compared with the use of silastic stent. Although the combined use of pedicle flap and stent was also recommended [11], we consider the use of pedicle flap without stent as an optimum and less invasive procedure for PACG.…”

“…Before the advent of endoscopic surgery, the recurrence rate following microscopic TSS for PACG was quite high [27]. In recent years, however, the recurrence rate of endoscopic TSS has extremely reduced [10,12,16,22]. Compared with microscopy, endoscopy can achieve a wide operative field, enabling a maximum puncture of CG.…”

“…Some reports recommend additional use of artificial material, such as silastic stent [10,11], to prevent restenosis of the drainage route. A previous systematic review [12] reported the rate of symptomatic recurrence as 10.7% in cases without the use of stent and 4.3% in cases with stent placement. The use of silastic stent would be effective in prevention of recurrence, but its removal would need additional surgery under local anesthesia, or general anesthesia in some cases [10].…”

“…Direct resection using a middle fossa approach would yield relatively few recurrences, but it is quite invasive and has a risk of severe postoperative complications [3][4][5][6]. Recently, many reports on endoscopic transsphenoidal surgery (TSS) for PACG drainage have been published [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. Although it is a less invasive approach, the frequency of recurrence is high compared with direct resection.…”