Lesions of the Petrous Apex: Diagnosis and Management

doi:10.1016/j.otc.2007.03.003

Otolaryngologic Clinics of North America

Volume 40, Issue 3, June 2007, Pages 479-519

https://doi.org/10.1016/j.otc.2007.03.003 Get rights and content

Management of petrous apex pathology poses a unique challenge even to the most seasoned skull base surgeons. The central location in the skull base with adjacent critical neurovascular structures makes access to this region more than a trivial matter. Significant advances in diagnostic imaging have greatly facilitated the diagnosis of petrous apex lesions. The introduction of modern skull base surgery techniques also has provided skull base surgeons with numerous avenues to the petrous apex while significantly decreasing morbidity. The latest diagnostic and management strategies are discussed and an update of some of the more common pathologic entities is provided.

Section snippets

Anatomy

The petrous apex is a pyramid-shaped structure that is the most medial aspect of the temporal bone. The base of the pyramid is the otic capsule, semi-canal of the tensor tympani and the petrous carotid artery. The superior surface—or meatal plane—extends from the arcuate eminence to the precavernous carotid artery and Meckel's cave. The posterior surface faces the cerebellopontine angle and begins laterally at the common crus/vestibular aqueduct and ends medially at Dorello's canal and

Presentation

Petrous apex lesions can present with various symptoms and signs, depending on the size, location, and nature of the pathologic process. Muckle and colleagues [2] reported hearing loss as the most common symptom followed by vestibular dysfunction, headache, tinnitus, facial spasm, diplopia, facial paralysis, and otorrhea. Symptoms often present months or years before diagnosis, and incidental discovery is not uncommon.

CT

CT of the temporal bone enables a detailed evaluation of the osseous architecture of the petrous apex. Lesions within or involving the petrous apex may be further characterized based with CT by evaluating for different patterns of bone erosion or invasion. A distinct advantage of CT is the ability to determine the proximity of a petrous apex lesion—with submillimeter accuracy—to critical structures, such as the internal auditory canal, otic capsule, and carotid artery. CT is often complementary

Infracochlear

Traditionally, the most common approach to cystic lesions of the petrous apex in patients with serviceable hearing was the infralabyrinthine approach. This approach is limited in patients with a high jugular bulb, however. The alternative in these patients is the infracochlear approach to the petrous apex [12], [13]. There are several advantages to the infracochlear approach, including dependent drainage in a well-aerated middle space adjacent to the eustachian tube, adequate access to the

Cholesterol granuloma

Cholesterol granuloma is the most common abnormality found within the petrous apex. It is a cystic lesion that was first recognized as a distinct clinical entity in the early 1980s [49]. Together with mucocele and cholesteatoma, cholesterol granuloma accounts for more than 90% of the lesions of the petrous apex. Cholesterol granuloma is an intraosseous cyst filled with dark, viscous, chocolate brown fluid and granulation tissue. Birefringent cholesterol crystals can be seen on microscopy. The

Cerebrospinal fluid cysts and cephaloceles

CSF cysts, also known as arachnoid cysts, are most commonly located in the middle fossa and arise from splitting of the arachnoid membrane [72]. CSF cysts located in the cerebellopontine angle may erode the posterior aspect of the petrous apex [71]. These lesions are often incidentally discovered but occasionally produce symptoms of hearing loss, vertigo, tinnitus, headaches, and dysequilibrium [71]. Symptoms are thought to arise from several possible mechanisms, including direct compression of

Chondrosarcoma

Chondrosarcomas are rare malignancies that arise from embryologic cartilage rests along the sphenopetroclival fissure. They account for 0.15% of all intracranial tumors and 6% of skull base neoplasms [93]. Chondrosarcomas are more common in patients with Ollier's disease, Maffucci syndrome (enchondroma with multiple angiomas), Paget's disease, and osteochondroma, although most chondrosarcomas arise de novo.

Because of the slow growth and insidious nature of chondrosarcomas, diagnosis is not

Uncommon lesions

Schwannomas, paragangliomas, and endolymphatic sac tumors occasionally involve the petrous apex. Petrous apex schwannomas may originate from cranial nerves IV, V, VI, VII, or VIII. Petrous apex involvement usually results from direct extension and typically does not arise within the petrous apex. Paragangliomas also may invade the petrous apex via preformed air cell tracts from their site of origin in the jugular foramen or middle ear. Endolymphatic sac tumors arise from the proximal rugose

Summary

Advances in diagnostic imaging, microsurgical techniques, and the introduction of stereotactic radiosurgery have made the management of petrous apex pathology less daunting for modern skull base surgeons. Decreasing patient morbidity and mortality and improving outcomes are the ultimate goal for surgeons treating petrous apex pathology. Unfortunately, meaningful prospective outcome studies are lacking and not likely to occur because of the rarity of these lesions.

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The petrous apex along with the petroclival region is a tight, compartmentalized skull base zone that contains important neurovascular structures. Surgery around this area has always been considered a challenging task, carrying the risk of considerable morbidity.6 In the quest for a safe and effective corridor to the petrous apex, a handful of skull base approaches have been devised.
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Lesions of the Petrous Apex: Diagnosis and Management

Section snippets

Anatomy

Presentation

CT

Infracochlear

Cholesterol granuloma

Cerebrospinal fluid cysts and cephaloceles

Chondrosarcoma

Uncommon lesions

Summary

Am J Otolaryngol

Otolaryngol Head Neck Surg

Otolaryngol Clin North Am

Otolaryngol Clin North Am

Otolaryngol Head Neck Surg

Surg Neurol

Petrous apicitis: surgical anatomy

Ann Otol Rhinol Laryngol

Petrous apex lesions

Am J Otol

Neurotology

“Leave me alone” lesions of the petrous apex

AJNR Am J Neuroradiol

Imaging destructive lesions of the petrous apex

Laryngoscope

Endovascular treatment of craniofacial lesions. In: Surgical neuroangiography

Preoperative embolization of the head and neck: indications, patient selection, goals, and precautions

AJNR Am J Neuroradiol

Arterial catheter embolization followed by surgery for large chemodectoma

Surgery

Effects of preoperative embolization on glomus jugulare tumors

Laryngoscope

Three dimensional computed tomography angiography in imaging jugular foramen lesions

Otol Neurotol

Subcochlear approach for cholesterol granulomas of the inferior petrous apex

Otolaryngol Head Neck Surg

Transcanal infracochlear approach to the petrous apex

Otolaryngol Head Neck Surg

Surgical management of petrous apex cholesterol granulomas

Otol Neurotol

Management of cholesterol granulomas of the petrous apex based on clinical and radiologic evaluation

Otol Neurotol

Technical modifications to the middle fossa craniotomy approach in removal of acoustic neuromas

Am J Otol

The enlarged middle cranial fossa approach for surgery of the temporal bone and of the cerebellopontine angle

Arch Otorhinolaryngol

Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients

Neurosurgery

Transpetrosal approach for aneurysms of the lower basilar artery

J Neurosurg

Risk-benefit analysis of using the middle fossa approach for acoustic neuromas with >10 mm cerebellopontine angle component

Laryngoscope

The vulnerability of the vein of Labbe' during combined craniotomies of the posterior and middle fossae

Skull Base Surgery

Anatomy of the combined retrolabyrinthine-middle fossa craniotomy

Neurosurg Focus

Transtemporal surgery of the internal auditory canal. Report of 92 cases, technique, indications and results

Adv Otorhinolaryngol

Surgical exposure of the internal auditory canal and its contents through the middle cranial fossa

Laryngoscope

Locating the internal auditory canal during the middle fossa approach: an alternative technique

Skull Base Surgery

Surgical exposure of the internal auditory canal and its contents through the middle cranial fossa

Laryngoscope

A logical survival approach to the tip cells of the petrous pyramid

Arch Otolaryngol

The supralabyrinthine exenteration of the petrous apex

Ann Otol Rhinol Laryngol

Cholesterol cysts of the temporal bone: diagnosis and treatment

Ann Otol Rhinol Laryngol

Supracochlear approach to the petrous apex: case report and anatomic study

Am J Otol

Interconnecting the posterior and middle cranial fossae for tumors that traverse Meckel's cave

Am J Otol

Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome

J Neurosurg

Suprameatal extension of the retrosigmoid approach: microsurgical anatomy

Neurosurgery

Retrosigmoid intradural suprameatal approach: advantages and disadvantages from an anatomical perspective