Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Otol Rhinol Vol: 3 Issue: 2

Management of the Facial Nerve in Complex Cases of Petrous Apex Cholesteatoma: Case Report

Masashi Hamada1*, Kyoko Odagiri1, Masahiro Iida1, Hiroaki Nakatani2
1Department of Otolaryngology, Tokai University, School of Medicine, Japan
2Department of Head and Neck Surgery, Tochigi Cancer Center, Japan
Corresponding author : Masashi Hamada
Department of Otolaryngology, Tokai University, School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
Tel: +81-463-93-1121; Fax: +81-463-94-1611
E-mail: [email protected]
Received: January 02, 2014 Accepted: February 19, 2014 Published: February 28, 2014
Citation: Hamada M, Odagiri K, Iida M, Nakatani H (2014) Management of the Facial Nerve in Complex Cases of Petrous Apex Cholesteatoma: Case Report. J Otol Rhinol 3:2. doi:10.4172/2324-8785.1000146


Management of the Facial Nerve in Complex Cases of Petrous Apex Cholesteatoma: Case Report

Congenital cholesteatoma in the petrous apex grows insidiously and causes profound sensorineural hearing loss, vertigo, and/or facial nerve paralysis. Although the goal of treatment of petrous apex cholesteatoma (PAC) is its complete removal, total removal followed by obliteration is often difficult because of the extent of cholesteatoma invasion and/or the anatomical complexity of the petrous apex. In complex cases with encasement of vital structures such as the internal carotid artery (ICA), sigmoid sinus, and jugular bulb and/or with further extension to the clivus, sphenoid sinus, or nasopharynx, control and management may be even more difficult. In this paper, three cases of complex PAC are presented and their optimum surgical treatment is discussed in detail, particularly management of the facial nerve in cases of PAC.

Keywords: Neurofibromatosis; Neck mass; Neuroimaging


Neurofibromatosis; Neck mass; Neuroimaging

Case Report

Case 1
A 45-year-old female was referred to our hospital for surgery. Transpetrosal (middle cranial fossa) surgery had been attempted for the removal of PAC in another hospital 7 years previously. She reported total hearing loss in the left ear, and ipsilateral facial paralysis was assessed as House-Brackmann (H-B) grade III. Highresolution computed tomography (HRCT) showed that the cochlea and labyrinth were already devastated. Magnetic resonance imaging (MRI) revealed a large cystic lesion in the petrous apex, extending up to the sphenoid sinus with the complete encasement of the internal auditory meatus (IAM) and the ICA (Figure 1). Complete removal was first attempted through the transtemporal (transotic) approach, and the cholesteatoma matrices were mostly removed from the ICA. However, the dura and contents of the IAM could not be distinguished from the cholesteatoma. Therefore, exteriorization of the lesion was performed (Figure 2). The position of the facial nerve was left intact in accordance with the patient’s desire for its preservation. The postoperative grade of facial palsy therefore, remained unchanged.
Figure 1: A T2 MRI scan of case 1. A large cholesteatoma in the left petrous apex extended up to the sphenoid sinus and the internal carotid artery (arrowhead), involving the internal auditory meatus (arrow), cochlea, and labyrinth.
Figure 2: Intraoperative findings in case 1. Petrous apex (*) was exteriorized using the transotic approach. Facial nerve was preserved in its original position. Co: cochlea, FN-M: mastoid segment of facial nerve, G: genu, IAM: internal auditory meatus, MFP: middle fossa plate, PFD: posterior fossa dura.
Case 2
A 36-year-old male presented with left facial paralysis lasting for more than 6 months. Ipsilateral total deafness was noted. Facial paralysis was assessed as H-B grade VI. HRCT and MRI revealed a large cystic lesion that was consistent with PAC extending into the inner ear, the ICA, and sphenoid sinus (Figure 3). A transotic approach was planned, but the facial nerve was observed to be pathologically swollen during surgery (Figure 4). Therefore, the facial nerve was transected and reconstructed using anastomosis with the hypoglossal nerve. The cavity was obliterated with abdominal fat. Postoperative facial palsy recovered up to H-B grade IV.
Figure 3: A T2 MRI scan of case 2. The internal carotid artery (arrowhead) was involved in a massive cholesteatoma in the petrous apex.
Figure 4: Intraoperative findings in case 2. The cochlea and labyrinth had already been exenterated. The facial nerve was pathologically swollen and blocking the center of the surgical field. Therefore, it was transected.
Case 3
A 60-year-old male, in whom transcochlear removal of the PAC in the right ear followed by hypoglosso-facial anastomosis had been performed 20 years previously, presented with ipsilateral temporal ache and pulsatile tinnitus. He reported total deafness in the right ear. Facial movement was subsequently assessed as H-B grade IV. HRCT and MRI revealed absence of the cochlea and labyrinth and the recurrence of a large cystic mass in the petrous apex with exposure of the ICA (Figure 5). After removal of adipose tissue from the previous surgery, total removal of the PAC was achieved with comparatively less difficulty. The facial nerve presented no obstacle during surgery. Wide surgical access enabled relatively good control of the ICA (Figure 6). Facial movement of H-B grade IV was maintained after surgery.
Figure 5: A T2 MRI scan of case 3. A recurrent lesion was observed medial to the adipose tissue invading the internal carotid artery (arrowhead).
Figure 6: Intraoperative findings of case 3 showing manipulation of the cholesteatoma. The remaining matrices of the cholesteatoma were relatively easily separated from the internal carotid artery (ICA). PFD: posterior fossa dura.


Congenital cholesteatoma in the petrous apex grows insidiously and frequently extends to destroy the cochlea and labyrinth, involving the facial nerve and ICA. This type of PAC is classified as ‘massive labyrinthine-apical’ in Moffat-Smith’s classification and ‘massive complex’ in Sanna’s [1-4]. Although total removal of cholesteatoma is the goal of treatment regardless of tumor size and location, massive PAC is difficult to remove and obliterate. The transotic approach is mainly selected in cases of PAC with profound deafness for preservation of the facial nerve when the position of the facial nerve can be retained. In contrast, the transcochlear approach [5] provides better access to the petrous apex; however, sacrificing the facial nerve may be necessary using this method, which involves posterior rerouting or tentative transection followed by reapproximation.
Posterior rerouting and tentative transection of the facial nerve never results in facial function of more than grade III [6,7] and outcomes using these techniques cannot be promised. Therefore, the transotic approach was selected in case 1. Furthermore, the patient’s strong desire to retain facial movement and preserve tongue function contributed to the decision to utilize this approach. Facial movement was therefore maintained at H-B grade III. However, the surgical view of the petrous apex was so limited that exteriorization of the complex cholesteatoma became necessary [8]. In contrast, transcochlear removal and reconstruction using hypoglosso-facial anastomosis were performed in case 2 because preoperative facial nerve function was minimal. According to Peitersen [9], recovery of facial movement begins within 5 months in cases with Bell’s palsy. Because the patient in case 2 had a history of severe facial paralysis for over 6 months, regeneration of the facial nerve up to grade III would not be expected even using the transotic approach. Furthermore, the facial nerve was observed to be pathologically swollen during surgery. Its location in the center of the surgical field led to the decision to perform transection followed by hypoglosso-facial anastomosis. This strategy was believed to result in better postoperative facial movement [10,11]. Consequently, transection of the facial nerve provided far better access to the petrous apex, where the ICA involved in the PAC could be easily reached.
In case 3, recurrent PAC occurred. This case was an example of the benefit of transcochlear removal with hypoglosso-facial anastomosis. Complex cases of massive PAC would always be at a risk of recurrence in the future, even if every effort toward complete resection is made. In case 3, the facial nerve had been removed during a previous surgery. Therefore, wide access was obtained after removal of the adipose tissue, and the ICA was relatively easily controlled. The first surgery with hypoglosso-facial anastomosis was performed at the age of 40 in case 3, and grade IV facial movement and no serious tongue malfunction had been observed postoperatively. Tongue malfunction after hypoglosso-facial anastomosis is believed to be lower in younger patients [10,11]. In addition, no change in grade IV facial function would be expected even after removal of recurrent lesions because the extratemporal site of the anastomosis would not be affected by the second surgery. Therefore, the transcochlear approach may be taken an account into the first line of the treatment for a young case with complex massive PAC.


Complex cases with massive PAC present particular surgical challenges. The transotic or transcochlear approach may be selected on the basis of the patient’s background and preoperative facial nerve function.


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