title: Endoscopic transsphenoidal drainage of an aggressive petrous apex cholesterol granuloma: unusual complications and lessons learnt.
abstract: OBJECTIVE
  This case report describes the endoscopic transsphenoidal management of a cholesterol granuloma situated in a technically challenging part of the petrous apex, and the associated peri- and post-operative complications that arose. The literature on diagnosis and management of petrous apex cholesterol granulomas is reviewed.
  
  
  RESULTS
  Surgical intervention was attempted on three occasions, each time via an endoscopic, transsphenoidal approach with image guidance. The procedure was abandoned on the first occasion as there was a significant risk to the carotid artery; only a small drainage ostium was created because of the proximity of the carotid artery. The second attempt, complicated by copious bleeding from the clival venous plexus, was arrested prematurely. Successful drainage was achieved at the third attempt, but recovery was complicated by tension pneumocephalus.
  
  
  CONCLUSIONS
  The transnasal route is less invasive than a lateral labyrinthine or cochlear approach, and spares cochlear and vestibular function. However, this approach is not without risk. It is important to consider the natural anatomical variance of vasculature when planning surgical intervention for a lesion situated in a technically challenging part of the petrous apex. Additional magnetic resonance venography is recommended to circumnavigate the venous plexus, thereby avoiding an unexpected breach.
authors.affiliation: Department of Otolaryngology, Charing Cross Hospital, London, UK.
authors.forename: K C
authors.initials: KC
authors.lastname: Park
authors.affiliation: Department of Otolaryngology, Charing Cross Hospital, London, UK.
authors.forename: G
authors.initials: G
authors.lastname: Wong
authors.affiliation: Department of Otolaryngology, Charing Cross Hospital, London, UK.
authors.forename: J C
authors.initials: JC
authors.lastname: Stephens
authors.affiliation: Department of Otolaryngology, Charing Cross Hospital, London, UK.
authors.forename: H A
authors.initials: HA
authors.lastname: Saleh
mesh_terms: D002784:Cholesterol; D004322:Drainage / Q000009:adverse effects / Q000379:methods*; D005260:Female; D015745:Granuloma, Foreign-Body / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects / Q000379:methods; D010579:Petrous Bone / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D011007:Pneumocephalus / Q000209:etiology / Q000628:therapy; D013101:Sphenoid Sinus; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D002784:Cholesterol