title: Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Cleveland Clinic Lerner College of Medicine.
authors.forename: Danielle F
authors.initials: DF
authors.lastname: Eytan
authors.forename: Varun R
authors.initials: VR
authors.lastname: Kshettry
authors.forename: Raj
authors.initials: R
authors.lastname: Sindwani
authors.forename: Troy D
authors.initials: TD
authors.lastname: Woodard
authors.forename: Pablo F
authors.initials: PF
authors.lastname: Recinos
mesh_terms: D002784:Cholesterol; D004724:Endoscopy / Q000379:methods*; D006099:Granuloma / Q000601:surgery*; D006801:Humans; D010579:Petrous Bone / Q000601:surgery*; D039781:PubMed / Q000706:statistics & numerical data
chemical_list: D002784:Cholesterol
keywords: ICA = internal carotid artery; OCEBM = Oxford Centre for Evidence Based Medicine; cholesterol granuloma; endonasal; endoscopie; petrous apex; petrous bone