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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 3  |  Page : 194-196

A rare case of recurrent massive petrous bone cholesteatoma: Subtotal petrosectomy without blind sac closure


Department of ENT, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission24-Jun-2020
Date of Decision24-Jun-2020
Date of Acceptance19-Jul-2020
Date of Web Publication22-Dec-2020

Correspondence Address:
Dr. Poornima Shankar Bhat
Department of ENT, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Puducherry - 605 107
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_138_20

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  Abstract 


Petrous bone cholesteatoma is a rare challenging disease that accounts for 4%–9% of all petrous bone lesions. Subtotal petrosectomy with mastoid obliteration without blind sac closure is presented here. A 25-year-old female patient presented with right ear discharge for 5 days, with a history of right ear surgery 19 years back. Right ear external auditory canal showed stenosis suggestive of blind sac closure in the past. High resolution computer tomography and magnetic resonance imaging of temporal bones were suggestive of massive cholesteatoma in right petrous bone with extension into the posterior cranial fossa. As the patient refused blind sac closure, the patient underwent right subtotal petrosectomy, with mastoid obliteration, with wide meatoplasty. The patient is on regular follow-up without any complications. Although blind sac closure is routinely done, mastoid obliteration with wide meatoplasty is an alternative method without increased incidence of complications. Early patient reporting and clinical suspicion of recurrence and prompt treatment is facilitated by wide meatoplasty.

Keywords: Cholesteatoma, meatoplasty, subtotal petrosectomy


How to cite this article:
Kaliavaradan S, Bhat PS, Muruganidhi N, Palaniappam S. A rare case of recurrent massive petrous bone cholesteatoma: Subtotal petrosectomy without blind sac closure. Indian J Otol 2020;26:194-6

How to cite this URL:
Kaliavaradan S, Bhat PS, Muruganidhi N, Palaniappam S. A rare case of recurrent massive petrous bone cholesteatoma: Subtotal petrosectomy without blind sac closure. Indian J Otol [serial online] 2020 [cited 2021 Jan 23];26:194-6. Available from: https://www.indianjotol.org/text.asp?2020/26/3/194/304282




  Introduction Top


Petrous bone cholesteatoma is a rare disease that accounts for 4%–9% of all petrous lesions which can be congenital or acquired cholesteatoma.[1] There are many types of petrous apex lesions such as cholesterol granuloma, mucocoele, arachnoid cyst, acoustic neuroma, epidermoid cyst. Incidence rate of congenital cholesteatoma is 2%–5% with a male predominance of 3:1.[2] Petrous bone cholesteatoma is classified according to Sanna's classification.[3] Subtotal petrosectomy was described by Fisch as the complete exenteration of all pneumatic tracts in the temporal bone.[4] Subtotal petrosectomy was performed in this case with mastoid obliteration without blind sac closure.


  Case Report Top


A 25-year-old female patient presented to ear, nose, and throat (ENT) outpatient department of a tertiary care hospital with complaints of scanty, foul-smelling discharge from right ear for 5 days associated with throbbing type of pain in the right ear. She gave a history of mild hearing loss in the right year since childhood. She gave a history of right ear surgery done at the age of 6 years elsewhere. Ear was free of discharge or pain since then. Complete ENT examination revealed purulent discharge in the right external auditory canal suggestive of previous blind sac closure. Tuning fork tests and Pure Tone Audiometry were suggestive of moderate conductive hearing loss in the right ear. Facial nerve and vestibular function tests were normal. The rest of the ear, nose, and throat examination was normal.

High-resolution computed tomography was suggestive of soft tissue lesion in the right mastoid cavity with erosion of tegmen tympani Suggestive of cholesteatoma [Figure 1]. Magnetic resonance imaging brain (plain) was suggestive of a well-defined T1 hypo, T2/STIR hyperintense, fluid-attenuated inversion recovery partially suppressed lesion of size 2.5 cm × 2.7 cm × 2.8 cm noted in the region of right middle ear cavity and mastoid part of temporal bone suggestive of cholesteatoma with erosion of tegmen tympani and extension to posterior cranial fossa [Figure 2].
Figure 1: Soft tissue lesion in the right mastoid cavity with erosion of tegmen tympani Suggestive of cholesteatoma

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Figure 2: Magnetic resonance imaging brain plain shows well-defined T1 hypo, T2/STIR hyperintense, fluid-attenuated inversion recovery partially suppressed lesion of size 2.5 cm × 2.7 cm × 2.8 cm in the right middle ear and mastoid part of temporal bone showing cholesteatoma with tegmen erosion and extension to posterior cranial fossa

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As the patient was not willing for blind sac closure and was not affordable for frequent radiological follow-up, after informed consent, subtotal petrosectomy with mastoid cavity obliteration and wide meatoplasty without blind sac closure was planned.

Intraoperatively, cholesteatomas occupying the retrofacial, perilabyrinthine, perisinus, protympanic areas, and extending over the posterior cranial fossa dura were removed [Figure 3] and [Figure 4]. All mastoid air cells exenterated and mucosa removed. Cavity obliteration was done using abdominal fat and temporalis fascia. Efforts were taken to precisely remove the cholesteatoma without compromising the vital structures. Postoperative events were uneventful and the patient was followed up regularly with healthy mastoid cavity.
Figure 3: Extensive cholesteatoma

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Figure 4: Cholesteatoma removing from facial nerve and labyrinth

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  Discussion Top


Cholesteatoma is classified as congenital and acquired. Congenital type is a first branchial arch remnant. Many theories had been put forward for the development of acquired cholesteatoma, namely invagination, immigration, basal hyperplasia, squamous metaplasia, and posttraumatic/postsurgery theory.[5],[6]

In a study of 200 patients with petrous bone cholesteatoma, supralabyrinthine was the most common type (45.8%), followed by the massive Petrous Bone Cholesteatomas (PBCs) (35.8%). Preservation of preoperative FN function was highest in the infralabyrinthine (72.2%) and infralabyrinthine apical (73.3%) types.[7] In our case, it was a massive petrous bone cholesteatoma, with facial nerve preservation.

The present case had a history of ear surgery at the age of 6 years, which indicates that it could be a case of congenital cholesteatoma, for which surgery with blind sac closure was done in the childhood. The patient did not follow up regularly due to absence of ear discharge.

In a large study of 460 cases of subtotal petrosectomy performed for various indications, recidivism and postauricular wound fistula were the most common complications (1.1%) in patients.[8]

Patel et al. noted in their study that, although blind sac closure of the external ear canal is a functionally useful procedure, it is associated with a significant rate of complications. In particular, they noted a higher rate of residual cholesteatoma.[9] In our case, postoperative period was uneventful. Long-term follow-up is required to look for recurrence.

As the patient did not want blind sac closure, subtotal petrosectomy with mastoid obliteration with wide meatoplasty was done. The patient is on regular follow-up without any complications.


  Conclusion Top


Petrous bone cholesteatoma is a rare pathology, with a tendency for recidivism. Complete exenteration of the disease should be done. Although blind sac closure is routinely done, mastoid obliteration with wide meatoplasty is an alternative method without increased incidence of complications. Early patient reporting and clinical suspicion of recurrence and prompt treatment is facilitated by wide meatoplasty. Further studies are required to compare the long-term outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
King TT, Benjamin JC, Morrison AW. Epidermoid and cholesterol cysts in the apex of the petrous bone. Br J Neurosurg 1989;3:451-61.  Back to cited text no. 1
    
2.
Turhan T, Oner K, Yurtseven T, Akalin T, Ovul I. Spinal meningeal melanocytoma. Report of two cases and review of the literature. J Neurosurg 2004;100:287-90.  Back to cited text no. 2
    
3.
Sanna M, Pandya Y, Mancini F, Sequino G, Piccirillo E. Petrous bone cholesteatoma: Classification, management and review of the literature. Audiol Neurootol 2011;16:124-36.  Back to cited text no. 3
    
4.
Fisch U, Mattox D. Microsurgery of the Skull Base. Germany: Georg Thieme Verlag Stuttgart; 1988.  Back to cited text no. 4
    
5.
Kuo C, Shiao A, Yung M, Sakagami M, Sudhoff H, Wang C et al. Updates and Knowledge Gaps in Cholesteatoma Research. BioMed Research International. 2015;2015:1-17.  Back to cited text no. 5
    
6.
Jackler R, Santa Maria P, Varsak Y, Nguyen A, Blevins N. A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. The Laryngoscope. 2015;125:S1-14.  Back to cited text no. 6
    
7.
Prasad S, Piras G, Piccirillo E, Taibah A, Russo A, He J et al. Surgical Strategy and Facial Nerve Outcomes in Petrous Bone Cholesteatoma. Audiology and Neurotology. 2016;21:275-85.  Back to cited text no. 7
    
8.
Prasad SC, Roustan V, Piras G, Caruso A, Lauda L, Sanna M. Subtotal petrosectomy: Surgical technique, indications, outcomes, and comprehensive review of literature. Laryngoscope 2017;127:2833-42.  Back to cited text no. 8
    
9.
Patel M, Loan FL, Lyon JR, Bird PA. Blind sac closure of the external auditory canal for chronic middle ear disease. Otol Neurotol 2014;35:e36-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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