Petrous Apex Final

Approaches to the petrous Apex
Presented by- Maj Pravin Singh Moderator-Surg Capt R K Verma
3/17/2012
ORLHNS-AFMC
Overview
Introduction Anatomy of the petrous apex Lesions of the petrous apex Pre-op evaluation Surgical approaches Complications Recent advances
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Introduction
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Anatomy
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Cell Tracts
The infralabyrinthine tract The posteromedial tract The subarcuate tract The anterior tract The superior tract
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Triangles of the Middle fossa

Anteromedial (Mullan's) Triangle Anterolateral Triangle Posterolateral (Glasscock's) Triangle Posteromedial (Kawase's) Triangle Inferolateral Triangle Inferomedial Triangle
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Lesions of the petrous apex

Cystic Lesions Vascular
Internal Carotid Aneurysm Venous Lake
Solid Lesions Benign

Chondroma Neurofibroma Meningioma Paraganglioma
Nonvascular
Apicitis(abscess) Congenital epidermoid Cholesterol Granuloma Arachanoid Cyst
Malignant
Chondrosarcoma Eosinophilic Granuloma Lymphoma Metastatic
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Cholesterol Granuloma
Most common cystic lesions of petrous apex Also called
Epidermoid cysts Giant cholesterol cysts Mucosal cysts
Not true cysts-no epithelial lining Result of Foreign Body reaction to cholesterol crystals Pathogenesis3/17/2012
haemorrhage blood breakdown cholesterol release Giant ORLHNS-AFMC cell FB reaction
Cholesteatoma
Congenital-epidermoid cysts Retention of epithelial remanants in the region of foramen lacerum Secondary from middle ear Spread via pre existing cell tracts Slowly expanding lesion that progressively erodes the bone of petrous apex
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Mucocele
Slowly expanding cystic lesion Formed by obstruction of mucous lines space containing glandular tissue Common in PNS rarely in pneumatized petrous apex
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Petrous apicitis Suppurative infection Bacteriology Pneumococcus H. Influenza B-haemolytic Streptococcus Staphylococcus sp. Pseudomonas sp
Gradenigo Syndrome Diplopa Otorrhea Retro-orbital pain
Complications Brain abscess Subdural empyema Meningitis Dural sinus thrombosis
Acute/ Chronic Spread of infection into pneumatized apex.

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Management
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Skull Base Osteomyelits

extension of bacterial infection from otitis externa Diabetic, immunocompromised Clinically
Deep pain Refractory Otitis Externa
Common pathogen Pseudomonas Management

Appropriate antibiotic Surgical if evidence of abcess, bony sequestra, necrotic tissue
Chondrosarcoma Slow growing Primary malignancy of bone 5 histologic types

Conventional Myxoid Mesenchymal Clear cell dedifferentiated
Grossly gray,avascular, gelatinous, Surgical excision cornerstone of treatment

Chondroma Rare Locally aggressive Midline lesions Arise from embryologic remanants of lnotocord Grossly Gelatinous, gray, avascular
Histologcally Vacuolated physaliporous cells within myxod matrix Lobulated, cords/ pseudoacini
Meningioma
Arise from arachanoid villi of the meninges Petroclival meningiomas from petroclival synchondrosis
Neurogenic tumours
Schwannomas or Neuromas arising from adjacent cranial nerves
Metastatic lesions
3/17/2012 15 Commonly from ORLHNS-AFMC breast, lung, prostate, melanoma,
Intrapetrous Carotid Aneurysm

Rare Congenital, Acquired-traumatic, mycotic, Inflammatory Angiography confirms diagnosis
Osteodystrophy

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Rare Fibrous dysplasia, Paget`s disease, osteopetrosis Hearing loss Surgical decompression improves hearing
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Clinical Presentation
Hearing loss- most common Vestibular dysfunction Headache Tinnitus Facial spasm Diplopia Facial paralysis Otorrhea
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( Muckle RP, De la Cruz A, Lo WM. Petrous lesions. AM J Otol 1998;19:219-25 )
Imaging
CT MRI Angiography
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Conventional MRA MR Venography CT Angiography/ Venography

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Approaches
Hearing preserving
Infracochlear approach Infralabyrinthine Approach Middle Fossa Approach Transsphenoidal Approach
Non hearing preserving

Translabyrinthine Approach Transotic approach Subtotal Petrosectomy
Infracochlear approach
Advantages
Hearing preserved Preservation of normal middle ear mechanism Dependant drainage Adequate access to petrous apex despite high jugular bulb
Disadvantages
Damage to facial nerve Intimate knowledge of the anatomy required
Incision
Standard postaural
Steps
Musculoperiosteal flap raised Meatotomy done Canal incision at 2 and 10 o`clock given Tympanomeatal flap raised
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Inf bony annulus and floor of EAC drilled Hypotympanic and infra cochlear air cells exposed Chorda Tympani & Facial nerve Identified Landmarks The cochlea The jugular bulb The carotid artery
Landmarks delineated Infracochlear air cells removed Air cell tract followed to the petrous apex Cyst wall opened and contents evacuated
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Drainage silastic tube placed Bony defect repaired TM flap repositioned EAC packed Wound closed in layers Mastoid dressing applied
Infralabyrinthine Approach
Advantages Familiar anatomy Preservation of normal middle ear mechanism Preservation of hearing
Disadvantages Access limited in high jugular bulb Larger lesions cannot be excised
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Incision Standard Postaural
Steps Musculoperiosteal flap raised Cortical mastoidectomy done Vertical portion of facial nerve identified
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Sigmoid sinus and posterior semicircular canal skeletonized Jugular bulb identified Bill`s island left Infalabyrinthine air cell tract followed
Petrous apex reached Cyst wall exposed Opened and drained Silastic catheter placed Wound closed in layers Mastoid dressing
Translabyrinthine Approach
Reintroduced by Hitselberger and House Advantages Greater exposure Drains cysts directly into the bony eustachian tube
Disadvantages Sacrifice hearing Drainage not dependant ORLHNS-AFMC Higher rate of CSF leak
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Incision Postaural C-shaped
Steps Musculoperiosteal flap raised Cortcal mastoidectomy done Posterior fossa dural plate, sigmoid sinus, sinudural angle, antrum and diagatric ridge exposed
Vertical portion of facial nerve identified Facial recess opened and incus removed 3 semicircular canals systematically removed jugular bulb defined IAC delineated
Bone removed superior and inferior to IAC Petrous apex reached Lesion excised/ drained Cavity obliterated Wound closed in layers Mastoid dressing applied
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Transotic/ Transcochlear approach

Extension of translabyrinthine approach Introduced by Fisch Advantage Greater exposure Reduced risk of CSF leak
Disadvantage Sacrifice hearing Facial nerve injury

Incision Postaural c-shaped
Steps Musculoperiosteal flap raised Meatotomy done Canalwall down mastoidectomy done Internal auditory canal skeletonised
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Stapes extracted from oval window Cochlea removed Limits of dissection Facial nerve Jugular bulb Internal carotid artery
Disease extracted Eustachian tube obliterated Cavity obliterated Wound closed in layers 3/17/2012 Mastoid dressing
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Middle Fossa Approach

1904 - Parry 1961 - William House Advantages Greater exposure Preserves hearing Exposes facial nerve
Disadvantages Temporal lobe retraction Risk of CSF fistula

Position
Supine Ear facing upwards
Incision
Vertical 5-6 cm 1cm ant to tragus Superiorly from zygomatic arch
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Steps Fascia and temporalis muscle split Retracted Square bone flap 3cmm x 3cm Upper limitsquamous suture One third post and two third ant to EAC
Temporal lobe elevated Foramen spinosum, arcuate eminance exposed GSPN identifed Traced to geniculate ganglion
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Kawase triangle Identified GSPN preserved/ resected Bone removed ant to cochlea Lesion exposed Drainage/excision Stenting Closure 3/17/2012 ORLHNS-AFMC Pressure dressing
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Transsphenoidal Approach
Large cysts in proximity to post wall Advantages Preservation of hearing
Disadvantage Increased risk to carotid artery Risk of damage to the the optic nerve
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Steps
Posterior wall of sphenoid sinus exposed Endospic assistance can be taken Cruciate incision made on post sphenoid wall Mucoperiosteal flap raised Small sphenoidotomy done
The orifice enlarged using pituitary rongeurs Cystic lesion exposed Cyst wall opened Contents drained Nasal cavity packed, spheoid not packed
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Subtotal Petrosectomy
Described by Fisch and Mattox Advantage Full exposure of petrous apex
Disadvantage Hearing is sacrificed
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Incision
Post aural C-shaped
Steps
Musculoperiosteal flap raised Meatotomy done EAC everted & sutured Canal wall down mastoidectomy done
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Remaining EAC skin, Tympanic membrane and annulus removed Air cells removed Bony Labyrinth and Cochlea removed Lesion visualized and removed Remaining middle ear mucosa removed
ET obliterated Cavity obliterated Temporalis muscle flap rotated inferiorly & sutured Wound closed in layers Mastoid dressing applied
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Complications
Hearing loss Cranial Nerve Deficits
III, IV, V, VI , VII
Central Nervous System Sequelae

Injury to temporal lobe Brain abscess Meningitis CSF leaks
Vascular Injury
Jugular bulb Extradural venous bleed
Problems relatedORLHNS-AFMCwound to the 3/17/2012
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Recent Advances
Image guided surgery
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Robotic Surgery
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Bibliography
Scott Brown , 7th Edition Brackmann; Otologic Surgery 3rd Edition Shambaugh; Surgery of the ear 6th Edition Jackler; Neurotology Eugene Myers; Operative Otolaryngology OCNA; 2007, Vol 40, Issue3, Neurotology Greenberg`s textbook of neurosurgery Google Search
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Petrous Apex Final

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Approaches to the petrous Apex

Presented by- Maj Pravin Singh Moderator-Surg Capt R K Verma

Triangles of the Middle fossa

Lesions of the petrous apex

Solid Lesions Benign

haemorrhage blood breakdown cholesterol release Giant ORLHNS-AFMC cell FB reaction

Gradenigo Syndrome Diplopa Otorrhea Retro-orbital pain

Complications Brain abscess Subdural empyema Meningitis Dural sinus thrombosis

Acute/ Chronic Spread of infection into pneumatized apex.

Skull Base Osteomyelits

Common pathogen Pseudomonas Management

Chondrosarcoma Slow growing Primary malignancy of bone 5 histologic types

Grossly gray,avascular, gelatinous, Surgical excision cornerstone of treatment

Intrapetrous Carotid Aneurysm

( Muckle RP, De la Cruz A, Lo WM. Petrous lesions. AM J Otol 1998;19:219-25 )

Conventional MRA MR Venography CT Angiography/ Venography

Non hearing preserving

Incision Standard Postaural

Incision Postaural C-shaped

Transotic/ Transcochlear approach

Disadvantage Sacrifice hearing Facial nerve injury

Incision Postaural c-shaped

Middle Fossa Approach

Disadvantages Temporal lobe retraction Risk of CSF fistula

Disadvantage Hearing is sacrificed

Central Nervous System Sequelae

Problems relatedORLHNS-AFMCwound to the 3/17/2012

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