eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Skull Base

Skull Base, Petrous Apex, Tumors: Follow-up

Author: Michael J Fucci, MD, Medical Director, Arizona Hearing and Balance Center
Contributor Information and Disclosures

Updated: Jul 2, 2009

Future and Controversies

Continual improvements in surgical techniques, imaging studies, intraoperative monitoring, and improved antimicrobials should decrease the morbidity and mortality of petrous apex surgery. Neurootologists and neurosurgeons have specialized training in treatment of these unusual disorders, so the operators are more experienced. Centers for skull base surgery are developing where petrous apex lesions could be sent. This will possibly allow pooling of these rare tumors, so that the centers would have increased experience and presumably increased expertise.

Cochlear implants now provide hearing in previously deaf individuals with an intact cochlea and cochlear nerve. Auditory brainstem implants to provide hearing in deaf individuals with no cochlear nerve by directly stimulating the cochlear nuclei are in development. An increased understanding of the vestibular system is possible through basic science research and through the space program, where scientists can study the effects of weightlessness on the vestibular system.

In 1968, the Karolinska Institute in Stockholm first used gamma stereotactic radiation to treat brain tumors. In 1987, the University of Pittsburgh School of Medicine became the first center in the United States to use gamma stereotactic radiation from cobalt-60 sources to treat brain tumors. Several published studies now suggest that certain intracranial neoplasms are best treated with stereotactic radiation rather than microsurgery. Recent studies have suggested that gamma stereotactic radiation prevents growth of acoustic neuromas in more than 90% of cases. Some studies suggest that, in selected populations, more than 70% of untreated acoustic neuromas do not grow. Nevertheless, gamma stereotactic radiation offers promise in treating petrous apex neoplasms. Studies are underway to determine whether stereotactic radiation is more therapeutically effective and economical than microsurgery. This controversy continues.

Medicolegal pitfalls
  • Obtain informed consent: Medicolegal issues often involve informed consent. The patient must be informed of all potential risks. A typewritten sheet that explains all risks and requires the patient's signature in addition to the standard hospital surgical consent form improves the patient's understanding of the potential consequences. Explain the risks with a family member present because the patient's understanding may be impaired due to emotional consequences.
  • Know and practice the standard of care: Standard of care issues are also significant medicolegal pitfalls. Use of a facial nerve monitor, an operating microscope, and the assistance of a neurosurgeon are often considered the standard of care. Close supervision of residents and fellows is critical to provide excellent education without sacrificing quality patient care.
  • Recognize limitations and obtain second opinions: Most attorneys scrutinize experience in treating these tumors. Do not risk performing these complicated operations without significant experience. Physicians are under ever-increasing pressure from insurance companies to perform operations that they would rather refer out because their more experienced colleague is not on the insurance panel. Avoid the pressure and refer out of network. Physicians rarely regret referring cases to more experienced colleagues. Realizing limitations and putting patient care at the pinnacle of the decision tree demonstrates excellent judgment.
  • Keep impeccable records: Carefully document all interactions with patients. Remember that if it was not recorded, it did not take place. Document follow-up recommendations, such as recommendation to return in 2 weeks if symptoms persist or patient refusal of tests such as MRI recommended for asymmetric hearing loss. Record missed appointments, cancellations, and phone conversations. Never, under any circumstances, alter a record. A case is indefensible if the record is altered.


 


More on Skull Base, Petrous Apex, Tumors

Overview: Skull Base, Petrous Apex, Tumors
Workup: Skull Base, Petrous Apex, Tumors
Treatment: Skull Base, Petrous Apex, Tumors
Follow-up: Skull Base, Petrous Apex, Tumors
Multimedia: Skull Base, Petrous Apex, Tumors
References
[ CLOSE WINDOW ]

References

  1. Gradenigo G. Sulla leptominingite circiscritta e sulla paralisi dell' abducente di origine otitica. G Acad Med Torino. 1904;10:59.

  2. Lindsay JR. Suppuration of the petrous apex. Ann Otol Rhinol Laryngol. 1938;47:3-36.

  3. Lindsay JR. Petrous pyramid of temporal bone: Pneumatization and roentgenologic appearance. Arch Otolaryngol. 1940;31:231-235.

  4. Jacob CE, Rupa V. Infralabyrinthine approach to the petrous apex. Clin Anat. Sep 2005;18(6):423-7. [Medline].

  5. Jackler RK, Parker DA. Radiographic differential diagnosis of petrous apex lesions. Am J Otol. Nov 1992;13(6):561-74. [Medline].

  6. Montgomery MM. Cystic lesions of the petrous apex: transphenoidal approach. Ann Otol. 1977;86:429-435.

  7. Fucci MJ, Romanczuk BJ, Bell RD. Superior sagittal sinus thrombosis after radical neck dissection. Skull Base Surgery. 1994;4(1):41-45.

  8. Giddings NA, Brackmann DE, Kwartler JA. Transcanal infracochlear approach to the petrous apex. Otolaryngol Head Neck Surg. Jan 1991;104(1):29-36. [Medline].

  9. Leonetti JP, Anderson DE, Marzo SJ, Origitano TC, Schuman R. The preauricular subtemporal approach for transcranial petrous apex tumors. Otol Neurotol. Apr 2008;29(3):380-3. [Medline].

  10. Bootz F, Keiner S, Schulz T, Scheffler B, Seifert V. Magnetic resonance imaging--guided biopsies of the petrous apex and petroclival region. Otol Neurotol. May 2001;22(3):383-8. [Medline].

  11. Borba LA, Ale-Bark S, London C. Surgical treatment of glomus jugulare tumors without rerouting of the facial nerve: an infralabyrinthine approach. Neurosurg Focus. Aug 15 2004;17(2):E8. [Medline].

  12. Brackmann DE, Toh EH. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol. Jul 2002;23(4):529-33. [Medline].

  13. Castillo MP, Samy RN, Isaacson B, Roland PS. Petrous apex cholesterol granuloma aeration: does it matter?. Otolaryngol Head Neck Surg. Apr 2008;138(4):518-22. [Medline].

  14. Chandler JR. Malignant external otitis. Laryngoscope. Aug 1968;78(8):1257-94. [Medline].

  15. Chang P, Fagan PA, Atlas MD, Roche J. Imaging destructive lesions of the petrous apex. Laryngoscope. Apr 1998;108(4 Pt 1):599-604. [Medline].

  16. Chole RA. Petrous apicitis: surgical anatomy. Ann Otol Rhinol Laryngol. May-Jun 1985;94(3):251-7. [Medline].

  17. Constantino PD, Wolpoe ME. Complications in skull base surgery: prevention, recognition and management. In: Arriaga MA, Day FD, eds. Neurosurgical Issues in Otolaryngology. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1999:95-106.

  18. Curtin HD, Som PM. The petrous apex. Otolaryngol Clin North Am. Jun 1995;28(3):473-96. [Medline].

  19. Fong BP, Brackmann DE, Telischi FF. The long-term follow-up of drainage procedures for petrous apex cholesterol granulomas. Arch Otolaryngol Head Neck Surg. Apr 1995;121(4):426-30. [Medline].

  20. Fucci MJ, Alford EL, Lowry LD. Endoscopic management of a giant cholesterol cyst of the petrous apex. Skull Base Surgery. 1994;41(1):52-58.

  21. Fucci MJ, Buchman CA, Brackmann DE, Berliner KI. Acoustic tumor growth: implications for treatment choices. Am J Otol. Jul 1999;20(4):495-9. [Medline].

  22. Fucci MJ, Buchman CA, Slattery III WH. Neurorrhaphy techniques for facial paralysis. Facial Plastic Surgery Clin N Am. 1997;5(3):223-240.

  23. Graham MD, Kemink JL, Latack JT, Kartush JM. The giant cholesterol cyst of the petrous apex: a distinct clinical entity. Laryngoscope. Nov 1985;95(11):1401-6. [Medline].

  24. Hendershot EL, Wood JW, Bennhoff D. The middle cranial fossa approach to the petrous apex. Laryngoscope. May 1976;86(5):658-63. [Medline].

  25. House WF. Surgical exposure of the internal auditory canal and its contents through the middle, cranial fossa. Laryngoscope. Nov 1961;71:1363-85. [Medline].

  26. House WF, Hitselberger WE. The transcochlear approach to the skull base. Arch Otolaryngol. Jun 1976;102(6):334-42. [Medline].

  27. Isaacson B, Kutz JW, Roland PS. Lesions of the petrous apex: diagnosis and management. Otolaryngol Clin North Am. Jun 2007;40(3):479-519, viii. [Medline].

  28. Kondziolka D, Lunsford LD, Flickinger JC. Acoustic neuroma radiosurgery. Origins, contemporary use and future expectations. Neurochirurgie. Jun 2004;50(2-3 Pt 2):427-35. [Medline].

  29. Lee YH, Lee NJ, Kim JH, Song JJ. CT, MRI and gallium SPECT in the diagnosis and treatment of petrous apicitis presenting as multiple cranial neuropathies. Br J Radiol. Oct 2005;78(934):948-51. [Medline].

  30. Leksell L. Stereotactic radiosurgery. J Neurol Neurosurg Psychiatry. Sep 1983;46(9):797-803. [Medline].

  31. Lunsford LD, Flickinger J, Lindner G, Maitz A. Stereotactic radiosurgery of the brain using the first United States 201 cobalt-60 source gamma knife. Neurosurgery. Feb 1989;24(2):151-9. [Medline].

  32. Mattox DE. Endoscopy-assisted surgery of the petrous apex. Otolaryngol Head Neck Surg. Feb 2004;130(2):229-41. [Medline].

  33. Muckle RP, De la Cruz A, Lo WM. Petrous apex lesions. Am J Otol. Mar 1998;19(2):219-25. [Medline].

  34. Presutti L, Villari D, Marchioni D. Petrous apex cholesterol granuloma: transsphenoid endoscopic approach. J Laryngol Otol. Jun 2006;120(6):e20. [Medline].

  35. Proctor B. Surgical anatomy of the ear and temporal bone. New York, NY: Thieme; 1989.

  36. Rohde V, Spangenberg P, Mayfrank L, Reinges M, Gilsbach JM, Coenen VA. Advanced neuronavigation in skull base tumors and vascular lesions. Minim Invasive Neurosurg. Feb 2005;48(1):13-8. [Medline].

  37. Schipper J, Ridder GJ, Maier W, Spetzger U. [The anterosigmoidal approach. A function-preserving surgical method for petroclival tumors]. HNO. Nov 2004;52(11):984-7, 990-4. [Medline].

  38. Thedinger BA, Jackler RK. Lesions of the petrous apex. In: Jackler RK, Brackmann DE, eds. Neurotology. St Louis, Mo: Mosby; 1994:1069-1188.

  39. Visosky AM, Isaacson B, Oghalai JS. Circumferential petrosectomy for petrous apicitis and cranial base osteomyelitis. Otol Neurotol. Oct 2006;27(7):1003-13. [Medline].

  40. Weinig BM. Atlas of head and neck pathology. New York, NY: Thieme; 1989.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

petrous apicitis, Gradenigo syndrome, Gradenigo's syndrome, giant cholesterol cyst of petrous apex, cholesterol granuloma of petrous apex, petrous apex schwannoma, clivus chordoma, clivus chondrosarcoma, petrous apex cholesteatoma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael J Fucci, MD, Medical Director, Arizona Hearing and Balance Center
Michael J Fucci, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Neurotology Society, and Arizona Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Douglas D Backous, MD, Director of Listen for Life Center, Department of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center
Douglas D Backous, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Association for Research in Otolaryngology, North American Skull Base Society, Society for Neuroscience, and Washington State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gerard J Gianoli, MD, Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center
Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.