Surgical Management Of Petrous Bone Cholesteatoma And Preservation Of Facial Nerve Function

Petrous bone cholesteatoma is located in the deep of the petrous portion of thetemporal bone.It is a rare pathologic entity with a reported incidence of4-9%of allpetrous pyramid lesion. Petrous bone cholesteatoma is a benign leasion.This pathologyis generally a slow-growing lesion that may remain asymptomatic for years. Followingthe development of the disease, the lision will invade the facial nerve and the labyrinth,leading facial palsy and hearing loss. In this study, surgical practice of PBC weresummarized up13years, summarize the clinicalmanifestations, surgical experience,recovery of facial nerve function postoperation, and analyze the relevant factor ofcomplication and treatment measure. In the end, provide a more reasonabletherapeutically to improve patient’s living quality.Part one: the diagnose of petrous bone cholesteatomaA retrospective case study was performed on78patients diagnosed and treated forpetrous bone cholesteatoma from1/1/00till31/12/12by the PLA general hospitalotolaryngologist.There was1patient with bilateral PBC,hence the totoal number ofcases was79. There were52males and27females.The clinical symptoms:hearing lossis77cases,followed by facial palsy60cases,otorrhea45cases,tinnitus23cases,vertigo17cases, headache13cases; oculomotor nerve palsy,abducens nerve palsy andhypoglossal nerve palsy occurred in two patient.Trigeminal nerve occurred in6cases.Give the facial nerve function preoperation of the seventy–nine cases with somerelevant factors use the single factor chi-square analysis. Only the duration ofpreoperation deficit duration was found to be significantly different. The duration underhalf the year compared to0.5~1year and under half the year compred to more than oneyear has the most significantly different. And use the sperman correlation test with preoperation deficit duration, found that as the duration extension, the facial nervefunction is getting worse gradually. And the0.5yeaar is the most critical time. Use thesperman test with preoperation hearing level and the course, found that as the durationextension, the hearing level is graduallydeclined. And the PBC cause of the parting andwhether it facial palsy or not was found to be significantly different, and compared tothe acquired PBC, the congenital PBC have the higher risk to get the facial palsy.In conclusion, PBC is a very rare disease, and have a lower incidence. The mostcommon clinic feature is the hearing loss, and following is facial palsy. As the courseextension, the hearing loss and facial palsy will getting worse. Especially0.5year is themost important time to the facial palsy. There have the significant different between lessthan0.5year and more than0.5year. This means that patient should seeing a doctorimmediately when facial palsy occurred, and early diagnosed. The congenital PBChave the higher risk to get the facial palsy. When the patient have the symptom likehearing loss and facial palsy, doctor should remember to give them the CT test oftemporal bone and head MRI to exclude the exist of PBC.Part two: surgical management of petrous bone cholesteatoma and dealing in thesurgeryA retrospective case study was performed on78patients diagnosed and treated forpetrous bone cholesteatoma from1/1/00till31/12/12by the PLA general hospitalotolaryngologist.According to Sanna’s classification, supralabyrinthine cholesteatoaaffected40ears, infralabyrinthine,infralabyrinthine–apical,massive,apicalcholesteatoma were found in two,seven,17,11,respectively.Nine patients underwenttransmastoid approach, translabyrinthine approach was performed on twenty-fourpatients, thirty-six patients underwent middle fossa approach, mastoid and middle fossaapproach was performed on nine patients and mastoid and sphenoid sinus approach wasperformed on only one patient.In conclusion, translabyrinthine approach is the basic approach, especially fit forthe poor hearing preoperation cases. Middle fossa approach is fit for the supralabyrinthine PBC. Combined transmastoid/middle fossa approach is used for thePBC with middle ear mastoid extension. The choice of the massive PBC is more.During the surgery, carefully dealing with the lesion on the surface of the labyrinthine,dura, ICA and jugular vein, and prevent the occurrence of the the most seriouscomplication.Part three：preservation and recovery postoperation of facial nerve function duringthe operation.A retrospective case study was performed on78patients diagnosed and treated forpetrous bone cholesteatoma from1/1/00till31/12/12by the PLA general hospitalotolaryngologist.Facial nerve decompression was performed in48cases,end-endanastomosis was done in5cases,rerouting of facial nerve was done in3cases,greatauricular nerve graft was performed in10cases,facial-hypoglossal anastomosis wasperformed in10cases.Out of the79cases48cases had a minimum follow-up of1year. Postoperatively,93.75%of the cases preserved the facial nerve function gradeⅠ. Out of the32facialpalsy patients preoperatively28cases (87.5%) facial nerve function gainedpostoperatively.Four cases stayed the same postoperatively. The preoperation of facialnerve function is grade1sixteen cases, grade2only1case, grade3seven cases, grade4only two cases, grade5forty cases, grade6eight cases. And postoperation grade1~6isrespectively twenty–four, three, seven, nine, four, one.The preoperation of facial nerve function is gradeⅠhas sixteen cases, grade Ⅱhasonly1case, grade Ⅲ has seven cases, grade Ⅳ only two cases, grade Ⅴ has fortycases, grade Ⅵ has eight cases. And postoperation grade Ⅰ~Ⅵ is respectivelytwenty–four, three, seven, nine, four, one.The difference between preoperation and the postoperation facial nerve functionhas the significant difference. And the deficit duration of facial palsy less than0.5yearand0.5~1year, less than0.5year and more than1year were found to be significantlydifferent. In inclusion, facial palsy is one of the most important symptoms. The preservationof facial nerve palsy postoperation is98.73%, and the preservation of facial nervefunction grade Ⅰis94.12%. The better facial nerve function preoperative, the betteroutcomes we have. And six month is the most important factor after facial palsy. Thatmeans patient should seeing a doctor as soon as possible when they get facial palsy, anddoctor should do their best to diagnose PBC as early as possible. During the operation,doctor should protect the facial nerve as possible as they could.Part four:surgical complication, recurrence of petrous bone cholesteatomarecurrence and the dealing methodA retrospective case study was performed on78patients diagnosed and treated forpetrous bone cholesteatoma from1/1/00till31/12/12by the PLA general hospitalotolaryngologist.Postoperatively complications are followed by recurrence was noted in3cases, cavity infection in4cases, CSF leak in3cases.Give the history of surgerycavity infection use the single factor chi-square analysis. And it has the significantdifference between them, means that patient who has a history of surgery in the sameear has the higher recurrence rate.As the science developed, the complication postoperation is getting down. Thedecline of the complication is relevant with the technique and experience of the surgeon.And cases with the higher recurrence factor must be follow up regularly, and detect therecurrence as soon as possible.