Petrous bone cholesteatoma: classification, management and review of the literature.

OBJECTIVE: To discuss the classification of petrous bone cholesteatoma (PBC) and add a subclassification; to review the existing literature and to propose the ideal surgical management of PBC based upon the experience of the largest series published in the literature until now. STUDY DESIGN: Retrospective analysis. SETTING: Quaternary referral neuro-otologic private practice. MATERIALS AND METHODS: The data of 129 patients who underwent surgery for PBC between 1979 and 2008 were analyzed with respect to the classification, type of the approach used, facial nerve lesion and its management, recurrences and outcome. RESULTS: Out of the 129 PBC cases 64 were supralabyrinthine, 9 infralabyrinthine, 7 infralabyrinthine-apical, 48 massive and 1 apical. The facial nerve was involved in 95% of the cases. Hearing could not be preserved in 82% of the cases due to the extent of the lesions and the surgical approaches used. The internal carotid artery, jugular bulb and the lower cranial nerves were infrequently involved, but demanded careful identification and meticulous care to avoid complications. Obliteration of the cavities provided a safe solution for protection of the exposed dura and the vital neurovascular structures. Recurrences were observed in 5 cases. CONCLUSION: The classification of PBC is fundamental to choose the appropriate surgical approach; the facial nerve is involved in almost all the cases, radical removal takes priority over hearing preservation and cavity obliteration is important to protect the vital neurovascular structures which may be exposed.