Characteristics and Clinical Management Strategy of Petrous Apex Cholesterol Granulomas

Simple Summary Cholesterol granulomas are cystic lesions that can occur in the temporal bone. When such a lesion is present in the petrous apex, various clinical symptoms can occur due to compression of cranial nerves. Growth is observed in a minority of cases. Therefore, sole wait-and-scan management with intermittent magnetic resonance imaging during follow-up can be sufficient. Surgical drainage of the lesion is considered in case of severe symptomatology or growth. The aim of this consecutive case series was to evaluate the clinical characteristics of petrous apex cholesterol granulomas and outcomes after different management strategies. We confirm that PACGs are slow-growing lesions with a low risk of adverse events. Solely using the wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms and without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth. Purpose: To evaluate the clinical characteristics of petrous apex cholesterol granulomas (PACG) and assess outcomes after different treatment strategies. Method: A consecutive case series of 34 patients with a PACG. Main outcomes were PACG growth, symptoms, and the outcomes of different treatment strategies: wait-and-scan (WS) and surgical drainage. Results: Thirty-four patients were analyzed; mean follow-up time was 7.1 years. Twenty-one patients (61.7%) showed symptoms, mostly more than one. Most symptoms reported were cranial nerve palsy (58.8%) and headache (35.3%). Twenty-one patients (61.8%) received solely wait-and-scan (WS), and thirteen patients (38.2%) underwent surgery, five of whom (38.5%) after an initial WS period. In the solely WS group, one (4.8%) developed new symptoms, and two (9.5%) reported symptom progression despite a stable granuloma size. Two (9.5%) showed granuloma growth on follow-up scans without symptom progression. Surgery consisted of drainage. Eleven (84.6%) of these thirteen patients reported partial recovery; one (7.7%) reported no recovery; and one (7.7%) reported full recovery of reported symptoms related to PACG. Among the patients with cranial nerve involvement, 7.7% showed full recovery after surgery; 84.6% showed partial recovery; and 7.7% did not recover. Adverse events occurred in five out of 13 patients who underwent surgery, all with full recovery. Conclusions: This study confirms that PACG are slow-growing lesions with a low risk of adverse events. Solely using wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth.