Cholesterol Granuloma Research Articles

Indocyanine Green Angiography–Assisted Marsupialization of a Petrous Apex Cholesterol Granuloma: 2-Dimensional Operative Video

Indocyanine Green Angiography–Assisted Marsupialization of a Petrous Apex Cholesterol Granuloma: 2-Dimensional Operative Video

Role of High-Resolution Computed Tomography in Classifying Pneumatization of the Temporal Bone: Typical Patterns, Prevalence, and Implications

Introduction: Pneumatization patterns in the temporal bone have been implicated in the prognostic outcomes of various pathological conditions, such as cholesterol granulomas, otitis media, and cholesteatomas. This study investigated how high-resolution computed tomography (HRCT) helps to classify pneumatization patterns in the temporal bone, exploring its impact on the pathogenesis, surgical outcomes of temporal bone diseases, and its association with age and gender. Methods: HRCT of temporal bone of fifty patients of age 13 years and more with normal findings were included. The petrous apex, mastoid, and infra-labyrinthine regions’ pneumatization patterns were categorized using previously published grading methods. Results: The dominant pattern of pneumatization in the petrous apex was classified as group 2, indicating that less than 50% of the pneumatization was located medially in the labyrinth. Conversely, in the mastoid, the prevailing pattern was group 4, which signifies hyper-pneumatization. In the infra-labyrinthine region, the prevailing pattern was categorized as type B, indicating limited pneumatization. It was found that patients who exhibited augmented pneumatization in one compartment of the temporal bone tended to display similar changes on the opposite side and in other compartments on the same side (P < 0.05). Importantly, it was observed that younger age (P < 0.001) and male gender (P = 0.001) were associated with increased pneumatization in the petrous apex and infra-labyrinthine compartments. Conclusion: Different compartments of temporal bone show varying degrees of pneumatization. The level of pneumatization of the temporal bone is highly associated with age and sex.

Orbital emphysema following orbital cholesterol granuloma surgery

A 50-year-old male presented with complaints of gradually progressive prominence of the left eye associated with a diminution of vision. Magnetic resonance imaging showed a well-circumscribed extraconal mass arising from the intradiploic space with erosion and thinning of the orbital roof. Excision and complete curettage were performed. On the 11th postoperative day, the patient presented with gross proptosis, ballooning of the conjunctiva, and exposure keratopathy following forceful nose blowing. An urgent computed tomography scan revealed an orbital emphysema, and a needle orbital decompression was performed. The patient improved clinically and radiologically with nil recurrence at follow-up. Orbital emphysema post-surgery, though rare, should be considered as a differential of acute-onset postoperative proptosis. Patients should be advised to avoid forceful blowing of nose or any Valsalva maneuver to prevent such a complication.

Cholesterol granuloma of the maxillary sinus: a case report

BackgroundCholesterol granuloma is not a common entity in the paranasal sinuses. It is a foreign body reaction to the cholesterol crystal deposition. Mostly associated with chronic middle ear diseases.Case presentationThis article reports a case of cholesterol granuloma in the maxillary sinus. A 23-year-old Asian man presented with cough, nasal obstruction, and postnasal discharge. On endoscopy, there was a mass protruding from the right maxillary ostium. On computed tomograpy imaging, there was a polypoidal mass in the right maxillary sinus. Endoscopic sinus surgery was performed, the cholesterol granuloma was removed from the right maxillary sinus, and the tissue was submitted for histopathological examination, which showed foreign body giant cell reaction to cholesterol crystals.ConclusionCholesterol granuloma of maxillary sinus is not common and often missed by clinicians. It is necessary to consider the cholesterol granuloma of maxillary sinus in the differential diagnosis sinonasal lesions. Histopathological analysis is required for confirmation and should be removed surgically. This case may help as a reference for clinician to approach these kinds of cases.

A report on five cases of cholesterol granulomas in the thymus

BackgroundCholesterol granuloma (CG) is a benign entity characterized by the presence of cholesterol crystals and foreign body giant cells. This condition can be attributed to cholesterol crystals that are deposited in the tissues and react with foreign body giant cells, resulting in granuloma formation. Lesions commonly develop in the otolaryngeal region, such as the middle ear. However, crystals rarely form in the thymus, accounting for 1% of all mediastinal tumors. Herein, we present five cases of mediastinal CG.Case presentationThe patients were aged 49–61 (mean, 55.4) years. Among them, three were men and two women. One patient had fever, and four patients were asymptomatic. The patients’ lesions were detected during follow-up of other diseases or medical examinations showing the presence of abnormal chest shadows. The patients did not have a history of trauma or surgery. All lesions were located within the thymus gland. Three patients presented with multifocal lesions and two with a single lesion. Four patients had contrast effect on computed tomography scan. Four patients had abnormal fluorodeoxyglucose accumulation (mean maximum standardized uptake value, 4.67) on positron emission tomography-computed tomography. Four patients underwent complete surgical resection. The size of the resected lesions ranged from 1.8 to 5.1 (mean, 3.24) cm. Histologically, all patients presented with small nodules with cholesterol clefts and foreign body giant cells and histiocyte infiltration within the thymic tissue. The postoperative course was excellent. None of the patients who underwent complete resection presented with recurrence. Moreover, the patient who underwent partial resection did not have lesion enlargement.ConclusionsCG in the thymus is clinically challenging to differentiate from malignant lesions, and histologic diagnosis via surgical resection is required.

Identification of apolipoprotein E-derived amyloid within cholesterol granulomas of leopard geckos (Eublepharis macularius)

Apolipoprotein E (ApoE) is involved in cholesterol transport among cells and also plays an important role in amyloid formation, co-depositing with amyloid fibrils in various types of amyloidosis. Although the in vivo amyloidogenicity of ApoE has not been previously demonstrated, this study provides evidence of ApoE amyloidogenicity in leopard geckos (Eublepharis macularius), belonging to the class Reptilia. Histologically, amyloid deposits were localized within cholesterol granulomas and exhibited positive Congo red staining, with yellow to green birefringence under polarized light. On mass spectrometry-based proteomic analysis, ApoE was detected as a dominant component of amyloid; of the full length of the 274 amino acid residues, peptides derived from Leu185-Arg230 were frequently detected with non-tryptic truncations. Immunohistochemistry with anti-leopard gecko ApoE antibody showed positive reactions of amyloid deposits. These results show that ApoE is an amyloid precursor protein within the cholesterol granulomas of leopard geckos. Although further investigations are needed, the C-terminal region of ApoE involved in amyloid formation is a lipid-binding region, and there should be a relationship between amyloidogenesis and the development of cholesterol granulomas in leopard geckos. This study provides novel insights into the pathogenesis of ApoE-related diseases.

Cholesterol granuloma of the Petrous Apex - a rare disease

Cholesterol granuloma of the Petrous Apex - a rare disease

Orbital Cholesterol Granuloma : A Rare Case Report.

Cholesterol Granuloma is a rare lesion which occurs at locations like ear, peritoneum, lungs, breast etc. and formed due to interaction of Cholesterol and living tissue. But Cholesterol Granuloma occurring in the orbit is a very rare entity and so we authors present a case of Cholesterol Granuloma of the orbit.

A Novel Case of Paediatric Petrous Apex Cholesterol Granuloma.

The petrous apex is medial most part of temporal bone, which is surrounded by vital structures. Cholesterol granuloma is the most common benign lesion of the petrous apex. Symptoms are related to mass effect and/or direct involvement of closely adjacent vital structures. The lesions can be manged either by open surgery via craniotomy or through the newer endoscopic approach. Case report and review of the literature concerning cholesterol granulomas of the petrous apex and their management. The lesion was approached endoscopically trans nasal and trans sphenoid and cholesterol granuloma was excised and marsupialised. Post operative patient recovery was uneventful. Endonasal Endoscopic approach has significantly lower complication rate when compared to open approaches. Petrous apex lesions are rare and need a multidisciplinary team approach for optimal management. By endoscopic approach one can remove lesion or marsupialize the sac with natural drainage into sinus and result in better prognosis and minimal chance of recurrence. Endonasal procedure has also lower complication rates and shorter median follow-up than open approaches.

Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma.

Background: Petrous apex cholesterol granulomas (PACGs) are benign inflammatory cystic lesions of the temporal bone. Usually, asymptomatic patients may develop symptoms as the lesions expand. The diagnosis is based on both CT and MRI scans and the management relies on "wait and scan" or surgery. This paper aims at evaluating surgical outcomes and proposing a CT-based classification and a management algorithm. Methods: Patients with PACGs who were surgically treated between 2014 and 2024 were included. Symptoms, imaging, approach type and complications were considered. CT scans were classified as Type A (preserved apex cellularity), Type B (erosion of the apex cellularity), and Type C (involvement of the noble structures bone boundaries). The possible connection of the lesion with the infracochlear, perilabyrinthine and sphenoidal cellularity was assessed. Results: Nineteen patients with symptoms like diplopia, headache and sensorineural hearing loss were included. According to our classification, 1/19 patients was Type A, 4/19 were Type B and 14/19 were Type C. Five patients underwent a total resection, seven a subtotal and seven a surgical drainage. Only two complications were recorded, and 17/19 patients showed symptom regression and stability during follow-up. Conclusions: While the management of PACGs is still controversial, according to our classification and surgical outcomes, Type A, being mostly asymptomatic, should be managed with "wait and scan", Type B should undergo surgery when symptoms are present, while Type C should always undergo surgery because of their invasiveness and potential complications. When possible, a drainage should be attempted; otherwise, a surgical resection is chosen, and its completeness depends on the preoperative general and hearing status.

Ossicular Reconstruction With Various Degrees of Malleus Preservation in Patients With Chronic Otitis Media.

Objective: We examined the relationship between factors of middle ear conditions and the outcome of ossiculoplasty in chronic otitis media (COM) by measuring the improvement in the air-bone gap (ABG) and air conduction threshold (TAC). Methods: This retrospective study analyzed 76 patients (77 ears) who underwent ossiculoplasty from among 520 COM patients who underwent tympanoplasty based on the maximum preservation of the original ossicles. The reconstructed ossicular chain was performed by preserving or utilizing the remaining malleus in all cases with the presence of the malleus manubrium. Patients with eardrum adhesion, cholesteatoma, and cholesterol granuloma were defined as having a compromised middle ear condition (Group A), and those without as having an uncompromised middle ear condition (Group B). In each group, pure-tone audiometry was performed preoperatively and postoperatively, and improvements in the ABG and TAC were compared. The effects of the types of tympanoplasty and the method of ossiculoplasty (columella versus incus interposition) on postoperative ABG and TAC were also compared. Results: The postoperative ABG improvement in Group B was significantly higher than that in Group A [β = 7.31, 95% confidence interval (CI) = 1.93-12.69, P < .05]. Type III minor columella tympanoplasty yielded significantly better results than type III major and type Vb tympanoplasty (β = 11.42, 95% CI = 5.16-17.68, P < .01). There were no significant differences in the postoperative ABG or TAC between the reconstruction groups with and without preservation of malleus. Conclusions: Our results indicate that complex cases compromised by adhesions, cholesteatoma, and cholesterol granuloma have worse outcomes regarding hearing improvement and success rates, while those with intact stapes suprastructure have better outcomes. Malleus was maximally preserved in the patients of this study; however, this showed no significant prognostic benefit in hearing.

Cerebellopontine Angle Cholesterol Granuloma: A Case Report

Cholesterol granulomas are benign growths that occur due to an inflammatory response to cholesterol and hemosiderin. These lesion typically originate in the temporal bone and middle ear, although cerebellopontine angle cholesterol granuloma is exceptionally rare. This report describes a rare occurrence of a cholesterol granuloma developing in the cerebellopontine angle. The patient exhibited unilateral hearing impairment in the left ear accompanied by tinnitus. High resonance computed tomography revealed a lobulated lesion situated at the right cerebellopontine angle, which is also causing erosion of the right mastoid bone, right posterior wall semicircular canal, and right jugular foramen. Magnetic resonance imaging demonstrated hyperintensity with peripheral hypointense haemosiderin rim on both T1-weighted and T2-weighted images. According to the authors' understanding, this is the third documented instance of cholesterol granuloma manifesting as a tumour in the cerebellopontine region. The authors provide a comprehensive description of the uncommon lesion, including its presentation, imaging findings, histological characteristics, pathophysiology, and surgical therapy.

Intraoperative imaging and navigation of the petrous apex by infralabyrinthine route

Intraoperative imaging during skull-base surgery allows the operator to control surgical dissection and to tailor the approach, reducing morbidity due to inadequate resection or reintervention. The O-arm® (Medtronic, Fridley, MN, USA) navigation system is an intraoperative cone-beam CT device that was first designed for spinal surgery but now has applications in lateral skull-base surgery. In this technical note, we present a patient with petrous apex cholesterol granuloma located medial to the intrapetrous internal carotid artery and in the infralabyrinthine compartment. We report the possibility of natural drainage, using intraoperative imaging to guide resection, through a rapid, safe and minimally invasive approach.

Cholesterol Granuloma in Middle Ear Mimicking Glomus Tumor

Cholesterol granuloma is one of the rare sequels of chronic otitis media, posing diagnostic dilemma. We report a case of cholesterol granuloma of middle ear and mastoid mimicking glomus tumor. To the best of our literature search this has never been reported in local literature. Case is presented with literature reviewed.

A Case of Cholesterol Granuloma in the Nasal Septum

Cholesterol granuloma is a rare disease in which cholesterol crystals act as a foreign substance in the surrounding tissues and cause granulomatous reactions and fibrosis. It is commonly found in the mastoid or petrous apex, but the involvement of the nasal septum is very rare. Mucocele, which has pathogenesis similar to that of cholesterol granuloma, is a relatively common cystic lesion of the paranasal sinus; but rarely, it also occurs in the nasal septum. We report a case of cholesterol granuloma, which was clinically thought of as mucocele at first but managed successfully by endoscope-assisted marsupialization.

Electromyographic predictors of abducens nerve palsy after endoscopic skull base surgery.

Recovery of abducens nerve palsy (ANP) after endoscopic endonasal skull base surgery (ESBS) has been shown to be potentially predicted by postoperative ophthalmological examination. Triggered electromyography (t-EMG) and free-run electromyography (f-EMG) activity provide an intraoperative assessment of abducens nerve function, but associations with long-term ANP outcomes have not been explored. The objective of this study was to describe intraoperative abducens EMG characteristics and determine whether these electrophysiological profiles are associated with immediately postoperative and long-term ANP outcomes after ESBS. The authors conducted a 5-year (2011-2016) retrospective case-control study of patients who underwent ESBS in whom the abducens nerve was stimulated (t-EMG). Electrophysiological metrics were compared between patients with a new postoperative ANP (cases) and those without ANP (controls). Pathologies included chordoma, pituitary adenoma, meningioma, cholesterol granuloma, and chondrosarcoma. Electrophysiological data included the presence of abnormal f-EMG activity, t-EMG stimulation voltage, stimulation threshold, evoked compound muscle action potential (CMAP) amplitude, onset latency, peak latency, and CMAP duration at various stages of the dissection. Controls were selected such that pathologies were similarly distributed between cases and controls. Fifty-six patients were included, 26 with new postoperative ANP and 30 controls without ANP. Abnormal f-EMG activity (28.0% vs 3.3%, p = 0.02) and lack of response to stimulation (27% vs 0%, p = 0.006) were more frequent in patients with immediately postoperative ANP than in controls. Patients with immediately postoperative ANP also had a lower median CMAP amplitude (35.0 vs 71.2 μV, p = 0.02) and longer onset latency (5.2 vs 2.8 msec, p = 0.04). Comparing patients with transient versus persistent ANP on follow-up, those with persistent ANP tended to have a lower CMAP amplitude (12.8 vs 57 μV, p = 0.07) and higher likelihood of not responding to stimulation at the end of the case (45.5% vs 7.1%, p = 0.06). Abnormal f-EMG was not associated with long-term ANP outcomes. The presence of f-EMG activity, lack of CMAP response to stimulation, decreased CMAP amplitude, and increased CMAP onset latency were associated with immediately postoperative ANP. Long-term ANP outcomes may be associated with t-EMG parameters, including whether the nerve is able to be stimulated once identified and CMAP amplitude. Future prospective studies may be designed to standardize abducens nerve electrophysiological monitoring protocols to further refine operative and prognostic utility.

A Case of Cutaneous Cholesterol Granulomas with Spontaneous Regression

A Case of Cutaneous Cholesterol Granulomas with Spontaneous Regression

Conductive Hearing Loss in Children.

A variety of congenital and acquired disorders result in pediatric conductive hearing loss. Malformations of the external auditory canal are invariably associated with malformations of the middle ear space and ossicles. Isolated ossicular malformations are uncommon. Syndromes associated with external and middle ear malformations are frequently associated with abnormal development of first and second pharyngeal arch derivatives. Chronic inflammatory disorders include cholesteatoma, cholesterol granuloma, and tympanosclerosis.

Delayed Diagnosis of Post-traumatic Temporal Lobe Meningo Encephalocele: A Rare Case Report of a Child

Introduction: Bone fracture after head trauma is common in children. When a fracture happens in the temporal bone, Cerebrospinal fluid (CSF) might leak and/or the temporal lobe protrude (named encephalocele) as a mass inside the middle ear or mastoid or both. Case Presentation: Here, a 10 year old presents with an initial diagnosis of bacterial meningitis. Three years ago after head trauma he had a forgotten bone fracture. Incomplete improvement after primary treatment was achieved. Finally, after seeing a bone fracture on the right roof of the tympani and soft tissue mass in brain High-Resolution Compound Tomography (HRCT),surgical exploration determined the CSF leakage from a right lobe temporal meningo encephalocele. The bone defect was repaired and the patient had complete improvement. Conclusion: In this case with forgotten post traumatic temporal bone fracture, temporal bone encephaloceles lead to CSF leakage inside the middle ear cavity and introduce bacterial meningitis. High-Resolution Compound Tomography (HRCT) of the cranial base defined the bone defect. In recent years, Magnetic Resonance Imaging(MRI) has been known as the best method for the diagnosis of brain tissue herniation in the middle ear cavity. Although to differentiate the encephalocele from other masses (e.g. granulation, cholesteatoma, cholesterol granuloma, etc.) inside the middle ear cavity in an MRI is not easy. Surgical multilayered closure of the dura and simultaneous repair of the bone defect is needed.

Surgical Approaches to Petrous Apex Cholesterol Granulomas: A Systematic Review and Network Meta-analysis.

To compare the outcomes of different surgical approaches to petrous apex cholesterol granulomas (PACG). PubMed, Embase, Google Scholar, Cochrane, and Web of Science. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Network Meta-analyses guidelines, databases were searched from inception to November 31, 2022. Studies comparing two or more approaches were included. Reviews and population studies were excluded. The main outcome measures were the resolution of symptoms, serviceable hearing, complication, and revision rates. The search yielded 2132 studies. After applying inclusion and exclusion criteria, 15 studies remained, consisting of 214 patients treated with lateral approaches (n = 182) or anterior endonasal approaches (n = 32). The efficacy of lateral and anterior endonasal approaches in achieving symptom resolution was comparable (73% vs. 68%, p = 0.5). Both exhibited similar rates of complications (33% vs. 37%, p = 0.3), albeit with distinct profiles. Lateral approaches were associated with higher rates of facial palsy and sensorineural hearing loss (44% vs. 18%, p = 0.03). Anterior endonasal approaches demonstrated higher rates of epistaxis and cerebrospinal fluid leak (15% vs. 1%, p = 0.001). Anterior endonasal approaches exhibited lower revision rates (OR: 0.35, 95% CI: 0.14-0.88). The placement of a stent in both approaches was associated with higher symptom resolution (OR: 5.12, 95% CI: 1.05-9.97) and lower revision rates (OR: 0.71, 95% CI: 0.33-0.92). Anterior endonasal approaches yield lower revision rates compared to lateral approaches for PACG. Both approaches demonstrate similar effectiveness in symptom resolution and comparable rates of complications, with distinct profiles. Facial nerve and hearing status are important factors that should be addressed when selecting the approach. Stenting is beneficial. NA Laryngoscope, 134:1540-1550, 2024.