The authors presented three patients with acquired petrosal dholesteatomas with facial paralysis.
Case I was a 40-year-old man with a history of otitis media, whose chief complaint was right facial paralysis. Examination of the right tympanic membrane showed retraction of pars flaccida. Physical examination demonstrated right facial paralysis, right canal paresis (50%) in caloric test, and normal hearing. Petrosal cholesteatoma was diagnosed and the patient underwent total removal of petrosal cholesteatoma via the transmastoid approach, the cavity being obliterated with temporal muscle fascia. The cholesteatoma extended from the region of supratubal recess, the anterior superior area of the anterior semicircular canal to the petrosal portion. The facial nerve was skeletonized and compressed by the cholesteatoma at the labyrinthine portion. Postoperatively, a moderate conductive hearing loss was demonstrated, but facial nerve paralysis recovered almost completely. Follow-up MRI of 10-months after the operation showed no evidence of recurrence.
Case 2 was a 43-year-old man with a history of left cholesteatoma for which he underwent an operation 23 years before. His chief complaint was left facial paralysis. Examination demonstrated recurrence of cholesteatoma in his left mastoid cavity, left sided deafness, and left canal paresis. Removal of recurrent cholesteatoma was performed via the transmastoid-translabyrinthine approach, and the cavity was obliterated with fat and temporal muscle fascia. The cholesteatoma exte nded from the region of attic, via the supralabyrinthine route, to the petrous portion. The facial nerve could not be identified because of severe atrophy. Seven months after the operation, he underwent a plastic surgery of cross-face nerve graft for left facial paralysis. And about a year after this first plastic surgery, second plastic surgery of free muscle transplant was done.
Case 3 was a 45-year-old man with a history of right hearing loss since childhood, whose chief complaint was right facial paralysis. Examination of right tympanic membrane showed retraction of the pars flaccida. Physical examination demonstrated right facial paralysis and a moderate mixed hearing loss (50dB) in his right ear. A right transmastoid approach was performed, and the operated cavity was obliterated with a temporal muscle flap. The cholesteatoma extended from the region of attic, via the supralabyrinthine route, to the petrous portion. The facial nerve was not exposed. Postoperatively, his facial paralysis resolved almost completely.
In this article, we discussed the facial paralysis due to petrosal cholesteatomas- its causes and its treatment. Two of our patients showed excellent return of their facial functions, and one patient needed plastic surgery twice, cross-face nerve graft and free muscle transplantation.
We also reviewed the surgical treatment for petrosal cholesteatomas. Various surgical approaches have been utilized; 1) transmastoid-translabyrinthine, 2) middle fossa, 3) suboccipital, 4) transethmoidtranssphenoid, 5) transpalatal-transclival. Decision making of surgical approach depends on extension of cholesteatomas, eighth nerve functions, and so on. It is still controversial whether obliteration of operated cavity should be done or not. We favor obliteration technique because it may prevent cavity infection, and, furthermore, with the advent of MRI, we can now assess the growth of residual lesions or evidence of recurrence.
We feel that annual MR imaging follow-up is indicated in cases with obliteration of operated cavity.
