COW - Case of the WeekMedPix® Home PageTeaching File Case - Patient: 11745
Peer Reviewed and Certified - Approved by: Alice Boyd Smith - 2008-01-26 11:23:48-05
Submitted by: Steven J Goldstein - Author Info
Affiliation: University of Kentucky
Approved By: Alice Boyd Smith - Editor Info
Affiliation: Uniformed Services University
::::::TF Case Summary ::::Print TF Case::
Demographics: 13 y.o. girl
History & Chief complaint:
13 year old female in a MVA 6 years ago. She was found to have an expansile lesion on CT scan done at that time. Lesion has been followed with MRI and found to be stable ever since that time.
 
Physical exam and Laboratory:
Negative
 
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Magnify Cholesterol Granuloma right petrous apex
Figure 1
Cholesterol Granuloma right petrous apex
Magnify Cholesterol Granuloma right petrous apex
Figure 2
Cholesterol Granuloma right petrous apex
Magnify Cholesterol Granuloma right petrous apex
Figure 3
Cholesterol Granuloma right petrous apex
Magnify Cholesterol Granuloma right petrous apex
Figure 4
Cholesterol Granuloma right petrous apex
Magnify Cholesterol Granuloma right petrous apex
Figure 5
Cholesterol Granuloma right petrous apex
Magnify Cholesterol Granuloma right petrous apex
Figure 6
Cholesterol Granuloma right petrous apex
Magnify Cholesterol Granuloma right petrous apex
Figure 7
Cholesterol Granuloma right petrous apex

 
Summary of Findings:
High signal intensity expansile lesion right petrous apex.

No associated enhancement
 
Differential Diagnosis:

- Assymetric fatty marrow: Non-expansile

- Congenital cholesteatoma of the petrous apex: Low to intermediate signal on T1

- Trapped fluid within petrous apex: Low to intermediate signal on T1

- Apical petrositis: Low signal on T1, psot-contrast thick enhancing rim.
 
Diagnosis:
More Like This ?   Cholesterol granuloma
Confirmed by: MRI
Treatment and Followup:
No Treatment.

 
Disease Discussion -  Cholesterol granuloma
Discussion Author: Peter Vangeertruyden
Cholesterol granuloma of the petrous apex is believed to result from chronic obstruction of the air cells of the petrous apex and subsequent inflammation (1,2). Obstruction of the air cells, which normally communicate with the middle ear, is usually the result of chronic disease such as chronic otitis media. The inflammatory process is believed to involve recurrent bleeding into the obstructed air cells. Products of blood degradation, including cholesterol crystals, form a slowly expansile, fluid-filled lesion.

Presenting signs and symptoms of this disease relate to the anatomic position of the granuloma. Petrous apex granulomas usually present with cranial nerve compression; cranial nerves V though VIII may be involved (4). Headache, diplopia, hearing loss, vertigo and facial nerve weakness or spasm may be present.

The characteristic appearance of a cholesterol granuloma of the petrous apex on CT is as an expansile soft-tissue mass in the petrous apex. On MR, the lesion does not enhance and has high signal on both T1WI and T2WI. The high TIWI signal is believed to be the result of blood products, and helps to differentiate the lesion from a cholesteatoma or a neoplasm.

Surgical treatment of the cholesterol granuloma is achieved by drainage. Re-establishment of air exchange prevents recurrence of the lesion (4).

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