Cholesterol granulomas are the most common lesions involving the petrous apex. However, they are still an uncommon finding overall, and they often remain undiagnosed until they have become extremely large and symptomatic. Many surgical approaches to the petrous apex exist. Factors that often influence the surgical approach include the surgeon's experience, the patient's anatomy, and the patient's hearing status. The purpose of this case report--which involved a 66-year-old woman who was referred to our clinic for evaluation of severe headaches, dizziness, and left-sided pulsatile tinnitus--is to demonstrate the definitive need for an extended middle fossa approach when a bilobed petrous apex mass is encountered.
Cholesterol granulomas are the most common pathologic entities in the petrous apex, accounting for 60% of all lesions in this area.1,2 Their pathogenesis remains controversial. The classic theory holds that a hemorrhage occurs as a result of an obstruction of ventilation in pneumatized bone.