Subarcuate supralabyrinthine approach for supralabyrinthine petrosal cholesteatoma

Congenital cholesteatomas of the petrosal apex account for 1% to 3% of all cholesteatomas and often present an important surgical challenge. This report describes an exceptional case of a "nondestructive" translabyrinthine surgical approach to a large congenital petrosal cholesteatoma that threatened the vestibulum, superior semicircular canal, facial nerve, and internal auditory canal. We applied a nonconventional transmastoid subarcuate supralabyrinthine approach in a 20-year-old patient by accessing the lesion through the center of the superior semicircular arch without damaging the integrity of the canal. This led to a complete removal of the petrosal cholesteatoma with preservation of hearing and vestibular function. Follow-up imaging performed 1 and 2 years after operation by means of non-echo-planar diffusion-weighted imaging did not show residual cholesteatoma. This report describes the first successful use of a subarcuate supralabyrinthine approach through the arches of the superior semicircular canal in a case of petrosal cholesteatoma.