[Temporal bone cholesterol granuloma penetrating into the middle cranial fossa]

The authors present a case report of a patient who was treated conservatively for a non-specific headache for more than a decade, while an arachnoidal cyst in the middle cranial fossa, over the temporal bone tegmen was diagnosed, but ruled out as the cause of the headache. The patient was referred to our ENT department with left, purulent ear discharge. Besides a chronic purulent otitis media, a cholesterol granuloma occupying the antrum, eroding the tegmen of the pyramid bone and penetrating into the middle cranial fossa was diagnosed. Case presentation of a patient with cholesterol granuloma, surgical options, differential diagnostic problems, and a literature review are presented. Tympanoplasty with cortical mastoidectomy was carried out to treat the chronic purulent otitis media, and the cholesterol granuloma was removed during transmastoid craniotomy. The iatrogenic temporal meningo-encephalic tissue herniation was repaired and the bone defect of the tegmen was reconstructed with septal cartilage. The patient's headache diminished immediately after the surgery. The chronic ear discharge stopped, the cholesterol granuloma was excised completely and the cerebral herniation was repaired successfully. Neither CSF leak, nor further herniation or meningitis were noticed. Two years after the operation the patient is asymptomatic. A large cholesterol granuloma, eroding into the middle cranial fossa can cause serious complications, and needs a high level of attention besides individualized surgical treatment based on the surgeon's abilities and skills. Orv Hetil. 2019; 160(52): 2067-2072.