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Updated: Jul 28, 2025
Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas
Published on: January 17, 2018
RHINOGENIC MENINGITIS CAUSED BY CONGENITAL PETROUS APEX CHOLESTEATOMA: SIMULTANEOUS SURGICAL TREATMENT THROUGH
Mateo Čukman1, Jakov Ajduk1,2, Luka Bukovac2
1Department of Otorhinolaryngology and Head & Neck Surgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia.
Abstract:
A 66-year-old male patient was admitted due to high fever, severe headaches and disturbance of consciousness. Meningitis was confirmed by lumbar puncture and intravenous antimicrobial therapy was started. Since he had undergone radical tympanomastoidectomy 15 years before, otogenic meningitis was suspected, so the patient was referred to our department. Clinically, the patient manifested watery discharge from the right nostril. Microbiological analysis verified Staphylococcus aureus in a cerebrospinal fluid (CSF) sample acquired by lumbar puncture. Radiological work-up, including computed tomography and magnetic resonance imaging scans, showed an expanding lesion of the petrous apex of the right temporal bone disrupting the posterior bony wall of the right sphenoid sinus with radiological characteristics indicating cholesteatoma. Those findings confirmed rhinogenic meningitis caused by expansion of the petrous apex congenital cholesteatoma into the sphenoid sinus, allowing nasal bacteria to enter the cranial cavity. The cholesteatoma was removed completely by the simultaneous transotic and transsphenoidal approach. Since the right labyrinth was already non-functional, there was no surgical morbidity after labyrinthectomy. The facial nerve remained preserved and intact. The transsphenoidal approach enabled removal of the sphenoid portion of the cholesteatoma and two surgeons met together at the level of the retrocarotid segment of the cholesteatoma, completely removing the lesion. This case represents an extremely rare condition in which a petrous apex congenital cholesteatoma expanded through the petrous apex to the sphenoid sinus, causing CSF rhinorrhea and rhinogenic meningitis. According to available literature, this is the first case of petrous apex congenital cholesteatoma causing rhinogenic meningitis successfully treated with the simultaneous transotic and transsphenoidal approach.
Insights
This study reports a rare case of rhinogenic meningitis caused by a petrous apex congenital cholesteatoma. The successful treatment involved a simultaneous transotic and transsphenoidal approach, highlighting a novel surgical strategy for this condition.
Area of Science:
- Neurosurgery
- Otolaryngology
- Infectious Diseases
Background:
- Meningitis is a serious infection of the membranes surrounding the brain and spinal cord.
- Congenital cholesteatomas are rare benign tumors that can develop in the petrous apex of the temporal bone.
- Rhinogenic meningitis, originating from the nasal cavity or sinuses, is less common than other forms of meningitis.
Observation:
- A 66-year-old male presented with fever, headache, and altered consciousness, diagnosed with meningitis.
- Cerebrospinal fluid analysis revealed Staphylococcus aureus, and imaging showed a petrous apex cholesteatoma extending into the sphenoid sinus.
- The patient exhibited cerebrospinal fluid (CSF) rhinorrhea, suggesting a connection between the cranial cavity and the nasal passages.
Findings:
- The cholesteatoma's expansion into the sphenoid sinus facilitated bacterial entry, causing rhinogenic meningitis.
- A simultaneous transotic and transsphenoidal surgical approach was employed for complete cholesteatoma removal.
- The surgery preserved facial nerve function and resulted in no additional morbidity, despite the labyrinthectomy.
Implications:
- This case highlights an extremely rare presentation of congenital cholesteatoma leading to rhinogenic meningitis.
- The simultaneous transotic and transsphenoidal approach offers a viable and effective treatment for such complex lesions.
- This successful intervention provides a potential new surgical strategy for similar rare otoneurosurgical conditions.
