■ OBJECTIVES: In this paper we present our experience with twelve cases of cholesteatoma involving the petrous apex and discuss the operative findings and postoperative results.

■ METHODS:From 1987 to 2006, twelve cases with cholesteatoma involving petrous apex were operated. The age at operation for removal of petrous apex cholesteatoma ranged from 14 years to 40 years with average of 27 years. There were 8 male and 4 female and average followup after operation was 19 months and ranged between 2 months to 48 months. The chief complaints, location of cholesteatoma, extension route between middle ear and petrous apex, surgical technique used and the result or treatment were analyzed.

■ RESULTS: The most common symptom was hearing loss and facial nerve paralysis. None of the cholesteatoma was confined to the petrous apex but they had connection between the petrous apex and middle ear. Nine cholesteatomas were expanding through anterosuperior route, three through posterosuperior route. In most of the cases, it was necessary to remove the labyrinth and a portion of cochlea due to the invasion into the inner ear. But in three cases with limited disease the cholesteatoma was removable via transmastoid approach or middle fossa approach. In our series, 9 out of 10 cholesteatomas were regarded as of congenital origin due to intact tympanic membrane: but it does not always mean that it originated from cell nest of petrous apex. Among the 6 cases with preoperative facial palsy, one was managed by greater auricular nerve interposition, another by facial nerve decompression, and the others underwent hypoglossal-facial hookup. The results of facialreanimation were House-Brackmann  grade IV in all cases. There were no perioperative problems, or recurrence during fellow-up period.

■ CONCLUSIONS: The possibility of hearing preservation in cases with petrous apex cholesteatoma may be very low and attempts at hearing conservation should not prejudice total removal of cholesteatoma. For the patients with serviceable hearing, the middle fossa approach or transmastoid approach may be considered but only in very limited disease. The best operative technique for petrous apex cholesteatoma may be the translabynthine and/or transotic approach.