In reference to endoscopic-assisted transmastoid decompression of petrous apex cholesterol granuloma.

It was with great interest that we read the article by Carlton et al. describing a surgical pearl for gaining access to the petrous apex using a microscope and an endoscope. Using an endoscope during the lateral microscopic approach to the petrous apex is still the subject of debate. Here, we would like to emphasize the advantage of endoscopes not only in cholesterol granulomas but also in other lesions of the petrous apex that require more drilling: successful microendoscopic-assisted removals of petrous apex cholesteatomas and low-grade chondrosarcomas already have been reported. Controlling this type of lesion is limited during microscopic lateral approaches because of the facial nerve, the carotid artery, and the internal auditory canal. Endoscopes pass through these obstacles, making it possible to reduce the drilling, thus avoid a facial nerve rerouting. With its angled view of 308, 458, or 708, the sinuscope can give access to the anterior part of the internal auditory canal, the front of the vertical portion of the carotid artery (C3), or even the sphenoid sinus (personal cases after microscopic transotic approach [Fig. 1]). Thus, the endoscope not only is used to control complete removal of the lesion but also is the core part of both the approach and the removal of the lesion itself. This removal also needs specific instruments, such as angle suction tubes, angled raspatories, elevators, dissectors, and the probes classically used in functional endoscopic sinus surgery. The threeor four-hand technique also can be used, as currently is the case in endonasal endoscopic skull base surgery. Thanks to the progress made with endoscopy in rhinology, otorhinolaryngologists already are familiar with these instruments and rapidly can learn how to use them in lateral temporal approaches. Consequently, when faced with a lesion in the petrous apex, surgeons always should consider using endoscopes to reduce morbidity of the approach and to better control the removal. This attitude soon should define a new paradigm for management of petrous apex lesions, with less need for translabyrinthine, transotic, or Fisch infratemporal type B approaches.