Middle Fossa Cholesteatoma
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This is an interesting case of a large skull-based Cholesteatomata that was removed via the middle fossa approach. And some of the complicating features doing intraoperative drainage of their Cholesteatoma. This is a 56 year old male who presented with right-sided proptosis and facial nerve palsy. On imaging a large cystic mass was noted along the medial aspect of the middle fossa causing significant erosion of the bone characteristic of Cholesteatoma and right-sided middle fossa approach was used for drainage of the mass. You can see the curvilinear incision, the floor of the middle fossa, the root of zygoma. As you can see, the dura of the middle fossa has been significantly elevated by the presence of the mass. The dura was subsequently opened. This is primarily an extract. So mass you are the contents of that cholesteatoma next dura was rifted, inferiorly and cut for further exposure of the cyst contents. However, irritation of the dura in this area led to cardiac arrest and CPR had to be started immediately. You can see that no simple procedure in neurosurgery without any significant complicating factors. The patient was subsequently resuscitated. Further opening in the Dura was continued. Cystic contents were aggressively curated away. Obviously the capsule of the mass was not removed because it was very adherent to the cavernous sinus and surrounding neurovascular structures and postoperative MRI revealed adequate drainage of the mass and this patient recovered from his surgery without any sequelae. Learning point in this cases, the significant irritation of the innervation to the middle fossa dura from the trigeminal nerve that can lead to cardiac reflexes and temporary cardiac arrest. And it's best to be prepared potentially with cardiac Pacers or other precautions to quickly respond to this cardiac emergency. Thank you.
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