Description

Cerebellar cholesteatoma represents a rare but severe form of advanced middle ear disease characterized by extracranial origin with intracranial extension, most commonly involving the posterior cranial fossa. These lesions typically arise from long-standing or recurrent cholesteatoma, often following previous otologic surgery, and may progress insidiously due to bone erosion and dural involvement. Clinical presentation is frequently nonspecific and may include chronic otorrhea, vertigo, headache, or subtle neurological symptoms, delaying diagnosis until advanced stages.

Surgical management of cerebellar cholesteatoma is particularly challenging because of its close relationship with critical neurovascular structures such as the sigmoid sinus, dura mater, cerebellum, and facial nerve. Successful treatment requires meticulous preoperative planning and a tailored surgical approach that ensures complete disease eradication while preserving neurological function. Extended surgical techniques, including revision radical mastoidectomy combined with careful infracerebellar dissection and dural repair, are often necessary. In selected cases, endoscopic assistance may improve visualization of hidden recesses and facilitate safer removal of residual disease without increasing morbidity

Outcome Objectives

At the conclusion of this presentation, participants will be able to:

1. Recognize the clinical and radiological features suggestive of cerebellar extension in patients with chronic or recurrent cholesteatoma.

2. Understand the anatomical challenges and risk factors associated with intracranial cholesteatoma spread, particularly involving the posterior cranial fossa.

3. Discuss extended surgical strategies, including radical mastoidectomy, infracerebellar dissection, and dural defect reconstruction, for safe and effective disease management.

4. Evaluate the role of endoscopic assistance in improving surgical visualization and reducing residual disease in complex cholesteatoma cases.

5. Appreciate postoperative outcomes and potential complications, emphasizing the importance of multidisciplinary care and long-term follow-up.

Background

Cholesteatoma is a destructive epithelial lesion with a well-known capacity for local bone erosion and intracranial complications. Although advances in otologic surgery and imaging have significantly reduced the incidence of life-threatening extensions, cerebellar involvement remains a serious clinical entity. Posterior fossa extension typically occurs through erosion of the mastoid cortex or Trautmann’s triangle, leading to dural exposure and, in advanced cases, cerebellar compression.

Historically, microscopic techniques have been the cornerstone of cholesteatoma surgery. However, limitations in visualizing hidden anatomical areas may contribute to residual disease, particularly in revision and extensive cases. Recent literature supports the adjunctive use of endoscopic techniques to enhance visualization and reduce recurrence rates without compromising audiological outcomes. In cases with intracranial extension, combining traditional microscopic surgery with endoscopic assistance and reconstructive techniques such as fascia lata grafting for dural repair offers a safe and effective solution.

Understanding cerebellar cholesteatoma is crucial for otologic surgeons, as timely diagnosis and appropriately extended surgical intervention can be lifesaving and function-preserving.