Introduction: Partial labyrinthectomy petrous apicectomy (PLPA) is a transpetrous route for approaching
clival pathology that is intended to preserve hearing while offering the advantages
of labyrinthectomy. A single-surgeon team composed of a fellowship-trained skull base
neurosurgeon, otolaryngologist, and neurophysiologist at a tertiary-care center have
completed a total of 66 cases utilizing this approach.
Methods: A description, diagrams, and intraoperative imaging of this surgical approach utilized
at our center is provided. Four handed surgery is performed using a diploscope which
has been shown to reduce operating time, blood loss, and improve resection rates in
skull base surgery. A cosmetic superficial mastoidectomy is performed prior to drilling,
allowing for replacement with titanium fixation. Removal of the lateral and superior
semicircular canals is performed by the otolaryngology team in addition to exposure
of the sigmoid sinus and petrous apicectomy offering a robust exposure that minimized
required retraction throughout the procedure. Intraoperative neurophysiological monitoring
is utilized in all cases but tailored to the requirements of the patient. Typically
for pathology in this region EMGs/motor evoked potentials of the relevant cranial
nerves, four limb SSEPs and MEPs, and brainstem auditory-evoked responses are utilized.
Additionally, a chart review was completed on all PLPA cases performed by our surgical
team for patient’s demographic, clinical, pathological, and radiographic information
pre- and postoperatively.
Results: A total of 66 cases, aged 16 to 74 years, were completed using a PLPA approach from
2002 to 2023 by our surgical team. The most common pathology approached with a PLPA
exposure at our institution was petroclival meningioma totalling 44/66 (66.7%) of
cases. Other pathology approached via PLPA at our institution include epidermoid tumors:
13/66 (19.7%), vestibular schwannoma: (3/66) 4.5%, trigeminal schwannoma: 2/66 (3%),
and 1/66 (1.5%) each of facial nerve and solitary fibrous tumors. The average diameter
of these lesions was 4.4 cm (range: 1.3–7.2 cm). A gross total resection was achieved
in 25/66 (37.8%), near total, defined as >90% tumor resection was achieved in an additional
14/66 (21.2%). An attempt to preserve hearing was made in all patients with hearing
at preoperative assessment totalling 44/65 patients. Of these patients, hearing was
preserved in 31/44 (70.45%). There were 27/66 (40.1%) cranial nerve deficits. There
were 2 of 66 (3%) CSF leaks that required readmission to hospital. One required operative
repair. 27 of 66 (40.1%) patients had postoperative cranial nerve deficits. Four of
66 (6%) patients had new motor deficits postoperatively. Eleven of 66 (16.7%) had
transient worsening of existing hemiparesis postoperatively. All cases improved. There
was a single case of postoperative dysphasia (1.5%), attributed to temporal lobe retraction.
There were zero mortality at 90 days postoperative.
Conclusion: Use of a PLPA approach is safe and robust in properly selected patients with reasonable
hearing preservation. Modifications to surgical technique can help improve the safety
and efficacy of this approach.
