Surgical Approaches to Petrous Apex Cholesterol Granulomas: A Systematic Review and Network Meta‐analysis

Objective To compare the outcomes of different surgical approaches to petrous apex cholesterol granulomas (PACG). Data Sources PubMed, Embase, Google Scholar, Cochrane, and Web of Science. Review Methods Following the Preferred Reporting Items for Systematic Reviews and Meta‐analyses‐Network Meta‐analyses guidelines, databases were searched from inception to November 31, 2022. Studies comparing two or more approaches were included. Reviews and population studies were excluded. The main outcome measures were the resolution of symptoms, serviceable hearing, complication, and revision rates. Results The search yielded 2132 studies. After applying inclusion and exclusion criteria, 15 studies remained, consisting of 214 patients treated with lateral approaches (n = 182) or anterior endonasal approaches (n = 32). The efficacy of lateral and anterior endonasal approaches in achieving symptom resolution was comparable (73% vs. 68%, p = 0.5). Both exhibited similar rates of complications (33% vs. 37%, p = 0.3), albeit with distinct profiles. Lateral approaches were associated with higher rates of facial palsy and sensorineural hearing loss (44% vs. 18%, p = 0.03). Anterior endonasal approaches demonstrated higher rates of epistaxis and cerebrospinal fluid leak (15% vs. 1%, p = 0.001). Anterior endonasal approaches exhibited lower revision rates (OR: 0.35, 95% CI: 0.14–0.88). The placement of a stent in both approaches was associated with higher symptom resolution (OR: 5.12, 95% CI: 1.05–9.97) and lower revision rates (OR: 0.71, 95% CI: 0.33–0.92). Conclusions Anterior endonasal approaches yield lower revision rates compared to lateral approaches for PACG. Both approaches demonstrate similar effectiveness in symptom resolution and comparable rates of complications, with distinct profiles. Facial nerve and hearing status are important factors that should be addressed when selecting the approach. Stenting is beneficial. Level of Evidence NA Laryngoscope, 134:1540–1550, 2024 Petrous apex cholesterol granulomas can be surgically removed with lateral or anterior endonasal approaches. In this systematic review and network meta‐analysis, we found that anterior endonasal approaches yield lower revision rates compared to lateral approaches. Both approaches demonstrate similar effectiveness in symptom resolution and comparable rates of complications, with distinct profiles. Facial nerve and hearing status are important factors that should be addressed when selecting the appro