Different surgical pathways, one objective: Management of petrous apex cholesterol granuloma

This study aims to present a case series of petrous apex cholesterol granulomas and to review the literature on imaging findings, indications, current surgical approaches, and outcomes. We retrospectively reviewed three cases of cholesterol granulomas diagnosed at the Ospedale Civico of Lugano between 2020 and 2025. Two patients underwent surgical treatment via different approaches – endonasal, transsphenoidal, and retroauricular – while one patient was managed conservatively. Preoperative and postoperative imaging findings, clinical outcomes, and follow-up data were analyzed. A narrative review of the literature was conducted to contextualize our findings within current evidence. All surgical cases demonstrated favourable outcomes with no significant complications. The choice of surgical approach was tailored to lesion topography and extension, patient anatomy, and hearing status. The literature review indicates an increasing preference for minimally invasive, hearing-preserving techniques, although high-level comparative data remain limited. The management of petrous apex cholesterol granulomas should be tailored to each case, with careful consideration of lesion characteristics and patient-specific factors. In properly selected patients, endoscopic and minimally invasive techniques are associated with favourable outcomes and lower morbidity. Preoperative imaging and surgical expertise are crucial for selecting the optimal approach.