You are on page 1of 7

Literature Review

Orbitofrontal Cholesterol Granuloma: Four Case Reports and
a Systematic Review of the English Literature
Joshua D. Hughes1, Jeffery T. Jacob1, James A. Garrity2, Diva R. Salomao3, Michael J. Link1

Key words - INTRODUCTION: Primary orbitofrontal cholesterol granuloma (OFCG) is rare.
- Cholesterol granuloma
- Chronic hematic cyst
We present 4 cases of OFCG and a systematic literature review to examine
- Orbital cholesterol granuloma patient characteristics, presentation, treatment, and outcome.
- Orbitofrontal cholesterol granuloma
- METHODOLOGY: Our institutional records were reviewed for OFCG cases. A
Abbreviations and Acronyms systematic literature review was performed using PubMed. Inclusion criteria
CG: Cholesterol granuloma were English-language studies with pathology-proven OFCG. Exclusion criteria
OFCG: Orbitofrontal cholesterol granuloma
MRI: Magnetic resonance imaging were OFCG in a craniofacial sinus. The search-string yielded 172 results. Fifty
studies met inclusion criteria (39 primary and 11 secondary), and relevant data
From the Departments of 1Neurologic Surgery, were reviewed.
Ophthalmology, and 3Pathology, Mayo Clinic School of
Medicine, Rochester, Minnesota, USA - RESULTS: Four patients underwent surgery for OFCG at our institution (ages
To whom correspondence should be addressed: 53, 43, 34, and 43; 3 females, 1 male). All patients were treated with surgery using
Michael J. Link, M.D.
[E-mail:] a tailored frontal-orbital craniotomy with complete resection. There was no
Citation: World Neurosurg. (2016) 87:355-361. recurrence at 12-month, 4-year, 10-year, and 22-year follow-up for each patient, respectively. Systematic review of the literature identified 172 patients. Follow-
Journal homepage: up was available in 93 patients (54.1%) with a mean follow-up of 43.3 months.
Available online: Seven patients demonstrated recurrence at a median of 36 months following
1878-8750/$ - see front matter ª 2016 Elsevier Inc. surgery. Combining our 4 cases with the 93 patients with reported follow-up
All rights reserved. gives a recurrence rate of 7% (7/97). Recurrence was associated with incom-
plete resection and an orbital approach.
- CONCLUSION: Thorough removal of the lesion with curettage of the boney
cavity is recommended for OFCG. Recurrence following complete removal of
Cholesterol granuloma (CG) occurs sec- OFCG is rare.
ondary to an inflammatory response to the
breakdown of blood products.1e5 The
most prominent features of CG are
cholesterol clefts with granulomatous METHODS secondary). See Figure 1, a flow diagram, for
inflammation without epithelial elements After institutional IRB approval, the medical systematic literature review. All patients
(which distinguishes CG from choles- records at our tertiary medical center were (both institutional and from the literature
teatoma).6 CG occurs most commonly in reviewed for cases of OFCG and 4 cases were review) were reviewed for patient
the petrous apex but has rarely been discovered. A PubMed search was per- demographics, signs and symptoms,
reported to occur in other regions of the formed on January 11, 2015 using the history of trauma, imaging, intracranial
head, including the orbit. Historically, following string: “cholesterol granuloma” OR extension, surgery, recurrence, and length
orbitofrontal CG (OFCG) occurs most “lipid granuloma” OR “hematic cysts” OR “hematic of follow-up. Various surgical approaches
commonly in the lacrimal fossa and has cyst” OR “chronic hematic cyst” OR “xanthoma- were categorized as a limited orbital or scalp
been labeled cholesteatoma, lipid tosis” AND (frontal OR orbit OR orbital OR orbi- flap approach and were analyzed for recur-
granuloma of the frontal bone, tofrontal) NOT sinus [title]. The PubMed search rence with a chi-square test. A P value < 0.05
xanthomatosis of the orbit, and chronic yielded 172 results, and 49 potential primary was considered statistically significant.
hematic cyst.4,7e10 Although there are studies were found and screened for further
case reports and small case series on sources not found in the PubMed search RESULTS
OFCG, no systematic literature review (secondary sources). Exclusion criteria were
has been done to examine patient non-English reports, animal studies, and Case 1
characteristics, presentation, treatment, undocumented pathology or imaging con- A 53-year-old female presented recently
and outcomes. We present 4 cases that firming OFCG. Using these criteria, 80 po- with 5 months of left ocular displacement
occurred at our institution and a tential sources (49 primary and 31 secondary) and 3 months of uncomfortable periorbital
systematic review of the English language were identified, 30 were excluded, and 50 pressure sensation. On examination, she
literature. met inclusion criteria (39 primary and 11 had intact extraocular movements and

WORLD NEUROSURGERY 87: 355-361, MARCH 2016 355

He underwent a right months. 44. ing (MRI. Case 4 A 43-year-old female presented with a sensation of pressure behind the right eye that had been increasing for a few years. and it was removed with curettes.7%) eye than her right for 20 years.0%) eye swelling.9%.2%) vision changes. in the left frontal bone expanding into the lacrimal fossa. no enhancement. The of pressure in his right eye.11. which was showed a 1. and 37 (21.5.8%) or left (n ¼ 60.8%) diplopia.2015. Her left globe restricted left upper gaze. She endorsed oc.and T2-weighted images. studies and patient demographics. patients com- headaches and 1. She underwent a right frontotemporal craniotomy. MRI (12.1016/j.0%) Case 2 remote history of trauma to the temporal patients. It had an expansile appearance otomy with left superior orbitotomy. and the pericranium was used to exclude the sinus.0%) patients. 21 noticed her left eye appeared different erosion into the right frontal sinus. He has had no recurrence at 264 months.5%) patients superior left orbit displacing the globe underwent a left frontotemporal crani. There was no erosion of the lesion into the periorbital or dura.5 cm with boney destruction of the lateral orbit and middle fossa. In 50 studies. HUGHES ET AL. There was no enhancement on MRI. The most common pre- restricted diffusion (Figure 2B and C).6% and 84.5 (0.25312) casional double vision. listing of patient signs and symptoms and Pathology was consistent with CG physical examination findings.SCIENCEDIRECT. she reported that people had mass in the right lacrimal fossa with (30. Systematic Literature Review Figure WORLD NEUROSURGERY. LITERATURE REVIEW JOSHUA D. She was curettaged until no membranes senting symptom and physical examination underwent a left orbitofrontal craniectomy remained. There was no history of trauma inferiorly. No MRI was done. There was no recurrence at 48 months. 172 patients were found with pathologically confirmed OFCG.wneu. 62 (36. mography (CT) of her head showed a 2. 35 (20. The most (Figure 3). She 1483) years. The defect trauma history. CT of his head showed a protrusion. 34. Computed to. with complete evacuation of the cyst CT showed a uniform soft tissue mass in the right lacrimal fossa that measured 2.5-year history of had 1 mm of proptosis and 2 mm of globe plained of the following: 106 (61. Magnetic resonance imag.6%) eye increasing left eye swelling.3%) pain. The median number normal visual acuity and visual fields to globe with proptosis of 23 mm and of patients in each study was 1 (range. The frontal sinus was breeched.1-50 The studies were published between 1934 and 2015 (median 1994). On further displacement. A small frontal craniotomy was per- formed around the lesion and was removed en bloc. See Table 1 for a list of included was depressed. Her exam- ination was significant for 3 mm of right eye proptosis and 2 mm of displacement. There was toms before diagnosis was 20. A 34-year-old male presented with 8 (n ¼ 77. See Table 2 for a complete contents and drilling of the boney cavity. On examination he Regarding symptoms. A 43-year-old female presented with area 45 years prior.doi. 53 history. ORBITOFRONTAL CHOLESTEROL GRANULOMA flap. and 154 (89.5%) and was T1 and T2 hyperintense with defect had eroded into the anterior fossa patients had either a remote or recent patchy mild enhancement and no but did not invade the dura.095 . respectively). On physical examination findings. He had a location was unspecified in 31 (18. There was no recurrence at 120 finding was proptosis (61. She had no history of trauma. confrontation in both eyes. and 8 (4. The mean duration of symp- confirmed by pictures. Case 3 common location was either the right month follow-up (see Figure 2D). 131). She had no recurrence at 12. http://dx.5-cm mass that was bright on displacement. T1.9%) months of blurred vision and a sensation superolateral portion of the orbit. Flow diagram of systematic literature review. The in 117 (68. she had downward displacement of the frontal craniotomy through a bicoronal patients suffered from the following: 146 356 www. On examination. Figure 2) showed an abnormality cm expansile cystic mass in the left The mean patient age was 42 (range. were male.

org 357 . Seven patients exhibited recurrence with a median time to recurrence of 36 (range.5%) patients were found to have intra- cranial extension. 1240) months. 90 (52. and 24 (14. the right or left lacrimal fossa (n ¼ 137. labeling the pathology “pseudo-cholesteatoma”.38 The other cases had surgery at other institutions..” Interestingly. Hanbery and Rayport20 were the first to offer Figure 3.1%) patients who had documented follow-up. it was excluded in our analysis. Out of 93 patients with known surgical approaches and follow-up.3%) eye displace. who called his findings a subperiosteal blood cyst.4 the first cholesterol granuloma. and MRI (D) showed no residual In a review by McNab et al. Pathology returned as orbitofrontal cholesterol granuloma. no cholesterol granules were (84.28. A 53-year-old female underwent a left orbitofrontal craniectomy for a left lacrimal fossa DISCUSSION lesion.9%) proptosis. The most common location was incision (n ¼ 79. other English literature papers support that Pincus’s microscopic pathology was consistent with CG.” Ramsey et al.9. 64 of them (73%) were orbital and 22 of them (27%) were scalp approaches (including our 4 cases). LITERATURE REVIEW JOSHUA D. and the cause was thought to be known residual.26. Figure 2. One case1 recurred after 7 months. Another case recurred 20 years after a prior surgery and then again 1 month after needle aspiration and drainage. 73 (42. However. Hematoxylin-eosin pathology slides for Case 1 at 100 (A) and 400 (B) magnification showing cholesterol crystals in an inflammatory background with hemosiderin deposits. Preoperative computed tomography (A) showed an osteolytic lesion. one of these cases was operated on by Wilder Penfield. reported on microscopic examination.38. reported OFCG was credited to Denig. 12. the extent of the first surgery was unknown. followed by a scalp OFCG in 1933. HUGHES ET AL.9%).WORLDNEUROSURGERY. and although the surgical approach was known.20.04 comparing orbital and scalp approaches for recurrence). which they labeled “post-traumatic granuloma. The most common surgical a review by Hanbery and Rayport. ORBITOFRONTAL CHOLESTEROL GRANULOMA flap with or without craniotomy (n ¼ 23. as Pincus’s article is in German. She had no recurrence at 3-month follow-up.0%) vision examination approach was an orbitotomy through a brow state that Pincus was the first to report changes.4%) extraocular motility prob. the label “orbitofrontal cholesterol granuloma. However. The surgical approach was un- known in 71 patients (39.36. MARCH 2016 www. In ment.3 (2204) months in the 93 (54.34 Knapp is the first to clearly report a pathology consistent with OFCG in the English literature.7%). 79.34 which he called “xanthomatosis. At surgery.25. All 7 patients with recurrence underwent an orbital approach (P ¼ 0. 44%).9%).20 they lems.47 Combining our 4 cases with the 93 patients with reported follow-up gives a recurrence rate of 7% (7/ 97). on review of this source. Mean follow-up was 43. 37 (21.” Despite this early suggestion WORLD NEUROSURGERY 87: 355-361.20. Preoperative magnetic resonance imaging (MRI) showed a primarily hyperintense lesion on both T1 and T2 sequences (B and C) with some contrast History and Nomenclature enhancement (B).1.40 were the next to report on OFCG.

2 14 the degree of trauma it might take to cause an abnormality in the bone to cause OFCG 25 Loeffler 1997 Cholesterol granuloma 6 43 6 is enough to be noted by the patient if it 26 Luxenberg 1990 Hematic cyst 1 46 0 occurred in the remote past.3 3 theory regarding development is the “obstruction-vacuum theory. This theory developed mainly 12 Garcia-Gonzalez 2010 Cholesterol granuloma 2 41 2 from experimental animal models. Selva et al. HUGHES ET AL.2 11 that CG develops after blockage of normal 10 Eugenidis 1980 Cholesterol granuloma 1 31 1 airflow in mastoid air cells that causes 11 Fukuta 1990 Cholesterol granuloma 1 41 1 negative pressure and subsequent hemorrhage. which was docu- 39 Rizvi 2014 Cholesterol granuloma 1 42 1 mented on clinical examination in 84. in our review.5 2 36 Pfeiffer 1948 Cholesteatoma 1 43 1 Presentation.5 2 was proptosis (61.4%.0%) had no history of 23 Knapp 1934 Xanthomatosis 2 35. 3 Alsuhaibani 2011 Cholesterol granuloma 2 49.5 2 significant trauma.wneu. lung.4.3 3 Pathophysiology The exact pathophysiology and mechanism 6 Chow 2005 Cholesterol granuloma 6 44.40 Evidence for 20 Kersten 1988 Chronic hematic cyst 2 37. and 37 Polito 1994 Cholesterol granuloma 1 32 1 Natural History The most common presenting symptom 38 Ramsey 1948 Post-traumatic granuloma 2 50.11. 4 Arat 2003 Cholesterol granuloma 8 45 6 5 Bergin 1988 Chronic hematic cysts 3 41. CG has been reported in other areas of the body such as 16 Hill 1992 Cholesterol granuloma 31 43 28 the breast.5 1 this is cited in that the vast majority of 21 Khalatbari 2012 Cholesterol granuloma 1 14 0 OFCG occurs in males (89. the prevailing 8 Dobben 1998 Cholesterol granuloma 3 50.7 24 arise from a nontraumatic irregularity in 30 Miller 1999 Cholesterol granuloma 1 53 1 the diploe. LITERATURE REVIEW JOSHUA D. but most reports have used “cholesterol granuloma” (n ¼ 34.6%).9% 40 Roman-Romero 2011 Cholesterol granuloma 2 41 2 of patients.5% in our re- view).7 6 of OFCG formation remain largely un- 7 Dickey 1992 Cholesterol granuloma 1 36 1 known.095 .SCIENCEDIRECT. 1 Aferzon 2002 Cholesterol granuloma 1 42 0 post-traumatic granuloma. Systematic Literature Review of Orbital Cholesterol Granuloma nomenclature continued to vary. This is assuming that 24 Lloyd 1986 Cholesterol granuloma 15 44. WORLD NEUROSURGERY. and abdomen. the major- 22 Kim 2014 Cholesterol granuloma 1 32 0 ity of patients (68. and lipid- 2 Alport 1954 Cholesteatoma 1 45 1 containing granuloma. Physical Examination.1016/j. There is one case of Paget 34 Ong 2008 Cholesterol granuloma 1 43 1 disease causing OFCG. theorized that OFCG may 29 McNab 1990 Cholesterol granuloma 27 43. chocolate cyst. xanthomatosis. ORBITOFRONTAL CHOLESTEROL GRANULOMA that clearly defined the pathology. as OFCG does not occur in 14 Hanbery 1955 Cholesterol granuloma 3 32 3 pneumatized bone. Furthermore.8% of patients.”51 which states 9 Eijpe 1990 Cholesterol granuloma 11 41. most 358 www.2015.52-60 13 Gillissen 1984 Chocolate cyst 3 31 2 However. Table 1. It could still 27 Madaree 1997 Chronic hematic cyst 1 50 0 be true that OFCG is induced by minimal trauma. this theory has fallen 15 Heaton 1993 Cholesterol granuloma 1 31 1 out of favor. 28 Mani 2001 Cholesterol granuloma 1 40 1 Parke et al.5 1 68%).32 35 Parke 1982 Cholesterol granuloma 2 32. Diplopia was present in 30.doi. and extraocular motility ab- Continues normalities were noted in 42.5 presented evidence in support of this theory in that there is 31 Milne 1987 Chronic hematic cysts 3 38 3 “woven bone arranged in a dysplastic 32 Nicholls 1956 Cholesterol-containing granuloma 3 47.7 3 fashion at the periphery” of 2 OFCGs in 33 Okay 2010 Cholesterol granuloma 1 50 1 which they subject bone specimens for analysis.61-63 17 Imre 2015 Cholesterol granuloma 1 44 1 One of the more common theories 18 Jordan 2007 Cholesterol granuloma 1 29 1 regarding OFCG is that it is associated with an anomaly that develops in the 19 Karim 2000 Cholesterol granuloma 1 51 1 frontal bone after trauma. In petrous apex CG. http://dx. including Author Year Term Number Age* Male the terms cholesteatoma. chronic hematic cyst.

Orbitofrontal Proptosis 146 (84.1 Another led to a phthisical Orbital frontal cholesterol granuloma is a induced astigmatism or choroidal folds. symptomatic and therefor undergo surgery.13. Dickey JB. One caused boney months.2 REFERENCES Physical examination findings Treatment and Outcomes 1. with any surgical approach the goal should 20. recommend removal of the lesions when Patients with Orbital Cholesterol ings are similar except the bone appears symptomatic. soft tissue mass can be seen diagnosis may lead to surgical treatment. we Table 2. including curettage and dril- though at least 1 case of pathology- Vision changes 21 (12. our careful review suggests that residual disease after 41 Rosca 2006 Cholesterol granuloma 4 40 4 incomplete removal is the most likely 42 Selva 2003 Cholesterol granuloma 2 38 2 cause of recurrence. there have *Average age when >1 patient. Visual acuity was affected in 24 extended into the middle and anterior CONCLUSION patients (14%) either by a mechanically cranial fossa. OFCG appears as an ported cases of OFCG becoming large and osteolytic lesion with clear. Globe displacement 8 (4. ORBITOFRONTAL CHOLESTEROL GRANULOMA all the cases reviewed.WORLDNEUROSURGERY. from weeks to extensive OFCG. Regardless. as 49 Wolter 1966 Blood cyst with foreign body reaction 1 54 1 opposed to a more limited orbital approach.0%) Recurrence has rarely been reported in the 2. LITERATURE REVIEW JOSHUA D. reconstruction of the orbit with calvarial reported cases of OFCG exist in the En- The natural history of OFCG is unknown bone graft. there are a few re- On skull radiographs.19:382-387. It is logical that better visualiza- 48 Wiot 1989 Chronic hematic cyst 2 37.11. though recurrence was because of the paramagnetic hemoglobin more likely after an orbital approach. fascial flap. the data are not enough to recommend one approach over 47 Wheeler 1937 Orbital cyst w/o epithelial lining 1 45 1 another.1. Globe displacement 90 (52. Asymptomatic lesions can Granuloma more corrugated. visualization of a scalp flap.4.7%) reported. requiring extensive surgery. though the need for tissue enhancing. non.0%) mass with both high T1 and T2 signal are acceptable.4%) by scalp flap-type approaches (12%). and almost all pa. Two cases had curettage or drilling of the boney cavity.47 to better allow for complete curettage.14.15. and a glish literature. regular mar. Vision changes 24 (14.45. Extraocular motility restriction 73 (42.7%) for OFCG. At least 172 location (79. One patient had an incidentally found pre.8%) degradation products. We report 4 additional secondary to its rarity. Therefore. should be the goal. allowing minimal invasion of an orbital incision with the often in the superolateral direction.6%) MRI typically shows a nonenhancing frontal flaps with or without craniotomy Orbital swelling 62 (36.9%) cholesterol granuloma: distinct diagnostic fea- Most patients were treated with a brow tures and management. before patients came to medical destruction of the lateral orbit and attention.2%) proven OCG with low T1 signal has been ling of involved bone. and none with craniotomy. Although severe pain was uncommon. Signs and symptoms extending into the affected orbit. Ophthal Plast Reconstr Surg. Though tients who come to medical attention are expansion causing extensive boney Imaging Characteristics destruction is rare.27 Either primary orbital approaches or Proptosis 106 (61. Clinical Findings in 172 gins and no sclerotic edges. be observed.3%) extirpation. Continued not enough data to analyze for factors Author Year Term Number Age* Male associated with recurrence. globe and extensive boney destruction rare pathology that commonly presents The lacrimal fossa was the most common and required orbital exoneration and with proptosis and diplopia. Mullenix CD. Boniuk M.26 Regardless of approach. Diplopia 53 (30.30 cases. Arat YO. Although there are Table 359 . Symptoms were present the outcome is unknown.04) between the approaches 46 Sia 2012 Cholesterol granuloma 1 66 1 regarding recurrence.25.5 1 tion is achieved with a scalp flap. complete surgical Pain 35 (20. Although we 44 Selva 2003 Cholesterol granuloma 1 50 1 did find a statistically significant differ- 45 Shapiro 1986 Hematic cyst 2 36.27 CT find. Recently.3% of patients had a dull ache in the sumed OFCG4 that was being observed. O’Grady RB. for a total of 176 cases. but be complete removal with thorough affected orbit. and an isodense. All 7 instances of 43 Selva 2004 Cholesterol granuloma 1 54 1 recurrence were with an orbital approach. over a wide time range. temporalis muscle.19. HUGHES ET AL.5 2 ence (P ¼ 0. followed 2003. Chaudhry IA. been reports of combining endoscopy with orbital approaches44.14. Atypical literature with only a total of 7 instances in magnetic resonance findings in an orbitofrontal WORLD NEUROSURGERY 87: 355-361.3%) incision and orbitotomy (44%). MARCH 2016 www. which likely leads to more 50 Wright 1970 Lipid-containing granuloma 1 33 1 through curettage.14.

genesis of petrous apex cholesterol granuloma. Rizvi SA. 1970. Clin Radiol. Green WR. Evaluation with MR imaging and CT. Jackson IT. Trans Am Ophthalmol Soc. Parke DW. Different patterns of orbital roof Ophthalmol. 30. 2004. 55.24:96-106 [discussion: 106]. due to orbitofrontal cholesterol granuloma. 1954. A 179-182. Blignault P. Vladescu TG.117:1084-1086. Cholesterol granu- A clinicopathologic study of hematic cysts of the Cholesterol granuloma of the frontal bone. Dermoids and epider- 1992. Elliott H. McCord CD. Roman-Romero L. ment.12:206-209. Leccisotti A. Brodkey JA.14:914-917. Rawlings N. 1999. Osteoplastic flap approach versus Posttraumatic granuloma of the bony orbit orbitotomy in case of orbitofrontal cholesterol simulating tumour. Orbital cholesterol granuloma and 21. Font RL. terol granuloma of the orbit. Epidermoid cholesteatoma and 1984. Tanton JH. terol granuloma of the orbit. Gonzalez-Garcia R. experimental and human. Paker I. 15. Brownstein S. McNab AA. 40. 2010. granuloma. Imre A. Orbit. analysis of controversial treatment. Chronic hematic cyst of the orbit. Acta Cytol. Hill CA. Cholesterol-containing granuloma of pneumatized bones. Ramdial PK. Orbit. 1987. ORBITOFRONTAL CHOLESTEROL GRANULOMA cholesterol granuloma.SCIENCEDIRECT. 2012. Kim YJ.59:481-485. of the orbit. 31:184-186. Philip B. Alsuhaibani AH. Arch Ophthalmol. Gessaga E. Late results of matoma. Ross JJ. Alport B. cholesterol granuloma. Pfeiffer RL. Nerad JA. Chen C.89:1144-1162. Shea 3rd JJ. body granuloma of the orbit. tofrontal cholesterol granuloma. involvement by cholesterol granuloma. Ophthal Plast Reconstr Surg. Putterman AM. Millman B. Childs Nerv Reconstr Surg.85:625-633. 2001. Gherghescu G. 49-52. 1990. Morris WM. Ophthalmology. Lateral orbitotomy Cholesterol granulomas of the petrous apex: 1990. 1988. Endoscopic approach to orbi- Syst.28:291-296.100:1803-1808. O’Donnell TR. Bergin DJ. Orbital Cyst without epithelial lining. 48. Peeters FL. 14.59: 5. lateral orbital roof. Jpn J Ophthalmol. Hanbery JW. Wolter JR. 37. Am J Ophthalmol. 44. approach to orbital tumors: report of 10 cases. McGibbon IC. Jackler RK.23: 9. Leone CR. AJNR Am J Neuroradiol. Bras J. Zonneveld FW. Cholesterol granuloma of the 51. Nicholl RJ. Pleatman CW. Trans Ophthalmol Soc UK. Khandelwal N. 29. 18. Report of cases and 24. Alam MS. 1986. Heaton RB.19:93-94. Chow LP. Ann Diagn Pathol. Wiot JG. Phipps SE.4:31-36. 7.41:234-247. management. Inoue M. Int Ophthalmol. Kommerell G. Otol Neurotol. Krishnan S.10:89-94. Fukuta K.. 33. A new theory to explain the frontal bone: CT diagnosis. Daglioglu E.20:167-172. Orbitofrontal cholesterol 22. Rootman J. Wheeler JM. Ozturkcan S. combined neurosurgical and otological manage- Turk Neurosurg. Selva D.46: orbital hemorrhagic lesions. Am J Ophthalmol. Surg. Jordan DR. Oto. 1980. Kincaid MC. Neuroradiology. Choi K. Verbeeten Jr B. Gonzalez-Garcia R. Polito E. 1948.68:57-79. Imai Y.90: 27.97:28-32.2015. Roman-Romero L.95:1549-1553. Indian cholesterol granuloma with destruction of the J Ophthalmol. Okay O. Hoffman RA. 50. Selva D. Ophthal Plast case report and review of the literature. Ophthal Plast Reconstr Surg. 26. the orbit. Pathogenesis of orbital cholesterol granuloma. loma of the orbit—pathogenesis and surgical orbit. Gilroy PA. 1937. 2014. Bloom HR. http://dx. Dame LR. Nicholls JV. Suri S. Dutton JJ. J Otolaryngol. granuloma. Eugenidis N. Plast granuloma. Belen D. Miller NR. Hematic Cyst of the Orbit. McCrary JA.102:237-241.11:141-147. 2000. Eijpe AA. 2002. Hanioka K.23:415-417. Yamamoto M. Tamargo RJ.11. Al-Rubaie K.26:e36-e37. Koornneef L. Cohen NL.18:333-335. Kersten RC. 11. 1934. Orbitofrontal choles- e109-e110. Henry MR. Shapiro A. Moseley IF. J Craniofac Surg. Otolaryngol Head Neck ‘Cholesteatoma’ of the orbit. 2012. Ann Otol Rhinol Laryngol. laryngol Head Neck Surg. Orbital subperiosteal he. Imaging of orbitofrontal 39. Kulwin DR. Clin Experiment Ophthalmol. Belmont H. 17.36:1185-1200. Garrett SN. skeleton. Duran R.1016/j. J Surg.3:137-142. J Comput Assist Tomogr.62:356-362. 2010.doi. Lai T. Orbitofrontal cholesterol atic cysts: a case for craniofacial correction. 2003. Friedmann I. 2011. J Laryngol Otol. 2003. Dorodi S. Ophthal- of a case. cholesterol granuloma. Lipid containing granuloma of the assisted curettage.127:578-581. Chronic hematic cysts of 31. and infection. 28. Al-Khiary H. Dobben GD.wneu. the orbital wall.21:93-98.31: 23. Reconstr Surg. Chrzanowski R. 1966. Rosca T. Goldofsky E.43:521-527. terol granuloma: percutaneous endoscopic- 10.10:166-169.62:528-532. 1993. Robertson JH. 16. 1956. McNab AA. Orbitofrontal cholesterol granuloma. Unilateral exophthalmos 38. LITERATURE REVIEW JOSHUA D. Am moids of the orbit. Chronic orbital hem. 1990. Arch cholesterol granuloma: a case report. Arch Ophthalmol. Knapp A. 1998. Choles. Can Med Assoc J. two. Hasan M. 100:612-616. J Clin Neurosci. Selva D. Laws HW. Ito H. 2003. Madaree A. Lytic Paget disease as a cause of orbital cholesterol granuloma. 46:218-243. Diagnosis and treatment of cholesteatoma: significance of differentiating the cholesterol granuloma. Carter N. Epidermoid cyst and 35.8:215-220. Chocolate cysts in and around the orbit. Role of mag. Pritchard JE. Nishizaki M.94:271-277. 36. Atasoy S. 1997. 1989. J Maxillofac Oral Chronic hematic cyst of the orbit. 1996. mology. 8. J Laryngol Otol. Spitellie P. 47. Imre SS. Recurrent orbitofrontal 12. Orbital uloma of the orbit: an atypical presentation. WORLD NEUROSURGERY. orbital hemorrhage simulating orbital neoplasm. Recurrent cholesterol granuloma thalmol. Bontas E. Clinical controversy in orbitary 25. Ophthal Plast Reconstr Surg. 19. 2006.27:119-121. St Tihoan C. 2008.117: frontal bone. Wright JE. 295-298. 41. North Am. 1988.58:575-579. Gilberg SM. 53. Uckun O. cholesterol granuloma of the orbit. Milne HL. Karim MM. 20. 1990. McCarthy EF. McNab AA. 1986. 1992. Moharamzad Y. Rayport M. 1955. Hayashi Y. Cholesterol cysts of the temporal bone: 360 www. Aferzon M. Arch Oph. 46. Mani NB. The effects of exclusion of air from scan and angiography for orbitofrontal cholesterol 34. Middle East Afr J Ophthalmol. Radiol Clin A false aneurysm and a blood cyst with foreign 32. Sa HS. 26:85-93. granuloma. Br J Radiol. report netic resonance imaging in diagnosis.. 1966. Ramsey GS. Sia DI. Gardner G. Tso MO. 1982. Fralick FB. Boniuk M.37:713-716. 1959.44: Cytologic diagnosis of cholesterol granuloma. 2007. Am J Ophthalmol. 1994. Orbital cholesteatoma. Pinar E. 237-242. Luxenberg M. Selva D.80: granuloma. 4. White VA. Bapuraj JR. Arch Ophthalmol. Koornneef L. Xanthomatosis of the orbit.30: 45. Ong LY.095 . Recurrent orbito. 13. 43. Khalatbari MR. Orbit. Brennan MW. Beaumont GD. Ophthalmology. Cholesterol granuloma of the facial 892-894. Ann Ophthalmol. Recurrent orbital cholesterol 54. Peeters FL.62:344-346. Holliday RA. Cho M. 6. 206-211. 1997. Davis G. Kersten JL. O’Connell JX. Trans Am Acad Ophthalmol Otolaryngol. frontal cholesterol granuloma in pediatric patient: Chronic hematic cyst of the orbit. 3. Surg. 42. Jochum JM. 2014. 1948. Wright JE.30:365-367. Loeffler KU. Br J Plast Surg. Dalgic A. 2011. 236-249. HUGHES ET AL. 2005. Bone 52. Choles- case report. 2015. Akdemir G.10:S37-39.108:886-887. Cholesterol gran- 78-82. Orbit. Gillissen JP.142:292-293. Mafee MF. Lloyd GA. Goldberg MF. J Neurosurg.

WORLDNEUROSURGERY. Hiraide F.100:181-187. Lim DJ. Carpenter AM. Cramer HM. 491-501. cholesterol granuloma. Otitis media with perforation of 60. 1990. Roggli VL. http://dx.172:1317-1319. J Laryngol Otol. (2016) 87:355-361.1016/j. Nolan RL. 1970. All rights reserved. Ann Otol Rhinol Lar. Paparella MM. 59. ORBITOFRONTAL CHOLESTEROL GRANULOMA diagnosis and treatment.see front matter ª 2016 Elsevier Inc. to disclose. Ann Otol Rhinol Laryngol. published or submitted for publication before.11. Cholesterol ethical. Goodman PC. 1994. Tapson VF. cholesterol granuloma. and none of the authors have any conflicts of 58. Experimental 63. Conflict of interest statement: No part of this draft has been mental study. Journal homepage: www. Walia HS. Nager GT. Sporn TA. Cholesterol granuloma the tympanic membrane: a longitudinal experi. Goycoolea MV. involving the temporal bone. Sawada M. yngol. Cholesterol granuloma 1991.sciencedirect. 356-359.82:164-169. MARCH 2016 www.90:2037-2045. Main TS. Citation: World Neurosurg. The pathogenesis of the experimentally granulomas in patients with pulmonary artery induced cholesterol granuloma (author’s transl).91: of the breast: a mimic of carcinoma. Histopathological and granuloma of the peritoneum.doi. Can J Surg. 1976. Shimada T. LITERATURE REVIEW JOSHUA D. Vanderveen TS.wneu. Nihon Jibiinkoka Gakkai kaiho. 1999. 1878-8750/$ .WORLDNEUROSURGERY.33: Received 17 October 2015. 56.96: 410-413. accepted 26 November 2015 histochemical studies. hypertension: chest radiographic and CT findings.191:249-250. Madda JP.85:204-209. Juhn SK. AJR Am J 361 . Pulmonary cholesterol Available online: www. financial or 57. 1980. Miyakogawa N. Inouye T. Hiraide F.095 Tsubaki Y. Reynolds HE. Inouye T. Radiology. Experimental 61. HUGHES ET AL. Arch Otolaryngol. al-Amer AF. 1979.2015. McAdams HP. WORLD NEUROSURGERY 87: 355-361. Laryngoscope. Miyakogawa N.