Petrous apex cholesterol granulomas are expansile, cystic lesions containing cholesterol crystals surrounded by foreign body giant cells, fibrous tissue reaction and chronic inflammation. Appropriate treatment relies on an accurate radiological diagnosis and an understanding of the distinguishing radiological features of relevant entities in the differential diagnosis of this condition.

Firstly, this paper presents a pictorial review of the relevant radiological features of petrous apex cholesterol granuloma, and highlights unique features relevant to the differential diagnosis. Secondly, it reviews the histopathological and radiological findings associated with surgical drainage of these lesions.

Radiological features relevant to the differential diagnosis of petrous apex cholesterol granuloma are reviewed, together with radiological and histopathological features relevant to surgical management. Following surgical management, histopathological and radiological evidence demonstrates that the patency of the surgical drainage pathway is maintained.

Accurate diagnosis of petrous apex cholesterol granuloma is essential in order to instigate appropriate treatment. Placement of a stent in the drainage pathway may help to maintain patency and decrease the likelihood of symptomatic recurrence.