The Temporal Bone and Transtemporal Approaches
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull base, Skull base neoplasm, Surgicalapproach, Temporal bone
he temporal bone is divided into squamosal, petrous,mastoid, tympanic, and styloid parts (
).The squamosal part helps enclose the brain. The mas-toid part is trabeculated and pneumatized to a variable de-gree and contains the mastoid antrum. The petrous part iscompact and encloses the cochlea, the vestibule, and the semi-circular, facial, and carotid canals (
). The tympanic partforms part of the wall of the tympanic cavity and the externalacoustic meatus. The styloid projects downward and serves asthe site of attachment of several muscles. This section exam-ines these parts in greater detail and defines the anatomic basis of the approaches directed through the temporal bone tothe posterior fossa and petroclival region. The approachesexamined are the middle fossa, translabyrinthine, transco-chlear, combined supra- and infratentorial presigmoid, sub-temporal anterior transpetrosal, subtemporal preauricular in-fratemporal, and the postauricular transtemporal approaches.The approaches directed through the surface of the tempo-ral bone forming the middle fossa floor include 1) the verylimited middle fossa exposure of the internal acoustic meatus;2) the anterior petrosectomy approach directed medial to theinternal acoustic meatus through the petrous apex to accessthe upper anterior part of the posterior fossa and clivus; 3) theextended middle fossa approach, which may include not onlyresection of the roof of the internal acoustic meatus and pe-trous apex, but is extended lateral to the internal acousticmeatus to include resection, as needed, of the semicircularcanals, vestibule, roof of the mastoid antrum and tympaniccavity, and the posterior face of the temporal bone; and 4) thesubtemporal preauricular infratemporal fossa approach inwhich the middle fossa exposure is combined with exposureof the infratemporal fossa and, if needed, the petrous carotid,petrous apex, pterygopalatine fossae, and orbit.The approaches directed through the mastoid in front of thesigmoid sinus vary in the amount of temporal bone resected.They include 1) the minimal mastoidectomy variant in whichonly enough presigmoid dura is exposed to open the dura infront of the sigmoid without exposing the labyrinth; 2) theretrolabyrinthine approach, which exposes the bony capsuleof the labyrinth; 3) the partial labyrinthectomy, which in-cludes removal of one or more of the semicircular canals; 4)the translabyrinthine approach, which includes resection ofthe semicircular canals and vestibule; and 5) the transcochlearmodification, which includes removal of all the labyrinth,including the cochlear and possibly the petrous apex. Thesevariants of the transmastoid approaches can all be combined,as needed, with the supra- and infratentorial presigmoid ap-proaches to the middle and posterior fossa.The final approach to be reviewed is the postauriculartranstemporal approach, which allows lesions involving themastoid, tympanic cavity, petrous apex, and jugular foramento be followed backward to the areas exposed by the retrosig-moid and far-lateral approaches and forward to the infratem-poral, pterygopalatine and middle fossae, lateral maxilla, andorbit. Selecting an approach directed through the temporal bone requires an understanding of its complex anatomy andits relationship to the petroclival region, the infratemporalfossa, and parapharyngeal space. Protecting and preservingthe facial nerve, the petrous carotid artery, and the sensoryorgans of the inner ear that are contained within the temporal bone are important elements in operative approaches directedthrough the lateral aspect of the cranial base.
THE TEMPORAL BONE ANDTRANSTEMPORAL APPROACHESLateral surface
When the skull and temporal bone are viewed from alateral perspective, some landmarks useful in performing ap-proaches directed around and through the temporal bone can be identified (
). The posterior end of the superiortemporal line continues inferiorly as the supramastoid crestand blends into the upper edge of the zygomatic arch. Thesupramastoid crest is located at the level of the floor ofthe middle fossa. The junction of the supramastoid crestwith the squamous suture is located at the lateral end of thepetrous ridge. The meeting point of the parietomastoid andsquamous sutures is located a few millimeters below the lateralend of the petrous ridge. The anterior edge of the junction of thesigmoid and transverse sinuses is located at the junction ofthe squamous and parietomastoid suture.The mastoid antrum, a pneumatized space opening into thetympanic cavity, is located about 1.5 cm deep to the su-
Vol. 47, No. 3, September 2000 Supplement