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The Temporal Bone and Transtemporal Approaches

The Temporal Bone and Transtemporal Approaches

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CHAPTER 8
The Temporal Bone and Transtemporal Approaches
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words:
Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull base, Skull base neoplasm, Surgicalapproach, Temporal bone
T
he temporal bone is divided into squamosal, petrous,mastoid, tympanic, and styloid parts (
Figs. 8.1
and
8.2
).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 (
Fig. 8.3
). 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 (
Fig. 8.2
). 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-
S211
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 
 
FIGURE 8.1. Temporal bone.
A
and
, inferior views.
A
, thetemporal bone has a squamosalpart, which forms some of thefloor and lateral wall of themiddle cranial fossa. It is also thesite of the mandibular fossa inwhich the mandibular condylesits. The tympanic part forms theanterior, lower, and part of theposterior wall of the externalcanal, part of the wall of thetympanic cavity, the osseousportion of the eustachian tube,and the posterior wall of themandibular fossa. The mastoidportion contains the mastoid aircells and mastoid antrum. Thepetrous part is the site of theauditory and vestibular labyrinth,the carotid canal, the internalacoustic meatus, and the facialcanal. The petrous part also formsthe anterior wall and the domeof the jugular fossa. The styloidpart projects downward andserves as the site of attachment of three muscles.
, inferior view of the temporal and surroundingbones. The squamosal andpetrous parts articulate anteriorlywith the greater wing of thesphenoid. The petrous apex facesthe foramen lacerum and isseparated from the clival part of the occipital bone by thepetroclival fissure. The occipitalbone joins with the petrous partof the temporal bone to form the jugular foramen. The mandibularfossa is located between theanterior and posterior roots of thezygomatic process.
and
,superior views.
, the medial partof the upper surface is the site of the trigeminal impression in which Meckel’s cave sits. Farther laterally is the prominence of the arcuate eminence overlying thesuperior semicircular canal. Anterolateral to the arcuate eminences is the tegmen, a thin plate of bone overlying the mastoidantrum and epitympanic area. The temporal bone articulates anteriorly with the sphenoid bone, above with the parietal bone, andposteriorly with the occipital bone. The zygomatic process of the squamosal part has an anterior and a posterior root betweenwhich, on the lower surface, is located the mandibular canal.
, temporal and surrounding bones. The squamosal part of thetemporal bone joins anteriorly with the sphenoid bone to form the floor of the middle cranial fossa. Posteriorly, it articulates withthe occipital bone to form a portion of the anterior wall of the posterior fossa. Medially, it articulates with the clival portion of theoccipital bone at the petroclival fissure. The sigmoid sulcus descends along the posterior surface of the mastoid portion and turnsforward to enter the jugular foramen. The foramen lacerum is located at the junction of the temporal, sphenoid, and occipitalbones. The porus of the internal acoustic meatus is located in the central part of the posterior surface.
Ac.
, acoustic;
Ant.
, anterior;
Arc.
, arcuate;
Car.
, carotid;
Cond.
, condyle;
Digast.
, digastric;
Emin.
, eminence;
For.
, foramen;
Gr.
, greater;
Impress.
, impression;
Int.
, internal;
Jug.
, jugular;
Mandib.
, mandibular;
N.
, nerve;
Occip.
, occipital;
Pet.
, petrosal;
Post.
, posterior;
Proc.,
process;
Sig.
,sigmoid;
Stylomast.
, stylomastoid;
Trig.
, trigeminal;
Tymp.
, tympanic.
S212
Rhoton
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 
 
prameatal triangle, a depression in the mastoid surface lo-cated between the posterosuperior edge of the external me-atus, the supramastoid crest, and the vertical tangent alongthe posterior edge of the meatus. The suprameatal spine ofHenle is located at the outer end of the posterosuperior edgeof the external canal along the anterior edge of the su-prameatal triangle and corresponds to the level of the lateralsemicircular canal and tympanic segment of the facial nerve ata depth of approximately 1.5 cm. Several landmarks are alsohelpful in identifying the location of the junction of the trans-verse and sigmoid sinuses at the posterior aspect of the mas-toid. The asterion located at the junction of the lambdoid,occipitomastoid, and parietomastoid sutures is usually lo-cated over the junction of the lower part of the transverse andsigmoid sinuses. A burr-hole placed at this site will usuallyexpose the lower edge of this junction. A burr-hole located atthe junction of the supramastoid crest and the squamosalsuture will be located at the posterior part of the middle fossafloor just above and anterior to the upper edge of the junctionof the transverse and sigmoid sinuses.
FIGURE 8.2. Temporal bone.
A
, posterior view of a right temporal bone. The squamosal part forms part of the floor and lat-eral wall of the middle fossa. The sigmoid sulcus descends along the posterior surface of the mastoid portion. The internalacoustic meatus enters the central portion of the petrous part of the bone. The trigeminal impression and arcuate eminenceare located on the upper surface of the petrous part. The vestibular aqueduct connects the vestibule in the petrous part withthe endolymphatic sac, which sits on the posterior petrous surface inferolateral to the internal acoustic meatus.
, enlargedview. The transverse crest separates the meatal fundus into a superior part where the facial canal and superior vestibularareas are situated, and an inferior part where the cochlear and inferior vestibular areas are located. The vertical crest sepa-rates the facial and superior vestibular areas.
, enlarged view of another internal acoustic meatus. The transverse crestdivides the meatal fundus into superior and inferior parts. The anterior part above the transverse crest is the site of the facialcanal and the posterior part is the site of the superior vestibular area. Below the transverse crest, the cochlear area is ante-rior and the inferior vestibular area is posterior.
, another internal acoustic meatus. The view is directed to expose the sin-gular foramen, for the singular branch of the inferior vestibular nerve that innervates the posterior ampullae. The inferior ves-tibular nerve also has a saccular and, occasionally, a utricular branch.
Ac.
, acoustic;
Arc.
, arcuate;
CN 
, cranial nerve;
Coch.
,cochlear;
Emin.
, eminence;
Ext.
, external;
For.
, foramen;
Impress.
, impression;
Inf.
, inferior;
Int.
, internal;
Mandib.
, mandibu-lar;
Occipitomast.
, occipitomastoid;
Parietomast.,
parietomastoid;
Proc.,
process;
Sig.
, sigmoid;
Sp.
, spine;
Sup.
, superior;
Supramast.
, supramastoid;
Trans.
, transverse;
Trig.
, trigeminal;
Vert.
, vertebral;
Vest.
, vestibular.
Temporal Bone
S213
Neurosurgery,
Vol. 47, No. 3, September 2000 Supplement 

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