The Temporal Bone: Basic Anatomy
and Approaches to Internal Auditory Canal
Keywords
Temporal bone  Facial nerve  Internal auditory canal
canals  Vestibular schwannoma surgery
18.1 Introduction
Surgeries through the temporal bone are challenging because
of its complicating anatomy inside the bone [15–17, 21, 22].
In this chapter, to understand the basic anatomy of the
temporal bone, we will describe the following:
• The basic structures of the temporal bone, both for sur-
gery and radiological interpretation
• The microsurgical anatomy of the three approaches to the
internal auditory canal (IAC) through the temporal bone
The important structures that neurosurgeons must have a
detailed knowledge of include IAC, cochlea, three semicir-
cular canals, and cranial nerve (CN) VII. In this chapter, we
describe the relationships between these structures. (Regard-
ing the transpetrosal approaches and surgeries related to
IAC, refer to Chap. 14: “Microsurgical Anatomy of the
Internal Auditory Canal and Surrounding Structures, and
Vestibular Schwannoma Surgery” and Chap. 19: “Posterior
and Anterior Transpetrosal Approaches.”) The approaches
through the temporal bone have many variations depending
on their purpose. However, they share one aim: to avoid
injury of CN VII and postoperative hearing disturbance.
18.2 Basic Structures
18.2.1 Constituents: The Squamous, Petrous,
and Tympanic Parts
The temporal bone contains the external ear, middle ear
(tympanic membrane, tympanic cavity, three ossicles,
Eustachian tube, and antrum), internal ear (vestibule, semi-
circular canals, and cochlea), and facial canal. The facial,
T. Matsushima, Microsurgical Anatomy and Surgery of the Posterior Cranial Fossa: Surgical Approaches
and Procedures Based on Anatomical Study, DOI 10.1007/978-4-431-54183-7_18, # Springer Japan 2015
18
 Cochlea  Semicircular
cochlear, and superior and inferior vestibular nerves course
inside the bone, especially within IAC (Fig. 18.1a).
The temporal bone, which is joined anteriorly to the
sphenoid bone, superiorly to the parietal bone, and posteri-
orly to the occipital bone, is comprised by three parts:
squamous, petrous, and tympanic. The junction of these
parts on the lateral side forms the external auditory canal
(Fig. 18.1b) [21]. The squamous part—a round, bony plate
standing erect sagittally—has a convex external surface,
and its zygomatic process projects forward from the
anterosuperior part of the porus acusticus externus to join
the zygomatic bone, forming the zygomatic arch. The
petrous part contains the mastoid process, which projects
downward, and the petrous bone, which projects
anteromedially and wedges between the sphenoid and
occipital bones (Fig. 18.1c, d). The digastric groove
below the mastoid process is the site of attachment of the
sternocleidomastoid muscle and can be palpated behind the
lower part of the auricle (Fig. 18.1b). The occipital artery
and occipital nerve pass superomedially through this
groove. The inner surface of the mastoid process also has
a groove, called the sigmoid sulcus, in which the sigmoid
sinus courses (Fig. 18.1d). The interior of the mastoid
process in adults is filled with mastoid air cells, which
communicate with the mastoid antrum. Therefore, the mas-
toid bone ultimately communicates with the external
environment.
The petrous bone contains IAC, which opens as the oval
porus acusticus internus (PAI) in the center of the posterior
surface of the petrous bone (Fig. 18.1d). The cochlea lies
anterolateral to IAC, the semicircular canals lie lateral to it,
the carotid canal courses anteroinferior to it, and the jugular
foramen lies posteroinferior to it.
249
250 18 The Temporal Bone: Basic Anatomy and Approaches to Internal Auditory Canal
Fig. 18.1 Basic structure of the ear and the three surfaces of the
temporal bone. (a) Illustration showing the structures of the right ear.
Anterior view (from Matsushima T [14] with permission). (b) Dry
18.2.2 Interior Structures of the Temporal Bone,
with Special Reference to the Internal
Auditory Canal and Surrounding
Structures
IAC is surrounded by the cochlea and three semicircular
canals. After coursing in IAC, CN VII runs in the facial
canal between the cochlea and semicircular canals from the
posterior to middle cranial fossa, where it forms the genicu-
late ganglion. The nerve then runs downward in the mastoid
bone toward the stylomastoid foramen. The dry bone shown
in Fig. 18.2a, b demonstrates the cochlea (highlighted in red)
anterolateral to IAC and the semicircular canals (highlighted
in green) posterolateral to it. CN VII, highlighted in yellow,
which enters the temporal bone through PAI, is also visible
coursing around the mastoid antrum after passing the middle
cranial fossa.
temporal bone: lateral surface. (c) Dry temporal bone: superior surface
(middle cranial fossa floor). (d) Dry temporal bone: medial surface
(posterior cranial fossa lateral wall)
Surrounding PAI on the surface of the posterior cranial
fossa are several structures relevant to neurosurgeons,
including the subarcuate fossa, which contains the
subarcuate artery, and the vestibular aqueduct, which
communicates with the aquaeductus cochleae
(Fig. 18.2c). In the dry bone shown in Fig. 18.2d, the
bone covering IAC and semicircular canals have been
removed, exposing the interior of IAC, superior semicircu-
lar canal, and posterior semicircular canal. The junction
between the superior and posterior semicircular canals is
termed the common crus. The lateral end of IAC is divided
into four parts. The transverse crest divides it into the upper
and lower parts, and the vertical crest further subdivides the
upper portion into the anterior and posterior parts. The
anterior part is the facial canal, in which CN VII passes,
and the posterior part is the superior vestibular part,
through which the superior vestibular nerve passes.
18.2 Basic Structures
Fig. 18.2 Dry bones showing the internal auditory canal (IAC) and
surrounding structures, such as the cochlea, three semicircular canals,
and facial canal (from Matsushima T [14] with permission). (a) Dry
skull. Superior view. The three semicircular canals have been exposed
on the left side, and the facial canal has been exposed on the right side.
(b) Dry left temporal bone. Superior view. IAC and surrounding
structures are visible. (c) Dry left temporal bone. Posterior view. The
The area below the transverse crest is also divided approx-
imately into two areas, and the cochlear nerve and inferior
vestibular nerve traverse them, respectively.
18.2.3 Imaging Anatomy
Osseous structures in the temporal bone are visible with
computed tomography (CT). Axial-view CT scans shown
in Fig. 18.3a, b demonstrate the structures present at the
levels of the external auditory canal and IAC. Air cells,
including the mastoid air cells, occupy most of the temporal
bone. Malleus and incus are visible in the middle ear, and the
cochlea, which is connected with them, is visible in the
internal ear (Fig. 18.3a). The compact bone, which does
not contain any air cells, lies posterolateral to IAC. It can
be seen as a white, high-density mass on CT (Fig. 18.3b).
The semicircular canals are situated inside this compact
bone (Fig. 18.3b).
251
vestibular aqueduct and subarcuate fossa are visible superolateral and
inferolateral to the porus acusticus internus, respectively. (d) Dry left
temporal bone. Posterior view. IAC and semicircular canals have been
opened. The fundus of IAC and common crus are visible. The common
crus is lateral to the fundus. The lateral end of the fundus is separated
into four parts by the transverse and vertical crests
Regarding the relationships between the external, middle,
and internal ears, the external auditory canal and middle ear
are bounded by the tympanic membrane, and a small foram-
ina called the round window and the oval window exist in the
boundary between the middle and internal ears. The base of
the stapes, an ear ossicle, fits into the oval window, and it
propagates vibration from the tympanic membrane to this
window (Fig. 18.3c). Vibration transmitted from the middle
ear excites the hair cells of the organ of Corti (or spiral organ)
in the cochlea, which transmits the stimulus to the cochlear
nerve. The semicircular canals monitor equilibrioception: the
semicircular canals, which contain endolymph liquid, are
located at right angles to one another, thus permitting differ-
entiation of rotational movement in all directions. The nerves
in the semicircular canals and saccule combine, forming the
superior and inferior vestibular nerves, and enter the medulla
oblongata after merging with the cochlear nerve within IAC.
The cochlear nerve from the cochlea runs in the
anteroinferior portion of IAC, and the superior and inferior
vestibular nerves run in the posterior half of IAC (Fig. 18.3c).
252 18 The Temporal Bone: Basic Anatomy and Approaches to Internal Auditory Canal
Fig. 18.3 Computed tomography (CT) imaging of the temporal bone
(from Matsushima T [14] with permission). CT reveals the internal
auditory canal (IAC), facial canal, cochlea, three semicircular canals,
incus, malleus, and jugular foramen. (a) Left side. Superior view at the
level of the ossicula auditus. (b) Left side. Superior view at the level of
the facial canal from the posterior to middle cranial fossa. (c)
18.2.4 The Course of Cranial Nerve VII
and Its Branches
Figure 18.4 shows the dry temporal bones after mastoidec-
tomy or unroofing of IAC. CN VII is visible running from
the posterior to the middle cranial fossa, then descending
toward the stylomastoid foramen inside the petrous bone,
running around the external auditory canal (Fig. 18.4). CN
VII, which originates from the lower pons, first runs in the
anterosuperior part of IAC, coursing in the facial canal
toward the middle cranial fossa to form the geniculate gan-
glion (Fig. 18.4a, b). The parasympathetic branch,
originating from the medulla oblongata and coursing
together with the nerve bundle of CN VII, divides from the
geniculate ganglion and joins the greater petrosal nerve. The
nerve courses in the great petrosal sulcus to the facial hiatus
(Fig. 18.4b). Gustatory nerve fibers, which originate from
nerve cells in the geniculate ganglion, combine to form the
nervus intermedius. Its central branch runs in IAC with CN
VII to enter the pons. While CN VII descends in the mastoid
bone, the peripheral branch divides from CN VII, joins the
Illustration showing the structures surrounding the left IAC. Superior
view. Cranial nerves (CNs) VII and VIII run in the canal. CN VII forms
the geniculate ganglion with the greater petrosal nerve on the middle
cranial fossa. The cochlea is anterolateral to the canal, and the three
semicircular canals are posterolateral to it
parasympathetic secreting fibers to form the chorda tympani,
and innervates the tongue.
The main trunk of CN VII emerges laterally from the
geniculate ganglion and descends in the shape of a bow lateral
to the compact bone containing the lateral and posterior
semicircular canals. In other words, the main trunk courses
around the posterior wall of the external auditory canal.
Finally, it exits the skull base through the stylomastoid fora-
men, giving off branches to the parotid gland (Fig. 18.4c).
CN VII has the following types of branches:
• Branches that arise from CN VII while it travels in the
facial canal, e.g., the greater petrosal and chorda tympani
nerves
• Branches that arise from CN VII shortly after it emerges
from the stylomastoid foramen
• Branches of CN VII that enter the parotid plexus and end
in the mimic muscles of the face
Nerve representatives of latter two types are motor fibers
with branches innervating the mimic muscles of the face,
controlling facial muscles such as the orbicularis oculi,
orbicularis oris, and platysma.
18.2 Basic Structures
Fig. 18.4 The course of cranial nerve (CN) VII (from Matsushima T
[14] with permission). The facial canal in the dry temporal bone has
been opened on the left side. (a) Temporal bone showing the posterior
and middle cranial fossae. Posterosuperior view. CN VII courses from
the posterior to middle cranial fossa between the cochlea and semicir-
cular canals. (b) Temporal bone showing the middle cranial fossa.
253
Superior view. CN VII forms the geniculate ganglion with the greater
petrosal nerve anterior to the arcuate eminence. (c) Temporal bone
showing the interior of the mastoid process. Lateral view. Mastoidec-
tomy has exposed the facial canal and CN VII. The nerve runs down-
ward from the middle cranial fossa to the stylomastoid foramen around
the external auditory canal
254 18 The Temporal Bone: Basic Anatomy and Approaches to Internal Auditory Canal

18.3.1 The Lateral Suboccipital Retrosigmoid

18.3 Three Surfaces of the Temporal Bone
and Three Approaches to the Internal
Auditory Canal
Because the temporal bone has three surfaces, there are three
approaches to IAC (Figs. 18.1 and 18.5) [16, 17, 21]: the
lateral suboccipital retrosigmoid approach from the posterior
cranial fossa [22, 23, 26]; the middle cranial fossa approach
from the middle cranial fossa [7, 9, 24, 25]; and the
translabyrinthine approach after mastoidectomy from the
lateral side [8]. We will now explain these three approaches.
Approach
In cases of vestibular schwannoma surgery, the lateral
suboccipital retrosigmoid approach is most frequently used by
neurosurgeons [22, 23, 26]. Because the semicircular canals
remain intact, the approach provides the opportunity to preserve
hearing postoperatively. However, there are a few demerits to
the approach. Using this approach, the cerebellar hemisphere
must be retracted and, in patients with large vestibular
schwannomas, CN VII is not visible during the early stages of
surgeries because the nerve usually runs ventral to the tumor.

Fig. 18.5 Illustrations showing the three surfaces of the temporal bone on the left side: these are utilized for temporal bone surgeries (from
Matsushima T [14] with permission). (a) Posterior cranial fossa side. (b) Middle cranial fossa side. (c) Lateral mastoid bone side
18.3 Three Surfaces of the Temporal Bone and Three Approaches to the Internal Auditory Canal
The series of images in Fig. 18.6 show posterior views of
the left cerebellopontine angle in a cadaveric specimen with
the cerebellar hemisphere resected. IAC and CNs VII and
VIII are in the center, and they are dissected step-by-step.
Meckel’s cave and CN V are visible above them, and the
jugular foramen and lower CNs are visible below them
(Fig. 18.6a). The plane of brainstem section is at the level
of the middle cerebellar peduncle. The subarcuate artery,
arising from the anterior inferior cerebellar artery (AICA), is
buried in the dura mater of the posterior edge of PAI. In
Fig. 18.6b, the dura mater in the posterior region around IAC
has been stripped, and the posterior wall of IAC has been
partially removed. Therefore, the subarcuate artery has been
cut. The vestibular aqueduct and dura mater buried in the
posterior part of IAC are visible on the bony petrosal surface
with the dura mater removed. In Fig. 18.6c, we drilled the
region lateral to IAC, exposing the common crus and poste-
rior semicircular canal to show the relationships of these
structures with IAC, which is not visible during surgery.
The curved canal is the posterior semicircular canal. The
common crus—the junction of the three semicircular
canals—is nearest to the lateral end of IAC. The average
distance from the lateral end of IAC to the common crus was
4 mm in our cadaveric study. Air cells in the posterior wall
of IAC are also visible. The jugular foramen, containing the
jugular bulb, sometimes extends anterosuperiorly to reach
the wall of IAC. In Fig. 18.6d, the lateral part of the posterior
wall of IAC is removed, exposing the bottom of IAC. When
the superior and inferior vestibular nerves are separated
using forceps, the transverse crest and cochlear nerve from
the cochlea are visible. In this case, the superior and inferior
vestibular nerves combine near PAI. In Fig. 18.6e, f, and g,
each nerve has been incised step-by-step to demonstrate the
four CNs at the bottom of IAC. The CNs are incised, and
their cut planes are presented in Fig. 18.6g.
To preserve hearing, it is essential to understand the
anatomical relationship between IAC and common crus,
especially observed from the direction of the surgical
approach. Through the lateral suboccipital retrosigmoid
approach, when the posterior wall of IAC is drilled and
opened, care should be taken not to injure the common
crus or semicircular canals. Tatagiba M et al. reported that
postoperative hearing loss following acoustic schwannoma
surgery correlated with damage of the common crus or
semicircular canals during removal of the posterior wall of
the IAC [26].
18.3.2 The Epidural Middle Cranial Fossa
Approach
The epidural middle cranial fossa approach is preferred for
the removal of vestibular schwannomas by otolaryngologists
255
[7, 9]. This is because, when IAC is opened from the middle
cranial fossa side using this approach, it is easy to identify
CN VII in IAC and separate it from the tumor. However, the
approach has some demerits: the surgical field is narrow and
the temporal lobe requires excessive retracted. It is thus
unsuitable for the removal of large tumors. To compensate
for these demerits, epidural opening of IAC or removal of
the petrous bone around IAC is included in improved
variations on the middle cranial fossa approach, such as the
extended middle cranial fossa approach [9, 24, 25]. The
middle cranial fossa approach can thus be subclassified
according to the method of opening IAC through the middle
cranial fossa:
• Opening only IAC
• Opening IAC with the anterior petrous portion resected
• Opening IAC, with resection of the bone posterior to it,
including the semicircular canals
It is important to understand the anatomy related to these
three variations of the epidural middle cranial fossa
approach related to the three subdivided approaches based
on IAC. The case, in which IAC is partially opened and the
petrous bone anterior to it is removed, is known as Kawase’s
approach, which is very famous as an approach for
petroclival lesions such as petroclival meningiomas [10–13].
For the epidural middle cranial fossa approach, it is
important to understand the relationships of the greater
petrosal nerve, geniculate ganglion, IAC, and cochlea with
the foramen spinosum and arcuate eminence, including the
superior semicircular canal, because intraoperative
anatomical landmarks on the bony surface are scarce, except
for the foramen spinosum, arcuate eminence, and Meckel’s
cave. To clarify the anatomy relevant to the epidural middle
cranial fossa approach, especially IAC and surrounding area,
the dura mater should be removed, and the roofs of the
sulcus of the greater petrosal nerve, IAC, and superior semi-
circular canal should be opened step-by-step (Fig. 18.7a–f).
The middle meningeal artery enters intracranially through
the foramen spinosum (Fig. 18.7a, b). The artery and fora-
men are the first intraoperative anatomical landmarks for the
epidural middle cranial fossa approach. After the dura mater
is removed, the middle meningeal artery, greater petrosal
nerve, and CN V are clearly visible (Fig. 18.7b). The third
division of CN V entering the foramen ovale is located
medial to the greater petrosal nerve. When the bone posterior
to the sulcus of the greater petrosal nerve is drilled, care
must be taken to avoid the internal carotid artery (ICA). ICA
runs below the nerve, and sometimes the bone over the
artery is thin or absent (Fig.18.7b, c). Following the greater
petrosal nerve laterally, the geniculate ganglion is exposed
(Fig. 18.7c, d). The lesser petrosal nerve courses parallel and
anterior to the greater petrosal nerve, and the arcuate emi-
nence is situated just posterolateral to the geniculate
ganglion (Fig. 18.7d, e). When the roofs of IAC and arcuate
256 18 The Temporal Bone: Basic Anatomy and Approaches to Internal Auditory Canal

Fig. 18.6 Step-by-step dissection for the lateral suboccipital
retrosigmoid (posterior cranial fossa) approach: posterior view on the
left side (from Matsushima T [14] with permission). (a) The intact
posterior surface of the temporal bone. The cerebellum has been
removed for demonstration of the left cerebellopontine angle. (b)
Opening of the internal auditory canal (IAC). The subarcuate artery
was cut. (c) Opening of the posterior semicircular canal. Cranial nerve
(CN) VIII has been separated into the superior and inferior vestibular
nerves near the transverse crest. (d) The lateral part of the IAC. The
transverse crest and the cochlear nerve are visible. (e) Section of the
superior vestibular nerve. (f) Section of the superior and inferior ves-
tibular nerves and CN VII. (g) The fundus of the canal after the removal
of CNs VII and VIII. The cut surfaces of four CNs are visible
18.3 Three Surfaces of the Temporal Bone and Three Approaches to the Internal Auditory Canal
Fig. 18.7 Step-by-step dissection for the epidural middle cranial fossa
approach: anterosuperior view with the cerebrum removed on the left
side. (a) The intact left middle cranial fossa. The cut surface of the
midbrain is visible. The middle meningeal artery can be seen through
the dura mater to travel intracranially through the foramen spinosum.
The superior petrosal sinus connects with the cavernous sinus medially.
(b) Removal of the dura mater. The middle meningeal artery, greater
petrosal nerve, and cranial nerve (CN) V are exposed. The internal
carotid artery (ICA) can be seen through the thin bone running behind
the greater petrosal nerve. (c) Exposure of the geniculate ganglion.
Following the greater petrosal nerve laterally, the bone has been
removed to expose the geniculate ganglion. The arcuate eminence is
situated posterolateral to the ganglion. The third division of CN V
entering the foramen ovale is also exposed. (d) Drilling the roof of
257
the internal auditory canal (IAC) and arcuate eminence. This drilled
specimen demonstrates the relationships between the IAC, superior
semicircular canal, geniculate ganglion, greater petrosal nerve, and
CN V. All cranial nerves in the middle fossa are exposed. The incus
and malleus are also visible. (e) High-magnification image of
Fig. 18.7d. The cochlea is exposed at the corner of the greater petrosal
nerve and CN VII. CN VII in the IAC has been retracted to show the
cochlear nerve. CN VII, branching from the geniculate ganglion, runs
downward between the superior semicircular canal and the malleus and
incus. The petrous portion of ICA, which courses under CN V, is also
exposed. Kawase’s triangle is intact. f: The petrous apex area in the
middle cranial fossa. The tentorium and superior petrosal sinus at
Meckel’s cave have been removed. All CNs around Kawase’s triangle
are exposed. The intracranial portions of CN V are entirely visible
258 18 The Temporal Bone: Basic Anatomy and Approaches to Internal Auditory Canal
eminence are opened, the relationships between IAC, supe-
rior semicircular canal, geniculate ganglion, greater petrosal
nerve, and CN V are revealed. The cochlea is located in the
deep area medial to the junction of the greater petrosal nerve
and CN VII (Fig. 18.7e). When the dura mater of the roof of
IAC is opened, CNs VII and VIII are exposed. CN VII
courses in the superoanterior portion of IAC, and the supe-
rior vestibular nerve runs in its superoposterior portion
(Fig. 18.7e). The nervus intermedius exists between these
nerves. The cochlear nerve courses under CN VII, entering
the cochlea at the deep area anterolateral to IAC. The meatal
loop of AICA runs between CNs VII and VIII. The internal
auditory arteries enter from the anterior side of IAC. When
the roof of IAC and surrounding area, especially the arcuate
eminence, are removed, a wide surgical field is obtained.
This approach can be applied in patients with no or insuffi-
cient hearing ability.
Kawase’s triangle (or the posteromedial triangle) is the
area surrounded by Meckel’s cave, CN V, IAC, and the
sulcus of the great petrosal nerve. During surgery, this area
resembles a triangle through the operating microscope. In the
images presented in Fig. 18.7, this triangle area is intact
(Fig. 18.7e, f). This space is small but useful when
approaching petroclival lesions, because no other structures
with the potential to cause neurological deficits exist in the
superficial area. However, when CN V is displaced medially
and the bone inferior to Meckel’s cave is resected, ICA exists
immediately below this area (Fig. 18.7f). In some cases, the
bone of Meckel’s cave superior to ICA is absent. Therefore,
great care must be taken not to damage the artery during
removal of the bone in the medial side of Kawase’s triangle.
18.3.3 The Translabyrinthine Approach
The translabyrinthine approach, through which IAC is
exposed extracranially, is another approach preferred by
otolaryngologists [6, 8]. After the development of various
transpetrosal approaches, the translabyrinthine approach has
proven useful for large vestibular schwannomas in the
cerebellopontine angle, and now neurosurgeons sometimes
use it. To use the approach, it is necessary to understand first
the mastoidectomy and then the translabyrinthine approach
[1–4, 18–20, 27]. The approach has the following advantages:
• Retraction of the cerebellar hemisphere is unnecessary.
• CN VII is distinguishable from the tumor by the lateral
part of the IAC at the early stage of surgery.
However, the main disadvantage of the approach is that,
to open IAC, the semicircular canal must be destroyed and,
consequently, hearing cannot be preserved postoperatively.
This approach is suitable for patients with acoustic tumors,
especially those who have lost their hearing, and with com-
paratively large tumors.
For this approach, mastoidectomy is performed first [5].
Figure 18.8a shows the start of drill resection from the
surface of the left temporal bone superior to Henle’s spine
(the suprameatal spine). The dura mater covering the sig-
moid sinus posteriorly and the mastoid antrum superiorly is
visible (Fig. 18.8b). Figure 18.8c shows the final stages of
mastoidectomy. The temporal bone, which should be
removed during mastoidectomy, is triangular. Drill resection
of the air cells is undertaken, exposing the mastoid antrum.
Compact bone, containing the semicircular canals and CN
VII descending in the petrous bone from the fossa incudis to
the anterior portion of the digastric groove, is visible. During
mastoidectomy, the fossa incudis represents a good
intraoperative landmark, indicating the turning point of CN
VII. Therefore, it is necessary to first expose the mastoid
antrum and then confirm the position of the fossa incudis,
which is situated at the inferior end of the lateral margin of
the compact bone protruding into the mastoid antrum
(Fig. 18.8c, d). CN VII gets close to the jugular foramen as
it descends. In Fig. 18.8d, e, CN VII and the chorda tympani
are exposed. When the compact bone, especially the bone
covering the posterior semicircular canal, is resected, IAC is
opened from the posterior side and the presigmoid
dura mater around IAC is also exposed (Fig. 18.8e, f).
During the final stage, after opening of the dura mater in
IAC, the superior and inferior vestibular nerves are visible
on the superior and inferior sides of the transverse crest, and
part of CN VII is also visible behind these nerves
(Fig. 18.8g).
We have explained the basic anatomy of the temporal
bone and three approaches to IAC. Surgeries related to the
temporal bone and transpetrosal approaches are described in
more detail in Chap. 19: “Posterior and Anterior
Transpetrosal Approaches” and Chap. 20: “Microsurgical
Anatomy of and Surgical Approaches to the Jugular
Foramen.”
(Matsushima T, Yoshioka F, Matsushima K)
Fig. 18.8 Step-by-step dissection for the translabyrinthine (lateral
mastoid) approach: lateral view on the left side. (a) Confirmation of
Henle’s spine and the starting point for drilling the mastoid bone.
(b) Beginning mastoidectomy. The blue sigmoid sinus can be seen
through the thin bone, and the mastoid antrum is also exposed.
(c) After mastoidectomy. The mastoid antrum, compact bone, sigmoid
sinus, and digastric ridge are exposed. (d) Exposure of cranial nerve
(CN) VII. CN VII runs downward, receiving the chorda tympani. The
incus and malleus can be seen in the mastoid antrum. (e) Opening the
semicircular canals (from Matsushima T [14] with permission).
(f) Removal of the semicircular canals and opening the internal audi-
tory canal (IAC). The posterior wall of the canal and the dura mater
were removed, exposing the CNs in the canal (from Matsushima T 14]
with permission). (g) The lateral portion of the IAC. The vertical and
transverse crests separate the canal at the lateral end, and the facial,
superior vestibular, and inferior vestibular nerves are visible (from
Matsushima T 14] with permission)
260 18 The Temporal Bone: Basic Anatomy and Approaches to Internal Auditory Canal
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