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Chapter 08 - The Temporal Bone & Transtemporal Approaches PDF
Chapter 08 - The Temporal Bone & Transtemporal Approaches PDF
Key words: Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull base, Skull base neoplasm, Surgical
approach, Temporal bone
T
he temporal bone is divided into squamosal, petrous, the semicircular canals and vestibule; and 5) the transcochlear
mastoid, tympanic, and styloid parts (Figs. 8.1 and 8.2). modification, which includes removal of all the labyrinth,
The squamosal part helps enclose the brain. The mas- including the cochlear and possibly the petrous apex. These
toid part is trabeculated and pneumatized to a variable de- variants of the transmastoid approaches can all be combined,
gree and contains the mastoid antrum. The petrous part is as needed, with the supra- and infratentorial presigmoid ap-
compact and encloses the cochlea, the vestibule, and the semi- proaches to the middle and posterior fossa.
circular, facial, and carotid canals (Fig. 8.3). The tympanic part The final approach to be reviewed is the postauricular
forms part of the wall of the tympanic cavity and the external transtemporal approach, which allows lesions involving the
acoustic meatus. The styloid projects downward and serves as mastoid, tympanic cavity, petrous apex, and jugular foramen
the site of attachment of several muscles. This section exam- to be followed backward to the areas exposed by the retrosig-
ines these parts in greater detail and defines the anatomic moid and far-lateral approaches and forward to the infratem-
basis of the approaches directed through the temporal bone to poral, pterygopalatine and middle fossae, lateral maxilla, and
the posterior fossa and petroclival region. The approaches orbit. Selecting an approach directed through the temporal
examined are the middle fossa, translabyrinthine, transco- bone requires an understanding of its complex anatomy and
chlear, combined supra- and infratentorial presigmoid, sub- its relationship to the petroclival region, the infratemporal
temporal anterior transpetrosal, subtemporal preauricular in- fossa, and parapharyngeal space. Protecting and preserving
fratemporal, and the postauricular transtemporal approaches. the facial nerve, the petrous carotid artery, and the sensory
The approaches directed through the surface of the tempo- organs of the inner ear that are contained within the temporal
ral bone forming the middle fossa floor include 1) the very bone are important elements in operative approaches directed
limited middle fossa exposure of the internal acoustic meatus; through the lateral aspect of the cranial base.
2) the anterior petrosectomy approach directed medial to the
internal acoustic meatus through the petrous apex to access
the upper anterior part of the posterior fossa and clivus; 3) the THE TEMPORAL BONE AND
extended middle fossa approach, which may include not only TRANSTEMPORAL APPROACHES
resection of the roof of the internal acoustic meatus and pe-
trous apex, but is extended lateral to the internal acoustic Lateral surface
meatus to include resection, as needed, of the semicircular When the skull and temporal bone are viewed from a
canals, vestibule, roof of the mastoid antrum and tympanic lateral perspective, some landmarks useful in performing ap-
cavity, and the posterior face of the temporal bone; and 4) the proaches directed around and through the temporal bone can
subtemporal preauricular infratemporal fossa approach in be identified (Fig. 8.2). The posterior end of the superior
which the middle fossa exposure is combined with exposure temporal line continues inferiorly as the supramastoid crest
of the infratemporal fossa and, if needed, the petrous carotid, and blends into the upper edge of the zygomatic arch. The
petrous apex, pterygopalatine fossae, and orbit. supramastoid crest is located at the level of the floor of
The approaches directed through the mastoid in front of the the middle fossa. The junction of the supramastoid crest
sigmoid sinus vary in the amount of temporal bone resected. with the squamous suture is located at the lateral end of the
They include 1) the minimal mastoidectomy variant in which petrous ridge. The meeting point of the parietomastoid and
only enough presigmoid dura is exposed to open the dura in squamous sutures is located a few millimeters below the lateral
front of the sigmoid without exposing the labyrinth; 2) the end of the petrous ridge. The anterior edge of the junction of the
retrolabyrinthine approach, which exposes the bony capsule sigmoid and transverse sinuses is located at the junction of
of the labyrinth; 3) the partial labyrinthectomy, which in- the squamous and parietomastoid suture.
cludes removal of one or more of the semicircular canals; 4) The mastoid antrum, a pneumatized space opening into the
the translabyrinthine approach, which includes resection of tympanic cavity, is located about 1.5 cm deep to the su-
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 internal
acoustic meatus enters the central portion of the petrous part of the bone. The trigeminal impression and arcuate eminence
are located on the upper surface of the petrous part. The vestibular aqueduct connects the vestibule in the petrous part with
the endolymphatic sac, which sits on the posterior petrous surface inferolateral to the internal acoustic meatus. B, enlarged
view. The transverse crest separates the meatal fundus into a superior part where the facial canal and superior vestibular
areas 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. C, enlarged view of another internal acoustic meatus. The transverse crest
divides the meatal fundus into superior and inferior parts. The anterior part above the transverse crest is the site of the facial
canal 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. D, 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.
prameatal triangle, a depression in the mastoid surface lo- verse and sigmoid sinuses at the posterior aspect of the mas-
cated between the posterosuperior edge of the external me- toid. The asterion located at the junction of the lambdoid,
atus, the supramastoid crest, and the vertical tangent along occipitomastoid, and parietomastoid sutures is usually lo-
the posterior edge of the meatus. The suprameatal spine of cated over the junction of the lower part of the transverse and
Henle is located at the outer end of the posterosuperior edge sigmoid sinuses. A burr-hole placed at this site will usually
of the external canal along the anterior edge of the su- expose the lower edge of this junction. A burr-hole located at
prameatal triangle and corresponds to the level of the lateral the junction of the supramastoid crest and the squamosal
semicircular canal and tympanic segment of the facial nerve at suture will be located at the posterior part of the middle fossa
a depth of approximately 1.5 cm. Several landmarks are also floor just above and anterior to the upper edge of the junction
helpful in identifying the location of the junction of the trans- of the transverse and sigmoid sinuses.
FIGURE 8.2. E, lateral view of the temporal bone. The squamosal part forms part of the lateral wall of the middle fossa, the
posterior part of the zygomatic arch, and the upper part of the mandibular fossa. The tympanic part forms the posterior wall of the
mandibular fossa and almost all of the wall of the external canal. The styloid process is ensheathed at its base by the tympanic part
and projects downward, serving as the attachment of several muscles. The mastoid part is located posteriorly and contains the mas-
toid air cells that coalesce at the mastoid antrum. F, enlarged view of the external auditory canal. The spine of Henley, an excellent
landmark for locating the deep site of the lateral canal and tympanic segment of the facial nerve, is located along the posterosupe-
rior margin of the external canal. The mastoid antrum is located deep to the depressed area, called the suprameatal triangle,
located behind the spine of Henley. The view into the canal exposes the tympanic cavity, which has the promontory overlying the
basal turn of the cochlea and the oval and round windows in its medial wall. G, lateral surface of the temporal bone in the intact
skull. The tympanic part forms the anterior and lower and part of the posterior wall of the external canal. The mandibular fossa is
formed above and anteriorly by the squamosal part and behind by the tympanic part. The mastoid antrum is located posterosupe-
rior to the spine of Henley, between the spine of Henley and the anterior part of the supramastoid crest. The asterion, the junction
of the lambdoid, parietomastoid, and occipital mastoid sutures, is usually located over the lower half of the junction of the sigmoid
and transverse sinuses. The midpoint of the parietal mastoid suture is usually located at the anterior margin of the junction of the
transverse and sigmoid sinuses, and the lateral edge of the petrous ridge is located at the junction of the squamosal suture and the
supramastoid crest. H, the supra- and infratentorial areas have been exposed while preserving the bone at the site of the sutures.
The asterion, located at the junction of the lambdoid, occipitomastoid, and parietomastoid sutures, overlies the lower half of the
junction of the transverse and sigmoid sinuses. The junction of the supramastoid crest and the squamosal suture is located at the
posterior edge of the middle fossa and slightly anterior and above the junction of the transverse and sigmoid sinuses.
The tympanic part which closes the medial end of the external canal. The
The tympanic part of the temporal bone is a curved plate anterior surface, which is concave, forms the posterior wall
anterior to the mastoid process (Figs. 8.1, 8.2, and 8.4). Its of the mandibular fossa. Its lateral border forms most of the
concave posterior surface forms the anterior wall, floor, margin of the external acoustic meatus. Medially, it joins
and part of the posterior wall of the external acoustic the petrous part at the petrotympanic fissure through
meatus. The roof and upper posterior wall are formed by which the chorda tympani passes. The carotid canal and
the squamosal part. Its surface contains a portion of the the jugular foramen are located medial to the tympanic
tympanic sulcus for attachment of the tympanic membrane, part.
FIGURE 8.3. A–D. Posterior surface of the temporal bone. A, the internal meatus is located near the center and the jugular
foramen at the lower edge of the posterior surface. The sigmoid sinus descends along the posterior surface of the mastoid
and turns forward on the occipital bone to pass through the sigmoid part of the jugular foramen. The inferior petrosal sinus
descends along the petroclival fissure and passes through the petrosal part of the jugular foramen. The subarcuate fossa is
located superolateral and the ostium for the vestibular aqueduct lateral to the internal acoustic meatus. The trigeminal
impression is a shallow trough on the upper surface of the temporal bone behind the foramen ovale. The arcuate eminence
overlies the superior semicircular canals. B, temporal bone with the nerves preserved. The abducens nerve ascends to enter
Dorello’s canal. The trigeminal nerve passes above the petrous apex to enter the porus of Meckel’s cave. The facial and ves-
tibulocochlear nerves enter the internal acoustic meatus, and the glossopharyngeal, vagus, and accessory nerves enter the
jugular foramen. The posterior and superior semicircular canals have been exposed. C, enlarged view. The upper end of the
posterior canal and the posterior end of the superior canal share the common crus. The endolymphatic duct extends down-
ward from the vestibule and opens into the endolymphatic sac located beneath the dura inferolateral to the meatus. The
endolymphatic ridge, the bridge of bone forming the posterior lip of the vestibular aqueduct, has been preserved. The jugular
bulb can be seen through the thin bone below the internal meatus. D, enlarged view of the fundus of the meatus after
removal of the posterior wall. The upper edge of the porus has been preserved. The subarcuate artery enters the subarcuate
fossa. The inferior vestibular nerve gives rise to the singular branch to the posterior ampullae, plus utricular and saccular
branches. The superior vestibular nerve innervates the ampullae of the superior and lateral semicircular canals and commonly
gives rise to a utricular branch. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch., cochlear;
Emin., eminence; Endolymph., endolymphatic; Fiss., fissure; For., foramen; Hypogl., hypoglossal; Impress., impression; Inf.,
inferior; Int., internal; Intermed., intermedius; Jug., jugular; Lat., lateral; N., nerve; Nerv., nervus; Pet., petrosal, petrous; Pet-
rocliv., petroclival; Post., posterior; Semicirc., semicircular; Sig., sigmoid; Subarc., subarcuate; Sup., superior; Trig., trigemi-
nal; Vest., vestibular.
The styloid process, a slender spicule ensheathed by the located immediately anterior to the emergence of the facial
inferior border of the tympanic bone, projects into the infra- nerve from the stylomastoid foramen and is covered laterally
temporal fossa and is the site of attachment for the styloglos- by the parotid gland. The stylomastoid foramen, the external
sus, stylopharyngeus, and stylohyoid muscles (Fig. 8.5). It is end of the facial canal, opens between the styloid and mastoid
FIGURE 8.3. E–H. Posterior surface of the temporal bone. E, the petrous apex medial to the internal acoustic meatus has
been removed to expose the petrous carotid. The lateral genu of the petrous carotid, located at the junction of the vertical
and horizontal segments of the petrous carotid, is situated below and medial to the cochlea. The jugular bulb extends upward
toward the vestibule and semicircular canals adjacent to the posterior meatal wall. The inferior petrosal sinus courses along
the petroclival fissure and enters the petrosal part of the jugular foramen, and the sigmoid sinus descends in the sigmoid
groove and enters the sigmoid part of the foramen. The glossopharyngeal, vagus, and accessory nerves pass through the cen-
tral or intrajugular part of the foramen between the sigmoid and petrosal parts. F, bone has been removed along the anterior
margin of the meatal fundus to open the cochlea, and along the posterior margin to expose the vestibule. The jugular bulb
extends upward toward the semicircular canals and vestibule. G, enlarged view. The cochlear nerve penetrates the modiolus
of the cochlea where its fibers are distributed to the turns of the cochlear duct. The basal turn of the cochlea communicates
below the modiolus with the vestibule. H, enlarged view of the vestibule and cochlea. The stapes has been removed from the
oval window. The promontory in the medial wall of the tympanic cavity is located lateral to the basal turn of the cochlea. A
silver fiber has been introduced into the superior canal, a red fiber into the lateral canal, and a blue fiber into the posterior
canal. The ampullated ends are located at the bulbous ends of the three fibers. The common crus of the superior and poste-
rior canals is located at the site where the tips of the blue and silver fibers overlap. The superior vestibular nerve passes to
the ampullae of the superior and lateral canals. The singular branch of the inferior vestibular nerve innervates the
posterior ampullae. A small black fiber has been introduced into the opening of the endolymphatic duct into the vestibule.
processes. The facial nerve crosses the lateral surface of the The supramastoid crest extends backward across its posterior
styloid process, and the external carotid artery crosses the tip. part, giving attachment to the temporalis muscle and fascia.
Resecting the styloid process and reflecting the attached mus- The suprameatal triangle, a depressed area, located below the
cles downward exposes the internal jugular vein as it exits the anterior part of the crest and behind the posterosuperior
jugular foramen and the carotid artery as it enters the carotid margin of the external meatus, marks the deep location of the
canal medial to the tympanic bone. mastoid antrum. The cerebral surface of the squamosal part is
concave, accommodating the temporal lobe and joining the
The squamous part greater wing of the sphenoid anteriorly. The zygomatic pro-
The externally convex surface of the squamosal part gives cess of the squamosal part projects forward and with the
attachment to the temporalis muscle (Figs. 8.1, 8.2, and 8.5). zygomatic bone completes the zygomatic arch. The attach-
ment of the zygomatic process to the squama is wide giving it foramina through which an emissary vein to the sigmoid
anterior and posterior edges, referred to as the anterior and sinus and a dural branch from the occipital artery pass.
posterior roots. The temporalis fascia attaches to the supe- The medial aspect of the mastoid process is grooved by the
rior border of the arch and the masseter attaches to the lower sigmoid sinus (Figs. 8.1-8.4). The sinus represents the poste-
border. The posterior root of the zygomatic process blends rior limit of the mastoid cavity. The sinus meets the roof of the
posteriorly into the suprameatal crest. The anterior root is cavity at the level of the petrous ridge. The angle between
located at the anterior margin of the temporomandibular the superior petrosal and sigmoid sinuses and the middle
joint, with the joint forming a rounded fossa on the lower fossa dura delimits a dural space called the sinodural angle.
margin of the zygomatic process between the anterior and The sinodural angle is an important landmark when exposing
posterior roots. The upper margin of the zygomatic process the contents of the mastoid. Inferiorly, the sigmoid sinus
between the two roots gives attachment to the posterior part curves medially and forward, crossing the occipital bone to
of the temporalis muscle. The mandibular fossa, located on enter the jugular foramen. The superior aspect of the jugular
the lower margin of the process between the two roots, is foramen corresponds to the apex of the jugular bulb and
delimited in front by the articular tubercle and posteriorly by constitutes the inferior limit of the mastoid cavity.
the postglenoid tubercle adjacent to its junction with the The medial limit of the mastoid cavity is formed by the
tympanic bone. The squamotympanic fissure is located be- block of solid bone, the otic capsule, containing the bony
tween the medial part of the squamosal part of the mandib- labyrinth (Figs. 8.4 and 8.6). The area of posterior fossa dura
ular fossa and the medial part of the tympanic bone. The mater that can be exposed through the mastoid cavity be-
petrotympanic fissure is situated between the tympanic plate tween the sigmoid and superior petrosal sinuses, the otic
and the petrosal part and leads into the tympanic cavity; it capsule, and the jugular bulb is called Trautman’s triangle.
contains the anterior ligament of the malleus and the anterior The size of this dural triangle is important in surgical proce-
tympanic branch of the maxillary artery. The anterior canal- dures in which the dura delimited by the triangle must be
iculus for the chorda tympani exits the tympanic cavity in the opened medial to the sigmoid sinus. The distance from the
petrotympanic fissure. The rootlets of the temporal branch of anterior margin of the sigmoid sinus to the otic capsule at
the facial nerve cross the lateral aspect of the zygomatic arch the level of the posterior semicircular canal averages 8 mm
and course through the subcutaneous tissues on the superfi- (range, 6–9 mm) on the right side, and 7 mm (range, 4–9 mm)
cial layer of the temporal fascia. During resection of the zy- on the left (44).
gomatic arch, the superficial temporalis fascia should be care- The distance between the apex of the jugular bulb and the
fully dissected from the underlying deep fascia, starting as superior petrosal sinus is also an important determinate of the
close as possible to the tragal cartilage, and carried forward, size of exposure that can be achieved by opening Trautman’s
reflecting the superficial fascia anteriorly to avoid damage to triangle. This distance is reduced if there is a high jugular
the filaments of the temporal branch to the frontalis muscle. bulb. The jugular bulb usually lies inferior to the ampulla of
the posterior semicircular canal, but it can project superiorly
as far as the level of the lateral semicircular canal (27). The
The mastoid part average distance from the jugular bulb to the superior petro-
The mastoid is the posterior part of the temporal bone (Figs. sal sinus is 14 mm (range, 10–19 mm) on the right side, and 16
8.1, 8.2, and 8.4). It projects downward to form the process mm (range, 11–21 mm) on the left (44).
that is the site of attachment, from superficial to deep, of the The mastoid interior is composed of trabeculated bone,
sternocleidomastoid, splenius capitis and longissimus capitis which coalesces to form a cavity, the mastoid antrum, that
muscles, and the posterior belly of the digastric muscle (Fig. communicates through an opening, the aditus, that leads
8.5). The lower surface medial to the mastoid process is forward to the epitympanic part of in the tympanic cavity
grooved by the mastoid notch to which the posterior belly of (Figs. 8.4 and 8.6). The lateral semicircular canal is medial to
the digastric attaches. Medial to the notch, the occipital the epitympanic recess. The medial wall of the antrum faces
groove gives passage to the occipital artery. The fascia cover- the posterior semicircular canal. The roof is formed by the
ing the anterior margin of the posterior belly of the digastric tegmen in the floor of the middle cranial fossa. The mastoid
is continuous anteriorly with the connective tissue surround- segment of the facial canal courses adjacent to the anteroin-
ing the emergence of the mastoid segment of the facial nerve ferior margin of the antrum. The lateral wall of the mastoid
from the stylomastoid foramen and can be used as a landmark antrum, through which it is usually approached surgically, is
for identifying the initial extracranial segment of the nerve. formed by the postmeatal part of the squamous temporal
After exiting the stylomastoid foramen, the nerve divides in bone. The lateral wall of the antrum is located deep to the
the substance of the parotid gland into temporal, zygomatic, suprameatal triangle, which is demarcated superiorly by
buccal, marginal mandibular, and cervical branches (Fig. 8.5). the suprameatal crest, located at the level of the floor of the
The temporal and zygomatic branches cross the zygomatic middle fossa; anteroinferior by the posterosuperior margin of
arch and the superficial fascia of the temporalis muscle. Keep- the acoustic meatus, which indicates approximately the posi-
ing the connective tissue surrounding the nerve at the stylo- tion of the descending or mastoid part of the facial canal; and
mastoid foramen intact during mobilization of the facial nerve posteriorly by a posterior vertical tangent to the posterior
will reduce the risk of facial nerve damage. The posterior margin of the external meatus. The air cells in the mastoid
border of the mastoid process is perforated by one or more may extend behind the sigmoid sinus and into the squamosal
FIGURE 8.4. Tympanic cavity and mastoid antrum. A, the tympanic bone forms the anterior, lower, and part of the posterior
wall of the external canal. The facial nerve exits the skull through the stylomastoid foramen, which is located medial to the
tympanomastoid suture. The spine of Henley approximates the deep site of the tympanic facial segment and the lateral canal.
The mastoid antrum is located between the posterosuperior wall of the external canal and middle fossa floor deep to the
depression behind the spine of Henle. B, a mastoidectomy has been completed to expose the capsule of the posterior and lat-
eral canals and the tympanic and mastoid facial segments. C, the posterior and superior wall of the external canal and the
tympanic membrane have been removed while preserving the malleus and chorda tympani. The mastoid segment of the facial
nerve descends through the facial canal and gives rise to the chorda tympani, which passes upward and forward across the
tympanic membrane and malleus neck. D, enlarged view. The head of the incus articulates with the head of the malleus, the
short process of the incus points backward toward the facial nerve, and the long process attaches to the stapes, which sits in
the oval window. The stapedial muscle passes forward below the tympanic segment of the facial nerve and attaches to the
neck of the stapes. E, the incus has been removed to expose the stapes sitting in the oval window. The chorda tympani
part of the temporal bone, the posterior root of the zygomatic stapes. The round window is posteroinferior to the oval win-
process, the osseous roof of the external acoustic meatus, the dow and opens under the overhanging edge of the promon-
floor of the tympanic cavity near the jugular bulb, and the tory. The prominence of the facial canal is located above the
petrous apex surrounding the carotid canal, eustachian tube, oval window. The posterior wall of the tympanic cavity is
and labyrinth. mainly the site of the aditus, the opening of the tympanic
The tympanic cavity is a narrow air-filled space between cavity, into the mastoid antrum. The medial wall of the aditus
the tympanic membrane laterally and the promontory con- has a round prominence overlying the lateral semicircular
taining the auditory and vestibular labyrinth medially (Figs. canal. The pyramidal eminence, which houses the stapedial
8.4, 8.6, and 8.7). It communicates posteriorly with the mas- muscle, is located just behind the oval window and anterior to
toid antrum and anteriorly through the eustachian tube with the mastoid part of the facial canal. The stapedius extends
the nasopharynx. It contains the malleus, incus, and stapes. forward from the eminence to attach to the neck of the stapes.
The tympanic cavity opens upward into the epitympanic The fossa incudis is a small depression low and posterior in
recess, which contains the heads of the malleus and the incus. the epitympanic recess; it contains the short process of the
The roof of the tympanic cavity is formed by a thin plate, the incus, which is fixed to the fossa by ligamentous fibers.
tegmen tympani, which separates the middle fossa and tym- The anterior wall of the tympanic cavity narrows and leads
panic cavities, and also roofs the mastoid antrum and the into the eustachian tube, which communicates the nasophar-
tensor tympani. The thin floor of the tympanic cavity sepa- ynx with the tympanic cavity (Figs. 8.4, 8.7, and 8.8). It has
rates the cavity from the jugular bulb. The medial part of the
bony and cartilaginous parts. The bony part begins in the
floor is perforated by an opening for the tympanic branch
anterior part of the tympanic cavity and is directed anteriorly
of the glossopharyngeal nerve. The lateral wall is formed
and medially. It joins the cartilaginous part at the junction of
by the tympanic membrane and the osseous ring to which
the squamous and petrous parts of the temporal bone. The
the membrane attaches. The ring is deficient above near the
cartilaginous part of the tube is attached to the lower margin
openings of the anterior and posterior canaliculi for the
of the sphenopetrosal groove, which is situated between the
chorda tympani (Figs. 8.4 and 8.6). The posterior canalicu-
petrous bone and the greater wing of the sphenoid bone, and
lus for the chorda tympani arises from the facial canal a few
its base lies directly under the mucous membrane of the
millimeters above the mastoid foramen and ascends in
front of the facial canal to open into the tympanic cavity at lateral wall of the nasaopharynx. Both the petrous carotid and
the level of the upper part of the handle of the malleus. The eustachian tube are directed anteromedially, with the eusta-
chorda tympani passes in close relation to the tympanic chian tube being located along the anterior margin of the
membrane and the medial aspect of the neck of the malleus carotid canal (Figs. 8.7 and 8.8). The tensor tympani muscle
and forward to enter its anterior canaliculus at the medial and its bony semicanal are located above the eustachian tube,
aspect of the petrotympanic fissure, and descends vertically parallel to the horizontal segment of the petrous carotid. The
medial to the sphenoid spine and lateral pterygoid muscle canals for the tensor tympani superiorly and the osseous part
to join the lingual nerve. of the eustachian tube inferiorly open into the upper part of
The medial wall of the tympanic cavity, which forms the the anterior wall of the tympanic cavity. These canals are
lateral boundary of the inner ear and the petrosal part of the inclined downward, anteriorly, and medially; they open into
temporal bone, is the site of the promontory, the oval and the angle between the squamous and petrous parts of the
round windows, and the prominence over the facial nerve temporal bone and are separated by a thin, bony septum. The
(Figs. 8.2 and 8.4). The tympanic nerve plexus grooves the canal for the tensor tympani extends posterolaterally on the
promontory overlying the lateral bulge of the basal turn of medial wall of the tympanic cavity, to end above the oval
the cochlea. The apex of the cochlea lies near the medial wall window where the posterior end of the canal curves laterally
of the cavity anterior to the promontory. The oval window is to form a pulley, the trochleariform process, around which the
posterosuperior to the promontory and connects the tympanic tensor tympani tendon turns laterally to attach to the handle
cavity to the vestibule, and is occupied by the footplate of the of the malleus.
Š
crosses the neck of the malleus. The promontory is located superficial to the basal turn of the cochlea. The labyrinth and fun-
dus of the internal meatus are located medial to the tympanic cavity. A line directed medially through the skull along the
long axis of the external meatus will also approximate the site of the long axis of the internal meatus on the medial side of
the promontory and acousticovestibular labyrinth. F, the stapes has been removed from the oval window. The handle of the
malleus attaches to the tympanic membrane, the neck is crossed by the chorda tympani, and the head articulates with the
incus, which has been removed. The tendon of the tensor tympani attaches to the upper part of the handle of the malleus.
The stapedial muscle is housed within the pyramidal eminence and its tendon inserts on the stapedial neck. Chor., chorda;
CN, cranial nerve; Emin., eminence; Endolymph., endolymphatic; Epitymp., epitympanic; Eust., eustachian; Jug., jugular; Lat.,
lateral; Long., longus; M., muscle; Mast., mastoid; Memb., membrane; N., nerve; Post., posterior; Proc., process; Seg., seg-
ment; Sig., sigmoid; Sp., spine; Squamomast., squamomastoid; Temp., temporal; Tymp., tympani, tympanic; Tympanomast.,
tympanomastoid.
FIGURE 8.5. A–F. Muscular and osseous relationships. A, the skin and subcutaneous tissues have been removed to expose the
parotid gland and the facial nerve branches that course deep to the parotid gland on their way to the facial muscles. The
masseter muscle has two heads: a more superficial anterior head, which passes downward to the lateral surface of the angle
of the jaw, and a deeper posterior head, which arises from the medial surface of the zygomatic arch and passes to the man-
dibular body. The sternocleidomastoid attaches to the lateral part of the superior nuchal line and mastoid process, descends
in an anterior direction, and is crossed by the greater auricular nerve. The temporalis fascia attaches to the upper surface of
the zygomatic arch. The trapezius muscle attaches to the medial part of the superior nuchal line. The posterior triangle of the
neck, located between the sternocleidomastoid and trapezius, has the semispinalis capitis, splenius capitis, and levator scapu-
lae in its floor. The terminal branches of the occipital artery and the greater occipital nerve reach the subcutaneous tissues
by passing between the attachment of the trapezius and sternocleidomastoid muscles to the superior nuchal line. B, enlarged
view. The facial nerve branches are exposed along the anterior edge of the parotid gland. C, the parotid gland has been
removed to expose the facial nerve and its branches distal to the stylomastoid foramen. The nerve passes lateral to the styloid
The petrous part 8.7 and 8.8). The greater petrosal nerve can be identified
medial to the arcuate eminence as it leaves the geniculate
The petrous part of the temporal bone is wedged between
ganglion by passing through the facial hiatus to reach the
the sphenoid and occipital bones (Figs. 8.1 and 8.3). It contains
the acoustic and vestibular labyrinth and is the site of the middle fossa floor. It runs beneath the dura of the middle
jugular fossa and the facial and carotid canals (Figs. 8.3, 8.4, fossa in the sphenopetrosal groove formed by the junction of
and 8.7). It has a base, apex, three surfaces and margins. The the petrous and sphenoid bones, immediately superior and
apex is located in the angle between the greater wing of the anterolateral to the horizontal segment of the petrous carotid.
sphenoid and the occipital bone and is the site of the carotid In a previous study, we found that bone of the middle cranial
canals medial opening. It forms the posterolateral limit of the fossa was absent over the geniculate ganglion in 16% of the
foramen lacerum. The anterior surface faces the floor of specimens, thus exposing the facial nerve and geniculate gan-
the middle cranial fossa and its surface is grooved by the glion to the danger of injury during elevation of the dura from
trigeminal impression for the trigeminal ganglion; anterolat- the floor of the middle fossa (31). Facial nerve injury can also
eral to this, it forms the roof of the carotid canal (Figs. 8.1 and result from damaging the branch of the middle meningeal
8.7). Lateral to the trigeminal impression is a shallow depres- artery, which passes through the facial hiatus to supply the
sion, which partially roofs the internal acoustic meatus and is nerve, or from traction applied to the ganglion when manip-
limited laterally by the arcuate eminence, which overlies the ulating the greater petrosal nerve (30).
superior semicircular canal. The posterior slope of the arcuate The lesser petrosal nerve from the tympanic plexus passes
eminence overlies the posterior and lateral semicircular ca- through the tympanic canaliculus, which is located anterior to
nals. Farther laterally, the roof covers the vestibule and part of the facial hiatus and courses in an anteromedial direction
the facial canal. The tegmen extends laterally from here and parallel to the greater petrosal nerve (Fig. 8.8). The cochlea lies
roofs the mastoid antrum and tympanic cavities and the canal below the floor of the middle fossa in the angle between the
for the tensor tympani. Opening the tegmen from above ex- labyrinthine segment of the facial nerve and the greater petro-
poses the heads of the malleus, incus, the tympanic segment sal nerve, just medial to the geniculate ganglion, anterior to
of the facial nerve, and the superior and lateral semicircular the fundus of the internal acoustic meatus, and posterosupe-
canals (Fig. 8.7). The tympanic segment of the facial nerve rior to the lateral genu of the petrous carotid artery. The
begins at the geniculate ganglion and ends at the level of the cochlea is separated from the petrous carotid by a 2.1 mm
stapes, where the nerve turns downward below the lateral (range, 0.6–10.0 mm) thickness of bone and can be injured
semicircular canal. The tegmen anteriorly is grooved by the during exposure of the petrous carotid. The middle meningeal
greater petrosal nerve extending anterior and medial from artery, an important landmark when approaching the struc-
the area in front of the arcuate imminence and crossing the tures of the middle fossa, enters the cranial cavity through the
floor of the middle fossa toward the foramen lacerum (Figs. foramen spinosum of the sphenoid bone. The foramen spino-
Š
process, the external carotid artery, and mandibular neck. The superficial and deep heads of the masseter muscle are
exposed. This lower end of the sternocleidomastoid muscle has been reflected posteriorly by dividing its attachment to the
clavicle and sternum. The superficial temporal artery ascends in front of the ear. D, the upper part of the mandibular ramus
and the lower part of the temporalis muscle and its attachment to the coronoid process have been removed while preserving
the inferior alveolar nerve. The infratemporal fossa is located medial to the mandible and on the deep side of the temporalis
muscle. The upper and lower heads of the lateral pterygoid, which insert along the temporomandibular joint, and the superfi-
cial head of the medial pterygoid, which extends from the lateral pterygoid plate to the angle of the jaw, have been exposed.
The structures in the infratemporal fossa include the pterygoid muscles, branches of the mandibular nerve, the maxillary
artery, and the pterygoid venous plexus. The sternocleidomastoid muscle has been reflected out of the exposure to expose
the splenius capitis muscle. E, posterolateral view. The splenius capitis has been reflected downward to expose the longissi-
mus capitis, superior oblique, and semispinalis capitis. The occipital artery passes along the occipital groove on the medial
side of the digastric groove. F, the longissimus capitis has been reflected downward to expose the rectus capitis posterior
minor and major, which descend from the occipital bone to attach to the spinous process of C1 and C2, respectively; the
superior oblique, which passes from the occipital bone to the transverse process of C1; and the inferior oblique, which
extends from the spinous process of C2 to the transverse process of C1. The vertebral artery, in its ascent from C2 to C1, is
exposed medial to the attachment of the levator scapulae to the C1 transverse process. The C1 transverse process is situated
immediately behind the internal jugular vein and a short distance below and behind the jugular foramen. A., artery; Alv.,
alveolar; Ant., anterior; Aur., auricular; Brs., branches; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Constr.,
constrictor; Eust., eustachian; Ext., external; Gl., gland; Gr., greater; Inf., inferior; Int., internal; Jug., jugular; Lat., lateral;
Lev., levator; Long., longus; Longiss., longissimus; M., muscle; Maj., major; Mandib., mandibular; Max., maxillary; Med., medi-
al; Memb., membrane; Min., minor; N., nerve; Obl., oblique; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal;
Pet., petrosal; Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; Scap., scapula;
Semispin., semispinalis; Splen., splenius; Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup., superior;
Superf., superficial; Temp., temporal, temporalis; Tens., tensor; TM., temporomandibular; Trans., transverse; Tymp., tympanic;
V., vein; Veli./Vel., veli; Vert., vertebral.
FIGURE 8.5. G–L. Muscular and osseous relationships. G, the mandibular condyle and ramus have been removed to expose the styloid
process and attached muscles. The pterygoid muscles and some branches of the mandibular nerve have been removed to expose the auri-
culotemporal nerve, which splits into two roots that surround the middle meningeal artery. The levator veli palatini, which attaches the
lower margin of the eustachian tube, is in the medial part of the exposure. The longus capitis is exposed medial to the internal carotid
artery in the retropharyngeal area. H, the muscles that attach to the styloid process have been divided at their origin. The facial nerve
crosses the lateral surface of the styloid process. The attachment of the tensor veli palatine to the skull base extends between the foramen
ovale and the eustachian tube. I, the external auditory canal has been removed, but the tympanic membrane and cavity have been pre-
served. The levator veli palatine and part of the tensor veli palatine have been removed and the membranous part of the eustachian tube
opened. The eustachian tube crosses anterior to and is separated from the petrous carotid by a thin shell of bone. The jugular bulb and
lateral bend of the petrous carotid are located below the osseous labyrinth. The pterygopalatine fossa is exposed anteriorly. J, the eusta-
chian tube has been resected and the mandibular nerve divided at the foramen ovale to expose the petrous carotid. This exposes the lon-
gus capitis and rectus capitis anterior, both of which are located behind the posterior pharyngeal wall. K, the petrous carotid has been
reflected forward out of the carotid canal to expose the petrous apex medial to the carotid canal. L, the petrous apex and upper clivus
have been drilled and the dura opened to expose the anterolateral aspect of the pons below the trigeminal nerve. The sigmoid sinus and
the jugular bulb have been removed to expose the nerves exiting the jugular foramen.
FIGURE 8.6. A–D. Translabyrinthine exposure. A, the insert shows the site of the exposure directed through the mastoid. The
spine of Henley at the posterosuperior margin of the external meatus is a superficial landmark that approximates the deep
site of the lateral semicircular canal and the tympanic segment of the facial nerve. The mastoidectomy has been completed.
The superior petrosal and sigmoid sinuses, the jugular bulb, and the facial nerve are usually skeletonized in the approach,
leaving a thin layer of bone over them. The semicircular canals, which are located in the cortical bone medial to the cancel-
lous mastoid and the mastoid antrum, have been exposed. The dura between the sigmoid and superior petrosal sinuses, the
jugular bulb, and the labyrinth, which faces the cerebellopontine angle, is referred to as Trautman’s triangle. B, the mastoid
antrum opens through the aditus into the epitympanic part of the tympanic cavity, which contains the upper part of the mal-
leus and incus. The tympanic segment of the facial nerve passes between the lateral canal and the stapes in the oval window
and then turns downward as the mastoid segment. The chorda tympani arises from the mastoid segment of the facial nerve
and passes upward and forward along the deep surface of the tympanic membrane crossing the neck of the malleus. The
incus, the head of which is located in the epitympanic area, has a long process that attaches to the stapes. C, the semicircular
canals and vestibule have been removed and the dura lining the internal acoustic meatus has been opened to expose the ves-
tibulocochlear nerve. D, the dura has been opened to expose the petrosal cerebellar surface and the structures in the cer-
ebellopontine angle. Anatomic variants that limit the exposure include an anterior position of the sigmoid sinus, a high jugu-
lar bulb, or a low middle fossa plate. The jugular bulb may extend upward into the posterior wall of the internal acoustic
meatus and be encountered as the posterior meatal wall is being removed by either the translabyrinthine or retrosigmoid
approaches. Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery; Chor., chorda; CN, cranial nerve; Coch., cochlear; Inf.,
inferior; Int., internal; Intermed., intermedius; Jug., jugular; Laby., labyrinthine; Lat., lateral; Mast., mastoid; N., nerve; Nerv.,
nervus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Seg., segment; Sig., sigmoid; Sup., superior;
Tymp., tympani, tympanic; V., vein; Vest., vestibular.
sum is an average of 4.5 mm (range, 3–6 mm) anterolateral to with the mastoid surface (Figs. 8.1-8.3). The opening for the
the carotid canal and 14.0 mm (range, 11.0–17.0 mm) antero- internal auditory meatus is situated midway between the base
lateral to the geniculate ganglion (44). and the apex on the posterior surface. The lateral end of the
The posterior surface of the petrosal part faces the posterior meatus is divided into superior and inferior halves by the
cranial fossa and cerebellopontine angle and is continuous transverse crest. The area above the transverse crest is further
divided by the vertical crest, also called Bill’s bar, which sac located between the dural layers. The opening of the
separates the anteriorly located facial canal from the posteri- cochlear aqueduct, also called the cochlear canaliculus and
orly located superior vestibular area (29). The cochlea and occupied by the perilymphatic duct, is situated inferior to the
inferior vestibular nerves penetrate the lateral end of the porus of the internal meatus at the anteromedial edge of the
meatus below the transverse crest, with the cochlear nerve jugular foramen, just superior and lateral to where the glos-
being located anteriorly. The posterior wall of the meatus, sopharyngeal nerve enters the intrajugular part of the jugular
lateral to the porus is the site of a small bony opening, the foramen.
subarcuate fossa, which gives passage to the subarcuate ar- The inferior surface is very irregular. The apex is connected
tery, a branch of the anteroinferior cerebellar artery (AICA), medially to the clivus by fibrocartilage and gives attachment
which usually ends blindly in the region of the superior to the levator veli palatini and the cartilaginous portion of the
semicircular canal. Inferolateral to the porus of the meatus is eustachian tube (Figs. 8.1 and 8.9). Behind this is the opening
the opening for the vestibular aqueduct, which transmits the of the carotid canal, behind which is the jugular fossa that
endolymphatic duct that opens below into the endolymphatic contains the jugular bulb. The small foramen for the tympanic
FIGURE 8.7. A–D. Middle fossa exposure of the temporal bone. A, superolateral view. The tentorium, except the edge, has
been removed. The dura has been removed from the middle fossa floor and cavernous sinus wall to expose the greater petro-
sal nerve, middle meningeal artery, and the nerves in the sinus wall. B, the middle fossa floor has been opened to expose the
cochlea, semicircular canals, petrous carotid artery, and the facial, cochlear, and superior vestibular nerves in the meatus.
The superior canal bulges upward into the middle fossa below the arcuate eminence. The cochlear nerve passes below the
facial nerve to enter the cochlea, which is located above the lateral genu of the petrous carotid in the angle between the pre-
geniculate facial and greater petrosal nerves. C, another temporal bone drilled to expose the internal acoustic meatus,
cochlea, vestibule, semicircular canals, tympanic cavity, and external meatus. The vestibule is located posterolateral and
the cochlea is anteromedial to the fundus of the internal meatus. The vestibule communicates below the meatal fundus
with the cochlea. The tensor tympani muscle and eustachian tube are layered along, but are separated from, the anterior sur-
face of the petrous carotid by a thin layer of bone. The tegmen has been opened to expose the head of the incus and malleus
in the epitympanic area. The internal acoustic meatus lies directly medial to, but is separated from, the external meatus by
the tympanic cavity and the labyrinth. D, the nerves in the meatus have been separated to expose the superior and inferior
vestibular, facial, and cochlear nerves. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery; Car., carotid; CN,
cranial nerve; Coch., cochlear; Eust., eustachian; Ext., external; Gang., ganglion; Genic., geniculate; Gr., greater; Inf., inferior;
Lat., lateral; M., muscle; Men., meningeal; Mid., middle; N., nerve; Pet., petrosal, petrous; Post., posterior; S.C.A., superior
cerebellar artery; Sup., superior; Tens., tensor; Tent., tentorial; Tymp., tympani, tympanic; Vert., vertebral; Vest., vestibular.
branch of the glossopharyngeal nerve is located on the ridge which resides the inferior petrosal sinus that connects the
between the carotid canal and jugular foramen (Fig. 9.2). On cavernous sinus and the medial wall of the jugular bulb.
the lateral wall of the jugular bulb is the mastoid canaliculus Behind this, the jugular fossa of the temporal bone joins with
for the auricular branch of the vagus nerve. The superior the jugular notch on the jugular process of the occipital bone
border, located along the petrous ridge, is grooved by the to form the margins of the jugular foramen.
superior petrosal sinus and serves as the attachment of The jugular foramen is located at the lower end of the
the tentorium cerebelli, except medially where it is crossed by petro-occipital fissure and is divided into a larger lateral
the posterior trigeminal root. The lower posterior border, opening, the sigmoid part, that receives the drainage of the
located along the petroclival fissure, is the site of a groove in sigmoid sinus, and a small medial part, the petrosal part, that
FIGURE 8.7. E–H. Middle fossa exposure of the temporal bone. E, enlarged view. The vestibule, into which the semicircular
canals open, communicates below the meatal fundus with the cochlea. The vertical crest, often called Bill’s bar, separates the
superior vestibular and facial nerves at the meatal fundus. The tendon of the tensor tympani makes a right-angle turn around
the trochleariform process in the medial margin of the tympanic cavity to insert on the malleus. F, enlarged view. The supe-
rior canal projects upward in the floor of the middle fossa. The lateral canal is situated above the tympanic segment of the
facial nerve in the posteromedial part of the epitympanic area, and the posterior canal is located lateral to the posterior wall
of the internal acoustic meatus. G, bone has been removed below the greater petrosal nerve to expose the petrous carotid.
The tensor tympani muscle above and the eustachian tube below are layered along the anterior surface of the petrous
carotid. H, enlarged view. Suture has been placed in the three semicircular canals. The anterior end of the superior and lat-
eral canals and the lower end of the posterior canal are the site of the ampullae. The posterior end of the superior canal and
the upper end of the posterior canal join to form a common crus. The facial and superior vestibular nerves have been
removed to expose the cochlear and inferior vestibular nerves. The singular branch of the inferior vestibular nerve innervates
the posterior ampullae. The superior vestibular nerve innervates the superior and lateral ampullae.
transmits the inferior petrosal sinus (Fig. 9.1). The intrajugular The floor of the vestibule is separated from the apex of the
part, located between the sigmoid and petrosal parts, trans- jugular bulb by a thickness of bone that averages 6 mm
mits the glossopharyngeal, vagus, and accessory nerves. The (range, 4–8 mm) on the right side and 8 mm (range, 4–10 mm)
anterior border is joined laterally to the temporal squama at on the left side (44). This distance is particularly important
the petrosquamosal suture and medially articulates with the during translabyrinthine approaches since the height of the
sphenoid’s greater wing. jugular bulb is a major determinant of the size of the exposure
The bony labyrinth consists of three parts: the vestibule, the of the cerebellopontine angle that can be achieved with this
semicircular canals, and the cochlea. The vestibule, located in approach. A high-placed jugular bulb may be the source of
the central part of the bony labyrinth, is a small cavity at the troublesome bleeding and air emboli if it is opened during
confluence of the ampullate and nonampullated ends of the exposure of the labyrinth or internal acoustic meatus.
semicircular canals. It is situated lateral to the meatal fundus, The semicircular canals are situated posterosuperior to the
medial to the tympanic cavity, posterior to the cochlea, and vestibule (Figs. 8.3, 8.4, and 8.7). The anterior part of the lateral
superior to the apex of the jugular bulb (Figs. 8.3, 8.4, and 8.7). semicircular canal is situated above the tympanic segment of
the facial nerve and can be used as a guide to locating that posterior canal may be damaged in removing the posterior
segment of the nerve. The posterior semicircular canal lies wall to expose the meatal contents by the retrosigmoid ap-
parallel to and in close proximity with the posterior surface of proach (Fig. 8.3).
the petrous bone in the area just behind and lateral to the During surgical approaches to the cerebellopontine angle in
lateral end of the internal acoustic meatus. The superior semi- which the posterior meatal lip is removed, care should be
circular canal projects toward the floor of the middle fossa, taken to avoid opening the vestibular aqueduct, vestibule,
usually in close relation to the arcuate eminence. Each canal posterior semicircular canal, or the common crus (Figs. 8.2 and
has an ampullated and a nonampullated end that opens into 8.3). In our studies, we observed that there is a constant set of
the vestibule. The anterior end of the lateral and superior relationships among the structures around the posterior
canals and the inferior end of the posterior canal are the site of meatal lip. The common crus of the posterior and superior
the ampullae, which are innervated by the vestibular nerves.
semicircular canals is located lateral to the entrance of the
The posterior ends of the superior and posterior canals, the
subarcuate artery into the subarcuate fossa. The vestibular
ends opposite the ampullae, join to form a common crus that
aqueduct has an oblique orientation. It leaves the vesti-
opens into the vestibule. The superior vestibular nerve inner-
vates the ampullae of the superior and lateral canals, and the bule and runs in a posterior direction to open beneath the
singular branch of the inferior vestibular nerve innervates dura mater at a level corresponding to that of the posterior
the posterior ampulla. The vestibular nerves also have semicircular canal. The average distance between the poste-
branches to the utricle and saccule located within the vesti- rior semicircular canal, at the level with the junction of the
bule. The internal auditory meatus can be found medial to the common crus, and the lateral edge of the porus was 7 mm
arcuate eminence at an angle of about 60 degrees medial from (range, 5–9 mm) (44).
the long axis of the superior semicircular canal. The superior The carotid artery, at the point where it enters the carotid
canal is the most susceptible to damage in completing the canal, is surrounded by a strong layer of connective tissue that
middle fossa approach to the internal acoustic meatus. The makes it difficult to mobilize the artery at this point (Figs. 8.9
and 8.10) (38, 39). The vertical segment of the artery passes ing bone lateral to the trigeminal ganglion averages 8.1 mm
upward in the canal toward the genu, where it curves (range, 4.0–11.0 mm) (44). The length that can be exposed can
anteromedially to form the horizontal segment. The eusta- be increased if the mandibular branch of the trigeminal nerve
chian tube and the tensor tympani muscle are located par- is retracted or divided, after which the average length that can
allel to and along the anterior margin of the horizontal be exposed increases to 20.1 mm (range, 17.5–28.0 mm) (Figs.
segment, where they are separated from the artery by a thin 8.7 and 8.8) (10, 17). Gaining this added exposure can be
layer of bone. particularly helpful during surgical procedures that are di-
The trigeminal ganglion and the adjacent part of the poste- rected through the petrous apex to complete a vascular anas-
rior root and their surrounding dural and arachnoidal cavern, tomosis, to occlude the artery for control of bleeding, and to
called Meckel’s cave, sit in an impression on the upper surface allow for mobilization of the vertical and horizontal segments
of the petrous apex above the medial part of the petrous of the artery (40). A venous plexus of variable size, an exten-
carotid (Figs. 8.1, 8.7, and 8.8). The length of the horizontal sion of the cavernous sinus within the periosteal covering of
segment of the petrous carotid that can be exposed by remov- the distal part of the canal, surrounds the artery.
FIGURE 8.10. E, a frontotemporal craniotomy has been completed and the dura of the lateral wall of the cavernous
sinus has been elevated. In addition, the lateral orbital wall has been removed to expose the globe, extraocular muscles,
and lacrimal gland. F, enlarged view of the region of the cavernous sinus. The PCA and SCA have been exposed coursing
above and below the oculomotor and trochlear nerves, respectively. The optic nerve is exposed above the internal
carotid artery. An opening has been made into the lateral wall of the sphenoid sinus between the first and second
divisions. The maxillary nerve passes forward to join the terminal branches of the maxillary artery in the pterygopalatine
fossa. The maxillary nerve continues forward along the floor of the orbit as the infraorbital nerve. The superior ophthalmic
vein descends across the origin of the lateral rectus muscle and enters the anterior portion of the cavernous sinus. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Bas., basilar; Brs., branches; Cap., capitis; Car., carotid; Cav., cavern-
ous; CN, cranial nerve; Ext., external; Front., frontal; Gl., gland; Inf., inferior; Infraorb., infraorbital; Int., internal; Jug., jugu-
lar; Lac., lacrimal; Lat., lateral; Long., longus; M., muscle; Max., maxillary; Med., medial; N., nerve; Ophth., ophthalmic;
P.C.A., posterior cerebral artery; Pet., petrosal, petrous; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; S.C.A.,
superior cerebellar artery; Sphen., sphenoid; Submandib., submandibular; Sup., superior; Temp., temporal; Tens., tensor; TM.,
temporomandibular; Tymp., tympani; V., vein; Vert., vertebral.
The facial nerve in the temporal bone, which often blocks point, the intradural compartments of the petroclival region
access to lesions within and deep to the temporal bone, is are divided along this petroclival line into 1) an inferior space
divided into three segments (Figs. 8.4, 8.5, and 8.7). The first, related to the medulla and to the structures around the re-
or labyrinthine segment, which is located in the petrous part, gion of the foramen magnum; 2) a middle space related to the
extends from the meatal fundus to the geniculate ganglion pons and to the structures in the prepontine and cerebel-
and is situated between the cochlea anteromedially and the lopontine angle; and 3) a superior space related to the con-
semicircular canals posterolaterally. The labyrinthine segment tents of the interpeduncular cistern, and to the sellar and
ends at the site at which the greater superficial petrosal nerve parasellar regions.
arises from the facial nerve at the level of the geniculate
ganglion. From there, the nerve turns laterally and posteriorly The inferior petroclival space
along the medial surface of the tympanic cavity, thus giving The inferior petroclival space corresponds to the anterior sur-
the name tympanic segment to that part of the nerve. The face of the medulla and adjacent part of the clivus and anterior
tympanic segment runs between the lateral semicircular canal margin of the foramen magnum (4). The neurovascular struc-
above and the oval window below. As the nerve passes below tures in this region are those contained in the premedullary
the midpoint of the lateral semicircular canal, it turns verti- cistern. The superior limit is the junction of the pons and me-
cally downward and courses through the petrous part adja- dulla. The inferior limit is the rostral margin of the first cervical
cent to the mastoid part of the temporal bone; thus the third nerve root, the site of the junction of the spinal cord and the
segment, which ends at the stylomastoid foramen, is called medulla. The inferior petroclival space includes the lower four
the mastoid or vertical segment. cranial nerves, lower part of the cerebellum, the vertebral artery
and its branches, and the structures around the occipital condyle.
Petroclival region
These transtemporal operative approaches are often di- The middle petroclival space
rected to the petroclival region located where the posterior The middle petroclival space corresponds to the anterolat-
surface of the petrous temporal bone meets the clival part of eral surface of the pons and cerebellum. Its superior limit is at
the occipital bone along the petroclival fissure. The junction of the pontomesencephalic sulcus and the lower limit is at the
the two bones forms a line that extends from the jugular pontomedullary sulcus. The lateral limits are formed by the
foramen to the petrous apex (Fig. 8.1). From a surgical stand- posterior surface of the petrous bone and by the contents of
the cerebellopontine angle including the trigeminal, abdu- cerebral artery (PCA) and superior cerebellar artery (SCA), and
cens, facial, and vestibulocochlear nerves, the basilar artery, the cavernous carotid and its intracavernous branches to the
and the AICA and the superior petrosal veins. dura of the upper clivus. The medial edge of the tentorium
divides the superior petroclival space into infra- and supraten-
The superior petroclival space torial compartments.
The superior petroclival space is located anterior to the
midbrain and corresponds to the anterior part of the tentorial
incisura. It extends anteriorly and laterally to the sellar and Adjacent structures
parasellar regions. Its roof is formed by the diencephalic The structures important in accessing the temporal bone
structures forming the floor of the third ventricle. The poste- from posteriorly and laterally have already been reviewed. This
rior limit is formed by the cerebral peduncles and the posterior section reviews the structures located in front of the temporal
perforated substance. The inferior limit is situated above the bone that are important in reaching lesions that involve the bone
origin of the trigeminal nerve at the pontomesencephalic sulcus. or involve both the bone and areas anterior to it. They include
It includes the intradural segment of the oculomotor and troch- several muscles, like the temporalis and masseter, the infratem-
lear nerves, the basilar artery and its branching into the posterior poral fossa, and the parapharyngeal spaces.
The temporalis muscle, along with the deep temporal ves- and arises with superficial and deep heads; the superficial head
sels, passes between the gap formed by the zygomatic arch arises from the lateral aspect of the palatine pyramidal process
and the floor of the temporal fossa (Fig. 8.5). The muscle and the maxillary tuberosity and passes superficial to the lower
attaches to the coronoid process of the mandible. The super- head of the lateral pterygoid; and the deep head originates from
ficial and the deep temporalis fasciae attach, respectively, to the medial surface of the lateral pterygoid plate and the ptery-
the lateral and medial aspects of the upper border of the goid fossa between the two pterygoid plates and passes deep to
zygomatic arch. Inferiorly, the parotid fascia invests the pa- the lower head of the lateral pterygoid. Both heads descend
rotid gland and the masseter muscle and attaches to the lower backward and laterally to attach to the medial surface of
border of the zygomatic arch. The masseter muscle has two the mandibular ramus below the mandibular foramen. The
superimposed layers. A superficial layer which attaches to the sphenomandibular ligament, located medial to the mandibular
zygomatic process of the maxilla and anterior part of the condylar process, descends from the sphenoid spine to attach to
lower border of the zygomatic arch and a deep layer which the lingula of the mandibular foramen. The structures located or
attaches to the medial aspect of the whole zygomatic arch. passing between the sphenomandibular ligament and the man-
Inferiorly it inserts onto the angle and ramus of the mandible. dible are the lateral pterygoid and the auriculotemporal nerve
The parotid gland, the parotid duct, and the branches of the superiorly, and the inferior alveolar nerve, the parotid gland, the
facial nerve are located superficial to the masseter muscle maxillary artery and its inferior alveolar branch inferiorly.
(Figs. 8.5, 8.9, and 8.10). In surgical procedures in which the The maxillary artery is divided into three segments: man-
mandibular condyle is resected or displaced inferiorly, the dibular, pterygoid, and pterygopalatine (Figs. 8.8-8.10). The
parotid gland, along with the branches of the facial nerve, can mandibular segment arises from the external carotid artery
be dissected from the underlying masseter to avoid excessive near the posterior border of the condylar process, passes
traction on the facial nerve and to reduce the risk of facial between the process and the sphenomandibular ligament,
palsy (33). along the inferior border of the lower head of the lateral
Muscles commonly encountered in operative approaches to pterygoid, and gives rise to the deep auricular, anterior tym-
the region of the temporal bone include the posterior belly of panic, middle and accessory meningeal, and the inferior alve-
the digastric muscle and the muscles attached to the styloid olar arteries. The middle meningeal ascends medial to the
process. The posterior digastric belly originates in the digas- lateral pterygoid to enter the foramen spinosum, the accessory
tric groove, lateral to the occipital groove in which the occip- meningeal arises from the maxillary or middle meningeal to
ital artery courses, and inserts onto the hyoid bone. The enter the foramen ovale, and the inferior alveolar descends
muscles attached to the styloid process, the stylohyoid, stylo- to enter the mandibular foramen. The pterygoid segment
glossus, and stylopharyngeus muscles, extend to the hyoid usually courses lateral to, but occasionally medial to, the
bone, tongue, and pharyngeal wall, respectively. lower head of the lateral pterygoid and gives rise to the deep
temporal, pterygoid, masseteric, and buccal arteries. The
pterygopalatine segment courses between the two heads of
Infratemporal fossa the lateral pterygoid and enters the pterygopalatine fossa by
The infratemporal fossa, a route through which some tem- passing through the pterygomaxillary fissure. Its branching
poral bone lesions can be reached, is a not uncommon site of will be described with the pterygopalatine fossa.
involvement by lesions that also involve the temporal bone The pterygoid venous plexus is located in the infratemporal
(11). The osseous boundaries of the infratemporal fossa are fossa and has two parts: a superficial part located between
the posterolateral maxillary surface anteriorly, the lateral the temporalis and lateral pterygoid; and a deep part situ-
pterygoid plate anteromedially, the mandibular ramus later- ated between the lateral and medial pterygoids anteriorly,
ally, and the tympanic part of the temporal bone and the and between the lateral pterygoid and the parapharyngeal
styloid process posteriorly. The fossa is domed anteriorly by space posteriorly. The deep part is more prominent and con-
the infratemporal surface of the greater sphenoid wing, the nects with the cavernous sinus by emissary veins passing
site of the foramina ovale and spinosum, and posteriorly by through the foramina ovale and spinosum, and occasionally
the squamous part of the temporal bone (Figs. 8.8-8.10). The through the sphenoidal emissary foramen (foramen of Vesalius).
inferior, posteromedial, and superolateral aspects are open The main drainage of the pterygoid plexus is through the maxillary
without bony walls. vein to the internal jugular vein.
The structures located in the infratemporal fossa are the The mandibular nerve enters the infratemporal fossa by
pterygoid muscles and venous plexus and the branches of the passing through the foramen ovale on the lateral side of the
maxillary artery and mandibular nerve. The lateral pterygoid parapharyngeal space, where it gives rise to several smaller
muscle crosses the upper part of the infratemporal fossa, branches, and then divides into a smaller anterior trunk and a
originating from the upper and lower heads; the upper head larger posterior trunk (Figs. 8.8-8.10). The anterior trunk gives
arises from the infratemporal surface of the greater sphenoid rise to the deep temporal and masseteric nerves, which supply
wing, and the lower head originates from the lateral ptery- the temporalis and the masseter, respectively, and the nerve
goid plate (Figs. 8.8-8.10). Both heads pass posterolaterally and to the lateral pterygoid. The buccal nerve, which conveys
insert on the neck of the mandibular condylar process and the sensory fibers, passes anterolaterally between the two heads
articular disc of the temporomandibular joint. The medial ptery- of the lateral pterygoid, and descends lateral to the lower
goid muscle crosses the lower part of the infratemporal fossa head to reach the buccinator and the buccal mucosa. The
posterior trunk gives off the lingual, inferior alveolar, and medial to the foramina ovale and spinosum to the sphenoid
auriculotemporal nerves, which descend medial to the lateral spine and the posterior margin of the glenoid fossa. The
pterygoid. The lingual and inferior alveolar nerves, the former sharply angled inferior boundary is situated at the junction of
coursing anterior to the latter, pass between the lateral and the posterior digastric belly and the greater hyoid cornu. The
medial pterygoids. The auriculotemporal nerve usually splits poststyloid part, which contains the internal carotid artery,
to encircle the middle meningeal artery and passes postero- internal jugular vein, and the initial extracranial segment of
laterally between the mandibular ramus and the sphenoman- cranial nerves IX through XII, is separated from the infratem-
dibular ligament. The chorda tympani nerve, which con- poral fossa by the posterolateral portion of the prestyloid part.
tains the taste fibers from the anterior two-thirds of the tongue The glossopharyngeal nerve exits the skull through the intra-
and the parasympathetic secretomotor fibers to the subman- jugular part of the jugular foramen, anterior to the vagus and
dibular and sublingual salivary glands, enters the infratem- accessory nerves, and passes forward, medial to the styloid
poral fossa through the petrotympanic fissure, descends me- process in close relationship to the lateral surface of the ca-
dial to the auriculotemporal and inferior alveolar nerves, and rotid artery as the artery enters the carotid canal (Fig. 8.9).
joins the lingual nerve. The otic ganglion is situated immedi- Care is required to avoid injury to the glossopharyngeal nerve
ately below the foramen ovale on the medial side of the if the artery is to be mobilized at the carotid canal. The vagus
mandibular nerve. The ganglion receives the lesser petrosal nerve leaves the skull through the anteromedial edge of the
nerve, which crosses the floor of the middle fossa anterolat- intrajugular part of the foramen and courses deep within
eral to the greater petrosal nerve to exit through the foramen the carotid sheath, between the internal carotid artery and the
ovale or the more posteriorly situated canaliculus innomina- jugular vein. The accessory nerve exits the intrajugular part
tus and conveys parasympathetic secretomotor fibers to the and runs backward, lateral to the jugular vein and medial to
parotid gland via the auriculotemporal nerve. The medial the styloid process and the posterior belly of the digastric
pterygoid nerve arises from the medial aspect of the mandib- muscle, to innervate the sternocleidomastoid muscle.
ular nerve close to the otic ganglion and descends to supply The hypoglossal nerve exits through the hypoglossal canal,
the medial pterygoid and tensor veli palatini. The nervus deep to the jugular vein and to the nerves emerging from the
spinosus, a meningeal branch, also arises near the otic gan- jugular foramen, and runs downward, between the carotid
glion and ascends through the foramen spinosum to innervate artery and the jugular vein (Figs. 8.9 and 8.10). It becomes
the middle fossa dura. superficial at the level of the angle of the jaw where it crosses
the internal and external carotid arteries, close to the level of
the common carotid bifurcation, to innervate the tongue.
Parapharyngeal space
The parapharyngeal space is located in the lateral pharyn-
geal wall and is shaped like an inverted pyramid, with its base Pterygopalatine fossa
on the skull base superiorly and its apex at the hyoid bone The pterygopalatine fossa, which opens laterally into the
inferiorly. The parapharyngeal space is subdivided into pre- medial part of the infratemporal fossa, is bounded posteriorly
styloid and poststyloid compartments by the styloid dia- by the sphenoid pterygoid process, medially by the palatine
phragm, a fibrous sheet that also constitutes the anterior part perpendicular plate, that bridges the interval between the
of the carotid sheath (Figs. 8.5 and 8.9). The prestyloid part, maxilla and pterygoid process, and opens superiorly through
situated anteriorly between the fascia covering the opposing the medial part of the inferior orbital fissure into the orbital
surfaces of the medial pterygoid and tensor veli palatini, is a apex (Figs. 8.5, 8.9, and 8.10) (11). The fossa contains the
thin fat-filled compartment separating the structures in the maxillary nerve, pterygopalatine ganglion, maxillary artery,
infratemporal fossa from the eustachian tube and the tensor and their branches, all embedded in fat tissue. Its lateral
and levator veli palatini muscles in the lateral nasopharyngeal boundary, the pterygomaxillary fissure, opens into the infra-
wall. The upper portion of the prestyloid part is situated temporal fossa and allows passage of the maxillary artery
between two fascial sheets, which are oriented in a sagittal from the infratemporal into the pterygopalatine fossa, where
plane. The lateral sheet arises from the medial surface of the the artery gives rise to its terminal branches. The lower part of
medial pterygoid, passes upward, backward, and medial to the fossa is funnel-shaped, with its inferior apex opening
the mandibular nerve and the middle meningeal artery, in- into the greater and lesser palatine canals, which transmit the
corporating the sphenomandibular ligament posteriorly, and greater and lesser palatine nerves and vessels, and communi-
reaching the retromandibular deep lobe of the parotid gland. cate with the oral cavity. The sphenopalatine foramen, located
The medial sheet is formed by the fascia overlying the lateral in the upper part of the fossa’s medial wall, conveys the
surface of the tensor veli palatini and is continuous inferiorly sphenopalatine nerve and vessels, and opens into the superior
with the fascia over the superior pharyngeal constrictor and nasal meatus just above the root of the middle nasal concha.
posteriorly with the thick styloid diaphragm, which enve- The foramen rotundum opens just below the superior orbital
lopes the stylopharyngeus, styloglossus, and stylohyoid and fissure through the superior part of the posterior wall of the
blends into the carotid sheath. The superior border is located fossa. The pterygoid canal opens through the sphenoid ptery-
where the two fascial sheets fuse together and insert in the goid process inferomedial to the foramen rotundum and con-
skull base along a line extending backward from the ptery- veys the vidian nerve carrying autonomic fibers to the ptery-
goid process lateral to the origin of the tensor veli palatini, gopalatine ganglion. The maxillary nerve, after entering the
fossa, gives off ganglionic branches to the pterygopalatine cervicalis, and by the lingual and facial veins. Medial to the
ganglion. It then deviates laterally just beneath the inferior digastric, it is crossed by the stylohyoid muscle and the oc-
orbital fissure, giving rise to, in order, the zygomatic and cipital and posterior auricular arteries. Superior to the digas-
posterosuperior alveolar nerves outside of the periorbita. It tric, the internal carotid artery is separated from the external
then turns medially as the infraorbital nerve, passing through carotid artery by the styloid process and the muscles attached
the inferior orbital fissure to enter the infraorbital groove, to it. At the entrance into the carotid canal, the artery is
where the anterior and middle superior alveolar nerves arise. involved by a dense sheath of connective tissue and is sepa-
Finally, it exits the infraorbital foramen to terminate on the rated from the internal jugular vein by the hypoglossal nerve
cheek. The pterygopalatine ganglion, located in front of the and by the nerves exiting from the jugular foramen.
pterygoid canal and inferomedial to the maxillary nerve, re- The internal carotid artery passes, almost straightly up-
ceives communicating rami from the maxillary nerve and ward, posterior to the external carotid artery and anterome-
gives rise to the greater and lesser palatine nerves from the dial to the internal jugular vein to reach the carotid canal. At
lower surface of the ganglion, the sphenopalatine nerve and the level of the skull base, the internal jugular vein courses
pharyngeal branch from the medial surface, and the orbital just posterior to the internal carotid artery, being separated
branch from the superior surface. The vidian nerve is formed from it by the carotid ridge. Between them, the glossopharyn-
by the union of the greater petrosal nerve, which conveys geal nerve is located laterally and the vagus, accessory, and
parasympathetic fibers arising from the facial nerve at the hypoglossal nerves medially.
level of the geniculate ganglion, and the deep petrosal nerve, After the internal carotid artery enters the carotid canal
which conveys sympathetic fibers from the carotid plexus, to with the carotid sympathetic nerves and surrounding venous
reach the lacrimal gland and nasal mucosa. The parasympa- plexus, it ascends a short distance (the vertical segment),
thetic fibers synapse in the pterygopalatine ganglion, whereas reaching the area below and slightly behind the cochlea,
the sympathetic fibers do not. The sympathetic fibers synapse where it turns anteromedially at a right angle (the site of the
in the superior cervical sympathetic ganglion. lateral bend) and courses horizontally (the horizontal seg-
The third or pterygopalatine segment of the maxillary ar- ment) toward the petrous apex (Figs. 8.8-8.10). At the medial
tery enters the pterygopalatine fossa by passing through the edge of the foramen lacerum, it turns sharply upward at the
pterygomaxillary fissure. This segment courses in an anterior, site of the medial bend to enter the posterior part of the
medial, and superior direction and gives rise to the infraor- cavernous sinus.
bital artery, which passes through the inferior orbital fissure
and courses with the infraorbital nerve; the posterosuperior
alveolar artery, which descends to pierce the posterolateral External carotid artery
wall of the maxilla; the recurrent meningeal branches, which The external carotid artery ascends anterior to the internal
pass through the foramen rotundum; and the greater and carotid artery on the posteromedial margin of the parotid
lesser palatine arteries, which descend through the greater gland and medial to the digastric and stylohyoid muscles.
and lesser palatine canals; the vidian artery to the pterygoid Proximal to its terminal bifurcation into the maxillary and the
canal; the pharyngeal branch to the palatovaginal canal; and superficial temporal arteries, it gives rise to six branches that
finally the sphenopalatine artery, which passes through the can be divided into anterior and posterior groups according to
sphenopalatine foramen to reach the nasal cavity and is con- their directions. The latter group is related to the region of the
sidered to be the terminal branch of the maxillary artery temporal bone.
because of its large diameter. The arterial structures in the The ascending pharyngeal artery, the first branch of the
pterygopalatine fossa are located anterior to the neural posterior group, often provides the most prominent supply to
structures. the meninges around the jugular foramen (18). It arises either
at the bifurcation or from the lowest part of the external or
Arterial relationships internal carotid arteries. Rarely, it arises from the origin of the
occipital artery. It courses upward between the internal and
The arteries that may be involved in pathological abnor- the external carotid arteries, giving rise to numerous branches
malities involving the temporal bone include the upper cer- to neighboring muscles, nerves, and lymph nodes. Its menin-
vical and petrous portions of the internal carotid artery, the geal branches pass through the foramen lacerum to be dis-
posteriorly directed branches of the external carotid artery, tributed to the dura lining the middle fossa and through the
and the upper portion of the vertebral artery. jugular foramen or the hypoglossal canal to supply the sur-
rounding dura of the posterior cranial fossa. The ascending
Common carotid artery pharyngeal artery also gives rise to the inferior tympanic
The common carotid artery bifurcates into the internal and artery, which reaches the tympanic cavity by way of the
external carotid arteries at the level of the upper border of the tympanic canaliculus along with the tympanic branch of the
thyroid cartilage. The internal carotid artery initially ascends glossopharyngeal nerve.
relatively superficial in the carotid triangle of the neck, but The occipital artery, the second and largest branch of the
assumes a much deeper position after passing medial to the posterior group, arises from the posterior surface of the ex-
posterior belly of the digastric (Figs. 8.9 and 8.10). Below the ternal carotid artery and courses obliquely upward between
digastric, it is crossed by the hypoglossal nerve and the ansa the posterior belly of the digastric muscle and the internal
jugular vein, and then medial to the mastoid process and clival area. It consists of one or more channels that, at its lower
either superficial or deep to the longissimus capitis muscle end, course rostral or caudal to or between the nerves passing
(Fig. 8.5). It courses deep to the latter muscle if it courses in the through the jugular foramen. It enters the medial wall of the
occipital groove of the mastoid bone, which is located medial jugular bulb just anterior to where the cranial nerves descend
to the digastric groove. After passing the longissimus capitis in the anteromedial wall of the jugular bulb (18). It joins the
muscle, the occipital artery courses deep to the splenius capi- cavernous sinus at its upper margin. The transverse sinus
tis muscle, finally reaching a subcutaneous location by pierc- begins at the level of the internal occipital protuberance and
ing the fascia between the attachment of the sternocleidomas- passes laterally and forward to the posterolateral part of the
toid and the trapezius muscles to the superior nuchal line. The temporal bone where it joins the superior petrosal sinus and
occipital artery gives rise to several muscular and meningeal continues as the sigmoid sinus. It receives drainage from the
branches, anastomoses with other branches of the external tentorial surface of the cerebellum through the tentorial si-
carotid including the ascending pharyngeal and also with nuses and from the temporal lobe through the vein of Labbé.
branches of the vertebral artery. Its meningeal branches, The basilar venous plexus consists of multiple interconnecting
which enter the posterior fossa through the jugular foramen channels situated between the layers of dura mater on the
or the condylar canal, may make a significant contribution to clivus. It forms the largest communication between the paired
tumors of the jugular foramen. cavernous sinus and communicates through the inferior
The posterior auricular artery, the last branch in the poste- petrosal sinuses with the sinuses in the region of the foramen
rior group, arises above the posterior belly of the digastric magnum (10).
muscle and travels between the parotid gland and the styloid
process. At the anterior margin of the mastoid process, it SURGICAL APPROACHES
divides into auricular and occipital branches, which are dis-
tributed to the postauricular and the occipital regions, respec- The suboccipital retrosigmoid approach, the traditional
tively. The stylomastoid branch, which arises below the stylo- neurosurgical route to intradural pathologies arising in the
mastoid foramen, enters the stylomastoid foramen to supply region of the cerebellopontine angle, lower clivus, and fora-
the facial nerve. Its loss can lead to a facial palsy, even though men magnum, is reviewed in the chapter on the cerebellopon-
it anastomoses with the petrosal branch of the middle men- tine angle. The approaches reviewed here are those directed
ingeal artery. The posterior auricular branch may share a through the temporal bone.
common trunk with the occipital artery, or sometimes it is
absent, in which case, the occipital artery gives rise to the Middle fossa approach
stylomastoid artery. Members of the anterior group, whose This section focuses on the middle fossa approach to the
origins may be visualized in exposing lesions in the region, internal acoustic meatus rather than on the more extensive
include the superior thyroid, lingual, and facial arteries. approaches directed through the petrous apex to the petroclival
The superficial temporal artery arises from the external region or the more extended approaches directed through the
carotid artery in the substance of the parotid gland behind the temporal bone lateral to the internal acoustic meatus. The middle
neck of the mandible where it is crossed by the temporal and fossa approach to the internal acoustic meatus is usually selected
zygomatic branches of the facial nerve (Fig. 8.5). It ascends for small tumors that are located predominantly within the
over the posterior root of the zygoma and divides into ante- internal acoustic meatus in which there is an opportunity to
rior and posterior branches that run with the superficial tem- preserve hearing. With this approach, the meatus is approached
poral vein and the auriculotemporal nerve over the superficial from above, through a temporal craniotomy located above the
temporalis fascia. ear and zygoma (Figs. 8.7 and 8.11) (2). The dura under the
temporal lobe is elevated from the floor of the middle cranial
Vertebral artery fossa until the arcuate eminence and the greater petrosal nerve
are identified. The distance from the inner table of the skull to the
The vertebral artery and its meningeal, posterior spinal,
facial hiatus, through which the greater petrosal nerve passes,
and posteroinferior cerebellar branches, which may be ex-
ranges from 1.3 to 2.3 cm (average, 1.7 cm) (42). When separating
posed in approaches directed through the temporal bone, are
the dura from the floor of the middle fossa, one should remem-
detailed in the chapter on the foramen magnum (4, 20, 24).
ber that bone may be absent over all or part of the geniculate
ganglion. In our previous study of 100 temporal bones, all or part
Venous relationships of the geniculate ganglion and the genu of the facial nerve were
The venous drainage of the structures of the skull base is found to be exposed in the floor of the middle fossa in 15 bones
through the internal jugular veins, the sinuses in the dura (15%) (31). In 15 other specimens, the geniculate ganglion was
mater, and a series of emissary veins communicating the completely covered, but no bone extended over the greater
intra- and extracranial compartments (25). The superior petro- petrosal nerve. The greatest length of greater petrosal nerve
sal sinus sits on the petrous ridge and connects the cavernous covered by bone was 6.0 mm. More than 50% of the specimens
and transverse sinuses. It receives tributaries from the inferior had less than 2.5 mm of greater petrosal nerve covered. It also is
surface of the temporal lobe and from the petrosal veins that important to remember that the petrous segment of the carotid
drain the cerebellum and brainstem. The inferior petrosal artery may be exposed without a covering of bone in the floor of
sinus courses along the petro-occipital fissure and drains the the middle fossa deep to the greater petrosal nerve (17) In a
FIGURE 8.11. Middle fossa approach to the internal acoustic meatus. A, the vertical line shows the site of the scalp incision and
the stippled area outlines the bone flap bordering the middle fossa floor. B, the dura has been elevated to expose the middle men-
ingeal artery, the greater petrosal nerve, and the arcuate eminence. C, bone has been removed to expose the junction of the
greater petrosal nerve and the geniculate ganglion. A portion of the upper wall of the internal meatus has been removed. The
upper surface of the arcuate eminence has been drilled to expose the superior semicircular canal. In the middle fossa approach, for
an acoustic neuroma, the cochlea and semicircular canal are not opened, as seen in this dissection illustrating some of the impor-
tant structures that are to be avoided in opening the meatus. D, enlarged view. The cochlea, located below the middle fossa floor
in the angle between the facial and greater petrosal nerves, has been opened in the area anteromedial to the meatal fundus. The
roof of the meatus has been opened to expose the superior vestibular nerve, which innervates the ampullae of the superior and
lateral canals and the meatal segment of the facial nerve. E, the vestibule and semicircular canals are located posterolateral and the
cochlea is located anteromedial to the meatal fundus. The tensor tympani is layered along the anterior edge and the greater petro-
sal nerve above the petrous carotid. F, enlarged view. The vertical crest (Bill’s bar) separates the facial and superior vestibular
nerves at the meatal fundus. The superior and inferior vestibular nerves are located posteriorly and the facial and cochlear nerves
anteriorly in the meatus, with the cochlear nerve passing below the facial nerve to enter the modiolus. The labyrinthine segment of
the facial nerve courses superolateral to the cochlea. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch.,
cochlear; Emin., eminence; Gang., ganglion; Genic., geniculate; Gr., greater; Inf., inferior; Int., internal; Laby., labyrinthine; M.,
muscle; Meat., meatal; Men., meningeal; Mid., middle; N., nerve; Pet., petrosal, petrous; Post., posterior; Seg., segment; Sup., supe-
rior; Tens., tensor; Tymp., tympani; Vert., vertebral; Vest., vestibular.
previous study, we found that a 7-mm length of petrous carotid Two different methods are used for exposing the internal
artery may be exposed without a bony covering in the area acoustic meatus. One is to remove bone over the greater
below where the greater petrosal nerve passes below the lateral petrosal nerve and to follow it to the geniculate ganglion and
margin of the trigeminal ganglion to reach the vidian canal at the the genu of the facial nerve. From here, the labyrinthine
anterior margin of the anterior margin of the foramen lacerum portion of the facial nerve is followed to the lateral end of the
(30, 31). The foramen spinosum and middle meningeal artery internal auditory canal, after which the canal is unroofed. The
and the foramen ovale and third trigeminal division are situated other method is begun by drilling just in front of the petrous
at the anterior margin of the extradural exposure. The extradural ridge in the area medial to the arcuate eminence. The angle
exposure can usually be completed without obliterating the mid- between the long axis of the superior semicircular canal or the
dle meningeal artery at the foramen spinosum. greater petrosal nerve and the long axis of the internal acous-
FIGURE 8.12. E–H. Anterior petrosectomy and extended middle fossa approach. E, additional bone has been removed
around the internal acoustic meatus and the dura opened to expose the facial and vestibulocochlear nerves. F, the exposure
has been extended lateral to the internal acoustic meatus. The tegmen has been opened to expose the head of the incus in
the epitympanic area. The osseous capsule of the labyrinth has been opened to expose the semicircular canals. The presig-
moid dura behind the labyrinth has been exposed and opened. G, a translabyrinthine approach directed through the middle
fossa has been completed by removing the semicircular canals and vestibule. The dura has been opened to give an exposure
through the middle fossa similar to that seen with the presigmoid approach. The labyrinthine, tympanic, and mastoid seg-
ments of the facial nerve have been exposed. H, this extended middle fossa exposure extends from the lateral wall of the cav-
ernous sinus, across the trigeminal nerve to the area lateral to the internal acoustic meatus, and provides wide access to the
anterior part of the posterior fossa.
tic meatus is helpful in selecting the site for drilling. The long approach if hearing is to be preserved. The vertical crest,
axis of the central part of the internal acoustic meatus is which is identified at the upper edge of the meatal fundus,
located an average of 61 degrees behind the long axis of the provides a valuable landmark for identifying the facial nerve.
greater petrosal nerve and an average of 37 degrees medial to In the final stage of bone removal, the upper wall of the
the long axis of the arcuate eminence and superior semicircu- internal auditory canal is removed to expose the dura lining
lar canal. The drilling is directed anterolateral to the meatal the entire superior surface of the internal auditory canal
fundus where the vertical crest is identified. from the vertical crest to the porus. The dura is opened to
The lateral part of the bone removal near the meatal fundus expose the pathology.
is limited posteriorly by the superior semicircular canal, The extended middle fossa approach used for the removal
which is located a few millimeters behind and oriented par- of larger acoustic neuromas includes wider opening of the
allel to the labyrinthine segment of the facial nerve (Figs. 8.7 posterior part of the petrous pyramid (21, 28, 42, 43). This
and 8.11). The anteromedial edge of the exposure is limited by approach combines different degrees of resection of the bony
the cochlea, which sits only a few millimeters anterior to the labyrinth with the subtemporal transtentorial routes (Fig.
site of bone removal, in the angle between the labyrinthine 8.12). Extending the resection of the petrous bone posteriorly
portion of the facial nerve and the greater petrosal nerve. The over the mastoid and the bony labyrinth exposes the whole
cochlea and the semicircular canals should be avoided in this intrapetrous course of the facial nerve, and provides access to
FIGURE 8.13. A–F. Subtemporal exposure of the right middle, infratemporal, and posterior fossae. A, the insert shows the side of the
scalp incision. A frontotemporal craniotomy has been completed and the dura has been elevated from the middle fossa floor and lateral
wall of the cavernous sinus. B, enlarged view. The bony roof over the geniculate ganglion and internal meatus has been removed and the
dura lining the meatus opened to expose the facial and superior vestibular nerves. C, additional middle fossa floor has been removed to
expose the petrous carotid, the cochlea in the angle between the greater petrosal nerve and pregeniculate part of the facial nerve, the
semicircular canals and tympanic cavity. The tensor tympani muscle and eustachian tube are exposed in front of the petrous carotid
artery. D, the bone between the superior and posterior canals has been removed to expose the vestibule with which both ends of the
semicircular canals communicate. The vestibule contains the utricle and saccule and communicates below the fundus of the meatus with
the cochlea. The meatal segment of the facial nerve courses in the internal acoustic meatus, the labyrinthine segment between the semi-
circular canals and the cochlea, the tympanic segment between the anterior margin of the lateral canal and the oval window on the
medial side of the tympanic cavity, and the mastoid segment descends to exit the stylomastoid foramen. E, the petrous apex, medial to
the cochlea and extending under the trigeminal nerve, has been removed to expose the lateral edge of the clivus and the posterior fossa
dura. F, the medial tentorial edge has been divided behind the petrous ridge to expose the oculomotor, trochlear, and trigeminal nerves
and the basilar artery. A., artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., anterior; Bas., basilar; Car., carotid; Chor.,
chorda, choroidal; CN, cranial nerve; Comm., communicating; Eust., eustachian; Gang., ganglion; Gen., geniculate; Genic., geniculate;
Gr., greater; Inf., inferior; Int., internal; Jug., jugular; Laby., labyrinthine; Lat., lateral; M., muscle; Mandib., mandibular; Mast., mastoid;
Max., maxillary; Meat., meatal; Men., meningeal; Mid., middle; N., nerve; P.C.A., posterior cerebral artery; Pet., petrosal, petrous; Post.,
posterior; S.C.A., superior cerebellar artery; Seg., segment; Sup., superior; Temp., temporal; Tens., tensor; Trig., trigeminal; Tymp., tym-
pani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.
FIGURE 8.13. G–L. Subtemporal exposure of the right middle, infratemporal, and posterior fossae. G, the dural opening has been
extended downward to expose the lateral edge of the clivus and the inferior petrosal sinus coursing along the petroclival fissure.
The abducens nerve and the AICA are in the lower margin of the exposure. H, an osteotomy of the zygomatic arch and the floor
of the middle fossa surrounding the mandibular fossa has been completed to aid in exposing the infratemporal fossa. I, the mandib-
ular fossa and floor of the middle fossa, extending medially to the level of the foramen ovale, have been removed. Branches of the
mandibular nerve and maxillary artery are exposed in the infratemporal fossa. The greater petrosal nerve joins the deep petrosal
nerve from the carotid sympathetic plexus to form the vidian nerve, which passes forward in the vidian canal to reach the pterygo-
palatine fossa. J, the upper portion of the cervical carotid is exposed medial to the jugular foramen. The petrous carotid crosses
behind the eustachian tube and tensor tympani. K, the eustachian tube and tensor tympani have been resected, the petrous carotid
reflected forward out of the carotid canal, the petrous apex removed, and the posterior fossa dura opened to expose the vertebral
artery and the AICA. L, enlarged view. The right vertebral artery has been displaced forward to expose the left vertebral artery.
The AICA passes toward the nerves entering the internal acoustic meatus.
the cerebellopontine angle by a combination of subtemporal, 8.13) (19). The dura is carefully elevated from the floor of the
translabyrinthine, and presigmoid routes, all directed through middle fossa to expose the middle meningeal artery, which
the posterior part of the floor of the middle fossa. may be obliterated and divided at the foramen spinosum.
Further elevation of the dura toward the petrous ridge will
Subtemporal anterior transpetrosal approach expose the arcuate eminence and greater petrosal nerve pos-
This approach is made through a temporal craniotomy that teriorly. The cochlea, which is to be preserved, and the ante-
extends down to the floor of the middle fossa (Figs. 8.12 and rior wall of the internal auditory canal constitute the lateral
limit of the exposure through the petrous apex. The bone layer the inferior petrosal sinus at the lateral edge of the clivus. Care is
over the superior wall of the internal auditory canal, which required to prevent damage to the abducens nerve as it passes
averages 5 mm (range, 3–7 mm) in thickness, can be removed through Dorello’s canal located at the upper edge of the petro-
with a drill to improve the exposure (44). The petrous carotid clival fissure. The width of the bone resection from the trigemi-
forms the anterior limit of the exposure. The limit above the nal impression to the posterior wall of the internal auditory canal
medial part of the bone resection is the trigeminal nerve in averages 13 mm (range, 9–14 mm) (44). The depth of the expo-
Meckel’s cave. Drilling is directed behind the petrous carotid, sure, from the trigeminal ganglion to the petroclival fissure,
through the petrous apex medial to the cochlea and under the averages 13 mm (range, 9–17 mm). The cochlea lies below the
trigeminal nerve. The petrous apex is removed and the bone floor of the middle fossa near the apex of the angle formed by
removal is extended to the lateral side of the clivus, exposing the greater petrosal nerve anteriorly and the internal acoustic
meatus posteriorly. The cochlea is to be avoided if hearing is to the lower margin of the opening through the petrous apex.
be preserved. The approach is then directed between the lower margin of
After the bone removal is completed, the superior petrosal the trigeminal nerve above, and the internal acoustic meatus
sinus is obliterated and divided in the area just lateral to the inferiorly and laterally (20).
trigeminal nerve, and the dural incision is extended across the The exposure is small, as described above, and may require
tentorium. The dural leaflets of the tentorium are retracted significant temporal lobe retraction, especially if the goal is to
with sutures and the dural incision is carried downward to reach the lower aspect of the brainstem. To reach the anterior
aspect of the pons, the view must be directed from lateral to the internal auditory canal and by the transverse and vertical
medial above the internal auditory canal. The angles of view crests. The approach may also be combined with a retrosigmoid
through the area of the petrousectomy can be increased if the or a supra- and infratentorial presigmoid approach.
cranium is approached at a higher level through a frontotem- A retroauricular incision starts above the pinna and extends
poral craniotomy combined with zygomatic arch resection. inferiorly to the mastoid tip (3). A flap of periosteum and soft
tissues overlying the mastoid and retromastoid areas is ele-
Translabyrinthine approach vated. The cortical bone over the mastoid is drilled away and
In the translabyrinthine approach, the internal acoustic me- the mastoid air cells are removed, exposing the mastoid an-
atus and cerebellopontine angle are approached through a trum, the cortical bone around the labyrinth, and the digastric
mastoidectomy and labyrinthectomy (Fig. 8.6) (16, 29, 38) ridge leading anteriorly to the mastoid segment of the facial
There are two goals of bone removal in this approach. The nerve as it exits the stylomastoid foramen and the sinodural
first is to expose the dura of Trautman’s triangle on the angle. Drilling is continued to expose the semicircular canals
posterior surface of the temporal bone facing the cerebel- and to skeletonize the sigmoid sinus, middle fossa dura,
lopontine angle. The second is to remove enough bone to be able mastoid segment of the facial nerve, and the upper surface of
to identify the nerves lateral to the tumor as they course through the jugular bulb, leaving only a thin shell of bone over these
structures. The lateral semicircular canal is the most laterally and the ampullae of the posterior canal and around the su-
projecting canal and is the first one encountered by this ap- perolateral margin of the vestibule.
proach. It provides a valuable landmark in identifying the The internal auditory canal is located medial and anterior to
tympanic segment of the facial nerve and the other canals. The the tympanic segment of the facial nerve. The dura lining the
nerve is found below the lateral canal. The retrofacial air cells internal canal is exposed by drilling away the semicircular
are removed and the dome of the jugular bulb is identified canals and vestibule and the bone around the superior, pos-
inferiorly. In removing bone behind the internal acoustic me- terior, and inferior margins of the internal canal. Further bone
atus, it is important to remember that the jugular bulb may removal at the lateral end of the meatus exposes the trans-
bulge upward behind the posterior semicircular canal or in- verse and vertical crests (Fig. 8.2). The intrameatal portion of
ternal auditory meatus. The vestibular aqueduct and the en- the facial nerve is separated from the superior vestibular
dolymphatic sac may be opened and removed during the nerve at the lateral end of the canal by the vertical crest, also
bone removal between the meatus and the jugular bulb. The called Bill’s bar, that can be used to positively identify the
cochlear canaliculus will be seen deep to the vestibular aque- facial nerve (13, 16). The initial part of labyrinthine segment of
duct as bone is removed in the area between the meatus and the facial nerve, which lies just in front of the vertical crest, is
the jugular bulb. The lower end of the cochlear canaliculus is exposed at the meatal fundus. After identifying the facial
situated just above the area where the glossopharyngeal nerve nerve, the dura lining the meatus is opened. The dural inci-
enters the medial half of the jugular foramen. The labyrinthec- sion in Trautman’s triangle is V-shaped with the apex of the
tomy portion of the procedure involves removing the semi- “V” extending to the incision along the meatal dura. One limb
circular canals and the vestibule to expose the dura lining the of the “V” extends below the superior petrosal sinus and the
internal auditory canal. The lateral and posterior semicircular other limb extends above the jugular bulb. The dural flap is
canals are drilled away. As the bone removal proceeds medi- then reflected posteriorly to expose the structures in the me-
ally, the ampullae of the lateral and superior semicircular atus and the cerebellopontine angle. The subarcuate artery, or
canals are exposed. At this point some bleeding can occur as the AICA, may be encountered in the dura of Trautman’s
the subarcuate artery is encountered in the bone near the triangle. Usually, the subarcuate artery arises from the AICA
center of the superior semicircular canal. The vestibule is an and passes through the dura on the upper posterior wall of
oval-shaped cavity located immediately lateral to the internal the meatus as a fine stem. Occasionally, however, the subar-
acoustic meatus, which forms the communication between the cuate artery, along with its origin from the AICA, may be
semicircular canals and the cochlea. Bone is removed medial incorporated into the dura on the posterior face of the tem-
and posterior to the vestibule, completely exposing it anterior poral bone. The approach may include transection of the
and inferior to the facial nerve. Care is required to avoid external canal and obliteration of the middle ear with packing
injury to the facial nerve as it courses below the lateral canal of the eustachian tube at closure.
FIGURE 8.16. A–F. Comparison of the retrosigmoid and the various modifications of the presigmoid exposure. The modifica-
tions of the presigmoid approach include the minimal mastoidectomy, retrolabyrinthine, partial labyrinthine, translabyrin-
thine, modified transcochlear, and the full transcochlear approach with facial nerve transposition. A, the scalp incision
(insert) is positioned for a supra- and infratentorial exposure through a temporo-occipital craniotomy. A temporo-occipital
craniotomy has been completed and the dura opened to expose the temporal lobe and the retrosigmoid area. The transverse
and sigmoid sinuses have been preserved. The cerebellum has been retracted to expose the nerves in the cerebellopontine
angle. B, enlarged view of the retrosigmoid exposure to compare with the exposure obtained with the various modification of
the presigmoid approach. C, in the retrosigmoid exposure the vestibulocochlear nerve has been elevated and the glossopha-
ryngeal nerve depressed to expose the basilar artery at the origin of the AICA. D, subtemporal exposure. The temporal lobe
has been elevated to expose the optic tract and oculomotor nerve and the PCA, internal carotid, and anterior choroidal arter-
ies. E, the tentorium has been opened while preserving the trochlear nerve. The SCA courses below and the PCA above the
Transcochlear approach canal. The facial canal is then left as a bridge over the opera-
tive field and the dura is exposed between the carotid artery
The transcochlear approach is primarily an anteromedial
and the jugular bulb.
extension of the translabyrinthine approach (Fig. 8.6) (3, 15,
16). It usually includes division and closure of the external
canal, resection of at least the posterior part of the osseous Combined supra- and infratentorial
external canal, and the tympanic membrane and ossicles, and presigmoid approach
obliteration of the eustachian tube. After exposing the dura The presigmoid approach combines the supra- and infrat-
lining the internal auditory canal, as described for the trans- entorial craniotomy centered on the mastoid and varying
labyrinthine approach, the incus is removed and the facial degrees of mastoid and labyrinthine resection (Fig. 8.14).
nerve is exposed from the geniculate ganglion to the stylo- The minimal degree of mastoid resection, which we refer to as
mastoid foramen. The greater superficial petrosal nerve is a minimal mastoidectomy, exposes only enough of the presig-
transected and the facial nerve is transposed posteriorly. In moid dura to open the dura in front of the sigmoid sinus for
the final stage, the bone removal is carried through the facial exposure of the cerebellopontine angle (Figs. 8.15 and 8.16).
canal, after nerve transposition, and the cochlea and adjacent The next more extensive degree of mastoid resection, the
part of the petrous apex are drilled away (Fig. 8.6). retrolabyrinthine modification, is a more complete mastoid-
Medially, the bone removal extends to the edge of the ectomy exposing the bony capsule of the semicircular canals
clivus, exposing the inferior petrosal sinus from the jugular and skeletonizing at least a portion of the facial nerve. In the
bulb below to the superior petrosal sinus above. The ascend- partial labyrinthectomy, one or two of the semicircular canals,
ing portion of the petrous carotid is exposed at the anterior commonly the superior and/or posterior canals, are resected
limit of the dissection. The bone removal, which now extends with preservation of the lateral canal. Removal of these canals
to the lateral edge of the clivus, could easily be carried medi- may, but not always, be associated with the loss of hearing
ally into the clivus. Extending the dural opening in this area (37). The posterior canal may be removed to increase access to
permits visualization of the abducent nerve medial to the the posterior fossa, and removing the superior canal alone
internal acoustic meatus, the lower margin of the trigeminal gives a more direct access to the petrous apex along the
nerve, the nerves entering the jugular foramen, a segment of middle fossa. The next more extensive modification is the
the basilar artery, and the origin and initial segment of the translabyrinthine approach, in which the semicircular canals
AICA. and vestibule are resected uniformly, resulting in the loss of
An alternative to transposing the facial nerve is to complete hearing. The translabyrinthine approach provides excellent
an extensive bone removal in the hypotympanic and retrofa- access to the internal auditory canal. The next more extensive
cial areas extending forward to the carotid canal, thus skele- modification is the transcochlear approach, in which the co-
tonizing the mastoid segment of the facial nerve and leaving chlea located anteromedial to the fundus of the meatus is
it suspended in a shell of bone, as described by Gantz and removed, thus providing access to the medial part of the
Fisch (7). In this approach, the external auditory canal is petrous apex and the side of the clivus. Another modification,
closed as a blind sac and the tympanic membrane, incus, and which we call the extended translabyrinthine approach, and is
body of the malleus are removed (7). A mastoidectomy is similar to the transcochlear approach, involves drilling bone
performed, including the removal of the retrofacial, retrolaby- both anterior and posterior to the facial nerve, leaving the
rinthine, and supralabyrinthine compartments. The facial facial nerve skeletonized in a column of bone and working
nerve is identified at its tympanic segment and at the stylo- both anterior and posterior to the facial nerve to remove the
mastoid foramen. The inferior part of the tympanic bone is cochlea and access the side of the clivus. Gaining access for
removed to expose the infralabyrinthine compartment, the drilling the cochlea anterior to the facial nerve commonly
jugular bulb, and the intrapetrous carotid artery. The retrofa- requires that at least part of the posterior part of the external
cial dissection is carried medially and superiorly, removing canal be removed, that the tympanic cavity be obliterated, and
the semicircular canals and vestibule. The dissection of the that the internal carotid artery be exposed below the
posterior fossa dura is carried inferiorly around the internal promontory.
auditory canal and under the facial canal. The cochlea is In evaluating these approaches in our laboratory, we have
drilled away by working inferior and anterior to the facial found that the minimal mastoidectomy gives approximately
Š
oculomotor and trochlear nerves. F, minimal mastoidectomy modification of the presigmoid approach. The minimal mastoid-
ectomy approach is completed by removing only enough bone in the front of the sigmoid sinus so that the presigmoid dura
can be opened to expose the posterior cranial fossa. The bony capsule of the labyrinth is not exposed in the minimal mastoid-
ectomy as it is in the retrolabyrinthine approach. The exposure shown with the minimal mastoidectomy in this figure is to be
compared with the retrosigmoid exposure shown in B. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery;
Ant., anterior; Bas., basilar; Car., carotid; Chor., choroidal; CN, cranial nerve; Comm., communicating; Inf., inferior; Int.,
internal; Lat., lateral; Mast., mastoid; P.C.A., posterior cerebral artery; Ped., peduncle; Pet., petrosal; P.I.C.A., posteroinferior
cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; Sig., sigmoid; Sup., superior; Temp., tem-
poral; Tent., tentorial; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.
the same exposure as the retrolabyrinthine approach, but is Labbé with the transverse sinus. The posterior fossa dura is
done at reduced risk since the semicircular canals and facial opened anterior to the sigmoid sinus in Trautman’s triangle.
nerve are not skeletonized (Figs. 8.14 and 8.15). Removing the The dural incision is extended across the superior petrosal
posterior canal increases access to the posterior fossa, but sinus to join the dural incision in the temporal dura. After
access is only slightly increased over that achieved with the division of the superior petrosal sinus, the tentorium is in-
retrolabyrinthine approach. Removing the superior canal in- cised parallel to and just behind the petrous ridge and supe-
creases access to the middle fossa and petrous apex and rior petrosal sinus. This dural incision is extended from the
reduces the needed retraction of the temporal lobe. The trans- site of division of the superior petrosal sinus through the
labyrinthine approach does not significantly increase the ac- medial edge of the tentorium to the incisura behind where the
cess to the area medial to the porus of the internal acoustic trochlear nerve enters the tentorial edge. Care is taken to
meatus over that achieved with the minimal mastoidectomy avoid injury to the IVth cranial nerve in its course near the
or retrolabyrinthine approach, but does provide access to the tentorial margin. The posterior portion of the temporal lobe is
internal auditory canal. The transcochlear modification, in elevated and the sigmoid sinus is displaced posteriorly along
which bone is removed up to the edge of the clivus, does with the cerebellar hemisphere while preserving the junction
significantly increase access to the front of the brainstem and of the vein of Labbé with the sigmoid sinus. The sigmoid
clivus over that achieved with the lesser degrees of bony sinus limits the ability for superior retraction of the temporal
resection. The retrosigmoid, the presigmoid minimal mastoid- lobe and can be ligated to improve the exposure if bilateral
ectomy, and the retrolabyrinthine approaches were compared venous angiography show adequate communication through
and yielded nearly the same exposure of the cerebellopontine the torcular to the opposite side (24). The petroclival region
angle, but the retrosigmoid approach did not provide the can be exposed from the middle fossa and tentorial incisura to
additional exposure of the middle fossa and petrous apex that near the foramen magnum, although access to the lower
could be achieved in the combined supra- and infratentorial petroclival region may be limited by the jugular bulb. The
presigmoid approach. presigmoid exposure provides a shorter working distance to
The skin incision is started in the temporal region above the the petroclival area and provides multiple angles for dissec-
zygoma, and extends above the ear and downward in the tion. The major arteries in the posterior fossa are easily acces-
suboccipital area medial to the mastoid process (Figs. 8.14, sible. The exposure can also be combined with a far-lateral
8.15, and 8.17). The skin flap is reflected forward to the level approach (Fig. 8.17).
of the external auditory canal. The temporal muscle is ele-
vated and reflected anteriorly, and the muscles over the mas-
toid and suboccipital areas are swept inferiorly. A temporo- Subtemporal preauricular infratemporal fossa approach
occipital craniotomy is performed and the transverse sinus is The subtemporal preauricular infratemporal approach is
exposed. After the bone flap is elevated, a mastoidectomy is directed through the infratemporal and middle fossae to the
carried out without entering the labyrinth. The sigmoid sinus part of the anterior surface of the petrous bone located medial
is skeletonized from the sinodural angle to the jugular bulb. to the cochlea and to the petroclival region (Figs. 8.10, 8.13,
Bone is removed superiorly to expose the floor of the middle and 8.18). This description outlines the full extent of the
fossa and the superior petrosal sinus. Trautman’s triangle is anatomic exposure available through this approach, but it can
exposed in the area lateral to the otic capsule. often be tailored to a smaller, more limited, approach. A
The dura mater is then incised along the base of the tem- curvilinear incision starting in the frontal region turns down-
poral craniotomy, while preserving the junction of the vein of ward in front of the ear into the cervical region. The incision
Š
FIGURE 8.16. G–N. Comparison of the retrosigmoid and the various modifications of the presigmoid exposure. G, deep
exposure with the minimal mastoidectomy with retraction of the vestibulocochlear and glossopharyngeal nerves, to be com-
pared with the retrosigmoid approach shown in C. The exposure is similar to that obtained with the retrosigmoid approach.
H, retrolabyrinthine approach in which more extensive drilling of the mastoid has been completed to expose the osseous cap-
sule of the semicircular canals. I, the dura has been folded forward after completing the retrolabyrinthine exposure. The
exposure differs little from that obtained with the minimal mastoidectomy exposure shown in F and G. J, the exposure with
the posterior canal partial labyrinthectomy is similar to that achieved with the minimal mastoidectomy. K, the partial laby-
rinthectomy has been extended by removing the superior canal in addition to removal of the posterior canal. L, the infraten-
torial exposure does not differ significantly from that achieved with the minimal mastoidectomy, as shown in F and G.
Removal of the superior canal reduces the required temporal lobe retraction and aids in the exposure along the middle fossa
floor and petrous apex. M, translabyrinthine exposure in which the semicircular canals and the vestibule have been removed.
This adds the internal auditory canal to the exposure, but does not improve the exposure of the structures medial to the
meatus, as compared with the minimal mastoidectomy or even the retrosigmoid approach. N, the facial nerve has been trans-
posed posteriorly out of the field and the cochlea has been removed to complete the transcochlear approach. This approach
greatly improves access to the front of the brainstem, clivus, and basilar artery, but is done at the cost of a temporary or per-
manent facial paralysis and loss of hearing.
may be extended downward only to the area just below the hypoglossal canal inferiorly. If the dura is opened, the struc-
tragus if only the petrous apex and upper part of the infra- tures along the lateral and anterior aspects of the upper me-
temporal fossa are to be exposed, but it can be extended onto dulla and lower two-thirds of the pons will be exposed (41).
the upper neck if a neck dissection is needed. The skin flap is The tentorium can be divided to give access to the upper clival
separated from the underlying tissues and reflected forward. region.
The facial nerve and its major branches are identified distal to Dividing the third trigeminal division above the foramen
the stylomastoid foramen and followed to the parotid gland. ovale will permit exposure of the junction of the petrous and
The parotid gland is separated from the masseteric fascia to cavernous carotid along with the structures in the inferolat-
avoid excessive stretching of the facial nerve at the stylomas- eral portion of the cavernous sinus (17, 39). The pterygopal-
toid foramen (33, 38, 39). The superficial temporalis fascia in atine fossa, parapharyngeal space, lateral maxilla, and orbit
which the upper facial branches course is separated from the can be exposed farther anteriorly. The lateral aspect of the
temporalis muscle and is reflected forward to prevent damage sphenoid bone and the sphenoid sinus can also be ap-
to the branch of the facial nerve to the frontalis muscle as the proached by removing bone medial to the maxillary nerve at
zygomatic arch is exposed. The zygomatic arch is divided at the root of the pterygoid process.
its anterior and posterior ends, and the temporalis muscle,
with the overlying segment of the zygomatic arch, is reflected
downward. The mandibular condyle and the capsule of the Postauricular transtemporal approach
temporomandibular joint are either dislocated downward or The postauricular transtemporal approach is most com-
excised. The temporomandibular joint can be removed in a monly selected for lesions that involve the mastoid and tym-
single piece for later replacement by dividing the mandibular panic cavities and track along the nerves and arteries to reach
neck below the condyle and osteotomizing the middle fossa the middle and infratemporal fossa (Figs. 8.19 and 8.20). It can,
floor around the mandibular fossa (Fig. 8.18). The internal however, be tailored at its posterior margin to include a
carotid artery, the internal jugular vein, and the vagus, acces- retrosigmoid, far-lateral, or presigmoid exposure of the pos-
sory, and hypoglossal nerves may be exposed in the neck if terior fossa or, at its anterior limits, to include exposure of the
needed. The posterior belly of the digastric muscle may be pterygopalatine fossa and lateral parts of the maxillary orbit
divided and the styloid process resected. or anterior cranial fossa.
A frontotemporal craniotomy is then performed. The dura A question mark incision is started behind the hairline in
is elevated from the floor of the middle fossa to expose and the temporal region, extending behind the ear over the mas-
obliterate the middle meningeal artery at the foramen spino- toid process and continuing inferiorly in front of the sterno-
sum and to expose the arcuate eminence, the third trigeminal cleidomastoid muscle onto the neck. The skin flap is then
division at the foramen ovale, and the greater petrosal nerve. reflected forward and the external auditory canal is divided at
The greater petrosal nerve is transected if necessary to avoid the bone-cartilage junction and closed as a blind sac. The
traction on the facial nerve. The floor of the middle fossa, includ- sternocleidomastoid muscle is detached from the mastoid
ing the lateral and inferior aspects of the superior orbital fissure, process and reflected inferiorly. The periosteum and posterior
and the lateral margin of the foramina ovale may be removed to portion of the temporalis muscle are reflected anteriorly, thus
expose the structures in the infratemporal fossa. exposing the temporal, mastoid, and retromastoid areas. The
If needed, bone can be removed medial to the mandibular posterior belly of the digastric muscle is divided and reflected
fossa to expose the eustachian tube and the tensor tympani inferiorly. At this point, the facial nerve is identified distal to
muscle, both of which may be resected (Figs. 8.10, 8.13, and the stylomastoid foramen and is followed, along with its
8.18). The bone removal is continued inferiorly, exposing the major branches, into the substance of the parotid gland (5).
ascending portion of the petrous carotid. In this segment, the The internal jugular vein, the carotid bifurcation, and the
carotid artery is surrounded by a periosteal sheath, which glossopharyngeal, vagus, accessory, and hypoglossal nerves
encloses a periarterial venous plexus that is an extension of are exposed and isolated in the neck. This allows for proximal
the cavernous sinus. At the entrance of the carotid canal, a control of the internal carotid artery and ligation of the main
dense fibrocartilaginous ring encircles the artery. If mobiliza- feeding vessels from the external carotid artery to a neoplasm
tion of the artery is required, care must be taken when divid- early in the procedure.
ing the ring not to damage the IXth cranial nerve that is in After this, temporal and/or retromastoid craniotomies may
close proximity to the carotid canal as it exits the jugular be performed with a simple mastoidectomy. The remaining
foramen. After mobilizing the carotid artery and displacing it skin of the external auditory canal, the tympanic membrane,
forward, the petrous apex and the clival region to the level of the malleus, incus, and stapes arch (leaving the footplate) are
the foramen magnum can be approached medial to and be- removed. The facial nerve is completely skeletonized from the
hind the artery. During drilling, the very hard cortical bone geniculate ganglion to the stylomastoid foramen.
along the petrous apex gives place to a crumbly cancellous If exposure of the jugular foramen and lower clival region
bone in the region of the clivus, as the dura of the anterior and is desired, a new facial canal is created by drilling a groove in
lateral aspects of the posterior fossa is being exposed. The area the bone of the anterior attic wall, between the geniculate
exposed is limited by Meckel’s cave superiorly, by the cochlea ganglion and the root of the zygoma. The facial nerve is
and internal auditory canal laterally, by the abducens nerve in carefully freed at the stylomastoid foramen, while leaving
its course through the Dorello’s canal medially, and by the some of the surrounding connective tissue attached to the
nerve, and the nerve is transposed anteriorly into the new nerves at the jugular foramen, as well as for their mobilization
bony groove of the epitympanum and imbedded for its pro- and posterior displacement if necessary. The posterior mobi-
tection into the parotid tissue (5). lization of the lower cranial nerves allows for a direct expo-
The dura of the middle fossa and the sigmoid sinus from sure of the structures along the lateral and anterior aspects of
the sinodural angle to the jugular bulb is skeletonized. Then the medulla and lower pons without the necessity for brain
the sigmoid sinus and the jugular vein are ligated in this retraction. Dissection in the area of the jugular foramen has
sequence, and the sigmoid sinus divided. Part of the wall of proven to be extremely difficult, as the lower cranial nerves
the sinus, bulb, and/or vein may be excised to increase the are particularly fragile and difficult to isolate from the sur-
exposure. This allows for dissection of the lower cranial rounding tissues.
Exposure of the middle clival structures requires removal of and medulla. This exposure extends from the inferior aspect
the bony labyrinth, as described for the translabyrinthine ap- of the trigeminal ganglion to the foramen magnum. The ex-
proach. The internal auditory canal is exposed, the facial nerve posure may be carried medially into the clivus and retropha-
identified, and the cochlear and vestibular nerves divided. The ryngeal space and anteriorly to expose the mucosa of the
greater superficial petrosal nerve is sectioned at its origin from sphenoid sinus.
the geniculate ganglion. The facial nerve is freed from all If the approach is to be extended to the parasellar and
its attachments in the temporal bone and reflected posteriorly. parasphenoidal areas, the zygomatic arch is divided and re-
The bony portion of the external auditory canal and the tym- flected inferiorly with the masseter muscle. The temporalis
panic bone are drilled away, exposing the ascending portion of muscle is separated from its attachment to the coronoid pro-
the intrapetrous carotid artery medial to the eustachian tube. cess of the mandible and reflected anteriorly and superiorly.
The dissection is continued by drilling away the cochlea, A temporal craniotomy is then performed, and extensive bone
starting at its basal turn, to expose part of the horizontal is removed along the whole lateral aspect of the middle
segment of the petrous carotid artery. Anterior displacement cranial fossa. The ascending ramus of the mandible is either
of the carotid artery and removal of the cochlea provides a displaced anteriorly or resected, and the petrous carotid is
wide exposure of the lateral and anterior portions of the pons exposed distally to the proximal portion of the intracavernous
FIGURE 8.17. I–L. Combined presigmoid and far-lateral approach. I, the insert shows the site of the additional skin incision
needed to add a retrosigmoid craniotomy and far-lateral approach. The scalp flap has been reflected to expose the suboccipi-
tal triangle located between the superior and inferior oblique and the rectus capitis posterior major and in the depths of
which the vertebral artery courses with a dense venous plexus. J, the venous plexus has been removed to expose the margins
of the suboccipital triangle. K, the rectus capitis posterior major and the inferior oblique have been reflected medially and
the superior oblique laterally to expose the vertebral artery and surrounding venous plexus behind the atlanto-occipital joint.
L, the venous plexus has been removed to expose the vertebral artery coursing with the C1 nerve behind the atlanto-occipital
joint and across the upper edge of the posterior atlantal arch.
segment after removing the cartilaginous portion of the eu- tend to achieve considerable size before producing clinical
stachian tube. The cavernous sinus can be approached and the manifestation (32). The distinction between the benign or
intracavernous carotid artery exposed by dividing the man- malignant tumors in this area is not rigid because many
dibular segment of the trigeminal nerve. The approach can benign tumors can have a very invasive characteristic. The
also be extended to the retrosigmoid area and down the selection of the best surgical approach depends on the loca-
vertebral artery to the C1 to C2 level, or to the suboccipital tion, extension, size, and nature of the pathology.
triangle for a far-lateral or transcondylar exposure. The lateral An advantage of these approaches directed through the
orbit and pterygopalatine fossa can be accessed at the anterior temporal bone to the petroclival area is that they reach the
limit of the exposure. area through tissue planes outside the oropharynx. They pro-
vide another route by which anterior intradural lesions situ-
DISCUSSION ated medial to the nerves entering the internal acoustic me-
Pathologies can arise anywhere within the petroclival re- atus and jugular foramen can be approached without entering
gion and frequently are not restricted to a single anatomic the nasopharynx. They also provide an avenue of exposure
compartment of the cranial base. Involvement of multiple for lesions that involve the temporal and sphenoid bones in
cranial nerves and arteries occurs because cranial base tumors addition to the clivus. One or a combination of the lateral
approaches is frequently used to expose intra- or extradural to the nerve-related segments of the arteries of the posterior
clival lesions that also involve the temporal and sphenoid circulation. The vertebrobasilar junction can be exposed in
bones. They also provide access to the anterior aspect of the some cases, although the lower cranial nerves and the jugular
midbrain, pons, and medulla and to the cerebellopontine tubercle are frequent obstacles. Retraction of the pons and
angle and nerves in the posterior fossa. They may also pro- working between the cranial nerves is necessary to reach the
vide better access to the temporal bone, jugular foramen, and origin of the AICA from the basilar artery. The far lateral
petrous segment of the internal carotid artery than the other modification of the retrosigmoid approach, described in the
anterior or posterior approaches. The area may be approached chapter on the far lateral approach, was devised to provide a
from directly lateral through the mastoid, labyrinth, and co- better exposure of the lateral and anterior aspects of the
chlea, as in the translabyrinthine and transcochlear approach- cervicomedullary junction (45).
es; from above through a subtemporal middle fossa route; The presigmoid approach (1, 8, 32) combines a supra- and
from behind in the retrosigmoid suboccipital approach; or infratentorial exposure with various degrees of petrousec-
from multiple directions using such combined supra- and tomy, while preserving the junction of the vein of Labbé with
infratentorial approaches as the presigmoid approach, to the transverse sinus (Figs. 8.14-8.17). The amount of resection
which a translabyrinthine or transcochlear approach may
of the petrous bone can vary from a retrolabyrinthine minimal
be added. Alternative or extended approaches, most of
mastoidectomy exposure to a translabyrinthine or transco-
which include some route through the mastoid and petrous
chlear exposure with posterior displacement of the facial
parts, include the anterior transpetrosal, the subtemporal pre-
nerve. In selected cases, where angiography shows patency of
auricular infratemporal, and the far-lateral transcondylar
the communication between the two transverse sinuses across
approach.
the midline, the sigmoid sinus can be ligated to improve the
The retrosigmoid suboccipital approach, described in the
chapter on the cerebellopontine angle, offers a wide view of exposure (24). Preservation of the drainage of the vein of
the cerebellopontine angle and of the intradural structures Labbé and avoidance of excessive temporal lobe retraction are
behind the ipsilateral lower clivus, but the dural surface of the major goals of this approach to the upper clival region. Ap-
petrous apex, upper clivus, and tentorial incisura are not well proaching the structures in the inferior petroclival space may
seen from this exposure (26, 35, 36, 46) (Figs. 8.15 and 8.16). be restricted by the jugular bulb, which could be overcome by
Removal of posterior wall of the internal auditory canal division of the sigmoid sinus or by working posterior to it
through the retrosigmoid provides access to the contents of (36). The major advantages of this approach are the shorter
the meatus as far lateral as the vertical and transverse crests. working distance to clival lesions and the various angles for
The vestibule can be opened if needed to remove a tumor dissection that are provided. The approach provides access to
extending into the labyrinth. Care is required to avoid injury the ipsilateral cranial nerves III through XII and to the major
to the posterior semicircular canal and common crus if there is arteries in the posterior circulation. A major drawback to this
the possibility of preserving hearing (29). The retrosigmoid exposure is provided by the anatomic variants, described
approach provides easy access to the intradural part of cranial below, that limit the size of the exposure through Trautman’s
nerves V, VII, VIII, and IX through XII. It also provides access triangle and the labyrinth.
The translabyrinthine approach provides access to the facial tic meatus is usually poor. The extent of exposure achieved
nerve from its origin at the brainstem to the stylomastoid with the translabyrinthine approach is dependent on several
foramen, and exposure of the contents of the internal auditory anatomic factors. A high jugular bulb, an anteriorly placed or
meatus (Fig. 8.6) (12, 14). The lateral surface of the pons, the large sigmoid sinus, or a low middle fossa plate may severely
inferior aspect of the origin of the trigeminal nerve, and the restrict the exposure (22, 27).
facial and vestibulocochlear nerve complexes are well visual- The transcochlear approach shares similar limitations with
ized, but exposure of the region inferior to the jugular bulb, the translabyrinthine exposure, although the posterior trans-
above the trigeminal nerve, and anterior to the internal acous- position of the facial nerve in the transcochlear approach
allows better visualization of the structures anterior to the cochlea to the petrous apex and petroclival junction, and from
internal auditory canal (15, 16). The area of exposure is very the petrous ridge posteriorly to the carotid canal anteriorly. A
narrow and restricted by the maintenance of the bony external significant degree of temporal lobe retraction may be re-
auditory canal, but can be increased by resecting the posterior quired. This may be reduced by using a frontotemporal cra-
part of the canal. Transposition of the facial nerve may be niotomy with zygomatic resection. Although only a small
followed by a transient or permanent facial palsy. window in the petrous bone is provided, exposure can be
The subtemporal anterior transpetrosal approach uses ex- expanded by dividing the adjacent part of the tentorium. The
tradural resection of the anterior petrous pyramid via a tem- lateral and anterior surfaces of the pons and the upper clivus
poral craniotomy (Figs. 8.12 and 8.13). It may be combined and adjacent part of the cavernous sinus can be approached
with zygomatic resection to increase access to the floor of the through this route (Fig. 8.13). The facial, vestibulocochlear,
middle fossa (20). The area of the petrous apex removal trigeminal, and abducens nerves can be identified. The pe-
extends from just medial to the internal auditory canal and trous carotid may limit the surgeon’s line of vision and restrict
access to the inferior part of the petroclival region, but this Removal of the posterior part of the petrous pyramid has
restriction may be overcome with anterior mobilization of the been used for acoustic neuroma removal as part of extended
artery (39, 41). The approach provides access to the anterior approaches directed through the middle fossa (21, 28, 42, 43)
aspect of the brainstem and basilar artery in the area between (Fig. 8.12). The extended approaches combine different de-
the trigeminal nerve above and the facial and vestibuloco- grees of resection of the bony labyrinth with the subtemporal
chlear nerves below. In approaching the basilar artery transtentorial routes. Extending the resection of the petrous
through this route, the size and location of the lesion in bone posteriorly over the mastoid and the bony labyrinth
relation to the petrous ridge is critical. The trigeminal nerve exposes the whole intrapetrous course of the facial nerve, and
can be mobilized to improve the exposure, although this may provides access to the cerebellopontine angle by a combina-
result in postoperative facial hypesthesia (19, 20). The anterior tion of subtemporal, translabyrinthine, and presigmoid routes
transpetrosal approach can be used alone for extradural pathol- (Figs. 8.12 and 8.13) (9).
ogies restricted to the petrous apex or as a surgical step to The subtemporal preauricular infratemporal approach
approaching intradural pathologies in the petroclival region. It reaches the skull base from an anterolateral direction (Figs.
provides a route for resecting extradural lesions that extend from 8.10, 8.13, and 8.18). Division of the zygomatic arch, resection
the level of the trigeminal nerve to the foramen magnum. or displacement of the mandibular condyle, and extensive
FIGURE 8.19. S–X. Anatomic basis of the postauricular transtemporal approach. S, enlarged view of the medial wall of the tympanic cav-
ity before mobilizing the facial nerve. The stapedial muscle passes forward from the pyramidal eminence below the facial nerve and
attaches on the neck of the stapes. The tensor tympani muscle passes backward and laterally, giving rise to a narrow tendon that makes a
sharp turn around the trochleariform process at the lateral end of its semicanal to insert on the handle of the malleus. The basal turn of
the cochlea is located deep to the promontory. The tympanic segment of the facial nerve courses above the stapes. T, enlarged view of
the labyrinth. The semicircular canals have been unroofed and the stapes has been removed from the oval window. The round window is
located below and behind the oval window. U, the facial nerve has been reflected forward out of the facial canal and the vestibule has
been opened. The ampullae of the superior and the lateral canal open into the vestibule anteriorly and are innervated by the superior
vestibular nerve. Only the upper edge of the superior canal was preserved in opening the vestibule. The ampullae of the posterior canal is
located at its lower end and is innervated by the singular branch of the inferior vestibular nerve. V, a probe is directed through the vesti-
bule to the inner surface of the membrane covering the round window, which is located behind and below the oval window. W,
enlarged view of the labyrinth after opening the promontory to expose the cochlea. The jugular bulb is located below the vestibule and
semicircular canals and the lateral genu of the internal carotid artery in position below the cochlea. The cochlea wraps around the modi-
olus through which the branches of the cochlear nerve are distributed to the cochlear duct. X, the temporal lobe has been elevated to
expose the internal carotid, PCA, and SCA in the basal cisterns. The dura has been elevated from the lateral wall of the cavernous sinus.
FIGURE 8.20. A–F. Postauricular transtemporal approach. This exposure includes the transtemporal and infratemporal approaches in
combination with a craniotomy. A, the scalp flap has been reflected forward to expose the sternocleidomastoid, parotid gland, and the
greater auricular nerve. B, the external canal has been divided to reflect the flap forward for a parotid and neck dissection that exposes
the facial nerve and its trunks, the posterior digastric belly, and the internal jugular vein. C, the mastoidectomy has been completed to
expose the presigmoid dura, the sigmoid sinus, and the semicircular canals. The mandibular condyle has been resected to provide access
to the infratemporal fossa. D, a temporo-occipital craniotomy has been completed, the zygomatic arch opened, and the temporalis mus-
cle reflected to expose the maxillary artery and pterygoid muscles in the infratemporal fossa. E, enlarged view of the temporal and infra-
temporal exposures. The posterior wall of the external canal has been removed. The auriculotemporal branch of the mandibular nerve is
often split into two rootlets by the middle meningeal artery. F, enlarged view of the tympanic cavity. The anterior part of the lateral semi-
circular canal is located above the tympanic segment of the facial nerve. The promontory overlies the basal cochlear turn. A., artery; Ac.,
acoustic; Aur., auricular; Bas., basilar; Car., carotid; Chor., chorda; CN, cranial nerve; Cond., condyle; Ext., external; Gl., gland; Gr., great-
er; Inf., inferior; Int., internal; Jug., jugular; Lat., lateral; M., muscle; Mandib., mandibular; Mast., mastoid; Max., maxillary; Mid., middle;
Men., meningeal; N., nerve; Pet., petrosal, petrous; Proc., process; Seg., segment; Semicirc., semicircular; Sig., sigmoid; Sternocleidomast.,
sternocleidomastoid; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani, tympanic; V., vein; Vert., vertebral.
FIGURE 8.20. G–L. Postauricular transtemporal approach. G, the external canal has been resected in preparation for
exposing the petrous carotid. H, the junction of the cervical and petrous carotid has been exposed in the area below the
promontory. The lateral margin of the stylomastoid and jugular foramina have been removed to expose the jugular bulb
below the semicircular canals. I, the mandibular nerve has been exposed below the foramen ovale. A more extensive
exposure of the petrous carotid has been completed so that the artery can be reflected forward out of the carotid canal
to provide access for drilling of the petrous apex. J, the petrous carotid has been reflected forward and the petrous apex
removed to expose the clivus and inferior petrosal sinus. K, the facial nerve has been moved out of the facial canal, and
a total labyrinth and petrous apicectomy have been completed. L, a segment of the sigmoid sinus and the jugular bulb
have been removed to expose the nerves passing through the jugular foramen. The dura has been opened and the facial
nerve displaced posteriorly. The temporal lobe has been elevated to expose the subtemporal area while preserving the
vein of Labbé.
easily be extended to the infratemporal fossa, and the same expo- 13. House WF: Middle cranial fossa approach to the petrous pyra-
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Anatomy of the human ear, a drawing by Max Brödel using Wolff’s carbon pencil and dust on Ross stippleboard.
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