MANUAL OF TEMPORAL BONE DISSECTION
by Maurizio Barbara
Kugler Publications/ The Hague/The Netherlands
MANUAL OF TEMPORAL BONE DISSECTION
MANUAL OF TEMPORAL BONE DISSECTION
Kugler Publications / The Hague / The Netherlands
Box 97747 2509 GC The Hague. microfilm. 2509 GC The Hague. P. or any other means without prior written permission of the publisher. No part of this book may be translated or reproduced in any form by print. Box 97747. The Netherlands Telefax (+31.com
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jugular bulb (subfacial approach) and petrous apex Phase 12: Facial nerve decompression (second and third portions) Phase 13: Identification of the endolymphatic sac Phase 14: Isolation of the labyrinthine block Phase 15: Labyrinthectomy and identification of the intraosseous endolymphatic sac and duct Phase 16: Opening of the vestibule Phase 17: Identification of the labyrinthine segment of the facial nerve Phase 18: Identification and opening of the internal auditory canal Supratemporal or middle fossa approach Phase 19: Opening of the epitympanic cavity and of the petrous apex cells
vii ix 1 7 10 12 16
18 21 24 27 30 33 34
37 39 42 44 46 48 49 51 54 56
. and exposure of the jugular bulb Phase 5: Posterior and anterior epitympanectomy Phase 6: Posterior tympanotomy (facial recess) Phase 7: Lowering of the posterior wall of the external auditory canal Phase 8: Classical radical mastoidectomy Phase 9: Opening of the petrous apex Phase 10: Cochleostomy and cochlear visualisation Phase 11: Identification and skeletonisation of the vertical intrapetrous tract of the internal carotid artery.V
TABLE OF CONTENTS
Foreword Preface Introduction Lateral (transmastoid) approach Phase 1: Removal of the mastoid cortex Phase 2: Opening of the superficial mastoid cell system Phase 3: Opening of the deep mastoid cell system and antrotomy Phase 4: Skeletonisation of the sigmoid sinus. opening of the retrofacial and medial tip cells.
Phase 20: Identification of the facial nerve and geniculate ganglion Phase 21: Exposure of the internal auditory canal Phase 22: Isolation of the cochlea Posterior cranial fossa approach Phase 23: Identification of the internal auditory canal Abbreviations Glossary Surgical applications Instrumentation
57 59 61 62 64 65 67 69 70
The temporal bone is an anatomical jewel box of extraordinary complexity. Both the minuscule scale of its vital structures and their convoluted three-dimensional relationships make microsurgery of this region one of the most technically demanding of all operative endeavours. Unravelling the mysteries of temporal bone anatomy is the foremost challenge faced by every otologist. The goal of achieving perfect knowledge and facility will never be achieved. No matter how experienced a surgeon becomes, ongoing study of the finer points of temporal bone anatomy (observed both in the operating room and dissection laboratory) serves to maintain and improve his or her skill. Dr Barbara has produced a highly useful Manual of Temporal Bone Dissection to guide exploration of the temporal bone. Its stepwise approach will prove useful for both the novice otologist and the experienced surgeon seeking to refresh his or her knowledge. Its orientation upon specific surgical procedures, rather than pure anatomy, enhances its utility for the practising surgeon. This written resource is an essential element of the three components needed for a high quality surgical dissection course: a lucid manual (such as that authored by Dr Barbara), informative didactic sessions, and anatomical dissection proctored by expert microsurgeons. The team at ‘La Sapienza’ are to be congratulated for their efforts in producing an outstanding educational programme. Robert K. Jackler, MD San Francisco July, 2002
When the Programme of the Permanent Educational Center in Otology at the University of Rome ‘La Sapienza’ started its First Basic Course on the Temporal Bone in 1996, a long-standing dream of both my teacher, Professor Roberto Filipo, and myself was realised: to create a reference point for all colleagues who, in mid-southern Italy, wished to make a start in, or to improve their knowledge of, otology and otosurgery. The presence of a prestigious foreign guest of honour at each course, the use of advanced technology and, last but not least, the informal setup of the courses expressly desired by Professor Filipo, have been the winning weapons for the ever greater diffusion of our Center in Italy as well as abroad. Therefore, in the present manual, it was natural to bring together all the teaching and advice that are offered to participants during the laboratory sessions, in a formula that combines pure anatomy with surgical applications. Although simple and certainly not exhaustive, this manual has required a huge amount of effort, and its realisation has only been possible thanks to: Professor Roberto Filipo, my teacher, for all his advice and stimulating criticism; Professor Robert Jackler, from the University of San Francisco (UCSF), who followed my work with his particular expertise; Mr John Ballantyne, who revised the English version of the manual with his renowned professionalism; Drs Aleandro Harguindey, Daniele Bernardeschi and Francesco Ronchetti for their constant dedication and tirelessness; Dr Francesca Auriti for enriching the iconography; and, most of all, my beloved Simonetta for her support. Maurizio Barbara
it is important to devote a few words to some aspects which emerge during laboratory (or live) dissections: • the dissection should always be carried out in a well-ventilated room. Hints ! Before starting on the topic.). which allows for air exchange. which is generally manipulated before working on the bone.1
This manual is for ENT specialists/residents wishing to deal with surgical dissection of the temporal bone. 1. make this type of exercise very useful. The only difference lies in the lack of soft tissue. It is also a stimulus for a deeper look at the surgical techniques in the major otosurgical textbooks. it should only be taken as a guide and not as a substitute for the many obligatory laboratory dissections. the progress in otosurgery as well as the more frequent cooperation with neurosurgeons. A proper sitting position is advised during the dissection. bone dust.
Fig. since it will sooner or later become saturated with noxious agents (fixatives. and thus to be initiated into ear surgery. In fact. However. etc.
. The major part of it will be dedicated to the lateral (transmastoid) approach – through which the huge majority of otological approaches are performed – but space will also be reserved for dissection of its superior (middle cranial fossa) and posterior (posterior cranial fossa) aspects.
mask. leaning against the back of the chair. surgical microinstruments. glasses. Topographic terminology always has to be used in a proper way.2
Fig. • maintain a proper sitting position. 3. with both feet (heels included) fully in contact with the floor. suction-irrigation system. wrist) (Fig. The instruments should be handled correctly.
. ear plugs!). • before starting.
• protect yourself against potentially infectious materials by dressing correctly (waterproof gown. familiarise yourself with the laboratory instruments: operating microscope. with a firm point. and both hands on a firm point (little finger. 1-2). 2.
without overtightening it. it is better to fix the bones by freezing. anterior: towards the nose. it is better first to select the highest magnification (usually 40x). it must be checked for the motility of each arm. internal carotid artery) are more resistant than expected. and should not prevent use of the specimen: this can also depend upon the poor fixation or storage of the bones. and middle ear anatomical structures.and micromovements. In order to get rapidly in focus.
. 5). i. posterior: towards the nape. prostheses. magnification can be reduced and the focus will be maintained or be adjustable with minimal micromovements (Fig. • unintentional holes in specific parts of the temporal bone (dura. some delicate anatomical structures (dura. since. When using a standard operating microscope. If you are responsible for bone collection. Remember that. but 300 or 350 mm are often used in neurotology and skull-base surgery. 3). in vivo.3 • always follow the same steps during each dissection. Clean the microscope (being careful with the lens).e. lateral (or external or superficial): towards the external meatus. Leave your dissection position as clean as you found it (Fig. jugular bulb. 4). use the biggest burr possible in every dissection region. sigmoid sinus. inferior: towards the feet. over time. • think (and talk) in millimetres regarding the size of surgical instruments (hooks. its mechanical characteristics could be altered. sinus) are possible. before looking through it. using macro. It is obviously important to correct for visual defects and interpupillary distance. medial (or internal or deep): towards the brainstem (Fig. • take into account the possible anatomical variations from one bone to another in different dissections. Once focused on an object. • topographic terminology is of the utmost importance and must always be used correctly.. superior: towards the vertex. burrs. and any other instruments used. • manoeuvre personally the drill pedal and do the same in the operating theatre. burrs). The focal lens should be 250 mm in the laboratory.
only electric drills allow the burr to rotate both clockwise and anticlockwise. electrical.
. 6). Two main types of burr are generally used: cutting (Fig. as well as increasing his profile in the operating theatre. 5. since familiarity with the technology and instruments helps to enrich the cultural baggage of the otologist. You must be familiar with mounting and dismounting the burrs of all the systems at your disposal. 4. 7a) or diamond (Fig. In general. 7b).
The drilling system can be threaded. Operating microscope. Dissection bench.
Fig. or pneumatic (Fig.
They are generally used in proximity to or in contact with soft tissues (dura.
A cutting burr is made of multiple blades. in some cases it is necessary to make the burr rotate anticlockwise for a two-fold purpose: a. Although diamonds last forever.
Fig. b. closing the vascular channel with the bone dust produced (momentarily stopping irrigation). sigmoid sinus or jugular bulb. 6. but the less well it cuts. Hence the need for continuous irrigation to avoid overheating. or when a bony bleeding point has to be stopped (only in live bones!). Diamond burr.
Fig. When using an electric drill. facial nerve (FN)). 7b. the more stable the burr.5
Fig. Cutting burr. Diamond burrs work by saucerising and thinning the contacted surface. more or less close to each other: the greater the number of blades. to avoid uncontrolled movements which make the burr hit an im-
. 7a. Pneumatic drill. the glue which binds them to the steel ball does not. to reduce the cutting power (better to select a diamond burr).
in order to increase the friction (and hence the cutting power) of the blade on the bone. The handpiece of the drill should be handled like a pen with obvious individual differences (Fig.g. part of internal auditory canal (IAC) skeletonisation). by avoiding accumulation of bone dust between the blades (for cutting burrs only).
portant structure (e. the short process of the incus). cochleostomy. repetitive. in order not to have vision impeded by the collecting fluids. it must be used in the opposite direction to the rotation. not fast or jumpy. platinotomy. ho-mogeneous. NEVER THE TIP! which is unstable. The movements must be slow. The continuous flow of water across the area of dissection will serve both to cool the drill burr and to wash away blood and bone debris. Finally. Suction-irrigation must be adjusted from the start: its perfect combination will ease the dissection work. regular strokes. the lateral face (shoulder) of the burrs must always be used. Whenever possible. in a right ear. Apart from a few exceptions (blockage of a bleeding point. thus reducing efficacy. during antrotomy. 8a-c. it is preferable to position the suction medially (deeper) to the working site.
. The hand piece of the drill as well as instruments have to be handled like a pen. When a cutting burr is used. using continuous. remember to use the largest burr at your disposal in relation to the region to be dissected. 8a-c)..6
Orientation of the TB specimen is achieved by using surface land-
. A right temporal bone placed in a bone-holder in the surgical position. Bone-holder.7 LATERAL (TRANSMASTOID) APPROACH
The temporal bone (TB) must be placed in a bone-holder in the surgical position (Fig. 9.
Fig. 9). 10.
Abbreviations 2. and the mastoid tip (T). vertical intrapetrous segment of the internal carotid artery (ICA). Only at this point will the dissection – up to this point adhering to the options of the surgical technique – deal with the identification of structures embedded within the TB. more or less pronounced. • Henle’s spine. aimed at visualising the surface anatomy of the medial wall of the middle ear as well as at carrying out a classical radical mastoidectomy. • the mastoid tip (T). jugular bulb). an operation which today is only rarely performed in otosurgery. posterior tympanotomy. which only pathological processes or neurootological approaches need to expose in practice (cochlea. Glossary
. to an ‘open’ technique (lowering of the EAC). located inferiorly (Fig. a scalpel or even by drilling. there is a rapid guide to: 1. All the soft tissues covering the lateral surface of the mastoid process must be removed with a knife periosteal elevator. ending with the translabyrinthine identification of the IAC: although conceptually far from this phase of surgical application. it is always exciting. a small bony crest. for those who are learning. The dissection will then continue with clinical applications. They will progress from a dissection centred on a ‘closed’ technique (enlarged mastoidectomy. to know how to reach the nerves within the IAC! At the end of this manual.8 marks: the zygomatic process (ZP) of the TB. with its muscular attachments. Steps in the dissection The steps described below aim to follow the dissection as close as possible to surgical reality (also including phases that are not routinely carried out). located superior to the external auditory canal (EAC). The following landmarks appear: • the EAC. visible on the surface at the level of the postero-superior wall of the EAC. epitympanectomy). a multiply-holed region posterior to Henle’s spine. situated in the most posterior area of the mastoid process. 10). • Chipault’s cribriform area. • the mastoid emissary vein (EV) orifice.
9 3. in the text it is possible to find: • surgical applications in bold • cell groups in blue • microsurgical instruments in red • anatomical structures and otological nomenclature in italics
. Instrumentation Moreover. Surgical applications of the dissection 4.
as a line that is prolonged posteriorly from the zygomatic process of the TB. antri. the bony removal has to be extended posteriorly. • A line perpendicular to the linea temporalis (B). as well as anterolaterally. and t. demarcated by a subtle ridge formed by the inferior edge of the temporal muscle. 11a-b): • The temporal line (linea temporalis) (A). epitympani. behind the SS. and inferiorly. since a large amount of bone dust is produced during this step of the dissection. mastoidei.10 Phase 1: Removal of the mastoid cortex This phase implies the removal of all the cortical bone on the lateral surface of the TB. • An oblique line (C) which unites the previous two and which corresponds roughly with the projection and direction of the sigmoid sinus (SS). to the mastoid tip. Hence. In enlarged mastoidectomy. which runs vertically. the bone separating mastoid and middle ear cavities from the middle cranial fossa (MCF) dura. In simple mastoidectomy. this is carried out within a triangular area (MacEwen’s triangle) delimited by (Fig. the tegmen is specifically defined as t.
. which covers the various superficial cell groups. parallel to the posterior wall of the EAC. Start the dissection with a large (8-mm) cutting burr and profuse irrigation with a large-calibre suction tip. t. to the ZP (taking as its anterior limit the anterior wall of the EAC). roughly corresponding to the tegmen. from the temporal line in the direction of the mastoid tip.
. b. The dark area marks the cortical mastoidectomy.
Fig. A triangular area (McEwen’s triangle) on the lateral mastoid aspect is traced with a cutting burr.
SS. diploic. superiorly limited by the tegmen. perisinus: subdivided into lateral. the latter two with a few cells limited to the antrum and the central cell tracts. without relying on personal mnemonic capabilities. In order to memorise the nomenclature of the different cell groups more easily. simply refer to the constant presence of some anatomical landmarks. and mastoid tip (Fig. labyrinthine block. perifacial.12 Phase 2: Opening of the superficial mastoid cell system Before starting this step. Central area: extending inferior to the antrum. c. b. Two main areas can be distinguished: • anterolateral (pars squamosa) • posteromedial. Three areas can be distinguished in the mastoid region: 1. antrum. after the first few months and in adults.
. located superiorly. and postero-inferiorly by the SS. including the tip (pars petrosa) These two portions are separated by the petrosquamous septum (Koerner’s). sinodural: occupying the posterosuperior corner of the mastoid. retrosinus (superior and inferior) and presinus. 2. Antrum: a large space which communicates – through the aditus – with the posterior epitympanum. as a single cavity or a group of cells. it can be pneumatic. partly divided by Koerner’s septum. medial. or sclerotic. a bony lamina which is usually reabsorbed. 13). and is laterally delimited by the squamous portion. Peripheral area: including five groups of cells: a. but at times can remain imperforate. FN. the distribution of cell groups within the mastoid cavity must be remembered. such as tegmen. Mastoid cells While in the newborn the mastoid is a single cavity (antrum) which lies rather superficially (beware of the retroauricular incision as the facial nerve (FN) is very superficial at this age!). d. tegmental: close to the tegmen. 3.
15. Removal of the mastoid cortex.
Fig. 14. A cutting burr should always work with its lateral face (shoulder). Sagittal drawing of the mastoid cavity.13
the bone becomes more fragile and the burr works more effectively.. retrofacial: often as an isolated individual cavity. i. it is advisable to use a diamond burr of the same size. separates the lateral (squamosal) from the medial (petrosal) part of the mastoid. the bony lamina that separates the mastoid cavity from the dura of the MCF. a larger cavity is created. become metallic. infralabyrinthine. a space may be encountered that is limited medially by a bony lamina. Once removal of the superficial mastoid cells has been completed. especially in the pneumatic (cellular) mastoid. Drilling can continue with a slightly smaller cutting burr (6 mm) and with a suitable suction tip. In fact.e. which can be confused with the compact bone of the lateral semicircular canal (LSC). 14). Once the mastoid cortex has been exenterated (Fig. precochlear or inferior prelabyrinthine. this will definitely mark the upper limit of the dissection in TBs of any type. situated medially and inferiorly to the vertical (mastoid) segment of the FN.e. g. 15). mastoid tip: separated by the posterior belly of the digastric muscle into medial and lateral cells. which. each with its
. At this point. i. is represented by the tegmen. When approaching the tegmen or the SS. This is the petrosquamosal septum. By identifying the tegmen (roughly corresponding to the linea temporalis) and isolating it in its postero-anterior course.. i. which is either continuous or has a narrow passage. including malformed TBs. when more than one group of adjacent cells is opened. perilabyrinthine: – superior prelabyrinthine – translabyrinthine or infralabyrinthine – supralabyrinthine or petrous crest – retrolabyrinthine superior or retrolabyrinthine. h. remembering that the sound of the working burr may change. known as Koerner’s septum. in which the burr can work more easily in contact with its shoulder (Fig. the most important anatomical landmark. as in congenital aural atresia. before reaching the deeper ones. f. in the early stages of mastoid development.14 e.
Cortical and lateral mastoid cells have been exenterated. 17): superficial supra.and retrosinus lateral tegmental lateral tip
.and infra-antral lateral pre. After finishing Phase 2. 16). 16. 17.
own cell groups and communicating independently with the antrum (Fig. Verification of the close anatomical relationship between antrum and LSC helps the novice to find his or her way.15
Fig. the following cell groups have been opened (Fig.
Fig. An incompletely reabsorbed Koerner’s septum (KS). considering how superficial the dissection still is.
before being visible in the surgical cavity (a).16 Phase 3: Opening of the deep mastoid cell system and antrotomy After having opened Koerner’s septum. In order to complete antrotomy. ‘Snake’s eyes’ as a result of the opening the dome of the LSC. not to open the LSC. 19. the dissection continues by drilling the anterolateral and superolateral cells. It is of the utmost importance to drill the most medial portion of the EAC. Obviously. a smaller-sized burr should be selected (4-5 mm or less). 18). is the body with the short process of the incus. Stagnation of the irrigation fluid during drilling often causes this structure to be visualised
Fig. causing what American authors call ‘snake’s eyes’: two small holes on the dome of the LSC (Fig. especially in sclerotic bones.
. the second landmark to be exposed. the dome of which may be violated by mistake. in order to better visualise the antral cavity. Care should be taken. The short process of the incus is first visualised (b) by refractive effect of the irrigation liquid. 18. after the LSC. between the posterior and superior walls.
17 (b) – by light refraction – before it is in fact visible in the surgical cavity (a) (Fig. a compact. 20. posteriorly and superiorly. erroneously considered to be the end of hurried dissection sessions. can be considered finished when the following are visible: • the short process of the incus and fossa incudis. exposing the tegmen antri.
Fig. • the dome of the LSC. Both superficial and deep cell groups will thus be drilled out (Fig.
. 19). which is brighter than the surrounding bone. All the mastoid cells have been exenterated. This phase. • the superior aspect (roof) of the antrum. 20). which must be at the same level as the tegmen mastoidei. occupied by whitish tissue resembling cholesteatoma or epidermisation (this is the posterior ligament of the incus). mat bone.
Working with a cutting burr (6 mm). opening of the retrofacial and medial tip cells. and exposure of the jugular bulb Retaining some of the perisinus cells already drilled during the previous phases for reference.
. posteriorly. SDA= Sino-dural angle (Citelli’s). In the central part of the SS. This is the first delicate step of the dissection and needs particular care. at the posterior cranial fossa dura level. performed by alternating cutting and diamond burrs in order to optimise time and quality of the dissection. reaching the jugular bulb (JB). The sigmoid sinus (SS) has been skeletonised. the orientation of the vertical course of the SS will be recognisable by the bluish colour of the laboratory as well as the live bones (more intense blue in live bones).
Fig.18 Phase 4: Skeletonisation of the sigmoid sinus. Skeletonisation of the posterior wall of the SS consists of the removal of retrosinus cell groups. 21). One important landmark is represented by the opening of the superoanterior part of the SS. in some bones. it is possible to visualise the channel of the posterior/mastoid emissary veins or the vein itself (remember the superficial landmark in the lateral aspect of the TB!). the dissection continues by opening the cells placed posteriorly and laterally to the SS. thus obtaining exposure of the sinodural angle (Citelli’s) (SDA) after drilling out the lateral and medial sinodural angle cells (Fig. 21. where the SS meets the MCF dura.
The retrofacial cells (RFC) give access to the jugular foramen area. medial.19
Fig. to be isolated (Fig. 22).
Fig. CT= Chorda tympani. Isolation of the jugular bulb (JB). Careful dissection of the medial tip cells will also allow the most inferior portion of the SS and its ascending tract towards the jugular bulb (JB). 22. 23). lateral and medial tip cell groups are delimited by a tangential line passing through the posterior belly of the digastric muscle (DM). the dissection continues towards the mastoid tip. At this level. 24. located at different heights with respect to the inferior wall of the EAC.
Fig. SS= Sigmoid sinus. which forms another important landmark anteriorly in TB surgery: the stylomastoid foramen as the exit for the FN (third to extracranial parotid segment) from the TB (Fig. superior. This step is also very delicate
. and inferior retrosinus cells have been opened. FN= Facial nerve.
Once all the lateral. 23. The insertion of the posterior belly of the digastric muscle (DM) at the mastoid tip level.
while the bony tissue around the JB is brownish in colour (due to the bone marrow). Only diamond burrs. medial and inferior to the third vertical segment of the FN. in the majority of TBs.20 since. to the petrous apex (Fig. often fused in one cavity only: the retrofacial cells (RFC). subsequently. At this point. of smaller and smaller calibre (from 5 to 3 mm) should be used.
. which are of the utmost importance during the approach to the inferior and posterior walls of the tympanic cavity and. 24). it is possible to visualise a group of cells. the venous wall is very fragile (more fragile than in live bones!).
25): a. It must be remembered that. It consists of progressive widening of the superoposterior access to the tympanic cavity already started with the antrotomy. Sometimes. it is absolutely essential to carry out a corrective osteo-(chondro)plasty. as one might think. which it is preferable not to perforate. the skin is missing or has been elevated as a flap. body. it is possible to visualise membranes around the ossicles or the bony epitympanic walls. c.e. in the absence of cholesteatoma. and finishes up by visualising (remember the refractory effect with irrigation liquid) the short process of the incus and its insertion into the fossa incudis. which is of extreme importance. the superior surface of the posterior aspect of the COG. by opening the epitympanic space. no complications should be expected. but the skin of the ear canal remains intact. part of the head of the malleus with its superior ligament. fibrotic reactions to in vivo inflammatory processes. it is possible to expose the MCF dura – with a change in the sound of the burr or the onset of bleeding (another cue in live bones!) – the inferior level corresponds to the postero-superior EAC wall. These are not. or if pathological processes such as cholesteatoma have eroded it. It is very important to carry out a complete removal of the mastoid cortex: this will allow the antrotomy to be widened progressively mediolaterally. if.. does not usually have to be completed with a posterior tympanotomy. on the other hand. If this occurs. and superior ligament of the incus. the incudomalleolar (diarthrodial) joint. i. CWU) tympanoplasty (TPL) which. the short process. d. while at the upper and lateral levels of the dissection. but rather mucosal folds (anterior malleal fold. concludes – in its initial part limited to the posterior epitympanum – the surgical approach in a closed (canal wall up.21 Phase 5: Posterior and anterior epitympanectomy This step. Opening of the posterior epitympanum will allow the following to be visualised (Fig. It is wise to carry out the most delicate opening of the posterior epitympanum with smallsized diamond burrs. posterior
. the main element that separates the posterior epitympanum from the anterior one. passing from the more fragile to the more resistant bony parts. b.
Posterior epitympanectomy is completed. I= Incus.
malleal fold. M= Malleus.
Fig. as in the case of a cholesteatoma which may already have induced local damage. Removal of the incus and head of the malleus and demolition
. such as tegmen or incus erosion. incudal fold. a conservative approach to the middle ear. M= Malleus. Opening of the anterior epitympanum is generally needed when a pathological process has invaded it. The dissection continues with an extension of a closed TPL. 26). as well as influence the development and extension of cholesteatoma. I= Incus. Mucosal folds around the ossicles in the posterior epitympanum. 26. LSC= Lateral semicircular canal. They are particularly visible in well-preserved bones (Fig. as well as COG demolition.22
Fig. stapedial fold (Proctor)) that delimit and direct air flows and mesotympanic and mastoid ventilation. 25.
through the posterior tympanotomy. The close relationship between the supratubaric recess. inserted into the tegmen with an irregular inferior concavity. are essential steps in order to gain access to the anterior epitympanum. The head of the malleus can be removed alone by using a special instrument (malleus nipper) placed medially to the malleus neck in order to separate the head from the handle. Once the posterior epitympanum has been freed from this part of the ossicular chain. 27a-b). the posterior aspect and inferior edge of the COG are visible (Fig. TT: Tensor Tympani tendon. in order to avoid involuntary luxation or fracture of the stapes crura or footplate. 27a-b. COG becomes visualised. the whole epitympanum is opened. in order not to damage the neighbouring structures. towards the tegmen. Disconnection of the upper ligaments of both ossicles is rather easy to perform using small hooks. drilling it inferosuperiorly. generally half-moon shaped. tubal orifice. and their removal should be carried out cautiously. Once the COG has been eliminated.
of the COG (if still intact) by drilling. and semicanal of the tensor tympani muscle should be taken into consideration. The incus has to be separated from the stapes head. Both ossicles are firmly anchored. The COG is a bony crest.0 mm) diamond burr. located superiorly to the tubal orifice.23
Fig. this manoeuvre can also be performed through the EAC after the creation of a tympanomeatal flap and is mandatory every time an ossicular manipulation is foreseen. Its removal must be carried out with a small (0. thus giving sight of the protympanum or supratubaric recess. with possible bad functional consequences.
. After removal of the ossicles from the posterior epitympanum.5-1.
24 Phase 6: Posterior tympanotomy (facial recess) Learning this step gives the otosurgeon (or. until the mastoid cavity and middle ear cleft are separated by only a very thin bone (Fig. insertion of some types of semi-implantable hearing aids. 28). at least. Its application ranges from closed TPL (in which the posterior wall of the EAC remains intact) to cochlear implant surgery. first of all. FN decompression. For its proper performance. which should be visible (by transparency) first laterally and later medially. 28. using wide movements. This thinning out must be performed by first using cutting burrs (6 mm). progressive. Thinning of the posterior EAC wall can be controlled visually – after removal of the overlying skin – putting the suction tube in the EAC.
Fig. Thinning out the posterior canal wall (EAC) is the first step in posterior tympanotomy. The aim of this approach is to allow visual (and instrumental) access to the tympanic cavity through the mastoidectomy cavity. while the inability to perform it should be reason enough for stopping that particular surgeon from cruising the otological highway. the middle-ear otosurgeon) his/her identity card and driving licence: when correctly performed. latero-medial thinning of the posterior wall of the EAC should be carried out. which – under continuous irrigation – must work homogeneously supero-inferiorly or vice versa. his/her effective capabilities are clearly visible.
29b. It is important to bear in mind that the lateral limit of posterior tympanotomy – the chorda tympani – coincides anteriorly with the fibrous annulus and. while the most medial part (where the facial recess is located) is still very thick.
Fig. after uniform thinning of the posterior EAC wall. after a simple mastoidectomy.25
Fig. chorda tympani (CT) and facial nerve (FN) when performing posterior tympanotomy. The space between CT and FN has been entered and posterior tympanotomy completed. which supports the short process of the incus (Fig. This fossa is always occupied by a whitish tissue (the posterior incudal ligament) which can be confused with epidermisation. greater thinning of the lateral part of the posterior EAC wall has already been carried out. 29a-b-c). Drawing showing the relationship between posterior canal (EAC). 29c. it will be possible to open a triangular bony space. 29a.
Fig. and superiorly by a bony lamina (buttress) that separates it from the fossa incudis.
It will be appreciated that. With this procedure. Chorda tympani (CT) and facial nerve (FN) represent two sides of the triangle which forms the facial recess area.
. posteromedially by the vertical segment of the FN. delimited antero-laterally by the chorda tympani (CT).
Once the drilling area of the posterior tympanotomy has been delineated. with the tympanic membrane: if the posterior EAC wall is opened more laterally. the EAC itself will inevitably be entered and not the tympanic cavity. these cells can erroneously mislead the surgeon into believing that the tympanic cavity has already been reached. the calibre of the burrs (always diamond) must become smaller and smaller. Often. so that. If a posterior tympanotomy is properly performed and the surgeon tilts the TB anteriorly. located in the middle ear rather than in the mastoid area. while this will only be true after further cell removal. the facial recess region contains more or less large cell groups. remembering that the distance between the FN and the CT at that level is only 2-3 mm. or less where the CT emerges from the FN. Nevertheless. the novice should choose a lateral rather than a medial (close to the FN!) approach. it should be possible to visualise the following structures: • incudo-stapedial joint • stapedius tendon • promontory and Jacobson’s nerve • round window niche • hypotympanic cells • medial aspect of the tympanic membrane with handle of the malleus • tubal orifice • fallopian canal (second segment-tympanic) • cochleariform process (CP) • semicanal of the tensor tympani muscle
.26 hence. at times.
In such cases. The second procedure implies the use of a mid-sized (5-6 mm) cutting burr. some otologists call a technique ‘closed’ even when. whatever the procedure. any technique of lowering the posterior EAC wall during an ‘open’ technique must correctly reach the level of the vertical or third segment of the FN. This latter technique also has different variants over and above classical or modified radical mastoidectomy. The posterior EAC wall may be lowered by choosing either of the two procedures. this step must be preceded by elevation or removal of the EAC skin together with the tympanic membrane. the resection can also be performed by a small cutting burr. Remembering (or better still. depending upon the proposed subsequent surgical sequence. a small circular saw can be used. superiorly (at the epitympanic level) and inferiorly (at the level where the CT emerges from the FN).27 Phase 7: Lowering of the posterior wall of the external auditory canal This step marks the passage from a ‘closed’ to a so-called ‘open’ technique. recording) what it was possible to visualise
. proceeding tangentially to the medial aspect of the handle itself. during the operation. in order to achieve a larger and more comfortable approach to the tympanic cavity whilst aiming to remove pathology (cholesteatoma) and thereafter planning to put it back again. In the TB. Instead of using a circular saw. In fact. and the attached handle of the malleus also has to be removed: this step is facilitated by cutting (Bellucci’s scissors) the tensor tympani tendon at the level of the CP. Since a posterior tympanotomy has already been carried out during the previous step. For this purpose. so as not to damage the nearby tympanic segment of the FN. The first option is to section the posterior wall temporarily. 30). When the lowering of the posterior EAC wall has been completed. the posterior EAC wall has been removed and is later reconstructed. to be used from lateral to medial along the whole length of the EAC posterior wall (Fig. but this will lead to a larger defect when the wall has to be put back in place. it should better be mentioned as a re-closed technique. it will be possible to make a note of what portion of the posterior mesotympanum it is possible to visualise with an open technique. this procedure can now be performed quite safely. However.
it can be concluded that the ‘open’ technique: a.
. b. In fact. which can only be exposed after destructive steps have been taken. a region which cannot anyway be explored unless otoendoscopes are used. It lies between the ponticulus. but perhaps allows a more comfortable use of the instruments. Posterior mesotympanum As mentioned above. does not allow to see the posterior mesotympanum. Other than the two major depressions in the posteromedial wall of the tympanic cavity. a ridge stretching inferiorly between the styloid eminence to the posterior lip of the round window niche. reaching several millimetres in the direction of the ampullary arm of the PSC (Fig. namely the round and oval window niches. this region lies medial to the FN canal (vertical or mastoid segment) and anterior to the posterior semicircular canal (PSC). The posterior depth of the sinus tympani is variable. this is the most hidden area of the TB. does not permit to see more than a ‘closed’ technique. The ‘open’ technique implies lowering of the posterior canal wall (PW). which bridges the gap between the pyramidal eminence and the promontory superiorly. 30. and the subiculum. the so-called sinus tympani.
through the posterior tympanotomy.28
Fig. the posterior mesotympanum is often named after only one part of it. TM= Tympanic membrane. 31).
. from Schuknecht and Gulya (1986): Anatomy of the temporal bone with surgical implications. (Modified.29
with laterally-based flaps that may be difficult to perform in a cadaver bone.
. However. namely a technique that requires lowering of the posterior EAC wall. For an optimal ‘radical’. At the end of Phase 7. it is also true that parts of this surgical technique may be included as steps in other. Drilling of the anterior EAC wall (AW). Moreover. ossicles). we have a cavity mimicking a modified radical. all EAC walls must be freed of skin. b. Drilling of the anterior canal wall (AW) is an important step during classic radical mastoidectomy. at the same time sparing the existing middle ear structures (eardrum remnants. according to the Mickey Mouse technique popularised by the House Ear Institute in Los An-
Fig. TMJ= Temporo-mandibular joint. Lowering of the posterior EAC wall (already obtained after the previous phase). 32. in order to carry out the main steps of this dissection.30 Phase 8: Classical radical mastoidectomy If it is true that the clinical indications for a ‘radical’ mastoidectomy are becoming fewer and fewer nowadays. mostly neurootological approaches. the following surgical steps have to be carried out: a. especially in the anterior part. a classical radical mastoidectomy implies the elimination of all middle ear structures (stapes or footplate excluded). and must therefore be part of the technical armamentarium of an otologist.
As already mentioned. if necessary.
. Drawing showing the Mickey-Mouse technique for drilling of the anterior canal wall. it is possible to open the anterior wall in its central portion adjacent to the TMJ. which aims at avoiding direct penetration of the glenoid fossa and. and. in vivo. usually without any symptom being experienced by the patient. 33). The purpose is to obtain a unique plan without any bulging of the anterior EAC wall.
geles. of the temporomandibular joint (TMJ) (Fig. opening this part does not necessarily involve exposure of the TMJ. bony ridge lying laterally to the tensor tympani muscle (anterior buttress). Union of the anterior EAC wall with the overlying epitympanic anterior wall.31
Fig. at the expense of a solid. 32). Removal of other bony ridges. but it should be remembered that. to remove any periannular skin remnants. therefore. and afterwards uniting them in the middle. d. hard. by drilling the central part (Mickey Mouse’s head) (Fig. This technique – preferably to be carried out with small-sized (1. but only of the pericapsular fibrous tissue.52 mm) diamond burrs – first schedules drilling of the superior and inferior parts of the wall (Mickey Mouse’s auricles). 33. c. especially at the level of the anterior aspect of the posterior EAC wall and of the inferior EAC wall. since they are not directly contiguous with the TMJ. until the marginal bony annulus is exposed medially.
a high jugular bulb) situations.. which are not generally included in the dissection steps of basic courses. it is important to remember that an essential non-osseous surgical step is represented by meatoplasty. to be able to deal with unusual pathological (cholesteatoma eroding the medial wall of the tympanic cavity) or anatomical (e. with both normal and malformed or ossified cochleas.
. 2. However. some of which has to be done by removal of the conchal cartilage.g. The next phase is the first of three. namely widening of the outer orifice of the EAC. to be familiar with the three-dimensional orientation of the cochlea for cochlear implant surgery. since the dissection is medial to the promontory wall.32 Before leaving the ‘radical’ phase. it is propitious that otosurgeons obtain knowledge of it for at least two reasons: 1.
Fig.g. Preferably with a diamond 1.33 Phase 9: Opening of the petrous apex The apex of the petrous bone is routinely opened in a transmastoid approach to the IAC or to deal with local pathologies related to hyperpneumatisation and hypoventilation of the petrous apex cells (e. It is perhaps one of the most delicate steps. postero-inferiorly by the JB.0-mm burr. by isolating the ‘blue lines’ of the ICA and the JB. transcanal approach where the antero-infero-posterior EAC walls have to be saucerised after making a superiorly-based tympanomeatal flap.. FN= Facial nerve. This step may be carried out by using an alternative. 34. cholesterol granuloma). since drilling in the region of the medial wall of the tympanic cavity is delimited anteriorly by the vertical tract of the ICA. and superiorly by the inferior border of the basal turn of the cochlea (BCT) (Fig. a triangularly-shaped area is delimited. The petrous apex (PA) is entered between the internal carotid artery (ICA) and the basal turn of the cochlea (BCT).5-2.
. in which a deeper dissection should be continued cautiously. 34).
the endocochlear cavity is finally entered at the level of the scala tympani (in laboratory bones. After having created a niche. always keeping the tip of the drill pushing slightly on the bone (remember that this is one of the few exceptions when the burr is not working as usual. the bone of the otic capsule is very compact and hard to penetrate. The initial step consists of cochleostomy. the endosteum may first be exposed. with the burr working perpendicularly to the promontory wall. everyone knows that the promontory (a convex area) corresponds to part of the basal turn of the cochlea.. in accordance with the ‘soft surgery’ procedure advised to minimise cochlear trauma. At times. being careful not to hit the bony spiral lamina and the basilar membrane located in the posterosuperior pole of the cochleostomy. in accordance with the modalities of cochlear implant surgery. a smaller (also cutting) burr is chosen and drilling continues. If a dummy is available. before entering the cavity. At that level. no perilymph leakage will be observed) (Fig. it is possible to try to simu-
. 35a-b). it is possible to widen the hole.34 Phase 10: Cochleostomy and cochlear visualisation This phase of the dissection contains anatomical and practical elements with respect to cochlear implant surgery. with the shoulder and with oscillating strokes). since their damage could interfere with the outcome of cochlear implant function. At this point.e. and kept in place while slight pressure is exerted. i. The surgical landmarks for the identification of the deep projection of the cochlea are: • round window (RW) niche • stapes (S) and oval window (OW) • cochleariform process (CP) • semicanal of the tensor tympani muscle (STTM) • tubal orifice (TO) • vertical trait of the ICA • Jacobson’s nerve (J) It is important to remember that the baso-apical direction of the cochlear turn is opposite to the side operated: left direction in a right cochlea and vice versa. A small (2 mm) diamond burr is placed 1 mm up and 2 mm anterior to the lip of the RW niche. Looking at the medial wall of the tympanic cavity. Carrying on.
36). STTM= Semicanal of the tensor tympani muscle. The arrow shows the direction burr.35
Fig. RW: Round window. If magnification is
Fig. 35b. posteroanteriorly and mediolaterally (Fig. it is also necessary to remove the stapes and to widen the drilling posterosuperiorly: it is important to acknowledge the central bearing axis (the modiolus). remembering the strict relationship between the anterosuperior margin of the apical cochlear area. OW= Oval window. CP= Cochleariform process. With a small (1. The lateral aspect of the cochlea has been removed and the cochlear turns are shown around the modiolus (MA). At this level.
. In order to dissect and visualise the entire cochlea. obliquely oriented from bottom to top. of the basal turn of the cochlea.
late its insertion. care should be taken not to penetrate the MCF dura. the geniculate ganglion. 36. This step is carried out by using a diamond burr. ending with the application. cochleostomy is performed. and then superiorly in the region which is medial to the pathway between the CP and the semicanal of the tensor tympani muscle. before starting with the anatomical dissection of the cochlea. 35a. and the semicanal itself.8 mm) diamond Fig. and removal of the superficial part of the cochlear wall is continued anteriorly up to the projecting area of the ICA.
with only a thin bone separating them. 3-5 mm in diameter. The bony part lies lateral to the ICA. tubal surgery is rarely necessary. pigmentation of the inner ear structures).
Although proposed by some authors. and small dehiscences for the passage of the caroticotympanic arteries. The entrance of the Eustachian tube orifice (TO) and the tensor tympani muscle (TTM) are shown.
. 37). except for removing a bony obstruction (always use small diamond burrs!. The tubal isthmus marks the transition. remember the closeness of the ICA and the possibility of bony dehiscences!). Its lumen is triangular. Eustachian tube orifice This is located in the anterosuperior portion of the middle ear cavity. and surrounded by various degrees of pneumatisation. 4-6 mm superior to the inferior wall of the hypotympanum and just beneath the semicanal of the tensor tympani muscle (TTM) (Fig. unimaginable cochlear structures can be recognised (basilar membrane. with cartilage occupying the anterolateral and superior walls. 37.
Fig.36 increased to the maximum (40x). scala tympani and vestibuli.
due to the constant position of the intrapetrous ICA.
. provided the burr is never stopped. BCT= Basal turn of the cochlea. A needle is touching the posterior wall of the vertical. The dis-
Fig. intra-petrous tract of the internal carotid artery (ICA). large cavity. colour variations can first be seen. and also a soft consistency (Fig. since inferomedial to it (by a few mm). TO= Tubal orifice. which has been exposed. as described at the end of Phase 4. 38). 38. as far as height and postero-anterior position are concerned. The JB represents one of those structures that can have an extremely variable position. By thinning out this area progressively and uniformly. the vertical ICA tract bends and proceeds anteriorly in its horizontal portion. drilling is concentrated in the anteroinferior part of the medial wall of the tympanic cavity and should be carried out – with a small diamond burr – superoinferiorly or vice versa. without movements that are too wide. often united in a single. At this point. the dissection previously performed arrives at the exposure and opening of the retrofacial cells.37 Phase 11: Identification and skeletonisation of the vertical intrapetrous tract of the internal carotid artery. jugular bulb (subfacial approach) and petrous apex In the first part of this phase. Its identification and exposure are generally carried out through a transmastoid subfacial (medial to the third segment of the FN) approach. FN= Facial nerve. An important superior landmark is represented by the eustachian tube orifice.
it is possible to go deeper. the labyrinthine block. having as its lateral limit the third portion of the FN. using smaller calibre (1-2 mm) diamond burrs. In order to optimise visualisation of the region to be opened. Once the JB has been identified.38 section will then proceed anteromedially. and more specifically. the burrs should also have a longer shaft. Apart from being smaller. always being careful not to open the labyrinth (PSC). finding an extreme variability of pneumatisation at this level. This manoeuvre will depend upon the degree of dissection of the retrosinus mastoidectomy. When necessary. It is thus possible to reach and open the petrous apex cells.
. the operating bed) anteriorly. the ampullary arm of the PSC. at this point. it is appropriate to tilt the specimen (in surgery. the posterior margin of which should not hamper visibility of the anterior regions. and as its upper limit. further drilling of the posterior margin of the cavity should be carried out until this goal has been achieved.
never coagulate! Await its spontaneous remission!). and can be anticipated in its third (mastoid). Isolation of the vertical (mastoid) segment of the FN. this can be useful to avoid damaging it. LSC= Lateral semicircular canal. when looking for the nerve. bleeding along its course (obviously. drilling with a 5-mm diamond burr under continuous irrigation (facial palsy can also occur when the FN is overheated) (Fig. Apart from the monitoring systems performed during live surgery. it is uncovered: on the contrary. at this stage of the dissection. but definitely separated from it. segment.
. the FN represents the structure around which the whole TB dissection rotates. It is noticeable that. in close contact with the FN. a soft structure can be seen. one sign that should alert the surgeon and make him realise that he/she is close to the FN is the mild. Another important concept is not to fear facial palsy if. 39. sometimes annoying. Before carrying out FN decompression. posterior to the fallopian canal.
Fig. 39). In the superior segment of the mastoid portion.39 Phase 12: Facial nerve decompression (second and third portions) As shown so far. the FN is visible in its second (tympanic). It is important not to forget that the best method for preventing damage to the FN is always to keep looking for it. CP= Cochleariform process. the nerve must be uncovered all along the vertical segment.
while it has a constant relationship with the superolateral dome of the LSC. it is opportune to expose the entire belly (medial insertion to the mastoid process). This is the stapedius muscle. the dissection allows the emerging point of the CT to be identified. up to the geniculate ganglion. Once the most poste-
. The landmark for the anterior deviation of the FN and its exit from the TB is the anterior margin of the posterior belly of the digastric muscle (which separates the lateral from the medial mastoid tip cells). 40). The region of the second genu is quite delicate. In order to ensure that drilling is being performed on the digastric belly. which will appear as a half-moon structure directed posteroanteriorly. breaking the bone into pieces by putting either instrument under it. 40. which should not be confused with a damaged FN.40
Fig. Once the fallopian canal of the third segment has been identified and decompressed. In decompression of the tympanic segment of the FN. and. more inferiorly. it should be borne in mind that at this level the nerve becomes more superficial. The stapedial muscle (SM) is found behind the vertical segment of the FN. but 1 cm higher.
which may cause bleeding (Fig. this should not be sought at the level of the mastoid tip. Inferiorly. the segment which precedes the exit of the FN from the temporal bone through the stylomastoid foramen. a sickle knife or dental excavator can be used. since the angle of curvature is not always the same (sometimes it is less than 90°). a similar decompression should be performed at the level of the second genu and in the tympanic segment.
thus mimicking anterior rerouting of the FN. it will be possible to raise both the second and third segments altogether. in glomus tumour surgery or cholesteatoma surgery. which is carried out. At this point. like an open book. it is easier to carry out the more anterior part. after setting the medial adherences in the fallopian canal free with a sickle knife or Rosen needle.41 rior part has been decompressed. when removing cholesteatoma that extend medially to the fallopian canal. for example. Osteo-epineurial decompression of the most anterior second segment will allow the strict relationship between two soft tissue components to be visualised: the exposed FN and the underlying tensor tympani muscle. the next step is to open the mid-lateral portion of the epineurial sheath (with a sickle knife or No.
. 11 scalpel). leaving the most medial portion intact. After isolation of the second and third segments of the FN from the bony canal.
during which the surgeon returns to large spaces. PSC= Posterior semicircular canal. even mimicking a surgical procedure that is still in use today for treatment of Ménière’s disease. an imaginary line which proceeds. After exposure of the entire PCF dura. 41. LSC= Lateral semicircular canal. surrounded upwards and downwards by a lighter or light blue colour. The need for such a wide exposure is justified by the extreme variability of position and course of the ES itself. SS= Sigmoid sinus. The arrow indicates Donaldson’s line. The endolymphatic sac (ES) is the membranous appendage of the posterior labyrinth that is a duplicate of the dura of the posterior cranial fossa (PCF). The endolymphatic sac (ES) is isolated as dural duplicature. Particular
Fig. it is necessary to search for a thicker or darker (due to its rich vascularisation) area. It is thus logical that the preliminary step for its identification is the exposure of the PCF dura situated anterior to the SS. towards the SS: this line marks the upper limit of the area within which the ES can lie. tangentially to the dome of the LSC. In this regard. and which extends inferiorly up to the JB (always remember the not infrequent possibility of a high JB!) (Fig. 41).42 Phase 13: Identification of the endolymphatic sac This is an exciting phase of the dissection. almost up to the JB. one of the suggested surgical landmarks is represented by Donaldson’s line (arrow). such as endolymphatic sac decompression or shunt.
.43 attention must be paid to not penetrating the PSC which. which is still the ES and not yet the duct (ED). in some TB. Once the presumed ES area has been identified. it is necessary to follow it cautiously anteriorly. may be close to an anteriorly located SS. using a small curette or a small diamond burr on the posteromedial aspect of the PSC. The ES will certainly have been found when – depressing the corresponding dura – the surgeon can see the anterior prolongation medially to the labyrinthine block (PSC).
The common crus of the PSC is much deeper. this is represented by the three semicircular canals (SCs). PSC= Posterior semicircular canal. they are not at the same level. During drilling of the central part of the SSC. Isolation of the three SCs is therefore obtained by delineating their tridimensional projection. performed to expose the PCF dura above Donaldson’s line as well. a small channel
Fig. SSC= Superior semicircular canal. 42. As already noted. 42). perpendicular to one another. taking into account the dome of the LSC. and that their name refers to the orientation of their dome. Hence. It is important to remember that the three SCs are located in the three spatial planes. LSC= Lateral semicircular canal.
. enables the posterior edge of the posterior labyrinthine block to be reached. their spatial orientation can be estimated. being glossy yellow and harder (Fig. At this point. both colour and compactness of the otic capsule bone differ from that of the surrounding cellular or acellular bone. but rather at a different depth: the most superficial is the LSC.44 Phase 14: Isolation of the labyrinthine block Drilling of the pre-sinus cells. while the level of the superior semicircular canal (SSC) is the deepest of the three. The labyrinthine block. while the level of the PSC lies halfway to the non-ampullary arm of the LSC. visualised with the antral opening.
It must be remembered that each SC is surrounded by pneumatised or sclerotic bone. the tegmen antri).45 containing the subarcuate artery (SA). a branch of the anterio-inferior cerebellar artery (AICA). which covers the bony otic capsule. being situated in its centre. will be encountered.
. which is a useful landmark for subsequent drilling. Before isolating the SSC. it is very important to skeletonise the tegmental line thoroughly (at that level. Isolation of the three SCs will be improved after exenterating the perilabyrinthine cell groups. since it is equidistant from the course of the SSC.
by performing careful opening of the PSC. it will be noted that the non-ampullary arm of the latter (common crus with SSC) lies on a deeper plane than the ampullary one. the SCs must be drilled away in the same order. drilling of the SSC should be continued. Thus. In principle. The LSC may also be the first canal to be opened. with attention being paid that the MCF dura. as labyrinthectomy proceeds. the opening of the SCs must proceed by highlighting – over its entire length – the groove containing the membranous labyrinth. so that if it should inadvertently slip. 43). which is in close contact with its dome. that the dissection should proceed by their total removal. drill on its superior side. as a thin whitish channel which
. c. change the rotation of the burr. which consists of drilling the dome of the PSC and progressive intraluminal blockage with a gelfoam-type material. The PSC can also represent the starting point for a surgical approach recently popularised in those rare cases of benign paroxysmal positional vertigo (BPPV) that cannot be controlled with classical positional manoeuvres: occlusion of the PSC. three main rules should be adhered to: a. must be borne in mind. From an anatomical point of view.46 Phase 15: Labyrinthectomy and identification of the intraosseous endolymphatic sac and duct Labyrinthectomy consists of the total destruction of all SCs and should be associated with the removal of saccular and utricular receptors. At this point. It is only after having exposed the internal part of the three SCs in this way. medially to the PSC. since it is clearly evident in the antral cavity since the first steps of the dissection. the anterior prolongation of the ES (intra-osseous portion). b. Already exposed. in a right ear. a disputable but codified surgical procedure is being carried out. it will be possible to see. which can start from either the LSC or the PSC. does not get torn (arcuate eminence (AE) in the MCF approach) (Fig. After having exposed the groove of the LSC and PSC. it is directed away from the nerve. The strict anatomical relationship between the LSC and the FN. because drilling laterally may jeopardise the FN. move the burr on the main axis of the canal. In order to prevent a cutting burr from damaging the FN. which always lies inferomedial to it.
44. LSC= Lateral semicircular canal. at which level it turns inferiorly to enter the vestibule. SSC= Superior semicircular canal. avoid drilling on the antero-inferior portion (ampullary arm) of the SSC: the presence of an intact ampulla is. The subarcuate artery (SA) is a landmark for the dissection of the SSC. PSC= Posterior semicircular canal. The three semicircular canals have been opened.
courses anterosuperiorly. then becoming the thinner ED. remember to use the channel of the subarcuate artery (SA) as landmark in order to facilitate SSC dissection (Fig. There are two other important points regarding drilling of the SSC: a. b. 43. 44).47
Fig. an important landmark for future IAC isolation. SA= Subarcuate artery. in fact. which passes medially to the common crus.
for the stapes footplate (if a needle is inserted through the oval window. with the ampullary arm of the LSC (ALSC). 3. This cavity has four small openings: 1. spherical recess. 2. delimiting the cochlear recess for the vestibular caecum of the cochlear duct. Between these two recesses the vestibular crest is located. it is possible to see it where it enters the vestibule). for the ampullary end of the PSC. accommodating part of the utricular macula. as well as to tilt the bone-holder (or the operating bed) anteriorly. taking particular care to thin it out close and parallel to the FN. lying anteroinferiorly. 45. and two depressions: 1.48 Phase 16: Opening of the vestibule Drilling on the base of the LSC. for the ampullary ends of the LSC and SSC. elliptical recess. will allow the vestibule cavity to be opened and visualised (Fig. for the cochlear duct. lying posterosuperiorly. accommodating the saccular macula. which bifurcates posteriorly into two wings.
. Visualisation of the vestibule (V). located anterosuperiorly. 4. 2.
2. • at the level of the geniculate ganglion (GG). above the cochleariform process (CP). thus having only two anchoring points: • its exit at the stylomastoid foramen. which has to be severed. 3-4 mm. up to the entrance in the IAC.
.49 Phase 17: Identification of the labyrinthine segment of the facial nerve After the previous steps of the dissection. Isolation of the labyrinthine segment of the FN (LFN). identify the GG with its anterior prolongation. the following dissection exercises must be performed: 1.
Fig. TFN= Tympanic segment of the facial nerve. and posteriorly by the superior prelabyrinthine cells and the SSC. 46). but also the most delicate). but also posteriorly. Dissection of the labyrinthine FN should not be hurried. not only anteriorly. SSC= Superior semicircular canal. opening the space delimited inferolaterally by the tympanic FN. GG= Geniculate ganglion. The first aim is reached by decompressing the most anterior part of the tympanic segment (12-13 mm long). decompress the labyrinthine segment (the shortest one. In order to allow its complete mobilisation (re-routing). the FN is decompressed osteo-epineurially and is lifted from the fallopian canal. superolaterally by the MCF dura. CP= Cochleariform process. 46. since the nerve can easily be avulsed (Fig. the greater superficial petrosal nerve (GSPN).
it will be possible to grasp it with a Hartmann cup forceps. in this segment. and to carry out a posterior dislocation (re-routing). and pull it posteriorly. Light. after sectioning the GSPN anteriorly to the GG with a sickle knife or small hook. but continuous irrigation will enable visualisation to be improved.
. as long as the dissection carries on. setting it free from the bony canal.50 In fact. for example. as is possible in the mastoid segment (15-20 mm long). At the end of this task. the FN is embedded in a very compact bony block which does not facilitate a gradual isolation. The dissection should then continue medially to the various segments of the FN.
there may be damage to the pars nervosa of the jugular foramen (IX. in the area corresponding to the posterior labyrinth (SCs).51 Phase 18: Identification and opening of the internal auditory canal This is the final dissection on a TB approached from its lateral aspect. At this point. remember the definition in Gray’s* English-language anatomical textbook. A cutting burr cannot avoid this. in its posterior. if the dissection is brought below this point. superior. and inferior aspects. in which smaller and smaller diamond burrs have to be used on a more and more compact bone. the two other well-codified landmarks for extension and facilitation of the dissection are: a. mid-calibre (8-10 mm) burr may be used. The dissection aims at isolating the IAC for 270° or more. superiorly. remembering that the position of the IAC is always more anterior than may be realised. and gentle pressure should also be exerted during drilling: a diamond burr will avoid tearing the underlying dura. the dissection must start posteriorly.” Basically. A diamond. the bone is very thick and compact. is never without danger. X and XI cranial nerves). While the posterior limit is delineated by the dural reflection of the PCF with the IAC dura. inferiorly. The following consideration should be borne in mind during all phases of the dissection: to hurry a dissection. which states: “If you put a pencil in the EAC. To make it easier to visualise. However. the ampulla of SSC. and push it medially.
. you will find it in the IAC.
* Anatomist at St George’s Hospital Medical School. the orifice of the cochlear aqueduct. b. the roof of the IAC is represented by the medial wall of the vestibule. London (1821-1865). where the posterior edge will delimit the posterosuperior border of the IAC superficially (laterally). It is one of the most delicate and difficult steps. as well as analogous cutting ones. especially in the case of an inexperienced surgeon. which has to be completely uncovered. which should not be sacrificed during labyrinthectomy because it is important for identification of the entrance of the FN in the IAC.
. the suction-irrigation tip can also be used as an instrument since it helps to move the acoustic-facial package away from the drilling zone. Removal of the two vestibular nerves allows visualisation of the anterior IAC compartment which includes the cochlear (CN) and the facial (FN) nerves. antero-inferiorly. the burr does not work in the usual (uniform and continuous strokes) way. postero-superiorly. and sometimes with the tip as well. Once isolation of the IAC dural surface is complete. During this step. • superior vestibular nerve (SVN). antero-superiorly. The dural layer of the IAC is then opened with a small hook. As has been pointed out above. but rather by means of a contact-and-pressure action. • the closeness of the soft tissues with possible minor (tearing of PCF or MCF dura) or major (IAC penetration. and the following four neural elements can be seen (Fig. when drilling on the IAC.
Superior and inferior dissections of the IAC are the most difficult stages in a TB dissection due to: • working with a small-sized diamond burr. with neural or vessel involvement) damage.52
Fig. the entrance of the labyrinthine FN into the IAC – in its superolateral part – can be identified. When the bone has been thinned out. Bill’s bar (BB) divides the facial nerve (FN) from the superior vestibular (SV) nerve. 48. 4748): • facial nerve (FN). this colour being due to the underlying fluid-immersed tissue.
Fig. • cochlear nerve (CN). a ‘blue-line’ may also have been produced. 47. • increasing postero-anterior thickness. and • inferior vestibular nerve (IVN) postero-inferiorly.
53 It is also possible to visualise the vertical crest – also known as Bill’s bar (B) after William House – which separates the FN from the SVN. the lateral approach to the TB is completed. When this final part of the dissection has been achieved. which separates the SVN from the IVN.
. The various steps of the dissection have been interspersed with true surgical approaches in order to render the dissection more stimulating and interesting. in the view of the author. as well as the transverse crest (TC).
in a right ear. 49. AE: Arcuate eminence. For example. depending on the quality of bone preservation.
Fig. so that it will be possible to have direct visualisation of the floor of the MCF itself (roof of the TB) (Fig.54
SUPRATEMPORAL OR MIDDLE FOSSA APPROACH
For this approach. the mastoid tip should point inferiorly. bearing in mind that the surgical position of the otologist is that of looking down from above. In order to make it easier. corresponding to the dome of the SSC. the GSPN. it is a good idea to rotate the TB in the hands. 49). This will be more or less hard. The surface anatomy of the MCF is quite difficult. arcuate eminence (AE). These landmarks are identifiable as: a. which leaves anteriorly from the GG. The floor of the middle cranial fossa. for a right ear it must then be rotated to the left. Once fixed in this position. correct placement of the TB in the bone-holder may present some initial problems. where the superior petrosal sinus (SPS) runs. located posteromedially. the dural lining should be removed by lifting it up to the passage from the MCF to the PCF. especially when landmarks are not clearly evident. and then upwards. b. a branch of the FN. SPS= Superior petrosal sinus.
d. the middle meningeal artery (MMA). • identification of the FN and GG. which exits from the foramen spinosum positioned in the most anterior part of the surgical field.
. In cases of difficult orientation. the GG. it may be necessary to find the way by drilling regions not directly correlated with the surgical objective. • isolation of the cochlea. covered by more or less compact bone. The following phases will be presented: • opening of the epitympanic cavity and of the petrous apex cells. is occupied by the tegmen. the eustachian tube can be found. in a medial projection. • exposure of the IAC. sometimes devoid of bone covering. which lines the superior epitympanic wall (and posteriorly the mastoid part). a branch of the external carotid artery. The most inferior part. which occupies a central position on the floor of the MCF. Anteriorly.55 c.
. stapes (S). GSPN= Greater superficial petrosal nerve. MAS= Mastoid cavity. cochleariform process (CP). corresponding to the SSC (Superior semicircular canal). 50. 51. AE= Arcuate eminence. Opening of the epitympanum from above allows visualisation of the incudomalleolar joint (IMJ).
Fig. HM= Head of the malleus. GG= Geniculate ganglion. or it may represent a preliminary step in the identification of MCF landmarks. and tympanic segment of the facial nerve (TFN). which cannot be removed by a transmastoid approach without violating the labyrinth. The roof of the epitympanum has been removed and some middle ear structures appear. LSC= Lateral semicircular canal.56 Phase 19: Opening of the epitympanic cavity and of the petrous apex cells This step can be used for the extirpation of local pathological processes. Due to the complex surface and deep
apical cells. with continuous irrigation.57 anatomy of the MCF. This also enables the prelabyrinthine. with care being taken not to penetrate the SSC. 50-51). it is always preferable to use diamond. to be entered. midcalibre (5-mm) burrs. The aperture of the epitympanum enables the head of the malleus (HM) with the body of the incus and the malleo-incudal joint to be seen (Fig.
. By widening the opening with smaller (2-3 mm) diamond burrs. it is then possible to visualise the stapes and CP.
As well as any possible damage to the FN. AE= Arcuate eminence. • to follow the FN superiorly up to the GG. Identification of the GSPN. the FN. either covered by a thin layer of bone or exposed.
. Isolation of the FN labyrinthine segment (LFN) must be carried out cautiously. since opening the epitympanum makes the following possible: • to use the tympanic FN as a landmark.
Fig. gradually thinning out the very compact bone. 52. At the level of the GG.58 Phase 20: Identification of the facial nerve and geniculate ganglion The previous step is of great value. represents the key to the following MCF step (Fig. under continuous irrigation. care should be taken not to fenestrate the SSC. bends medially towards the tympanic segment. 52). and anteriorly gives rise to the GSPN. GG= Geniculate ganglion. at times discovered after the dura has been lifted. superiorly towards the labyrinthine segment. Isolation of the labyrinthine segment of the facial nerve (LFN). GSPN= Greater superficial petrosal nerve.
exposing the neural content: cochlear nerve (CN). the anterior side is not well defined. 53. • GSPN. using as a landmark the bisectrix passing through the obtuse angle formed between the course of the GSPN and the line of the arcuate eminence.59 Phase 21: Exposure of the internal auditory canal This is the most important part of this approach due to its surgical implications (vestibular neurectomy.: • arcuate eminence (dome of the SSC). The projection of the IAC in the MCF is in a broadly triangular area with its base on the course of the superior petrosal sinus (SPS). Approach 1 Drilling starts directly at the presumed IAC level. anterior to the GG. but coincides with a large. ‘mute’ area that extends anteriorly up to the exit of the MMA. The roof and superior wall of the internal auditory canal have been opened. Considering the major anatomical complexity of the inferolateral part in relation to the superomedial. the latter will first be drilled close to the reflection zone between the MCF and the PCF. The methods of approach depend on the anatomical landmarks used. and hence to the SPS. inferiorly.e. i. acoustic tumour removal with hearing preservation). facial nerve (FN) and vestibular nerves (VN). Conversely. • GG.
Fig. and with its posterior side on the dome of the SSC.
the surgeon must be aware that. the posterior edge of which will coincide with the anterior IAC wall. • the cochlear nerve (CN). drilling will allow the vertical crest or Bill’s bar. when proceeding with drilling. he/she will find the cochlear projection which. 53): • the FN. anterolaterally. drilling can continue towards the fundus of the IAC. Whatever the approach. • the superior vestibular nerve. at the level of the antero-inferior IAC wall.60 Approach 2 In this approach. which separates the FN from the SVN. to be exposed. posteromedially. Thereafter. the dome of the SSC. particularly recommended in an enlarged MCF approach. which must be carefully drilled in order to expose the ‘blue-line’ and then to proceed postero-anteriorly to delimit the anterior IAC border. Approach 3 This final approach. must not be fenestrated. posterolaterally. the initial landmark is represented by the arcuate eminence. anteromedially. At the level of the fundus of the IAC. Drilling has to go deeper superomedially until precise identification of the IAC can be made. and • the inferior vestibular nerve. it will be opened by means of a small hook in order to identify its internal content with (Fig.
. Once the IAC dura has been exposed along its entire course. in order to avoid a functional impairment that should be avoided when choosing a MCF approach. takes into account the ‘mute’. anteromedial area. similarly to the SSC.
54. CN= Cochlear nerve. the dissection can continue by isolating and exposing the cochlea. It should also be remembered that an MCF approach to the cochlea has also been proposed for cochlear implant surgery. until the contiguity of the cochlear basal wall and CN are evident (Fig. Drilling anterior to the internal auditory canal. FN= facial nerve. This is accomplished by progressive drilling of the postero-superior part of the IAC.
Fig. 54). the cochlea is exposed.
.61 Phase 22: Isolation of the cochlea For complete knowledge of the supratemporal bone anatomy.
POSTERIOR CRANIAL FOSSA APPROACH
The anatomy of the posterior aspect of the TB. More laterally. it is advisable to reflect on some aspects of the topographic anatomy of the posterior aspect of the TB. which usually follows cerebellar retraction. although not complex. Five or 6 mm. a step that cannot be reproduced unless the entire head is available. a fissure is located. and foramina (Fig. SF= Subarcuate fossa. The IAC orifice is located between the medial and the central third of the posterior aspect of the TB. 55. 10 mm from the IAC orifice. Before treating IAC landmarks. The posterior aspect of the TB forms a vertical wall. prominences. Bearing in mind the advances in modern neurootosurgery and the frequent contact with neurosurgeons. SS= Sigmoid sinus groove. can be seen. the operculum (Op). IAC= Internal auditory canal. the subarcuate fossa (SF). it is obvious that good experience is also necessary with this type of dissection.
. The major indication is for the IAC approach. at the exit of
Fig. presents difficulties because it uses a route which is unfamiliar to most otosurgeons. an irregular depression. laterally. a combination of grooves. which accommodates the cerebellar flocculum. Posterior aspect of the temporal bone. JF= Jugular fossa. higher laterally than medially. 55).
. JF= Jugular foramen. More medially. and from which the extraosseus ES emerges. close to the jugular foramen (JF).63
Fig. the cochlear aqueduct orifice is located (Fig. 1 cm wide. Op= Operculum. the groove of the SS is visible. ES= Endolymphatic sac region. PSC= Posterior semicircular canal. 56. exposing its neural content. 56).
the vestibular aqueduct. which contains the ED and the intraosseus ES. with the mastoid region anteriorly. Posterolaterally to this. The internal auditory canal (IAC) has been opened.
11 scalpel or Bellucci’s scissors.64 Phase 23: Identification of the internal auditory canal Drilling is usually carried out with the acoustic-facial package (vestibular neurectomy) or tumour (acoustic neuroma. the dissection is started in a lateroanterior direction. care must be taken regarding a possible high JB.
Fig. in order to expose about two-thirds of its circumference (Fig. the overlying dura has to be cut with a sickle knife and then lifted anteriorly and posteriorly.
. With small diamond burrs and under continuous irrigation. However. in order to open it and visualise its content. drilling should go deeper both superiorly and inferiorly. VC= Vertical crest. At this same level. VNs= Vestibular nerves. FN= Facial nerve. a longitudinal cut will be carried out with a No. without running the risk of violating the vestibule or the PSC. meningioma) arising from the vestibular nerve as the posteromedial landmark. It is extremely important to be cautious in posterior dissections. 57. Before starting drilling. since it is possible to injure the ES or ED. Once the posterior wall of the IAC has been identified. since this type of approach is generally selected as a last resort. Once this step has been completed. or even worse functionally. It is generally possible only to expose the medial two-thirds of the IAC. this aim would not be relevant in such a case. The opened IAC. 57). CN= Cochlear nerve. to fenestrate the PSC.
A AE ALSC AICA ACT AW BB BCT CN CP CT DM EAC ED ES EV FN GSPN HM IAC ICA IMJ IVN JB LFN LSC MA MAS MCF Op OW PA PCF PSC
antrum arcuate eminence ampulla of the lateral semicircular canal antero-inferior cerebellar artery apical turn of the cochlea anterior wall of the EAC Bill’s bar basal turn of the cochlea cochlear nerve cochleariform process chorda tympani digastric muscle external auditory canal endolymphatic duct endolymphatic sac emissary vein facial nerve greater superficial petrosal nerve head of the malleus internal auditory canal internal carotid artery incudomalleolar joint inferior vestibular nerve jugular bulb labyrinthine segment of the FN lateral semicircular canal modiolar axis mastoid cavity middle cranial fossa operculum oval window petrous apex posterior cranial fossa posterior semicircular canal
66 PW RFC RW S SA SC SDA SM SPS SS SSC STTM SVN T TB TFN TO TL TM TMJ TT TTM V ZP posterior wall of the EAC retrofacial cells round window stapes subarcuate artery semicircular canals sinodural angle stapedius muscle superior petrosal sinus sigmoid sinus superior semicircular canal semicanal of the tensor tympani muscle superior vestibular nerve tip of the mastoid temporal bone tympanic segment of the FN tubal orifice temporal line tympanic membrane temporomandibular joint tensor tympani tendon tensor tympani muscle vestibule zygomatic process
Donaldson’s line: the posterior prolongation of a line passing over the dome of the LSC. In general. a bony septum that. divides the petrous (medial) from the squamous (lateral) cells. Novices may be misled and confuse its smooth and compact aspect with the LSC. Some authors believe that it is the outmastoid part of Koerner’s septum. representing the base of the triangular zone of attack in posterior tympanotomy (facial recess).which proceeds vertically from the tegmen to the direction of the CP. in a conspicuous number of TBs. Facial recess: the space. Blue line: optical effect obtained when bony walls contain. marking the upper dural limit where the ES can be localised. FN. it may persist as a bony lamina parallel to the lateral aspect of the mastoid process. Koerner’s septum: or petrous-squamosal suture. which has to be opened in order to gain access to the middle ear through the mastoid cavity (posterior tympanotomy). not reflection. anatomical landmark for the identification of the IAC.67
Arcuate eminence: bony overhang of the middle cranial fossa that corresponds to the dome of the SSC. Bill’s bar: crest of the IAC that separates the FN from the SV nerve. and fossa incudis. Light refraction of the short process of the incus: an optic phenomenon due to irrigation fluid that makes this structure visible before it actually appears in the surgical field. liquid (or when they are already thin anatomically. Buttress: thin bony wall inferior to the fossa incudis. COG: a half-moon shaped bony septum located just anteriorly to the head of the malleus. during mastoid development. this septum is reabsorbed more or less completely but. delimited by the CT. or are close to. without reaching it.
. which explains the exteriorisation of antral infection to the overlying subcutaneous tissue in early childhood. Chipault’s cribriform area: a multiply-holed area situated posterior to Henle’s spine for the passage of small vessels. when development is complete. such as normal stapes footplate) as a result of light resorption.
Metallic sound of the burr: a sound variation when a burr – especially a cutting burr – works in close proximity to soft tissue. this separates the superior (FN and SVN) from the inferior (CN and IVN) compartment. such as dura. Transverse crest: in the IAC. Subarcuate fossa: a depression of the posterior aspect of the TB.
. causing the anterior wall to be flat and uniform. Posterior tympanotomy: see Facial recess. delimited between the ponticulus and subiculum. Mickey Mouse technique: a dissection technique of the anterior wall of the EAC (in radical mastoidectomy) which implies first drilling the upper and lower parts of the wall. Sinodural angle-Citelli’s: a mastoid space occupied by cells (lateral and medial) which is found between the mastoid tegmen and the SS. Snake’s eye: the way – as similitude – appears a flat opened dome of the LSC.68 Linea temporalis: an imaginary line that corresponds with the subtle ridge of the inferior edge of the temporal muscle. often identified by its name. hence ATM – which is drilled afterwards. in order initially to avoid the central part of it – the closest to glenoid fossa. Vertical crest: see Bill’s bar. MacEwen’s triangle: a triangular area on the lateral aspect of the TB which corresponds medially to the antral region. accommodating the cerebellar flocculum. Sinus tympani: a depression of the posterior mesotympanum. Tegmen: the bony plate that separates the mastoid and middle ear cavity from the middle cranial fossa dura.
12. 13. 18.
Antrotomy Enlarged mastoidectomy Simple mastoidectomy Isolation of the sigmoid sinus Closed tympanoplasty Closed tympanoplasty with mastoidectomy and posterior tympanotomy Open tympanoplasty (modified radical mastoidectomy) Open tympanoplasty (classic radical mastoidectomy) Petrous apicotomy Cochlear implant Tubal surgery Facial nerve decompression (second and third segments) Facial nerve re-routing Subfacial approach Endolymphatic sac surgery Occlusion of the posterior semicircular canal Labyrinthectomy Transmastoid decompression of the labyrinthine segment of the facial nerve TLB internal auditory canal isolation and exposure Middle cranial fossa epitympanectomy and mastoidectomy Middle cranial fossa decompression of the labyrinthine segment of the facial nerve Middle cranial fossa neurectomy Posterior cranial fossa internal auditory canal exposure
. 14. 11. 17. 21. 20. 15. 19. 22. 23. 16. 6 7 8 9 10.69
1 2 3 4 5.
knife periosteal elevator burrs (diamond.6. from 0. cutting. 0.2. 11 scalpel Rosen needle curette hooks Hartmann cup forceps
.2 mm) suction tip (0.4. 1 cm) malleus nipper Bellucci’s scissors circular saw sickle knife dental excavator No.8-0.
Its stepwise approach will prove useful for both the novice otologist and the experienced surgeon seeking to refresh his or her knowledge. informative didactic sessions. This Manual of Temporal Bone Dissection is highly useful to guide exploration of the temporal bone. Its orientation upon specific surgical procedures. Both the minuscule scale of its vital structures and their convoluted three-dimensional relationships make microsurgery of this region one of the most technically demanding of all operative endeavours. rather than pure anatomy. Unravelling the mysteries of temporal bone anatomy is the foremost challenge faced by every otologist.The temporal bone is an anatomical jewel box of extraordinary complexity. and anatomical dissection proctored by expert microsurgeons. This written resource is an essential element of the three components needed for a high quality surgical dissection course: a lucid manual. enhances its utility for the practising surgeon.
Kugler Publications/ The Hague/The Netherlands