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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
Kugler Publications is an imprint of SPB Academic Publishing bv.com website: kuglerpublications. Box 97747. 2509 GC The Hague. microfilm.IV ISBN 90 6299 190 4 Distributors: For the USA and Canada: Pathway Book Service 4 White Brook Road Gilsum. No part of this book may be translated or reproduced in any form by print. photoprint.O. The Netherlands Telefax (+31.70) 3300254 E-mail: info@kuglerpublications. The Netherlands . NH 03448 USA Telefax (603) 357 2073 For all other countries: Kugler Publications P.com © Copyright 2002 Kugler Publications All rights reserved.O. or any other means without prior written permission of the publisher. Box 97747 2509 GC The Hague. P.
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.
VI 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
which is generally manipulated before working on the bone. it should only be taken as a guide and not as a substitute for the many obligatory laboratory dissections. . In fact. the progress in otosurgery as well as the more frequent cooperation with neurosurgeons. It is also a stimulus for a deeper look at the surgical techniques in the major otosurgical textbooks. make this type of exercise very useful. etc. which allows for air exchange. since it will sooner or later become saturated with noxious agents (fixatives. 1. However. A proper sitting position is advised during the dissection. Fig. The only difference lies in the lack of soft tissue.). bone dust. and thus to be initiated into ear surgery. Hints ! Before starting on the topic.1 INTRODUCTION This manual is for ENT specialists/residents wishing to deal with surgical dissection of the temporal bone. 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. 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.
with both feet (heels included) fully in contact with the floor. • maintain a proper sitting position. suction-irrigation system. • protect yourself against potentially infectious materials by dressing correctly (waterproof gown. • before starting. mask.2 Fig. The instruments should be handled correctly. ear plugs!). Superior view Lateral view Fig. with a firm point. glasses. surgical microinstruments. 2. . 1-2). drill. wrist) (Fig. familiarise yourself with the laboratory instruments: operating microscope. leaning against the back of the chair. 3. Topographic terminology always has to be used in a proper way. and both hands on a firm point (little finger.
some delicate anatomical structures (dura. 4). anterior: towards the nose. • manoeuvre personally the drill pedal and do the same in the operating theatre. • topographic terminology is of the utmost importance and must always be used correctly. superior: towards the vertex. Leave your dissection position as clean as you found it (Fig. but 300 or 350 mm are often used in neurotology and skull-base surgery. Clean the microscope (being careful with the lens). . it is better to fix the bones by freezing. The focal lens should be 250 mm in the laboratory. internal carotid artery) are more resistant than expected. 5). over time. and any other instruments used. burrs. and should not prevent use of the specimen: this can also depend upon the poor fixation or storage of the bones. prostheses. • think (and talk) in millimetres regarding the size of surgical instruments (hooks. magnification can be reduced and the focus will be maintained or be adjustable with minimal micromovements (Fig. use the biggest burr possible in every dissection region. jugular bulb. sinus) are possible. sigmoid sinus. i. • unintentional holes in specific parts of the temporal bone (dura. When using a standard operating microscope.and micromovements. in vivo. posterior: towards the nape. it is better first to select the highest magnification (usually 40x). since. before looking through it.. without overtightening it. medial (or internal or deep): towards the brainstem (Fig. Remember that. • take into account the possible anatomical variations from one bone to another in different dissections.3 • always follow the same steps during each dissection. its mechanical characteristics could be altered. burrs). It is obviously important to correct for visual defects and interpupillary distance. inferior: towards the feet. it must be checked for the motility of each arm. 3). and middle ear anatomical structures.e. If you are responsible for bone collection. In order to get rapidly in focus. lateral (or external or superficial): towards the external meatus. using macro. Once focused on an object.
4 Fig. You must be familiar with mounting and dismounting the burrs of all the systems at your disposal. since familiarity with the technology and instruments helps to enrich the cultural baggage of the otologist. Two main types of burr are generally used: cutting (Fig. 7a) or diamond (Fig. In general. electrical. 4. . only electric drills allow the burr to rotate both clockwise and anticlockwise. as well as increasing his profile in the operating theatre. Dissection bench. The drilling system can be threaded. 6). 5. Fig. 7b). or pneumatic (Fig. Operating microscope.
Although diamonds last forever. When using an electric drill. or when a bony bleeding point has to be stopped (only in live bones!). closing the vascular channel with the bone dust produced (momentarily stopping irrigation). Fig. to avoid uncontrolled movements which make the burr hit an im- . Hence the need for continuous irrigation to avoid overheating. 7b. b. 7a. A cutting burr is made of multiple blades. the more stable the burr.5 Fig. sigmoid sinus or jugular bulb. to reduce the cutting power (better to select a diamond burr). They are generally used in proximity to or in contact with soft tissues (dura. 6. facial nerve (FN)). Pneumatic drill. but the less well it cuts. Diamond burrs work by saucerising and thinning the contacted surface. the glue which binds them to the steel ball does not. Cutting burr. Fig. more or less close to each other: the greater the number of blades. Diamond burr. in some cases it is necessary to make the burr rotate anticlockwise for a two-fold purpose: a.
The movements must be slow. remember to use the largest burr at your disposal in relation to the region to be dissected. during antrotomy. cochleostomy. the lateral face (shoulder) of the burrs must always be used. portant structure (e. . Whenever possible. repetitive. in a right ear. 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. 8a-c). ho-mogeneous. it must be used in the opposite direction to the rotation.g. 8a-c. regular strokes. in order to increase the friction (and hence the cutting power) of the blade on the bone. in order not to have vision impeded by the collecting fluids. The handpiece of the drill should be handled like a pen with obvious individual differences (Fig. When a cutting burr is used. part of internal auditory canal (IAC) skeletonisation). NEVER THE TIP! which is unstable. platinotomy. not fast or jumpy. Finally. thus reducing efficacy. The hand piece of the drill as well as instruments have to be handled like a pen. it is preferable to position the suction medially (deeper) to the working site. by avoiding accumulation of bone dust between the blades (for cutting burrs only). the short process of the incus). Apart from a few exceptions (blockage of a bleeding point. Suction-irrigation must be adjusted from the start: its perfect combination will ease the dissection work.. using continuous.6 Fig.
Orientation of the TB specimen is achieved by using surface land- Fig. Fig. 9). . 9. A right temporal bone placed in a bone-holder in the surgical position. Bone-holder. 10.7 LATERAL (TRANSMASTOID) APPROACH The temporal bone (TB) must be placed in a bone-holder in the surgical position (Fig.
jugular bulb). situated in the most posterior area of the mastoid process. vertical intrapetrous segment of the internal carotid artery (ICA). visible on the surface at the level of the postero-superior wall of the EAC. • the mastoid tip (T). a small bony crest. • Chipault’s cribriform area. epitympanectomy). with its muscular attachments. a scalpel or even by drilling. it is always exciting. Abbreviations 2. Glossary . 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). more or less pronounced. All the soft tissues covering the lateral surface of the mastoid process must be removed with a knife periosteal elevator. located superior to the external auditory canal (EAC). The following landmarks appear: • the EAC.8 marks: the zygomatic process (ZP) of the TB. located inferiorly (Fig. The dissection will then continue with clinical applications. to know how to reach the nerves within the IAC! At the end of this manual. and the mastoid tip (T). an operation which today is only rarely performed in otosurgery. 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. posterior tympanotomy. there is a rapid guide to: 1. They will progress from a dissection centred on a ‘closed’ technique (enlarged mastoidectomy. • the mastoid emissary vein (EV) orifice. 10). for those who are learning. a multiply-holed region posterior to Henle’s spine. to an ‘open’ technique (lowering of the EAC). which only pathological processes or neurootological approaches need to expose in practice (cochlea. • 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. ending with the translabyrinthine identification of the IAC: although conceptually far from this phase of surgical application.
Instrumentation Moreover. 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 .9 3. Surgical applications of the dissection 4.
In simple mastoidectomy. • A line perpendicular to the linea temporalis (B). to the ZP (taking as its anterior limit the anterior wall of the EAC). antri. which runs vertically. .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. Hence. t. and t. as well as anterolaterally. from the temporal line in the direction of the mastoid tip. as a line that is prolonged posteriorly from the zygomatic process of the TB. behind the SS. epitympani. 11a-b): • The temporal line (linea temporalis) (A). parallel to the posterior wall of the EAC. and inferiorly. the bone separating mastoid and middle ear cavities from the middle cranial fossa (MCF) dura. • An oblique line (C) which unites the previous two and which corresponds roughly with the projection and direction of the sigmoid sinus (SS). since a large amount of bone dust is produced during this step of the dissection. In enlarged mastoidectomy. the bony removal has to be extended posteriorly. the tegmen is specifically defined as t. to the mastoid tip. which covers the various superficial cell groups. roughly corresponding to the tegmen. Start the dissection with a large (8-mm) cutting burr and profuse irrigation with a large-calibre suction tip. this is carried out within a triangular area (MacEwen’s triangle) delimited by (Fig. mastoidei. demarcated by a subtle ridge formed by the inferior edge of the temporal muscle.
Fig. A triangular area (McEwen’s triangle) on the lateral mastoid aspect is traced with a cutting burr. The dark area marks the cortical mastoidectomy.11 a b Fig. b. 11a. . 12.
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!). such as tegmen. without relying on personal mnemonic capabilities. and postero-inferiorly by the SS. including the tip (pars petrosa) These two portions are separated by the petrosquamous septum (Koerner’s). located superiorly. perisinus: subdivided into lateral. Three areas can be distinguished in the mastoid region: 1. antrum. diploic. FN. In order to memorise the nomenclature of the different cell groups more easily. . d. b. Peripheral area: including five groups of cells: a. simply refer to the constant presence of some anatomical landmarks. SS. tegmental: close to the tegmen. after the first few months and in adults.12 Phase 2: Opening of the superficial mastoid cell system Before starting this step. as a single cavity or a group of cells. labyrinthine block. 3. superiorly limited by the tegmen. medial. the distribution of cell groups within the mastoid cavity must be remembered. the latter two with a few cells limited to the antrum and the central cell tracts. Two main areas can be distinguished: • anterolateral (pars squamosa) • posteromedial. but at times can remain imperforate. retrosinus (superior and inferior) and presinus. a bony lamina which is usually reabsorbed. partly divided by Koerner’s septum. perifacial. c. sinodural: occupying the posterosuperior corner of the mastoid. 13). and is laterally delimited by the squamous portion. and mastoid tip (Fig. Antrum: a large space which communicates – through the aditus – with the posterior epitympanum. 2. it can be pneumatic. Central area: extending inferior to the antrum. or sclerotic.
13 Fig. Removal of the mastoid cortex. A cutting burr should always work with its lateral face (shoulder). 15. Fig. 13. . 14. Fig. Sagittal drawing of the mastoid cavity.
a space may be encountered that is limited medially by a bony lamina.14 e. retrofacial: often as an isolated individual cavity. which. become metallic. h. especially in the pneumatic (cellular) mastoid. Once the mastoid cortex has been exenterated (Fig. f. g. remembering that the sound of the working burr may change. as in congenital aural atresia. infralabyrinthine.e. in the early stages of mastoid development. i. In fact. 15). each with its . perilabyrinthine: – superior prelabyrinthine – translabyrinthine or infralabyrinthine – supralabyrinthine or petrous crest – retrolabyrinthine superior or retrolabyrinthine. precochlear or inferior prelabyrinthine. Once removal of the superficial mastoid cells has been completed. in which the burr can work more easily in contact with its shoulder (Fig. before reaching the deeper ones. when more than one group of adjacent cells is opened. which is either continuous or has a narrow passage. 14). i.e. is represented by the tegmen. When approaching the tegmen or the SS. the bone becomes more fragile and the burr works more effectively. This is the petrosquamosal septum. this will definitely mark the upper limit of the dissection in TBs of any type. Drilling can continue with a slightly smaller cutting burr (6 mm) and with a suitable suction tip. a larger cavity is created. mastoid tip: separated by the posterior belly of the digastric muscle into medial and lateral cells. it is advisable to use a diamond burr of the same size. the bony lamina that separates the mastoid cavity from the dura of the MCF. known as Koerner’s septum. i... which can be confused with the compact bone of the lateral semicircular canal (LSC). separates the lateral (squamosal) from the medial (petrosal) part of the mastoid. At this point. By identifying the tegmen (roughly corresponding to the linea temporalis) and isolating it in its postero-anterior course. including malformed TBs. the most important anatomical landmark. situated medially and inferiorly to the vertical (mastoid) segment of the FN.
considering how superficial the dissection still is.and infra-antral lateral pre. An incompletely reabsorbed Koerner’s septum (KS). 17): superficial supra. 16.and retrosinus lateral tegmental lateral tip . Lateral cells Fig. 16). the following cell groups have been opened (Fig. 17.15 Fig. After finishing Phase 2. Verification of the close anatomical relationship between antrum and LSC helps the novice to find his or her way. own cell groups and communicating independently with the antrum (Fig. Cortical and lateral mastoid cells have been exenterated.
18. The short process of the incus is first visualised (b) by refractive effect of the irrigation liquid. not to open the LSC. causing what American authors call ‘snake’s eyes’: two small holes on the dome of the LSC (Fig. especially in sclerotic bones. 18). a smaller-sized burr should be selected (4-5 mm or less). the second landmark to be exposed. in order to better visualise the antral cavity. the dissection continues by drilling the anterolateral and superolateral cells. the dome of which may be violated by mistake. before being visible in the surgical cavity (a). is the body with the short process of the incus. after the LSC. Obviously. Fig. In order to complete antrotomy. ‘Snake’s eyes’ as a result of the opening the dome of the LSC. 19. between the posterior and superior walls.16 Phase 3: Opening of the deep mastoid cell system and antrotomy After having opened Koerner’s septum. Stagnation of the irrigation fluid during drilling often causes this structure to be visualised Fig. Care should be taken. . It is of the utmost importance to drill the most medial portion of the EAC.
which is brighter than the surrounding bone. Both superficial and deep cell groups will thus be drilled out (Fig. 20. exposing the tegmen antri. 20). Fig. can be considered finished when the following are visible: • the short process of the incus and fossa incudis. occupied by whitish tissue resembling cholesteatoma or epidermisation (this is the posterior ligament of the incus). which must be at the same level as the tegmen mastoidei. • the superior aspect (roof) of the antrum. a compact. . posteriorly and superiorly. 19). erroneously considered to be the end of hurried dissection sessions. This phase. • the dome of the LSC. mat bone. All the mastoid cells have been exenterated.17 (b) – by light refraction – before it is in fact visible in the surgical cavity (a) (Fig.
The sigmoid sinus (SS) has been skeletonised. reaching the jugular bulb (JB). SDA= Sino-dural angle (Citelli’s). 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). This is the first delicate step of the dissection and needs particular care. and exposure of the jugular bulb Retaining some of the perisinus cells already drilled during the previous phases for reference. performed by alternating cutting and diamond burrs in order to optimise time and quality of the dissection. Fig. in some bones. where the SS meets the MCF dura. thus obtaining exposure of the sinodural angle (Citelli’s) (SDA) after drilling out the lateral and medial sinodural angle cells (Fig. Working with a cutting burr (6 mm). In the central part of the SS. Skeletonisation of the posterior wall of the SS consists of the removal of retrosinus cell groups. at the posterior cranial fossa dura level. 21.18 Phase 4: Skeletonisation of the sigmoid sinus. 21). . One important landmark is represented by the opening of the superoanterior part of the SS. the dissection continues by opening the cells placed posteriorly and laterally to the SS. posteriorly. 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!). opening of the retrofacial and medial tip cells.
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. The retrofacial cells (RFC) give access to the jugular foramen area. lateral and medial tip cell groups are delimited by a tangential line passing through the posterior belly of the digastric muscle (DM). SS= Sigmoid sinus. At this level. to be isolated (Fig. Fig. and inferior retrosinus cells have been opened. The insertion of the posterior belly of the digastric muscle (DM) at the mastoid tip level. 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). CT= Chorda tympani. 23. medial. Once all the lateral. This step is also very delicate . 22.19 Fig. the dissection continues towards the mastoid tip. Fig. 23). superior. 22). FN= Facial nerve. located at different heights with respect to the inferior wall of the EAC. Isolation of the jugular bulb (JB). 24.
in the majority of TBs. Only diamond burrs. which are of the utmost importance during the approach to the inferior and posterior walls of the tympanic cavity and. to the petrous apex (Fig. medial and inferior to the third vertical segment of the FN. the venous wall is very fragile (more fragile than in live bones!). while the bony tissue around the JB is brownish in colour (due to the bone marrow). 24). of smaller and smaller calibre (from 5 to 3 mm) should be used. . subsequently. often fused in one cavity only: the retrofacial cells (RFC).20 since. it is possible to visualise a group of cells. At this point.
21 Phase 5: Posterior and anterior epitympanectomy This step. no complications should be expected. it is absolutely essential to carry out a corrective osteo-(chondro)plasty. which is of extreme importance. or if pathological processes such as cholesteatoma have eroded it. which it is preferable not to perforate. the short process. while at the upper and lateral levels of the dissection.e. 25): a. passing from the more fragile to the more resistant bony parts.. Sometimes. CWU) tympanoplasty (TPL) which. the incudomalleolar (diarthrodial) joint. but the skin of the ear canal remains intact. i. 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. the main element that separates the posterior epitympanum from the anterior one. the skin is missing or has been elevated as a flap. b. on the other hand. It is wise to carry out the most delicate opening of the posterior epitympanum with smallsized diamond burrs. It consists of progressive widening of the superoposterior access to the tympanic cavity already started with the antrotomy. d. and superior ligament of the incus. These are not. If this occurs. if. it is possible to visualise membranes around the ossicles or the bony epitympanic walls. fibrotic reactions to in vivo inflammatory processes. concludes – in its initial part limited to the posterior epitympanum – the surgical approach in a closed (canal wall up. It is very important to carry out a complete removal of the mastoid cortex: this will allow the antrotomy to be widened progressively mediolaterally. c. 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. Opening of the posterior epitympanum will allow the following to be visualised (Fig. does not usually have to be completed with a posterior tympanotomy. part of the head of the malleus with its superior ligament. the superior surface of the posterior aspect of the COG. body. but rather mucosal folds (anterior malleal fold. posterior . as one might think. in the absence of cholesteatoma. It must be remembered that. by opening the epitympanic space.
I= Incus. Opening of the anterior epitympanum is generally needed when a pathological process has invaded it. a conservative approach to the middle ear. 25. incudal fold. 26). as well as influence the development and extension of cholesteatoma. M= Malleus. The dissection continues with an extension of a closed TPL. Fig. LSC= Lateral semicircular canal. Removal of the incus and head of the malleus and demolition . malleal fold. Posterior epitympanectomy is completed. I= Incus. as well as COG demolition. 26. such as tegmen or incus erosion.22 Fig. M= Malleus. They are particularly visible in well-preserved bones (Fig. Mucosal folds around the ossicles in the posterior epitympanum. stapedial fold (Proctor)) that delimit and direct air flows and mesotympanic and mastoid ventilation. as in the case of a cholesteatoma which may already have induced local damage.
the whole epitympanum is opened. TT: Tensor Tympani tendon. located superiorly to the tubal orifice. . towards the tegmen. through the posterior tympanotomy. in order to avoid involuntary luxation or fracture of the stapes crura or footplate. The close relationship between the supratubaric recess. drilling it inferosuperiorly. Once the posterior epitympanum has been freed from this part of the ossicular chain. in order not to damage the neighbouring structures. Once the COG has been eliminated.5-1. tubal orifice. Disconnection of the upper ligaments of both ossicles is rather easy to perform using small hooks.0 mm) diamond burr. 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. thus giving sight of the protympanum or supratubaric recess. COG becomes visualised. After removal of the ossicles from the posterior epitympanum. Both ossicles are firmly anchored. 27a-b). of the COG (if still intact) by drilling. The incus has to be separated from the stapes head. Its removal must be carried out with a small (0. 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. 27a-b. and their removal should be carried out cautiously. The COG is a bony crest. the posterior aspect and inferior edge of the COG are visible (Fig. and semicanal of the tensor tympani muscle should be taken into consideration.23 Fig. with possible bad functional consequences. generally half-moon shaped. are essential steps in order to gain access to the anterior epitympanum. inserted into the tegmen with an irregular inferior concavity.
Fig. FN decompression. progressive. his/her effective capabilities are clearly visible. This thinning out must be performed by first using cutting burrs (6 mm). Its application ranges from closed TPL (in which the posterior wall of the EAC remains intact) to cochlear implant surgery. . which – under continuous irrigation – must work homogeneously supero-inferiorly or vice versa. Thinning of the posterior EAC wall can be controlled visually – after removal of the overlying skin – putting the suction tube in the EAC. 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.24 Phase 6: Posterior tympanotomy (facial recess) Learning this step gives the otosurgeon (or. at least. first of all. For its proper performance. which should be visible (by transparency) first laterally and later medially. Thinning out the posterior canal wall (EAC) is the first step in posterior tympanotomy. until the mastoid cavity and middle ear cleft are separated by only a very thin bone (Fig. 28). the middle-ear otosurgeon) his/her identity card and driving licence: when correctly performed. insertion of some types of semi-implantable hearing aids. latero-medial thinning of the posterior wall of the EAC should be carried out. 28. using wide movements.
29a. The space between CT and FN has been entered and posterior tympanotomy completed. Fig. delimited antero-laterally by the chorda tympani (CT). 29c. Drawing showing the relationship between posterior canal (EAC). 29a-b-c). which supports the short process of the incus (Fig. . while the most medial part (where the facial recess is located) is still very thick. posteromedially by the vertical segment of the FN. This fossa is always occupied by a whitish tissue (the posterior incudal ligament) which can be confused with epidermisation. it will be possible to open a triangular bony space. after a simple mastoidectomy. With this procedure. Fig. after uniform thinning of the posterior EAC wall. chorda tympani (CT) and facial nerve (FN) when performing posterior tympanotomy.25 Fig. greater thinning of the lateral part of the posterior EAC wall has already been carried out. It is important to bear in mind that the lateral limit of posterior tympanotomy – the chorda tympani – coincides anteriorly with the fibrous annulus and. 29b. and superiorly by a bony lamina (buttress) that separates it from the fossa incudis. It will be appreciated that. Chorda tympani (CT) and facial nerve (FN) represent two sides of the triangle which forms the facial recess area.
with the tympanic membrane: if the posterior EAC wall is opened more laterally. so that. the facial recess region contains more or less large cell groups. Often. 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. Nevertheless. If a posterior tympanotomy is properly performed and the surgeon tilts the TB anteriorly. while this will only be true after further cell removal.26 hence. remembering that the distance between the FN and the CT at that level is only 2-3 mm. the EAC itself will inevitably be entered and not the tympanic cavity. located in the middle ear rather than in the mastoid area. Once the drilling area of the posterior tympanotomy has been delineated. 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 . the novice should choose a lateral rather than a medial (close to the FN!) approach. or less where the CT emerges from the FN. at times.
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. during the operation. 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. this procedure can now be performed quite safely. In such cases. Remembering (or better still. The second procedure implies the use of a mid-sized (5-6 mm) cutting burr. a small circular saw can be used. whatever the procedure. In fact.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. However. recording) what it was possible to visualise . Instead of using a circular saw. For this purpose. 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. The posterior EAC wall may be lowered by choosing either of the two procedures. it will be possible to make a note of what portion of the posterior mesotympanum it is possible to visualise with an open technique. 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. the resection can also be performed by a small cutting burr. The first option is to section the posterior wall temporarily. to be used from lateral to medial along the whole length of the EAC posterior wall (Fig. proceeding tangentially to the medial aspect of the handle itself. Since a posterior tympanotomy has already been carried out during the previous step. this step must be preceded by elevation or removal of the EAC skin together with the tympanic membrane. depending upon the proposed subsequent surgical sequence. When the lowering of the posterior EAC wall has been completed. the posterior EAC wall has been removed and is later reconstructed. In the TB. superiorly (at the epitympanic level) and inferiorly (at the level where the CT emerges from the FN). so as not to damage the nearby tympanic segment of the FN. 30). This latter technique also has different variants over and above classical or modified radical mastoidectomy. some otologists call a technique ‘closed’ even when.
this region lies medial to the FN canal (vertical or mastoid segment) and anterior to the posterior semicircular canal (PSC). a region which cannot anyway be explored unless otoendoscopes are used. TM= Tympanic membrane. does not allow to see the posterior mesotympanum. . The posterior depth of the sinus tympani is variable. does not permit to see more than a ‘closed’ technique. namely the round and oval window niches. Other than the two major depressions in the posteromedial wall of the tympanic cavity.28 Fig. a ridge stretching inferiorly between the styloid eminence to the posterior lip of the round window niche. through the posterior tympanotomy. In fact. 30. and the subiculum. The ‘open’ technique implies lowering of the posterior canal wall (PW). but perhaps allows a more comfortable use of the instruments. this is the most hidden area of the TB. It lies between the ponticulus. which can only be exposed after destructive steps have been taken. Posterior mesotympanum As mentioned above. 31). the posterior mesotympanum is often named after only one part of it. b. reaching several millimetres in the direction of the ampullary arm of the PSC (Fig. which bridges the gap between the pyramidal eminence and the promontory superiorly. the so-called sinus tympani. it can be concluded that the ‘open’ technique: a.
) . from Schuknecht and Gulya (1986): Anatomy of the temporal bone with surgical implications.29 Fig. with permission. 31. (Modified.
in order to carry out the main steps of this dissection. namely a technique that requires lowering of the posterior EAC wall. the following surgical steps have to be carried out: a.30 Phase 8: Classical radical mastoidectomy If it is true that the clinical indications for a ‘radical’ mastoidectomy are becoming fewer and fewer nowadays. Lowering of the posterior EAC wall (already obtained after the previous phase). Drilling of the anterior EAC wall (AW). At the end of Phase 7. we have a cavity mimicking a modified radical. according to the Mickey Mouse technique popularised by the House Ear Institute in Los An- Fig. However. ossicles). TMJ= Temporo-mandibular joint. Drilling of the anterior canal wall (AW) is an important step during classic radical mastoidectomy. with laterally-based flaps that may be difficult to perform in a cadaver bone. all EAC walls must be freed of skin. and must therefore be part of the technical armamentarium of an otologist. mostly neurootological approaches. it is also true that parts of this surgical technique may be included as steps in other. b. especially in the anterior part. For an optimal ‘radical’. at the same time sparing the existing middle ear structures (eardrum remnants. Moreover. 32. . a classical radical mastoidectomy implies the elimination of all middle ear structures (stapes or footplate excluded).
since they are not directly contiguous with the TMJ. to remove any periannular skin remnants. in vivo. by drilling the central part (Mickey Mouse’s head) (Fig. and afterwards uniting them in the middle. especially at the level of the anterior aspect of the posterior EAC wall and of the inferior EAC wall. The purpose is to obtain a unique plan without any bulging of the anterior EAC wall. . 32). bony ridge lying laterally to the tensor tympani muscle (anterior buttress). at the expense of a solid. 33). of the temporomandibular joint (TMJ) (Fig. Union of the anterior EAC wall with the overlying epitympanic anterior wall. Removal of other bony ridges. This technique – preferably to be carried out with small-sized (1. c. usually without any symptom being experienced by the patient. but only of the pericapsular fibrous tissue. until the marginal bony annulus is exposed medially. it is possible to open the anterior wall in its central portion adjacent to the TMJ. therefore. Drawing showing the Mickey-Mouse technique for drilling of the anterior canal wall. opening this part does not necessarily involve exposure of the TMJ. but it should be remembered that. geles. and.52 mm) diamond burrs – first schedules drilling of the superior and inferior parts of the wall (Mickey Mouse’s auricles). which aims at avoiding direct penetration of the glenoid fossa and. if necessary. 33. hard. d. As already mentioned.31 Fig.
The next phase is the first of three. it is propitious that otosurgeons obtain knowledge of it for at least two reasons: 1. 2. some of which has to be done by removal of the conchal cartilage. since the dissection is medial to the promontory wall. a high jugular bulb) situations.g. to be able to deal with unusual pathological (cholesteatoma eroding the medial wall of the tympanic cavity) or anatomical (e. However. it is important to remember that an essential non-osseous surgical step is represented by meatoplasty.32 Before leaving the ‘radical’ phase.. . namely widening of the outer orifice of the EAC. with both normal and malformed or ossified cochleas. to be familiar with the three-dimensional orientation of the cochlea for cochlear implant surgery. which are not generally included in the dissection steps of basic courses.
g. Preferably with a diamond 1. and superiorly by the inferior border of the basal turn of the cochlea (BCT) (Fig. cholesterol granuloma)..5-2. 34. This step may be carried out by using an alternative. in which a deeper dissection should be continued cautiously. It is perhaps one of the most delicate steps. FN= Facial nerve. Fig. 34). a triangularly-shaped area is delimited. since drilling in the region of the medial wall of the tympanic cavity is delimited anteriorly by the vertical tract of the ICA. The petrous apex (PA) is entered between the internal carotid artery (ICA) and the basal turn of the cochlea (BCT). . by isolating the ‘blue lines’ of the ICA and the JB.0-mm burr. postero-inferiorly by the JB.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. transcanal approach where the antero-infero-posterior EAC walls have to be saucerised after making a superiorly-based tympanomeatal flap.
Looking at the medial wall of the tympanic cavity. before entering the cavity.e. Carrying on. The initial step consists of cochleostomy. since their damage could interfere with the outcome of cochlear implant function. 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. the bone of the otic capsule is very compact and hard to penetrate. a smaller (also cutting) burr is chosen and drilling continues. i. everyone knows that the promontory (a convex area) corresponds to part of the basal turn of the cochlea. being careful not to hit the bony spiral lamina and the basilar membrane located in the posterosuperior pole of the cochleostomy. At this point. the endosteum may first be exposed.. 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. At times. it is possible to widen the hole. and kept in place while slight pressure is exerted. the endocochlear cavity is finally entered at the level of the scala tympani (in laboratory bones. no perilymph leakage will be observed) (Fig. with the burr working perpendicularly to the promontory wall. At that level. with the shoulder and with oscillating strokes). it is possible to try to simu- . If a dummy is available. in accordance with the modalities of cochlear implant surgery. in accordance with the ‘soft surgery’ procedure advised to minimise cochlear trauma. 35a-b). A small (2 mm) diamond burr is placed 1 mm up and 2 mm anterior to the lip of the RW niche.34 Phase 10: Cochleostomy and cochlear visualisation This phase of the dissection contains anatomical and practical elements with respect to cochlear implant surgery. After having created a niche.
of the basal turn of the cochlea. The lateral aspect of the cochlea has been removed and the cochlear turns are shown around the modiolus (MA). CP= Cochleariform process. and the semicanal itself. At this level. and then superiorly in the region which is medial to the pathway between the CP and the semicanal of the tensor tympani muscle. obliquely oriented from bottom to top. RW: Round window. OW= Oval window. With a small (1. 35b. 36. the geniculate ganglion. . before starting with the anatomical dissection of the cochlea.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. ending with the application. posteroanteriorly and mediolaterally (Fig. 36). If magnification is Fig. 35a. remembering the strict relationship between the anterosuperior margin of the apical cochlear area. late its insertion. care should be taken not to penetrate the MCF dura. STTM= Semicanal of the tensor tympani muscle. The arrow shows the direction burr.35 J Fig. cochleostomy is performed. In order to dissect and visualise the entire cochlea. 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). This step is carried out by using a diamond burr.
except for removing a bony obstruction (always use small diamond burrs!. Its lumen is triangular. remember the closeness of the ICA and the possibility of bony dehiscences!). and surrounded by various degrees of pneumatisation. and small dehiscences for the passage of the caroticotympanic arteries. pigmentation of the inner ear structures). 3-5 mm in diameter. Fig. Eustachian tube orifice This is located in the anterosuperior portion of the middle ear cavity. 37). with only a thin bone separating them. unimaginable cochlear structures can be recognised (basilar membrane. 37. tubal surgery is rarely necessary. The entrance of the Eustachian tube orifice (TO) and the tensor tympani muscle (TTM) are shown. 4-6 mm superior to the inferior wall of the hypotympanum and just beneath the semicanal of the tensor tympani muscle (TTM) (Fig. Although proposed by some authors. scala tympani and vestibuli. . The tubal isthmus marks the transition.36 increased to the maximum (40x). with cartilage occupying the anterolateral and superior walls. The bony part lies lateral to the ICA.
due to the constant position of the intrapetrous ICA. and also a soft consistency (Fig. since inferomedial to it (by a few mm). often united in a single. which has been exposed. BCT= Basal turn of the cochlea. The JB represents one of those structures that can have an extremely variable position. TO= Tubal orifice. FN= Facial nerve. An important superior landmark is represented by the eustachian tube orifice. 38). By thinning out this area progressively and uniformly. the dissection previously performed arrives at the exposure and opening of the retrofacial cells. the vertical ICA tract bends and proceeds anteriorly in its horizontal portion.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. . colour variations can first be seen. without movements that are too wide. provided the burr is never stopped. A needle is touching the posterior wall of the vertical. intra-petrous tract of the internal carotid artery (ICA). large cavity. as described at the end of Phase 4. At this point. as far as height and postero-anterior position are concerned. 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. 38. The dis- BCT Fig. Its identification and exposure are generally carried out through a transmastoid subfacial (medial to the third segment of the FN) approach.
it is appropriate to tilt the specimen (in surgery. finding an extreme variability of pneumatisation at this level. at this point.38 section will then proceed anteromedially. It is thus possible to reach and open the petrous apex cells. Once the JB has been identified. the ampullary arm of the PSC. and as its upper limit. When necessary. the operating bed) anteriorly. In order to optimise visualisation of the region to be opened. it is possible to go deeper. the labyrinthine block. . and more specifically. always being careful not to open the labyrinth (PSC). using smaller calibre (1-2 mm) diamond burrs. further drilling of the posterior margin of the cavity should be carried out until this goal has been achieved. the posterior margin of which should not hamper visibility of the anterior regions. the burrs should also have a longer shaft. Apart from being smaller. This manoeuvre will depend upon the degree of dissection of the retrosinus mastoidectomy. having as its lateral limit the third portion of the FN.
this can be useful to avoid damaging it. the FN is visible in its second (tympanic). but definitely separated from it. It is important not to forget that the best method for preventing damage to the FN is always to keep looking for it. 39. in close contact with the FN. Apart from the monitoring systems performed during live surgery. never coagulate! Await its spontaneous remission!). 39). Fig. . at this stage of the dissection. when looking for the nerve. it is uncovered: on the contrary.39 Phase 12: Facial nerve decompression (second and third portions) As shown so far. a soft structure can be seen. CP= Cochleariform process. bleeding along its course (obviously. one sign that should alert the surgeon and make him realise that he/she is close to the FN is the mild. segment. LSC= Lateral semicircular canal. and can be anticipated in its third (mastoid). Isolation of the vertical (mastoid) segment of the FN. the FN represents the structure around which the whole TB dissection rotates. sometimes annoying. drilling with a 5-mm diamond burr under continuous irrigation (facial palsy can also occur when the FN is overheated) (Fig. Another important concept is not to fear facial palsy if. Before carrying out FN decompression. the nerve must be uncovered all along the vertical segment. In the superior segment of the mastoid portion. It is noticeable that. posterior to the fallopian canal.
The stapedial muscle (SM) is found behind the vertical segment of the FN. more inferiorly. 40). since the angle of curvature is not always the same (sometimes it is less than 90°). Once the most poste- . This is the stapedius muscle. this should not be sought at the level of the mastoid tip. In decompression of the tympanic segment of the FN. In order to ensure that drilling is being performed on the digastric belly. 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). it is opportune to expose the entire belly (medial insertion to the mastoid process). The region of the second genu is quite delicate. but 1 cm higher. which may cause bleeding (Fig. 40. while it has a constant relationship with the superolateral dome of the LSC. a sickle knife or dental excavator can be used. which should not be confused with a damaged FN. and. Once the fallopian canal of the third segment has been identified and decompressed. which will appear as a half-moon structure directed posteroanteriorly. a similar decompression should be performed at the level of the second genu and in the tympanic segment. breaking the bone into pieces by putting either instrument under it. it should be borne in mind that at this level the nerve becomes more superficial. the segment which precedes the exit of the FN from the temporal bone through the stylomastoid foramen. the dissection allows the emerging point of the CT to be identified.40 Fig. up to the geniculate ganglion. Inferiorly.
At this point. in glomus tumour surgery or cholesteatoma surgery. the next step is to open the mid-lateral portion of the epineurial sheath (with a sickle knife or No. for example. . 11 scalpel). 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. after setting the medial adherences in the fallopian canal free with a sickle knife or Rosen needle. when removing cholesteatoma that extend medially to the fallopian canal. After isolation of the second and third segments of the FN from the bony canal. leaving the most medial portion intact. thus mimicking anterior rerouting of the FN. like an open book. it is easier to carry out the more anterior part. which is carried out. it will be possible to raise both the second and third segments altogether.41 rior part has been decompressed.
even mimicking a surgical procedure that is still in use today for treatment of Ménière’s disease. 41. an imaginary line which proceeds. towards the SS: this line marks the upper limit of the area within which the ES can lie. PSC= Posterior semicircular canal. In this regard. 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).42 Phase 13: Identification of the endolymphatic sac This is an exciting phase of the dissection. It is thus logical that the preliminary step for its identification is the exposure of the PCF dura situated anterior to the SS. SS= Sigmoid sinus. . Particular Fig. The arrow indicates Donaldson’s line. 41). LSC= Lateral semicircular canal. such as endolymphatic sac decompression or shunt. and which extends inferiorly up to the JB (always remember the not infrequent possibility of a high JB!) (Fig. surrounded upwards and downwards by a lighter or light blue colour. it is necessary to search for a thicker or darker (due to its rich vascularisation) area. The need for such a wide exposure is justified by the extreme variability of position and course of the ES itself. After exposure of the entire PCF dura. tangentially to the dome of the LSC. almost up to the JB. one of the suggested surgical landmarks is represented by Donaldson’s line (arrow). The endolymphatic sac (ES) is isolated as dural duplicature. during which the surgeon returns to large spaces.
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). which is still the ES and not yet the duct (ED). may be close to an anteriorly located SS. it is necessary to follow it cautiously anteriorly. Once the presumed ES area has been identified. . in some TB.43 attention must be paid to not penetrating the PSC which. using a small curette or a small diamond burr on the posteromedial aspect of the PSC.
The labyrinthine block. LSC= Lateral semicircular canal. . their spatial orientation can be estimated. At this point. while the level of the PSC lies halfway to the non-ampullary arm of the LSC. and that their name refers to the orientation of their dome. During drilling of the central part of the SSC. 42). As already noted. while the level of the superior semicircular canal (SSC) is the deepest of the three. It is important to remember that the three SCs are located in the three spatial planes. enables the posterior edge of the posterior labyrinthine block to be reached. PSC= Posterior semicircular canal. being glossy yellow and harder (Fig. Hence. a small channel Fig. but rather at a different depth: the most superficial is the LSC. 42.44 Phase 14: Isolation of the labyrinthine block Drilling of the pre-sinus cells. Isolation of the three SCs is therefore obtained by delineating their tridimensional projection. SSC= Superior semicircular canal. The common crus of the PSC is much deeper. visualised with the antral opening. both colour and compactness of the otic capsule bone differ from that of the surrounding cellular or acellular bone. performed to expose the PCF dura above Donaldson’s line as well. perpendicular to one another. this is represented by the three semicircular canals (SCs). taking into account the dome of the LSC. they are not at the same level.
the tegmen antri). which is a useful landmark for subsequent drilling. Before isolating the SSC. It must be remembered that each SC is surrounded by pneumatised or sclerotic bone. . it is very important to skeletonise the tegmental line thoroughly (at that level. a branch of the anterio-inferior cerebellar artery (AICA). will be encountered. Isolation of the three SCs will be improved after exenterating the perilabyrinthine cell groups.45 containing the subarcuate artery (SA). being situated in its centre. which covers the bony otic capsule. since it is equidistant from the course of the SSC.
change the rotation of the burr. the SCs must be drilled away in the same order. The strict anatomical relationship between the LSC and the FN. In principle. 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. it is directed away from the nerve. by performing careful opening of the PSC. does not get torn (arcuate eminence (AE) in the MCF approach) (Fig. which can start from either the LSC or the PSC. that the dissection should proceed by their total removal. the opening of the SCs must proceed by highlighting – over its entire length – the groove containing the membranous labyrinth. Thus. c. At this point. The LSC may also be the first canal to be opened. must be borne in mind.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. which always lies inferomedial to it. drill on its superior side. From an anatomical point of view. 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. as a thin whitish channel which . which is in close contact with its dome. It is only after having exposed the internal part of the three SCs in this way. Already exposed. as labyrinthectomy proceeds. In order to prevent a cutting burr from damaging the FN. because drilling laterally may jeopardise the FN. so that if it should inadvertently slip. since it is clearly evident in the antral cavity since the first steps of the dissection. which consists of drilling the dome of the PSC and progressive intraluminal blockage with a gelfoam-type material. with attention being paid that the MCF dura. 43). in a right ear. b. it will be possible to see. After having exposed the groove of the LSC and PSC. move the burr on the main axis of the canal. a disputable but codified surgical procedure is being carried out. medially to the PSC. drilling of the SSC should be continued. the anterior prolongation of the ES (intra-osseous portion).
PSC= Posterior semicircular canal. in fact. The subarcuate artery (SA) is a landmark for the dissection of the SSC. The three semicircular canals have been opened. 44). b. courses anterosuperiorly. SA= Subarcuate artery. at which level it turns inferiorly to enter the vestibule. avoid drilling on the antero-inferior portion (ampullary arm) of the SSC: the presence of an intact ampulla is. 43. SSC= Superior semicircular canal. then becoming the thinner ED.47 Fig. which passes medially to the common crus. Fig. 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. 44. an important landmark for future IAC isolation. LSC= Lateral semicircular canal.
45). for the ampullary end of the PSC. lying posterosuperiorly. located anterosuperiorly. Between these two recesses the vestibular crest is located. spherical recess. 2. 2.48 Phase 16: Opening of the vestibule Drilling on the base of the LSC. 3. for the cochlear duct. taking particular care to thin it out close and parallel to the FN. Fig. delimiting the cochlear recess for the vestibular caecum of the cochlear duct. for the stapes footplate (if a needle is inserted through the oval window. 45. for the ampullary ends of the LSC and SSC. accommodating part of the utricular macula. This cavity has four small openings: 1. it is possible to see it where it enters the vestibule). and two depressions: 1. accommodating the saccular macula. 4. will allow the vestibule cavity to be opened and visualised (Fig. as well as to tilt the bone-holder (or the operating bed) anteriorly. which bifurcates posteriorly into two wings. Visualisation of the vestibule (V). elliptical recess. . with the ampullary arm of the LSC (ALSC). lying anteroinferiorly.
decompress the labyrinthine segment (the shortest one. superolaterally by the MCF dura. but also posteriorly. 46). • at the level of the geniculate ganglion (GG). CP= Cochleariform process. thus having only two anchoring points: • its exit at the stylomastoid foramen. but also the most delicate). the greater superficial petrosal nerve (GSPN).49 Phase 17: Identification of the labyrinthine segment of the facial nerve After the previous steps of the dissection. GG= Geniculate ganglion. SSC= Superior semicircular canal. Isolation of the labyrinthine segment of the FN (LFN). not only anteriorly. . Fig. above the cochleariform process (CP). since the nerve can easily be avulsed (Fig. The first aim is reached by decompressing the most anterior part of the tympanic segment (12-13 mm long). the FN is decompressed osteo-epineurially and is lifted from the fallopian canal. 3-4 mm. 2. 46. and posteriorly by the superior prelabyrinthine cells and the SSC. which has to be severed. the following dissection exercises must be performed: 1. opening the space delimited inferolaterally by the tympanic FN. Dissection of the labyrinthine FN should not be hurried. up to the entrance in the IAC. In order to allow its complete mobilisation (re-routing). TFN= Tympanic segment of the facial nerve. identify the GG with its anterior prolongation.
and pull it posteriorly. it will be possible to grasp it with a Hartmann cup forceps. in this segment. . The dissection should then continue medially to the various segments of the FN. the FN is embedded in a very compact bony block which does not facilitate a gradual isolation. as long as the dissection carries on. setting it free from the bony canal. as is possible in the mastoid segment (15-20 mm long). and to carry out a posterior dislocation (re-routing).50 In fact. At the end of this task. for example. but continuous irrigation will enable visualisation to be improved. after sectioning the GSPN anteriorly to the GG with a sickle knife or small hook. Light.
The dissection aims at isolating the IAC for 270° or more. in its posterior. The following consideration should be borne in mind during all phases of the dissection: to hurry a dissection.” Basically. the ampulla of SSC. London (1821-1865). * Anatomist at St George’s Hospital Medical School. It is one of the most delicate and difficult steps. in the area corresponding to the posterior labyrinth (SCs). At this point. A cutting burr cannot avoid this. To make it easier to visualise. However. inferiorly. the orifice of the cochlear aqueduct. remember the definition in Gray’s* English-language anatomical textbook. which has to be completely uncovered. the two other well-codified landmarks for extension and facilitation of the dissection are: a. the bone is very thick and compact. A diamond. and push it medially. in which smaller and smaller diamond burrs have to be used on a more and more compact bone. which states: “If you put a pencil in the EAC. which should not be sacrificed during labyrinthectomy because it is important for identification of the entrance of the FN in the IAC. you will find it in the IAC. if the dissection is brought below this point. the dissection must start posteriorly. b. X and XI cranial nerves). While the posterior limit is delineated by the dural reflection of the PCF with the IAC dura. there may be damage to the pars nervosa of the jugular foramen (IX. superior. mid-calibre (8-10 mm) burr may be used. especially in the case of an inexperienced surgeon. where the posterior edge will delimit the posterosuperior border of the IAC superficially (laterally).51 Phase 18: Identification and opening of the internal auditory canal This is the final dissection on a TB approached from its lateral aspect. as well as analogous cutting ones. and inferior aspects. and gentle pressure should also be exerted during drilling: a diamond burr will avoid tearing the underlying dura. remembering that the position of the IAC is always more anterior than may be realised. superiorly. . the roof of the IAC is represented by the medial wall of the vestibule. is never without danger.
antero-superiorly. • increasing postero-anterior thickness. the burr does not work in the usual (uniform and continuous strokes) way. The dural layer of the IAC is then opened with a small hook. but rather by means of a contact-and-pressure action. Fig. When the bone has been thinned out. and the following four neural elements can be seen (Fig. 4748): • facial nerve (FN). this colour being due to the underlying fluid-immersed tissue. Bill’s bar (BB) divides the facial nerve (FN) from the superior vestibular (SV) nerve. 47. Removal of the two vestibular nerves allows visualisation of the anterior IAC compartment which includes the cochlear (CN) and the facial (FN) nerves. when drilling on the IAC. As has been pointed out above. the entrance of the labyrinthine FN into the IAC – in its superolateral part – can be identified. • cochlear nerve (CN). • the closeness of the soft tissues with possible minor (tearing of PCF or MCF dura) or major (IAC penetration. and sometimes with the tip as well. and • inferior vestibular nerve (IVN) postero-inferiorly. 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. antero-inferiorly. • superior vestibular nerve (SVN). 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. During this step. Once isolation of the IAC dural surface is complete. postero-superiorly. 48. . a ‘blue-line’ may also have been produced.52 Fig.
The various steps of the dissection have been interspersed with true surgical approaches in order to render the dissection more stimulating and interesting.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. which separates the SVN from the IVN. as well as the transverse crest (TC). When this final part of the dissection has been achieved. the lateral approach to the TB is completed. . in the view of the author.
. arcuate eminence (AE).54 SUPRATEMPORAL OR MIDDLE FOSSA APPROACH For this approach. the mastoid tip should point inferiorly. Once fixed in this position. The surface anatomy of the MCF is quite difficult. for a right ear it must then be rotated to the left. correct placement of the TB in the bone-holder may present some initial problems. so that it will be possible to have direct visualisation of the floor of the MCF itself (roof of the TB) (Fig. in a right ear. the GSPN. bearing in mind that the surgical position of the otologist is that of looking down from above. which leaves anteriorly from the GG. located posteromedially. SPS= Superior petrosal sinus. This will be more or less hard. a branch of the FN. corresponding to the dome of the SSC. especially when landmarks are not clearly evident. the dural lining should be removed by lifting it up to the passage from the MCF to the PCF. In order to make it easier. b. The floor of the middle cranial fossa. it is a good idea to rotate the TB in the hands. For example. Fig. 49. depending on the quality of bone preservation. where the superior petrosal sinus (SPS) runs. AE: Arcuate eminence. These landmarks are identifiable as: a. and then upwards. 49).
which occupies a central position on the floor of the MCF. is occupied by the tegmen. which exits from the foramen spinosum positioned in the most anterior part of the surgical field. which lines the superior epitympanic wall (and posteriorly the mastoid part). d. • identification of the FN and GG. In cases of difficult orientation. The most inferior part. a branch of the external carotid artery. it may be necessary to find the way by drilling regions not directly correlated with the surgical objective.55 c. • exposure of the IAC. in a medial projection. the GG. • isolation of the cochlea. covered by more or less compact bone. Anteriorly. sometimes devoid of bone covering. . the eustachian tube can be found. The following phases will be presented: • opening of the epitympanic cavity and of the petrous apex cells. the middle meningeal artery (MMA).
AE= Arcuate eminence. LSC= Lateral semicircular canal. corresponding to the SSC (Superior semicircular canal). Fig. which cannot be removed by a transmastoid approach without violating the labyrinth. MAS= Mastoid cavity. stapes (S).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 Fig. . and tympanic segment of the facial nerve (TFN). 50. Opening of the epitympanum from above allows visualisation of the incudomalleolar joint (IMJ). GSPN= Greater superficial petrosal nerve. GG= Geniculate ganglion. HM= Head of the malleus. The roof of the epitympanum has been removed and some middle ear structures appear. or it may represent a preliminary step in the identification of MCF landmarks. cochleariform process (CP). 51.
apical cells. 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. This also enables the prelabyrinthine. By widening the opening with smaller (2-3 mm) diamond burrs.57 anatomy of the MCF. with care being taken not to penetrate the SSC. 50-51). midcalibre (5-mm) burrs. it is always preferable to use diamond. with continuous irrigation. . to be entered. it is then possible to visualise the stapes and CP.
since opening the epitympanum makes the following possible: • to use the tympanic FN as a landmark. and anteriorly gives rise to the GSPN. 52. superiorly towards the labyrinthine segment. GSPN= Greater superficial petrosal nerve. Identification of the GSPN. gradually thinning out the very compact bone. Isolation of the labyrinthine segment of the facial nerve (LFN). represents the key to the following MCF step (Fig. . • to follow the FN superiorly up to the GG. 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. at times discovered after the dura has been lifted. care should be taken not to fenestrate the SSC. bends medially towards the tympanic segment. under continuous irrigation. As well as any possible damage to the FN. Fig. AE= Arcuate eminence. either covered by a thin layer of bone or exposed. GG= Geniculate ganglion. the FN. Isolation of the FN labyrinthine segment (LFN) must be carried out cautiously.
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. anterior to the GG. and hence to the SPS. 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. posteriorly. 53. Approach 1 Drilling starts directly at the presumed IAC level. The methods of approach depend on the anatomical landmarks used. Conversely. Fig. the latter will first be drilled close to the reflection zone between the MCF and the PCF. The roof and superior wall of the internal auditory canal have been opened. • GG. Considering the major anatomical complexity of the inferolateral part in relation to the superomedial.: • arcuate eminence (dome of the SSC). and with its posterior side on the dome of the SSC.e. but coincides with a large. i. • GSPN. exposing the neural content: cochlear nerve (CN). acoustic tumour removal with hearing preservation). the anterior side is not well defined. ‘mute’ area that extends anteriorly up to the exit of the MMA. facial nerve (FN) and vestibular nerves (VN). inferiorly. 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). .
when proceeding with drilling. Whatever the approach. which separates the FN from the SVN. Drilling has to go deeper superomedially until precise identification of the IAC can be made. anteromedially. anteromedial area. which must be carefully drilled in order to expose the ‘blue-line’ and then to proceed postero-anteriorly to delimit the anterior IAC border. . the initial landmark is represented by the arcuate eminence. at the level of the antero-inferior IAC wall. • the superior vestibular nerve. posterolaterally. particularly recommended in an enlarged MCF approach. takes into account the ‘mute’. drilling can continue towards the fundus of the IAC. he/she will find the cochlear projection which. At the level of the fundus of the IAC. to be exposed.60 Approach 2 In this approach. in order to avoid a functional impairment that should be avoided when choosing a MCF approach. must not be fenestrated. drilling will allow the vertical crest or Bill’s bar. the dome of the SSC. Approach 3 This final approach. 53): • the FN. anterolaterally. similarly to the SSC. the posterior edge of which will coincide with the anterior IAC wall. Thereafter. and • the inferior vestibular nerve. Once the IAC dura has been exposed along its entire course. posteromedially. it will be opened by means of a small hook in order to identify its internal content with (Fig. • the cochlear nerve (CN). the surgeon must be aware that.
FN= facial nerve.61 Phase 22: Isolation of the cochlea For complete knowledge of the supratemporal bone anatomy. CN= Cochlear nerve. 54). This is accomplished by progressive drilling of the postero-superior part of the IAC. the cochlea is exposed. Fig. Drilling anterior to the internal auditory canal. . the dissection can continue by isolating and exposing the cochlea. 54. 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.
a step that cannot be reproduced unless the entire head is available. . laterally.62 POSTERIOR CRANIAL FOSSA APPROACH The anatomy of the posterior aspect of the TB. SF= Subarcuate fossa. JF= Jugular fossa. an irregular depression. it is advisable to reflect on some aspects of the topographic anatomy of the posterior aspect of the TB. IAC= Internal auditory canal. it is obvious that good experience is also necessary with this type of dissection. 55). a fissure is located. SS= Sigmoid sinus groove. can be seen. at the exit of Fig. and foramina (Fig. Bearing in mind the advances in modern neurootosurgery and the frequent contact with neurosurgeons. prominences. which usually follows cerebellar retraction. The posterior aspect of the TB forms a vertical wall. presents difficulties because it uses a route which is unfamiliar to most otosurgeons. higher laterally than medially. a combination of grooves. the operculum (Op). The major indication is for the IAC approach. Before treating IAC landmarks. 55. 10 mm from the IAC orifice. More laterally. the subarcuate fossa (SF). Posterior aspect of the temporal bone. which accommodates the cerebellar flocculum. although not complex. Five or 6 mm. The IAC orifice is located between the medial and the central third of the posterior aspect of the TB.
and from which the extraosseus ES emerges. The internal auditory canal (IAC) has been opened. 56). exposing its neural content. close to the jugular foramen (JF). More medially. .63 Fig. with the mastoid region anteriorly. Op= Operculum. the groove of the SS is visible. JF= Jugular foramen. ES= Endolymphatic sac region. which contains the ED and the intraosseus ES. PSC= Posterior semicircular canal. the vestibular aqueduct. the cochlear aqueduct orifice is located (Fig. 1 cm wide. 56. Posterolaterally to this.
without running the risk of violating the vestibule or the PSC. this aim would not be relevant in such a case. It is extremely important to be cautious in posterior dissections. 57). It is generally possible only to expose the medial two-thirds of the IAC. With small diamond burrs and under continuous irrigation. However. The opened IAC. VC= Vertical crest. since this type of approach is generally selected as a last resort.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. meningioma) arising from the vestibular nerve as the posteromedial landmark. FN= Facial nerve. Once this step has been completed. 11 scalpel or Bellucci’s scissors. VNs= Vestibular nerves. the dissection is started in a lateroanterior direction. the overlying dura has to be cut with a sickle knife and then lifted anteriorly and posteriorly. care must be taken regarding a possible high JB. in order to expose about two-thirds of its circumference (Fig. . Before starting drilling. since it is possible to injure the ES or ED. to fenestrate the PSC. At this same level. in order to open it and visualise its content. CN= Cochlear nerve. drilling should go deeper both superiorly and inferiorly. 57. a longitudinal cut will be carried out with a No. or even worse functionally. Once the posterior wall of the IAC has been identified. Fig.
65 ABBREVIATIONS 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 .
divides the petrous (medial) from the squamous (lateral) cells. Blue line: optical effect obtained when bony walls contain. during mastoid development. Some authors believe that it is the outmastoid part of Koerner’s septum. COG: a half-moon shaped bony septum located just anteriorly to the head of the malleus. a bony septum that. . which explains the exteriorisation of antral infection to the overlying subcutaneous tissue in early childhood. this septum is reabsorbed more or less completely but. in a conspicuous number of TBs. 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. not reflection. without reaching it. when development is complete. or are close to. Novices may be misled and confuse its smooth and compact aspect with the LSC. which has to be opened in order to gain access to the middle ear through the mastoid cavity (posterior tympanotomy). it may persist as a bony lamina parallel to the lateral aspect of the mastoid process. such as normal stapes footplate) as a result of light resorption. Donaldson’s line: the posterior prolongation of a line passing over the dome of the LSC. representing the base of the triangular zone of attack in posterior tympanotomy (facial recess). liquid (or when they are already thin anatomically. Chipault’s cribriform area: a multiply-holed area situated posterior to Henle’s spine for the passage of small vessels.67 GLOSSARY Arcuate eminence: bony overhang of the middle cranial fossa that corresponds to the dome of the SSC.which proceeds vertically from the tegmen to the direction of the CP. Koerner’s septum: or petrous-squamosal suture. marking the upper dural limit where the ES can be localised. In general. Buttress: thin bony wall inferior to the fossa incudis. Bill’s bar: crest of the IAC that separates the FN from the SV nerve. anatomical landmark for the identification of the IAC. FN. Facial recess: the space. and fossa incudis. delimited by the CT.
Transverse crest: in the IAC. Vertical crest: see Bill’s bar. hence ATM – which is drilled afterwards.68 Linea temporalis: an imaginary line that corresponds with the subtle ridge of the inferior edge of the temporal muscle. accommodating the cerebellar flocculum. Snake’s eye: the way – as similitude – appears a flat opened dome of the LSC. Subarcuate fossa: a depression of the posterior aspect of the TB. Posterior tympanotomy: see Facial recess. Sinus tympani: a depression of the posterior mesotympanum. Metallic sound of the burr: a sound variation when a burr – especially a cutting burr – works in close proximity to soft tissue. in order initially to avoid the central part of it – the closest to glenoid fossa. 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. this separates the superior (FN and SVN) from the inferior (CN and IVN) compartment. MacEwen’s triangle: a triangular area on the lateral aspect of the TB which corresponds medially to the antral region. such as dura. . causing the anterior wall to be flat and uniform. often identified by its name. Sinodural angle-Citelli’s: a mastoid space occupied by cells (lateral and medial) which is found between the mastoid tegmen and the SS. delimited between the ponticulus and subiculum. Tegmen: the bony plate that separates the mastoid and middle ear cavity from the middle cranial fossa dura.
12. 13. 18. 19. 6 7 8 9 10. 20. 11. 21. 17. 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 . 23. 22. 14.69 SURGICAL APPLICATIONS 1 2 3 4 5. 16. 15.
11 scalpel Rosen needle curette hooks Hartmann cup forceps .2 mm) suction tip (0. 0.8.70 INSTRUMENTATION knife periosteal elevator burrs (diamond. from 0.2. 1 cm) malleus nipper Bellucci’s scissors circular saw sickle knife dental excavator No. 0. 0.8-0.4.6. cutting.
and anatomical dissection proctored by expert microsurgeons. Kugler Publications/ The Hague/The Netherlands . rather than pure anatomy. This written resource is an essential element of the three components needed for a high quality surgical dissection course: a lucid manual. informative didactic sessions. This Manual of Temporal Bone Dissection is highly useful to guide exploration of the temporal bone.The temporal bone is an anatomical jewel box of extraordinary complexity. enhances its utility for the practising surgeon. Its stepwise approach will prove useful for both the novice otologist and the experienced surgeon seeking to refresh his or her knowledge. 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. Its orientation upon specific surgical procedures. Unravelling the mysteries of temporal bone anatomy is the foremost challenge faced by every otologist.
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