Eur Arch Otorhinolaryngol (2010) 267:1867–1871
DOI 10.1007/s00405-010-1328-6
OTOLOGY
Using greater superficial petrosal nerve and geniculate ganglion
as the only two landmarks for identifying internal auditory canal
in middle fossa approach
Ming-Ying Lan • Jiun-Yih Shiao
Received: 1 April 2010 / Accepted: 25 June 2010 / Published online: 8 July 2010
Ó Springer-Verlag 2010
Abstract The middle fossa approach is a surgical tech-
nique indicated for acoustic neuroma with advantages of
complete tumor removal and hearing preservation. Various
methods have been developed for identifying internal
auditory canal (IAC). Here, we describe a new method,
which uses greater superficial petrosal nerve (GSPN) and
geniculate ganglion (GG) as the only two landmarks to
identify IAC. In this study, the surgical anatomy and
relations between GSPN, GG, petrous ridge, and IAC were
measured on 20 temporal bone specimens and 40 HRCT
scans of normal inner ear structures. The temporal bone
study showed that the GSPN is nearly parallel to the pet-
rous ridge, with an average angle of about 6 degrees. The
line perpendicular to the GSPN from the tip of the GG to
the petrous ridge reaches at the porus acousticus, with an
average distance of 12.95 mm. The temporal bone HRCT
scan study revealed that the length from the tip of the GG
to the midpoint of the IAC portion on the line perpendic-
ular to the petrous ridge is about 9.9 mm. We applied this
method on 20 temporal bones by drilling the point away
from the tip of the GG about 9.9 mm on a line angled with
the GSPN about 96 degrees. All IACs were safely identi-
fied without damaging the cochlea, the labyrinthine portion
of the facial nerve, or the vestibule. In conclusion, the
GSPN and GG can be the only two landmarks for safely
M.-Y. Lan
J.-Y. Shiao (&)
Department of Otolaryngology, Taichung Veterans General
Hospital, #160, Section 3, Chung-Kang Rd,
40705 Taichung, Taiwan, ROC
e-mail: jy_shiao@yahoo.com.tw
M.-Y. Lan
Institute of Clinical Medicine, National Yang-Ming University,
Taipei, Taiwan, ROC
identifying the IAC without injury to the inner ear
structures in the middle fossa approach.
Keywords Internal auditory canal

Middle fossa approach
Acoustic neuroma

Geniculate ganglion
Greater superficial petrosal nerve
Introduction
The middle fossa approach is a surgical access indicated
for various conditions, including vestibular neurectomy,
facial nerve decompression, intracanalicular tumors, such
as acoustic neuromas, facial nerve neuromas, and petrous
bone cholesteatoma [1]. It became popular after House [2]
first introduced this technique in 1961.
House’s approach provides direct vision of the internal
auditory canal (IAC) for possible complete removal of
tumors and while preserving hearing and facial nerve
functions [3]. However, the proximity of several critical
structures without definite landmarks on the superior sur-
face of the temporal bone makes this approach challenging,
even for experienced surgeons [1, 4, 5]. Various methods
thus were developed for identifying the IAC [1].
The technique proposed by House [2] is to identify the
greater superficial petrosal nerve (GSPN) first, followed by
exposing the geniculate ganglion (GG), and the first genu
of the facial nerve. Then, the labyrinthine portion of the
facial nerve is followed to the lateral end of the IAC. This
method endangers the closely related important structures
at the fundus of the IAC [1, 4]. Fisch [6] described the
method of locating the IAC, which lies at an angle 60
degrees anterior to the superior semicircular canal (SSCC).
However, the angle is inconstant and blue lining the SSCC
carries the risk of opening it [1, 4]. Garcia-Ibanez [7]
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identified the IAC by bisecting the angle formed by the
GSPN and the arcuate eminence. However, the arcuate
eminence is not identified in all the cases and the arcuate
eminence is not at the same axis with the SSCC in 48% of
cases [1, 4, 5, 8].
In this study, we present a new and simple method of
middle fossa approach by using the GSPN and the GG as
the only two landmarks to safely identify the IAC without
the risk of damaging the cochlea, facial nerve, and
vestibule.
Materials and methods
Cadaveric temporal bone study
Twenty temporal bone specimens with an adequate portion
of the petrous apex and attached middle fossa dura were
selected. The middle fossa dura mater was detached from
the superior surface of the temporal bone. The GSPN, GG,
and petrous ridge were identified. Digital images of tem-
poral bones from a view from above were taken for mea-
suring the angle h between the GSPN and the petrous ridge
using imaging processing software (Fig. 1a, b). A line
perpendicular to the GSPN from the tip of the GG to the
petrous ridge was drawn and the distance X was measured
(Fig. 1a, c). The Y (width of the porus acousticus) and the
distance Z (from the anterior lip of the IAC to the junction
of the line at the porus acousticus) were also measured
(Fig. 1a, d).
Temporal bone HRCT study
We retrospectively reviewed the HRCT scans of 40 ears in
20 adult patients (10 males and 10 females) with normal
inner ear structures reported by radiologists. Our study was
approved by our hospital’s Institutional Review Board. The
patients had HRCT scans between January 2007 and
January 2008 to evaluate the presence of cholesteatoma,
mastoiditis, a middle ear ossicular chain problem, or
external ear disease. The studies consisted of contiguous
1-mm scans of the temporal bone in the axial planes.
Measurements were taken on picture archiving and com-
munications systems (PACS) terminals with electronic
calipers under magnification. A line perpendicular to the
petrous ridge and through the tip of the GG was drawn on
the axial plane. Three measurements on the line were
obtained. Length A is the distance from the GG to the first
junction of the line with the IAC. Length B is the distance
from the GG to the porus acousticus. Length C is defined as
the length from the GG to the midpoint of the IAC portion
on the line (Fig. 2). We used the following formula: Length
C = Length A ? (Length B - Length A)/2.
Statistical comparisons by the Student’s t test were
analyzed by using SPSS 12.0 software. P \ 0.05 was
considered statistically significant.

Fig. 1 a The drawing of

temporal bone measurements.
(X distance from the GG to the
petrous ridge on the line
perpendicular to the GSPN,
Y width of porus acousticus,
Z distance from the anterior lip
of IAC to the junction of the
line at the porus acousticus.)
b Digital image of temporal
bone from middle fossa view
was taken for measuring the
angle between the GSPN and
the petrous ridge. c The line
perpendicular to the GSPN from
the GG to the petrous ridge was
marked in black and the
distance X was measured. d The
line was extended from middle
fossa to the porus acousticus
where Y and Z were measured

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Table 1 Temporal bone measurements results

Temporal bone h (degrees) X (mm) Y (mm) Z (mm) Z/Y

1 8 11 8 6 0.75
2 4 11 11 8 0.73
3 7 12 7 4 0.57
4 4 13 9 8 0.89
5 4 12 8 3 0.38
6 1 16 9 6 0.67
7 3 10 8 6 0.75
8 7 14 9 6 0.67
9 10 15 9 2 0.22
10 8 12 11 4 0.36
Fig. 2 HRCT scan of axial cut through the midportion of the IAC. 11 -5 14 10 6 0.6
Three measurements on the line perpendicular to the petrous ridge 12 6 13 8 3 0.38
were evaluated. Length A is the distance from the GG to the first 13 15 14 10 3 0.3
junction of the line with the IAC. Length B is the distance from the
GG to the porus acousticus. Length C is the distance from the GG to 14 7 13 10 3 0.3
the midpoint of the IAC portion 15 5 14 9 2 0.22
16 7 14 12 8 0.67
17 8 13 9 4 0.44
Results 18 11 15 12 1 0.08
19 4 12 11 9 0.82
Cadaveric temporal bone study
20 6 11 11 9 0.82
Mean 6 12.95 9.55 5.05 0.53
The mean angle h between the GSPN and petrous ridge is
SD 3.94 1.57 1.43 2.48 0.24
6 degrees. This means that the GSPN is nearly parallel to
the petrous ridge. A line perpendicular to the GSPN from h Angle between the GSPN and the petrous ridge, X distance from the
GG to the petrous ridge on the line perpendicular to the GSPN,
the tip of the GG to the petrous ridge was drawn and the
Y width of porus acousticus, Z distance from the anterior lip of the
distance X was 12.95 mm on average. All the lines ended at IAC to the junction of the line at the porus acousticus, Z/Y ratio
the porus acousticus. The porus acousticus width (Y) was between Z and Y
about 9.55 mm. The distance Z from the anterior lip of the
IAC to the junction of the line at the porus acousticus was Table 2 Measurements of lengths of A, B, and C on the temporal
about 5.05 mm; the ratio between Z and Y was 53% bone HRCT scans
(Table 1). Male Female t test All

Mean SD Mean SD P value Mean SD Min Max

Temporal bone HRCT study
Length A 6.11 0.76 6.63 0.76 0.036 6.37 0.80 5.1 7.81
Three measurements on the line perpendicular to the pet- Length B 12.93 1.15 13.93 0.96 0.005 13.43 1.16 11.25 15.82
rous ridge and through the tip of the GG were obtained. Length C 9.52 0.85 10.28 0.77 0.005 9.90 0.89 8.26 11.6
The mean values of lengths A, B, and C were 6.37, 13.43,
and 9.9 mm, respectively (Table 2). There were no sig-
nificant differences in the measurements of the lengths of Discussion
A, B, and C between the left and right (P [ 0.05), but there
were significant differences in the three measurements Since the introduction of microsurgery, the mortality rate
between male and female patients (P \ 0.05). of acoustic neuroma surgery has reduced [2]. This may also
From above the temporal bone and the HRCT studies, partly be because of the popularity of magnetic resonance
we can conclude that the IAC can be safely identified at the imaging nowadays, which helps to detect acoustic neuro-
point which is about 9.9 mm away from the tip of the GG mas at an early stage. The aim of the surgery for acoustic
on a line angled with the GSPN at about 96 degrees neuroma is not only tumor removal but also hearing pres-
(Fig. 3). We applied this method on the 20 temporal bone ervation [1, 4]. The middle fossa approach is a technique
specimens and all the IACs were safely identified without which can achieve both. It provides direct vision of the
damaging the cochlea, the labyrinthine portion of facial IAC, while makes complete removal of the tumor and
nerve or the vestibule. preservation of hearing possible. However, the complex

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Fig. 3 The IAC can be safely identified by dissecting a point which is
about 9.9 mm away from the GG on a line angled with the GSPN
about 96 degrees
anatomic structure of the middle cranial fossa makes this
approach seem to be difficult.
Although various methods have been developed to
identify the IAC in the middle fossa approach, all have
their disadvantages. House’s method endangers the closely
related important structures at the fundus of the IAC,
including the cochlea and facial nerve [1, 4]. Fisch’s
method may have problems of an inconstant angle between
the IAC and the SSCC, and the possible opening of the
SSCC [1, 4]. Garcia-Ibanez identified the IAC by bisecting
the angle formed by the GSPN and the arcuate eminence
[7]. However, Kartush et al. [8] found that only 50% of
their cases had an arcuate eminence. Sennaroglu et al. [5]
revealed that an arcuate eminence was not present in 30%
of their cases. Therefore, its role as a reliable landmark for
identifying the IAC is questionable. Catalano et al. [9]
proposed to open the tegmen to find the malleus head as the
first landmark for the middle fossa approach. This method
has the potential risk of CSF leakage, meningitis, and
conductive hearing loss, especially unsuitable for patients
with middle ear infection [4, 5].
In order to safely identify the IAC without risk of
harming the cochlea and facial nerve, in our study we used
the only two easily identified landmarks of the middle
cranial fossa: the GSPN and GG. From our results above,
we know that the GSPN is nearly parallel to the petrous
ridge, with an average angle of about only 6 degrees. The
line perpendicular to the GSPN from the tip of the GG to
the petrous ridge ends at the porus acousticus. This means
that if we trace backwards from the end of the line at the
porus acousticus, we can identify the location of the IAC
quite definitely. To determine the point to start drilling by
this method, we made some further measurements on the
HRCT scans of 40 ears. As already mentioned, based on
our cadaveric temporal bone study, the GSPN is nearly
parallel to the petrous ridge. Because the GSPN is not
easily identified on the HRCT scan in some cases, we drew
a line through the tip of GG and perpendicular to the pet-
rous ridge, instead of the GSPN. Our results showed that
the length from the tip of the GG to the midpoint of the
IAC portion on the line is about 9.9 mm, nearly 1 cm.
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Eur Arch Otorhinolaryngol (2010) 267:1867–1871
Accordingly, the IAC can be safely identified by dissecting
a point which is about 9.9 mm away from the tip of the GG
on a line angled with the GSPN, by about 96 degrees
(Fig. 3).
To determine whether this method is feasible and safe,
we applied it on 20 temporal bone specimens. All IACs
were found without damaging the cochlea, the labyrinthine
portion of facial nerve or the vestibule. This proved that the
GG and GSPN are reliable surface landmarks for locating
the IAC in the middle fossa approach with potential to
preserve hearing and facial nerve function. Besides, since
we use the tip of the GG as a landmark, instead of drilling
out the whole GG, this reduces the risk of injury to the
motor function of the facial nerve.
Interestingly, our data showed that there is a significant
difference between males and females on the three mea-
surements of the line from the GG perpendicular to the
petrous ridge. Preoperative measurements on the HRCT
scan thus can help to locate the precise point for dissecting
the IAC safely for each individual.
With the advancement of computer science and medical
instrument, an image-guided navigation system is now
widely applied in various surgical fields. Although it can
also be used for identifying IAC during surgery, it is still
not available at all hospitals. We believe that the easily
approached surgical landmarks, like the GSPN and the GG
we used in this study, not only helps surgeons locating
important structures during surgery, but also are useful for
young residents at temporal bone dissection courses. In
order to clarify the method more cleary, we made a short
movie which can be accessed on http://www3.vghtc.gov.
tw/ent/OTHERS/middle_fossa.MPG. We believe this
method can help surgeons to locate IAC more easily and
safely.
Conclusion
The present study provides a new and safe way to locate
the IAC in the middle fossa approach which preserves
hearing and facial nerve function.
Conflict of interest statement None.
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