TEMPORAL BONE

DISSECTION
 TEMPORAL BONE DISSECTION

E. Additional Temporal Bone Dissection

General Considerations
Additional temporal bone dissection may be carried out at the
end of the procedure. They represented a transition from
temporal bone to lateral skull base surgery.
In the author’ opinion, these dissections belong within the
curriculum of a modern otologist, who in fact should not
remain a middle ear surgeon, but become a temporal bone
surgeon.
 Subtotal Petrosectomy (SP)

The principle of the SP is the complete elimination of the

pneumatic middle ear cleft associated with the permanent
occlusion of the isthmus of the eustachian tube. The cavity
may be left open or be obliterated (with pedicled muscle flaps
or free abdominal fat grafts). In the latter case, the EAC is
closed in two layers as a blind sack.
There are two types of subtotal petrosectomy, one with
preservation the other with removal of the otic capsule
 Subtotal Petrosectomy with Preservation of the Otic
Capsule

General Considerations
This operation is performed to remove extensive temporal bone
cholesteatomas, adenomas, extensive facial nerve neuromas,
angiomas and Class B paragangliomas. It is also used to seal
congenital CSF leaks and those of a traumatic nature( e.g.
following transverse fractures of the temporal bone), to
introduce CI in sclerotic temporal bones, or when there is a
meningitis risk due to a possible CSF leak.
 Exenteration of Pneumatic Cell Tracts

The cell tracts of middle ear cleft are exenterated in the following
order: retrosigmoid, retrofacial, retrolabyrinthine,
supralabyrinthine, supratubal, infralabyrinthine and
pericarotid.
Most of these cellular tracts have been dealt with when
performing an open MET.
In fact, an open-cavity procedure performed according to the
authors’ surgical principles is a subtotal petrosectomy, with
the exception of the infralabyrinthine and pericarotid cells that
are left intact.
 Surgical site following exenteration of pneumatic cell
tracts and preservation of the otic capsule
The pneumatic cells tracts of the temporal bone (with the
exception of the apical) are removed. To make sure that no
cells are left behind, the jugular bulb and the vertical
intratemporal carotid artery are skeletonized.
The tympanic segment of the facial nerve is also skeletonized
until the geniculate ganglion and greater superficial petrosal
nerve are identified. Note that the labyrinthin segment of the
facial nerve is medial to and covered by its tympanic segment,
and that the proximal tympanic segment and the geniculate
ganglion form a border between the supratubal and
supralabyrinthine recesses. The otic capsule and, therefore,
inner ear function are preserved.
Pericarotid cells and obliteration of the eustachian tube
The vertical segment of the intratemporal carotid artery (ICA) is
exposed to the bend indicating the beginning of the horizontal
segment. Note that the isthmus of the eustachian tube is below
and anterior to the ICA. The semicanal of the tensor tympani
muscle covers part of the posterior aspect of the horizontal
segment of the ICA. Remember that the ICA may be dehiscent
alonf the medial wall of the protympanum. The anterocarotid
pneumatic cells can extend into the pyramid apex, and their
exenteration may require precise work with a diamond burr.
When all pericarotid cells are exenterated, the isthmus of the
eustachian tube is ready for obliteration with bone wax.
Subtotal Petrosectomy with Removal of the Otic
Capsule

General Consideration
The otic capsule is removed to gain access to lesions situated
along the medial aspect of the inner ear spaces (e.g.
supralabyrinthine and infralabyrinthine-apical cholesteatoma,
and temporal paragangliomas class C3-4 De1-2, Di 1-2). The
SP with removal of the otic capsule is also part of the transotic
approach used for acoustic neuromas associated with a total
loss of hearing. Remember that SP with removal of the otic
capsula is not a transcochlear approach. The transcochlear
approach (House WF, Hitselberger WE) consists of the
removal of the cochlea and posterior rerouting of the facial
nerve, leaving the middle ear and EAC intact. Lesions
requiring SP with removal of the otic capsule involve the dura
and, therefore, require obliteration of the pneumatic middle ear
cleft.
Removal of the Posterior Otic Capsula (Labyrinth)

The semicircular canals are removed as in a translabyrinthine

approach.
The tympanic and labyrinthine segments of the facial nerve must
be watched. Removal of the cochlea continues until the medial
wall of the vestibule, the posterior ampullary and the superior
ampullary nerve become visible. The labyrinthine segment of
the facial nerve is identified 2mm anterior and 2mm lateral to
the superior edge of the internal auditory canal. The posterior
wall of the internal auditory canal is skeletonized to the porus
acousticus internus.
Removal of the Anterior Otic Capsula (Cochlea)
Skeletonize the mastoid segment of the facial nerve and the
jugular bulb. Follow the jugular bulb as far a s possible medial
to the facial nerve toward the round window niche. Remove
the bone covering the basal, middle and apical turn of the
cochlea (the apical turn may be covered by the semicanal of
the tensor tympani muscle) working anterior to the facial
nerve. Skeletonize the inferior and anterior walls of the
internal auditory canal until you reach the anterior porus. Note
that the internal auditory canal is situated deep and anterior to
the skeletonized tympanic and mastoid facial nerve.
Expose the posterior fossa dura between the internal auditory
canal, superior petrosal sinus (medial to the semicanal of the
tensor tympani muscle), vertical carotid artery, and jugular
bulb. Opening this dura would lead in the transotic approach,
which is the only approach permitting the surgeon to first
separate the intracranial segment of the facial nerve from the
anterior pole of the tumor.
Final surgical site of SP with removal of the otic
capsula

The complete medial wall of the temporal bone is exposed

between sigmoid sinus, superior petrosal sinus (separating
dura of the middle and posterior cranial fossa), internal carotid
artery and jugular bulb. The cell tracts located medial to the
otic capsula and extending toward the pyramid apex have been
completely exenterated.