Anatomy and Surgical Appraches of The Temporal Bone PDF

NEUROSURGERY VOLUME 61 | NUMBER 4 | OCTOBER 2007 SUPPLEMENT 4 | S4-1
INTRODUCTION
ANATOMY AND SURGICAL APPROACHES OF THE
TEMPORAL BONE AND ADJACENT AREAS
Neurosurgery 61:S4-1, 2007 DOI: 10.1227/01.NEU.0000280027.92382.2B www.neurosurgery-online.com
T
he temporal bone is the most complicated osseous struc-
ture in the human body. Five parts participate in its for-
mation. The facial and carotid canals in the temporal bone
are the longest canals of passage of any cranial nerve or artery
through the cranium. This complexity is further increased by
the genus, and bends in the facial nerve and carotid artery
within the temporal bone. The presence of the delicate cochlear
and vestibular membranes within the temporal bone makes it
the only bone that houses the end organs of a cranial nerve. It
also houses the complicated mechanism for transmitting
sounds from the outward world to the inner ear. The fact that
the temporal bone faces the middle and posterior cranial fossa
and also has lateral and lower surfaces yields the potential for
multiple complex surgical routes to the temporal bone, and
through it to deeper areas. It is the focus of more surgical routes
and approaches than any other bone in the cranium. The deli-
cate neural, vascular, and transmission systems within the bone
add to the complexity of these surgical approaches and provide
a special challenge in dealing with lesions in the area. This
work, done with many of our research fellows, represents
knowledge gained from nearly ve decades of the study of
microsurgical anatomy. We hope that the illustrations in three
dimensions will aid all who deal with this complicated and
delicate anatomy.
Our previous article (Chapter 1) on the temporal bone was
included as a starting point because it provides an up-to-date
two-dimensional description of the anatomy and approaches
to the temporal bone (1). Additional information on the sur-
rounding area will be found in the volume Cranial Anatomy and
Operative Approaches published by NEUROSURGERY (2). The
three-dimensional (3D) part begins with a review of the osseous
relationships and proceeds through the anatomy and surgical
approaches directed to and through the temporal bone from
the middle and posterior fossa and laterally through the mas-
toid. This is followed by sections related to the exposures
directed along the margins of the temporal bone, which include
the far lateral and transcondylar approaches and the approaches
to the jugular foramen and fourth ventricle. Each of the latter
sections is preceded by a short description of the approach.
The pages with the 3D illustrations are to be viewed with the
colored glasses. On the lower right, below the large 3D illustra-
tion, is a two-dimensional illustration with labels guiding the
viewer to the important structures in the area. Each illustration
is followed by a short legend. The 3D illustrations are to be
viewed with the blue lens of the colored glasses placed in front
of the right eye and the red lens in front of the left eye. Some of
the cardboard glasses can be bent so the red and blue are
reversed with a resulting loss of 3D viewing.
This volume is dedicated to the fellows who have labored in
our microsurgery laboratory beginning more than 40 years ago.
Each fellow has been challenged to improve and build upon
the efforts of the previous fellow. Several dozen fellows, begin-
ning with Shigeaki Kobayashi in 1966, have made contribu-
tions to our knowledge of the temporal bone and surrounding
areas. Special thanks go to Robin Barry, who has worked with
us for more than two decades and who aligned all the pictures
for 3D images, and to Laura Dickinson, who has labored over
this manuscript.
Capturing 3D images of the quality presented here requires
careful preparation of the specimen and meticulous dissection,
followed by the even greater challenge of obtaining satisfactory
3D images. Obtaining excellent specimens, completing meticu-
lous specimen preparation, and combining that with surgically
precise dissections, and outstanding two- and 3D photography
is a rare achievement. We hope this work will enhance the
readers understanding of this complex area and that it will
result in accurate, gentle, and safe operative procedures for
patients requiring surgery in this delicate area.
This work is dedicated to the microsurgery fellows at the
University of Florida who, for more than 40 years, have taught
me so much about microsurgical anatomy and the temporal bone.
Hiroshi Abe, Japan
Hajime Arai, Japan
Allen S. Boyd, Jr., Tennessee
Robert Buza, Oregon
Alvaro Campero, Argentina
Alberto C. Cardoso, Brazil
Christopher C. Carver, California
Patrick Chaynes, France
Chanyoung Choi, Korea
Evandro de Oliveira, Brazil
Hatem El Khouly, Egypt
W. Frank Emmons, Washington
J. Paul Ferguson, Georgia
Juan C. Fernandez-Miranda, Spain
Andrew D. Fine, Florida
Brandon Fradd, Florida
Kiyotaka Fujii, Japan
Yutaka Fukushima, Japan
Adriano Garcia-Scaff, Brazil
RHOTON
Hirohiko Gibo, Japan
John L. Grant, Virginia
Kristinn Gudmundsson, Iceland
David G. Hardy, England
Frank S. Harris, Texas
Tsutomu Hitotsumatsu, Japan
Takuya Inoue, Japan
Tooru Inoue, Japan
Yukinari Kakizawa, Japan
Toshiro Katsuta, Japan
Masatou Kawashima, Japan
Chang Jin Kim, South Korea
Robert S. Knego, Florida
Shigeaki Kobayashi, Japan
Chae Heuck Lee, South Korea
Xiao-Yong Li, China
William Lineaweaver, California
J. Richard Lister, Florida
Qing Liang Liu, China
Jack E. Maniscalco, Florida
Richard G. Martin, Alabama
Carolina Martins, Brazil
Haruo Matsuno, Japan
Toshio Matsushima, Japan
J. Robert Mozingo, deceased
Hiroshi Muratani, Japan
Antonio C.M. Mussi, Brazil
Shinji Nagata, Japan
Yoshihiro Natori, Japan
Kazunari Oka, Japan
Michio Ono, Japan
Shigeyuki Osawa, Japan
T. Glenn Pait, Arkansas
Wayne S. Paullus, Texas
David Perlmutter, Florida
Mark Renfro, Texas
Wade H. Renn, Georgia
Saran S. Rosner, New York
Pablo Rubino, Argentina
Naokatsu Saeki, Japan
Shuji Sakata, Japan
Eduardo R. Seoane, Argentina
Xiang-en Shi, China
Satoru Shimizu, Japan
Ryusui Tanaka, Japan
Necmettin Tanriover, Turkey
Helder Tedeschi, Brazil
Erdener Timurkaynak, Turkey
Xiaoguang Tong, China
Satoshi Tsutsumi, Japan
Jay Ulm, Florida
Hung T. Wen, Brazil
C.J. Whang, South Korea
Isao Yamamoto, Japan
Alexandre Yasuda, Brazil
Nobutaka Yoshioka, Japan
Arnold A. Zeal, Florida
1. Rhoton AL Jr: The temporal bone and transtemporal approaches.
Neurosurgery 47 [Suppl 3]:S211S265, 2000.
2. Rhoton AL Jr: Cranial Anatomy and Surgical Approaches. Baltimore,
Lippincott Williams & Wilkins, 2003.
From Pernkopf E, Ferner H: Atlas of Topographical and Applied Human Anatomy. Philadelphia, W.B. Saunders Company, 1963.
O
nly a broad collection of superlatives can begin to describe
my impression of this meisterwerk from Professor
Rhoton. As is the case with the majority of Rhotons works, this
exhibition of the temporal bone and its relationships to the sur-
rounding neuroanatomy must be viewed as required study by
those aspiring to master the regions complex construction.
For many of our colleagues, the temporal bone has essen-
tially been the purview of our otological colleagues. Owing to
its intricate construction, a higher level of dedication to its sur-
gery and pathology has been mandated. Despite the prociency
of our otological partners in lateral cranial base surgery, it is
equally important for the neurosurgeon to share this anatomical
expertise. Such mastery on the part of the neurosurgeon is
essential in helping our colleagues help us by providing optimal
exposure from our perspective as the surgeon largely responsi-
ble for dissection in and around critical brain and cranial nerve
structures, as well as the cerebral vasculature. Presentation of
this material in three-dimensional (3D) format is an important
adjunct to our educational corpus as it brings everyone the
opportunity to see the material in a fashion available to only
those otherwise granted personal access to these phenomenal
anatomical preparations. I can personally attest to the difculty
of reproducing such exquisite preparations. No other laboratory
has produced relevant dissections in such painstaking, exquisite
detail. This work represents a true legacy in the continuum of
neurosurgical education. Neurosurgeons young and mature
owe Dr. Rhoton a debt of gratitude for his contributions to our
most relevant science as surgeons, surgical neuroanatomy.
J. Diaz Day
Burlington, Massachusetts
T
his supplement continues Professor Rhotons wonderful
instruction of the anatomy of the head and neck. This work is
devoted to the temporal bone and adjacent areas. In addition to
anatomical dissections, the supplement contains details of surgi-
cal approaches. Production in 3D adds tremendously to its value.
The 3D portion of the supplement is divided into 12 sections.
The osseous relationships are described rst. Following this,
attention is directed to the middle cranial fossa anatomy, dis-
cussing relationships of the temporal bone as viewed from above.
The next chapter details the surgical anatomy of the middle cra-
nial fossa approach. Chapter 4 is strictly an anatomic dissection
of the temporal bone from an anterior view. This greatly helps
one to appreciate the relationships of the various structures from
an approach not normally seen. Next, the temporal bone is dis-
sected laterally; again demonstrating the intricate anatomy of
this structure. Chapter 6 illustrates the relationships of the soft tis-
sue of the neck and face to the temporal bone. These structures
are frequently encountered in lateral cranial base surgery.
The following six chapters discuss surgical approaches.
Chapter 7 details the retrolabyrinthine and transcochlear
approaches. Stepwise dissections detail these approaches. The
presigmoid approach is illustrated in Chapter 8 and the ret-
rosigmoid approach in Chapter 9. The detailed anatomic rela-
tionships of structures in the cerebellopontine angle and poste-
rior fossa are beautifully demonstrated. Chapter 10 details the
COMMENTS
telovelar approach to the fourth ventricle. As in all of Professor
Rhotons work, the illustrations beautifully demonstrate this
anatomy. The far lateral and transcondylar approaches are illus-
trated in Chapter 11. This anatomy is less frequently encoun-
tered by the cranial base surgeon, and readers will nd it partic-
ularly helpful. The same may be said for Chapter 12, which
illustrates the complex anatomy of the jugular foramen. The
relationships of the lower cranial nerves are particularly well
demonstrated.
Production of Professor Rhotons marvelous dissections in 3D
literally and guratively adds a whole new dimension to the
value of this wonderful work. 3D illustrations add signicantly to
understanding the complex anatomy of this region. The surgical
approaches in particular are much better understood in the 3D
format. We should all be grateful to Professor Rhoton for his ded-
ication in producing these outstanding teaching tools. Everyone
should utilize these materials not only in learning these
approaches but for periodic review of this complex anatomy.
Derald E. Brackmann
Neuro-otologist
Los Angeles, California
D
r. Rhotons description of the microanatomy and operative
approaches to the temporal bone and adjacent areas is a very
worthwhile contribution to neurosurgery, particularly for the
education of those interested in cranial base approaches. The
presentation of these complex anatomical structures in such a 3D
mode helps to provide an overview of all relevant structures
within the chosen surgical corridor.
This work is unique in the history of neurosurgery. It greatly
facilitates the detailed understanding of the microanatomy of
the temporal bone and its surrounding structures. Avariety of
very important cranial nerves and vessels runs through this rel-
atively small area. Both the normal anatomy and its variations
are presented in detail. The reader has to consider these anatom-
ical variations that can create complications during surgery (e.g.,
as discussed in the supplement, 15% of the greater petrosal
nerves are located directly under the dura in the middle cranial
fossa). Thus, a facial palsy may occur in the case of elevation or
transection of the dura.
For younger and less experienced neurosurgeons, this
extraordinary anatomical demonstration is highly valuable for
learning the functional importance of these structures and the
spatial relationships between them. Intraoperative neurovascu-
lar injury can lead to signicant surgical morbidity. The opera-
tive approaches should be selected so that only minimal expo-
sure of important structures is required. In my 40 years of
experience with cranial base surgery during which I operated
on more than 8000 cases, I gradually developed my neurosurgi-
cal strategy. In the beginning, we thought we needed to expose
all cranial nerves and vessels around the lesion in order to
achieve complete removal of large tumors and to preserve the
anatomical structures. The increased experience and knowledge
of microsurgical anatomy have highlighted two important
aspects. First, the pathological lesion displaces the structures in
different directions. Therefore, the normal anatomy does not
always completely correspond to the pathological anatomy. The
knowledge of the spatial orientation and relations of space-
occupying lesions helps the precise planning of surgeries. The
second aspect is that tumor removal does not necessitate a large
approach and exposure of all surrounding structures. The art
and quality of neurosurgery relate to the ability to select the
simplest trajectory to the lesion that does not involve or compro-
mise structures with functional importance. Another very
important and still underestimated point is the avoidance of
venous occlusion, which could cause excessive brain edema or
intracerebral hematomas in certain cases. Furthermore, the vari-
ability in venous anatomy among different individuals is aston-
ishing. The beautiful and precise description of the various
venous drainage patterns performed by Dr. Rhoton will de-
nitely help to focus attention on this topic.
The philosophy of simple non-risky approaches to the pathol-
ogy in the temporal bone, middle and/or posterior fossae can
only be accomplished with a profound knowledge of the
microanatomy, as well as of all possible approaches to this area.
Dr. Rhotons study of the temporal bone anatomy contains 13
chapters, beginning with the description of the osseous relation-
ships, and includes chapters on the anatomical view of the cranial
base. It is valuable for its presentation of the structures viewed
through the most frequently utilized surgical approaches, includ-
ing the retrosigmoid, the telovelar, the far lateral, and the differ-
ent petrosal approaches. The excellent 3D views of the structures
allow the reader the possibility to appreciate the depth and spa-
tial relationships, making this a great educational contribution.
Finally, I would like to personally thank Dr. Rhoton for his com-
mitment and effort and to congratulate him for this outstanding
achievement in modern neurosurgery.
Madjid Samii
Hannover, Germany
COMMENTS
S4-4 | VOLUME 61 | NUMBER 4 | OCTOBER 2007 SUPPLEMENT 4 www.neurosurgery-online.com
From Pernkopf E, Ferner H: Atlas of Topographical and Applied Human Anatomy. Philadelphia, W.B. Saunders Company, 1963.
PART 1
OVERVIEW OF THE
TEMPORAL BONE IN
TWO DIMENSIONS
CHAPTER 1
Albert L. Rhoton, Jr., M.D.
Department of Neurosurgery,
University of Florida,
Gainesville, Florida
Reprint requests:
Albert L. Rhoton, Jr., M.D.,
University of Florida,
Department of Neurological Surgery,
McKnight Brain Institute,
P.O. Box 100265,
Gainesville, FL 326100265.
Email: rhoton@neurosurgery.u.edu
Osseous Relationships
T
he temporal bone is divided into squa-
mosal, petrous, mastoid, tympanic, and
styloid parts (Figs. 1-1 and 1-2). The
squamosal part helps enclose the brain. The
mastoid part is trabeculated and pneumatized
to a variable degree and contains the mastoid
antrum. The petrous part is compact and
encloses the cochlea, the vestibule, and the
semicircular, facial, and carotid canals (Fig.
1-3). The tympanic part forms part of the wall
of the tympanic cavity and the external
acoustic meatus. The styloid projects down-
ward and serves as the site of attachment of
several muscles. This section examines these
parts in greater detail and defines the ana-
tomic basis of the approaches directed
through the temporal bone to the posterior
fossa and petroclival region. The approaches
examined are the middle fossa, translab-
yrinthine, transcochlear, combined supra- and
infratentorial presigmoid, subtemporal ante-
rior transpetrosal, subtemporal preauricular
infratemporal, and the postauricular trans-
temporal approaches.
The approaches directed through the sur-
face of the temporal bone forming the middle
fossa floor include 1) the very limited middle
fossa exposure of the internal acoustic mea-
tus; 2) the anterior petrosectomy approach
directed medial to the internal acoustic mea-
tus through the petrous apex to access the
upper anterior part of the posterior fossa and
clivus; 3) the extended middle fossa ap-
proach, which may include not only resection
of the roof of the internal acoustic meatus and
petrous apex, but is extended lateral to the
internal acoustic meatus to include resection,
as needed, of the semicircular canals, vesti-
bule, roof of the mastoid antrum and tym-
panic cavity, and the posterior face of the
temporal bone; and 4) the subtemporal pre-
auricular infratemporal fossa approach in
which the middle fossa exposure is combined
with exposure of the infratemporal fossa and,
if needed, the petrous carotid, petrous apex,
pterygopalatine fossae, and orbit.
The approaches directed through the mas-
toid in front of the sigmoid sinus vary in the
amount of temporal bone resected. They
include 1) the minimal mastoidectomy vari-
ant in which only enough presigmoid dura is
exposed to open the dura in front of the sig-
moid without exposing the labyrinth; 2) the
retrolabyrinthine approach, which exposes the
bony capsule of the labyrinth; 3) the partial
labyrinthectomy, which includes removal of
one or more of the semicircular canals; 4) the
translabyrinthine approach, which includes
resection of the semicircular canals and
vestibule; and 5) the transcochlear modica-
tion, which includes removal of all the
labyrinth, including the cochlear and possibly
the petrous apex. These variants of the trans-
mastoid approaches can all be combined, as
needed, with the supra- and infratentorial pre-
sigmoid approaches to the middle and poste-
rior fossa.
The final approach to be reviewed is the
postauricular transtemporal approach, which
allows lesions involving the mastoid, tym-
panic cavity, petrous apex, and jugular fora-
men to be followed backward to the areas
exposed by the retrosigmoid and far-lateral
approaches and forward to the infratemporal,
pterygopalatine and middle fossae, lateral
maxilla, and orbit. Selecting an approach
directed through the temporal bone requires
an understanding of its complex anatomy and
its relationship to the petroclival region, the
infratemporal fossa, and parapharyngeal
space. Protecting and preserving the facial
nerve, the petrous carotid artery, and the sen-
sory organs of the inner ear that are contained
within the temporal bone are important ele-
ments in operative approaches directed
through the lateral aspect of the cranial base.
OVERVIEW OF TEMPORAL BONE
KEY WORDS: Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull
base, Skull base neoplasm, Surgical approach, Temporal bone
Neurosurgery 61:S4-7S4-60, 2007 DOI: 10.1227/01.NEU.0000280024.07630.65 www.neurosurgery-online.com
RHOTON
FIGURE 1-1. Temporal bone. A and B, infe-
rior views. A, the temporal bone has a
squamosal part, which forms some of the oor
and lateral wall of the middle cranial fossa. It
is also the site of the mandibular fossa in
which the mandibular condyle sits. The tym-
panic part forms the anterior, lower, and part
of the posterior wall of the external canal, part
of the wall of the tympanic cavity, the osseous
portion of the eustachian tube, and the poste-
rior wall of the mandibular fossa. The mastoid
portion contains the mastoid air cells and
mastoid antrum. The petrous part is the site
of the auditory and vestibular labyrinth, the
carotid canal, the internal acoustic meatus,
and the facial canal. The petrous part also
forms the anterior wall and the dome of the
jugular fossa. The styloid part projects down-
ward and serves as the site of attachment of
three muscles. B, inferior view of the temporal
and surrounding bones. The squamosal and
petrous parts articulate anteriorly with the
greater wing of the sphenoid. The petrous
apex faces the foramen lacerum and is sepa-
rated from the clival part of the occipital bone
by the petroclival ssure. The occipital bone
joins with the petrous part of the temporal
bone to form the jugular foramen. The
mandibular fossa is located between the ante-
rior and posterior roots of the zygomatic
process. C and D, superior views. C, the
medial part of the upper surface is the site of
the trigeminal impression in which Meckels
cave sits. Farther laterally is the prominence
of the arcuate eminence overlying the superior
semicircular canal. Anterolateral to the arcu-
ate eminences is the tegmen, a thin plate of
bone overlying the mastoid antrum and epi-
tympanic area. The temporal bone articulates
anteriorly with the sphenoid bone, above with
the parietal bone, and posteriorly with the
occipital bone. The zygomatic process of the
squamosal part has an anterior and a poste-
rior root between which, on the lower surface,
is located the mandibular canal. D, temporal
and surrounding bones. The squamosal part
of the temporal bone joins anteriorly with the
sphenoid bone to form the oor of the middle
cranial fossa. Posteriorly, it articulates with
the occipital bone to form a portion of the
anterior wall of the posterior fossa. Medially, it articulates with the clival por-
tion of the occipital bone at the petroclival ssure. The sigmoid sulcus descends
along the posterior surface of the mastoid portion and turns forward to enter the
jugular foramen. The foramen lacerum is located at the junction of the tempo-
ral, sphenoid, and occipital bones. The porus of the internal acoustic meatus is
located in the central part of the posterior surface. Ac., acoustic; Ant., anterior;
Arc., arcuate; Car., carotid; Cond., condyle; Digast., digastric; Emin., emi-
nence; For., foramen; Gr., greater; Impress., impression; Int., internal; Jug.,
jugular; Mandib., mandibular; N., nerve; Occip., occipital; Pet., petrosal;
Post., posterior; Proc., process; Sig., sigmoid; Stylomast., stylomastoid; Trig.,
trigeminal; Tymp., tympanic.
THE TEMPORAL BONE AND
TRANSTEMPORAL APPROACHES
Lateral Surface
When the skull and temporal bone are viewed from a lateral
perspective, some landmarks useful in performing approaches
directed around and through the temporal bone can be identi-
ed (Fig. 1-2). The posterior end of the superior temporal line
continues inferiorly as the supramastoid crest and blends into
the upper edge of the zygomatic arch. The supramastoid crest
is located at the level of the oor of the middle fossa. The junc-
tion of the supramastoid crest with the squamous suture is
located at the lateral end of the petrous ridge. The meeting
point of the parietomastoid and squamous sutures is located a
few millimeters below the lateral end of the petrous ridge. The
superior edge of the junction of the sigmoid and transverse
sinuses is located at the junction of the squamous and pari-
etomastoid suture.
The mastoid antrum, a pneumatized space opening into the
tympanic cavity, is located about 1.5 cm deep to the suprameatal
triangle, a depression in the mastoid surface located between
the posterosuperior edge of the external meatus, the supramas-
toid crest, and the vertical tangent along the posterior edge of
the meatus. The suprameatal spine of Henle is located at the
outer end of the posterosuperior edge of the external canal
along the anterior edge of the suprameatal triangle and corre-
sponds to the level of the lateral semicircular canal and tym-
FIGURE 1-2. Temporal bone. A, posterior view of a right temporal bone. The
squamosal part forms part of the oor and lateral wall of the middle fossa. The
sigmoid sulcus descends along the posterior surface of the mastoid portion. The
internal acoustic meatus enters the central portion of the petrous part of the
bone. The trigeminal impression and arcuate eminence are located on the upper
surface of the petrous part. The vestibular aqueduct connects the vestibule in
the petrous part with the endolymphatic sac, which sits on the posterior petrous
surface inferolateral to the internal acoustic meatus. B, enlarged view. The
transverse crest separates the meatal fundus into a superior part where the
facial canal and superior vestibular areas are situated, and an inferior part
where the cochlear and inferior vestibular areas are located. The vertical crest
separates the facial and superior vestibular areas. C, enlarged view of another
internal acoustic meatus. The transverse crest divides the meatal fundus into
superior and inferior parts. The anterior part above the transverse crest is the
site of the facial canal and the posterior part is the site of the superior vestibu-
lar area. Below the transverse crest, the cochlear area is anterior and the infe-
rior vestibular area is posterior. D, another internal acoustic meatus. The view
is directed to expose the singular foramen, for the singular branch of the inferior
vestibular nerve that innervates the posterior ampullae. The inferior vestibular
nerve also has a saccular and, occasionally, a utricular branch. (Continues)
panic segment of the facial nerve at a depth of approximately
1.5 cm. Several landmarks are also helpful in identifying the
location of the junction of the transverse and sigmoid sinuses at
the posterior aspect of the mastoid. The asterion located at the
junction of the lambdoid, occipitomastoid, and parietomastoid
sutures is usually located over the junction of the lower part of
the transverse and sigmoid sinuses. A burr-hole placed at this
site will usually expose the lower edge of this junction. Aburr-
hole located at the junction of the supramastoid crest and the
squamosal suture will be located at the posterior part of the
middle fossa oor just above and anterior to the upper edge of
the junction of the transverse and sigmoid sinuses.
RHOTON
FIGURE 1-2. (Continued) E, lateral view of the temporal bone. The squamosal
part forms part of the lateral wall of the middle fossa, the posterior part of the
zygomatic arch, and the upper part of the mandibular fossa. The tympanic
part forms the posterior wall of the mandibular fossa and almost all of the wall
of the external canal. The styloid process is ensheathed at its base by the tym-
panic part and projects downward, serving as the attachment of several mus-
cles. The mastoid part is located posteriorly and contains the mastoid air cells
that coalesce at the mastoid antrum. F, enlarged view of the external auditory
canal. The spine of Henley, an excellent landmark for locating the deep site of
the lateral canal and tympanic segment of the facial nerve, is located along the
posterosuperior margin of the external canal. The mastoid antrum is located
deep to the depressed area, called the suprameatal triangle, located behind the
spine of Henley. The view into the canal exposes the tympanic cavity, which has
the promontory overlying the basal turn of the cochlea and the oval and round
windows in its medial wall. G, lateral surface of the temporal bone in the
intact skull. The tympanic part forms the anterior and lower and part of the
posterior wall of the external canal. The mandibular fossa is formed above and
anteriorly by the squamosal part and behind by the tympanic part. The mastoid
antrum is located posterosuperior to the spine of Henley, between the spine of
Henley and the anterior part of the supramastoid crest. The asterion, the junc-
tion of the lambdoid, parietomastoid, and occipital mastoid sutures, is usually
located over the lower half of the junction of the sigmoid and transverse sinuses.
The midpoint of the parietal mastoid suture is usually located at the anterior
margin of the junction of the transverse and sigmoid sinuses, and the lateral
edge of the petrous ridge is located at the junction of the squamosal suture and
the supramastoid crest. H, the supra- and infratentorial areas have been exposed
while preserving the bone at the site of the sutures. The asterion, located at the
junction of the lambdoid, occipitomastoid, and parietomastoid sutures, overlies
the lower half of the junction of the transverse and sigmoid sinuses. The junc-
tion of the supramastoid crest and the squamosal suture is located at the pos-
terior edge of the middle fossa and slightly anterior and above the junction of
the transverse and sigmoid sinuses. Ac., acoustic; Arc., arcuate; CN, cranial
nerve; Coch., cochlear; Emin., eminence; Ext., external; For., foramen;
Impress., impression; Inf., inferior; Int., internal; Mandib., mandibular;
Occipitomast., occipitomastoid; Parietomast., parietomastoid; Proc., process;
Sig., sigmoid; Sp., spine; Sup., superior; Supramast., supramastoid; Trans.,
transverse; Trig., trigeminal; Vert., vertebral; Vest., vestibular.
FIGURE 1-3. AD, posterior surface of the temporal bone. A, the internal
meatus is located near the center and the jugular foramen at the lower edge
of the posterior surface. The sigmoid sinus descends along the posterior sur-
face of the mastoid and turns forward on the occipital bone to pass through
the sigmoid part of the jugular foramen. The inferior petrosal sinus descends
along the petroclival fissure and passes through the petrosal part of the jugu-
lar foramen. The subarcuate fossa is located superolateral and the ostium for
the vestibular aqueduct lateral to the internal acoustic meatus. The trigemi-
nal impression is a shallow trough on the upper surface of the temporal bone
behind the foramen ovale. The arcuate eminence overlies the superior semicir-
cular canals. B, temporal bone with the nerves preserved. The abducens nerve
ascends to enter Dorellos canal. The trigeminal nerve passes above the
petrous apex to enter the porus of Meckels cave. The facial and vestibulo-
cochlear nerves enter the internal acoustic meatus, and the glossopharyngeal,
vagus, and accessory nerves enter the jugular foramen. The posterior and
superior semicircular canals have been exposed. C, enlarged view. The upper
end of the posterior canal and the posterior end of the superior canal share the
common crus. The endolymphatic duct extends downward from the vestibule
and opens into the endolymphatic sac located beneath the dura inferolateral
to the meatus. The endolymphatic ridge, the bridge of bone forming the pos-
terior lip of the vestibular aqueduct, has been preserved. The jugular bulb can
be seen through the thin bone below the internal meatus. D, enlarged view of
the fundus of the meatus after removal of the posterior wall. The upper edge
of the porus has been preserved. The subarcuate artery enters the subarcuate
fossa. The inferior vestibular nerve gives rise to the singular branch to the
posterior ampullae, plus utricular and saccular branches. The superior
vestibular nerve innervates the ampullae of the superior and lateral semicir-
cular canals and commonly gives rise to a utricular branch. (Continues)
The Tympanic Part
The tympanic part of the temporal bone is a curved plate
anterior to the mastoid process (Figs. 1-1, 1-2, and 1-4). It forms
part of the wall of the external acoustic meatus, tympanic cav-
ity, and osseous part of the Eustachian tube. Its concave poste-
rior surface forms the anterior wall, oor, and part of the pos-
terior wall of the external acoustic meatus. The roof and upper
posterior wall are formed by the squamosal part. Its surface
contains a portion of the tympanic sulcus for attachment of the
tympanic membrane, which closes the medial end of the exter-
nal canal. The anterior surface, which is concave, forms the
posterior wall of the mandibular fossa. Its lateral border forms
most of the margin of the external acoustic meatus. Medially, it
joins the petrous part at the petrotympanic fissure through
which the chorda tympani passes. The carotid canal and the
jugular foramen are located medial to the tympanic part.
The styloid process, a slender spicule ensheathed by the infe-
rior border of the tympanic bone, projects into the infratempo-
ral fossa and is the site of attachment for the styloglossus, sty-
lopharyngeus, and stylohyoid muscles (Fig. 1-5). It is located
immediately anterior to the emergence of the facial nerve from
the stylomastoid foramen and is covered laterally by the
parotid gland. The stylomastoid foramen, the external end of
the facial canal, opens between the styloid and mastoid
processes. The facial nerve crosses the lateral surface of the sty-
loid process, and the external carotid artery crosses the tip.
Resecting the styloid process and reecting the attached mus-
cles downward exposes the internal jugular vein as it exits the
jugular foramen and the carotid artery as it enters the carotid
canal medial to the tympanic bone.
The Squamous Part
The externally convex surface of the squamosal part gives
attachment to the temporalis muscle (Figs. 1-1, 1-2, and 1-5).
RHOTON
FIGURE 1-3. (Continued) EH, posterior surface of the temporal bone. E, the
petrous apex medial to the internal acoustic meatus has been removed to expose
the petrous carotid. The lateral genu of the petrous carotid, located at the junc-
tion of the vertical and horizontal segments of the petrous carotid, is situated
below and medial to the cochlea. The jugular bulb extends upward toward the
vestibule and semicircular canals adjacent to the posterior meatal wall. The infe-
rior petrosal sinus courses along the petroclival ssure and enters the petrosal
part of the jugular foramen, and the sigmoid sinus descends in the sigmoid
groove and enters the sigmoid part of the foramen. The glossopharyngeal,
vagus, and accessory nerves pass through the central or intrajugular part of the
foramen between the sigmoid and petrosal parts. F, bone has been removed
along the anterior margin of the meatal fundus to open the cochlea, and along
the posterior margin to expose the vestibule. The jugular bulb extends upward
toward the semicircular canals and vestibule. G, enlarged view. The cochlear
nerve penetrates the modiolus of the cochlea where its bers are distributed to
the turns of the cochlear duct. The basal turn of the cochlea communicates below
the modiolus with the vestibule. H, enlarged view of the vestibule and cochlea.
The stapes has been removed from the oval window. The promontory in the
medial wall of the tympanic cavity is located lateral to the basal turn of the
cochlea. A silver ber has been introduced into the superior canal, a red ber
into the lateral canal, and a blue ber into the posterior canal. The ampullated
ends are located at the bulbous ends of the three bers. The common crus of the
superior and posterior canals is located at the site where the tips of the blue and
silver bers overlap. The superior vestibular nerve passes to the ampullae of the
superior and lateral canals. The singular branch of the inferior vestibular nerve
innervates the posterior ampullae. Asmall black ber has been introduced into
the opening of the endolymphatic duct into the vestibule. A., artery; Ac.,
acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch., cochlear;
Emin., eminence; Endolymph., endolymphatic; Fiss., ssure; For., foramen;
Hypogl., hypoglossal; Impress., impression; Inf., inferior; Int., internal;
Intermed., intermedius; Jug., jugular; Lat., lateral; N., nerve; Nerv., nervus;
Pet., petrosal, petrous; Petrocliv., petroclival; Post., posterior; Semicirc., semi-
circular; Sig., sigmoid; Subarc., subarcuate; Sup., superior; Trig., trigeminal;
Vest., vestibular.
FIGURE 1-4. Tympanic cavity and mastoid antrum. A, the tympanic bone
forms the anterior, lower, and part of the posterior wall of the external canal.
The facial nerve exits the skull through the stylomastoid foramen, which is
located medial to the tympanomastoid suture. The spine of Henley approximates
the deep site of the tympanic facial segment and the lateral canal. The mastoid
antrum is located between the posterosuperior wall of the external canal and
middle fossa oor deep to the depression behind the spine of Henle. B, a mas-
toidectomy has been completed to expose the capsule of the posterior and lateral
canals and the tympanic and mastoid facial segments. C, the posterior and
superior wall of the external canal and the tympanic membrane have been
removed while preserving the malleus and chorda tympani. The mastoid seg-
ment of the facial nerve descends through the facial canal and gives rise to the
chorda tympani, which passes upward and forward across the tympanic mem-
brane and malleus neck. D, enlarged view. The head of the incus articulates
with the head of the malleus, the short process of the incus points backward
toward the facial nerve, and the long process attaches to the stapes, which sits
in the oval window. The stapedial muscle passes forward below the tympanic
segment of the facial nerve and attaches to the neck of the stapes. E, the incus
has been removed to expose the stapes sitting in the oval window. The chorda
tympani crosses the neck of the malleus. The promontory is located (Continues)
The supramastoid crest extends backward across its posterior
part, giving attachment to the temporalis muscle and fascia.
The suprameatal triangle, a depressed area, located below the
anterior part of the crest and behind the posterosuperior mar-
gin of the external meatus, marks the deep location of the mas-
toid antrum. The cerebral surface of the squamosal part is con-
cave, accommodating the temporal lobe and joining the greater
wing of the sphenoid anteriorly. The zygomatic process of the
squamosal part projects forward and with the zygomatic bone
completes the zygomatic arch. The attachment of the zygo-
matic process to the squama is wide giving it anterior and pos-
terior edges, referred to as the anterior and posterior roots. The
temporalis fascia attaches to the superior border of the arch
and the masseter attaches to the lower border. The posterior
root of the zygomatic process blends posteriorly into the
suprameatal crest. The anterior root is located at the anterior
margin of the temporomandibular joint, with the joint forming
a rounded fossa on the lower margin of the zygomatic process
between the anterior and posterior roots. The upper margin of
the zygomatic process between the two roots gives attachment
to the posterior part of the temporalis muscle. The mandibular
fossa, located on the lower margin of the process between the
two roots, is delimited in front by the articular tubercle and
posteriorly by the postglenoid tubercle adjacent to its junction
with the tympanic bone. The squamotympanic fissure is
located between the medial part of the squamosal part of the
mandibular fossa and the medial part of the tympanic bone.
The petrotympanic ssure is situated between the tympanic
plate and the petrosal part and leads into the tympanic cavity;
it contains the anterior ligament of the malleus and the anterior
tympanic branch of the maxillary artery. The anterior canalicu-
lus for the chorda tympani exits the tympanic cavity in the
petrotympanic ssure. The rootlets of the temporal branch of
the facial nerve cross the lateral aspect of the zygomatic arch
and course through the subcutaneous tissues on the supercial
layer of the temporal fascia. During resection of the zygomatic
arch, the supercial temporalis fascia should be carefully dis-
sected from the underlying deep fascia, starting as close as pos-
sible to the tragal cartilage, and carried forward, reecting the
supercial fascia anteriorly to avoid damage to the laments of
the temporal branch to the frontalis muscle, which crosses the
outer surface of the supercial fascia.
The Mastoid Part
The mastoid is the posterior part of the temporal bone (Figs.
1-1, 1-2, and 1-4). It projects downward to form the process
that is the site of attachment, from supercial to deep, of the
sternocleidomastoid, splenius capitis and longissimus capitis
muscles, and the posterior belly of the digastric muscle (Fig.
1-5). The lower surface medial to the mastoid process is
grooved by the mastoid notch to which the posterior belly of
the digastric attaches. Medial to the notch, the occipital groove
gives passage to the occipital artery. The fascia covering the
anterior margin of the posterior belly of the digastric is contin-
uous anteriorly with the connective tissue surrounding the
emergence of the mastoid segment of the facial nerve from the
stylomastoid foramen and can be used as a landmark for iden-
tifying the initial extracranial segment of the nerve. After exit-
ing the stylomastoid foramen, the nerve divides in the sub-
stance of the parotid gland into temporal, zygomatic, buccal,
marginal mandibular, and cervical branches (Fig. 1-5). The tem-
poral and zygomatic branches cross the zygomatic arch and the
outer surface of the supercial fascia of the temporalis muscle.
Keeping the connective tissue surrounding the nerve at the sty-
lomastoid foramen intact during mobilization of the facial
nerve will reduce the risk of facial nerve damage. The posterior
border of the mastoid process is perforated by one or more
foramina through which an emissary vein to the sigmoid sinus
and a dural branch from the occipital artery pass.
The medial aspect of the mastoid process is grooved by the
sigmoid sinus (Figs. 1-11-4). The sinus represents the posterior
limit of the mastoid cavity. The sinus meets the roof of the cav-
ity at the level of the petrous ridge. The angle between the
superior petrosal and sigmoid sinuses and the middle fossa
dura delimits a dural space called the sinodural angle. The sin-
odural angle is an important landmark when exposing the con-
tents of the mastoid. Inferiorly, the sigmoid sinus curves medi-
ally and forward, crossing the occipital bone to enter the
jugular foramen. The superior aspect of the jugular foramen
corresponds to the apex of the jugular bulb and constitutes the
inferior limit of the mastoid cavity.
The medial limit of the mastoid cavity is formed by the
block of solid bone, the otic capsule, containing the bony
labyrinth (Figs. 1-4 and 1-6). The area of posterior fossa dura
mater that can be exposed through the mastoid cavity between
the sigmoid and superior petrosal sinuses, the otic capsule,
and the jugular bulb is called Trautmans triangle. The size of
this dural triangle is important in surgical procedures in which
the dura delimited by the triangle must be opened medial to
the sigmoid sinus. The distance from the anterior margin of
the sigmoid sinus to the otic capsule at the level of the poste-
rior semicircular canal averages 8 mm (range, 69 mm) on the
RHOTON
FIGURE 1-4. (Continued) supercial to the basal turn of the cochlea. The
labyrinth and fundus of the internal meatus are located medial to the tympanic
cavity. A line directed medially through the skull along the long axis of the
external meatus will also approximate the site of the long axis of the internal
meatus on the medial side of the promontory and acousticovestibular labyrinth.
F, the stapes has been removed from the oval window. The handle of the malleus
attaches to the tympanic membrane, the neck is crossed by the chorda tympani,
and the head articulates with the incus, which has been removed. The tendon
of the tensor tympani attaches to the upper part of the handle of the malleus.
The stapedial muscle is housed within the pyramidal eminence and its tendon
inserts on the stapedial neck. Chor., chorda; CN, cranial nerve; Emin., emi-
nence; Endolymph., endolymphatic; Epitymp., epitympanic; Eust.,
eustachian; Jug., jugular; Lat., lateral; Long., longus; M., muscle; Mast.,
mastoid; Memb., membrane; N., nerve; Post., posterior; Proc., process; Seg.,
segment; Sig., sigmoid; Sp., spine; Squamomast., squamomastoid; Temp.,
temporal; Tymp., tympani, tympanic; Tympanomast., tympanomastoid.
FIGURE 1-5. AF, muscular and osseous relationships. A, the skin and sub-
cutaneous tissues have been removed to expose the parotid gland and the facial
nerve branches that course deep to the parotid gland on their way to the facial
muscles. The masseter muscle has two heads: a more supercial anterior head,
which passes downward to the lateral surface of the angle of the jaw, and a
deeper posterior head, which arises from the medial surface of the zygomatic
arch and passes to the mandibular body. The sternocleidomastoid attaches to the
lateral part of the superior nuchal line and mastoid process, descends in an
anterior direction, and is crossed by the greater auricular nerve. The temporalis
fascia attaches to the upper surface of the zygomatic arch. The trapezius mus-
cle attaches to the medial part of the superior nuchal line. The posterior trian-
gle of the neck, located between the sternocleidomastoid and trapezius, has the
semispinalis capitis, splenius capitis, and levator scapulae in its oor. The ter-
minal branches of the occipital artery and the greater occipital nerve reach the
subcutaneous tissues by passing between the attachment of the trapezius and
sternocleidomastoid muscles to the superior nuchal line. B, enlarged view. The
facial nerve branches are exposed along the anterior edge of the parotid gland.
C, the parotid gland has been removed to expose the facial nerve and its
branches distal to the stylomastoid foramen. The nerve passes lateral to the sty-
loid process, the external carotid artery, and mandibular neck. The supercial
and deep heads of the masseter muscle are exposed. This lower end of the ster-
nocleidomastoid muscle has been reected posteriorly by dividing (Continues)
RHOTON
FIGURE 1-5. (Continued) its attachment to the clavicle and sternum. The
supercial temporal artery ascends in front of the ear. D, the upper part of the
mandibular ramus and the lower part of the temporalis muscle and its attach-
ment to the coronoid process have been removed while preserving the inferior
alveolar nerve. The infratemporal fossa is located medial to the mandible and on
the deep side of the temporalis muscle. The upper and lower heads of the lateral
pterygoid, which insert along the temporomandibular joint, and the supercial
head of the medial pterygoid, which extends from the lateral pterygoid plate to
the angle of the jaw, have been exposed. The structures in the infratemporal
fossa include the pterygoid muscles, branches of the mandibular nerve, the
maxillary artery, and the pterygoid venous plexus. The sternocleidomastoid
muscle has been reected out of the exposure to expose the splenius capitis mus-
cle. E, posterolateral view. The splenius capitis has been reected downward to
expose the longissimus capitis, superior oblique, and semispinalis capitis. The
occipital artery passes along the occipital groove on the medial side of the digas-
tric groove. F, the longissimus capitis has been reected downward to expose the
rectus capitis posterior minor and major, which descend from the occipital bone
to attach to the spinous process of C1 and C2, respectively; the superior oblique,
which passes from the occipital bone to the transverse process of C1; and the
inferior oblique, which extends from the spinous process of C2 to the transverse
process of C1. The vertebral artery, in its ascent from C2 to C1, is exposed
medial to the attachment of the levator scapulae to the C1 transverse process.
The C1 transverse process is situated immediately behind the internal jugular
vein and a short distance below and behind the jugular foramen. (Continues)
right side, and 7 mm (range, 49 mm) on the left (44). The dis-
tance between the apex of the jugular bulb and the superior
petrosal sinus is also an important determinate of the size of
exposure that can be achieved by opening Trautmans triangle.
This distance is reduced if there is a high jugular bulb. The
jugular bulb usually lies inferior to the ampulla of the poste-
rior semicircular canal, but it can project superiorly as far as
the level of the lateral semicircular canal (27). The average dis-
tance from the jugular bulb to the superior petrosal sinus is
1446p10.5mm (range, 1019 mm) on the right side, and 16 mm
(range, 1121 mm) on the left (44).
The mastoid interior is composed of trabeculated bone,
which coalesces to form a cavity, the mastoid antrum, that com-
municates through an opening, the aditus, that leads forward
to the epitympanic part of the tympanic cavity (Figs. 1-4 and
1-6). The lateral semicircular canal is medial to the epitympanic
recess. The medial wall of the antrum faces the posterior semi-
circular canal. The roof is formed by the tegmen in the oor of
the middle cranial fossa. The mastoid segment of the facial
canal courses adjacent to the anteroinferior margin of the
antrum. The lateral wall of the mastoid antrum, through which
it is usually approached surgically, is formed by the postmeatal
part of the squamous temporal bone. The lateral wall of the
antrum is located deep to the suprameatal triangle, which is
demarcated superiorly by the suprameatal crest, located at the
level of the oor of the middle fossa; anteroinferior by the pos-
terosuperior margin of the acoustic meatus, which indicates
approximately the position of the descending or mastoid part
of the facial canal; and posteriorly by a posterior vertical tan-
gent to the posterior margin of the external meatus. The air
cells in the mastoid may extend behind the sigmoid sinus and
into the squamosal part of the temporal bone, the posterior
root of the zygomatic process, the osseous roof of the external
acoustic meatus, the oor of the tympanic cavity near the jugu-
lar bulb, and the petrous apex surrounding the carotid canal,
eustachian tube, and labyrinth.
The tympanic cavity is a narrow air-lled space between the
tympanic membrane laterally and the promontory containing
the auditory and vestibular labyrinth medially (Figs. 1-4, 1-6,
and 1-7). It communicates posteriorly with the mastoid antrum
and anteriorly through the eustachian tube with the nasophar-
ynx. It contains the malleus, incus, and stapes. The tympanic
cavity opens upward into the epitympanic recess, which con-
tains the head of the malleus and body of the incus. The roof of
the tympanic cavity is formed by a thin plate, the tegmen tym-
pani, which separates the middle fossa and tympanic cavities,
and also roofs the mastoid antrum and the tensor tympani.
The thin oor of the tympanic cavity separates the cavity from
the jugular bulb. The medial part of the oor is perforated by
an opening for the tympanic branch of the glossopharyngeal
nerve. The lateral wall is formed by the tympanic membrane
and the osseous ring to which the membrane attaches. The ring
is decient above near the openings of the anterior and poste-
rior canaliculi for the chorda tympani (Figs. 1-4 and 1-6). The
posterior canaliculus for the chorda tympani arises from the
facial canal a few millimeters above the stylomastoid foramen
and ascends in front of the facial canal to open into the tym-
panic cavity at the level of the upper part of the handle of the
malleus. The chorda tympani passes in close relation to the
tympanic membrane and the upper part of the handle of the
malleus and forward to enter its anterior canaliculus at the
medial aspect of the petrotympanic ssure, and descends ver-
tically medial to the sphenoid spine and lateral pterygoid mus-
cle to join the lingual nerve.
The medial wall of the tympanic cavity, which forms the lat-
eral boundary of the inner ear and the petrosal part of the tem-
poral bone, is the site of the promontory, the oval and round
windows, and the prominence over the facial nerve (Figs. 1-2
and 1-4). The tympanic nerve plexus grooves the promontory
overlying the lateral bulge of the basal turn of the cochlea. The
apex of the cochlea lies near the medial wall of the cavity ante-
rior to the promontory. The oval window is posterosuperior to
FIGURE 1-5. (Continued) GL, muscular and osseous relationships. G, the
mandibular condyle and ramus have been removed to expose the styloid process
and attached muscles. The pterygoid muscles and some branches of the mandibu-
lar nerve have been removed to expose the auriculotemporal nerve, which splits
into two roots that surround the middle meningeal artery. The levator veli pala-
tini, which attaches the lower margin of the eustachian tube, is in the medial part
of the exposure. The longus capitis is exposed medial to the internal carotid
artery in the retropharyngeal area. H, the muscles that attach to the styloid
process have been divided at their origin. The facial nerve crosses the lateral sur-
face of the styloid process. The attachment of the tensor veli palatine to the skull
base extends between the foramen ovale and the eustachian tube. I, the external
auditory canal has been removed, but the tympanic membrane and cavity have
been preserved. The levator veli palatine and part of the tensor veli palatine have
been removed and the membranous part of the eustachian tube opened. The
eustachian tube crosses anterior to and is separated from the petrous carotid by
a thin shell of bone. The jugular bulb and lateral bend of the petrous carotid are
located below the osseous labyrinth. The pterygopalatine fossa is exposed ante-
riorly. J, the Eustachian tube has been resected and the mandibular nerve divided
at the foramen ovale to expose the petrous carotid. This exposes the longus capi-
tis and rectus capitis anterior, both of which are located behind the posterior pha-
ryngeal wall. K, the petrous carotid has been reected forward out of the carotid
canal to expose the petrous apex medial to the carotid canal. L, the petrous apex
and upper clivus have been drilled and the dura opened to expose the anterolat-
eral aspect of the pons below the trigeminal nerve. The sigmoid sinus and the
jugular bulb have been removed to expose the nerves exiting the jugular fora-
men. A., artery; Alv., alveolar; Ant., anterior; Aur., auricular; Brs., branches;
Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Constr., con-
strictor; Eust., eustachian; Ext., external; Gl., gland; Gr., greater; Inf., inferior;
Int., internal; Jug., jugular; Lat., lateral; Lev., levator; Long., longus; Longiss.,
longissimus; M., muscle; Maj., major; Mandib., mandibular; Max., maxillary;
Med., medial; Memb., membrane; Min., minor; N., nerve; Obl., oblique;
Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal; Pet., petrosal;
Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopala-
tine; Rec., rectus; Scap., scapula; Semispin., semispinalis; Splen., splenius;
Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup., supe-
rior; Superf., supercial; Temp., temporal, temporalis; Tens., tensor; TM., tem-
poromandibular; Trans., transverse; Tymp., tympanic; V., vein; Veli./Vel.,
veli; Vert., vertebral.
the promontory and connects the tympanic cavity to the
vestibule, and is occupied by the footplate of the stapes. The
round window is posteroinferior to the oval window and
opens under the overhanging edge of the promontory. The
prominence of the facial canal is located above the oval win-
dow. The posterior wall of the tympanic cavity is mainly the
site of the aditus, the opening of the tympanic cavity, into the
mastoid antrum. The medial wall of the aditus has a round
prominence overlying the lateral semicircular canal. The
pyramidal eminence, which houses the stapedial muscle, is
located just behind the oval window and anterior to the mas-
toid part of the facial canal. The stapedius extends forward
from the eminence to attach to the neck of the stapes. The fossa
incudis is a small depression low and posterior in the epitym-
panic recess; it contains the short process of the incus, which is
xed to the fossa by ligamentous bers.
The anterior wall of the tympanic cavity narrows and leads
into the eustachian tube, which communicates the nasopharynx
with the tympanic cavity (Figs.1-4, 1-7, and 1-8). It has bony
and cartilaginous parts. The bony part begins in the anterior
RHOTON
FIGURE 1-6. AD, translabyrinthine exposure. A, the insert shows the site
of the exposure directed through the mastoid. The spine of Henley at the pos-
terosuperior margin of the external meatus is a superficial landmark that
approximates the deep site of the lateral semicircular canal and the tympanic
segment of the facial nerve. The mastoidectomy has been completed. The
superior petrosal and sigmoid sinuses, the jugular bulb, and the facial nerve
are usually skeletonized in the approach, leaving a thin layer of bone over
them. The semicircular canals, which are located in the cortical bone medial
to the cancellous mastoid and the mastoid antrum, have been exposed. The
dura between the sigmoid and superior petrosal sinuses, the jugular bulb, and
the labyrinth, which faces the cerebellopontine angle, is referred to as
Trautmans triangle. B, the mastoid antrum opens through the aditus into the
epitympanic part of the tympanic cavity, which contains the upper part of the
malleus and incus. The tympanic segment of the facial nerve passes between
the lateral canal and the stapes in the oval window and then turns down-
ward as the mastoid segment. The chorda tympani arises from the mastoid
segment of the facial nerve and passes upward and forward along the deep
surface of the tympanic membrane crossing the neck of the malleus. The
incus, the head of which is located in the epitympanic area, has a long process
that attaches to the stapes. C, the semicircular canals and vestibule have been
removed and the dura lining the internal acoustic meatus has been opened to
expose the vestibulocochlear nerve. D, the dura has been opened to expose the
petrosal cerebellar surface and the structures in the cerebellopontine angle.
Anatomic variants that limit the exposure include an anterior position of the
sigmoid sinus, a high jugular bulb, or a low middle fossa plate. The jugular
bulb may extend upward into the posterior wall of the internal acoustic mea-
tus and be encountered as the posterior meatal wall is being removed by
either the translabyrinthine or retrosigmoid approaches. (Continues)
part of the tympanic cavity and is directed anteriorly and medi-
ally. It joins the cartilaginous part at the junction of the squa-
mous and petrous parts of the temporal bone. The cartilaginous
part of the tube is attached to the lower margin of the
sphenopetrosal groove, which is situated between the petrous
bone and the greater wing of the sphenoid bone, and its base
lies directly under the mucous membrane of the lateral wall of
the nasaopharynx. Both the petrous carotid and eustachian
tube are directed anteromedially, with the Eustachian tube
being located along the anterior margin of the carotid canal
(Figs. 1-7 and 1-8). The tensor tympani muscle and its bony
semicanal are located above the eustachian tube, parallel to the
horizontal segment of the petrous carotid. The canals for the
tensor tympani superiorly and the osseous part of the
eustachian tube inferiorly open into the upper part of the ante-
rior wall of the tympanic cavity. These canals are inclined
downward, anteriorly, and medially; they open into the angle
between the squamous and petrous parts of the temporal bone
and are separated by a thin, bony septum. The canal for the ten-
sor tympani extends posterolaterally on the medial wall of the
tympanic cavity, to end above the oval window where the pos-
terior end of the canal curves laterally to form a pulley, the
FIGURE 1-6. (Continued) EH, trans-
labyrinthine exposure. E, enlarged view of the
exposure in the cerebellopontine angle. In this
case, the glossopharyngeal and vagus nerves
can be seen, although, in the translabyrinthine
exposure, the jugular bulb often obstructs the
view of the nerves entering the jugular fora-
men. F, the vestibulocochlear nerve has been
elevated to expose the facial nerve. G, the
labyrinthine, tympanic, and mastoid segments
of the facial nerve have been exposed in prepa-
ration for transposition of the nerve for a
transcochlear approach. H, the facial nerve has
been transposed backward and the bone ante-
rior to the meatal fundus has been removed to
expose the cochlea for a transcochlear approach
in which the cochlea is removed to gain access
to the side of the clivus and front of the brain-
stem. The cochlear nerve has been divided. The
cochlear fibers innervating the cochlear duct
pass through the modiolus. Ac., acoustic;
A.I.C.A., anteroinferior cerebellar artery;
Chor., chorda; CN, cranial nerve; Coch.,
cochl ear; Inf. , i nf eri or; Int. , i nternal ;
Intermed., intermedius; Jug., jugular; Laby.,
labyrinthine; Lat., lateral; Mast., mastoid; N.,
nerve; Nerv., nervus; Pet., petrosal; P.I.C.A.,
posteroinferior cerebellar artery; Post., poste-
rior; Seg., segment; Sig., sigmoid; Sup., supe-
rior; Tymp., tympani, tympanic; V., vein;
Vest., vestibular.
trochleariform process, around which the tensor tympani ten-
don turns laterally to attach to the handle of the malleus.
The Petrous Part
The petrous part of the temporal bone is wedged between
the sphenoid and occipital bones (Figs. 1-1 and 1-3). It contains
the acoustic and vestibular labyrinth and is the site of the jugu-
lar fossa and the facial and carotid canals (Figs. 1-3, 1-4, and
1-7). It has a base, apex, three surfaces and margins. The apex
is located in the angle between the greater wing of the sphe-
noid and the occipital bone and is the site of the carotid canals
medial opening. It forms the posterolateral limit of the foramen
lacerum. The anterior surface faces the oor of the middle cra-
nial fossa and its surface is grooved by the trigeminal impres-
sion for the trigeminal ganglion; anterolateral to this, it forms
the roof of the carotid canal (Figs. 1-1 and 1-7). Lateral to the
trigeminal impression is a shallow depression, which partially
roofs the internal acoustic meatus and is limited laterally by the
arcuate eminence, which overlies the superior semicircular
canal. The posterior slope of the arcuate eminence overlies the
posterior and lateral semicircular canals. Farther laterally, the
roof covers the vestibule and part of the facial canal. The
tegmen extends laterally from here and roofs the mastoid
antrum and tympanic cavities and the canal for the tensor tym-
pani. Opening the tegmen from above exposes the heads of
the malleus, incus, the tympanic segment of the facial nerve,
RHOTON
FIGURE 1-7. AD, middle fossa exposure of the temporal bone. A, super-
olateral view. The tentorium, except the edge, has been removed. The dura
has been removed from the middle fossa floor and cavernous sinus wall to
expose the greater petrosal nerve, middle meningeal artery, and the nerves in
the sinus wall. B, the middle fossa floor has been opened to expose the
cochlea, semicircular canals, petrous carotid artery, and the facial, cochlear,
and superior vestibular nerves in the meatus. The superior canal bulges
upward into the middle fossa below the arcuate eminence. The cochlear nerve
passes below the facial nerve to enter the cochlea, which is located above the
lateral genu of the petrous carotid in the angle between the pregeniculate
facial and greater petrosal nerves. C, another temporal bone drilled to expose
the internal acoustic meatus, cochlea, vestibule, semicircular canals, tym-
panic cavity, and external meatus. The vestibule is located posterolateral and
the cochlea is anteromedial to the fundus of the internal meatus. The
vestibule communicates below the meatal fundus with the cochlea. The ten-
sor tympani muscle and eustachian tube are layered along, but are separated
from, the anterior surface of the petrous carotid by a thin layer of bone. The
tegmen has been opened to expose the head of the incus and malleus in the
epitympanic area. The internal acoustic meatus lies directly medial to, but is
separated from, the external meatus by the tympanic cavity and the
labyrinth. D, the nerves in the meatus have been separated to expose the
superior and inferior vestibular, facial, and cochlear nerves. (Continues)
and the superior and lateral semicircular canals (Fig. 1-7). The
tympanic segment of the facial nerve begins at the geniculate
ganglion and ends at the level of the stapes, where the nerve
turns downward below the lateral semicircular canal. The
tegmen anteriorly is grooved by the greater petrosal nerve
extending anterior and medial from the area in front of the
arcuate imminence and crossing the oor of the middle fossa
toward the foramen lacerum (Figs. 1-7 and 1-8). The greater
petrosal nerve can be identified medial to the arcuate emi-
nence as it leaves the geniculate ganglion by passing through
the facial hiatus to reach the middle fossa oor. It runs beneath
the dura of the middle fossa in the sphenopetrosal groove
formed by the junction of the petrous and sphenoid bones,
immediately superior and anterolateral to the horizontal seg-
ment of the petrous carotid. In a previous study, we found
that bone of the middle cranial fossa was absent over the
geniculate ganglion in 16% of the specimens, thus exposing the
facial nerve and geniculate ganglion to the danger of injury
during elevation of the dura from the oor of the middle fossa
(31). Facial nerve injury can also result from damaging the
branch of the middle meningeal artery, which passes through
the facial hiatus to supply the nerve, or from traction applied
FIGURE 1-7. (Continued) EH, middle fossa exposure of the temporal bone.
E, enlarged view. The vestibule, into which the semicircular canals open, com-
municates below the meatal fundus with the cochlea. The vertical crest, often
called Bills bar, separates the superior vestibular and facial nerves at the
meatal fundus. The tendon of the tensor tympani makes a right-angle turn
around the trochleariform process in the medial margin of the tympanic cav-
ity to insert on the malleus. F, enlarged view. The superior canal projects
upward in the oor of the middle fossa. The lateral canal is situated above the
tympanic segment of the facial nerve in the posteromedial part of the epitym-
panic area, and the posterior canal is located lateral to the posterior wall of the
internal acoustic meatus. G, bone has been removed below the greater petrosal
nerve to expose the petrous carotid. The tensor tympani muscle above and the
eustachian tube below are layered along the anterior surface of the petrous
carotid. H, enlarged view. Suture has been placed in the three semicircular
canals. The anterior end of the superior and lateral canals and the lower end
of the posterior canal are the site of the ampullae. The posterior end of the supe-
rior canal and the upper end of the posterior canal join to form a common crus.
The facial and superior vestibular nerves have been removed to expose the
cochlear and inferior vestibular nerves. The singular branch of the inferior
vestibular nerve innervates the posterior ampullae. The superior vestibular
nerve innervates the superior and lateral ampullae. A., artery; Ac., acoustic;
A.I.C.A., anteroinferior cerebellar artery; Car., carotid; CN, cranial nerve;
Coch., cochlear; Eust., eustachian; Ext., external; Gang., ganglion; Genic.,
geniculate; Gr., greater; Inf., inferior; Lat., lateral; M., muscle; Men.,
meningeal; Mid., middle; N., nerve; Pet., petrosal, petrous; Post., posterior;
S.C.A., superior cerebellar artery; Sup., superior; Tens., tensor; Tent., tento-
rial; Tymp., tympani, tympanic; Vert., vertebral; Vest., vestibular.
t o t he gangl i on when
manipulating the greater
petrosal nerve (30).
The l esser pet rosal
nerve from the tympanic
plexus passes through the
tympani c canal i cul us,
which is located anterior
to the facial hiatus and
courses in an anterome-
dial direction parallel to
the greater petrosal nerve
(Fig. 1-8). The cochlea lies
below the floor of the
middle fossa in the angle
between the labyrinthine
segment of t he f aci al
nerve and the greater pet-
rosal nerve, just medial to
the geniculate ganglion,
anterior to the fundus of
the internal acoustic mea-
tus, and posterosuperior
to the lateral genu of the
petrous carotid artery.
The cochlea is separated
from the petrous carotid
by a 2. 1 mm ( r ange ,
0.610.0 mm) thickness of
bone and can be injured
during exposure of the
petrous carotid. The mid-
dl e meni ngeal art ery,
an important landmark
when approaching the
structures of the middle fossa, enters the cranial cavity
through the foramen spinosum of the sphenoid bone. The
foramen spino-sum is an average of 4.5 mm (range, 36 mm)
anterolateral to the carotid canal and 14.0 mm (range,
11.017.0 mm) anterolateral to the geniculate ganglion (44).
The posterior surface of the petrosal part faces the poste-
rior cranial fossa and cerebellopontine angle and is continu-
ous with the mastoid surface (Figs. 1-11-.3). The opening
for the internal auditory meatus is situated midway between
the base and the apex on the posterior surface. The lateral
end of the meatus is divided into superior and inferior halves
by the transverse crest. The area above the transverse crest is
further divided by the vertical crest, also called Bills bar,
which separates the anteriorly located facial canal from the
posteriorly located superior vestibular area (29). The cochlea
and inferior vestibular nerves penetrate the lateral end of the
meatus below the transverse crest, with the cochlear nerve
being located anteriorly. The posterior wall of the meatus,
lateral to the porus is the site of a small bony opening, the
subarcuate fossa, which gives passage to the subarcuate
artery, a branch of the anteroinferior cerebellar artery (AICA),
which usually ends blindly in the region of the superior
semicircular canal. Inferolateral to the porus of the meatus is
the opening for the vestibular aqueduct, which transmits the
endolymphatic duct that opens below into the endolym-
phatic sac located between the dural layers. The opening of
the cochlear aqueduct, also called the cochlear canaliculus
and occupied by the perilymphatic duct, is situated inferior
to the porus of the internal meatus at the anteromedial edge
of the jugular foramen, just superior and lateral to where the
glossopharyngeal nerve enters the intrajugular part of the
jugular foramen.
The inferior surface is very irregular. The apex is connected
medially to the clivus by brocartilage and gives attachment to
the levator veli palatini and the cartilaginous portion of the
eustachian tube (Figs. 1-1 and 1-9). Behind this is the opening of
the carotid canal, behind which is the jugular fossa that con-
tains the jugular bulb. The small foramen for the tympanic
branch of the glossopharyngeal nerve is located on the ridge
between the carotid canal and jugular foramen. On the lateral
wall of the jugular bulb is the mastoid canaliculus for the auric-
ular branch of the vagus nerve.
RHOTON
FIGURE 1-8. A, superior view of the temporal bone and infratemporal fossa and orbit. The oor of the middle fossa has been
removed to expose the temporalis muscle in the temporal fossa and the pterygoid muscles and branches of the third trigemi-
nal division in the infratemporal fossa. The posterior part of the middle fossa forming the upper surface of the temporomandibu-
lar joint has been removed to expose the mandibular condyle. The internal acoustic meatus extends laterally from the poste-
rior surface of the temporal bone. The mastoid is located behind the external canal and lateral to the semicircular canals and
vestibule. B, enlarged view. The trigeminal nerve has been reected forward and bone has been removed over the eustachian
tube, tensor tympani muscle, petrous carotid, and internal acoustic meatus. Dura has been removed from the lateral wall of
the cavernous sinus to expose the trochlear, trigeminal, and oculomotor nerves in the sinus wall and the abducens nerve pass-
ing below the petrosphenoid ligament and through Dorellos canal. The greater petrosal nerve is joined by the deep petrosal
branches of the carotid sympathetic plexus to form the vidian nerve, which passes forward in the vidian canal, which has been
unroofed. The lesser petrosal nerve arises from the tympanic branch of the glossopharyngeal nerve, which passes across the
promontory in the tympanic nerve plexus and regroups to cross the oor of the middle fossa, exiting the skull to provide
parasympathetic innervation through the otic ganglion to the parotid gland. The tensor tympani muscle and eustachian are
layered along, but are separated from, the anterior surface of the petrous carotid by a thin layer of bone. A., artery; Car.,
carotid; Cav., cavernous; Chor., chorda; CN, cranial nerve; Cond., condyle; Eust., eustachian; Gang., ganglion; Gen., genic-
ulate; Gr., greater; Lat., lateral; Less., lesser; Lig., ligament; M., muscle; Mandib., mandibular; Max., maxillary; N.,
nerve; Ophth., ophthalmic; Pet., petrosal, petrous; Pteryg., pterygoid; Semicirc., semicircular; Sphen., sphenoid; Temp.,
temporal; Tens., tensor; Tymp., tympani, tympanic.
The superior border, located along the petrous ridge, is
grooved by the superior petrosal sinus and serves as the attach-
ment of the tentorium cerebelli, except medially where it is
crossed by the posterior trigeminal root. The lower posterior
border, located along the petroclival fissure, is the site of a
groove in which resides the inferior petrosal sinus that connects
FIGURE 1-9. Inferior views of an axial sec-
tion of the skull base. A, the infratemporal
fossa is surrounded by the maxillary sinus
anteriorly, the mandible laterally, the sphe-
noid pterygoid process anteromedially, and
the parapharyngeal space posteromedially,
and contains the mandibular nerve and max-
illary artery and their branches, the medial
and lateral pterygoid muscles, and the ptery-
goid venous plexus. B, part of the lateral
pterygoid muscle has been removed to expose
the branches of the trigeminal nerve coursing
in the infratemporal fossa below the greater
sphenoid wing. The pterygopalatine fossa is
located between the posterior maxillary wall
anteriorly, the sphenoid pterygoid process
posteriorly, the nasal cavity medially, and the
infratemporal fossa laterally. The pharyngeal
recess (fossa of Rosenmller) projects later-
ally from the posterolateral corner of the
nasopharynx with its lateral apex facing the
internal carotid artery laterally and the fora-
men lacerum above. The posterior nasopha-
ryngeal wall is separated from the lower
clivus and the upper cervical vertebra by the
longus capitis, and the nasopharyngeal roof
rests against the upper clivus and the poste-
rior part of the sphenoid sinus oor. C, the
sphenoid pterygoid process has been removed
to expose the maxillary nerve passing through
the foramen rotundum to enter the ptery-
gopalatine fossa where it gives rise to the
infraorbital nerve, which courses in the roof of
the maxillary sinus. The maxillary nerve
within the pterygopalatine fossa gives off
communicating rami to the pterygopalatine
ganglion. The vidian nerve, formed by the
union of the deep petrosal nerve from the
carotid sympathetic plexus and the greater
petrosal nerve, courses forward through the
vidian canal to join the pterygopalatine gan-
glion. The terminal part of the petrous carotid
is exposed above the foramen lacerum. D,
enlarged view with highlighting of the pre-
(red) and poststyloid (yellow) compartments
of the parapharyngeal space. The styloid
diaphragm, formed by the anterior part of the
carotid sheath, separates the parapharyngeal
space into pre- and poststyloid parts. The
prestyloid compartment, a narrow fat-
containing space between the medial ptery-
goid and tensor veli palatini, separates the infratemporal fossa from the medi-
ally located lateral nasopharyngeal region containing the tensor and levator veli
palatini and the eustachian tube. The oststyloid compartment, located behind
the prestyloid part, contains the internal carotid artery, internal jugular vein,
and the cranial nerves IX through XII. A., artery; Cap., capitis; Car., carotid;
CN, cranial nerve; Cond., condyle; Eust., eustachian; For., foramen; Gl.,
gland; Gr., greater; Infraorb., infraorbital; Infratemp., infratemporal; Int.,
internal; Jug., jugular; Lat., lateral, lateralis; Lev., levator; Long., longus; M.,
muscle; Mandib., mandibular; Max., maxillary; N., nerve; Nasolac., naso-
lacrimal; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal;
Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rec-
tus; Tens., tensor; V., vein; Vel., veli.
the cavernous sinus and the medial wall of the jugular bulb.
Behind this, the jugular fossa of the temporal bone joins with
the jugular notch on the jugular process of the occipital bone to
form the margins of the jugular foramen.
The jugular foramen is located at the lower end of the petro-
occipital ssure and is divided into a larger lateral opening,
the sigmoid part, that receives the drainage of the sigmoid
sinus, and a small medial part, the petrosal part, that transmits
the inferior petrosal sinus (Fig. 1-1). The intrajugular part,
located between the sigmoid and petrosal parts, transmits the
glossopharyngeal, vagus, and accessory nerves. The anterior
border is joined laterally to the temporal squama at the pet-
rosquamosal suture and medially articulates with the sphe-
noids greater wing.
The bony labyrinth consists of three parts: the vestibule, the
semicircular canals, and the cochlea. The vestibule, located in
the central part of the bony labyrinth, is a small cavity at the
conuence of the ampullate and nonampullated ends of the
semicircular canals. It is situated lateral to the meatal fundus,
medial to the tympanic cavity, posterior to the cochlea, and
superior to the apex of the jugular bulb (Figs. 1-3, 1-4, and 1-7).
The oor of the vestibule is separated from the apex of the
jugular bulb by a thickness of bone that averages 6 mm (range,
48 mm) on the right side and 8 mm (range, 410 mm) on the
left side (44). This distance is particularly important during
translabyrinthine approaches since the height of the jugular
bulb is a major determinant of the size of the exposure of the
cerebellopontine angle that can be achieved with this approach.
A high-placed jugular bulb may be the source of troublesome
bleeding and air emboli if it is opened during exposure of the
labyrinth or internal acoustic meatus.
The semicircular canals are situated posterosuperior to the
vestibule (Figs. 1-3, 1-4, and 1-7). The anterior part of the lat-
eral semicircular canal is situated above the tympanic seg-
ment of the facial nerve and can be used as a guide to locat-
ing that segment of the nerve. The posterior semicircular
canal lies parallel to and in close proximity with the posterior
surface of the petrous bone in the area just behind and lateral
to the lateral end of the internal acoustic meatus. The superior
semicircular canal projects toward the floor of the middle
fossa, usually in close relation to the arcuate eminence. Each
canal has an ampullated and a nonampullated end that opens
into the vestibule. The anterior end of the lateral and superior
canals and the inferior end of the posterior canal are the site
of the ampullae, which are innervated by the vestibular
nerves. The posterior ends of the superior and posterior
canals, the ends opposite the ampullae, join to form a com-
mon crus that opens into the vestibule. The superior vestibu-
lar nerve innervates the ampullae of the superior and lateral
canals, and the singular branch of the inferior vestibular nerve
innervates the posterior ampulla. The vestibular nerves also
have branches to the utricle and saccule located within the
vestibule. The internal auditory meatus can be found medial
to the arcuate eminence at an angle of about 60 degrees
medial from the long axis of the superior semicircular canal.
The superior canal is the most susceptible to damage in com-
pleting the middle fossa approach to the internal acoustic
meatus. The posterior canal may be damaged in removing
the posterior wall to expose the meatal contents by the ret-
rosigmoid approach (Fig. 1-3).
During surgical approaches to the cerebellopontine angle
in which the posterior meatal lip is removed, care should be
taken to avoid opening the vestibular aqueduct, vestibule,
posterior semicircular canal, or the common crus (Figs. 1-2
and 1-3). In our studies, we observed that there is a constant
set of relationships among the structures around the poste-
rior meatal lip. The common crus of the posterior and supe-
rior semicircular canals is located lateral to the entrance of
the subarcuate artery into the subarcuate fossa. The vestibu-
lar aqueduct has an oblique orientation. It leaves the
vestibule and runs in a posterior direction to open beneath
the dura mater at a level corresponding to that of the poste-
rior semicircular canal. The average distance between the
posterior semicircular canal, at the level with the junction of
the common crus, and the lateral edge of the porus was 7 mm
(range, 59 mm) (44).
The carotid artery, at the point where it enters the carotid
canal, is surrounded by a strong layer of connective tissue that
makes it difcult to mobilize the artery at this point (Figs. 1-9
and 1-10) (38, 39). The vertical segment of the artery passes
upward in the canal toward the genu, where it curves antero-
medially to form the horizontal segment. The Eustachian tube
and the tensor tympani muscle are located parallel to and along
the anterior margin of the horizontal segment, where they are
separated from the artery by a thin layer of bone.
The trigeminal ganglion and the adjacent part of the poste-
rior root and their surrounding dural and arachnoidal cavern,
called Meckels cave, sit in an impression on the upper surface
of the petrous apex above the medial part of the petrous carotid
(Figs. 1-1, 1-7, and 1-8). The length of the horizontal segment of
the petrous carotid that can be exposed by removing bone lat-
eral to the trigeminal ganglion averages 1-1 mm (range,
4.011.0 mm) (44). The length that can be exposed can be
increased if the mandibular branch of the trigeminal nerve is
retracted or divided, after which the average length that can be
exposed increases to 20.1 mm (range, 17.521-0 mm) (Figs. 1-7
and 1-8) (10, 17). Gaining this added exposure can be particu-
larly helpful during surgical procedures that are directed
through the petrous apex to complete a vascular anastomosis,
to occlude the artery for control of bleeding, and to allow for
mobilization of the vertical and horizontal segments of the
artery (40). Avenous plexus of variable size, an extension of the
cavernous sinus within the periosteal covering of the distal
part of the canal, surrounds the artery.
The facial nerve in the temporal bone, which often blocks
access to lesions within and deep to the temporal bone, is
divided into three segments (Figs. 1-4, 1-5, and 1-7). The first,
or labyrinthine segment, which is located in the petrous part,
extends from the meatal fundus to the geniculate ganglion
and is situated between the cochlea anteromedially and the
semicircular canals posterolaterally. The labyrinthine segment
ends at the site at which the greater superficial petrosal nerve
RHOTON
arises from the facial nerve at the level of the geniculate gan-
glion. From there, the nerve in its canal turns laterally and
posteriorly along the medial surface of the tympanic cavity,
thus giving the name tympanic segment to that part of the
nerve. The tympanic segment runs between the lateral semi-
circular canal above and the oval window below. As the nerve
passes below the midpoint of the lateral semicircular canal, it
turns vertically downward and courses through the petrous
part adjacent to the mastoid part of the temporal bone; thus
the third segment, which ends at the stylomastoid foramen, is
called the mastoid or vertical segment.
Petroclival Region
These transtemporal operative approaches are often directed
to the petroclival region located where the posterior surface of
the petrous temporal bone meets the clival part of the occipital
bone along the petroclival fissure. The junction of the two
bones forms a line that extends from the jugular foramen to the
petrous apex (Fig. 1-1). From a surgical standpoint, the
intradural compartments of the petroclival region are divided
along this petroclival line into 1) an inferior space related to the
medulla and to the structures around the region of the foramen
magnum; 2) a middle space related to the pons and to the struc-
FIGURE 1-10. AD, preauricular subtem-
poral-infratemporal fossa approach. A, the
scalp flap has been reflected forward. The flap
is positioned so that a neck dissection as well
as a frontotemporal craniotomy can be com-
pleted. The scalp flap has been reflected for-
ward while protecting the facial nerve and its
branches. The neck dissection has been com-
pleted below the parotid gland. The facial
nerve branches passing deep to the parotid
have been preserved. B, the dissection has
been carried around the parotid gland to
expose the branches of the facial nerve. The
internal jugular vein and internal carotid
artery are exposed below the gland. C, the
parotid gland has been removed to expose the
branches of the facial nerve distal to the sty-
lomastoid foramen. D, a segment of the
mandibular ramus has been removed, leaving
the mandibular condyle in the mandibular
fossa, to expose the maxillary artery and
pterygoid muscles in the infratemporal fossa.
Branches of the third trigeminal division pass
between the lateral and medial pterygoid
muscles. The inferior alveolar nerve descends
to enter the inferior alveolar foramen and
canal. (Continues)
tures in the prepontine and cerebellopontine angle; and 3) a
superior space related to the contents of the interpeduncular
cistern, and to the sellar and parasellar regions.
The Inferior Petroclival Space
The inferior petroclival space corresponds to the anterior
surface of the medulla and adjacent part of the clivus and ante-
rior margin of the foramen magnum (4). The neurovascular
structures in this region are those contained in the pre-
medullary cistern. The superior limit is the junction of the pons
and medulla. The inferior limit is the rostral margin of the rst
cervical nerve root, the site of the junction of the spinal cord
and the medulla. The inferior petroclival space includes the
lower four cranial nerves, lower part of the cerebellum, the
vertebral artery and its branches, and the structures around
the occipital condyle.
The Middle Petroclival Space
The middle petroclival space corresponds to the anterolateral
surface of the pons and cerebellum. Its superior limit is at the
pontomesencephalic sulcus and the lower limit is at the pon-
tomedullary sulcus. The lateral limits are formed by the poste-
rior surface of the petrous bone and by the contents of the cere-
bellopontine angle including the trigeminal, abducens, facial,
and vestibulocochlear nerves, the basilar artery, and the AICA
and the superior petrosal veins.
The Superior Petroclival Space
The superior petroclival space is located anterior to the mid-
brain and corresponds to the anterior part of the tentorial
incisura. It extends anteriorly and laterally to the sellar and
parasellar regions. Its roof is formed by the diencephalic struc-
tures forming the oor of the third ventricle. The posterior limit
is formed by the cerebral peduncles and the posterior perfo-
rated substance. The inferior limit is situated above the origin
of the trigeminal nerve at the pontomesencephalic sulcus. It
includes the intradural segment of the oculomotor and
trochlear nerves, the basilar artery and its branching into the
posterior cerebral artery (PCA) and superior cerebellar artery
(SCA), and the cavernous carotid and its intracavernous
branches to the dura of the upper clivus. The medial edge of
the tentorium divides the superior petroclival space into infra-
and supratentorial compartments.
Adjacent Structures
The structures important in accessing the temporal bone
from posteriorly and laterally have already been reviewed. This
section reviews the structures located in front of the temporal
bone that are important in reaching lesions that involve the
bone or involve both the bone and areas anterior to it. They
include several muscles, like the temporalis and masseter, the
infratemporal fossa, and the parapharyngeal spaces.
The temporalis muscle, along with the deep temporal ves-
sels, passes between the gap formed by the zygomatic arch
and the floor of the temporal fossa (Fig. 1-5). The muscle
attaches to the coronoid process of the mandible. The super-
cial and the deep temporalis fasciae attach, respectively, to the
lateral and medial aspects of the upper border of the zygo-
matic arch. Inferiorly, the parotid fascia invests the parotid
gland and the masseter muscle and attaches to the lower bor-
der of the zygomatic arch. The masseter muscle has two super-
imposed layers. Asupercial layer which attaches to the zygo-
matic process of the maxilla and anterior part of the lower
border of the zygomatic arch and a deep layer which attaches
RHOTON
FIGURE 1-10. (Continued) E, a frontotemporal craniotomy has been com-
pleted and the dura of the lateral wall of the cavernous sinus has been ele-
vated. In addition, the lateral orbital wall has been removed to expose the
globe, extraocular muscles, and lacrimal gland. F, enlarged view of the
region of the cavernous sinus. The PCA and SCA have been exposed cours-
ing above and below the oculomotor and trochlear nerves, respectively. The
optic nerve is exposed above the internal carotid artery. An opening has been
made into the lateral wall of the sphenoid sinus between the first and second
divisions. The maxillary nerve passes forward to join the terminal branches
of the maxillary artery in the pterygopalatine fossa. The maxillary nerve con-
tinues forward along the floor of the orbit as the infraorbital nerve. The
superior ophthalmic vein descends across the origin of the lateral rectus
muscle and enters the anterior portion of the cavernous sinus. (Continues)
to the medial aspect of the whole zygomatic arch. Inferiorly it
inserts onto the angle and ramus of the mandible.
The parotid gland, the parotid duct, and the branches of the
facial nerve are located superficial to the masseter muscle
(Figs. 1-5, 1-9, and 1-10). In surgical procedures in which the
mandibular condyle is resected or displaced inferiorly, the
parotid gland, along with the branches of the facial nerve,
can be dissected from the underlying masseter to avoid exces-
sive traction on the facial nerve and to reduce the risk of facial
palsy (33).
Muscles commonly encountered in operative approaches to
the region of the temporal bone include the posterior belly of
the digastric muscle and the muscles attached to the styloid
process. The posterior digastric belly originates in the digastric
groove, lateral to the occipital groove in which the occipital
artery courses, and inserts onto the hyoid bone. The muscles
attached to the styloid process, the stylohyoid, styloglossus,
and stylopharyngeus muscles, extend to the hyoid bone,
tongue, and pharyngeal wall, respectively.
Infratemporal Fossa
The infratemporal fossa, a route through which some tem-
poral bone lesions can be reached, is a not uncommon site of
involvement by lesions that also involve the temporal bone
(11). The osseous boundaries of the infratemporal fossa are
the posterolateral maxillary surface anteriorly, the lateral
FIGURE 1-10. (Continued) GJ, preauricu-
lar subtemporalinfratemporal fossa approach.
G, the floor of the middle fossa has been
resected back to the level of the tensor tym-
pani muscle and eustachian tube, and the
petrous carotid artery. The nerves exiting the
jugular foramen and hypoglossal canal pass
laterally between the internal carotid artery
and internal jugular vein to reach their end
organs. H, the eustachian tube and tensor
tympani have been resected and the bone lat-
eral to the foramen ovale removed. This
exposes the full length of the petrous carotid. I,
the petrous carotid has been reected forward
out of the carotid canal to expose the petrous
apex medial to the jugular foramen and lateral
wall of the clivus. J, the petrous apex and adja-
cent part of the clivus medial to the jugular
foramen and cochlea have been removed and
the dura opened to expose the junction of the
vertebral and basilar arteries and the origin of
the AICA. A., artery; A.I.C.A., anteroinfe-
rior cerebellar artery; Alv., alveolar; Bas.,
basilar; Brs., branches; Cap., capitis; Car.,
carotid; Cav., cavernous; CN, cranial nerve;
Ext., external; Front., frontal; Gl., gland;
Inf., inferior; Infraorb., infraorbital; Int.,
internal; Jug., jugular; Lac., lacrimal; Lat.,
lateral; Long., longus; M., muscle; Max.,
maxillary; Med., medial; N., nerve; Ophth.,
ophthalmic; P.C.A., posterior cerebral artery;
Pet., petrosal, petrous; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Rec., rectus;
S.C.A., superior cerebellar artery; Sphen.,
sphenoid; Submandib., submandibular;
Sup., superior; Temp., temporal; Tens., ten-
sor; TM., temporomandibular; Tymp., tym-
pani; V., vein; Vert., vertebral.
RHOTON
pterygoid plate anteromedially, the mandibular ramus later-
ally, and the tympanic part of the temporal bone and the sty-
loid process posteriorly. The fossa is domed anteriorly by the
infratemporal surface of the greater sphenoid wing, the site of
the foramina ovale and spinosum, and posteriorly by the
squamous part of the temporal bone (Figs. 1-8-1-10). The infe-
rior, posteromedial, and superolateral aspects are open with-
out bony walls.
The structures located in the infratemporal fossa are the
pterygoid muscles and venous plexus and the branches of the
maxillary artery and mandibular nerve. The lateral pterygoid
muscle crosses the upper part of the infratemporal fossa, orig-
inating from the upper and lower heads; the upper head arises
from the infratemporal surface of the greater sphenoid wing,
and the lower head originates from the lateral pterygoid plate
(Figs. 1-8-1-10). Both heads pass posterolaterally and insert on
the neck of the mandibular condylar process and the articular
disc of the temporomandibular joint. The medial pterygoid
muscle crosses the lower part of the infratemporal fossa and
arises with superficial and deep heads; the superficial head
arises from the lateral aspect of the palatine pyramidal process
and the maxillary tuberosity and passes supercial to the lower
head of the lateral pterygoid; and the deep head originates
from the medial surface of the lateral pterygoid plate and the
pterygoid fossa between the two pterygoid plates and passes
deep to the lower head of the lateral pterygoid. Both heads
descend backward and laterally to attach to the medial surface
of the mandibular ramus below the mandibular foramen. The
sphenomandibular ligament, located medial to the mandibular
condylar process, descends from the sphenoid spine to attach
to the lingula of the mandibular foramen. The structures
located or passing between the sphenomandibular ligament
and the mandible are the lateral pterygoid and the auriculotem-
poral nerve superiorly, and the inferior alveolar nerve, the
parotid gland, the maxillary artery and its inferior alveolar
branch inferiorly.
The maxillary artery is divided into three segments:
mandibular, pterygoid, and pterygopalatine (Figs. 1-8-1-10).
The mandibular segment arises from the external carotid artery
near the posterior border of the condylar process, passes
between the process and the sphenomandibular ligament,
along the inferior border of the lower head of the lateral ptery-
goid, and gives rise to the deep auricular, anterior tympanic,
middle and accessory meningeal, and the inferior alveolar
arteries. The middle meningeal ascends medial to the lateral
pterygoid to enter the foramen spinosum, the accessory
meningeal arises from the maxillary or middle meningeal to
enter the foramen ovale, and the inferior alveolar descends to
enter the mandibular foramen. The pterygoid segment usually
courses lateral to, but occasionally medial to, the lower head of
the lateral pterygoid and gives rise to the deep temporal, ptery-
goid, masseteric, and buccal arteries. The pterygopalatine seg-
ment courses between the two heads of the lateral pterygoid
and enters the pterygopalatine fossa by passing through the
pterygomaxillary ssure. Its branching will be described with
the pterygopalatine fossa.
The pterygoid venous plexus is located in the infratemporal
fossa and has two parts: a supercial part located between the
temporalis and lateral pterygoid; and a deep part situated
between the lateral and medial pterygoids anteriorly, and
between the lateral pterygoid and the parapharyngeal space
posteriorly. The deep part is more prominent and connects with
the cavernous sinus by emissary veins passing through the
foramina ovale and spinosum, and occasionally through the
sphenoidal emissary foramen (foramen of Vesalius). The main
drainage of the pterygoid plexus is through the maxillary vein
to the internal jugular vein.
The mandibular nerve enters the infratemporal fossa by
passing through the foramen ovale on the lateral side of the
parapharyngeal space, where it gives rise to several smaller
branches, and then divides into a smaller anterior trunk and a
larger posterior trunk (Figs. 1-8-1-10). The anterior trunk gives
rise to the deep temporal and masseteric nerves, which supply
the temporalis and the masseter, respectively, and the nerve to
the lateral pterygoid. The buccal nerve, which conveys sensory
bers, passes anterolaterally between the two heads of the lat-
eral pterygoid, and descends lateral to the lower head to reach
the buccinator and the buccal mucosa. The posterior trunk
gives off the lingual, inferior alveolar, and auriculotemporal
nerves, which descend medial to the lateral pterygoid. The lin-
gual and inferior alveolar nerves, the former coursing anterior
to the latter, pass between the lateral and medial pterygoids.
The auriculotemporal nerve usually splits to encircle the mid-
dle meningeal artery and passes posterolaterally between the
mandibular ramus and the sphenomandibular ligament. The
chorda tympani nerve, which contains the taste bers from the
anterior two-thirds of the tongue and the parasympathetic
secretomotor bers to the submandibular and sublingual sali-
vary glands, enters the infratemporal fossa through the
petrotympanic ssure, descends medial to the auriculotempo-
ral and inferior alveolar nerves, and joins the lingual nerve.
The otic ganglion is situated immediately below the foramen
ovale on the medial side of the mandibular nerve. The ganglion
receives the lesser petrosal nerve, which crosses the oor of
the middle fossa anterolateral to the greater petrosal nerve to
exit through the foramen ovale or the more posteriorly situated
canaliculus innominatus and conveys parasympathetic secreto-
motor fibers to the parotid gland via the auriculotemporal
nerve. The medial pterygoid nerve arises from the medial
aspect of the mandibular nerve close to the otic ganglion and
descends to supply the medial pterygoid and tensor veli pala-
tini. The nervus spinosus, a meningeal branch, also arises near
the otic ganglion and ascends through the foramen spinosum
to innervate the middle fossa dura.
Parapharyngeal Space
The parapharyngeal space is located in the lateral pharyngeal
wall and is shaped like an inverted pyramid, with its base on
the skull base superiorly and its apex at the hyoid bone inferi-
orly. The parapharyngeal space is subdivided into prestyloid
and poststyloid compartments by the styloid diaphragm, a
fibrous sheet that also constitutes the anterior part of the
carotid sheath (Figs. 1-5 and 1-9). The prestyloid part, situated
anteriorly between the fascia covering the opposing surfaces of
the medial pterygoid and tensor veli palatini, is a thin fat-lled
compartment separating the structures in the infratemporal
fossa from the eustachian tube and the tensor and levator veli
palatini muscles in the lateral nasopharyngeal wall. The upper
portion of the prestyloid part is situated between two fascial
sheets, which are oriented in a sagittal plane. The lateral sheet
arises from the medial surface of the medial pterygoid, passes
upward, backward, and medial to the mandibular nerve and
the middle meningeal artery, incorporating the spheno-
mandibular ligament posteriorly, and reaching the retro-
mandibular deep lobe of the parotid gland. The medial sheet is
formed by the fascia overlying the lateral surface of the tensor
veli palatini and is continuous inferiorly with the fascia over
the superior pharyngeal constrictor and posteriorly with the
thick styloid diaphragm, which envelopes the stylopharyngeus,
styloglossus, and stylohyoid and blends into the carotid sheath.
The superior border is located where the two fascial sheets fuse
together and insert in the skull base along a line extending
backward from the pterygoid process lateral to the origin of the
tensor veli palatini, medial to the foramina ovale and spin-
osum to the sphenoid spine and the posterior margin of the gle-
noid fossa. The sharply angled inferior boundary is situated at
the junction of the posterior digastric belly and the greater
hyoid cornu. The poststyloid part, which contains the internal
carotid artery, internal jugular vein, and the initial extracranial
segment of cranial nerves IX through XII, is separated from the
infratemporal fossa by the posterolateral portion of the presty-
loid part. The glossopharyngeal nerve exits the skull through
the intrajugular part of the jugular foramen, anterior to the
vagus and accessory nerves, and passes forward, medial to the
styloid process in close relationship to the lateral surface of the
carotid artery as the artery enters the carotid canal (Fig. 1-9).
Care is required to avoid injury to the glossopharyngeal nerve
if the artery is to be mobilized at the carotid canal. The vagus
nerve leaves the skull through the anteromedial edge of the
intrajugular part of the foramen and courses deep within the
carotid sheath, between the internal carotid artery and the
jugular vein. The accessory nerve exits the intrajugular part
and runs backward, lateral to the jugular vein and medial to
the styloid process and the posterior belly of the digastric mus-
cle, to innervate the sternocleidomastoid muscle.
The hypoglossal nerve exits through the hypoglossal canal,
deep to the jugular vein and to the nerves emerging from the
jugular foramen, and runs downward, between the carotid
artery and the jugular vein (Figs. 1-9 and 1-10). It becomes
supercial at the level of the angle of the jaw where it crosses
the internal and external carotid arteries, close to the level of
the common carotid bifurcation, to innervate the tongue.
Pterygopalatine Fossa
The pterygopalatine fossa, which opens laterally into the
medial part of the infratemporal fossa, is bounded posteriorly
by the sphenoid pterygoid process, medially by the palatine
perpendicular plate, that bridges the interval between the max-
illa and pterygoid process, and opens superiorly through the
medial part of the inferior orbital ssure into the orbital apex
(Figs. 1-5, 1-9, and 1-10) (11). The fossa contains the maxillary
nerve, pterygopalatine ganglion, maxillary artery, and their
branches, all embedded in fat tissue. Its lateral boundary, the
pterygomaxillary ssure, opens into the infratemporal fossa
and allows passage of the maxillary artery from the infratem-
poral into the pterygopalatine fossa, where the artery gives rise
to its terminal branches. The lower part of the fossa is funnel-
shaped, with its inferior apex opening into the greater and
lesser palatine canals, which transmit the greater and lesser
palatine nerves and vessels, and communicate with the oral
cavity. The sphenopalatine foramen, located in the upper part
of the fossas medial wall, conveys the sphenopalatine nerve
and vessels, and opens into the superior nasal meatus just
above the root of the middle nasal concha. The foramen rotun-
dum opens just below the superior orbital ssure through the
superior part of the posterior wall of the fossa. The pterygoid
canal opens through the sphenoid pterygoid process inferome-
dial to the foramen rotundum and conveys the vidian nerve
carrying autonomic bers to the pterygopalatine ganglion. The
maxillary nerve, after entering the fossa, gives off ganglionic
branches to the pterygopalatine ganglion. It then deviates lat-
erally just beneath the inferior orbital ssure, giving rise to, in
order, the zygomatic and posterosuperior alveolar nerves out-
side of the periorbita. It then turns medially as the infraorbital
nerve, passing through the inferior orbital ssure to enter the
infraorbital groove, where the anterior and middle superior
alveolar nerves arise. Finally, it exits the infraorbital foramen to
terminate on the cheek. The pterygopalatine ganglion, located
in front of the pterygoid canal and inferomedial to the maxil-
lary nerve, receives communicating rami from the maxillary
nerve and gives rise to the greater and lesser palatine nerves
from the lower surface of the ganglion, the sphenopalatine
nerve and pharyngeal branch from the medial surface, and the
orbital branch from the superior surface. The vidian nerve is
formed by the union of the greater petrosal nerve, which con-
veys parasympathetic bers arising from the facial nerve at the
level of the geniculate ganglion, and the deep petrosal nerve,
which conveys sympathetic bers from the carotid plexus, to
reach the lacrimal gland and nasal mucosa. The parasympa-
thetic bers synapse in the pterygopalatine ganglion, whereas
the sympathetic bers do not. The sympathetic bers synapse
in the superior cervical sympathetic ganglion.
The third or pterygopalatine segment of the maxillary
artery enters the pterygopalatine fossa by passing through
the pterygomaxillary fissure. This segment courses in an
anterior, medial, and superior direction and gives rise to the
infraorbital artery, which passes through the inferior orbital
fissure and courses with the infraorbital nerve; the posterosu-
perior alveolar artery, which descends to pierce the postero-
lateral wall of the maxilla; the recurrent meningeal branches,
which pass through the foramen rotundum; and the greater
and lesser palatine arteries, which descend through the
greater and lesser palatine canals; the vidian artery to the
pterygoid canal; the pharyngeal branch to the palatovaginal
canal; and finally the sphenopalatine artery, which passes
through the sphenopalatine foramen to reach the nasal cav-
ity and is considered to be the terminal branch of the maxil-
lary artery because of its large diameter. The arterial struc-
tures in the pterygopalatine fossa are located anterior to the
neural structures.
Arterial Relationships
The arteries that may be involved in pathological abnormal-
ities involving the temporal bone include the upper cervical
and petrous portions of the internal carotid artery, the posteri-
orly directed branches of the external carotid artery, and the
upper portion of the vertebral artery.
Common Carotid Artery
The common carotid artery bifurcates into the internal and
external carotid arteries at the level of the upper border of the
thyroid cartilage. The internal carotid artery initially ascends
relatively superficial in the carotid triangle of the neck, but
assumes a much deeper position after passing medial to the
posterior belly of the digastric (Figs. 1-9 and 1-10). Below the
digastric, it is crossed by the hypoglossal nerve and the ansa
cervicalis, and by the lingual and facial veins. Medial to the
digastric, it is crossed by the stylohyoid muscle and the occip-
ital and posterior auricular arteries. Superior to the digastric,
the internal carotid artery is separated from the external carotid
artery by the styloid process and the muscles attached to it. At
the entrance into the carotid canal, the artery is involved by a
dense sheath of connective tissue and is separated from the
internal jugular vein by the hypoglossal nerve and by the
nerves exiting from the jugular foramen.
The internal carotid artery passes, almost straightly upward,
posterior to the external carotid artery and anteromedial to the
internal jugular vein to reach the carotid canal. At the level of
the skull base, the internal jugular vein courses just posterior to
the internal carotid artery, being separated from it by the
carotid ridge. Between them, the glossopharyngeal nerve is
located laterally and the vagus, accessory, and hypoglossal
nerves medially.
After the internal carotid artery enters the carotid canal with
the carotid sympathetic nerves and surrounding venous
plexus, it ascends a short distance (the vertical segment), reach-
ing the area below and slightly behind the cochlea, where it
turns anteromedially at a right angle (the site of the lateral
bend) and courses horizontally (the horizontal segment)
toward the petrous apex (Figs. 1-8-1-10). At the medial edge of
the foramen lacerum, it turns sharply upward at the site of the
medial bend to enter the posterior part of the cavernous sinus.
The petrolingual ligament, which extends from the lingual
process of the sphenoid bone to the petrous apex, crosses above
the junction of the petrous and cavernous carotid.
External Carotid Artery
The external carotid artery ascends anterior to the internal
carotid artery on the posteromedial margin of the parotid gland
and medial to the digastric and stylohyoid muscles. Proximal
to its terminal bifurcation into the maxillary and the supercial
temporal arteries, it gives rise to six branches that can be
divided into anterior and posterior groups according to their
directions. The latter group is related to the region of the tem-
poral bone.
The ascending pharyngeal artery, the rst branch of the pos-
terior group, often provides the most prominent supply to the
meninges around the jugular foramen (18). It arises either at the
bifurcation or from the lowest part of the external or internal
carotid arteries. Rarely, it arises from the origin of the occipital
artery. It courses upward between the internal and the external
carotid arteries, giving rise to numerous branches to neighbor-
ing muscles, nerves, and lymph nodes. Its meningeal branches
pass through the foramen lacerum to be distributed to the dura
lining the middle fossa and through the jugular foramen or the
hypoglossal canal to supply the surrounding dura of the pos-
terior cranial fossa. The ascending pharyngeal artery also gives
rise to the inferior tympanic artery, which reaches the tympanic
cavity by way of the tympanic canaliculus along with the tym-
panic branch of the glossopharyngeal nerve.
The occipital artery, the second and largest branch of the
posterior group, arises from the posterior surface of the exter-
nal carotid artery and courses obliquely upward between the
posterior belly of the digastric muscle and the internal jugular
vein, and then medial to the mastoid process and either super-
cial or deep to the longissimus capitis muscle (Fig. 1-5). It
courses deep to the latter muscle if it courses in the occipital
groove of the mastoid bone, which is located medial to the
digastric groove. After passing the longissimus capitis muscle,
the occipital artery courses deep to the splenius capitis muscle,
nally reaching a subcutaneous location by piercing the fascia
between the attachment of the sternocleidomastoid and the
trapezius muscles to the superior nuchal line. The occipital
artery gives rise to several muscular and meningeal branches,
anastomoses with other branches of the external carotid includ-
ing the ascending pharyngeal and superficial temporal and
also with branches of the vertebral artery. Its meningeal
branches, which enter the posterior fossa through the jugular
foramen or the condylar canal, may make a signicant contri-
bution to tumors of the jugular foramen.
The posterior auricular artery, the last branch in the posterior
group, arises above the posterior belly of the digastric muscle
and travels between the parotid gland and the styloid process.
At the anterior margin of the mastoid process, it divides into
auricular and occipital branches, which are distributed to the
postauricular and the occipital regions, respectively. The stylo-
mastoid branch, which arises below the stylomastoid foramen,
enters the stylomastoid foramen to supply the facial nerve. Its
loss can lead to a facial palsy, even though it anastomoses with
the petrosal branch of the middle meningeal artery. The poste-
rior auricular branch may share a common trunk with the
occipital artery, or sometimes it is absent, in which case, the
occipital artery gives rise to the stylomastoid artery. Members
of the anterior group, whose origins may be visualized in
exposing lesions in the region, include the superior thyroid,
lingual, and facial arteries.
RHOTON
The superficial temporal artery arises from the external
carotid artery in the substance of the parotid gland behind the
neck of the mandible where it is crossed by the temporal and
zygomatic branches of the facial nerve (Fig. 1-5). It ascends
over the posterior root of the zygoma and divides into anterior
and posterior branches that run with the supercial temporal
vein and the auriculotemporal nerve over the supercial tem-
poralis fascia.
Vertebral Artery
The vertebral artery, above the transverse foramen of the
axis, veers laterallt to reach the transverse foramen of the atlas,
which is situated further lateral than the transverse foramen of
the axis. The artery, after ascending through the transverse
process of the atlas, is located on the medial side of the rectus
capitis lateralis muscle. From here, it turns medially behind
the lateral mass of the atlas and the atlanto-occipital joint and
is pressed into the groove on the upper surface of the posterior
arch of the atlas. The rst cervical nerve courses on the lower
surface of the artery between the artery and the posterior arch
of the atlas. After passing medially above the lateral part of the
posterior arch of the atlas, the artery enters the vertebral canal
by passing below the lower, arched border of the posterior
atlanto-occipital membrane, which transforms the sulcus in
which the artery courses on the upper edge of the posterior
arch of the atlas into an osseobrous casing that may ossify,
transforming it into a complete or incomplete bony canal sur-
rounding the artery.
Opening the dura exposes the intradural segment of the ver-
tebral artery. As the artery pierces the dura, it is encased in a
brous tunnel that binds the posterior spinal artery, dentate
ligament, rst cervical nerve, and the spinal accessory nerve to
the vertebral artery. Care should be taken to preserve the pos-
terior spinal artery during the dural opening and mobilization
of the vertebral artery because it may be incorporated into the
dural cuff around the vertebral artery. The intradural segment
of the vertebral artery, after emerging from the brous dural
tunnel, ascends in front of the rootlets of the hypoglossal nerve
to reach the front of the medulla. Oblongata where it unites
near the junction of pons and medulla with its mate to form the
basilar artery. Before reaching the lower border of pons, the
vertebral artery gives off the PICA, which courses backward
around the lateral surface of the medulla and between the
rootlets of glossopharyngeal, vagus, and accessory nerves.
Venous Relationships
The venous drainage of the structures of the skull base is
through the internal jugular veins, the sinuses in the dura
mater, and a series of emissary veins communicating the intra-
and extracranial compartments (25). The superior petrosal
sinus sits on the petrous ridge and connects the cavernous
and transverse sinuses. It receives tributaries from the inferior
surface of the temporal lobe and from the petrosal veins that
drain the cerebellum and brainstem. The inferior petrosal sinus
courses along the petro-occipital ssure and drains the clival
area. It consists of one or more channels that, at its lower end,
course rostral or caudal to or between the nerves passing
through the jugular foramen. It enters the medial wall of the
jugular bulb just anterior to where the cranial nerves descend
in the anteromedial wall of the jugular bulb (18). It joins the
cavernous sinus at its upper margin. The transverse sinus
begins at the level of the internal occipital protuberance and
passes laterally and forward to the posterolateral part of the
temporal bone where it joins the superior petrosal sinus and
continues as the sigmoid sinus. It receives drainage from the
tentorial surface of the cerebellum through the tentorial
sinuses and from the temporal lobe through the vein of Labb.
The basilar venous plexus consists of multiple interconnecting
channels situated between the layers of dura mater on the
clivus. It forms the largest communication between the paired
cavernous sinus and communicates through the inferior pet-
rosal sinuses with the sinuses in the region of the foramen
magnum (10).
SURGICAL APPROACHES
The suboccipital retrosigmoid and far lateral approaches to
intradural pathologies arising in the region of the cerebello-
pontine angle, lower clivus, and foramen magnum, are
reviewed later in this volume. The approaches reviewed here
are those directed through the temporal bone.
Middle Fossa Approach
The middle fossa approach to the internal acoustic meatus
is usually selected for small tumors that are located predom-
inantly within the internal acoustic meatus in which there is
an opportunity to preserve hearing. With this approach, the
meatus is approached from above, through a temporal cran-
iotomy located above the ear and zygoma (Figs. 1-7 and 1-11)
(2). The dura under the temporal lobe is elevated from the
floor of the middle cranial fossa until the arcuate eminence
and the greater petrosal nerve are identified. The distance
from the inner table of the skull to the facial hiatus, through
which the greater petrosal nerve passes, ranges from 1.3 to 2.3
cm (average, 1.7 cm) (42). When separating the dura from the
floor of the middle fossa, one should remember that bone
may be absent over all or part of the geniculate ganglion. In
our previous study of 100 temporal bones, all or part of the
geniculate ganglion and the genu of the facial nerve were
found to be exposed in the floor of the middle fossa in 15
bones (15%) (31). In 15 other specimens, the geniculate gan-
glion was completely covered, but no bone extended over the
greater petrosal nerve. The greatest length of greater petrosal
nerve covered by bone was 6.0 mm. More than 50% of the
specimens had less than 2.5 mm of greater petrosal nerve cov-
ered. It also is important to remember that the petrous seg-
ment of the carotid artery may be exposed without a covering
of bone in the floor of the middle fossa deep to the greater
petrosal nerve (17) In a previous study, we found that a 7-mm
length of petrous carotid artery may be exposed without a
RHOTON
FIGURE 1-11. Middle fossa approach to the internal acoustic meatus. A, the
vertical line shows the site of the scalp incision and the stippled area outlines
the bone flap bordering the middle fossa floor. B, the dura has been elevated
to expose the middle meningeal artery, the greater petrosal nerve, and the
arcuate eminence. C, bone has been removed to expose the junction of the
greater petrosal nerve and the geniculate ganglion. A portion of the upper
wall of the internal meatus has been removed. The upper surface of the arcu-
ate eminence has been drilled to expose the superior semicircular canal. In the
middle fossa approach, for an acoustic neuroma, the cochlea and semicircular
canal are not opened, as seen in this dissection illustrating some of the impor-
tant structures that are to be avoided in opening the meatus. D, enlarged
view. The cochlea, located below the middle fossa floor in the angle between
the facial and greater petrosal nerves, has been opened in the area anterome-
dial to the meatal fundus. The roof of the meatus has been opened to expose
the superior vestibular nerve, which innervates the ampullae of the superior
and lateral canals and the meatal segment of the facial nerve. E, the vestibule
and semicircular canals are located posterolateral and the cochlea is located
anteromedial to the meatal fundus. The tensor tympani is layered along the
anterior edge and the greater petrosal nerve above the petrous carotid. F,
enlarged view. The vertical crest (Bills bar) separates the facial and superior
vestibular nerves at the meatal fundus. The superior and inferior vestibular
nerves are located posteriorly and the facial and cochlear nerves anteriorly in
the meatus, with the cochlear nerve passing below the facial nerve to enter the
modiolus. The labyrinthine segment of the facial nerve courses superolateral
to the cochlea. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cra-
nial nerve; Coch., cochlear; Emin., eminence; Gang., ganglion; Genic.,
geniculate; Gr., greater; Inf., inferior; Int., internal; Laby., labyrinthine;
M., muscle; Meat., meatal; Men., meningeal; Mid., middle; N., nerve; Pet.,
petrosal, petrous; Post., posterior; Seg., segment; Sup., superior; Tens., ten-
sor; Tymp., tympani; Vert., vertebral; Vest., vestibular.
bony covering in the area below where the greater petrosal
nerve passes below the lateral margin of the trigeminal gan-
glion to reach the vidian canal at the anterior margin of the
anterior margin of the foramen lacerum (30, 31). The foramen
spinosum and middle meningeal artery and the foramen
ovale and third trigeminal division are situated at the anterior
margin of the extradural exposure. The extradural exposure
can usually be completed without obliterating the middle
meningeal artery at the foramen spinosum.
Two different methods are used for exposing the internal
acoustic meatus. One, the older method, is to remove bone
over the greater petrosal nerve and to follow it to the genic-
ulate ganglion and the genu of the facial nerve. From here,
the labyrinthine portion of the facial nerve is followed to
the lateral end of the internal auditory canal, after which
the canal is unroofed. The other or preferred method is
begun by drilling at the petrous ridge above the fundus of
the meatus in the area medial to the arcuate eminence. The
angle between the long axis of the superior semicircular
canal or the greater petrosal nerve and the long axis of the
internal acoustic meatus is helpful in selecting the site for
drilling. The long axis of the central part of the internal
acoustic meatus is located an average of 61 degrees behind
the long axis of the greater petrosal nerve and an average of
37 degrees medial to the long axis of the arcuate eminence
and superior semicircular canal. The drilling is directed
anterolateral from the meatal porus to the meatal fundus
where the vertical crest is identified.
The lateral part of the bone removal near the meatal fundus
is limited posteriorly by the superior semicircular canal and
vestibule, which are located a few millimeters behind and ori-
ented parallel to the labyrinthine segment of the facial nerve
(Figs. 1-7 and 1-11). The anteromedial edge of the exposure is
limited by the cochlea, which sits only a few millimeters ante-
rior to the site of bone removal, in the angle between the
labyrinthine portion of the facial nerve and the greater petrosal
nerve. The cochlea and the semicircular canals should be
avoided in this approach if hearing is to be preserved. The ver-
tical crest, which is identied at the upper edge of the meatal
fundus, provides a valuable landmark for identifying the facial
nerve. In the nal stage of bone removal, the upper wall of the
internal auditory canal is removed to expose the dura lining the
entire superior surface of the internal auditory canal from the
vertical crest to the porus. The dura is opened to expose the
pathology.
The extended middle fossa approach used for the removal of
larger acoustic neuromas includes wider opening of the poste-
rior part of the petrous pyramid (21, 28, 42, 43). This approach
combines different degrees of resection of the bony labyrinth
with the subtemporal transtentorial routes (Fig. 1-12).
Extending the resection of the petrous bone posteriorly over the
mastoid and the bony labyrinth exposes the whole intrapetrous
course of the facial nerve, and provides access to the cerebello-
pontine angle by a combination of subtemporal, trans-
labyrinthine, and presigmoid routes, all directed through the
posterior part of the oor of the middle fossa.
Subtemporal Anterior Transpetrosal Approach
This approach is made through a temporal or orbitozygo-
matic craniotomy that extends down to the oor of the middle
fossa (Figs. 1-12 and 1-13) (19). The dura is carefully elevated
from the floor of the middle fossa to expose the middle
meningeal artery, which may be obliterated and divided at the
foramen spinosum. Further elevation of the dura toward the
petrous ridge will expose the arcuate eminence and greater
petrosal nerve posteriorly. The cochlea, which is to be pre-
served, and the anterior wall of the internal auditory canal con-
stitute the lateral limit of the exposure through the petrous
apex. Aportion of the bone layer above the superior wall of the
internal auditory canal, which averages 5 mm (range, 37 mm)
in thickness, can be removed with a drill to improve the expo-
sure (44). The petrous carotid forms the anterior limit of the
exposure. The limit above the medial part of the bone resection
is the trigeminal nerve in Meckels cave. Drilling is directed
behind the petrous carotid, through the petrous apex medial to
the cochlea and under the trigeminal nerve. The petrous apex
is removed and the bone removal is extended to the lateral
side of the clivus, exposing the inferior petrosal sinus at the lat-
eral edge of the clivus. Care is required to prevent damage to
the abducens nerve as it passes through Dorellos canal located
at the upper edge of the petroclival ssure. The width of the
bone resection from the trigeminal impression to the posterior
wall of the internal auditory canal averages 13 mm (range,
914 mm) (44). The depth of the exposure, from the trigeminal
ganglion to the petroclival fissure, averages 13 mm (range,
917 mm). The cochlea lies below the oor of the middle fossa
near the apex of the angle formed by the greater petrosal nerve
anteriorly and the internal acoustic meatus posteriorly. The
cochlea is to be avoided if hearing is to be preserved.
After the bone removal is completed, the superior petrosal
sinus is obliterated and divided in the area just lateral to the
trigeminal nerve, and the dural incision is extended across the
tentorium. The dural leaets of the tentorium are retracted with
sutures and the dural incision is carried downward below the
superior petrosal sinus to the lower margin of the opening
through the petrous apex. The approach is then directed
between the lower margin of the trigeminal nerve above, and
the internal acoustic meatus inferiorly and laterally (20).
The exposure is small, as described above, and may require
signicant temporal lobe retraction, especially if the goal is to
reach the lower aspect of the brainstem. To reach the anterior
aspect of the pons, the view must be directed from lateral to
medial above the internal auditory canal. The angles of view
through the area of the petrousectomy can be increased if the
cranium is approached at a higher level through a frontotempo-
ral craniotomy combined with zygomatic arch resection.
Translabyrinthine Approach
In the translabyrinthine approach, the internal acoustic mea-
tus and cerebellopontine angle are approached through a mas-
toidectomy and labyrinthectomy (Fig. 1-6) (16, 29, 38) There
are two goals of bone removal in this approach. The rst is to
expose the dura of Trautmans triangle on the posterior surface
of the temporal bone facing the cerebellopontine angle. The
second is to remove enough bone to be able to identify the
nerves lateral to the tumor as they course through the internal
auditory canal and by the transverse and vertical crests. The
approach may also be combined with a retrosigmoid or a
supra- and infratentorial presigmoid approach.
Aretroauricular incision starts above the pinna and extends
inferiorly to the mastoid tip (3). Aap of periosteum and soft
tissues overlying the mastoid and retromastoid areas is ele-
vated. The cortical bone over the mastoid is drilled away and
the mastoid air cells are removed, exposing the mastoid
antrum, the cortical bone around the labyrinth, and the digas-
tric ridge leading anteriorly to the mastoid segment of the
facial nerve as it exits the stylomastoid foramen and the sin-
odural angle. Drilling is continued to expose the semicircular
canals and to skeletonize the sigmoid sinus, middle fossa dura,
mastoid segment of the facial nerve, and the upper surface of
the jugular bulb, leaving only a thin shell of bone over these
structures. The lateral semicircular canal is the most laterally
projecting canal and is the first one encountered by this
approach. It provides a valuable landmark in identifying the
tympanic segment of the facial nerve and the other canals. The
nerve is found below the lateral canal. The retrofacial air cells
are removed and the dome of the jugular bulb is identied
inferiorly. In removing bone behind the internal acoustic mea-
tus, it is important to remember that the jugular bulb may
bulge upward behind the posterior semicircular canal or inter-
RHOTON
FIGURE 1-12. AD, anterior petrosectomy and extended middle fossa
approach. A, the site of the bone ap is the same as shown in Figure 1-11A. The
dura has been elevated from the oor of the middle fossa. Bone has been removed
to expose the geniculate ganglion, the dura lining the internal acoustic meatus,
the tensor tympani, some of the petrous carotid, and the superior semicircular
canal. B, the bone of the petrous apex between the trigeminal nerve and the inter-
nal acoustic meatus has been removed to expose the side of the clivus. C, the
exposure under the trigeminal nerve extends to the edge of the inferior petrosal
sinus. D, the posterior fossa dura has been opened to expose the prepontine cis-
tern, basilar artery, and abducens nerve. (Continues)
nal auditory meatus. The vestibular aqueduct and the
endolymphatic sac may be opened and removed during the
bone removal between the meatus and the jugular bulb. The
cochlear canaliculus will be seen deep to the vestibular aque-
duct as bone is removed in the area between the meatus and
the jugular bulb. The lower end of the cochlear canaliculus is
situated just above the area where the glossopharyngeal nerve
enters the medial half of the jugular foramen. The labyrinthec-
tomy portion of the procedure involves removing the semicir-
cular canals and the vestibule to expose the dura lining the
internal auditory canal. The lateral and posterior semicircular
canals are drilled away. As the bone removal proceeds medi-
ally, the ampullae of the lateral and superior semicircular
canals are exposed. At this point some bleeding can occur as
the subarcuate artery is encountered in the bone near the cen-
ter of the superior semicircular canal. The vestibule is an oval-
shaped cavity located immediately lateral to the internal
acoustic meatus, which forms the communication between the
semicircular canals and the cochlea. Bone is removed medial
and posterior to the vestibule, completely exposing it anterior
and inferior to the facial nerve. Care is required to avoid injury
to the facial nerve as it courses below the lateral canal and the
ampullae of the posterior canal and around the superolateral
margin of the vestibule.
FIGURE 1-12. (Continued) EH, anterior petrosectomy and extended mid-
dle fossa approach. E, additional bone has been removed around the internal
acoustic meatus and the dura opened to expose the facial and vestibulo-
cochlear nerves. F, the exposure has been extended lateral to the internal
acoustic meatus. The tegmen has been opened to expose the head of the incus
in the epitympanic area. The osseous capsule of the labyrinth has been opened
to expose the semicircular canals. The presigmoid dura behind the labyrinth
has been exposed and opened. G, a translabyrinthine approach directed
through the middle fossa has been completed by removing the semicircular
canals and vestibule. The dura has been opened to give an exposure through
the middle fossa similar to that seen with the presigmoid approach. The
labyrinthine, tympanic, and mastoid segments of the facial nerve have been
exposed. H, this extended middle fossa exposure extends from the lateral wall
of the cavernous sinus, across the trigeminal nerve to the area lateral to the
internal acoustic meatus, and provides wide access to the anterior part of the
posterior fossa. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar
artery; Bas., basilar; Car., carotid; Cav., cavernous; Chor., chorda; CN, cra-
nial nerve; Ext., external; Gang., ganglion; Gen., geniculate; Genic., genic-
ulate; Inf., inferior; Int., internal; Laby., abyrinthine; Lat., lateral; M., mus-
cle; Mast., mastoid; Men., meningeal; Mid., middle; N., nerve; P.C.A.,
posterior cerebral artery; Pet., petrosal, petrous; P.I.C.A., posteroinferior
cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg.,
segment; Sup., superior; Tens., tensor; Tymp., tympani; Tent., tentorial;
Trig., trigeminal; Tymp., tympani, tympanic.
RHOTON
FIGURE 1-13. AF, subtemporal exposure of the right middle, infratem-
poral, and posterior fossae. A, the insert shows the side of the scalp incision.
A frontotemporal craniotomy has been completed and the dura has been ele-
vated from the middle fossa floor and lateralwall of the cavernous sinus. B,
enlarged view. The bony roof over the geniculate ganglion and internal
meatus has been removed and the dura lining the meatus opened to expose
the facial and superior vestibular nerves. C, additional middle fossa floor
has been removed to expose the petrous carotid, the cochlea in the angle
between the greater petrosal nerve and pregeniculate part of the facial nerve,
the semicircular canals and tympanic cavity. The tensor tympani muscle
and eustachian tube are exposed in front of the petrous carotid artery. D, the
bone between the superior and posterior canals has been removed to expose
the vestibule with which both ends of the semicircular canals communicate.
The vestibule contains the utricle and saccule and communicates below the
fundus of the meatus with the cochlea. The meatal segment of the facial
nerve courses in the internal acoustic meatus, the labyrinthine segment
between the semicircular canals and the cochlea, the tympanic segment
between the anterior margin of the lateral canal and the oval window on the
medial side of the tympanic cavity, and the mastoid segment descends to
exit the stylomastoid foramen. E, the petrous apex, medial to the cochlea and
extending under the trigeminal nerve, has been removed to expose the lat-
eral edge of the clivus and the posterior fossa dura. F, the medial tentorial
edge has been divided behind the petrous ridge to expose the oculomotor,
trochlear, and trigeminal nerves and the basilar artery. (Continues)
FIGURE 1-13. (Continued) GL, subtemporal exposure of the right middle,
infratemporal, and posterior fossae. G, the dural opening has been extended
downward to expose the lateral edge of the clivus and the inferior petrosal
sinus coursing along the petroclival fissure. The abducens nerve and the
AICA are in the lower margin of the exposure. H, an osteotomy of the zygo-
matic arch and the floor of the middle fossa surrounding the mandibular
fossa has been completed to aid in exposing the infratemporal fossa. I, the
mandibular fossa and floor of the middle fossa, extending medially to the level
of the foramen ovale, have been removed. Branches of the mandibular nerve
and maxillary artery are exposed in the infratemporal fossa. The greater pet-
rosal nerve joins the deep petrosal nerve from the carotid sympathetic plexus
to form the vidian nerve, which passes forward in the vidian canal to reach
the pterygopalatine fossa. J, the upper portion of the cervical carotid is
exposed medial to the jugular foramen. The petrous carotid crosses behind the
eustachian tube and tensor tympani. K, the eustachian tube and tensor tym-
pani have been resected, the petrous carotid reflected forward out of the carotid
canal, the petrous apex removed, and the posterior fossa dura opened to expose
the vertebral artery and the AICA. L, enlarged view. The right vertebral
artery has been displaced forward to expose the left vertebral artery. The
AICA passes toward the nerves entering the internal acoustic meatus. A.,
artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., ante-
rior; Bas., basilar; Car., carotid; Chor., chorda, choroidal; CN, cranial nerve;
Comm., communicating; Eust., eustachian; Gang., ganglion; Gen., genic-
ulate; Genic., geniculate; Gr., greater; Inf., inferior; Int., internal; Jug.,
jugular; Laby., labyrinthine; Lat., lateral; M., muscle; Mandib., mandibu-
lar; Mast., mastoid; Max., maxillary; Meat., meatal; Men., meningeal; Mid.,
middle; N., nerve; P.C.A., posterior cerebral artery; Pet., petrosal, petrous;
Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; Sup.,
superior; Temp., temporal; Tens., tensor; Trig., trigeminal; Tymp., tym-
pani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.
The internal auditory canal is located medial and anterior to
the tympanic segment of the facial nerve. The dura lining the
internal canal is exposed by drilling away the semicircular
canals and vestibule and the bone around the superior, poste-
rior, and inferior margins of the internal canal. Further bone
removal at the lateral end of the meatus exposes the transverse
and vertical crests (Fig. 1-2). The intrameatal portion of the
facial nerve is separated from the superior vestibular nerve at
the lateral end of the canal by the vertical crest, also called
Bills bar, that can be used to positively identify the facial nerve
(13, 16). The initial part of labyrinthine segment of the facial
nerve, which lies just in front of the vertical crest, is exposed at
the meatal fundus. After identifying the facial nerve, the dura
lining the meatus is opened. The dural incision in Trautmans
triangle is V-shaped with the apex of the V extending to the
incision along the meatal dura. One limb of the V extends
below the superior petrosal sinus and the other limb extends
above the jugular bulb. The dural ap is then reected posteri-
orly to expose the structures in the meatus and the cerebello-
pontine angle. The subarcuate artery, or the AICA, may be
encountered in the dura of Trautmans triangle. Usually, the
subarcuate artery arises from the AICAand passes through the
dura on the upper posterior wall of the meatus as a ne stem.
Occasionally, however, the subarcuate artery, along with its ori-
gin from the AICA, may be incorporated into the dura on the
posterior face of the temporal bone. The approach may include
transection of the external canal and obliteration of the middle
ear with packing of the eustachian tube at closure.
Transcochlear Approach
The transcochlear approach is primarily an anteromedial
extension of the translabyrinthine approach (Fig. 1-6) (3, 15,
16). It usually includes division and closure of the external
canal, resection of at least the posterior part of the osseous
external canal, and the tympanic membrane and ossicles, and
obliteration of the eustachian tube. After exposing the dura lin-
ing the internal auditory canal, as described for the
translabyrinthine approach, the incus is removed and the facial
nerve is exposed from the geniculate ganglion to the stylomas-
toid foramen. The greater superficial petrosal nerve is tran-
sected and the facial nerve is transposed posteriorly. In the
nal stage, the bone removal is carried through the facial canal,
after nerve transposition, and the cochlea and adjacent part of
the petrous apex are drilled away (Fig. 1-6).
Medially, the bone removal extends to the edge of the clivus,
exposing the inferior petrosal sinus from the jugular bulb
below to the superior petrosal sinus above. The ascending por-
tion of the petrous carotid is exposed at the anterior limit of the
dissection. The bone removal, which now extends to the lateral
edge of the clivus, could easily be carried medially into the
clivus. Extending the dural opening in this area permits visu-
alization of the abducent nerve medial to the internal acoustic
meatus, the lower margin of the trigeminal nerve, the nerves
entering the jugular foramen, a segment of the basilar artery,
and the origin and initial segment of the AICA.
An alternative to transposing the facial nerve is to complete
an extensive bone removal in the hypotympanic and retrofacial
areas extending forward to the carotid canal, thus skeletonizing
the mastoid segment of the facial nerve and leaving it sus-
pended in a shell of bone, as described by Gantz and Fisch (7).
In this approach, the external auditory canal is closed as a blind
sac and the tympanic membrane, incus, and body of the
malleus are removed (7). A mastoidectomy is performed,
including the removal of the retrofacial, retrolabyrinthine, and
supralabyrinthine compartments. The facial nerve is identied
at its tympanic segment and at the stylomastoid foramen. The
inferior part of the tympanic bone is removed to expose the
infralabyrinthine compartment, the jugular bulb, and the
intrapetrous carotid artery. The retrofacial dissection is carried
medially and superiorly, removing the semicircular canals and
vestibule. The dissection of the posterior fossa dura is carried
inferiorly around the internal auditory canal and under the
facial canal. The cochlea is drilled away by working inferior
and anterior to the facial canal. The facial canal is then left as a
bridge over the operative field and the dura is exposed
between the carotid artery and the jugular bulb.
Combined Supra- and Infratentorial
Presigmoid Approach
The presigmoid approach combines the supra- and infraten-
torial craniotomy centered on the mastoid and varying degrees
of mastoid and labyrinthine resection (Fig. 1-14). The minimal
degree of mastoid resection, which we refer to as a minimal
mastoidectomy, exposes only enough of the presigmoid dura to
open the dura in front of the sigmoid sinus for exposure of the
cerebellopontine angle (Figs. 1-15 and 1-16). The next more
extensive degree of mastoid resection, the retrolabyrinthine
modication, is a more complete mastoidectomy exposing the
bony capsule of the semicircular canals and skeletonizing at
least a portion of the facial nerve. In the partial labyrinthec-
tomy, one or two of the semicircular canals, commonly the
superior and/or posterior canals, are resected with preserva-
tion of the lateral canal. Removal of these canals may, but not
always, be associated with the loss of hearing (37). The poste-
rior canal may be removed to increase access to the posterior
fossa, and removing the superior canal alone gives a more
direct access to the petrous apex along the middle fossa. The
next more extensive modification is the translabyrinthine
approach, in which the semicircular canals and vestibule are
resected uniformly, resulting in the loss of hearing. The
translabyrinthine approach provides excellent access to the
internal auditory canal. The next more extensive modication
is the transcochlear approach, in which the cochlea located
anteromedial to the fundus of the meatus is removed, thus pro-
viding access to the medial part of the petrous apex and the
side of the clivus. Another modification, which we call the
extended translabyrinthine approach, and is similar to the
transcochlear approach, involves drilling bone both anterior
and posterior to the facial nerve, leaving the facial nerve skele-
tonized in a column of bone and working both anterior and
RHOTON
posterior to the facial nerve to remove the cochlea and access
the side of the clivus. Gaining access for drilling the cochlea
anterior to the facial nerve commonly requires that at least part
of the posterior part of the external canal be removed, that the
tympanic cavity be obliterated, and that the internal carotid
artery be exposed below the promontory.
In evaluating these approaches in our laboratory, we have
found that the minimal mastoidectomy gives approximately the
same exposure as the retrolabyrinthine approach, but is done at
reduced risk since the semicircular canals and facial nerve are
not skeletonized (Figs. 1-14 and 1-15). Removing the posterior
canal increases access to the posterior fossa, but access is only
slightly increased over that achieved with the retrolabyrinthine
approach. Removing the superior canal increases access to the
middle fossa and petrous apex and reduces the needed retrac-
tion of the temporal lobe. The translabyrinthine approach does
not signicantly increase the access to the area medial to the
porus of the internal acoustic meatus over that achieved with
the minimal mastoidectomy or retrolabyrinthine approach, but
does provide access to the internal auditory canal. The
transcochlear modication, in which bone is removed up to the
edge of the clivus, does signicantly increase access to the front
of the brainstem and clivus over that achieved with the lesser
degrees of bony resection. The retrosigmoid, the presigmoid
minimal mastoidectomy, and the retrolabyrinthine approaches
were compared and yielded nearly the same exposure of the
cerebellopontine angle, but the retrosigmoid approach did not
provide the additional exposure of the middle fossa and petrous
FIGURE 1-14. AD, presigmoid approach.
A, the insert shows the temporo-occipital cran-
iotomy and the mastoid exposure. The mas-
toidectomy has been completed and the dense
cortical bone around the labyrinth has been
exposed. The tympanic segment of the facial
nerve and the lateral canal are situated deep to
the spine of Henley. Trautmans triangle, the
patch of dura in front of the sigmoid sinus, faces
the cerebellopontine angle. B, the presigmoid
dura has been opened and the superior petrosal
sinus and tentorium divided, taking care to pre-
serve the vein of Labb that joins the transverse
sinus, and the trochlear nerve that enters the
anterior edge of the tentorium. The abducens
and facial nerves are exposed medial to the
vestibulocochlear nerve. The posteroinferior
cerebellar artery courses in the lower margin of
the exposure with the glossopharyngeal and
vagus nerves. The SCApasses below the oculo-
motor and trochlear nerves and above the
trigeminal nerve. C, the semicircular canals
have been opened. The superior canal is located
under the middle fossas arcuate eminence and
the posterior canal is located immediately lat-
eral to the posterior wall of the internal acoustic
meatus. D, labyrinthine exposure in another
specimen. The tympanic segment of the facial
nerve courses below the lateral canal and turns
downward as the mastoid segment where it
gives origin to the chorda tympani, seen
ascending along the inner surface of the tym-
panic membrane and neck of the malleus. The
head of the malleus and incus are located in the
epitympanic area above the level of the tym-
panic membrane. The mastoid antrum commu-
nicates through the aditus with the epitympanic
area and tympanic cavity. (Continues)
apex that could be achieved in the combined supra- and
infratentorial presigmoid approach.
The skin incision is started in the temporal region above the
zygoma, and extends above the ear and downward in the sub-
occipital area medial to the mastoid process (Figs. 1-14, 1-15,
and 1-17). The skin ap is reected forward to the level of the
external auditory canal. The temporal muscle is elevated and
reected anteriorly, and the muscles over the mastoid and sub-
occipital areas are swept inferiorly. A temporooccipital cran-
iotomy is performed and the transverse sinus is exposed. After
the bone ap is elevated, a mastoidectomy is carried out with-
out entering the labyrinth. The sigmoid sinus is skeletonized
from the sinodural angle to the jugular bulb. Bone is removed
superiorly to expose the oor of the middle fossa and the supe-
rior petrosal sinus. Trautmans triangle is exposed in the area
lateral to the otic capsule.
The dura mater is then incised along the base of the tempo-
ral craniotomy, while preserving the junction of the vein of
Labb with the transverse sinus. The posterior fossa dura is
opened anterior to the sigmoid sinus in Trautmans triangle.
The dural incision is extended across the superior petrosal
sinus to join the dural incision in the temporal dura. After divi-
RHOTON
FIGURE 1-14. (Continued) EH, presigmoid
approach. E, the labyrinthectomy has been
completed to expose the internal acoustic mea-
tus. F, the dura lining the meatus has been
opened and the facial nerve has been trans-
posed posteriorly. The facial segments are the
cisternal segment located in the cistern medial
to the meatal porus, the meatal segment that
extends laterally from the porus to the meatal
fundus, the labyrinthine segment that is
located between the fundus and the geniculate
ganglion, the tympanic segment that arises at
the ganglion and the sharp turn, the genu, and
passes between the lateral semicircular canal
and the oval window, and the mastoid segment
that descends to exit the stylomastoid foramen.
The labyrinthine segment courses between the
semicircular canals and vestibule on its pos-
terolateral side and the cochlea on its anterome-
dial margin. The superior and inferior vestibu-
lar nerves have lost their end organs with the
drilling of the semicircular canals and
vestibule. The cochlear nerve passes laterally to
enter the cochlea, which is still preserved in
the bone anteromedial to the fundus of the mea-
tus. G, the cochlear nerve has been divided and
reflected and bone removed to expose the
cochlea. H, the transcochlear exposure, com-
pleted by removing the cochlea and surround-
ing petrous apex, provides access to the front of
the brainstem and vertebrobasilar junction, but
at the cost of loss of hearing due to the
labyrinthectomy and almost certain temporary
or permanent facial weakness associated with
the posterior transposition of the facial nerve.
A., artery; Ac., acoustic; A.I.C.A., anteroinfe-
rior cerebellar artery; Bas., basilar; Br., branch;
Chor., chorda; Cist., cisternal; CN, cranial
nerve; Coch., cochlear; Gang., ganglion;
Genic., geniculate; Inf., inferior; Int., inter-
nal; Jug., jugular; Laby., labyrinthine; Lat.,
lateral; Marg., margin; Mast., mastoid; Meat.,
meatal; Memb., membrane; N., nerve; Pet.,
petrosal; P.I.C.A., posteroinferior cerebellar
artery; Post., posterior; S.C.A., superior cere-
bellar artery; Seg., segment; Sp., spine; Sup.,
superior; Tymp., tympani, tympanic; V., vein;
Vert., vertebral; Vest., vestibular.
sion of the superior petrosal sinus,
the tentorium is incised parallel to
and just behind the petrous ridge
and superior petrosal sinus. This
dural incision is extended from the
site of division of the superior pet-
rosal sinus through the medial edge
of the tentorium to the incisura
behind where the trochlear nerve
enters the tentorial edge. Care is
taken to avoid injury to the IVth cra-
nial nerve in its course near the ten-
torial margin. The posterior portion
of the temporal lobe is elevated and
the sigmoid sinus is displaced poste-
riorly along with the cerebellar hemi-
sphere while preserving the junction
of the vein of Labb with the sig-
moid sinus. The sigmoid sinus limits
the ability for superior retraction of
the temporal lobe and can be ligated
to improve the exposure if bilateral
venous angiography show adequate
communication through the torcular
to the opposite side (24). The petro-
clival region can be exposed from the
middle fossa and tentorial incisura
t o near t he f oramen magnum,
although access to the lower petrocli-
val region may be limited by the
jugular bulb. The presigmoid expo-
sure provides a shorter working dis-
tance to the petroclival area and pro-
vides multiple angles for dissection.
The major arteries in the posterior
fossa are easily accessible. The expo-
sure can also be combined with a far-
lateral approach (Fig. 1-17).
Subtemporal Preauricular
Infratemporal Fossa Approach
The subtemporal preauricular
infratemporal approach is directed
through the infratemporal and mid-
dle fossae to the part of the anterior
surface of the petrous bone located
medial to the cochlea and to the
petroclival region (Figs. 1-10, 1-13,
and 1-18). This description outlines
the full extent of the anatomic expo-
sure available through this approach,
but it can often be tailored to a
smaller, more limited, approach. A
curvilinear incision starting in the
frontal region turns downward in
front of the ear into the cervical
FIGURE 1-15. AD, comparison of the retrosigmoid
approach and the minimal mastoidectomy, retro-
labyrinthine, translabyrinthine, and transcochlear
approach modifications of the presigmoid approach.
A, retrosigmoid approach. The left cerebellum has
been elevated to expose the cranial nerves V through
XI in the cerebellopontine angle. The illustrations
from each step are to be compared with the views
from the other modifications of the approach. B, the
facial and vestibulocochlear nerves and the flocculus have been retracted to expose the side of the basilar artery.
C, for the minimal mastoidectomy, only enough bone is removed in front of the sigmoid sinus to open the pre-
sigmoid dura and divide the superior petrosal sinus and tentorium. D, the presigmoid dura has been opened
and the sigmoid sinus has been retracted posteriorly. The view is approximately the same as that seen with
the retrosigmoid exposure. The retrosigmoid approach provides a better view of the nerves entering the jugu-
lar foramen. (Continues)
region. The incision may be extended downward only to the
area just below the tragus if only the petrous apex and upper
part of the infratemporal fossa are to be exposed, but it can be
extended onto the upper neck if a neck dissection is needed.
The skin flap is separated from the underlying tissues and
reected forward. The facial nerve and its major branches are
identied distal to the stylomastoid foramen and followed to
the parotid gland. The parotid gland is separated from the mas-
seteric fascia to avoid excessive stretching of the facial nerve at
the stylomastoid foramen (33, 38, 39). The supercial tempo-
ralis fascia in which the upper facial branches course is sepa-
rated from the temporalis muscle and is reected forward to
prevent damage to the branch of the facial nerve to the frontalis
muscle as the zygomatic arch is exposed. The zygomatic arch is
divided at its anterior and posterior ends, and the temporalis
muscle, with the overlying segment of the zygomatic arch, is
reected downward. The mandibular condyle and the capsule
of the temporomandibular joint are either dislocated down-
ward or excised. The temporomandibular joint can be removed
in a single piece for later replacement by dividing the mandibu-
lar neck below the condyle and osteotomizing the middle fossa
floor around the mandibular fossa (Fig. 1-18). The internal
carotid artery, the internal jugular vein, and the vagus, acces-
sory, and hypoglossal nerves may be exposed in the neck if
needed. The posterior belly of the digastric muscle may be
divided and the styloid process resected.
RHOTON
FIGURE 1-15. (Continued) EH, compari-
son of the retrosigmoid approach and the min-
imal mastoidectomy, retrolabyrinthine, trans-
labyrinthine, and transcochlear approach
modications of the presigmoid approach. E,
the bony capsule around the semicircular
canals and the facial nerve have been exposed
for the retrolabyrinthine variant of the presig-
moid approach. F, the exposure with the retro-
labyrinthine version does not differ signifi-
cantly from that achieved with the minimal
mastoidectomy. G, the semicircular canals and
vestibule have been removed and the dura lin-
ing the internal acoustic meatus has been
opened to complete the translabyrinthine expo-
sure. This yields an exposure of the internal
acoustic meatus but provides only minimal
improvement in the exposure of the structures
medial to the porus of the meatus. H, the
nerves have been separated beginning laterally
at the fundus of the meatus and extending the
cleavage plane medially toward the brainstem.
The superior vestibular nerve is behind the
facial nerve and the inferior vestibular nerve is
behind the cochlear nerve. (Continues)
Afrontotemporal craniotomy is then performed. The dura is
elevated from the oor of the middle fossa to expose and oblit-
erate the middle meningeal artery at the foramen spinosum
and to expose the arcuate eminence, the third trigeminal divi-
sion at the foramen ovale, and the greater petrosal nerve. The
greater petrosal nerve is transected if necessary to avoid trac-
tion on the facial nerve. The oor of the middle fossa, includ-
ing the lateral and inferior aspects of the superior orbital s-
sure, and the lateral margin of the foramina ovale may be
removed to expose the structures in the infratemporal fossa.
If needed, bone can be removed medial to the mandibular
fossa to expose the eustachian tube and the tensor tympani
muscle, both of which may be resected (Figs. 1-10, 1-13, and
1-18). The bone removal is continued inferiorly, exposing the
ascending portion of the petrous carotid. In this segment, the
carotid artery is surrounded by a periosteal sheath, which
encloses a periarterial venous plexus that is an extension of the
cavernous sinus. At the entrance of the carotid canal, a dense
brocartilaginous ring encircles the artery. If mobilizationof the
artery is required, care must be taken when dividing the ring
not to damage the IXth cranial nerve that is in close proximity
to the carotid canal as it exits the jugular foramen. After mobi-
lizing the carotid artery and displacing it forward, the petrous
apex and the clival region to the level of the foramen magnum
can be approached medial to and behind the artery. During
drilling, the very hard cortical bone along the petrous apex
gives place to a crumbly cancellous bone in the region of the
clivus, as the dura of the anterior and lateral aspects of the
posterior fossa is being exposed. The area exposed is limited by
Meckels cave superiorly, by the cochlea and internal auditory
canal laterally, by the abducens nerve in its course through the
Dorellos canal medially, and by the hypoglossal canal inferi-
orly. If the dura is opened, the structures along the lateral and
anterior aspects of the upper medulla and lower two-thirds of
the pons will be exposed (41). The tentorium can be divided to
give access to the upper clival region.
Dividing the third trigeminal division above the foramen
ovale will permit exposure of the junction of the petrous and
cavernous carotid along with the structures in the inferolateral
portion of the cavernous sinus (17, 39). The pterygopalatine
fossa, parapharyngeal space, lateral maxilla, and orbit can be
exposed farther anteriorly. The lateral aspect of the sphenoid
bone and the sphenoid sinus can also be approached by remov-
ing bone medial to the maxillary nerve at the root of the ptery-
goid process.
Postauricular Transtemporal Approach
The postauricular transtemporal approach is most commonly
selected for lesions that involve the mastoid and tympanic
cavities and track along the nerves and arteries to reach the
middle and infratemporal fossa (Figs. 1-19 and 1-20). It can,
however, be tailored at its posterior margin to include a ret-
rosigmoid, far-lateral, or presigmoid exposure of the posterior
fossa or, at its anterior limits, to include exposure of the ptery-
gopalatine fossa and lateral parts of the maxillary orbit or ante-
rior cranial fossa.
Aquestion mark incision is started behind the hairline in the
temporal region, extending behind the ear over the mastoid
FIGURE 1-15. (Continued) I and J, compar-
ison of the retrosigmoid approach and the
minimal mastoidectomy, retrolabyrinthine,
translabyrinthine, and transcochlear approach
modifications of the presigmoid approach. I,
the labyrinthine, tympanic, and mastoid seg-
ments of the facial nerve have been exposed in
preparation for the posterior transposition of
the nerve needed to complete the transcochlear
exposure. J, the facial nerve has been trans-
posed and the cochlea and petrous apex
removed to complete the transcochlear expo-
sure of the anterior aspect of the brainstem
and the basilar artery. A., artery; A.I.C.A.,
anteroinferior cerebellar artery; Bas., basilar;
Cist., cisternal; CN, cranial nerve; Coch.,
cochlear; Flocc., flocculus; Inf., inferior;
Laby., labyrinthine; Lat., lateral; Mast., mas-
toid; Meat., meatal; N., nerve; Pet., petrosal;
P.I.C.A., posteroinferior cerebellar artery;
Post., posterior; Presig., presigmoid; S.C.A.,
superior cerebellar artery; Seg., segment; Sig.,
sigmoid; Suboccip., suboccipital; Sup., supe-
rior; Tymp., tympanic; V., vein; Vest.,
vestibular.
RHOTON
FIGURE 1-16. AF, comparison of the retrosigmoid and the various modi-
cations of the presigmoid exposure. The modications of the presigmoid
approach include the minimal mastoidectomy, retrolabyrinthine, partial
labyrinthine, translabyrinthine, modied transcochlear, and the full
transcochlear approach with facial nerve transposition. A, the scalp incision
(insert) is positioned for a supra- and infratentorial exposure through a tem-
poro-occipital craniotomy. Atemporo-occipital craniotomy has been completed
and the dura opened to expose the temporal lobe and the retrosigmoid area. The
transverse and sigmoid sinuses have been preserved. The cerebellum has been
retracted to expose the nerves in the cerebellopontine angle. B, enlarged view of
the retrosigmoid exposure to compare with the exposure obtained with the var-
ious modication of the presigmoid approach. C, in the retrosigmoid exposure
the vestibulocochlear nerve has been elevated and the glossopharyngeal nerve
depressed to expose the basilar artery at the origin of the AICA. D, subtempo-
ral exposure. The temporal lobe has been elevated to expose the optic tract and
oculomotor nerve and the PCA, internal carotid, and anterior choroidal arter-
ies. E, the tentorium has been opened while preserving the trochlear nerve. The
SCA courses below and the PCA above the oculomotor and (Continues)
process and continuing inferiorly in front of the sternocleido-
mastoid muscle onto the neck. The skin ap is then reected
forward and the external auditory canal is divided at the bone-
cartilage junction and closed as a blind sac. The sternocleido-
mastoid muscle is detached from the mastoid process and
reected inferiorly. The periosteum and posterior portion of
the temporalis muscle are reected anteriorly, thus exposing
the temporal, mastoid, and retromastoid areas. The posterior
belly of the digastric muscle is divided and reected inferiorly.
At this point, the facial nerve is identied distal to the stylo-
mastoid foramen and is followed, along with its major
branches, into the substance of the parotid gland (5). The inter-
nal jugular vein, the carotid bifurcation, and the glossopharyn-
geal, vagus, accessory, and hypoglossal nerves are exposed
and isolated in the neck. This allows for proximal control of
the internal carotid artery and ligation of the main feeding
vessels from the external carotid artery to a neoplasm early in
the procedure.
After this, temporal and/or retromastoid craniotomies may
be performed with a simple mastoidectomy. The remaining
skin of the external auditory canal, the tympanic membrane,
the malleus, incus, and stapes arch (leaving the footplate) are
removed. The facial nerve is completely skeletonized from the
geniculate ganglion to the stylomastoid foramen.
If exposure of the jugular foramen and lower clival region is
desired, a new facial canal is created by drilling a groove in the
bone of the anterior attic wall, between the geniculate ganglion
and the root of the zygoma. The facial nerve is carefully freed at
the stylomastoid foramen, while leaving some of the surround-
ing connective tissue attached to the nerve, and the nerve is
transposed anteriorly into the new bony groove of the epitympa-
num and imbedded for its protection into the parotid tissue (5).
The dura of the middle fossa and the sigmoid sinus from the
sinodural angle to the jugular bulb is skeletonized. Then the
sigmoid sinus and the jugular vein are ligated in this sequence,
and the sigmoid sinus divided. Part of the wall of the sinus,
bulb, and/or vein may be excised to increase the exposure.
This allows for dissection of the lower cranial nerves at the
jugular foramen, as well as for their mobilization and posterior
displacement if necessary. The posterior mobilization of the
lower cranial nerves allows for a direct exposure of the struc-
tures along the lateral and anterior aspects of the medulla and
lower pons without the necessity for brain retraction.
Dissection in the area of the jugular foramen has proven to be
extremely difcult, as the lower cranial nerves are particularly
fragile and difcult to isolate from the surrounding tissues.
Exposure of the middle clival structures requires removal of
the bony labyrinth, as described for the translabyrinthine
approach. The internal auditory canal is exposed, the facial nerve
identied, and the cochlear and vestibular nerves divided. The
greater supercial petrosal nerve is sectioned at its origin from
the geniculate ganglion. The facial nerve is freed from all its
attachments in the temporal bone and reected posteriorly. The
bony portion of the external auditory canal and the tympanic
bone are drilled away, exposing the ascending portion of the
intrapetrous carotid artery medial to the eustachian tube.
The dissection is continued by drilling away the cochlea,
starting at its basal turn, to expose part of the horizontal seg-
ment of the petrous carotid artery. Anterior displacement of the
carotid artery and removal of the cochlea provides a wide expo-
sure of the lateral and anterior portions of the pons and
medulla. This exposure extends from the inferior aspect of the
trigeminal ganglion to the foramen magnum. The exposure may
be carried medially into the clivus and retropharyngeal space
and anteriorly to expose the mucosa of the sphenoid sinus.
If the approach is to be extended to the parasellar and paras-
phenoidal areas, the zygomatic arch is divided and reected
inferiorly with the masseter muscle. The temporalis muscle is
separated from its attachment to the coronoid process of the
mandible and reected anteriorly and superiorly. A temporal
RHOTON
FIGURE 1-16. (Continued) trochlear nerves. F, minimal mastoidectomy
modification of the presigmoid approach. The minimal mastoidectomy
approach is completed by removing only enough bone in the front of the sig-
moid sinus so that the presigmoid dura can be opened to expose the posterior
cranial fossa. The bony capsule of the labyrinth is not exposed in the minimal
mastoidectomy as it is in the retrolabyrinthine approach. The exposure shown
with the minimal mastoidectomy in this figure is to be compared with the ret-
rosigmoid exposure shown in B. GN, comparison of the retrosigmoid and
the various modifications of the presigmoid exposure. G, deep exposure with
the minimal mastoidectomy with retraction of the vestibulocochlear and glos-
sopharyngeal nerves, to be compared with the retrosigmoid approach shown
in C. The exposure is similar to that obtained with the retrosigmoid approach.
H, retrolabyrinthine approach in which more extensive drilling of the mastoid
has been completed to expose the osseous capsule of the semicircular canals.
I, the dura has been folded forward after completing the retrolabyrinthine
exposure. The exposure differs little from that obtained with the minimal
mastoidectomy exposure shown in F and G. J, the exposure with the poste-
rior canal partial labyrinthectomy is similar to that achieved with the mini-
mal mastoidectomy. K, the partial labyrinthectomy has been extended by
removing the superior canal in addition to removal of the posterior canal. L,
the infratentorial exposure does not differ significantly from that achieved
with the minimal mastoidectomy, as shown in F and G. Removal of the supe-
rior canal reduces the required temporal lobe retraction and aids in the expo-
sure along the middle fossa floor and petrous apex. M, translabyrinthine
exposure in which the semicircular canals and the vestibule have been
removed. This adds the internal auditory canal to the exposure, but does not
improve the exposure of the structures medial to the meatus, as compared with
the minimal mastoidectomy or even the retrosigmoid approach. N, the facial
nerve has been transposed posteriorly out of the field and the cochlea has been
removed to complete the transcochlear approach. This approach greatly
improves access to the front of the brainstem, clivus, and basilar artery, but
is done at the cost of a temporary or permanent facial paralysis and loss of
hearing. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery;
Ant., anterior; Bas., basilar; Car., carotid; Chor., choroidal; CN, cranial
nerve; Comm., communicating; Inf., inferior; Int., internal; Lat., lateral;
Mast., mastoid; P.C.A., posterior cerebral artery; Ped., peduncle; Pet., pet-
rosal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; S.C.A.,
superior cerebellar artery; Seg., segment; Sig., sigmoid; Sup., superior;
Temp., temporal; Tent., tentorial; Tr., trunk; Trans., transverse; V., vein;
Vert., vertebral.
craniotomy is then performed, and extensive bone is removed
along the whole lateral aspect of the middle cranial fossa. The
ascending ramus of the mandible is either displaced anteriorly
or resected, and the petrous carotid is exposed distally to the
proximal portion of the intracavernous segment after removing
the cartilaginous portion of the Eustachian tube. The cavernous
sinus can be approached and the intracavernous carotid artery
exposed by dividing the mandibular segment of the trigeminal
nerve. The approach can also be extended to the retrosigmoid
area and down the vertebral artery to the C1 to C2 level, or to
the suboccipital triangle for a far-lateral or transcondylar expo-
sure. The lateral orbit and pterygopalatine fossa can be
accessed at the anterior limit of the exposure.
DISCUSSION
Pathologies can arise anywhere within the petroclival
region and frequently are not restricted to a single anatomic
compartment of the cranial base. Involvement of multiple cra-
nial nerves and arteries occurs because cranial base tumors
FIGURE 1-17. AD, combined presigmoid
and far-lateral approach. A, the insert shows
the site of the scalp incision and mastoid tip.
The scalp ap has been reected forward. The
mastoidectomy exposes the dense cortical bone
housing the semicircular canals. The bone ap
is outlined. The occipital artery courses back-
ward between the digastric and superior
oblique. B, enlarged view. The tympanic seg-
ment of the facial nerve courses below the lat-
eral canal. The chorda tympani arises from the
mastoid segment of the facial nerve. The mas-
toid antrum, which has been drilled away,
opens through the aditus into the epitympanic
part of the tympanic cavity. C, the presigmoid
and temporal dural incisions have been out-
lined. D, the temporal and presigmoid dura
has been opened. One goal of the procedure is
to preserve the vein of Labbe, which empties
into the transverse sinus. (Continues)
tend to achieve considerable size before producing clinical
manifestation (32). The distinction between the benign or
malignant tumors in this area is not rigid because many
benign tumors can have a very invasive characteristic. The
selection of the best surgical approach depends on the loca-
tion, extension, size, and nature of the pathology. An advan-
tage of these approaches directed through the temporal bone
to the petroclival area is that they reach the area through tis-
sue planes outside the oropharynx. They provide another
route by which anterior intradural lesions situated medial to
the nerves entering the internal acoustic meatus and jugular
foramen can be approached without entering the nasophar-
ynx. They also provide an avenue of exposure for lesions that
involve the temporal and sphenoid bones in addition to the
clivus. One or a combination of the lateral approaches is fre-
quently used to expose intra- or extradural clival lesions that
also involve the temporal and sphenoid bones. They also pro-
vide access to the anterior aspect of the midbrain, pons, and
medulla and to the cerebellopontine angle and nerves in the
posterior fossa. They may also provide better access to the
temporal bone, jugular foramen, and petrous segment of the
internal carotid artery than the other anterior or posterior
approaches. The area may be approached from directly lateral
through the mastoid, labyrinth, and cochlea, as in the
translabyrinthine and transcochlear approaches; from above
through a subtemporal middle fossa route; from behind in
RHOTON
FIGURE 1-17. (Continued) EH, combined
presigmoid and far-lateral approach. E, the dural
incision has been extended through Trautmans
triangle and across the superior petrosal sinus
and tentorium, taking care to preserve the vein
of Labbe and the trochlear nerve. The semicircu-
lar canals have been opened. F, enlarged view.
The posterior canal faces the posterior fossa lat-
eral to the internal acoustic meatus. The supe-
rior canal projects upward, below the arcuate
eminence, toward the oor of the middle fossa.
The lateral canal is a useful landmark for iden-
tifying the tympanic segment of the facial nerve,
which courses between the canal and the stapes
sitting in the oval window. The epitympanic
area opens through the aditus into the mastoid
antrum. G, the labyrinthectomy has been com-
pleted and the dura lining the meatus opened to
expose the cisternal, meatal, labyrinthine, tym-
panic, and mastoid segments of the facial nerve.
The SCAcourses above the trigeminal nerve. H,
enlarged view along the opened tentorial
incisura. The oculomotor and trochlear nerves
course between the PCA and SCA. The SCA
rests against the upper surface of the trigeminal
nerve. (Continues)
the retrosigmoid suboccipital approach; or from multiple
directions using such combined supra- and infratentorial
approaches as the presi gmoi d approach, to whi ch a
translabyrinthine or transcochlear approach may be added.
Alternative or extended approaches, most of which include
some route through the mastoid and petrous parts, include
the anterior transpetrosal, the subtemporal preauricular
infratemporal, and the far-lateral transcondylar approach.
The retrosigmoid suboccipital approach, described in the
chapter on the cerebellopontine angle, offers a wide view of
the cerebellopontine angle and of the intradural structures
behind the ipsilateral lower clivus, but the dural surface of the
petrous apex, upper clivus, and tentorial incisura are not well
seen from this exposure (26, 35, 36, 46) (Figs. 1-15 and 1-16).
Removal of posterior wall of the internal auditory canal
through the retrosigmoid provides access to the contents of
the meatus as far lateral as the vertical and transverse crests.
The vestibule can be opened if needed to remove a tumor
extending into the labyrinth. Care is required to avoid injury
to the posterior semicircular canal and common crus if there
is the possibility of preserving hearing (29). The retrosigmoid
approach provides easy access to the intradural part of cranial
nerves V, VII, VIII, and IX through XII. It also provides access
to the nerve-related segments of the arteries of the posterior
circulation. The vertebrobasilar junction can be exposed in
some cases, although the lower cranial nerves and the jugular
tubercle are frequent obstacles. Retraction of the pons and
working between the cranial nerves is necessary to reach the
FIGURE 1-17. (Continued) IL, combined presigmoid and far-lateral
approach. I, the insert shows the site of the additional skin incision needed
to add a retrosigmoid craniotomy and far-lateral approach. The scalp flap has
been reflected to expose the suboccipital triangle located between the superior
and inferior oblique and the rectus capitis posterior major and in the depths
of which the vertebral artery courses with a dense venous plexus. J, the
venous plexus has been removed to expose the margins of the suboccipital tri-
angle. K, the rectus capitis posterior major and the inferior oblique have been
reflected medially and the superior oblique laterally to expose the vertebral
artery and surrounding venous plexus behind the atlanto-occipital joint. L,
the venous plexus has been removed to expose the vertebral artery coursing
with the C1 nerve behind the atlanto-occipital joint and across the upper
edge of the posterior atlantal arch. M and N, combined presigmoid and far-
lateral approach. (Continues)
origin of the AICAfrom the basilar artery. The far lateral mod-
ification of the retrosigmoid approach, described in the chap-
ter on the far lateral approach, was devised to provide a bet-
ter exposure of the lateral and anterior aspects of the
cervicomedullary junction (45).
The presigmoid approach (1, 8, 32) combines a supra- and
infratentorial exposure with various degrees of petrousec-
tomy, while preserving the junction of the vein of Labb
with the transverse sinus (Figs. 1-14-1-17). The amount of
resection of the petrous bone can vary from a retro-
labyrinthine minimal mastoidectomy exposure to a trans-
labyrinthine or transcochlear exposure with posterior dis-
placement of the facial nerve. In selected cases, where
angiography shows patency of the communication between
the two transverse sinuses across the midline, the sigmoid
sinus can be ligated to improve the exposure (24). Preserva-
tion of the drainage of the vein of Labb and avoidance of
excessive temporal lobe retraction are major goals of this
approach to the upper clival region. Approaching the struc-
tures in the inferior petroclival space may be restricted by
the jugular bulb, which could be overcome by division of the
sigmoid sinus or by working posterior to it (36). The major
advantages of the presigmoid approach are the shorter
working distance to clival lesions and the various angles for
dissection that are provided. The approach provides access
to the ipsilateral cranial nerves III through XII and to the
major arteries in the posterior circulation. Amajor drawback
to this exposure is provided by the anatomic variants,
described below, that limit the size of the exposure through
Trautmans triangle and the labyrinth.
The translabyrinthine approach provides access to the facial
nerve from its origin at the brainstem to the stylomastoid fora-
men, and exposure of the contents of the internal auditory mea-
tus (Fig. 1-6) (12, 14). The lateral surface of the pons, the inferior
aspect of the origin of the trigeminal nerve, and the facial and
vestibulocochlear nerve complexes are well visualized, but
exposure of the region inferior to the jugular bulb, above the
trigeminal nerve, and anterior to the internal acoustic meatus is
usually poor. The extent of exposure achieved with the
translabyrinthine approach is dependent on several anatomic
factors. A high jugular bulb, an anteriorly placed or large sig-
moid sinus, or a low middle fossa plate may severely restrict
the exposure (22, 27).
The transcochlear approach shares similar limitations with
the translabyrinthine exposure, although the posterior transpo-
sition of the facial nerve in the transcochlear approach allows
better visualization of the structures anterior to the internal
auditory canal (15, 16). The area of exposure is very narrow and
restricted by the maintenance of the bony external auditory
canal, but can be increased by resecting the posterior part of the
canal. Transposition of the facial nerve may be followed by a
transient or permanent facial palsy.
The subtemporal anterior transpetrosal approach uses
extradural resection of the anterior petrous pyramid via a
temporal craniotomy (Figs. 1-12 and 1-13). It may be com-
bined with zygomatic resection to increase access to the floor
of the middle fossa (20). The area of the petrous apex removal
extends from just medial to the internal auditory canal and
cochlea to the petrous apex and petroclival junction, and
from the petrous ridge posteriorly to the carotid canal ante-
RHOTON
FIGURE 1-17. (Continued) M, a suboccipi-
tal craniotomy has been completed, the poste-
rior arch and posterior ramus of the trans-
verse process of the atlas removed, and the
dural incision has been outlined. The poste-
rior meningeal artery arises before the verte-
bral artery penetrates the dura. The C1 nerve
root adheres to the lower margin of the verte-
bral artery. N, the dura has been opened and
the nerves passing toward the jugular fora-
men exposed. Bone has been removed above
the atlantooccipital joint to expose the hypo-
glossal nerve in the hypoglossal canal. The
accessory rootlets cross the jugular tubercle
on their way to the jugular foramen. A.,
artery; A.I.C.A., anteroinferior cerebellar
artery; Atl-Occip., atlanto-occipital; Cap.,
capitis; Car., carotid; Chor., chorda; Cist.,
cisternal; CN, cranial nerve; Epitymp., epi-
tympanic; For., foramen; Gang., ganglion;
Genic., geniculate; Hypogl., hypoglossal;
I nf . , i nf eri or; J ug. , j ugul ar; Laby. ,
labyrinthine; Lat., lateral; Lev., levator; M.,
muscle; Meat., meatal; Memb., membrane;
Men., meningeal; N., nerve; Obl., oblique; Occip., occipital; P.C.A., posterior
cerebral artery; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; Post.,
posterior; Rec., rectus; S.C.A., superior cerebellar artery; Scap., scapula; Seg.,
segment; Semicirc., semicircular; Sig., sigmoid; Sp., spine; Suboccip., suboc-
cipital; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani,
tympanic; V., vein; Vert., vertebral; Vest., vestibular.
FIGURE 1-18. Preauricular subtemporal-infratem-
poral fossa approach. A, the scalp incision is posi-
tioned so that a frontotemporal craniotomy can be
completed. The operation is often completed with an
incision that extends downward only to the level of
the tragus. However, it can be extended if a neck dis-
section is needed. The scalp ap has been reected
forward, taking care to protect the branches of the
facial nerve. B, the temporalis muscle has been
refracted forward and the craniotomy completed. The
mandibular condyle and fossa and a portion of the
zygomatic arch were removed in a single piece, as
shown in the insert, and the middle fossa floor
removed. C, exposure after removal of the middle
fossa floor lateral to the foramen ovale and before
resection of the tensor tympani muscle. The lower
orice of the carotid canal is located in front of the
jugular foramen. The eustachian tube, which passes
across the front of the petrous carotid, has been
opened. D, the tensor tympani and Eustachian tube
have been resected to expose the horizontal segment of
the petrous carotid. E, the internal carotid artery has
been reected forward and the petrous apex drilled to
expose the posterior fossa dura and the inferior pet-
rosal sinus coursing along the petroclival ssure. F,
the dura facing the petrous apex has been opened and
the vertebral arteries and AICA exposed. This expo-
sure is directed through the petrous apex medial to the
cochlea and jugular foramen and does not risk loss of
facial nerve function or hearing, as do the approaches
directed through the petrous apex that require facial
nerve transposition and resection of the labyrinth.
A., artery; A.I.C.A., anteroinferior cerebellar artery;
Brs., branches; Car., carotid; CN, cranial nerve;
Eust., eustachian; Gang., ganglion; Gl., gland; Gr.,
greater; Inf., inferior; Int., internal; Jug., jugular;
M., muscle; Max., maxillary; Men., meningeal;
Mid., middle; N., nerve; Pet., petrosal, petrous;
Post., posterior; Temp., temporal; Tens., tensor;
TM., temporomandibular; Trig., trigeminal; Tymp.,
tympani; V., vein; Vert., vertebral; Zygo., zygomatic.
riorly. Asignificant degree of temporal lobe retraction may be
required. This may be reduced by using a frontotemporal
craniotomy with zygomatic resection. Although only a small
window in the petrous bone is provided, exposure can be
expanded by dividing the adjacent part of the tentorium. The
lateral and anterior surfaces of the pons and the upper clivus
and adjacent part of the cavernous sinus can be approached
through this route (Fig. 1-13). The facial, vestibulocochlear,
trigeminal, and abducens nerves can be identified. The
petrous carotid may limit the surgeons line of vision and
restrict access to the inferior part of the petroclival region, but
this restriction may be overcome with anterior mobilization
of the artery (39, 41). The approach provides access to the
anterior aspect of the brainstem and basilar artery in the area
between the trigeminal nerve above and the facial and
vestibulocochlear nerves below. In approaching the basilar
artery through this route, the size and location of the lesion
in relation to the petrous ridge is critical. The trigeminal
nerve can be mobilized to improve the exposure, although
this may result in postoperative facial hypesthesia (19, 20).
The anterior transpetrosal approach can be used alone for
extradural pathologies restricted to the petrous apex or as a
surgical step to approaching intradural pathologies in the
petroclival region. It provides a route for resecting extradural
lesions that extend from the level of the trigeminal nerve to
the foramen magnum.
RHOTON
FIGURE 1-19. AD, anatomic basis of the postauric-
ular transtemporal approach. A, the incision sweeps
widely around the posterior margin of the ear so that a
retrosigmoid, presigmoid, and far-lateral exposure can
be obtained behind the ear, and a subtemporal, infratem-
poral, pterygopalatine, and orbital exposure can be
obtained in front of the ear. B, the scalp ap has been
reected forward, the external canal transected, and the
parotid gland and superficial branches of the facial
nerve exposed. C, the sternocleidomastoid muscle has
been reected. The neck dissection exposes the internal
jugular vein, C1 transverse process, and the glossopha-
ryngeal, vagus, accessory, and hypoglossal nerves. The
accessory nerve is retracted forward. D, the parotid
gland has been removed to expose the temporofacial and
cervicofacial trunks of the facial nerve and the temporo-
mandibular joint. The splenius capitis muscle has been
reected downward to expose the superior and inferior
oblique muscles, which insert on the transverse process
of C1 and border the suboccipital triangle in which the
vertebral artery courses. (Continues)
Removal of the posterior part of the petrous pyramid has
been used for acoustic neuroma removal as part of extended
approaches directed through the middle fossa (21, 28, 42, 43)
(Fig. 1-12). The extended approaches combine different degrees
of resection of the bony labyrinth with the subtemporal
transtentorial routes. Extending the resection of the petrous
bone posteriorly over the mastoid and the bony labyrinth
exposes the whole intrapetrous course of the facial nerve, and
provides access to the cerebellopontine angle by a combina-
tion of subtemporal, translabyrinthine, and presigmoid routes
(Figs. 1-12 and 1-13) (9).
The subtemporal preauricular infratemporal approach
reaches the skull base from an anterolateral direction (Figs.
1-10, 1-13, and 1-18). Division of the zygomatic arch, resection
or displacement of the mandibular condyle, and extensive
resection of the lateral part of the middle fossa oor exposes
the infratemporal fossa, the nasopharynx, the para- and
retropharyngeal areas, and the ethmoid, sphenoid, and maxil-
lary sinuses. The approach also provides access to the upper
cervical and petrous carotid. The cavernous sinus also can be
approached through its lateral and basal aspects. Anterior dis-
placement of the petrous carotid allows direct access to the
clivus and for extensive resection of the petrous bone medial
to the cochlea. This exposes the extradural clival region from
the level of the trigeminal nerve to the foramen magnum (33,
36, 38, 39). The approach can also provide access to the
intradural space ventral to the brainstem (41). The exposure of
the cerebellopontine angle and foramen magnum is limited
FIGURE 1-19. (Continued) EH, anatomic basis of
the postauricular transtemporal approach. E, a segment
of the mandibular ramus has been removed to expose the
upper and lower head of the lateral pterygoid and the
maxillary artery in the infratemporal fossa. The inferior
alveolar canal and nerve have been exposed. F, the
mandibular ramus, in front of the inferior alveolar
canal, has been removed to provide a wider exposure of
the inferotemporal fossa. The upper head of the lateral
pterygoid muscle passes backward from the inferotempo-
ral surface of the greater sphenoid wing and the lower
head passes upward from the lateral pterygoid plate.
Both heads insert on the mandibular neck and the joint
capsule. The superficial head of the medial pterygoid
muscle passes from the maxillary tuberosity and ptery-
goid plate to the mandibular angle. The deep head of the
medial pterygoid arises from the pterygoid fossa between
the pterygoid plates. G, enlarged view of the infratem-
poral area after removal of the mandibular condyle and
lateral pterygoid muscles. The branches of the mandibu-
lar nerve are exposed below the foramen ovale. The
largest branches are the lingual and superior alveolar
nerves, which are predominantly sensory. The auricu-
lotemporal nerve arises as two roots, which often pass
around the middle meningeal artery before joining. H,
the pterygoid muscles, a segment of the maxillary
artery, and the mandibular and facial nerve branches
have been reected or removed to expose the internal
jugular vein exiting the jugular foramen on the medial
side of the stylomastoid foramen, the internal carotid
artery ascending to enter the carotid canal, the tensor
and levator veli palatini descending from their origin
bordering the eustachian tube, and the terminal seg-
ment of the maxillary artery entering the pterygopala-
tine fossa. (Continues)
because the approach is carried anterior and medial to cranial
nerves VII through XII and the cochlea is not resected (36).
Anterior transposition of the petrous carotid artery allows
unhindered exposure of the origin of the AICAand the verte-
brobasilar junction. The approach could be used as an alterna-
tive lateral route to vascular lesions of the midbasilar artery or
at the vertebrobasilar junction, when these lesions cannot be
exposed through either the retromastoid or subtemporal
transtentorial approaches.
The postauricular transtemporal approach, which combines
a transcochlear exposure with an infratemporal approach,
may be used as an alternative to the preauricular infratempo-
ral approach when the pathology involves the mastoid and
the infratemporal fossa and extends to the facial recess, hypo-
tympanic area, and jugular bulb (5, 6, 34) (Figs. 1-19 and 1-20).
The structures of the lower and middle clivus can be exposed
without the need for brain retraction. The facial nerve is dis-
placed anterosuperiorly and the sigmoid sinus ligated and
divided. Displacement of the facial nerve from its bony canal
seriously interferes with its vascular supply and temporary or
permanent loss of function is to be expected (33). Resection of
the jugular bulb allows for exposure of the lower cranial
nerves in the jugular foramen. Mobilization of the nerves in
the medial part of the jugular foramen is extremely difficult
and nerve damage is likely to occur if it is attempted. The lat-
eral and anterior surfaces of the lower pons, medulla, and
cervicomedullary junction are well exposed. The extent of
exposure of the major arteries is dependent on the different
RHOTON
FIGURE 1-19. (Continued) IL, anatomic basis of the
postauricular transtemporal approach. I, a mastoidec-
tomy has been completed to expose the semicircular
canals and the mastoid segment of the facial canal. The
endolymphatic sac sits under the presigmoid dura. J,
the external canal has been resected to expose the struc-
tures in the tympanic cavity. The tympanic segment of
the facial nerve courses between the lateral semicircular
canal and the stapes sitting in the oval window. The
chorda tympani arises from the mastoid segment of the
facial nerve, passes forward along the inner surface of
the tympanic membrane and the neck of the malleus to
enter its anterior canaliculus, exits the skull along the
petrotympanic suture, and joins the lingual nerve in the
infratemporal fossa. The promontory overlies the basal
turn of the cochlea. The tendon of the tensor tympani
muscle makes a right-angle turn around the trochlei-
form process to insert on the malleus. K, the incus and
malleus have been removed while preserving the stapes
and the tensor tympani muscle. The petrous carotid has
been exposed. The nerves exiting the jugular foramen
have been retracted forward to expose the hypoglossal
nerve exiting the hypoglossal canal. L, a frontotempo-
ral craniotomy has been completed and the oor of the
middle cranial fossa removed. The semicircular canals
have been exposed above the jugular bulb and the stapes
has been removed from the oval window. The maxillary
nerve has been exposed in the pterygopalatine fossa.
The membranous wall of the Eustachian tube has been
opened to expose the tubes opening into the nasophar-
ynx. (Continues)
FIGURE 1-19. (Continued) MR, anatomic basis of the
postauricular transtemporal approach. M, a retrosigmoid
craniotomy has been completed and the nerves in the cerebel-
lopontine angle exposed. The vestibulocochlear nerve has been
depressed to expose the facial nerve. N, the facial nerve has
been reected forward out of the facial canal. The promontory
has been drilled to expose the cochlea and the vestibule. Both
ends of the semicircular canals open into the vestibule, as does
the basal turn of the cochlea. The jugular bulb has been
removed to expose the jugular fossa in which the bulb resides.
The jugular bulb is located below the vestibule. The nerves
exiting the jugular foramen have been reected backward to
expose the hypoglossal nerve exiting the hypoglossal canal.
The nerves passing through the jugular foramen and hypoglos-
sal canal exit the skull on the medial side of the internal jugu-
lar vein and descend between the internal carotid artery and
internal jugular vein. O, the bone above the occipital condyle
has been drilled to expose the hypoglossal nerve in the
hypoglossal canal. P, the posterior wall of the internal acoustic
meatus has been removed to provide this presigmoid inferolat-
eral view of the nerves in the internal meatus. The cochlear
nerve separates off the main bundle of the vestibulocochlear
nerve and penetrates the modiolus. The inferior vestibular
nerve divides into the singular nerve to the posterior ampul-
lae and a branch to the saccule. The superior vestibular nerve
innervates the superior and lateral ampullae and sends a
branch to the utricle. Q, the medial wall of the jugular fossa
has been removed and the nerves passing through the jugular
foramen have been exposed. The glossopharyngeal nerve passes
through the foramen anterior to the vagus and accessory
nerves. A large superior petrosal vein ascends to the superior
petrosal sinus. R, the glossopharyngeal, vagus, and accessory
rootlets arise behind and the hypoglossal rootlets arise anterior
to the inferior olive. (Continues)
RHOTON
FIGURE 1-19. (Continued) SX, anatomic basis of the postauricular
transtemporal approach. S, enlarged view of the medial wall of the tym-
panic cavity before mobilizing the facial nerve. The stapedial muscle passes
forward from the pyramidal eminence below the facial nerve and attaches on
the neck of the stapes. The tensor tympani muscle passes backward and lat-
erally, giving rise to a narrow tendon that makes a sharp turn around the
trochleariform process at the lateral end of its semicanal to insert on the han-
dle of the malleus. The basal turn of the cochlea is located deep to the
promontory. The tympanic segment of the facial nerve courses above the
stapes. T, enlarged view of the labyrinth. The semicircular canals have been
unroofed and the stapes has been removed from the oval window. The round
window is located below and behind the oval window. U, the facial nerve has
been reflected forward out of the facial canal and the vestibule has been
opened. The ampullae of the superior and the lateral canal open into the
vestibule anteriorly and are innervated by the superior vestibular nerve.
Only the upper edge of the superior canal was preserved in opening the
vestibule. The ampullae of the posterior canal is located at its lower end and
is innervated by the singular branch of the inferior vestibular nerve. V, a
probe is directed through the vestibule to the inner surface of the membrane
covering the round window, which is located behind and below the oval
window. W, enlarged view of the labyrinth after opening the promontory to
expose the cochlea. The jugular bulb is located below the vestibule and semi-
circular canals and the lateral genu of the internal carotid artery in position
below the cochlea. The cochlea wraps around the modiolus through which the
branches of the cochlear nerve are distributed to the cochlear duct. X, the
temporal lobe has been elevated to expose the internal carotid, PCA, and
SCA in the basal cisterns. The dura has been elevated from the lateral wall
of the cavernous sinus. (Continues)
anatomic variants and direction of displacement of the ves-
sels. Exposure of the structures of the middle clivus requires
posterior facial nerve displacement and drilling of the
labyrinth with consequent destruction of any residual hear-
ing. The lateral and part of the anterior surfaces of the pons
can be exposed up to the point of emergence of the trigeminal
nerve. Exposure of the superior petroclival space requires that
the transtemporal exposure be combined with a subtemporal
exposure. The transtemporal approach can easily be extended
to the infratemporal fossa, and the same exposure provided
by the preauricular approach can be achieved. When this
approach is combined with an infratemporal fossa exposure
and anterior displacement of the intrapetrous carotid artery,
the petrous part of the temporal bone can be completely
removed, providing the widest possible exposure of the petro-
clival region (Figs. 1-19 and 1-20). The retrosigmoid, far-
lateral, and transcondylar exposures can be obtained at the
posterior margin of the exposure, and the anterior limit can be
extended to include the pterygopalatine fossa and lateral part
of the maxilla, orbit, and anterior cranial fossa.
Extensive removal of lesions involving the skull base fre-
quently require reconstruction of the resultant bony, neural,
and dural defects (Fig. 1-21). The presence of cerebrospinal
fluid leaks and the close proximity to contaminated spaces
of the oro- or nasopharynx increases the risks of meningitis.
Opened sinuses should be obliterated, dural incisions and
openings should be sutured and sealed, nerves should be
reanastomosed or grafted, and devascularized grafts of bone
or dura should be covered with vascularized tissue when-
ever possible.
FIGURE 1-19. (Continued) Y and Z, anatomic
basis of the postauricular transtemporal approach.
Y, overview before opening the dura. The postau-
ricular approach offers the potential for providing
retrosigmoid, presigmoid, and farlateral exposures
and can be used to access the infratemporal and
pterygopalatine fossae, the orbit, and the subtem-
poral areas. In this case, the exposure extends from
the retrosigmoid area forward to the orbit. The
maxillary sinus has been opened below the orbital
oor. Z, overview of exposure after opening the
dura. A., artery; Alv., alveolar; Aur., auricular;
Br., branch; Brs., branches; Cap., capitis; Car.,
carotid; Cerv., cervical; Chor., chorda, choroid;
CN, cranial nerve; Coch., cochlear; Cond.,
condyle; Endolymph., endolymphatic; Eust.,
eustachian; Ext., external; Fac., facial; Gang.,
ganglion; Genic., geniculate; Gl., gland; Gr.,
greater; Hypogl., hypoglossal; Inf., inferior;
Infraorb., infraorbital; Infratemp., infratempo-
ral ; Int. , i nternal ; Jug. , j ugul ar; Laby. ,
labyrinthine; Lat., lateral; Lev., levator; M., mus-
cle; Mandib., mandibular; Mast., mastoid; Max.,
maxillary; Med., medial; N., nerve; Obl., oblique;
Occip., occipital; Pal., palatini; P.C.A., posterior
cerebral artery; Ped., peduncle; Pet., petrosal,
petrous; P.I.C.A., posteroinferior cerebellar artery;
Plex., plexus; Post., posterior; Proc., process;
Pteryg., pterygoid; Pterygopal., pterygopalatine;
Rec., rectus; S.C.A., superior cerebellar artery;
Scap., scapula; Seg., segment; Semicirc., semi-
circular; Sig., sigmoid; Sphen., sphenoid; Splen.,
splenus; Sternocleidomast., sternocleidomastoid;
Sup., superior; Superf., supercial; Symp., sym-
pathetic; Temp., temporal; Tens., tensor; TM.,
temporomandibular; Trans., transverse; Tymp.,
tympani, tympanic; V., vein; Vel., veli; Vert., ver-
tebral; Vest., vestibular.
RHOTON
FIGURE 1-20. AF, postauricular transtemporal approach. This exposure
includes the transtemporal and infratemporal approaches in combination
with a craniotomy. A, the scalp flap has been reflected forward to expose the
sternocleidomastoid, parotid gland, and the greater auricular nerve. B, the
external canal has been divided to reflect the flap forward for a parotid and
neck dissection that exposes the facial nerve and its trunks, the posterior
digastric belly, and the internal jugular vein. C, the mastoidectomy has
been completed to expose the presigmoid dura, the sigmoid sinus, and the
semicircular canals. The mandibular condyle has been resected to provide
access to the infratemporal fossa. D, a temporo-occipital craniotomy has
been completed, the zygomatic arch opened, and the temporalis muscle
reflected to expose the maxillary artery and pterygoid muscles in the
infratemporal fossa. E, enlarged view of the temporal and infratemporal
exposures. The posterior wall of the external canal has been removed. The
auriculotemporal branch of the mandibular nerve is often split into two
rootlets by the middle meningeal artery. F, enlarged view of the tympanic
cavity. The anterior part of the lateral semicircular canal is located above the
tympanic segment of the facial nerve. The promontory overlies the basal
cochlear turn. (Continues)
FIGURE 1-20. (Continued) GL, postauricular transtemporal approach. G,
the external canal has been resected in preparation for exposing the petrous
carotid. H, the junction of the cervical and petrous carotid has been exposed
in the area below the promontory. The lateral margin of the stylomastoid and
jugular foramina have been removed to expose the jugular bulb below the
semicircular canals. I, the mandibular nerve has been exposed below the fora-
men ovale. A more extensive exposure of the petrous carotid has been com-
pleted so that the artery can be reflected forward out of the carotid canal to
provide access for drilling of the petrous apex. J, the petrous carotid has been
reflected forward and the petrous apex removed to expose the clivus and infe-
rior petrosal sinus. K, the facial nerve has been moved out of the facial canal,
and a total labyrinth and petrous apicectomy have been completed. L, a seg-
ment of the sigmoid sinus and the jugular bulb have been removed to expose
the nerves passing through the jugular foramen. The dura has been opened
and the facial nerve displaced posteriorly. The temporal lobe has been elevated
to expose the subtemporal area while preserving the vein of Labbe. A., artery;
Ac., acoustic; Aur., auricular; Bas., basilar; Car., carotid; Chor., chorda;
CN, cranial nerve; Cond., condyle; Ext., external; Gl., gland; Gr., greater;
Inf., inferior; Int., internal; Jug., jugular; Lat., lateral; M., muscle; Mandib.,
mandibular; Mast., mastoid; Max., maxillary; Mid., middle; Men.,
meningeal; N., nerve; Pet., petrosal, petrous; Proc., process; Seg., segment;
Semicirc., semicircular; Sig., sigmoid; Sternocleidomast., sternocleidomas-
toid; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani,
tympanic; V., vein; Vert., vertebral.
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RHOTON
PART 2
THE TEMPORAL BONE IN
THREE DIMENSIONS
CHAPTER 1
OSSEOUS RELATIONSHIPS
FIGURE 1-1. Temporal bone and adjacent cranial base. A, superior view of
the middle and posterior cranial base formed by the sphenoid, temporal, and
occipital bones. The temporal bone has ve parts: the squamosal, petrous, mas-
toid, tympanic, and styloid parts. Only the squamosal, petrous, and mastoid
parts are seen on the upper surface. The styloid and tympanic parts are not
seen because they are on the lower surface. The upper surface of the squamosal
part forms some of the oor and lateral wall of the middle cranial fossa. The
lower surface is the site of the roof of the mandibular fossa in which the
mandibular condyle sits. The petrous part of the temporal bone houses the
internal acoustic meatus, acousticovestibular labyrinth, and the carotid and
facial canals. The mastoid part contains the mastoid air cells and mastoid
antrum. The squamosal part of the temporal bone joins anteriorly with the
greater wing of the sphenoid bone to form the oor of the middle cranial fossa.
The petrous part articulates medially with the body of the sphenoid bone and
the clival portion of the occipital bone at the petroclival ssure to form the ante-
rior wall of the posterior fossa. The sigmoid sulcus descends along the poste-
rior surface of the mastoid portion of the temporal bone and turns forward on
the upper surface of the occipital bone to enter the jugular foramen. The fora-
men lacerum, which is located at the junction of the temporal, sphenoid, and
occipital bones, is usually covered below the terminal part of the carotid canal
by cartilage. The foramina spinosum and ovale of the sphenoid bone are posi-
tioned anterior to the petrous apex. The greater petrosal nerve courses along
the medial part of the petrosphenoid junction.
FIGURE 1-2. Relationships of the sphenoid, occipital, and temporal bones.
Superior view. The three bones have been separated along their sutures. The
squamosal and petrosal parts of the temporal bone articulate anteriorly with
the greater wing of the sphenoid to form the oor of the middle cranial fossa.
The petrous part articulates posteriorly with the clival part of the occipital bone
along the petroclival ssure. The mastoid part articulates with the squamosal
part of the occipital bone along the occipitomastoid suture. The part of the tem-
poral and occipital bones, between the lower ends of the petroclival ssure and
the occipitomastoid suture, forms the margins of the jugular foramen. The
petrous part of the temporal bone forms the anterior margin, and the condy-
lar part of the occipital bone forms the posterior margin of the jugular foramen.
The petrous apex is wedged into the space between the medial part of the
greater sphenoid wing and the clival and condylar parts of the occipital bone,
and faces the foramen lacerum in the area just behind the foramen ovale and
spinosum of the sphenoid bone.
RHOTON
FIGURE 1-3. Separate temporal and sphenoid bones have been tted together along the
squamosal suture. The greater wing of the sphenoid bone forms the anterior wall and the
anterior part of the oor of the middle fossa. The posterior part of the oor of the middle
fossa is formed by the petrous and mastoid parts of the temporal bone. The foramen ovale
and spinosum in the greater sphenoid wing are positioned anterior to the petrous apex. The
trigeminal impression is located on the middle fossa surface of the petrous apex. The arcu-
ate eminence overlies the superior semicircular canal. The tegmen is the site of a paper-thin
layer of bone that roofs the mastoid antrum, the external acoustic meatus, and the tympanic
cavity. The mastoid part of the temporal bone is the site of the mastoid air cells and mas-
toid antrum. The sigmoid sulcus descends along the inner surface of the mastoid part. The
lingual process of the sphenoid bone extends posteriorly toward the petrous apex and par-
tially surrounds the junction of the petrous and cavernous segments of the internal carotid
artery. The petrolingual ligament extends from the lingual process to the petrous apex
above the junction of the petrous and cavernous segments of the internal carotid artery.
FIGURE 1-4. Separate sphenoid, temporal, and occipital bones have been fitted together,
along their adjoining sutures. The petrous apex is wedged into the area between the sphe-
noid and occipital bones. The squamosal suture extends along the lateral wall and floor of
the middle fossa and ends behind the foramen spinosum. The petrous portion of the tempo-
ral bone is separated from the clival portion of the occipital bone by the petroclival fissure.
The squamosal part of the occipital bone is separated from the mastoid part of the temporal
bone by the occipitomastoid sutures. The lower end of the occipitomastoid suture crosses the
sigmoid sulcus. The jugular foramen is situated between the petrous part of the temporal
bone and the condylar part of the occipital bone, and between the lower end of the petrocli-
val fissure and the occipitomastoid suture.
RHOTON
FIGURE 1-5. Oblique view of the temporal
and surrounding bones. The petrous and mas-
toid parts of the temporal bone articulate poste-
riorly with the occipital bone to form the lateral
part of the anterior wall of the posterior fossa.
Medially, the petrous part of the temporal bone
articulates along the petroclival ssure with the
clival portion of the occipital bone and the body
of the sphenoid bone to form the medial part of
the anterior wall of the posterior fossa. The
jugular foramen is positioned between the
occipital and temporal bone at the inferolateral
edge of the petroclival ssure. The petrous part
of the temporal bone forms the anterior edge,
and the condylar part of the occipital bone forms
the posterior edge of the jugular foramen. The
jugular foramen has three parts: a laterally
placed sigmoid part, through which the sigmoid
sinus drains; a smaller medial part, the petrosal
part, through which the inferior petrosal sinus
drains; and an intermediate part, the intrajugu-
lar part, through which the glossopharyngeal,
vagus, and accessory nerves pass.
FIGURE 1-6. Inferior view of both temporal bones and the occipital bone. The
petrous apex ts against the clival part of the occipital bone along the petro-
clival ssure. The jugular foramen is located between the lower ends of the
petroclival ssure and the occipitomastoid suture. The jugular fossa, in which
the jugular bulb resides, is on the lower surface of the petrous part of the tem-
poral bone. The stylomastoid foramen is positioned directly lateral to the jugu-
lar foramen. The external orice of the carotid canal is located anterior to the
jugular foramen. The right jugular foramen is larger than the left, as is com-
mon. The mandibular fossa, in which the mandibular condyle sits, is located
medial to the root of the zygomatic process.
RHOTON
FIGURE 1-7. Inferior view of the middle
and posterior parts of the cranial base
formed by the sphenoid, temporal, and
occipital bones. The squamosal part of the
temporal bone forms the posterior part of
the floor and lateral wall of the middle
cranial fossa, the roof of the mandibular
fossa in which the mandibular condyle
sits, and the posterior part of the zygo-
matic arch. The tympanic part of the tem-
poral bone forms the anterior, lower, and
part of the posterior wall of the external
canal, part of the osseous oor of the tym-
panic cavity and Eustachian tube, and
the posterior wall of the mandibular fossa.
The mastoid part contains the mastoid air
cells and mastoid antrum. The petrous
part is the site of the auditory and
vestibular labyrinth, the carotid and facial
canals, and the internal acoustic meatus.
The external orice of the carotid canal
opens anterior to the jugular foramen.
The jugular fossa, in which the jugular
bulb sits, is located on the lower surface of the petrous part. The stylomastoid
foramen opens between the anterior edge of the digastric groove and the sty-
loid process. The styloid part projects downward behind the tympanic part and
serves as the site of attachment of the three styloid muscles.
FIGURE 1-8. Oblique enlarged infe-
rior view of the right temporal, sphe-
noid, and occipital bones. The tym-
panic part of the temporal bone is
positioned between the squamosal part
anteriorly and the petrous and mas-
toid parts posteriorly. The petrous part
of the trigeminal bone is wedged
between the sphenoid and occipital
bones. The petrous apex faces the fora-
men lacerum and is separated from the
clival part of the occipital bone by the
petroclival fissure. The dome of the
jugular fossa, in which the jugular
bulb sits, is on the lower surface of the
petrous part. The carotid canal is posi-
tioned anterior to the jugular foramen.
The tympanic canaliculus, located
between the jugular fossa and carotid
canal, is the opening through which
Jacobsons branch of the glossopharyn-
geal nerve passes to reach the tym-
panic cavity and, nally, the middle
fossa, where it becomes the lesser pet-
rosal nerve.
RHOTON
FIGURE 1-9. Anterior view of a right temporal bone. The squamosal part of the temporal bone
forms the lateral wall and oor of the middle fossa, the posterior part of the zygomatic arch, and
the roof of the mandibular fossa in which the mandibular condyle sits. The zygomatic process of
the squamosal part projects forward to join the zygomatic bone in completing the zygomatic arch.
The tympanic part forms the posterior wall of the mandibular fossa, the anterior, lower, and part
of the posterior wall of the external auditory canal and part of the oor of the tympanic cavity
and osseous part of the Eustachian tube. The petrous part, located medial to the squamosal, tym-
panic, and mastoid parts, is the site of the internal acoustic meatus, the acoustic and vestibular
labyrinth, and the facial and carotid canals. The mastoid part is located behind the lateral part
of the tympanic and squamosal parts and is the site of the mastoid air cells and mastoid antrum.
FIGURE 1-10. Lateral view of a right temporal bone. The squamosal
part forms part of the lateral wall and oor of the middle fossa, the pos-
terior part of the zygomatic arch, and the upper surface of the mandibu-
lar fossa. The tympanic part forms the posterior wall of the mandibular
fossa; the anterior wall, lower wall, and part of the posterior wall of the
external canal; and the oor of the tympanic cavity and adjacent osseous
portion of the eustachian tube. The styloid process is ensheathed at its
base by the tympanic part and projects downward, serving as the attach-
ment of three styloid muscles. The mastoid part is located posterior to the
external acoustic meatus and contains the mastoid air cells, which coa-
lesce into a large cavity at the mastoid antrum. The retrolabyrinthine,
translabyrinthine, and transcochlear approaches are directed through
the mastoid part. The digastric muscle attaches medial to the mastoid tip
in the digastric groove. The oval window is exposed in the medial wall
of the tympanic cavity.
RHOTON
FIGURE 1-11. Enlarged view of the
right external acoustic meatus. The
spine of Henle, located along the
posterosuperior margin of the exter-
nal canal, is positioned superficial
to the deep site of the lateral semicir-
cular canal and the junction of the
tympanic and mastoid segments of
t he f aci al nerve. The mast oi d
antrum is positioned deep to the
superficial depressed area, called the
suprameatal triangle, located above
and behind the spine of Henle. The
medial wall of the tympanic cavity
is the site of the promontory, which
overlies the basal turn of the cochlea
and the oval and round windows.
The footplate of the stapes sits in the
oval window. The round window is
separated from the cochlea by a thin
membrane.
FIGURE 1-12. Superior view of the
left and right temporal bones. The
medial part of the upper surface is the
site of the trigeminal impression in
which the trigeminal nerve and gan-
glion and Meckels cave sits. Farther
laterally is the prominence of the
arcuate eminence overlying the supe-
rior semicircular canal. Lateral to the
arcuate eminences is the tegmen, a
thin plate of bone roong the mastoid
antrum, epitympanic area, and exter-
nal acoustic meatus. The temporal
bone articulates anteriorly with the
sphenoid bone, above with the pari-
etal bone, and posteriorly with the
occipital bone. The zygomatic process
of the squamosal part has an anterior
and a posterior root, between which,
on the lower surface, is located the
mandibular condyle.
RHOTON
FIGURE 1-13. The oor of the right
middle fossa has been drilled to
remove bone and air cells and expose
the osseous capsule of the cochlea,
semicircular canals, and internal
acoustic meatus. The cochlea is
located anteromedial to the fundus of
the meatus. The superior, lateral, and
posterior semicircular canals are sit-
uated posterolateral to the fundus of
the meatus. The transverse crest sep-
arates the fundus of the meatus into
upper and lower parts. The facial and
superior vestibular nerves course
above and the cochlear and inferior
vestibular nerves course below the
transverse crest.
FIGURE 1-14. Posterior view of a right temporal bone. The squamosal part forms part of the
oor and lateral wall of the middle fossa. The sigmoid sulcus descends along the inner surface of
the mastoid portion. The porus of the internal acoustic meatus opens onto the central portion of
the posterior surface of the petrous part. The trigeminal impression, trigeminal prominence,
meatal depression, and arcuate eminence are located on the upper surface of the petrous part. The
endolymphatic duct connects the vestibule in the petrous part with the endolymphatic sac, which
sits on the posterior petrous surface inferolateral to the internal acoustic meatus. The intrajugu-
lar process separates the petrosal and sigmoid parts of the jugular foramen.
RHOTON
FIGURE 1-15. Enlarged view of Figure
1-14. The upper edge of the petrous ridge
is the site of two shallow depressions, the
trigeminal impression and the meatal
depressi on, and two el evati ons, the
trigeminal prominence and the arcuate
eminence. The trigeminal impression, in
which Meckels cave and the enclosed part
of the trigeminal nerve sits, is located on
the medial part of the upper surface. The
trigeminal prominence is positioned at the
lateral edge of the trigeminal impression.
The area between the trigeminal promi-
nence and the arcuate eminence is the site
of another shallow depression, the meatal
depression, which is positioned above the
internal acoustic meatus. The tegmen, a
paper-thin area of bone that roofs the
external canal, mastoid antrum, and tym-
panic cavity, is positioned on the upper
surface lateral to the arcuate eminence.
The subarcuate fossa, through which the
subarcuate branch of the anterior inferior
cerebellar artery passes, is located supero-
lateral to and the hiatus of the endolymphatic duct is positioned inferolateral to the internal acoustic meatus.
FIGURE 1-16. The posterior surface of
the right temporal bone has been drilled
while preserving the bone around the
internal acoustic meatus, semicircular
canals, and cochlea. The superior canal
protrudes upward toward the arcuate
eminence in the oor of the middle fossa.
The posterior canal is exposed on the lat-
eral side of the superior canal. The poste-
rior end of the superior canal and the
upper end of the posterior canal join to
form the common crus, which opens into
the vestibule. The mastoid air cells have
been removed from the petrous apex. The
cochlea bulges upward anteromedial to
the fundus of the internal acoustic mea-
tus. Some of the mastoid air cells medial
to the sigmoid sulcus have been removed.
The cochlear aqueduct, which ends just
above the petrosal part of the jugular fora-
men, has been preserved. The endolym-
phatic sac sits on the posterior surface of
the temporal bone below the superior and
lateral canals. The intrajugular processes
of the temporal and occipital bones separates the petrosal and sigmoid parts of
the jugular foramen. The glossopharyngeal, vagus, and accessory nerves exit
the cranium through the intrajugular part of the jugular foramen located
between the petrosal and sigmoid parts.
RHOTON
FIGURE 1-17. Oblique posterior view of another right temporal
bone. The sigmoid sinus descends along the posterior surface of the
mastoid portion in the sigmoid sulcus and turns upward along the
lower surface of the petrous part to form the jugular bulb, which sits
in the jugular fossa. The internal acoustic meatus opens onto the cen-
tral portion of the posterior surface of the petrous part. The trigemi-
nal impression and arcuate eminence are located on the upper surface
of the petrous part. The porus of the internal acoustic meatus is posi-
tioned below the shallow depression, the meatal depression, posi-
tioned between the lateral edge of the trigeminal prominence and the
arcuate eminence. The endolymphatic duct connects the vestibule in
the petrous part with the endolymphatic sac, which sits on the pos-
terior surface inferolateral to the internal acoustic meatus.
FIGURE 1-18. View of the fundus
of the right internal acoustic meatus.
The transverse crest divides the
meatal fundus into superior and
inferior parts. Above the transverse
crest, the facial canal is anterior and
the superior vestibular area is poste-
rior. The facial canal and the supe-
rior vestibular area are separated by
the vertical crest (Bills Bar). Below
the transverse crest, the cochlear area
is anterior and the inferior vestibular
area is posterior. The singular fora-
men, through which the singular
branch of the inferior vestibular
nerve passes to innervate the poste-
rior canal ampullae, is located poste-
rior to the inferior vestibular area.
The inferior vestibular nerve also has
a saccular and, occasionally, a utric-
ular branch.
RHOTON
FIGURE 1-19. Inferior view of a left temporal bone. The temporal bone has a squamosal
part, which forms some of the oor and lateral wall of the middle cranial fossa. It is also
the site of the roof of the mandibular fossa in which the mandibular condyle sits. The
tympanic part forms the anterior, lower, and part of the posterior wall of the external
canal, the posterior wall of the mandibular fossa, and part of the oor of the tympanic
cavity and osseous portion of the Eustachian tube. The mastoid portion contains the
mastoid air cells and mastoid antrum. The petrous part is the site of the auditory and
vestibular labyrinth, the internal acoustic meatus, and the carotid and facial canals. The
petrous part also forms the anterior edge of the jugular foramen and is the site of the
jugular fossa, in which the jugular bulb resides. The carotid artery enters the external
orice of the carotid canal, which is positioned anterior to the jugular fossa. The inter-
nal orice of the carotid canal is located at the petrous apex, where the artery turns
upward to enter the cavernous sinus. The styloid part projects downward and is par-
tially ensheathed at its base by the tympanic part. The stylomastoid foramen is located
behind the styloid process near the anterior end of the digastric groove.
FIGURE 1-20. Posterior inferior view of the lower surface of a right temporal bone. The jugular
fossa, the site of the jugular bulb, is positioned below the lateral part of the petrous part of the tem-
poral bone. The intrajugular ridge extends forward along the medial part of the jugular fossa to sep-
arate the petrosal and sigmoid parts of the jugular foramen. The carotid canal opens onto the lower
surface and is directed upward before turning medially toward the petrous apex. The stylomastoid
foramen, located at the anterior margin of the digastric groove, is hidden by the mastoid tip. The sty-
loid projects downward and is ensheathed along its anterior margin by the posterior edge of the tym-
panic part of the temporal bone. Ac., acoustic; Ant., anterior; Arc., arcuate; Canalic., canaliculus;
Car., carotid; Clin., clinoid; Coch., cochlear; Comm., common; Cond., condylar, condyle;
Depress., depression; Digast., digastric; Emin., eminence; Endolymph., endolymphatic; Eust.,
eustachian; Ext., external; Fiss., ssure; For., foramen; Gr., greater; Hypogloss., hypoglossal;
Impress., impression; Inf., inferior; Int., internal; Intrajug., intrajugular; Jug., jugular; Lat., lat-
eral; Ling., lingual; Mag., magnum; Mandib., mandibular; N., nerve; Occip., occipital;
Occipitomast., occipitomastoid; Orb., orbital; Pet., petrosal, petrous; Petrocliv., petroclival; Post.,
posterior; Proc., process; Prom., prominence; Pteryg., pterygoid; Semicirc., semicircular; Sig., sig-
moid; Sp., spine; Stylomast., stylomastoid; Subarc., subarcuate; Sup., superior; Trans., transverse;
Trig., trigeminal; Tymp., tympanic; Vert., vertical; Vest., vestibular.
RHOTON
MIDDLE FOSSA: ANATOMIC VIEW
CHAPTER 2
FIGURE 2-1. Middle fossa, anatomic view. Middle fossa surface of the tem-
poral bone. The dura has been elevated from the floor of the middle fossa. The
tentorium, except for the attachment along the petrous ridge and superior
petrosal sinus, has been removed. The petrosphenoid ligament (Grubers lig-
ament) forms the roof of Dorellos canal, through which the abducens nerve
passes on the medial side of the first trigeminal division. The trigeminal
nerve sits in a depression on the upper surface of the petrous part. At the lat-
eral edge of the trigeminal impression, the floor of the middle fossa, adjacent
to the sphenoid ridge, rises upward to form the trigeminal prominence. The
posterior part of the floor then settles into another depression between the
trigeminal prominence and the arcuate eminence. The depression between the
trigeminal prominence and the arcuate eminence, the meatal depression,
roofs the majority of the internal acoustic meatus. The bone in the area lat-
eral to the arcuate eminence, referred to as the tegmen, is usually paper-thin.
The tegmen forms part of the roof of the external auditory canal, tympanic
cavity, and mastoid antrum and air cells. The greater petrosal nerve is
exposed directly under the dura of the middle fossa. In this case, the termi-
nal part of the petrous carotid artery is also exposed under the dura and
below the greater petrosal nerve, as occurs in approximately 15% of tempo-
ral bones. The petrous carotid artery is usually covered by bone up to the lat-
eral side of the third trigeminal division.
RHOTON
FIGURE 2-2. The bone above the internal acoustic
meatus has been removed. The meatus is situated
below the meatal depression. In the past, the drilling to
expose the internal acoustic meatus by the middle
fossa approach was begun above the greater petrosal
nerve, the geniculate ganglion, and the distal part of
the labyrinthine segment. From there, the drilling was
directed proximally from the fundus to the porus of the
meatus. It is now common practice to begin the
drilling above the porus at the level of the petrous
ridge. It is in this area that the meatus is the widest
and easiest to identify. From there, the drilling is
directed distally toward the fundus of the meatus and
the labyrinthine segment of the facial nerve. The ante-
rior wall of the meatus is usually located 6 to 9 mm
lateral to the point the trigeminal nerve crosses the
petrous ridge. Another method used to identify the
approximate site of the porus is to measure the angle
between the arcuate eminence or superior semicircular
canal and the greater petrosal nerve, and to begin the
drilling at the point that a line bisecting that angle
would cross the petrous apex. The superior semicircu-
lar canal underlies the arcuate eminence, although, as
seen here, it may not sit directly under the most prominent area and, in some
cases, it may be separated from the floor of the middle fossa by a several mil-
limeter layer of mastoid air cells. The canal is positioned slightly medial to
the arcuate eminence, as shown here, more often than it is situated directly
under or lateral to the most prominent part of the arcuate eminence.
FIGURE 2-3. The dura lining the internal
acoustic meatus has been opened to identify
the facial and vestibulocochlear nerves and
the nervus intermedius. The tegmen has
been opened and the mastoid air cells have
been removed to expose the semicircular
canals. The oor of the middle fossa above
the tympanic cavity has been opened to
expose the body of the incus and head of the
malleus in the epitympanic area. The exter-
nal acoustic meatus has been unroofed and
four segments of the facial nerve have been
exposed. The cisternal segment begins at
the brainstem and ends at the porus of the
meatus. The meatal segment extends from
the porus to the fundus of the meatus. The
labyrinthine segment, which is very short,
begins at the fundus of the meatus and
ends at the geniculate ganglion. The tym-
panic segment passes laterally and back-
ward from the geniculate ganglion and
below the lateral semicircular canal. The
tympanic membrane separates the external
acoustic meatus and the tympanic cavity.
RHOTON
FIGURE 2-4. Enlarged view of the internal
acoustic meatus. The cisternal segment of the
facial nerve has been retracted to expose the
nervus intermedius, which arises along the ven-
tral surface of the vestibulocochlear nerve and
jumps to the facial nerve in the cistern or mea-
tus. The nervus intermedius can be made up of
as many as four separate bundles of bers. The
superior vestibular and facial nerves pass above
the transverse crest. The cochlear nerve courses
in the anterior-inferior quadrant of the meatus
below the transverse crest. The inferior vestibu-
lar nerve is hidden below the superior vestibular
nerve. The vestibular nerves innervate the
ampullated ends of the semicircular canals. The
superior vestibular nerve innervates the ampul-
lae positioned at the anterior end of the superior
and lateral canals. The inferior vestibular nerve
innervates the ampulla at the lower end of the
posterior semicircular canal. The nonampul-
lated posterior end of the superior canal and the
upper end of the posterior canal join to form a
single common channel, the common crus,
which opens into the vestibule.
FIGURE 2-5. Additional bone has been
removed anterior to the greater petrosal nerve
to expose the tensor tympani and eustachian
tube, which are separated from each other
and from the terminal part of petrous carotid
by a thin shell of bone. The cochlea is exposed
in the angle between the labyrinthine seg-
ment of the facial nerve and the greater pet-
rosal nerve. The vestibule into which the
semicircular canals open is positioned behind
the fundus of the meatus. The tensor tym-
pani is a long slender muscle. Its tendon
turns sharply laterally around the trochlear-
iform process to attach to the upper part of
the handle of the malleus. The temporal bone,
when viewed from above, is organized similar
to the letter Y. The lower single limb of the
Y is located along the external canal. The
upper two limbs of the Y are directed along
the internal acoustic meatus posteriorly and
the eustachian tube anteriorly. Thus, the
i nt ernal and ext ernal meat i and t he
eustachian tube together, when viewed from
above, have a configuration similar to the let-
ter Y. The labyrinth, which wraps around the fundus of the meatus and the tympanic cavity, is located at the junction of the three limbs of the Y.
RHOTON
FIGURE 2-6. Enlarged superior view of the
junction of the labyrinth, tympanic cavity, and
adjacent portions of the external and internal
acoustic meati and eustachian tube. The verti-
cal crest (Bills bar) separates the superior
vestibular area and facial canal at the fundus of
the meatus. The inferior vestibular nerve is
positioned below the transverse crest in the pos-
terior-inferior quadrant of the meatus and is
hidden by the superior vestibular nerve. The
cochlear nerve is positioned below the trans-
verse crest in the anterior-inferior quadrant of
the meatus. The superior vestibular nerve
innervates the ampulla of the superior and lat-
eral canals, which are located at the anterior
end of these canals near the fundus of the mea-
tus. The inferior vestibular nerve innervates
the ampullae of the posterior semicircular
canal, which is located at the inferior end of the
posterior canal. The tensor tympani, which is
innervated by the trigeminal nerve, has a sharp
bend around the trochleariform process, at the
site it gives rise to a narrow tendon, which
attaches to the malleus. The body and short
process of the incus are exposed posterior to the articulation of the incus with
the malleus. The tensor tympani is separated from the roof of the eustachian
tube, carotid canal, and floor of the middle fossa by a thin shell of bone. The
chorda tympani crosses the inner surface of the tympanic membrane and the
upper part of the handle of the malleus.
oor of the middle fossa after expos-
ing the cochlea and vestibule. The
vestibule has been exposed below the
anterior ends of the superior and lat-
eral canals. The vestibule communi-
cates, below the fundus of the mea-
tus, with the cochlea. The cochlea is
located below the oor of the middle
fossa in the angle between the
labyrinthine segment of the facial
nerve and the greater petrosal nerve.
The vertical segment of the petrous
carotid turns medially to form the
horizontal segment at its lateral
bend, which is positioned below the
cochlea. Fibers from the cervical
sympathetic ganglia ascend on the
surface of the carotid artery. The
articulation of the lenticular process
of the incus with the head of the
stapes is seen below the anterior por-
tion of the lateral semicircular canal.
RHOTON
FIGURE 2-8. Superolateral view. The
cisternal segment of the facial nerve has
been retracted to expose the nervus inter-
medius. The petrous apex, which extends
below the trigeminal nerve and up to the
side of the clivus, has been preserved. The
tympanic segment of the facial nerve
passes below the lateral semicircular
canal and turns downward to form the
mastoid (vertical or descending) seg-
ment.
FIGURE 2-9. Superolateral view. The
petrous apex medial to the internal
acoustic meatus and posterior to the
petrous segment of the internal carotid
artery has been removed, as would be per-
formed in an anterior petrosectomy
approach. The exposure extends to the lat-
eral edge of the clivus and inferior pet-
rosal sinus. The abducens nerve passes
above the anterior inferior cerebellar
artery and through the inferior petrosal
sinus. The oculomotor nerve enters the
roof of the cavernous sinus just below the
origin of the posterior communicating
artery from the internal carotid artery.
The trochlear nerve passes along the
lower margin of the tentorial edge. The
superior cerebellar artery sits on the
upper edge of the trigeminal nerve.
RHOTON
FIGURE 2-10. Another specimen with the
upper surface of the temporal bone drilled to
expose the labyrinth and internal and external
acoustic meati. The vertical crest (Bills bar)
separates the facial nerve and superior vestibu-
lar nerve at the fundus of the meatus. The
cochlea is positioned below the floor of the mid-
dle fossa in the angle between the labyrinthine
segment of the facial nerve and the greater pet-
rosal nerve. Both ends of the semicircular
canals communicate with the vestibule. The
semicircular canals have only five openings into
the vestibule, even though they communicate
with the vestibule at both ends. The reason is
that the posterior end of the superior canal and
the upper end of the posterior canal join to form
a common limb, or crus, before opening into the
vestibule. The body of the incus and head of the
malleus are exposed in the epitympanic area.
The tympanic segment of the facial nerve passes
below the lateral semicircular canal. The inter-
nal acoustic meatus sits below the depressed
area between the trigeminal prominence and the
arcuate eminence. The position of the internal
acoustic meatus can be approximated by bisecting the angle between the
greater petrosal nerve and the superior semicircular canal. The drilling to
expose the internal acoustic meatus is begun above the porus of the meatus,
where the bisection line crosses the petrous ridge and is directed from there
toward the fundus. Entering either the cochlea or vestibule at the fundus of
the meatus will result in a loss of hearing.
FIGURE 2-11. Superolateral view of
the right middle fossa in another speci-
men. The bone has been removed to
expose the nerves in the internal
acoustic meatus. The cochlea is enclosed
in the bone in the angle between the
labyrinthine segment of the facial nerve
and the greater petrosal nerve. The
incus and malleus are exposed in the
epitympanic area. The superior semicir-
cular canal, which sits below the medial
side of the arcuate eminence, has been
unroofed.
RHOTON
FIGURE 2-12. Bone has been
removed to expose the semicircular
canals and the internal and external
acoustic meati. A portion of the
petrous apex has been removed and
the dura below the trigeminal nerve
has been opened to expose a tortuous
basilar artery. The tensor tympani
sits in the roof of the eustachian tube
behind the petrous carotid.
FIGURE 2-13. The trigeminal nerve has been
removed to expose the cavernous sinus. The greater
petrosal nerve passes forward and medially, where it
is joined by the deep petrosal branch of the carotid
plexus to form the Vidian nerve. The abducens nerve
passes under the petrosphenoid ligament to enter the
cavernous sinus. A portion of the petrous apex below
the trigeminal nerve has been removed. Removal of
the floor of the middle fossa exposes the pterygoid
muscles and venous complex and branches of the
mandibular nerve and maxillary artery in the
infratemporal fossa. The temporalis muscle lls the
temporal fossa. A., artery; A.I.C.A., anterior inferior
cerebellar artery; Ac., acoustic; Arc., arcuate; Bas.,
basilar; Car., carotid; Chor., chorda; Cist., cisternal;
CN, cranial nerve; Coch., cochlear; Emin., eminence;
Eust., eustachian; Ext., external; Gang., ganglion;
Gen., geniculate; Gr., greater; Inf., inferior, infero;
Infratemp., infratemporal; Intermed., intermedius;
Laby., labyrinthine; Lat., lateral; Lig., ligament;
Ling., lingual; M., muscle; Mast., mastoid; Meat.,
meatal; Memb., membrane; Men., meningeal; Mid.,
middle; N., nerve; Nerv., nervus; Pet., petro, pet-
rosal, petrous; Post., posterior; Proc., process; Prom.,
prominence; S.C.A., superior cerebellar artery; Seg., segment; Semicirc.,
semicircular; Sig., sigmoid; Sphen., sphenoid; Sup., superior; Temp., tempo-
ral; Tens., tensor; Tent., tentorial; Trig., trigeminal; Troch., trochleariform;
Tymp., tympani, tympanic; Vert., vertical; Vest., vestibular.
CHAPTER 3
MIDDLE FOSSA: SURGICAL APPROACH
FIGURE 3-1. Middle fossa. The right middle fossa with the head in the typ-
ical surgical position. The surgeon usually sits at the head of the table for mid-
dle fossa approaches. This leads to the viewing of the anatomy upsidedown,
thus placing the oor of the middle fossa in the upper part of the exposure.
The trigeminal nerve sits in the trigeminal depression on the medial part of
the petrous apex and medial to the trigeminal prominence. There is an addi-
tional depression above the internal acoustic meatus, the meatal depression,
between the trigeminal prominence and the arcuate eminence. The tegmen,
positioned lateral to the arcuate eminence, provides a paper-thin roof for the
tympanic cavity, external auditory canal, and mastoid antrum. The petrous
carotid is usually covered by bone up to the lateral edge of the trigeminal
nerve but, here, the terminal segment of the petrous carotid artery is exposed
beneath the dura and the greater petrosal nerve. The trochlear nerve passes
below the tentorial margin.
Neurosurgery 61:S4-98S4-117, 2007 DOI: 10.1227/01.NEU.0000280013.46641.EC www.neurosurgery-online.com
MIDDLE FOSSA SURGICAL APPROACH
FIGURE 3-2. The bone in the meatal depression
between the trigeminal prominence and the arcuate
eminence has been removed to expose the dura lining
the internal acoustic meatus. The drilling was begun
above the meatal porus at the level of the petrous
ridge. The drilling proceeds distally toward the
meatal fundus and above the labyrinthine segment of
the facial nerve. One method of identifying the porus
for the initial drilling is to begin the drilling at the
petrous ridge 5 to 7 mm lateral to the trigeminal
impression or nerve. The distance from the lateral
edge of the trigeminal impression or nerve at the
level of the petrous ridge to the anterior and posterior
walls of the porus of the meatus averages 6.4 mm
(range, 4.09.0 mm) and 14.2 mm (range, 12.018.0
mm), respectively. Care is taken to preserve the
cochlea, which is enclosed in the bone between the
labyrinthine segment of the facial nerve and the
greater petrosal nerve, and the semicircular canals
and vestibule positioned posterolateral to the fundus
of the meatus. The labyrinthine segment of the facial
nerve and the geniculate ganglion have been exposed.
The facial and vestibulocochlear nerves are exposed
in the cerebellopontine angle adjacent the occulus.
The greater petrosal nerve passes medially above the terminal part of the petrous carotid and below the lower surface of the trigeminal nerve.
FIGURE 3-3. Additional bone ante-
rior to the terminal part of the
petrous carotid has been removed to
expose the tensor tympani muscle
and eustachian tube. Bone removal
lateral to the fundus of the internal
acoustic meatus exposes the semicir-
cular canals, tympanic cavity, and
external auditory canal. The dura lin-
ing the internal acoustic meatus has
been opened to expose the facial and
vestibulocochlear nerves. The tegmen
has been opened, and the mastoid air
cells have been removed to expose the
dura medial to the sigmoid sinus,
referred to as Trautmanns triangle,
which faces the cerebellum. The
cochlea is exposed anteromedial and
the vestibule posterolateral to the fun-
dus of the meatus.
FIGURE 3-4. Superior view of the auditory
ossicles. The auditory ossicles are connected
to the walls of the tympanic cavity by liga-
ments, three for the malleus and one each for
the incus and stapes. The anterior ligament of
the malleus is attached at one end to the neck
and at the other end to the anterior wall of the
tympanic cavity close to the petrotympanic
fissure. The lateral ligament of the malleus
(not shown) is a triangular band passing
from the posterior part of the border of the
tympanic incisura to the head of the malleus.
The superior ligament of the malleus (not
shown) attaches the head of the malleus to
the roof of the epitympanic area. The posterior
ligament of the incus connects the end of the
short process of the fossa incudis, a shallow
depression in which the tip of the short
process sits. The superior ligament of the
incus is a small fold of mucus membrane
passing from the body of the incus to the roof
of the epitympanic area. The circumference of
the base of the stapes is attached to the mar-
gin of the oval window by a ring of elastic
fibers termed the anular ligament of the base of the stapes. The tendon of the
tensor makes a right angle turn around the trochleariform process to attach
to the upper part of the handle of the malleus. The stapedial tendon attaches
to the neck of the stapes.
FIGURE 3-5. The petrous apex has
been removed to expose the lateral side of
the clivus and the inferior petrosal
sinus. The layer of bone that separates
the internal acoustic meatus from the
area drilled for the anterior petrosectomy
has been preserved. The middle fossa
approach to the internal acoustic meatus
is usually selected for small tumors
within the internal acoustic meatus in
which it is possible to preserve hearing.
Preserving hearing requires that the
vestibule, semicircular canals, and
cochlea be preserved in exposing the
meatus. The approach for the anterior
petrosectomy, which exposes the lateral
edge of the clivus, upper brainstem, and
basilar artery, is directed through the
area medial to the internal acoustic mea-
tus. Care is required to avoid damaging
the cochlea, which would result in a loss
of hearing in both the middle fossa
approach to the internal acoustic meatus
and the anterior petrosectomy.
FIGURE 3-6. The petrous apex has
been removed to expose the lateral
edge of the clivus and the inferior pet-
rosal sinus. The dura has been opened
to expose the anterolateral surface of
the pons above and below the trigemi-
nal nerve and the anterior inferior
cerebellar artery crossing the abducens
nerve. Care must be taken to avoid
damage to the abducens nerve at the
medial margin of the drilling, where
the nerve passes through the inferior
petrosal sinus. The anterior petrousec-
tomy is one of our favored approaches
for exposing a low basilar bifurcation
and the portion of the basilar artery
below the trigeminal nerve.
FIGURE 3-7. Extradural right mid-
dle fossa exposure. The craniotomy is
positioned above the root of the zygo-
matic arch and extends to the middle
fossa oor. The dura has been elevated
from the floor of the right middle
fossa to expose the greater petrosal
nerve and middle meningeal artery.
The middle fossa approach to the
internal acoustic meatus is usually
directed through the extradural
space.
FIGURE 3-8. Enlarged view. The
geniculate ganglion and the distal
labyrinthine and proximal tympanic
segments of the facial nerve are exposed
directly under the dura. The ganglion is
exposed without a bony covering in
approximately 15% of temporal bones.
Trauma to the ganglion during eleva-
tion of the dura may cause a facial
palsy. The middle meningeal artery
sends a small branch along the greater
petrosal nerve to the geniculate gan-
glion and adjacent segments of the
facial nerve. Occluding this small
artery may cause facial paralysis.
FIGURE 3-9. Bone has been removed to show the two most com-
mon approaches directed through the middle fossa surface of the
temporal bone. The more medial approach, the anterior petrosec-
tomy, is directed through the petrous apex, and below the trigeminal
nerve to the lateral edge of the clivus and brainstem. The more lat-
eral channel is the middle fossa approach to the internal acoustic
meatus. In both approaches, an effort is made to avoid damaging the
cochlea, which sits in the area between the fundus of the meatus and
the greater petrosal nerves. The superior semicircular canal has been
exposed lateral to the drilling to expose the internal acoustic meatus.
This drilling to expose the internal acoustic meatus usually begins
at the level of the petrous ridge above the porus of the meatus and is
directed laterally and forward toward the fundus of the meatus,
where the exposure progressively narrows.
FIGURE 3-10. The dura lining the internal acoustic meatus has
been opened to expose the cisternal, meatal, labyrinthine, and tym-
panic segments of the facial nerve; the superior, inferior, and
cochlear nerves; two rootlets of the nervus intermedius; and the
geniculate ganglion.
FIGURE 3-11. The dri l l i ng has been
extended to expose the cochlea along the
anteromedial edge of the fundus of the meatus
and the vestibule and semicircular canals
along the posterolateral margin of the meatal
fundus. Care must be taken in the middle
fossa approach to the internal acoustic meatus
to avoid entering the cochlea and vestibule. If
either the cochlea or vestibule is entered, hear-
ing will be lost. The transverse crest divides
the fundus of the meatus into an upper and a
lower compartment. The facial and superior
vestibular nerves course above the transverse
crest and the cochlear and inferior vestibular
nerves pass below the crest. The facial nerve
passes through the anterior-superior quad-
rant, the inferior vestibular nerve passes
through the posterior-superior quadrant, the
cochlear nerve passes through the anterior-
inferior quadrant, and the inferior vestibular
nerve passes through the posterior-inferior
quadrant of the meatal fundus. The vertical
crest (Bills bar) separates the facial and supe-
rior vestibular nerves.
FIGURE 3-12. The anterior petro-
sectomy directed through the area
medial to the internal acoustic mea-
tus has been completed. The exposure
is directed posterior to the greater
petrosal nerve and below the trigem-
inal nerve to the lateral edge of the
clivus adjacent to the inferior petrosal
sinus, and to the posterior fossa dura
that faces the brainstem.
FIGURE 3-13. The dura below the
superior petrosal sinus and lateral to
the trigeminal nerve has been opened
to expose the anterior surface of the
pons. The dural incision crosses the
superior petrosal sinus and tento-
rium. The trochlear nerve was pre-
served in opening the tentorial edge.
The dural edges have been retracted
with sutures to expose the lower mid-
brain and the superior cerebellar
artery. The exposure extends above
and below the trigeminal nerve to the
anterolateral pons and to the lateral
edge of the clivus.
FIGURE 3-14. Drilling has been completed and
the dura opened. The exposure extends below the
trigeminal nerve and to the anterolateral surface
of the pons and lateral edge of the clivus. The
anterior inferior cerebellar artery passes next to
the abducens nerve in the lower part of the expo-
sure. The abducens nerve ascends and passes
below the petrosphenoid (Grubers) ligament to
reach the cavernous sinus between the cavernous
carotid artery and the rst trigeminal division.
The exposure extends superiorly to the level of
the oculomotor nerve. This approach can be
directed to a basilar bifurcation located below the
level of the dorsum sellae or to selected lesions
along the trunk of the basilar artery or anterolat-
eral brainstem. The approach also provides a
pathway to the clivus that avoids going through
the oral cavity.
middle fossa. The bone above the
eustachian tube, tensor tympani
muscle, petrous carotid, and internal
acoustic meatus and below the sec-
ond trigeminal division has been
removed. Dura has been removed
from the lateral wall of the cavernous
sinus to expose the trochlear, trigem-
inal, and oculomotor nerves in the
sinus wall and the abducens nerve
passing below the petrosphenoid lig-
ament and through Dorellos canal.
The greater petrosal nerve passes
medially above the petrous carotid
artery. The lesser petrosal nerve
arises from the tympanic branch of
the glossopharyngeal nerve, ascends
across the promontory in the tym-
panic plexus, and crosses the floor of
the middle fossa above the tensor
tympani. The lesser petrosal nerve
provides autonomic innervation
through the otic ganglion to the
parotid gland. The tensor tympani
muscle and eustachian tube are lay-
ered along but are separated from each other and from the anterior surface of the petrous carotid by a thin layer of bone.
FIGURE 3-16. The trigeminal nerve
has been reflected forward. The
petrolingual ligament extends from
the lingual process of the sphenoid
bone to the petrous apex and passes
above the junction of the petrous and
cavernous segments of the internal
carotid artery. The greater petrosal
nerve joins the deep petrosal branch
of the carotid sympathetic plexus to
form the vidian nerve. The vidian
canal has been unroofed to expose the
vidian nerve. The lesser petrosal
nerve arises from the tympanic
branch of the glossopharyngeal nerve,
passes across the promontory of the
middle ear in the tympanic nerve
plexus, crosses the oor of the middle
fossa above the tensor tympani, and
exits the cranium to provide para-
sympathetic innervation through the
otic ganglion to the parotid gland.
FIGURE 3-17. Enlarged superior view of the
junction of the eustachian tube and the internal
and external meati. The mastoid air cells on the
lateral side of the semicircular canals have been
removed. The superior vestibular, inferior
vestibular, facial, and cochlear nerves are
exposed at the fundus of the meatus. The
cochlear nerve enters the modiolus of the cochlea.
The vertical crest (Bills Bar) separates the facial
and superior vestibular nerves at the fundus of
the meatus. The superior vestibular nerve inner-
vates the ampullated anterior ends of the supe-
rior and lateral canals. The inferior vestibular
nerve innervates the lower or ampullated end of
the posterior canal. The chorda tympani crosses
the tympanic membrane and the upper part of
the handle of the malleus. The greater petrosal
nerve passes medially above the petrous carotid.
The cochlea sits in the angle between the
labyrinthine segment of the facial nerve and the
greater petrosal nerve. The lesser petrosal nerve
crosses above the tensor tympani and exits the
cranium near the foramen ovale to reach the otic
ganglion and innervate the parotid gland.
FIGURE 3-18. The mastoid antrum
and air cells, which are positioned
behind the external canal and lateral
to the semi ci rcul ar canal s and
vestibule, have been removed. Note
that the internal and external audi-
tory canals are located in a straight
line from each other. The cochlea is
exposed below the oor of the middle
fossa in the angle between the greater
petrosal nerve and the labyrinthine
segment of the facial nerve. The
petrous carotid is exposed below the
greater petrosal nerve and behind the
eustachian tube. The chorda tympani
crosses the inner surface of the tym-
panic membrane. The facial and
superior vestibular nerves pass above
and the cochlear and inferior vestibu-
lar nerves pass below the transverse
crest. The vertical crest (Bills Bar)
separates the facial and superior
vestibular nerves at the fundus of the
meatus. The lower segment of the
sigmoid sinus has been preserved.
FIGURE 3-19. Superior view of the temporal bone, infratemporal fossa,
and orbital apex. Aggressive lesions involving the temporal bone often
extend forward to the infratemporal fossa. The oor of the middle fossa has
been removed to expose the temporal and infratemporal fossae. The tempo-
ralis muscle lls the temporal fossa. The pterygoid muscles and venous
plexus, branches of the third trigeminal division, and the maxillary artery
are positioned in the infratemporal fossa. The posterior part of the middle
fossa formed by the squamous portion of the temporal bone, and which
forms the upper surface of the temporomandibular joint, has been removed
to expose the mandibular condyle. The posterior surface of the mandibular
condyle rests against the tympanic part of the temporal bone.
FIGURE 3-20. Lateral view. The anterior surface of the temporal
bone faces the posterior part of the infratemporal fossa, which con-
tains the branches of the maxillary artery and mandibular nerve
and the pterygoid muscles and venous plexus. The infratemporal
fossa opens medially into the pterygopalatine fossa. The maxillary
nerve passes through the foramen rotundum to enter the ptery-
gopalatine fossa and send branches along the orbital oor. The
ophthalmic nerve passes through the superior orbital ssure and
sends branches along the orbital roof. Bone has been removed to
expose the sphenoid sinus above and below the maxillary nerve,
and the vidian nerve below the maxillary nerve. A., artery;
A.I.C.A., anterior inferior cerebellar artery; Ac., acoustic; Ant.,
anterior; Arc., arcuate; Bas., basilar; Car., carotid; Cav., cav-
ernous; Chor., chorda; CN, cranial nerve; Coch., cochlear; Cond.,
condyle; Emin., eminence; Eust., eustachian; Ext., external; Fiss.,
ssure; Flocc., occulus; Gang., ganglion; Gen., geniculate; Gr.,
greater; Inf., inferior; Int., internal; Intermed., intermedius;
Laby., labyrinthine; Lat., lateral; Lent., lenticular; Less., lesser;
Lig., ligament; Ling., lingual; M., muscle; Mandib., mandibular;
Max., maxillary; Meat., meatal; Memb., membrane; Men.,
meningeal; Mid., middle; N., nerve; Nerv., nervus; Ophth., ophthalmic;
Orb., orbital; Pet., petro, petrosal, petrous; Post., posterior; Proc., process;
Prom., prominence; Pteryg., pterygoid; Pterygopal., pterygopalatine; S.C.A.,
superior cerebellar artery; Seg., segment; Semicirc., semicircular; Sig., sig-
moid; Sphen., sphenoid; Stap., stapedial; Sup., superior; Temp., temporal,
temporalis; Tens., tensor; Tent., tentorial, tentorium; Transv., transverse;
Trig., trigeminal; Troch., trochleariform; Tymp., tympani, tympanic; Vert.,
vertical; Vest., vestibular; Zygo., zygomatic.
CHAPTER 4
ANTERIOR VIEW
FIGURE 4-1. Anterior view of a stepwise dissection of a cross section through
the anterior part of the temporal bone. The coronal section crosses the tempo-
ral lobe and oor of the middle fossa just anterior to the external canal and
tympanic part of the temporal bone. The mandibular condyle has been removed
from the mandibular fossa. The posterior margin of the mandibular fossa is
formed by the tympanic part of the temporal bone, which also forms the lower
and anterior wall and part of the posterior wall of the external canal. Three
muscles arise from the styloid process, which projects downward, and is
ensheathed at its base by the tympanic part of the temporal bone. The internal
carotid artery ascends medial and slightly posterior to the styloid process to
enter the carotid canal. The facial nerve exits the stylomastoid foramen postero-
lateral to the styloid process.
Neurosurgery 61:S4-118S4-125, 2007 DOI: 10.1227/01.NEU.0000280015.54264.5E www.neurosurgery-online.com
ANTERIOR VIEW
FIGURE 4-2. Enlarged view. The anterior
part of the tympanic part of the temporal bone
has been removed to expose the cartilaginous
and osseous parts of the external acoustic
meatus. The lateral edge of the osseous part of
the external acoustic meatus and the osseous
ring to which the tympanic membrane
attaches have been preserved. The facial nerve
is exposed posterolateral to the styloid
process. The chorda tympani arises from the
mastoid segment of the facial nerve, ascends
through its posterior canaliculus and along
the inner surface of the posterior edge of the
tympanic membrane, crosses the upper part
of the handle of the malleus, and descends
through its anterior canaliculus and the
petrotympanic fissure. A probe has been
advanced through the eustachian tube into
the tympanic cavity. The internal jugular
vein is exposed between the styloid process
and the internal carotid artery.
RHOTON
FIGURE 4-3. The tympanic membrane has been
removed to expose the tympanic cavity. Bone has
been removed below the oor of the middle fossa to
expose the epitympanic area, where the head of the
malleus and body of the incus reside. The handle of
the malleus is exposed at the lateral edge of the
tympanic cavity. The promontory overlying the
basal turn of the cochlea forms part of the medial
wall of the tympanic cavity. The tympanic cavity
opens upward into the epitympanic area. The epi-
tympanic area opens posteriorly into the mastoid
antrum.
FIGURE 4-4. Enlarged view. The handle
of the malleus and the long process of the
incus are exposed in the tympanic cavity.
The lower end of the long process of the
incus turns sharply medially to form the
lenticular process, which articulates with
the head of the stapes. The footplate of the
stapes sits in the oval window. The
chorda tympani crosses the inner surface
of the tympanic membrane and the upper
part of the handle of the malleus. The
head of the malleus and body of the incus
are exposed in the epitympanic area. The
pyramidal eminence, which houses the
stapedial muscle, is exposed to the left of
the long process of the incus. The stape-
dial muscle is innervated by the facial
nerve. The tympanic cavity opens for-
ward and medially into the eustachian
tube. The tensor tympani muscle, which
is innervated by the trigeminal nerve, is
separated from the roof of the eustachian
tube by a thin shell of bone. The niche
leading to the round window is located
below the promontory.
ANTERIOR VIEW
RHOTON
FIGURE 4-5. Enlarged view. The tendon of the stapedial muscle
extends forward from the apex of the pyramidal eminence to insert on
the neck of the stapes. The chorda tympani crosses the upper part of the
tympanic membrane and the handle of the malleus in the area lateral
to the long process of the incus. The footplate of the stapes sits in the
oval window. The promontory in the medial wall of the tympanic cav-
ity overlies the basal turn of the cochlea. The niche leading to the round
window is located below the promontory. The lenticular process of the
incus articulates with the head of the stapes.
FIGURE 4-6. Additional bone has
been removed behind the epitym-
panic area and head of the malleus
and body of the incus to expose the
superior semicircular canal. The
promontory has been drilled to
expose the basal turn of the cochlea.
The osseous spiral lamina projects
into the area between the scala tym-
pani and the scala vestibuli. The del-
icate membranes that surround and
support the cochlear duct attach to
the spiral lamina and the outer wall
of the cochlea. The scala tympani is
separated from the tympanic cavity
by a thin membrane across the round
window. The oval window, in which
the footplate of the stapes sits, leads
from the tympanic cavity to the
vestibule of the inner ear. The stapes
has been removed from the oval win-
dow. The pyramidal eminence is
exposed below the segment of the
chorda tympani ascending to reach
the upper part of the handle of the
malleus.
ANTERIOR VIEW
RHOTON
FIGURE 4-7. Enlarged view of the epi-
tympanic area anteriorly and the semi-
circular canals posteriorly. The head of
the malleus and body of the incus are
exposed in the epitympanic area. The
superior, lateral, and posterior semicir-
cular canals have been exposed by
removing some of the mastoid air cells
and mastoid antrum. The superior canal
projects upward toward the oor of the
middle fossa in the area below the arcu-
ate eminence. The medial wall of the
tympanic cavity has been drilled to
expose the tympanic segment of the
facial nerve and the geniculate ganglion.
The tympanic segment passes above the
oval window and below the lateral semi-
circular canal.
FIGURE 4-8. Anterior superior view. Additional drilling along
the floor of the middle fossa exposes the meatal segment of the
facial nerve in the internal acoustic meatus. The labyrinthine
segment of the facial nerve extends from the fundus of the mea-
tus to the geniculate ganglion. The tympanic segment of the
facial nerve arises at the level of the geniculate ganglion and
passes posteriorly below the lateral canal and above the oval
window. The tensor tympani muscle, which is innervated by the
trigeminal nerve, is enclosed in an osseous canal, which is sep-
arated by a thin shell of bone from the carotid canal and the roof
of the tympanic cavity. The tendon of the tensor tympani has a
right angle turn around the cochleaform process before attaching
to the upper part of the neck of the malleus. The chorda tympani
arises from the mastoid segment of the facial nerve, ascends in its
posterior canaliculus, crosses the tympanic membrane and the
upper part of the handle of the malleus, and descends through its
anterior canaliculus and the petrotympanic fissure. A., artery;
Ac., acoustic; Car., carotid; Chor., chorda; CN, cranial nerve;
Emin., eminence; Epitymp., epitympanic; Eust., eustachian;
Ext., external; Gang., ganglion; Gen., geniculate; Gr., greater;
Int., internal; Jug., jugular; Laby., labyrinthine; Lat., lateral;
Lent., lenticular; M., muscle; Mandib., mandibular; Meat.,
meatal; Memb., membrane; Mid., middle; N., nerve; Pet., petrosal; Post.,
posterior; Proc., process; Seg., segment; Semicirc., semicircular; Sup., supe-
rior; Temp., temporal; Tens., tensor; Tymp., tympani, tympanic; V., vein.
ANTERIOR VIEW
CHAPTER 5
LATERAL VIEW
FIGURE 5-1. Lateral view of the temporal bone. Stepwise dissec-
tion. The tympanic part of the temporal bone forms the anterior
and lower walls and part of the posterior wall of the external
canal, part of the oor of the tympanic cavity, and the osseous por-
tion of the eustachian tube. The facial nerve exits the cranium
through the stylomastoid foramen medial to the lower part of the
tympanomastoid suture at the anterior end of the digastric groove.
The spine of Henle, at the junction of the upper and posterior
edge of the external canal, approximates the deep site of the tym-
panic segment of the facial nerve and the lateral semicircular
canal. The suprameatal triangle, a depressed area posterosuperior
to the external canal and behind the spine of Henle, is located
supercial to the mastoid antrum. The antrum is located super-
cial to the semicircular canals. The squamosal and tympanic parts
of the temporal bone form the upper and posterior surfaces of the
mandibular fossa.
Neurosurgery 61:S4-126S4-134, 2007 DOI: 10.1227/01.NEU.0000280016.31394.A0 www.neurosurgery-online.com
LATERAL VIEW
FIGURE 5-2. A mastoidectomy has
been completed to expose the osseous
capsule of the posterior and lateral
canals, the sigmoid sinus, and the
dura of the middle fossa. The jugular
bulb is medial to the cortical bone
above the digastric groove. The
chorda tympani crosses the inner
surface of the tympanic membrane.
RHOTON
FIGURE 5-3. The posterior and superior
wall of the external canal and the tym-
panic membrane have been removed while
preserving the ossicles and the chorda
t ympani . The mast oi d ( vert i cal or
descending) segment of the facial nerve
descends below the lateral canal and gives
rise to the chorda tympani, which passes
upward and forward on the inner aspect of
the tympanic membrane and across the
The head of the malleus articulates with
the body of the incus. The short process of
the incus points backward toward the
tympanic segment of the facial nerve. The
lenticular process at the lower end of the
long process of the incus articulates with
the stapes, which sits in the oval window.
The tendon of the stapedial muscle passes
forward from the muscles enclosure in the
pyramidal eminence to attach to the neck
of the stapes. The dura between the sig-
moid sinus and the semicircular canals,
called Trautmanns triangle, has been
opened. The endolymphatic sac, into which a blue piece of material has
been placed, sits beneath the dura of Trautmanns triangle on the posterior
surface of the temporal bone. The jugular bulb is positioned below the semi-
circular canals and vestibule.
FIGURE 5-4. Enlarged view of the auditory ossicles. The
malleus, below the lateral process, attaches to the inner surface
of the tympanic membrane. The chorda tympani, a segment of
which has been preserved, crosses the upper part of the handle
or neck of the malleus. The head of the malleus and body of the
incus are situated in the epitympanic area below the oor of the
middle fossa. The short process of the incus points posteriorly
toward the tympanic segment of the facial nerve as it passes
between the lateral canal above and the stapes sitting in the
oval window below. The long process of the incus terminates in
a sharp right angle turn to form the lenticular process, which
articulates with the head of the stapes.
LATERAL VIEW
RHOTON
incus has been removed to expose the
stapes sitting in the oval window.
The chorda tympani crosses the upper
part of the handle of the malleus. The
promontory is located supercial to
the basal turn of the cochlea. The fun-
dus of the internal acoustic meatus is
located medial to the tympanic cavity
and acousticovestibular labyrinth. A
line directed medially through the
cranial base along the long axis of the
external meatus will, at its depth,
approximate the site of the long axis
of the internal meatus deep to the
promontory. The fibers of the tym-
panic plexus, which arise from the
tympanic (Jacobsons) branch of the
glossopharyngeal nerve, cross the
promontory on their way to the oor
of the middle fossa, where they form
the lesser petrosal nerve.
FIGURE 5-6. The malleus and tym-
panic membrane have been removed.
The lateral portion of the lateral semi-
circular canal has been removed and
the vestibule is exposed deep in the
area of the ampullated end of the lat-
eral canal. A portion of the superior
and lateral canals have also been
removed. The posterior end of the
superior canal and the upper end of
the posterior canal join deep to the
bridge of bone outlined by the arrows
to form the common crus.
LATERAL VIEW
RHOTON
FIGURE 5-7. View directed laterally from
the oval window through the tympanic
cavity to the tympanic membrane. The
labyrinthine segment of the facial nerve
passes from the fundus of the meatus to
the geniculate ganglion. The tympanic seg-
ment arises at the geniculate ganglion and
passes above the footplate of the stapes,
which normally sits in the oval window.
The mastoid segment descends through the
facial canal medial to the mastoid part of
the temporal bone. The handle of the
malleus is attached to the tympanic mem-
brane. The chorda tympani crosses the
The head of the malleus articulates with
the body of the incus. The long process of
the incus ends in the medially directed
lenticular process that articulates with the
head of the stapes. The upper part of the
tympanic membrane, the pars accida, is
situated between the anterior and poste-
rior malleolar folds, which pass upward
from their attachment to the lateral process
of the malleus.
FIGURE 5-8. Medial aspect of the auditory ossicles. The head of the malleus
is the site of a facet, which articulates with the facet on the body of the incus.
The handle of the malleus, below the lateral process, is attached to the inner
surface of the tympanic membrane. The chorda tympani passes along the inner
surface of the tympanic membrane and across the upper part of the handle of
the malleus. The lateral process is the site of attachment of the lower end of the
anterior and posterior malleolar folds, between which is located the pars ac-
cida of the upper portion of the tympanic membrane. The stapedial tendon,
which has been preserved, attaches to the neck of the stapes. The long process
of the incus turns at a right angle at its lower end and gives rise to the lentic-
ular process, which articulates with the head of the stapes. The neck of the
stapes is connected by anterior and posterior limbs to join the footplate or base,
which sits in the oval window.
LATERAL VIEW
RHOTON
FIGURE 5-9. The medial wall of the epitympanic area
and mastoid have been exposed. The tympanic segment of
the facial nerve passes above the oval window. The semi-
circular canals are located above and behind the tym-
panic segment of the facial nerve. The oval window is
located below and the lateral canal above the tympanic
segment. The area of the promontory has been drilled to
expose the basal turn of the cochlea. A dark suture has
been placed in the basal and second turn of the cochlea.
Ant., anterior; Artic., articulate; Bas., basal; Chor.,
chorda; CN, cranial nerve; Comm., common; Digast.,
digastric; Emin., eminence; Endolymph., endolym-
phatic; Epitymp., epitympanic; Eust., eustachian;
Gang., ganglion; Gen., geniculate; Gr., greater; Jug.,
jugular; Laby., labyrinthine; Lat., lateral; Lent., lentic-
ular; M., muscle; Mandib., mandibular; Mast., mastoid;
Memb., membrane; N., nerve; Pet., petrosal; Plex.,
plexus; Post., posterior; Proc., process; Seg., segment;
Semicirc., semicircular; Sig., sigmoid; Sp., spine;
Squamomast., squamomastoid; Sup., superior;
Suprameat., suprameatal; Tens., tensor; Triang., trian-
gle; Tymp., tympani, tympanic; Tympanomast., tympa-
nomastoid.
CHAPTER 6
RELATIONSHIPS OF THE TEMPORAL BONE TO THE LATERAL CRANIAL BASE
FIGURE 6-1. Relationships of the temporal bone to the lateral cranial base.
Lateral view. Figures 6-16-15, stepwise dissection of left temporal area and
temporal bone. The skin and subcutaneous tissues have been removed to
expose the parotid gland and the facial nerve branches that course deep to
the parotid gland on their way to the facial muscles. The sternocleidomas-
toid attaches to the lateral part of the superior nuchal line and mastoid
process, descends in an anterior direction, and is crossed by the greater
auricular nerve. The temporalis fascia attaches to the upper surface of the
zygomatic arch. The trapezius muscle attaches to the medial part of the
superior nuchal line. The posterior triangle of the neck, located between the
sternocleidomastoid and trapezius, has the semispinalis capitis, splenius
capitis, and levator scapulae in its oor. The masseter muscle passes down-
ward from the zygomatic bone and arch to attach to the body and angle of
the mandible. The terminal branches of the occipital artery and the greater
occipital nerve reach the subcutaneous tissues by passing between the
attachment of the trapezius and sternocleidomastoid muscles to the superior
nuchal line.
RHOTON
FIGURE 6-2. Enlarged view. The facial nerve
branches are exposed along the anterior edge of the
parotid gland. The parotid duct crosses the temporalis
muscle.
LATERAL CRANIAL BASE
FIGURE 6-3. The parotid gland has been
removed to expose the facial nerve and its
branches distal to the stylomastoid foramen.
The nerve passes lateral to the styloid process,
the external carotid artery, and mandibular
neck. The masseter muscle has two heads: a
more supercial anterior head, which passes
downward to the lateral surface of the angle of
the jaw, and a deeper posterior head, which
arises from the medial surface of the zygomatic
arch and passes to the mandibular body. This
lower end of the sternocleidomastoid muscle
has been reflected backward by dividing its
attachment to the clavicle and sternum. The
supercial temporal artery ascends in front of
the ear.
RHOTON
FIGURE 6-4. The upper part of the
mandibular ramus and the lower
part of the temporalis muscle and its
attachment to the coronoid process
have been removed while preserving
the inferior alveolar and lingual
nerves. The infratemporal fossa is
located medial to the mandible on the
deep side of the temporalis muscle.
The exposure includes the upper and
lower heads of the lateral pterygoid
muscle, which insert along the tem-
poromandibular joint, and the super-
cial head of the medial pterygoid,
which extends from the lateral ptery-
goid plate to the angle of the jaw. The
structures in the infratemporal fossa
include the pterygoid muscles,
branches of the mandibular nerve,
t he maxi l l ar y ar t e r y and i t s
branches, and the pterygoid venous
plexus. Pathology involving the tem-
poral bone may extend to involve the
infratemporal fossa.
FIGURE 6-5. The lateral pterygoid
muscl es have been removed to
expose the branches of the trigemi-
nal nerve passing through the fora-
men ovale to convey sensation from
the mandibular area and to supply
the muscles in the infratemporal
fossa. The middle meningeal artery
passes between two rootlets of the
auriculotemporal nerve to reach the
foramen spinosum. The lingual and
inferior alveolar branches of the
third division have been preserved.
Removal of the remaining part of
the ramus of the mandible exposes
the styloid process and adjacent
muscles. The deep temporal arteries
and nerves course along to the
periosteal surface of the sphenoid
and temporal bones to reach the
deep surface of the temporalis mus-
cle. Preserving the temporalis mus-
cle requires that the muscle be ele-
vated using careful subperiosteal
dissection because its nerve and
vascular supply course on the deep
periosteal surface. Loss of the deep temporal nerve and arteries will result in temporalis atrophy and a poor cosmetic result after surgery.
RHOTON
FIGURE 6-6. Posterolateral view.
The spl eni us capi t i s has been
reflected downward to expose the
longissimus capitis, superior oblique,
and semispinalis capitis. The occipi-
tal artery passes along the occipital
groove on the medial side of the
digastric groove.
FIGURE 6-7. The longissimus capitis has
been reected downward to expose the rectus
capitis posterior minor and major, which
descend from the occipital bone to attach to
the spinous process of C1 and C2, respectively;
the superior oblique, which passes from the
occipital bone to the transverse process of C1;
and the inferior oblique, which extends from
the spinous process of C2 to the transverse
process of C1. The site of passage of vertebral
artery behind the atlanto-occipital joint is
located deep in the suboccipital triangle
located between the superior and inferior
oblique and the rectus capitis posterior major
muscles. The C1 transverse process is situated
immediately behind the internal jugular vein
and a short distance below and behind the
jugular foramen.
RHOTON
FIGURE 6-8. The superior and infe-
rior oblique and rectus capitus poste-
rior major muscles have been removed
to expose the vertebral artery passing
behind the atlanto-occipital joint. The
rectus capitus lateralis muscle extends
upward from the transverse process of
C1 to attach to the occipital bone behind
the jugular foramen. The vertebral
artery courses in the depths of the sub-
occipital triangle located between the
inferior and superior oblique muscles
and the rectus capitus posterior major,
all of which have been removed.
FIGURE 6-9. The mandibular condyle and ramus have been
removed to expose the muscles attached to the styloid process.
The pterygoid muscles and some branches of the mandibular
nerve have been removed to expose the auriculotemporal nerve,
which splits into two roots that surround the middle
meningeal artery below the foramen spinosum. The tensor and
levator veli palatini muscles, which attach along or near the
lower margin of the eustachian tube, are in the medial part of
the exposure. The longus capitis is exposed medial to the inter-
nal carotid artery in the retropharyngeal area.
RHOTON
FIGURE 6-10. The exposure has been
extended forward by removing the lateral wall
and oor of the orbit and the medial and lat-
eral walls of the maxillary sinus. The external
auditory canal has been removed, but the
tympanic membrane and cavity have been
preserved. The mastoid segment of the facial
nerve, the semicircular canals, the sigmoid
sinus, and the presigmoid dura have been
exposed. The infraorbital branch of the sec-
ond trigeminal division courses along the
oor of the orbit. The branches of the maxil-
lary nerve and artery in the pterygopalatine
fossa have been preserved. The maxillary
artery gives rise to the middle meningeal
artery, which passes through the foramen
spinosum posterolateral to the third trigemi-
nal division exiting the foramen ovale.
Lesions involving the temporal bone may
extend forward to involve the infratemporal
fossa and, from there, they can extend into
the pterygopalatine fossa and into the anterior
cranial base.
FIGURE 6-11. The external audi-
tory canal has been removed but the
tympanic membrane and cavity have
been preserved. The levator and ten-
sor veli palatini muscles have been
removed and the membranous part of
the eustachian tube has been opened.
The eustachian tube crosses anterior
to and is separated from the petrous
carotid by a thin shell of bone. The
jugular bulb and lateral bend of the
petrous carotid are located below the
acousticovestibular labyrinth. The
second trigeminal division exits the
foramen rotundum and enters the
pterygopalatine fossa. The third divi-
sion exits the foramen ovale to reach
the infratemporal fossa.
RHOTON
vertical segment of the petrous
carotid has been exposed by remov-
ing the eustachian tube and drilling
the bone lateral to the carotid canal.
The jugular bulb is positioned below
the semicircular canals.
FIGURE 6-13. The eustachian tube
has been resected and the mandibular
nerve divided at the foramen ovale to
expose the petrous carotid. This exposes
the longus capitis and rectus capitis
anterior muscles, both of which are
located behind the posterior pharyngeal
wall. The clivus is exposed between the
longus capitis and rectus capitis anteri-
orly. The orifice of the contralateral
eustachian is exposed in the nasophar-
ynx. The accessory nerve descends pos-
teriorly on the lateral side of the inter-
nal jugular vein.
RHOTON
FIGURE 6-14. The petrous carotid
has been reected forward out of the
carotid canal to expose the petrous
apex medial to the carotid canal.
FIGURE 6-15. The petrous apex and
upper clivus have been drilled and the
dura opened to expose the anterolat-
eral aspect of the pons below the
trigeminal nerve. The sigmoid sinus
and the jugular bulb have been
removed to expose the nerves exiting
the jugular foramen. The chorda tym-
pani, malleus, and incus have been
preserved.
RHOTON
FIGURES 6-166-18. Another specimen. The
cortical bone surrounding the osseous part of
the external canal, the semicircular canals, and
the incus and malleus has been preserved. The
petrous apex in front of the labyrinth has been
removed to expose the petrous carotid. A short
segment of the tensor tympani muscle has been
preserved. The facial and vestibulocochlear
nerves arise at the junction of the pons and
medulla. The labyrinthine, tympanic, and mas-
toid segments of the facial nerve and the
branches of the mandibular nerve in the
infratemporal fossa have been preserved.
FIGURE 6-17. The osseous portion of the external
acoustic meatus and the tympanic membrane have been
removed. The distal part of the tensor tympani has been
preserved. The tympanic segment of the facial nerve
passes below the lateral canal and above the stapes in
the oval window. The chorda tympani arises from the
mastoid segment of the facial nerve and ascends to cross
the upper part of the handle of the malleus.
RHOTON
FIGURE 6-18. The incus, malleus, and stapes have been
removed. Removing the stapes exposes the oval window in
which the stapes sits. The tympanic segment of the facial
nerve passes between the oval window and the lateral semi-
circular canal. A short segment of the tensor tympani mus-
cle and the tendon of the stapedial muscle have been pre-
served. The round window is exposed below the promontory.
A., artery; Ac., acoustic; Alv., alveolar; Ant., anterior; Atl.,
atlanto; Aur., auricular; Auriculotemp., auricutemporal;
Brs., branches; Cap., capitis; Car., carotid; Chor., chorda;
CN, cranial nerve; Cond., condyle; Constr., constrictor;
Contralat., contralateral; Eust., eustachian; Ext., external;
Front., frontal; Gang., ganglion; Gen., geniculate; Gl.,
gland; Gr., greater; Inf., inferior; Infraorb., infraorbital;
Infratemp., infratemporal; Int., internal; Jug., jugular;
Laby., labyrinthine; Lat., lateral, lateralis; Lev., levator;
Long., longus; Longiss., longissimus; M., muscle; Maj.,
major; Mandib., mandibular; Mast., mastoid; Max., max-
illary; Med., medial; Memb., membrane; Men., meningeal;
Mid., middle; Min., minor; N., nerve; Obl., oblique;
Occip., occipital; Pal., palatine; Pet., petrous, petrosal;
Post., posterior; Proc., process; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Rec., rectus; Scap., scapulae;
Seg., segment; Semicirc., semicircular; Semispin., semispinalis; Sig., sig-
moid; Splen., splenius; Sternocleidomast., sternocleidomastoid; Suboccip.,
suboccipital; Sup., superior; Temp., temporal; Tens., tensor; TM, temporo-
mandibular; Transv., transverse; Triang., triangle; Tymp., tympani, tym-
panic; V., vein; Vert., vertebral.
CHAPTER 7
RETROLABYRINTHINE, TRANSLABYRINTHINE,
AND TRANSCOCHLEAR APPROACHES
FIGURE 7-1. Mastoidectomy and retrolabyrinthine, partial labyrinthine,
translabyrinthine, and transcochlear approaches. Right mastoid. The retroau-
ricular ap and the sternocleidomastoid muscle have been reected forward
and the trapezius and underlying splenius capitus have been reected back-
ward to expose the mastoid and attachment of the longissimus capitus muscle.
The posterior belly of the digastric muscle originates medial to the mastoid tip
along the digastric groove. The spine of Henle is positioned at the posterior
superior margin of the external meatus. The spine is positioned supercial to
the deep site of the lateral semicircular canal and junction of the tympanic and
mastoid segments of the facial nerve. The supramastoid crest, a continuation
of the superior temporal line, is positioned at approximately the level of the
upper margin of the transverse and sigmoid sinuses. The area below the ante-
rior part of the supramastoid crest and behind the spine of Henle, called the
suprameatal triangle, is positioned supercial to the mastoid antrum. The
semicircular canals are positioned deep to the mastoid antrum.
Neurosurgery 61:S4-153S4-168, 2007 DOI: 10.1227/01.NEU.0000280018.39017.D0 www.neurosurgery-online.com
RHOTON
FIGURE 7-2. The supercial mastoid air cells
have been removed. The air cells coalesce in the
area deep to the suprameatal triangle to form the
mastoid antrum, which is positioned lateral to
the bone enclosing the semicircular canals.
TRANSLABYRINTHINE APPROACHES
FIGURE 7-3. The dri l l i ng has been
extended through the mastoid antrum to
expose the epitympanic area where the body
of the incus and head of the malleus reside.
The facial recess, located between the mas-
toid segment of the facial nerve and the
chorda tympani, has been opened to expose
the long process of the incus and the articu-
lation of the lenticular process of the incus
with the head of the stapes. The bridge of
bone, positioned posterior to the tip of the
short process of the incus, between the epi-
tympanic area and facial recess, is referred
to as the buttress. The chorda tympani
arises from the lower portion of the mastoid
segment of the facial nerve, ascends ante-
rior to the facial recess, and crosses the inner
surface of the tympanic membrane.
RHOTON
FIGURE 7-4. The drilling has been extended
to expose the middle fossa dura above, the sig-
moid sinus posteriorly, and the jugular bulb
below. The superior, lateral, and posterior semi-
circular canals are located deep to the mastoid
antrum and suprameatal triangle. The anterior
end of the superior canal projects upward below
the arcuate eminence. The posterior canal faces
the posterior fossa dura. The lateral canal is
positioned above the tympanic segment of the
facial nerve. The facial nerve passes below the
lateral canal and turns downward to form the
mastoid segment. The dura between the sig-
moid sinus and the semicircular canals, named
Trautmanns triangle, faces the anterior surface
of the cerebellum and cerebellopontine angle. A
meningeal branch of the ascending pharyngeal
artery passes through the jugular foramen and
ascends in the dura of Trautmanns triangle.
The jugular bulb is positioned medial to the
cortical bone overlying the digastric groove. The
sinodural angle is positioned at the junction of
the sigmoid, transverse, and superior petrosal
sinuses, and where the sigmoid sinus intersects
the middle fossa dura.
FIGURE 7-5. Enlarged view. The short
process of the incus points toward the
tympanic segment of the facial nerve
passing between the lateral semicircular
canal and the stapes sitting in the oval
window. The superior and lateral canal
ampullae, located at the anterior end of
these canals, are innervated by the supe-
rior vestibular nerve. The posterior canal
ampulla, located at the lower end of the
posterior canal, is innervated by the sin-
gular branch of the inferior vestibular
nerve. In the translabyrinthine approach,
drilling through the anterior (ampul-
lated) ends of the superior and lateral
canals exposes the superior vestibular
area and nerve at the fundus of the mea-
tus. Drilling the lower (ampullated) end
of the posterior canal exposes the infe-
rior vestibular area and nerve at the fun-
dus of the meatus. The posterior end of
the superior canal and the upper end of
the posterior canal join to form a single
channel, the common crus, which opens
into the vestibule.
RHOTON
FIGURE 7-6. The lateral edge of the
endolymphatic sac has been separated
from the dura of Trautmanns trian-
gle. The endolymphatic sac sits
beneath the dura on the posterior sur-
face of the temporal bone above and
medial to the lower part of the sig-
moid sinus. The endolymphatic sac
communicates through the endolym-
phatic duct with the vestibule.
FIGURE 7-7. Apartial labyrinthec-
tomy has been completed by remov-
ing the posterior and superior semi-
circular canals. Silver and black
sutures mark the previous position of
the superior and posterior canals.
The lateral canal has been preserved.
Removing these two canals may not
result in a total loss of hearing. The
chance of preserving some hearing
after this type of partial labyrinthec-
tomy is improved if the drilled ends
of the two canals are obliterated with
bone dust or wax or other material.
The upper end of the posterior canal
and the posterior end of the superior
canal join to form the common crus.
RHOTON
FIGURE 7-8. The lateral canal has
been removed, leaving an opening
into the vestibule. The exposure has
not been extended into the internal
meatus to complete the translaby-
rinthine exposure.
FIGURE 7-9. The translabyrinthine
exposure has been completed to expose the
vestibulocochlear and facial nerves in the
internal acoustic meatus. The meatal and
labyrinthine segments of the facial nerve
are exposed proximal to the geniculate
ganglion with the tympanic and mastoid
segments exposed distally. The short
process of the incus points toward the
tympanic segment of the facial nerve,
which passes above the stapes sitting in
the oval window. The mastoid segment of
the facial nerve descends toward the sty-
lomastoid foramen and gives rise to the
chorda tympani. The dura of Trautmanns
triangle has been opened to expose the
trigeminal, glossopharyngeal, and vagus
nerves in the cerebellopontine angle. The
anterior inferior cerebellar artery loops
laterally into the meatus before turning
back toward the brainstem. The facial,
superior, and inferior vestibular nerves
are exposed at the fundus of the meatus.
The cochlear nerve is hidden anterior to
the inferior vestibular nerve.
RHOTON
FIGURE 7-10. The dura has been
opened to expose the Cranial Nerves in
the cerebellopontine angle. The vestibulo-
cochlear nerve has been depressed to
expose the facial nerve and the nervus
intermedius. The motor root of the
trigeminal nerve has been exposed supe-
rior and medial to the main sensory root.
The glossopharyngeal and vagus nerves
are at the lower margin of the exposure
just above the jugular bulb. The occulus
and choroid plexus protrude from the
foramen of Luschka behind the vestibulo-
cochlear nerve. The anterior inferior cere-
bellar artery loops laterally between the
facial and vestibulocochlear nerves. A
small branch of the posterior inferior
cerebellar artery descends posterior to the
glossopharyngeal and vagus nerves.
labyrinthine, tympanic, and mastoid seg-
ments of the facial nerve. The incus has been
removed. The tympanic segment passes
above the stapes sitting in the oval window.
The junction of the labyrinthine and tym-
panic segments and the geniculate ganglion
are tethered to the oor of the middle fossa
by the greater petrosal nerve. The cochlea is
located anterior to the fundus of the meatus
and anterior to the stapes sitting in the oval
window. Completing a transcochlear
approach requires either displacing the facial
nerve posteriorly or leaving a thin shell of
bone encasing the nerve and working
around the encased nerve. Untethering the
facial nerve for a posterior transposition
requires that the greater petrosal nerve be
sectioned just medial to the geniculate gan-
glion. The lateral process and handle of the
malleus are attached to the inner surface of
the tympanic membrane.
RHOTON
FIGURE 7-12. The greater petrosal
nerve has been sectioned just distal to
the apex of the geniculate ganglion. The
facial nerve has been displaced posteri-
orly for removal of the cochlea in the
transcochlear approach. The semicircu-
lar canals and vestibule, the end organs
of the superior and vestibular nerves,
have been removed. The incus has been
removed but the malleus remains
attached to the tympanic membrane.
FIGURE 7-13. Drilling has been extended for-
ward into the cochlea. The cochlear nerve enters
the modiolus in the center of the spiral turns of the
cochlea. The scala tympani and vestibuli and the
osseous spiral crest in the auditory labyrinth have
been exposed. Drilling the cochlea often requires
that at least the posterior portion of the ring of
bone supporting the tympanic membrane be
removed and that the external canal be closed at
the end of the procedure. The malleus and tym-
panic membrane have been preserved at this stage.
RHOTON
anterior inferior cerebellar artery
loops laterally to the fundus of the
meatus. The cochlear nerve pene-
trates the modiolus at the fundus of
the meatus. The scala tympani and
vestibuli and the osseous spiral crest
in the cochlea are exposed.
FIGURE 7-15. Removal of the
cochlea opens the channel for remov-
ing the remainder of the petrous
apex. The exposure, directed below
the trigeminal nerve, extends medi-
ally to the front of the pons and
medulla and to the lateral side of the
basilar artery. The abducens nerve
ascends lateral to the basilar artery.
The tympanic membrane has been
removed. Removing the cochlea and
petrous apex exposes a short segment
of the petrous carotid artery.
RHOTON
FIGURE 7-16. Enlarged view of the com-
pleted transcochlear approach. The expo-
sure extends to the lateral edge of the clivus
and the inferior petrosal sinus. The basilar
artery and anterior surface of the pons are
at the deep end of the exposure. A high
jugular bulb may block access to the area
below the glossopharyngeal nerve. The
abducens nerve passes behind the anterior
inferior cerebellar artery and lateral to the
basilar artery. A., artery; A.I.C.A., ante-
rior inferior cerebellar artery; Asc., ascend-
ing; Bas., basilar; Br., branch; Cap., capi-
tis; Car., carotid; Chor., chorda; CN,
cranial nerve; Coch., cochlear; Comm.,
common; Endolymph., endolymphatic;
Epitymp., epitympanic; Flocc., occulus;
Gang., ganglion; Gen., geniculate; Inf.,
inferior; Intermed., intermedius; Jug.,
jugular; Laby., labyrinthine; Lat., lateral;
Lent., lenticular; Longiss., longissimus;
M., muscle; Mast., mastoid; Meat., meatal;
Memb., membrane; Mid., middle; N.,
nerve; Nerv., nervus; Pet., petrosal,
petrous; Pharyng., pharyngeal; Post., pos-
terior; Proc., process; Seg., segment; Semicirc., semicircular; Sig., sigmoid;
Sp., spine; Sternocleidomast., sternocleidomastoid; Sup., superior;
Suprameat., suprameatal; Triang., triangle; Tymp., tympani, tympanic;
Vest., vestibular.
CHAPTER 8
PRESIGMOID APPROACH
Neurosurgery 61:S4-169S4-174, 2007 DOI: 10.1227/01.NEU.0000280025.07630.2C www.neurosurgery-online.com
FIGURE 8-1. Presigmoid
approach, left presigmoid
approach. The scalp incision
is shown on the lower left.
The mastoidectomy has
been completed and the
dense cortical bone around
the semicircular canals has
been exposed. The tympanic
segment of the facial nerve
and the lateral canal are situated deep to the spine of Henle.
Trautmanns triangle, the patch of dura in front of the sigmoid sinus,
faces the cerebellopontine angle. The endolymphatic sac sits beneath
the dura in Trautmanns triangle.
RHOTON
presigmoid dura is opened anterior to
the sigmoid sinus. The incision, out-
lined with strips of suture, should
cross the superior petrosal sinus a few
millimeters forward of the area shown
in this illustration. The temporal
dura is opened and the tentorium is
divided, taking care to preserve the
vein of Labb that joins the transverse
sinus and the trochlear nerve that
enters the anterior margin of the ten-
torium.
PRESIGMOID APPROACH
FIGURE 8-3. Retrolabyrinthine
presigmoid exposure in which the
semicircular canals have been pre-
served. The presigmoid dura has
been opened and the superior pet-
rosal sinus and tentorium divided.
The abducens and facial nerves are
exposed medial to the vestibulo-
cochlear nerve. The anterior inferior
cerebellar artery passes below the
vestibulocochlear nerve. The supe-
rior cerebellar artery passes above
the trigeminal nerve. The posteroin-
ferior cerebellar artery courses in the
lower margin of the exposure with
the glossopharyngeal and vagus
nerves. Choroid plexus protrudes
into the cerebellopontine angle
behind the glossopharyngeal and
vagus nerves.
RHOTON
FIGURE 8-4. The vestibulocochlear
nerve has been retracted downward
to expose the nervus intermedius and
facial nerve. The trigeminal nerve is
at the upper margin of the exposure.
The motor root of the trigeminal
nerve arises as a series of rootlets
positioned superomedial to the main
sensory root. The glossopharyngeal,
vagus, and accessory nerves are at the
lower margin of the exposure. The
occulus protrudes into the cerebel-
lopontine angle behind the glossopha-
ryngeal nerve.
PRESIGMOID APPROACH
FIGURE 8-5. The semicircular canals and vestibule
have been removed to complete the translabyrinthine
approach to the internal acoustic meatus and cerebel-
lopontine angle and to expose the vestibulocochlear
and facial nerves in the internal acoustic meatus.
The temporal lobe has been elevated. The segment of
the trochlear nerve that passes below the medial edge
of the tentorium and the junction of the vein of Labb
with the transverse sinus have been preserved. The
jugular bulb is at the lower margin of the exposure.
RHOTON
FIGURE 8-6. The cochlea has been removed
to complete a transcochlear exposure that
extends to the lateral margin of the clivus
and the inferior petrosal sinus. The vertical
segment of the petrous carotid is exposed
anterior to the jugular bulb. The lateral side
of the basilar artery and the anterior surface
of the pons are in the depths of the exposure.
The superior cerebellar artery passes below
the trochlear nerve and above the trigeminal
nerve. A., artery; A.I.C.A., anterior inferior
cerebellar artery; Bas., basilar; Car., carotid;
Chor., chorda, choroid; CN, cranial nerve;
Endolymph., endolymphatic; Flocc., oc-
culus; Inf., inferior; Intermed., inter-
medius; Jug., jugular; Lat., lateral; Mast.,
mastoid; Meat., meatal; Memb., membrane;
Mid., middle; N., nerve; Nerv., nervus;
P.I.C.A., posterior inferior cerebellar artery;
Pet., petrosal, petrous; Plex., plexus; Post.,
posterior; S.C.A., superior cerebellar artery;
Seg., segment; Semicirc., semicircular; Sig.,
sigmoid; Sup., superior; Temp., temporal;
Triang., triangle; Tymp., tympani, tym-
panic; V., vein.
CHAPTER 9
CEREBELLOPONTINE ANGLE AND RETROSIGMOID APPROACH
CEREBELLOPONTINE ANGLE AND
RETROSIGMOID APPROACH
Cerebellopontine Angle
The cerebellopontine angle is located between the superior
and inferior limbs of the cerebellopontine ssure, an angular
cleft formed by the petrosal cerebellar surface folding around
the pons and middle cerebellar peduncle (1). The cerebellopon-
tine ssure faces the posterior surface of the temporal bone
and has superior and inferior limbs that meet at a lateral apex.
Cranial Nerves IV through XI are located near or within the
angular space between the two limbs commonly referred to as
the cerebellopontine angle. The trochlear and trigeminal nerves
are located near the ssures superior limb, and the glossopha-
ryngeal, vagus, and accessory nerves are located near the infe-
rior limb. The facial and acousticovestibular nerve rises near
the central part of the ssure. The abducens nerve is located
near the base of the ssure, along a line connecting the anterior
ends of the superior and inferior limbs.
Optimizing operative approaches to the cerebellopontine
angle requires an understanding of the relationship of the cere-
bellar arteries to the cranial nerves, brainstem, cerebellar
peduncles, ssures between the cerebellum and brainstem, and
the cerebellar surfaces. When examining these relationships,
three neurovascular complexes are dened: an upper complex
related to the superior cerebellar artery (SCA), a middle com-
plex related to the anterior inferior cerebellar artery (AICA),
and a lower complex related to the posterior inferior cerebellar
artery (PICA).
Other structures, in addition to the three cerebellar arteries,
occurring in sets of three in the posterior fossa that bear a con-
sistent relationship to the SCA, AICA, and PICA are the parts
of the brainstem (midbrain, pons, and medulla), the cerebellar
peduncles (superior, middle, and inferior), the ssures between
the brainstem and the cerebellum (cerebellomesencephalic,
cerebellopontine, and cerebellomedullary), and the surfaces of
the cerebellum (tentorial, petrosal, and suboccipital). Each neu-
rovascular complex includes one of the three parts of the brain-
stem, one of the three surfaces of the cerebellum, one of the
three cerebellar peduncles, and one of the three major ssures
between the cerebellum and the brainstem. In addition, each
neurovascular complex contains a group of cranial nerves. The
upper complex includes the oculomotor, trochlear, and trigem-
inal nerves that are related to the SCA. The middle complex
includes the abducens, facial, and vestibulocochlear nerves that
are related to the AICA. The lower complex includes the glos-
sopharyngeal, vagus, accessory, and hypoglossal nerves that
are related to the PICA.
In summary, the upper complex includes the SCA, midbrain,
cerebellomesencephalic ssure, superior cerebellar peduncle,
tentorial surface of the cerebellum, and the oculomotor,
trochlear, and trigeminal nerves. The SCAarises in front of the
midbrain, and passes below the oculomotor and trochlear
nerves and above the trigeminal nerve to reach the cerebel-
lomesencephalic ssure, where it runs on the superior cerebel-
lar peduncle and terminates by supplying the tentorial surface
of the cerebellum.
The middle complex includes the AICA, pons, middle cere-
bellar peduncle, cerebellopontine ssure, petrosal surface of
the cerebellum, and the abducens, facial, and vestibulocochlear
nerves. The AICA arises at the pontine level, courses in rela-
tionship to the abducens, facial, and vestibulocochlear nerves
to reach the surface of the middle cerebellar peduncle, where it
courses along the cerebellopontine ssure and terminates by
supplying the petrosal surface of the cerebellum.
The lower complex includes the PICA, medulla, inferior cere-
bellar peduncle, cerebellomedullary ssure, suboccipital sur-
face of the cerebellum, and the glossopharyngeal, vagus, acces-
sory, and hypoglossal nerves. The PICAarises at the medullary
level, encircles the medulla, passing in relationship to the glos-
sopharyngeal, vagus, accessory, and hypoglossal nerves to
reach the surface of the inferior cerebellar peduncle, where it
dips into the cerebellomedullary ssure and terminates by sup-
plying the suboccipital surface of the cerebellum.
Retrosigmoid Approach
The most common operation directed to the upper neurovas-
cular complex is the exposure of the posterior root of the trigem-
inal nerve for a vascular decompression procedure for trigemi-
nal neuralgia. For a vascular decompression operation, this
upper neurovascular complex is approached using a vertical
scalp incision crossing the asterion, which usually overlies the
lower half of the junction of the transverse and sigmoid sinuses.
The bone opening, a small craniotomy, located behind the upper
half of the sigmoid sinus, exposes the edge of the junction of the
transverse and sigmoid sinuses in its superolateral margin. The
most common nding at a vascular decompression operation
for trigeminal neuralgia is that a segment of the SCA com-
presses the trigeminal nerve. The AICAor basilar artery is less
commonly the compressing vessel. The most common venous
compression is by a tributary of a superior petrosal vein.
Operations directed to the middle complex are for the
removal of acoustic neuromas and other tumors and for the
The operation for hemifacial spasm is directed along the
inferolateral margin of the cerebellum. The craniotomy is
located medial to the lower half of the sigmoid sinus. It is
not necessary to extend the bone opening downward to
the foramen magnum or upward to the transverse sinus.
The inferolateral margin of the cerebellum is elevated with
a small brain spatula and the arachnoid behind the glos-
sopharyngeal and vagus nerves is opened. This will
expose the tuft of choroid plexus protruding from the fora-
men of Luschka, and sitting on the posterior surface of the
glossopharyngeal and vagus nerves. Commonly, the oc-
culus is seen protruding behind the nerves and blocks their
visualization at the junction with the brainstem. It may
also be difcult to see the facial nerve that is hidden in
front of the vestibulocochlear nerve. At this time in the
operation, it is important to recall that the facial nerve root
exits the brainstem 2 to 3 mm rostral to the point at which
the glossopharyngeal nerve enters the brainstem. To
expose the nerves exit from the brainstem, the choroid
plexus is gently separated from the posterior margin of
the glossopharyngeal nerve so that its junction with the
brainstem can be seen. The brain spatula is advanced
upward to elevate the choroid plexus away from the pos-
terior margin of the glossopharyngeal nerve. The expo-
sure is then directed several millimeters above the glos-
sopharyngeal nerve to where the facial nerve will be seen
joining the brainstem below and in front of the vestibulo-
cochlear nerve. At this point, it usually becomes obvious
which vessel is compressing the nerve.
Our most common operation directed to the lower
complex is for glossopharyngeal neuralgia. We have usu-
ally treated glossopharyngeal neuralgia by dividing the
glossopharyngeal nerve and the upper quarter of the
vagal rootlets. It is suggested that fewer of the rostral
rootlets of the vagus nerve be cut if the diameters of the
upper rootlets are large rather than small. Vascular de-
compression is an option for treating glossopharyngeal
neuralgia, although we had excellent results with glos-
sopharyngeal and upper vagal neurectomy. A detailed
description of these operations and others dealing with
pathologies in the cerebellopontine angle can be found
elsewhere (1).
REFERENCES
1. Rhoton AL Jr: The cerebellopontine angle and posterior fossa cranial
nerves by the retrosigmoid approach. Neurosurgery 47 [Suppl
3]:S93S129, 2000.
relief of hemifacial spasm. The considerations related to
acoustic neuromas will be dealt with rst. The retrosig-
moid approach to an acoustic neuroma is directed through
a vertical scalp incision that crosses the asterion. A burr
hole is placed below the asterion and a craniotomy is per-
formed, exposing the lower margin of the transverse sinus
superiorly, the posterior margin of the sigmoid sinus later-
ally, and the inferior portion of the squamous part of the
occipital bone inferiorly. The nerves in the lateral part of
the internal acoustic meatus are the facial, cochlear, and
inferior and superior vestibular nerves. The position of the
nerves is most constant in the lateral portion of the meatus,
which is divided into a superior and an inferior portion by
a horizontal ridge, called either the transverse or the falci-
form crest. The facial and the superior vestibular nerves
are superior to the crest. The facial nerve is anterior to the
superior vestibular nerve and is separated from it at the
lateral end of the meatus by a vertical ridge of bone, called
the vertical crest. The vertical crest is also called Bills
bar in recognition of William Houses role in focusing on
the importance of this crest in identifying the facial nerve
at the lateral end of the meatus. The cochlear and inferior
vestibular nerves run below the transverse crest, with the
cochlear nerve located anteriorly. Thus, the lateral meatus
can be considered to be divided into four portions, with
the facial nerve being anterosuperior, the cochlear nerve
anteroinferior, the superior vestibular nerve posterosupe-
rior, and the inferior vestibular nerve posteroinferior. The
facial nerve is commonly identified, even with a large
tumor, in the anterosuperior quadrant at the lateral end of
the meatus after removing the posterior meatal lip. The
cochlear nerve is identied in the anteroinferior quadrant
of the meatus.
There is also a consistent set of relationships on the brain-
stem side of an acoustic neuroma that aids in identication
of the facial and cochlear nerves on the medial side of the
tumor. The landmarks on the medial or brainstem side that
are helpful in guiding the surgeon to the junction of the
facial nerve with the brainstem are the pontomedullary sul-
cus; the junction of the glossopharyngeal, vagus, and spinal
accessory nerves with the medulla; the foramen of Luschka
and its choroid plexus; and the occulus. These facial and
cochlear nerves, although distorted by the tumor, usually
can be identied on the brainstem side of the tumor at the
lateral end of the pontomedullary sulcus, just rostral to the
glossopharyngeal nerve and just anterosuperior to the fora-
men of Luschka, the occulus, and the choroid plexus pro-
truding from the foramen of Luschka.
RHOTON
CEREBELLOPONTINE ANGLE
FIGURE 9-1. Cerebellopontine angle and the retrosigmoid
approach. The petrosal surface of the cerebellum faces forward
toward the posterior surface of the temporal bone. It is the
surface that is elevated to reach the cerebellopontine angle.
The cerebellopontine fissure, a V-shaped fissure formed by the
cerebellum wrapping around the pons and middle cerebellar
peduncle, has superior and inferior limbs that define the mar-
gins of the cerebellopontine angle. Cranial Nerves V to XI
arise in, or near, the cerebellopontine fissure or angle. The
superior limb extends above the trigeminal nerve and the infe-
rior limb passes below the flocculus and the nerves that pass
to the jugular foramen. The superior and inferior limbs meet
laterally at the apex located at the anterior end of the petrosal
fissure that divides the petrosal surface of the cerebellum into
superior and inferior parts. The fourth ventricle is located
behind the pons and medulla. The midbrain and pons are sep-
arated by the pontomesencephalic sulcus and the pons and
medulla by the pontomedullary sulcus. The trigeminal nerves
arise from the mid pons. The abducens nerve arises in the
medial part of the pontomedullary sulcus, rostral to the
medullary pyramids. The facial and vestibulocochlear nerves
arise at the lateral end of the pontomedullary sulcus immedi-
ately rostral to the foramen of Luschka. The hypoglossal nerves arise ante-
rior to the olives and the glossopharyngeal and vagus nerves arise posterior
to the olives. The flocculus and choroid plexus protrude from the foramen of
Luschka behind to the glossopharyngeal and vagus nerves. The foramen of
Luschka opens into the cerebellopontine angle below the junction of the facial
and vestibulocochlear nerves with the lateral end of the pontomedullary sul-
cus. The choroid plexus protrudes from the lateral recess and foramen of
Luschka behind the glossopharyngeal, vagus, and accessory nerves.
RHOTON
FIGURE 9-2. Enlarged view of the right
cerebellopontine angle. The petrosal surface
of the cerebellum faces forward toward the
petrous bone and is the surface that is ele-
vated to expose the cerebellopontine angle
and posterior surface of the temporal bone.
The cerebellopontine fissure, which might
also be referred to as the cerebellopontine
angle, is a V-shaped fissure formed where
the cerebellum wraps around the pons and
middle cerebellar peduncle. Cranial Nerves
V through XI arise in or near the margins
of the cerebellopontine fissure. The flocculus
and choroid plexus extend laterally from the
foramen of Magendie above the lower limb
of the fissure. The abducens nerve arises in
the medial part of the pontomedullary sul-
cus rostral to the medullary pyramids. The
facial and vestibulocochlear nerves arise
just rostral to the foramen of Luschka near
the flocculus at the lateral end of the pon-
tomedullary sulcus. The hypoglossal nerves
arise anterior to, and the glossopharyngeal,
vagus, and accessory nerves arise posterior
to, the olives. The facial and vestibulocochlear nerves join the brainstem 2 or
3 mm rostral to the glossopharyngeal nerve, along a line drawn dorsal to the
olive along the origin of the rootlets of the glossopharyngeal, vagus, and
accessory rootlets.
FIGURE 9-3. The supratentorial
and infratentorial areas have been
exposed while preserving the bone at
the site of the sutures. The asterion,
located at the junction of the lamb-
doid, occipitomastoid, and pari-
etomastoid sutures, usually overlies
the lower half of the junction of the
transverse and sigmoid sinuses. The
vertical lateral suboccipital incision
for the retrosigmoid approach usually
crosses the asterion. The burr hole for
elevating a suboccipital bone ap is
usually placed at the lower edge of the
asterion. The junction of the supra-
mastoid crest and the squamosal
suture is located at the posterior edge
of the middle fossa and slightly ante-
rior to and above the junction of the
transverse and sigmoid sinuses. The
supramastoid crest is an inferior con-
tinuation of the superior temporal
line.
RHOTON
FIGURE 9-4. The cerebellum has
been removed in this specimen to
expose the dura covering the part of
the posterior fossa that faces the cere-
bellopontine angle and is exposed in
the retrosigmoid approach. The fourth
ventricle sits on the posterior surface
of the pons and medulla. The occu-
lus projects laterally into the cerebel-
lopontine angle. An inferior petrosal
vein passes from the right side of the
medulla to the jugular bulb. The glos-
sopharyngeal, vagus, and accessory
nerves enter the jugular foramen. The
SCA is at the upper margin of the
exposure. The PICA courses around
the glossopharyngeal, vagus, and
accessory nerves. The endolymphatic
sac sits beneath the dura inferolateral
to the acoustic meatus.
FIGURE 9-5. Retrosigmoid exposure of the right cerebellopontine angle. The
facial nerve has been elevated and the vestibulocochlear nerve depressed to
expose both nerves entering the internal acoustic meatus. The AICA passes
between the facial and vestibulocochlear nerves and turns medially to course
above the occulus and along the middle cerebellar peduncle and cerebellopon-
tine ssure. Alarge superior petrosal vein passes behind the trigeminal nerve.
The occulus hides the junction of the facial and vestibulocochlear nerves
with the brainstem. The PICApasses between the glossopharyngeal and vagus
nerves. The posterior trigeminal root is deeper, by the retrosigmoid approach,
than the facial and vestibulocochlear nerves.
RHOTON
FIGURE 9-6. Upper part of the cerebellopontine angle. A large superior petrosal vein with multiple
tributaries, including the pontotrigeminal and transverse pontine veins and the vein of the cerebello-
pontine ssure, passes behind the trigeminal nerve. The trochlear nerve courses below the SCA. The
AICA passes between the facial and vestibulocochlear nerves and turns medially to course along the
middle cerebellar peduncle and cerebellopontine ssure.
FIGURE 9-7. The flocculus and
choroid plexus, which protrude from
the foramen of Luschka, have been
elevated to expose the junction of the
facial and vestibulocochlear nerves
with the brainstem. The facial nerve
is exposed below the vestibulo-
cochlear nerve. Abranch of the AICA
gives rise to both the subarcuate and
labyrinthine arteries. The subarcuate
artery enters the dura and bone
superolateral to the meatus. The
junction of the facial nerve with the
brainstem is easier to expose from
below rather than above the occu-
lus and vestibulocochlear nerve in an
operation for hemifacial spasm. This
approach for decompressing the facial
nerve in hemifacial spasm is referred
to as an infraoccular approach. A
large PICA loops upward behind the
vestibulocochlear nerve.
RHOTON
FIGURE 9-8. The dura lining the
posterior wall of the internal acoustic
meatus has been removed and the
posterior meatal wall has been
opened to expose the dura lining the
meatus. The subarcuate artery usu-
ally has to be obliterated and divided
before removing the posterior meatal
wall. Two bundles from the nervus
intermedius are exposed above the
vestibulocochlear nerve. Care is taken
to avoid entering the semicircular
canals and vestibule during drilling
of the posterior wall of the meatus if
hearing is to be preserved.
FIGURE 9-9. The meatal dura has
been opened, the facial nerve has
been elevated, and the vestibulo-
cochlear nerve has been depressed to
expose the facial nerve coursing in
the anterior-superior quadrant of
the meatus. The nervus inter-
medius, which arises along the ante-
rior surface of the vestibulocochlear
nerve and passes laterally to join
the facial nerve, is composed of sev-
eral rootlets, as is common. The
superior vestibular nerve passes
posterior to the facial nerve, and the
cochlear nerve is hidden anterior to
the inferior vestibular nerve.
RHOTON
FI GURE 9- 10. The cl eavage pl ane
between the superior and inferior vestibular
nerves has been developed. The superior
vestibular and facial nerves pass above the
transverse crest and the inferior vestibular
and cochlear nerves pass below the trans-
verse crest. The facial nerve courses anterior
to the superior vestibular nerve and the
cochlear nerve is located anterior to the infe-
rior vestibular nerve. The vertical crest sep-
arates the superior vestibular and facial
nerves at the fundus of the meatus.
FIGURE 9-11. Posterior surface of a right
temporal bone. The internal meatus is
located near the center of the posterior sur-
face and the jugular foramen at the lower
edge of the posterior surface. The sigmoid
sinus descends along the posterior surface
of the mastoid part of the temporal bone
and turns forward on the occipital bone to
pass through the sigmoid part of the jugu-
lar foramen. The inferior petrosal sinus
descends along the petroclival ssure and
passes through the petrosal part of the
jugular foramen. The glossopharyngeal,
vagus, and accessory nerves pass through
the intrajugular part of the foramen
between the sigmoid and petrosal part. The
subarcuate fossa is located superolateral to
the internal acoustic meatus and the
ostium for the endolymphatic duct is posi-
tioned lateral to the internal acoustic mea-
tus. The trigeminal impression is a shallow
trough on the upper surface of the petrous
part behind the foramen ovale. The arcuate
eminence overlies the superior semicircu-
lar canal.
RHOTON
FIGURE 9-12. The fundus of the right
internal acoustic meatus. The trans-
verse crest divides the meatal fundus
into superior and inferior parts. Above
the transverse crest, the facial canal is
anterior and the superior vestibular
area is posterior. Below the transverse
crest, the cochlear area is anterior and
the inferior vestibular area is posterior.
The singular foramen, through which
the singular branch of the inferior
vestibular nerve passes to innervate the
posterior canal ampullae, is located pos-
terior to the inferior vestibular area.
The inferior vestibular nerve also has a
saccular and, occasionally, a utricular
branch. The cochlear nerve splits into
tiny laments as its bers pass through
the cochlear area. These laments are
easily torn, with a resulting loss of
hearing, with medially directed retrac-
tion of the cerebellum and nerve.
FIGURE 9-13. The trigeminal
nerve passes above the petrous apex
and through the porus of Meckels
cave. The facial and vestibulo-
cochlear nerves enter the internal
acoustic meatus, and the glossopha-
ryngeal , vagus, and accessory
nerves enter the jugular foramen.
The posterior and superior semicir-
cular canals have been exposed. The
superior semicircular canal is posi-
tioned below the medial edge of the
arcuate eminence. The upper end of
the posterior canal and the posterior
end of the superior canal join to
form a common channel, the com-
mon crus, which opens into the
vestibule. The endolymphatic duct
e xt e nds do wnwa r d f r o m t he
ve s t i bul e and ope ns i nt o t he
endolymphatic sac located beneath
the dura inferolateral to the internal
acoustic meatus. The endolymphatic
ridge, the bridge of bone forming the
upper lip of the endolymphatic duct,
has been preserved. The jugular bulb can be seen through the thin bone
below the internal meatus. Entering the posterior canal, common crus, pos-
terior portion of the superior canal, or the vestibule during drilling of the
posterior meatal wall may result in a loss of hearing.
RHOTON
fundus of the meatus after removal of
the posterior wall. The upper edge of
the porus has been preserved. The
facial nerve and nervus intermedius
are exposed medial to the porus of the
meatus. The subarcuate artery enters
the subarcuate fossa. The inferior
vestibular nerve gives rise to the sin-
gular branch to the posterior ampul-
lae, plus utricular and saccular
branches. The superior vestibular
nerve innervates the ampullae of the
superior and lateral semicircular
canals and commonly gives rise to a
utricular branch. Care is taken to
preserve the superior and posterior
canals and the common crus, plus the
endolymphatic sac in those cases in
which there is the opportunity to pre-
serve hearing when drilling the pos-
terior wall of the meatus.
FIGURE 9-15. The petrous apex
medial to the internal acoustic mea-
tus has been partially removed to
expose the petrous segment of the
internal carotid artery. The lateral
genu of the petrous carotid, located at
the junction of the vertical and hori-
zontal segments, is situated below
and medial to the cochlea. The jugu-
lar bulb extends upward, adjacent to
the posterior meatal wall, toward the
vestibule and semicircular canals.
The inferior petrosal sinus courses
along the petroclival fissure and
enters the petrosal part of the jugular
foramen. The sigmoid sinus descends
in the sigmoid sulcus and enters the
sigmoid part of the foramen. The
glossopharyngeal, vagus, and acces-
sory nerves pass through the central
or intrajugular part of the jugular
foramen located between the sigmoid
and petrosal parts.
RHOTON
FIGURE 9-16. Bone has been removed along the anterior margin
of the meatal fundus to open the cochlea, and along the posterior
margin to expose the vestibule. The cochlear nerve penetrates the
modiolus of the cochlea, where its bers are distributed to the turns
of the cochlear duct. The basal turn of the cochlea communicates
below the modiolus with the vestibule. The stapes has been removed
from the oval window. The promontory in the medial wall of the
tympanic cavity is located lateral to the basal turn of the cochlea. A
silver ber has been introduced into the superior semicircular canal,
a red ber into the lateral canal, and a blue ber into the posterior
canal. The ampullated ends of the canals are located at the bulbous
ends of the three bers. The common crus of the superior and pos-
terior canals is located where the tips of the blue and silver bers
cross. The superior vestibular nerve passes to the ampullae of the
superior and lateral canals. The singular branch of the inferior
vestibular nerve innervates the posterior ampullae. A small black
ber has been introduced into the opening of the endolymphatic
duct into the vestibule. A., artery; Ac., acoustic; Arc., arcuate;
Atl., atlanto; Car., carotid; Cer. Mes., cerebellomesencephalic; Cer.,
cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; CN, cranial
nerve; Coch., cochlear; Comm., common; Cond., condyle; Emin.,
eminence; Endolymph., endolymphatic; Fiss., ssure; Flocc., oc-
culus; For., foramen; Hypogl., hypoglossal; Impress., impression; Inf., infe-
rior; Int., internal; Intermed., intermedius; Intrajug., intrajugular; Jug., jugu-
lar; Laby., labyrinthine; Lat., lateral; Med., medial; Mid., middle; N., nerve;
Nerv., nervus; Occip., occipital; Occipitomast., occipitomastoid;
Parietomast., parietomastoid; Ped., peduncle; Pet., petrosal, petrous;
Petrocliv., petroclival; Plex., plexus; Pon. Med., pontomedullary; Pon. Mes.,
pontomesencephalic; Pon. Trig., pontotrigeminal; Pon., pontine; Post., poste-
rior; Semicirc., semicircular; Sig., sigmoid; Subarc., subarcuate; Sup., supe-
rior; Supramast., supramastoid; Trans., transverse; Trig., trigeminal; V., vein;
Vert., vertebral, vertical; Vest., vestibular.
CHAPTER 10
TELOVELAR APPROACH TO THE FOURTH VENTRICLE
Neurosurgery 61:S4-193S4-210, 2007 DOI: 10.1227/01.NEU.0000280026.15254.1F www.neurosurgery-online.com
I
n the past, operative access to the fourth ventricle
was obtained by splitting the cerebellar vermis or
removing part of a cerebellar hemisphere (1). In
exami ni ng t he cl ef t s and wal l s of t he cerebel -
lomedullary fissure, we found that the inferior half of
the roof of the fourth ventricle was formed by tela
choroidea in which the choroid plexus arises, and the
inferior medullary velum, another paper-thin layer,
which attaches to the upper edge of the tela and
extends from the nodule of the vermis to the flocculus.
We also found that opening the tela alone will provide
adequate ventricular exposure, in most cases, without
splitting the vermis. The inferior medullary velum can
also be opened if opening the tela does not provide ade-
quate exposure. Opening the tela alone provides access
to the full length of the floor and the entire ventricular
cavity except, possibly, the fastigium, superolateral
recess, and the superior half of the roof. Opening the
inferior medullary velum accesses the latter areas,
including the superior half of the roof. Extending the
opening in the tela laterally toward the foramen of
Luschka opens the lateral recess and exposes the sur-
faces of the cerebellar peduncles bordering the recess.
Tumors in the fourth ventricle may stretch and thin
these two semitranslucent membranes to a degree that
one may not be aware that they are being opened in
exposing a fourth ventricular tumor.
There are no reports of deficits after isolate opening
of the tela and velum. However, other structures
exposed in the ventricle walls at risk for producing
deficits include the dentate nuclei, cerebellar pedun-
cles, the floor of the fourth ventricle, and the posterior
inferior cerebellar artery (PICA). During an operation
on the caudal part of the roof, one should remember
that the dentate nuclei are located just rostral to the
superior pole of the tonsils underlying the dentate
tubercles in the posterolateral part of the roof, where
they are wrapped around the superolateral recesses
near the lateral edges of the inferior medullary velum.
All of the cerebellar peduncles converge on the lateral
wall and roof, where they may be damaged. The supe-
rior cerebellar peduncle is more likely to be injured dur-
ing operations on lesions involving the superior part of
the roof above the level of the dentate tubercles; the
inferior peduncle is most susceptible to damage in
exposing lesions within the lateral recess; and the mid-
dle cerebellar peduncle is susceptible to injury during
procedures in the cerebellopontine angle, because the
middle peduncle forms a major part of the cisternal sur-
face facing the cerebellopontine angle.
The PICA is frequently exposed in approaches
directed through the tela choroidea or inferior medullar
velum. Occlusion of the branches of the PICA distal to
the medullary branches at the level of roof of the fourth
ventricle avoids the syndrome of medullary infarction
but produces a syndrome resembling labyrinthitis,
which includes rotatory dizziness, nausea, vomiting,
inability to stand or walk unaided, and nystagmus
without appendicular dysmetria (1). The main trunk of
the anterior inferior cerebellar artery is infrequently
exposed in opening the cerebellomedullary fissure, but
it may also send choroidal branches to the tela and
choroid plexus in the lateral recess.
REFERENCES
1. Rhoton AL Jr: Cerebellum and fourth ventricle. Neurosurgery 47
[Suppl 3]:S7S27, 2000.
RHOTON
FIGURE 10-1. Telovelar approach to
the fourth ventricle and lateral recess.
The suboccipital cerebellar surface is
located below and between the sig-
moid and lateral sinuses and is the
surface that is exposed in a suboccip-
ital craniectomy. The vermis sits in a
depression, the posterior cerebellar
incisura, between the hemispheres.
The cerebel l omedul l ary f i ssure
extends superiorly between the cere-
bellum and medulla along the infe-
rior half of the ventricular roof and
lateral recess. The vallecula extends
upward between the tonsils and com-
municates through the foramen of
Magendie with the fourth ventricle.
The PICAs loop above the tonsil and
exit the ssure to supply the suboc-
cipital surface.
TELOVELAR APPROACH
cerebellomedullary ssure and infe-
rior half of the fourth ventricular
roof. The lower parts of the vermis
behind the ventricle are the pyramid
and uvula. The uvula hangs down-
ward between the tonsils, thus, mim-
icking the situation in the orophar-
ynx. The tela choroidea, a paper-thin
ependymal membrane exposed below
the uvula, forms the lower part of the
fourth ventricular roof. The choroid
plexus arises on the inner surface of
the tela and extends downward in the
mi dl i ne though the f oramen of
Magendie and laterally through the
foramen of Luschka behind the glos-
sopharyngeal and vagus nerves.
RHOTON
FIGURE 10-3. The right tonsil has been
retracted to expose the lower half of the
roof, which is formed by the inferior
medullary velum and tela choroidea. The
cerebellomedullary fissure extends
upward between the rostral pole of the
tonsil on one side and the tela choroidea
and inferior medullary velum on the
opposite side. The segment of the PICA
passing through this ssure is called the
telovelotonsillar segment. The choroid
plexus arises on the inner surface of the
tela and extends downward in the midline
through the foramen of Magendie and lat-
erally through the foramen of Luschka.
The inferior medullary velum arises on
the surface of the nodule, drapes across
the superior pole of the tonsil, and blends
into the occulus laterally.
FIGURE 10-4. Both tonsils have been
removed t o expose t he i nf eri or
medullary velum and tela choroidea
bilaterally. The telovelar junction is
the junction between the velum and
tela. The rhomboid lip is a sheet-like
layer of neural tissue attached to the
lateral margin of the ventricular oor,
which extends posterior to the glos-
sopharyngeal and vagus nerves and
joins the tela choroidea to form a
pouch at the outer extremity of the lat-
eral recess. The right half of the tela
has been removed to expose the ventri-
cle and the lateral recess. The inferior
medullary velum extends laterally to
form a peduncle, the peduncle of the
occulus, which blends into the occu-
lus at the outer margin of the lateral
recess.
TELOVELAR APPROACH
RHOTON
FIGURE 10-5. The cerebellum has been sec-
tioned in an oblique coronal plane to show
the relationship of the rostral pole of the ton-
sil to the inferior medullary velum and den-
tate nucleus. The dentate nucleus is located
in the ventricular roof, near the fastigium,
where it wraps around, and is separated
from, the rostral pole of the tonsil by the infe-
rior medullary velum. The left tonsil has been
removed while preserving the left half of the
inferior medullary velum. The PICA passes
between the walls of the cerebellomedullary
f i ssure f ormed above by t he i nf eri or
medullary velum and below by the upper
pole of the tonsil.
FI GURE 10- 610- 13. Te l ove l ar
approach to the fourth ventricle. The
lower part of the cerebellomedullary s-
sure extends upward between the tonsils
posteriorly and the medulla anteriorly.
The upper part of the fissure extends
between the tonsil and the tela and
velum. The vallecula opens between the
tonsils into the fourth ventricle. The infe-
rior vermian vein ascends to enter the
sinuses in the tentorium.
TELOVELAR APPROACH
RHOTON
FIGURE 10-7. Both tonsils have
been retracted laterally to expose the
inferior medullary velum and tela
choroidea that form the lower half of
the ventricular roof. The nodule of
the vermis, on which the inferior
medullary arises, is hidden deep to
the uvula.
FIGURE 10-8. The uvula has been
retracted to the right and the tonsil
to the left to expose the inferior
medul l ary vel um and the tel a
choroidea forming the lower half of
the roof of the ventricle.
TELOVELAR APPROACH
RHOTON
FIGURE 10-9. The tela choroidea
has been opened, extending from the
foramen of Magendie to the junction
with the inferior medullary velum.
The uvula has been displaced to the
right side to provide this view
extending from the obex up to the
aqueduct.
FIGURE 10-10. The left half of the
inferior medullary velum has been
divided to expose the superolateral
recess and the ventricular surface
formed by the superior and inferior
peduncles.
TELOVELAR APPROACH
RHOTON
FIGURE 10-11. The entire right
half and the medial part of the left
half of the cerebellum have been
removed to expose the lateral recess.
The right tonsil has been removed
and t he t e l a and t he i nf e r i or
medullary velum, which form the
lower part of the roof of the lateral
recess, have been retracted downward
to expose the opening into the lateral
recess. The dentate nucleus is posi-
tioned near the superolateral recess
of the roof of the fourth ventricle near
the site of attachment of the inferior
medullary velum.
FIGURE 10-12. The cerebellar tonsil
has been elevated to expose the tela
forming the lower part of the roof of
the lateral recess.
TELOVELAR APPROACH
RHOTON
FIGURE 10-13. The tela has been
opened to expose the lateral recess.
The opening extends laterally to the
foramen of Luschka. The choroid
plexus and occulus are exposed in
the cerebellopontine angle behind the
glossopharyngeal nerve.
FI GURES 10- 14 and 10- 15.
Relationships of the lateral margin of
the cerebellar tonsil to the biventral
lobule. Figure 10-14. The peduncle
of the tonsil is the bundle of white
matter, located at the superolateral
margin of the tonsil, that attaches the
tonsil to the remainder of the cerebel-
lum. All of the margins of the tonsil,
other than the site of the tonsilar
peduncle, are free margins. The left
tonsil has been retracted medially to
open the deep cleft between the tonsil
and the biventral lobule. The pedun-
cle of the tonsil is at the superolateral
margin of the tonsillobiventral fis-
sure.
TELOVELAR APPROACH
RHOTON
FIGURE 10-15. The peduncle of the tonsil has been divided and the tonsil has
been lifted out of the cerebellomedullary ssure to expose the caudal surface of
the inferior medullary velum and the tela choroidea that form the lower half of
the ventricular roof.
FI GURES 10- 16 and 10- 17.
Another specimen. Figure 10-16.
Both tonsils have been removed to
expose the inferior medullary velum
and tela choroidea. The inferior
medullary velum extends from the
nodule along the inferior half of the
roof of the fourth and blends later-
ally into the occulus. The tela, in
which the choroid plexus arises, has
been removed on the left side. A dis-
sector has been placed inside the
superolateral recess to show the
paper-thin inferior medullary velum.
Opening the velum will expose the
superolateral recess. The dorsal
cochlear nucleus sits in the oor of
the lateral recess.
TELOVELAR APPROACH
RHOTON
FIGURE 10-17. The velum has been
removed on the left side. Opening the
velum or removing it gives excellent
access to the cerebellar peduncles and to
the superolateral recess of the fourth
ventricle. The auditory tubercle is a
prominence in the lateral recess that
overlies the dorsal cochlear nucleus. A.,
artery; Bivent., biventral; Cer., cere-
bellar; Cer. Med., cerebellomedullary;
Cer. Mes., cerebellomesencephalic;
Coch., cochlear; Chor., choroid; CN,
cranial nerve; Dent., dentate; Dors.,
dorsal; Fiss., ssure; Flocc., occulus;
For., foramen; Inf., inferior; Lat., lat-
eral; Med., medullary; Mid., middle;
Nucl., nucleus; Ped., peduncle; Plex.,
plexus; S.C.A., superior cerebellar
artery; Suboccip., suboccipital; Sup.,
s upe r i o r ; Tel ovel . , t e l o ve l a r ;
Tonsillobivent., tonsillobiventral; V.,
vein; Ve., vermian; Vel., velum; Vent.,
ventricle; Vert., vertebral.
CHAPTER 11
FAR LATERAL AND TRANSCONDYLAR APPROACHES
The basic far lateral approach is a low suboccipital approach that
extends up to, but does not include removal of, part of the atlantal or
occipital condyles. The far lateral approach usually includes a suboc-
cipital craniectomy or craniotomy with removal of at least half of the
posterior arch of the atlas, dissection of the muscles along the postero-
lateral aspect of the craniocervical junction to permit an adequate expo-
sure of the Cl transverse process and the suboccipital triangle, and
early identication of the vertebral artery either above the posterior
arch of the atlas or in its ascending course between the transverse
processes of the atlas and axis. The far lateral approach provides access
for the following three approaches: 1) the transcondylar approach
directed through the occipital condyle or the atlanto-occipital joint and
adjoining parts of the condyles, 2) the supracondylar approach directed
through the part of the occipital bone above the occipital condyle, and
3) the paracondylar exposure directed through the area lateral to the
occipital condyle. The transcondylar extension, accomplished by
drilling the occipital condyle, allows a more lateral approach and pro-
vides access to the lower clivus and premedullary area. The supra-
condylar approach provides access to the region of and medial to the
hypoglossal canal and jugular tubercle. The paracondylar approach,
which includes drilling of the jugular process of the occipital bone in
the area lateral to the occipital condyle, accesses the posterior part of
the jugular foramen, and, if needed, the posterior aspect of the facial
nerve and mastoid on the lateral side of the jugular foramen.
The basic far lateral approach without drilling of the occipital
condyle may be all that is required to reach some lesions located along
the anterolateral margin of the foramen magnum. However, it also
provides a route through which the transcondylar, supracondylar, and
paracondylar approaches and several modifications of these
approaches can be completed. The transcondylar exposures can be cat-
egorized into several variants. One variant is an atlanto-occipital
transarticular approach, in which the adjacent posterior part of the
occipital condyle and/or the superior articular facet of C1 is removed
to facilitate completion of a circular dural incision, permitting the ver-
tebral artery with the surrounding cuff of dura to be mobilized. Amore
extensive removal of the articular surfaces and condyles can be per-
formed to gain access to extradural lesions situated along the anterior
and lateral margins of the foramen magnum. Another variant, the
occipital transcondylar variant, is directed above the atlanto-occipital
joint through the occipital condyle and below the hypoglossal canal to
access the lower clivus and the area in front of the medulla. The supra-
condylar approach directed above the occipital condyle can also be
varied, depending on the pathology to be exposed. The supracondylar
exposure can be directed above the occipital condyle to the hypoglos-
sal canal or both above and below the hypoglossal canal to the lateral
side of the clivus. In the transtubercular variant of the supracondylar
approach, the prominence of the jugular tubercle that blocks access to
the brainstem and cistern in front of the glossopharyngeal, vagus, and
accessory nerves is removed extradurally to increase visualization of
the area in front of the brainstem and to expose the origin of a poste-
rior inferior cerebellar artery that arises from the distal part of the ver-
tebral artery near the midline. The paracondylar approach also has
several variants. In the transjugular variant, the exposure is directed
lateral to the condyle through the jugular process of the occipital bone
to the posterior surface of the jugular bulb. The approach can also be
extended lateral to the jugular foramen into the posterior aspect of the
mastoid to access the mastoid segment of the facial nerve and the sty-
lomastoid foramen.
In the standard posterior and posterolateral approaches, an under-
standing of the individual suboccipital muscles is not essential.
However, these muscles provide important landmarks for the far lateral
approach and its modications. In this description, the muscles are
reected separately, but, during an operation, the scalp and muscles
supercial to the muscles forming the suboccipital triangle are reected
from the suboccipital area in a single layer, leaving a musculofascial cuff
attached along the superior nuchal line for closure. The procedure has
been performed through either a horseshoe type suboccipital ap, a C-
shaped retroauricular incision similar to that shown in the section on the
jugular foramen, or a hockey stick incision that has a vertical lateral limb
behind the ear with a medial extension along the superior nuchal line.
We prefer the horseshoe scalp ap that begins in the midline, approxi-
mately 5 cm below the external occipital protuberance, is directed
upward to the external occipital protuberance, turns laterally just below
the superior nuchal line, reaches the mastoid area, and turns down-
ward in front of the posterior border of the sternocleidomastoid muscle
onto the lateral aspect of the neck below the mastoid tip and where the
transverse process of the atlas can be palpated through the skin. The
scalp ap is reected downward with the muscular layer that includes
the sternocleidomastoid, trapezius, and splenius, longissimus, and semi-
spinalis capitis muscles. The three muscles, the superior and inferior
oblique and the rectus capitis posterior, forming the suboccipital trian-
gle are reected separately to expose the vertebral artery.
The vertebral artery, above the transverse foramen of the axis, veers
laterally to reach the transverse foramen of the atlas, which is situated
further lateral than the transverse foramen of the axis. The artery,
after ascending through the transverse process of the atlas, is located
on the medial side of the rectus capitis lateralis muscle. From here, the
artery turns medially behind the lateral mass of the atlas and the
atlanto-occipital joint and is pressed into the groove on the upper
surface of the posterior arch of the atlas, where it courses in the floor
of the suboccipital triangle and is covered behind the triangle by the
semispinalis capitis muscle. The first cervical nerve courses on the
lower surface of the artery between the artery and the posterior arch
of the atlas. After passing medially above the lateral part of the pos-
terior arch of the atlas, the artery enters the vertebral canal by pass-
ing below the lower, arched border of the posterior atlanto-occipital
membrane, which transforms the sulcus in which the artery courses
on the upper edge of the posterior arch of the atlas into an osseofi-
brous casing that may ossify, transforming it into a complete or
incomplete bony canal surrounding the artery.
The third segment of the vertebral artery, the segment located
between the C1 transverse process and the dural entrance, gives rise
to muscular branches and the posterior meningeal artery. The muscu-
lar branches arise as the artery exits the transverse foramen of C1 and
courses behind the lateral mass of the atlas to supply the deep mus-
cles and anastomose with the occipital and ascending and deep cer-
vical arteries. Some of the muscular branches may need to be divided
to mobilize and transpose the vertebral artery. The posterior
meningeal artery arises from the posterior surface of the vertebral
artery as it passes behind the lateral mass or above the posterior arch
of the atlas or just before penetrating the dura in the region of the
foramen magnum, but it may also have an intradural origin from the
vertebral artery, in which case it pierces the arachnoid over the cis-
terna magna to reach the dura. Six to eight percent of posterior infe-
rior cerebellar arteries arise extradurally and penetrate the dura with
the vertebral artery.
RHOTON
FIGURE 11-1. Far lateral and
transcondylar approaches. The far
lateral approach involves a dissection
of the muscles along the posterolat-
eral aspect of the craniocervical junc-
tion to permit exposure of the C1
transverse process and the vertebral
artery in the suboccipital triangle.
The insert in the lower right illus-
tration shows the scalp incision. A
suboccipital horseshoe type flap is
commonly selected for the far lateral
exposure. The medial limb extends
downward in the midline so that an
upper cervical laminectomy can be
completed if needed. The lateral limb extends below the C1 transverse process,
which can be palpated between the mastoid tip and the angle of the jaw. The
lateral limb of the incision provides access to the vertebral artery as it ascends
through the C1 transverse process and passes medially along the upper surface
of the posterior arch of C1. In this section, the muscles are dissected separately
to show the anatomy, however, during an operation, the muscles supercial to
the suboccipital triangle can be reected in a single layer with the scalp ap
while leaving a cuff of fascia along the superior nuchal line, to which the
reected muscles can be attached during the closure. The illustrations on the
lower left in Figures 11-1 to 11-4 show the unilateral exposure on the right
side. The scalp ap has been reected to expose the sternocleidomastoid and
trapezius muscles, the edges of which form the margins of the posterior trian-
gle of the neck. The splenius and semispinalis capitis are in the oor of the tri-
angle. The three-dimensional illustration above and the orienting illustration
on the lower right show the supercial muscles bilaterally.
FAR LATERAL APPROACHES
FIGURE 11-2. The sternocleidomastoid and trapezius muscles have been
detached from the superior nuchal line. The sternocleidomastoid has been
reected laterally and the trapezius downward to expose the splenius and semi-
spinalis capitis, which are attached just below the superior nuchal line.
RHOTON
FIGURE 11-3. The splenius capitis has been reected downward to expose the
longissimus and the semispinalis capitis muscles. The occipital artery on the left
passes deep and the right passes supercial to the longissimus capitis. The
deep cervical fascia has been preserved in the illustration on the lower left.
FIGURE 11-4. The longissimus and semispinalis have been reected to expose
the suboccipital triangle formed by the superior and inferior oblique and rectus
capitis posterior major muscles. The superior oblique extends from the occipital
bone to the transverse process of C1; the inferior oblique muscle extends from the
transverse process of C1 to the spinous process of C2; and the rectus capitis pos-
terior major extends from the occipital bone to the spinous process of C2. The
vertebral artery crosses behind the atlanto-occipital joint and across the upper
surface of the posterior arch of C1 in the depths of the suboccipital triangle.
RHOTON
FIGURE 11-5. The right superior oblique muscle has been reected laterally.
The rectus capitis posterior major extends from the occipital bone to the C2
spinous process. The rectus capitis posterior minor extends from the occipital
bone to the midline tubercle on the posterior arch of C1. The inferior oblique
muscle extends from the C2 spinous process to the transverse process of C1. The
occipital artery passes medial to the digastric muscle. The dense venous plexus
in the suboccipital triangle surrounds the vertebral artery as it passes behind
the atlanto-occipital joint. The lower left shows the right unilateral exposure.
FIGURE 11-6. The rectus capitis
posterior major and the adjacent part
of the rectus capitis posterior minor
have been reected inferior and medi-
ally. The superior and inferior oblique
muscles have been reflected down-
ward. The vertebral artery passes
behind the atlantal condyle, gives rise
to a posterior meningeal branch, and
passes deep to the posterior atlanto-
occipital membrane to enter the dura.
The rectus capitis lateralis extends
from the transverse process of C1 to
the occipital bone behind the jugular
foramen.
RHOTON
FIGURE 11-7. The muscles forming
the margins of the suboccipital trian-
gle have been removed while preserv-
ing the rectus capitis posterior minor,
which extends from the part of the
occipital bone just above the foramen
magnum to the posterior tubercle on
C1. The vertebral artery gives off
muscular branches and passes medi-
ally on the upper surface of the poste-
rior arch of C1, where it is partially
encased in a bony ring. The venous
plexus around the vertebral artery
has been removed.
FIGURE 11-8. The vertebral artery
gi ve s or i gi n t o t he pos t e r i or
meningeal artery, which ascends
through the foramen magnum and
along the occipital dura. Several
muscular branches of the vertebral
artery have been divided. The C1
nerve passes between the vertebral
artery and the posterior arch of C1.
RHOTON
FIGURE 11-9. A suboccipital cran-
iotomy has been completed and the pos-
terior arch of C1 has been removed. The
vertebral artery passes behind and par-
tially hides the atlanto-occipital joint.
The facial and vestibulocochlear nerves
enter the internal acoustic meatus. The
glossopharyngeal, vagus, and accessory
nerves enter the jugular foramen. The
rootlets of the hypoglossal nerve are
stretched around the posterior surface of
the vertebral artery. The rectus capitis
lateralis muscle extends from the occip-
ital bone behind the jugular bulb to the
transverse process of C1. The posterior
inferior cerebellar artery rises just out-
side the dura and penetrates the dura
with the vertebral artery. The dentate
ligament and spinal accessory nerve
ascend through the foramen magnum.
The rostral attachment of the dentate
ligament is at the level of the foramen
magnum.
FIGURE 11-10. The vertebral artery has
been depressed to expose the atlanto-occip-
ital joint. Drilling above the occipital
condyle has exposed the hypoglossal canal
and the venous plexus accompanying the
hypoglossal nerve through the canal. The
rectus capitis lateralis has been reflected
and bone has been removed in the para-
condylar area to expose the posterior surface
of the jugular bulb. The occipital artery and
facial nerve are exposed below the stylomas-
toid foramen in the paracondylar region lat-
eral to the jugular bulb. Aposterior condy-
lar vein connects the venous plexus around
the vertebral artery to the jugular bulb and
venous plexus in the hypoglossal canal.
RHOTON
FIGURE 11-11. The dural incision com-
pletely encircles the vertebral artery, leaving a
narrow dural cuff on the artery, thus, allow-
ing the artery to be mobilized. The drilling in
the supracondylar area exposes the hypoglos-
sal nerve in the hypoglossal canal and can be
extended extradurally to the level of the jugu-
lar tubercles to increase access to the front of
the brainstem and clivus.
FIGURE 11-12. Comparison of expo-
sure with the far lateral and transcondy-
lar approaches. The far lateral exposure
on the right side extends to the posterior
margin of the atlantal and occipital
condyles and the atlanto-occipital joint.
The prominence of the condyles on the
right side limits the exposure along the
anterolateral margin of the foramen
magnum. On the left side, a transcondy-
lar exposure has been completed by
removing the upper part of the occipital
condyle. The dura can be reected fur-
ther laterally with the transcondylar
approach than with the far lateral
approach. The condylar drilling provides
an increased angle of view and addi-
tional space for exposure and dissection.
The dentate ligament and accessory
nerve ascend through the foramen mag-
num. The rostral attachment of the den-
tate ligament is at the level of the fora-
men magnum.
RHOTON
FIGURE 11-13. The part of the left occipital condyle above the atlanto-occipital joint has been
drilled to expose the hypoglossal nerve in the hypoglossal canal. The glossopharyngeal and
vagus nerves descend behind the jugular tubercle. Drilling the condyle above and below the
hypoglossal canal provides entry into the lower part of the clivus medial to the condyle. Acuff
of dura has been left on the vertebral artery.
FIGURE 11-14. The right occipital condyle and bone above the atlanto-occipital condyle joint
have been drilled to expose the hypoglossal nerve in the hypoglossal canal. The C1 nerve root
passes laterally between the vertebral artery and the posterior arch of C1.
RHOTON
FIGURE 11-15. Another specimen with the brainstem removed. The bone
above the occipital condyle has been removed to expose the hypoglossal nerve
in the hypoglossal canal. The glossopharyngeal, vagus, and accessory nerves
cross the jugular tubercle. The jugular bulb is located lateral to the occipital
condyle and can be exposed by drilling the occipital bone in the paracondylar
area.
FIGURE 11-16. The medial part of the right occipital condyle and the poste-
rior arch of C1 have been removed. The extradural segment of the right verte-
bral artery, which normally courses above the C1 nerve root, has been retracted
below the level of the C1 nerve root. The intradural segment of the right ver-
tebral artery has been retracted posteriorly to provide access to the cervi-
comedullary region. The contralateral vertebral artery is exposed anterior to
the medulla. The hypoglossal nerve passes behind the vertebral artery. The
drilling has provided wide access to the lower clivus adjacent to the occipital
condyle and also to the lateral and anterior aspects of the brainstem.
RHOTON
FIGURE 11-17. The bone lateral to the occipital condyle has been
removed to expose the jugular bulb. The occipital and atlantal condyles
have been drilled to provide access to the clivus. The condylar emissary
vein connects the jugular bulb and vertebral venous plexus. The hypoglos-
sal nerve, in the hypoglossal canal, has been exposed. A., artery; Atl.,
atlanto; Bas., basilar; Br., branch; Cap., capitis; Cerv., cervical; CN, cra-
nial nerve; Cond., condylar, condyle; Dent., dentate; Digast., digastric;
Dors., dorsal; Flocc., occulus; Gr., greater; Hypogloss., hypoglossal;
Inf., inferior; Int., internal; Jug., jugular; Lat., lateralis; Lev., levator;
Lig., ligament; Longiss., longissimus; M., muscle; Maj., major; Memb.,
membrane; Men., meningeal; Min., minor; Musc., muscular; N., nerve;
Obl., oblique; Occip., occipital; P.I.C.A., posterior inferior cerebellar
artery; Plex., plexus; Post., posterior; Proc., process; Rec., rectus; Scap.,
scapulae; Semispin., semispinalis; Sig., sigmoid; Splen., splenius;
Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup.,
superior; Trans., transverse; Triang., triangle; V., vein; Vent., ventral,
ventricle; Vert., vertebral.
CHAPTER 12
JUGULAR FORAMEN
Neurosurgery 61:S4-229S4-250, 2007 DOI: 10.1227/01.NEU.0000280041.55157.E0 www.neurosurgery-online.com
The jugular foramen is located between the temporal and the occip-
ital bones. It can be regarded as a hiatus between the temporal and the
occipital bones (1). The right foramen is usually larger than the left. The
foramen is configured around the sigmoid and inferior petrosal
sinuses. The jugular foramen is divided into three compartments: two
venous compartments and a neural or intrajugular compartment. The
venous compartments consist of a larger posterolateral venous channel,
the sigmoid part, which receives the ow of the sigmoid sinus, and a
smaller anteromedial venous channel, the petrosal part, which receives
the drainage of the inferior petrosal sinus. The petrosal part forms a
characteristic venous conuens by also receiving tributaries from the
hypoglossal canal, petroclival ssure, and vertebral venous plexus. The
petrosal part empties into the sigmoid part through an opening
between the glossopharyngeal and the vagus nerves in the medial wall
of the jugular bulb. The intrajugular or neural part, through which the
glossopharyngeal, vagus, and accessory nerves course, is located
between the sigmoid and petrosal parts. The junction of the sigmoid
and petrosal parts of the foramen, when viewed from above, is the site
of bony prominences on the opposing surfaces of the temporal and
occipital bones, called the intrajugular processes, which are joined by
a brous, or, less commonly, an osseous bridge, the intrajugular sep-
tum, separating the sigmoid and petrosal part of the foramen. The
glossopharyngeal, vagus, and accessory nerves penetrate the dura on
the medial margin of the intrajugular process of the temporal bone to
reach the medial wall of the jugular bulb and internal jugular vein.
The jugular foramen is difcult to access surgically. The difculties
in exposing this foramen are created by its deep location and the sur-
rounding structures, such as the carotid artery anteriorly, the facial
nerve laterally, the hypoglossal nerve medially, and the vertebral artery
inferiorly, all of which block access to the foramen and require careful
management.
The structures that traverse the jugular foramen are the sigmoid
sinus and jugular bulb, the inferior petrosal sinus, meningeal branches
of the ascending pharyngeal and occipital arteries, the glossopharyn-
geal, vagus, and accessory nerves with their ganglia, the tympanic
branch of the glossopharyngeal nerve (Jacobsons nerve), the auricular
branch of the vagus nerve (Arnolds nerve), and the cochlear aqueduct.
Tumors involving the jugular foramen can extend as follows: 1) along
the eustachian tube into the nasopharynx and through the foramina at
the base of the cranium, 2) along the carotid artery to the middle fossa,
3) through the intracranial orice of the jugular foramen or along the
hypoglossal canal to the posterior fossa, 4) through the tegmen tym-
pani to the oor of the middle fossa, 5) through the round window and
the internal acoustic meatus to the cerebellopontine angle, and 6)
through the extracranial orice of the jugular foramen to the upper cer-
vical region.
Surgical Approaches
The most common operative approaches used to access various
aspects of the foramen and adjacent areas are the postauricular
transtemporal, retrosigmoid, and far lateral approaches.
Postauricular Transtemporal Approach
The postauricular transtemporal approach, the most common
approach selected for a lesion in the jugular foramen, accesses the
region from laterally, through the mastoid, and from below, through the
neck. A C-shaped postauricular skin incision provides the exposure
for a mastoidectomy and the neck dissection. The external auditory
canal is either preserved or transected, depending on the anterior
extent of the pathological abnormality. The neck dissection is com-
pleted initially to gain control of the major vessels and the branches
supplying the tumor. The internal carotid artery, branches of the exter-
nal carotid artery, internal jugular vein, and lower cranial nerves are
exposed in the carotid sheath. Amastoidectomy with extensive drilling
of the infralabyrinthine region accesses the jugular bulb. Alimited mas-
toidectomy conned to the area behind the stylomastoid foramen and
mastoid segment of the facial nerve, combined with removal of the
adjacent part of the jugular process of the temporal bone, will provide
access to the posterior and posterolateral aspect of the jugular foramen.
Three obstacles to exposure of the full lateral half of the jugular fora-
men, the facial nerve, styloid process, and rectus capitis lateralis mus-
cle are dealt with by transposing the facial nerve, removing the styloid
process, and dividing the rectus capitis lateralis muscle. Anterior exten-
sions of the pathological abnormality are reached by sacricing the
external and the middle ear structures. Sensorineural hearing can be
preserved by maintaining the footplate of the stapes in the oval win-
dow to avoid opening the labyrinth. Intracranial extensions of the
lesion are reached by the retrosigmoid or presigmoid approaches after
adding a suboccipital craniectomy. Some lesions can be removed by a
transtemporal infralabyrinthine approach directed through the tem-
poral bone below the labyrinth without a neck dissection, if the
extracranial extension of the lesion is not prominent. The exposure can
be extended by opening the otic capsule (translabyrinthine approach).
Retrosigmoid Approach
Alesion located predominantly intradurally above the jugular fora-
men can be resected by the retrosigmoid approach. Alateral suboccip-
ital craniectomy exposes the dura behind the sigmoid sinus. The dura
is opened, and the cerebellum is gently elevated away from the poste-
rior surface of the temporal bone to expose the cisterns in the cerebel-
lopontine angle and the intracranial aspect of the cranial nerves enter-
ing the jugular foramen, hypoglossal canal, and internal acoustic
meatus. Lesions can be followed into only the upper part of the fora-
men by this approach.
Far Lateral Approach
An extended modication of the retrosigmoid approach, the far lat-
eral approach, may be selected if the tumor extends down to the fora-
men magnum in front of or lateral to the lower brainstem. In this
approach, the jugular foramen is opened from behind by completing a
paracondylar modication of the far lateral approach. In this modica-
tion, the rectus capitis lateralis is detached from the occipital bone at
the posterior margin of the foramen and the posterior margin is
removed. The dura is opened and the cerebellum elevated to expose
the intracranial extension of the pathological abnormality at the lower
clivus and at the foramen magnum. In another variant of the approach,
depending on the location and extent of the pathological abnormality,
the jugular tubercle is removed extradurally to minimize the retraction
of the brainstem needed to reach the area anterior to the medulla and
pontomedullary junction. Most jugular foramen tumors cannot be
reached by this route because they extend forward beyond the limits of
this approach to the posterior part of the foramen.
REFERENCES
1. Rhoton AL Jr: Jugular foramen. Neurosurgery 47 [Suppl 3]:S267S285, 2000.
RHOTON
FIGURE 12-1. Jugular foramen.
Posterior view of the cranial base with
the cranial nerves and arteries pre-
served. The jugular foramen is posi-
tioned below the internal acoustic
meatus and superolateral to the
hypoglossal nerves entering the
hypoglossal canal. The glossopharyn-
geal, vagus, and accessory nerves
enter the dural roof of the jugular
foramen. The superior cerebellar arter-
ies arise at the midbrain level and pass
below the oculomotor and trochlear
nerves and above the trigeminal
nerve. The anterior inferior cerebellar
arteries arise at the pontine level and
course by the abducens, facial, and
vestibulocochlear nerves. The poste-
rior inferior cerebellar arteries arise
from the vertebral artery at the
medullary level and course near the
glossopharyngeal, vagus, accessory,
and hypoglossal nerves.
JUGULAR FORAMEN
FIGURE 12-2. The dural roof of the left jugular foramen has been exposed below the facial and
vestibulocochlear nerves. There is a dural septum between the glossopharyngeal and vagus
nerves at the roof of the jugular foramen. The glossopharyngeal nerve is often adherent to the
rootlets of the vagus nerve in the cistern, however, at the roof of the jugular foramen, there is
consistently a dural septum separating the glossopharyngeal from the vagus nerve. The glos-
sopharyngeal nerve enters a shallow meatus, the glossopharyngeal meatus, in the dural roof of
the foramen. The glossopharyngeal dural fold passes above the glossopharyngeal nerve at the
entrance to the glossopharyngeal meatus. The vagus nerve enters the vagal meatus, which is
broader than, but not as deep, as the glossopharyngeal meatus, at the roof of the jugular fora-
men. There is also a dural fold around the upper and lateral margin of the vagal meatus. The
accessory nerve ascends to enter the lower part of the vagal meatus.
RHOTON
FIGURE 12-3. The left sigmoid and infe-
rior petrosal sinuses have been unroofed.
The glossopharyngeal, vagus, and acces-
sory nerves are exposed at the roof of the
jugular foramen. The jugular foramen has
three parts: sigmoid, petrosal, and intra-
jugular. The sigmoid sinus descends and
turns forward to pass through the sigmoid
part of the jugular foramen. The inferior
petrosal sinus descends and passes
through the petrosal part of the jugular
foramen. The glossopharyngeal, vagus,
and accessory nerves exit the cranium
through the intrajugular part of the fora-
men, which is located between the sigmoid
and petrosal parts. Two bundles of
hypoglossal rootlets enter a bid hypoglos-
sal canal above the occipital condyle and
join after exiting the hypoglossal canal.
FIGURE 12-4. The jugular bulb has
been removed to expose the jugular
fossa on the lower surface of the tem-
poral bone. The glossopharyngeal
nerve enters the jugular foramen
above and medial to the vagus nerve.
The tympanic branch (Jacobsons
nerve) of the glossopharyngeal nerve
arises in the medial part of the jugular
fossa, ascends to cross the promontory
in the tympanic cavity, and gives rise
to the lesser petrosal nerve. The auric-
ular branch (Arnolds nerve) of the
vagus nerve arises in the intrajugular
part of the foramen and passes later-
ally across the anterior margin of the
jugular fossa. The bone above the
hypoglossal canal has been drilled to
expose a bid hypoglossal canal. The
two bundles of hypoglossal rootlets
join at the extracranial end of the
hypoglossal canal and descend in the
carotid sheath with the glossopharyn-
geal, vagus, and accessory nerves.
JUGULAR FORAMEN
RHOTON
FIGURES 12-5 AND 12-6. Inferior view of the temporal bone
and jugular foramen. Figure 12-5, the internal jugular vein is
exposed below the jugular foramen and descends on the medial
side of the facial nerve and styloid process. The glossopharyngeal,
vagus, accessory, and hypoglossal nerves descend in the carotid
sheath with the internal carotid artery and internal jugular vein.
The occipital condyle has been drilled to expose the passage of the
hypoglossal nerve behind the vertebral artery and through the
hypoglossal canal. The mandibular head, which sits in the
mandibular fossa, is exposed anterolateral to the jugular foramen.
The middle meningeal artery and branches of the third trigemi-
nal division are exposed below the greater sphenoid wing in the
infratemporal fossa. Bone has been removed to expose the
eustachian tube and the petrous segment of the internal carotid
artery. The Vidian nerve, which arises from the union of the
greater and deep petrosal nerves, continues forward in the Vidian
canal. The rectus capitis lateralis muscle attaches to the occipital
bone behind the jugular foramen. The auriculotemporal branch of
the third trigeminal division conveys autonomic bers from the
lesser petrosal nerve to the otic ganglion, which provides auto-
nomic innervation to the parotid gland.
FIGURE 12-6. The rectus capitis lateralis muscle has been resected
and the part of the occipital bone forming the posterior margin of the
jugular foramen has been removed to expose the lower part of the
sigmoid sinus as it hooks forward to form the jugular bulb. The
venous plexus in the hypoglossal canal has been removed. The infe-
rior petroclival vein, which courses along the extracranial surface of
the petroclival ssure, has been removed to expose the petrous apex
articulating with the lateral edge of the clivus along the petroclival
ssure.
JUGULAR FORAMEN
RHOTON
FIGURE 12-7. Lateral view of the left tympanic cavity and mastoid area. The tympanic part
of the temporal bone, which forms the lower and anterior margin of the external meatus, has
been removed, but the tympanic sulcus and osseous ring to which the tympanic membrane
attaches has been preserved. The carotid ridge separates the carotid canal and jugular foramen.
Meningeal branches of the ascending pharyngeal and occipital arteries enter the jugular fora-
men. The glossopharyngeal, vagus, and accessory nerves pass through the jugular foramen on
the medial side of the jugular bulb. The malleus, incus, and stapes are exposed in the tympanic
cavity. The stylomastoid branch of the occipital artery joins the facial nerve at the stylomas-
toid foramen. The surface of the temporal and occipital bones surrounding the jugular foramen
and carotid canal has an irregular surface that serves as the site of attachment of the upper end
of the carotid sheath. The mastoid segment of the facial nerve and the stylomastoid foramen are
situated lateral to the jugular bulb. The chorda tympani arises from the mastoid segment of the
facial nerve and courses along the deep surface of the tympanic membrane and crosses the upper
part of the handle of the malleus.
FIGURE 12-8. Lateral view of the
left tympanic cavity, mastoid area,
and adjacent part of the infratempo-
ral fossa. The tympanic segment of
the facial nerve passes below the lat-
eral semicircular canal and turns
downward to form the mastoid seg-
ment, which exits the stylomastoid
foramen. The stylomastoid foramen
and the mastoid segment are posi-
tioned lateral to the jugular bulb.
The semicircular canals are located
above the jugular bulb. The third
trigeminal division exits the fora-
men ovale to enter the infratemporal
fossa. The chorda tympani arises
from the mastoid segment of the
facial nerve, courses along the deep
surface of the tympanic membrane,
crosses the upper part of the handle
of the malleus, exits the cranium by
passing through the petrotympanic
fissure, and joins the lingual branch
of the mandibular nerve in the
infratemporal fossa.
JUGULAR FORAMEN
RHOTON
FIGURE 12-9. The oor of the mid-
dle fossa and the tympanic ring have
been removed to expose the jugular
bulb and petrous carotid. The jugular
bulb is positioned below the semicir-
cular canals. The junction of the ver-
tical and horizontal segments of the
petrous carotid is positioned below
the cochlea. The malleus and medial
wall of the tympanic cavity have
been preserved. The eustachian tube
extends downward and medially
across the anterior surface of the
petrous carotid. The third trigeminal
division has been elevated out of the
foramen ovale.
FIGURE 12-10. A short segment of the
Eustachian tube has been removed to expose
more of the horizontal segment of the
petrous carotid. The greater petrosal nerve
courses along the oor of the middle fossa
on the upper surface of the petrous carotid.
The deep petrosal nerves arise from the sym-
pathetic nerves accompanying the internal
carotid artery. The deep and greater petrosal
nerves join to form the vidian nerve, which
passes forward through the vidian canal to
join the maxillary nerve and pterygopala-
tine ganglion in the pterygopalatine fossa.
The pharyngobasilar fascia has been opened
to expose the upper part of the longus capi-
tis muscle.
JUGULAR FORAMEN
RHOTON
FIGURE 12-11. The internal carotid artery has been displaced forward out of the carotid
canal to expose the carotid nerves, which arise in the cervical sympathetic ganglia and ascend
with the artery. The glossopharyngeal, vagus, accessory, and hypoglossal nerves exit the cra-
nium on the medial side of the internal carotid artery and jugular vein. The hypoglossal nerve
passes forward along the lateral surface of the internal carotid artery, and the accessory nerve
descends posteriorly across the lateral surface of the internal jugular vein. The vagus nerve
descends in the carotid sheath. The glossopharyngeal nerve descends along the medial side of
the internal carotid artery.
JUGULAR FORAMEN
FIGURE 12-12. The jugular bulb, positioned below the
vestibule and semicircular canals, has been removed. The
vertical segment of the petrous carotid has been removed
while preserving the horizontal segment. The cochlea,
which has been opened, is located above the lateral genu of
the petrous carotid artery. The tympanic segment of the
facial nerve passes between the lateral semicircular canal
and oval window. The mastoid segment of the nerve
descends lateral to the jugular fossa.
RHOTON
FIGURE 12-13. Posterior view of the nerves in the jugular foramen with the venous struc-
tures removed. The posterior wall of the jugular foramen and hypoglossal canal have been
opened. The glossopharyngeal nerve enters the jugular foramen caudal to the cochlear aqueduct.
The vagus nerve enters the jugular foramen behind the glossopharyngeal nerve. The auricu-
lar branch of the vagus nerve (Arnolds nerve) arises at the level of the superior ganglion and
passes across the anterior wall of the jugular bulb. The accessory nerve is formed by multiple
rootlets that arise from the medulla and cervical spinal cord and collect together to form a bun-
dle that blends into the lower margin of the vagus nerve at the level of the jugular foramen. The
vagal and accessory rootlets cross the surface of the jugular tubercle. The glossopharyngeal
nerve expands at the site of the superior and inferior ganglia. The superior ganglion of the
vagus nerve is located at the level of or just below the dural roof of the foramen, and the infe-
rior ganglion is located below the foramen at the level of the atlanto-occipital joint.
FIGURE 12-1412-21. Postauri-
cular approach to the jugular fora-
men. Figure 12-14, the C-shaped
retroauricular incision (lower left)
provides access for the mastoidec-
tomy, neck dissection, and reecting
the parotid gland forward. The scalp
flap and superficial muscles have
been reected forward to expose the
posterior part of the parotid gland,
the posterior belly of the digastric
muscle, the internal jugular vein
and longissimus capitis, and the superior and inferior oblique muscles.
JUGULAR FORAMEN
RHOTON
FIGURE 12-15. A mastoidectomy
has been completed to expose the
facial nerve, sigmoid sinus, jugular
bulb, and the osseous capsule of the
semicircular canals. The facial nerve
and styloid process block access to the
extracranial orifice of the jugular
foramen. The facial nerve crosses the
lateral surface of the styloid process.
The stylomastoid artery arises from
the postauricular artery and joins the
facial nerve at the stylomastoid fora-
men. The superior and inferior
oblique and levator scapulae muscles
attach to the transverse process of
C1.
FIGURE 12-16. The tympanic
membrane and the posterior part of
the tympanic sulcus and ring have
been removed while preserving the
ossicles. A cuff of tissues around the
facial nerve has been preserved at the
stylomastoid foramen to avoid dissec-
tion directly on the surface of the
nerve and also to preserve the vascu-
lar supply to the nerve from the sty-
lomastoid artery. It will be necessary
to resect the tympanic ring if the
pathology must be followed into the
Eustachian tube or along the petrous
carotid artery. Some hearing will be
preserved if the stapes remains in the
oval window.
JUGULAR FORAMEN
RHOTON
FIGURE 12-17. The external audi-
tory canal has been transected and the
middle ear structures have been
removed, except the stapes, which has
been left in the oval window. The lat-
eral edge of the jugular foramen has
been exposed by completing the mas-
toidectomy, transposing the facial
nerve anteriorly, and fracturing the
styloid process across its base and
reecting it caudally. The rectus capi-
tis lateralis muscle has been detached
from the jugular process of the occip-
ital bone. The petrous carotid is sur-
rounded in the carotid canal by a
venous plexus.
FIGURE 12-18. The dura behind
the sigmoid sinus has been opened to
expose the facial and vestibulo-
cochlear nerves entering the internal
acoustic meatus and the glossopha-
ryngeal and vagus nerves entering
the jugular foramen. The vertebral
artery is exposed medial to the
nerves.
JUGULAR FORAMEN
RHOTON
FIGURE 12-19. A segment of the
sigmoid sinus, jugular bulb, and
internal jugular vein have been
removed. The lateral wall of the
jugular bulb has been removed while
preserving the medial wall and the
opening of the inferior petrosal sinus
into the lower part of the bulb. The
glossopharyngeal, vagus, accessory,
and hypoglossal nerves are exposed
below the jugular bulb. The likeli-
hood of preserving these nerves in
exposing a jugular foramen lesion is
greatly enhanced if the medial
venous wall can be preserved. The
main inflow from the inferior pet-
rosal sinus is directed between the
glossopharyngeal and vagus nerves.
FIGURE 12-20. The medial venous wall of
the jugular bulb has been removed. The
intrajugular ridge extends forward from the
intrajugular process of the temporal bone
along the medial side of the jugular bulb. The
glossopharyngeal, vagus, and accessory
nerves enter the dura on the medial side of
the intrajugular process, but only the glos-
sopharyngeal nerve courses through the fora-
men entirely on the medial side of the intra-
jugular ridge.
JUGULAR FORAMEN
RHOTON
FIGURE 12-21. The intrajugular process and ridge have been removed to expose the passage
of the glossopharyngeal, vagus, and accessory nerves through the jugular foramen. The tip of a
right-angle probe identies the lower end of the cochlear aqueduct just above where the glossopha-
ryngeal nerve penetrates the dura. A., artery; Ac., acoustic; A.I.C.A., anterior inferior cerebel-
lar artery; Asc., ascending; Atl., atlanto; Aur., auricular; Auriculotemp., auriculotemporal;
Bas., basilar; Br., branch; Cap., capitis; Car., carotid; Chor., chorda, choroid; Cliv., clival; CN,
cranial nerve; Coch., cochlear; Cond., condyle; Eust., eustachian; Ext., external; Fiss., ssure;
Flocc., occulus; For., foramen; Gang., ganglion; Gl., gland; Glossopharyng., glossopharyn-
geal; Gr., greater; Hypogl., hypoglossal; Inf., inferior; Int., internal; Intrajug., intrajugular;
Jug., jugular; Lat., lateral, lateralis; Long., longus; Longiss., longissimus; M., muscle;
Mandib., mandibular; Mast., mastoid; Max., maxillary; Med., medial; Men., meningeal;
Mid., middle; N., nerve; Obl., oblique; Occip., occipital; Pet., petro, petrosal, petrous; Pharyng.,
pharyngeal; Plex., plexus; P.I.C.A., posterior inferior cerebellar artery; Post., posterior; Proc.,
process; Pterygopal., pterygopalatine; Rec., rectus; S.C.A., superior cerebellar artery; Seg., seg-
ment; Semicirc., semicircular; Sig., sigmoid; Stylomast., stylomastoid; Sup., superior; Tens.,
tensor; Trans., transverse; Tymp., tympanic, tympani; V., vein; Vert., vertebral.

Anatomy and Surgical Appraches of The Temporal Bone PDF

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NEUROSURGERY VOLUME 61 | NUMBER 4 | OCTOBER 2007 SUPPLEMENT 4 | S4-1

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