CHAPTER 8
The Temporal Bone and Transtemporal Approaches
Albert L. Rhoton, Jr., M.D.
Department of Neurological Surgery, University of Florida, Gainesville, Florida
Key words: Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull base, Skull base neoplasm, Surgical
approach, Temporal bone
T
he temporal bone is divided into squamosal, petrous,
mastoid, tympanic, and styloid parts (Figs. 8.1 and 8.2).
The squamosal part helps enclose the brain. The mas-
toid part is trabeculated and pneumatized to a variable de-
gree and contains the mastoid antrum. The petrous part is
compact and encloses the cochlea, the vestibule, and the semi-
circular, facial, and carotid canals (Fig. 8.3). The tympanic part
forms part of the wall of the tympanic cavity and the external
acoustic meatus. The styloid projects downward and serves as
the site of attachment of several muscles. This section exam-
ines these parts in greater detail and defines the anatomic
basis of the approaches directed through the temporal bone to
the posterior fossa and petroclival region. The approaches
examined are the middle fossa, translabyrinthine, transco-
chlear, combined supra- and infratentorial presigmoid, sub-
temporal anterior transpetrosal, subtemporal preauricular in-
fratemporal, and the postauricular transtemporal approaches.
The approaches directed through the surface of the tempo-
ral bone forming the middle fossa floor include 1) the very
limited middle fossa exposure of the internal acoustic meatus;
2) the anterior petrosectomy approach directed medial to the
internal acoustic meatus through the petrous apex to access
the upper anterior part of the posterior fossa and clivus; 3) the
extended middle fossa approach, which may include not only
resection of the roof of the internal acoustic meatus and pe-
trous apex, but is extended lateral to the internal acoustic
meatus to include resection, as needed, of the semicircular
canals, vestibule, roof of the mastoid antrum and tympanic
cavity, and the posterior face of the temporal bone; and 4) the
subtemporal preauricular 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 mastoid in front of the
sigmoid sinus vary in the amount of temporal bone resected.
They include 1) the minimal mastoidectomy variant in which
only enough presigmoid dura is exposed to open the dura in
front of the sigmoid without exposing the labyrinth; 2) the
retrolabyrinthine approach, which exposes the bony capsule
of the labyrinth; 3) the partial labyrinthectomy, which in-
cludes removal of one or more of the semicircular canals; 4)
the translabyrinthine approach, which includes resection of
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
the semicircular canals and vestibule; and 5) the transcochlear
modification, which includes removal of all the labyrinth,
including the cochlear and possibly the petrous apex. These
variants of the transmastoid approaches can all be combined,
as needed, with the supra- and infratentorial presigmoid ap-
proaches to the middle and posterior fossa.
The final approach to be reviewed is the postauricular
transtemporal approach, which allows lesions involving the
mastoid, tympanic cavity, petrous apex, and jugular foramen
to be followed backward to the areas exposed by the retrosig-
moid and far-lateral approaches and forward to the infratem-
poral, 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 sensory
organs of the inner ear that are contained within the temporal
bone are important elements in operative approaches directed
through the lateral aspect of the cranial base.
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 ap-
proaches directed around and through the temporal bone can
be identified (Fig. 8.2). 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 floor of
the middle fossa. The junction 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 anterior edge of the junction of the
sigmoid and transverse sinuses is located at the junction of
the squamous and parietomastoid suture.
The mastoid antrum, a pneumatized space opening into the
tympanic cavity, is located about 1.5 cm deep to the su-
S211
S212 Rhoton

FIGURE 8.1. Temporal bone. A

and B, inferior views. A, the
temporal bone has a squamosal
part, which forms some of the
floor and lateral wall of the
middle cranial fossa. It is also the
site 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, part of the wall of the
tympanic cavity, the osseous
portion of the eustachian tube,
and the posterior 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 downward 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
separated from the clival part of
the occipital bone by the
petroclival fissure. The occipital
bone joins with the petrous part
of the temporal bone to form the
jugular foramen. The mandibular
fossa is located between the
anterior 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 Meckel’s cave sits. Farther laterally is the prominence of the arcuate eminence overlying the
superior semicircular canal. Anterolateral to the arcuate eminences is the tegmen, a thin plate of bone overlying the mastoid
antrum and epitympanic 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 posterior 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 floor 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 portion of the
occipital bone at the petroclival fissure. 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 temporal, 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., eminence; 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.

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FIGURE 8.2. Temporal bone. A, posterior view of a right temporal bone. The squamosal part forms part of the floor and lat-
eral 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 sepa-
rates 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 vestibular area. Below the transverse crest, the cochlear area is ante-
rior and the inferior vestibular area is posterior. D, another internal acoustic meatus. The view is directed to expose the sin-
gular foramen, for the singular branch of the inferior vestibular nerve that innervates the posterior ampullae. The inferior ves-
tibular nerve also has a saccular and, occasionally, a utricular branch. Ac., acoustic; Arc., arcuate; CN, cranial nerve; Coch.,
cochlear; Emin., eminence; Ext., external; For., foramen; Impress., impression; Inf., inferior; Int., internal; Mandib., mandibu-
lar; Occipitomast., occipitomastoid; Parietomast., parietomastoid; Proc., process; Sig., sigmoid; Sp., spine; Sup., superior;
Supramast., supramastoid; Trans., transverse; Trig., trigeminal; Vert., vertebral; Vest., vestibular.

prameatal triangle, a depression in the mastoid surface lo-
cated between the posterosuperior edge of the external me-
atus, the supramastoid 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 su-
prameatal triangle and corresponds to the level of the lateral
semicircular canal and tympanic 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 trans-
verse and sigmoid sinuses at the posterior aspect of the mas-
toid. The asterion located at the junction of the lambdoid,
occipitomastoid, and parietomastoid sutures is usually lo-
cated 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. A burr-hole located at
the junction of the supramastoid crest and the squamosal
suture will be located at the posterior part of the middle fossa
floor just above and anterior to the upper edge of the junction
of the transverse and sigmoid sinuses.

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FIGURE 8.2. 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 tympanic part
and projects downward, serving as the attachment of several muscles. The mastoid part is located posteriorly and contains the mas-
toid 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 posterosupe-
rior 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 posterosupe-
rior to the spine of Henley, between the spine of Henley and the anterior part of the supramastoid crest. The asterion, the junction
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 junction of the supramastoid crest and the squamosal suture is located at the
posterior edge of the middle fossa and slightly anterior and above the junction of the transverse and sigmoid sinuses.

The tympanic part
The tympanic part of the temporal bone is a curved plate
anterior to the mastoid process (Figs. 8.1, 8.2, and 8.4). Its
concave posterior surface forms the anterior wall, floor,
and part of the posterior 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 external 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.

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FIGURE 8.3. A–D. 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 surface 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 jugular foramen. The subarcuate fossa is
located superolateral and the ostium for the vestibular aqueduct lateral to the internal acoustic meatus. The trigeminal
impression is a shallow trough on the upper surface of the temporal bone behind the foramen ovale. The arcuate eminence
overlies the superior semicircular canals. B, temporal bone with the nerves preserved. The abducens nerve ascends to enter
Dorello’s canal. The trigeminal nerve passes above the petrous apex to enter the porus of Meckel’s cave. The facial and ves-
tibulocochlear 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 down-
ward 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 posterior 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 semicircular canals and commonly
gives rise to a utricular branch. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch., cochlear;
Emin., eminence; Endolymph., endolymphatic; Fiss., fissure; For., foramen; Hypogl., hypoglossal; Impress., impression; Inf.,
inferior; Int., internal; Intermed., intermedius; Jug., jugular; Lat., lateral; N., nerve; Nerv., nervus; Pet., petrosal, petrous; Pet-
rocliv., petroclival; Post., posterior; Semicirc., semicircular; Sig., sigmoid; Subarc., subarcuate; Sup., superior; Trig., trigemi-
nal; Vest., vestibular.

The styloid process, a slender spicule ensheathed by the located immediately anterior to the emergence of the facial
inferior border of the tympanic bone, projects into the infra- nerve from the stylomastoid foramen and is covered laterally
temporal fossa and is the site of attachment for the styloglos- by the parotid gland. The stylomastoid foramen, the external
sus, stylopharyngeus, and stylohyoid muscles (Fig. 8.5). It is end of the facial canal, opens between the styloid and mastoid

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FIGURE 8.3. E–H. 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 junction 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 inferior petrosal sinus courses along
the petroclival fissure 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 cen-
tral 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 fibers 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 fiber has been introduced into the superior canal, a red fiber into the lateral canal, and a blue fiber into the posterior
canal. The ampullated ends are located at the bulbous ends of the three fibers. The common crus of the superior and poste-
rior canals is located at the site where the tips of the blue and silver fibers 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. A small black fiber has been introduced into the opening of the endolymphatic duct into the vestibule.
processes. The facial nerve crosses the lateral surface of the The supramastoid crest extends backward across its posterior
styloid process, and the external carotid artery crosses the tip. part, giving attachment to the temporalis muscle and fascia.
Resecting the styloid process and reflecting the attached mus- The suprameatal triangle, a depressed area, located below the
cles downward exposes the internal jugular vein as it exits the anterior part of the crest and behind the posterosuperior
jugular foramen and the carotid artery as it enters the carotid margin of the external meatus, marks the deep location of the
canal medial to the tympanic bone. mastoid antrum. The cerebral surface of the squamosal part is
concave, accommodating the temporal lobe and joining the
The squamous part greater wing of the sphenoid anteriorly. The zygomatic pro-
The externally convex surface of the squamosal part gives cess of the squamosal part projects forward and with the
attachment to the temporalis muscle (Figs. 8.1, 8.2, and 8.5). zygomatic bone completes the zygomatic arch. The attach-

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ment of the zygomatic process to the squama is wide giving it
anterior and posterior edges, referred to as the anterior and
posterior roots. The temporalis fascia attaches to the supe-
rior 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 be-
tween the medial part of the squamosal part of the mandib-
ular fossa and the medial part of the tympanic bone. The
petrotympanic fissure 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 canal-
iculus for the chorda tympani exits the tympanic cavity in the
petrotympanic fissure. 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 superfi-
cial layer of the temporal fascia. During resection of the zy-
gomatic arch, the superficial temporalis fascia should be care-
fully dissected from the underlying deep fascia, starting as
close as possible to the tragal cartilage, and carried forward,
reflecting the superficial fascia anteriorly to avoid damage to
the filaments of the temporal branch to the frontalis muscle.
The mastoid part
The mastoid is the posterior part of the temporal bone (Figs.
8.1, 8.2, and 8.4). It projects downward to form the process
that is the site of attachment, from superficial to deep, of the
sternocleidomastoid, splenius capitis and longissimus capitis
muscles, and the posterior belly of the digastric muscle (Fig.
8.5). 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 cover-
ing the anterior margin of the posterior belly of the digastric
is continuous anteriorly with the connective tissue surround-
ing the emergence of the mastoid segment of the facial nerve
from the stylomastoid foramen and can be used as a landmark
for identifying the initial extracranial segment of the nerve.
After exiting the stylomastoid foramen, the nerve divides in
the substance of the parotid gland into temporal, zygomatic,
buccal, marginal mandibular, and cervical branches (Fig. 8.5).
The temporal and zygomatic branches cross the zygomatic
arch and the superficial fascia of the temporalis muscle. Keep-
ing the connective tissue surrounding the nerve at the stylo-
mastoid 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
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Temporal Bone S217
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. 8.1-8.4). The sinus represents the poste-
rior limit of the mastoid cavity. The sinus meets the roof of the
cavity 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 sinodural angle is an important landmark when exposing
the contents of the mastoid. Inferiorly, the sigmoid sinus
curves medially 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. 8.4 and 8.6). The area of posterior fossa dura
mater that can be exposed through the mastoid cavity be-
tween the sigmoid and superior petrosal sinuses, the otic
capsule, and the jugular bulb is called Trautman’s triangle.
The size of this dural triangle is important in surgical proce-
dures 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 posterior semicircular canal averages 8 mm
(range, 6–9 mm) on the right side, and 7 mm (range, 4–9 mm)
on the left (44).
The distance 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 Trautman’s
triangle. This distance is reduced if there is a high jugular
bulb. The jugular bulb usually lies inferior to the ampulla of
the posterior semicircular canal, but it can project superiorly
as far as the level of the lateral semicircular canal (27). The
average distance from the jugular bulb to the superior petro-
sal sinus is 14 mm (range, 10–19 mm) on the right side, and 16
mm (range, 11–21 mm) on the left (44).
The mastoid interior is composed of trabeculated bone,
which coalesces to form a cavity, the mastoid antrum, that
communicates through an opening, the aditus, that leads
forward to the epitympanic part of in the tympanic cavity
(Figs. 8.4 and 8.6). The lateral semicircular canal is medial to
the epitympanic recess. The medial wall of the antrum faces
the posterior semicircular canal. The roof is formed by the
tegmen in the floor of the middle cranial fossa. The mastoid
segment of the facial canal courses adjacent to the anteroin-
ferior 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 floor of the
middle fossa; anteroinferior by the posterosuperior margin of
the acoustic meatus, which indicates approximately the posi-
tion of the descending or mastoid part of the facial canal; and
posteriorly by a posterior vertical tangent to the posterior
margin of the external meatus. The air cells in the mastoid
may extend behind the sigmoid sinus and into the squamosal
S218 Rhoton

FIGURE 8.4. 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 floor deep to the
depression behind the spine of Henle. B, a mastoidectomy has been completed to expose the capsule of the posterior and lat-
eral 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 segment of the facial
nerve descends through the facial canal and gives rise to the chorda tympani, which passes upward and forward across the
tympanic membrane 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

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 Temporal Bone S219

part of the temporal bone, the posterior root of the zygomatic
process, the osseous roof of the external acoustic meatus, the
floor of the tympanic cavity near the jugular bulb, and the
petrous apex surrounding the carotid canal, eustachian tube,
and labyrinth.
The tympanic cavity is a narrow air-filled space between
the tympanic membrane laterally and the promontory con-
taining the auditory and vestibular labyrinth medially (Figs.
8.4, 8.6, and 8.7). It communicates posteriorly with the mas-
toid antrum and anteriorly through the eustachian tube with
the nasopharynx. It contains the malleus, incus, and stapes.
The tympanic cavity opens upward into the epitympanic
recess, which contains the heads of the malleus and the incus.
The roof of the tympanic cavity is formed by a thin plate, the
tegmen tympani, which separates the middle fossa and tym-
panic cavities, and also roofs the mastoid antrum and the
tensor tympani. The thin floor of the tympanic cavity sepa-
rates the cavity from the jugular bulb. The medial part of the
floor 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 deficient above near the
openings of the anterior and posterior canaliculi for the
chorda tympani (Figs. 8.4 and 8.6). The posterior canalicu-
lus for the chorda tympani arises from the facial canal a few
millimeters above the mastoid foramen and ascends in
front of the facial canal to open into the tympanic 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 medial aspect of the neck of the malleus
and forward to enter its anterior canaliculus at the medial
aspect of the petrotympanic fissure, and descends vertically
medial to the sphenoid spine and lateral pterygoid muscle
to join the lingual nerve.
The medial wall of the tympanic cavity, which forms the
lateral boundary of the inner ear and the petrosal part of the
temporal bone, is the site of the promontory, the oval and
round windows, and the prominence over the facial nerve
(Figs. 8.2 and 8.4). 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 anterior to the promontory. The oval window is
posterosuperior to 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 win-
dow and opens under the overhanging edge of the promon-
tory. The prominence of the facial canal is located above the
oval window. 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 mastoid 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 epitympanic recess; it contains the short process of the
incus, which is fixed to the fossa by ligamentous fibers.
The anterior wall of the tympanic cavity narrows and leads
into the eustachian tube, which communicates the nasophar-
ynx with the tympanic cavity (Figs. 8.4, 8.7, and 8.8). It has
bony and cartilaginous parts. The bony part begins in the
anterior part of the tympanic cavity and is directed anteriorly
and medially. It joins the cartilaginous part at the junction of
the squamous 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 eusta-
chian tube being located along the anterior margin of the
carotid canal (Figs. 8.7 and 8.8). 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 anterior 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 tensor tympani extends posterolaterally on the
medial wall of the tympanic cavity, to end above the oval
window where the posterior end of the canal curves laterally
to form a pulley, the trochleariform process, around which the
tensor tympani tendon turns laterally to attach to the handle
of the malleus.

Š
crosses the neck of the malleus. The promontory is located superficial to the basal turn of the cochlea. The labyrinth and fun-
dus 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., eminence; 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., seg-
ment; Sig., sigmoid; Sp., spine; Squamomast., squamomastoid; Temp., temporal; Tymp., tympani, tympanic; Tympanomast.,
tympanomastoid.

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FIGURE 8.5. A–F. Muscular and osseous relationships. A, 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
masseter muscle has two heads: a more superficial 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 man-
dibular 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 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 scapu-
lae in its floor. 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. 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 styloid

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 Temporal Bone S221

The petrous part
The petrous part of the temporal bone is wedged between
the sphenoid and occipital bones (Figs. 8.1 and 8.3). It contains
the acoustic and vestibular labyrinth and is the site of the
jugular fossa and the facial and carotid canals (Figs. 8.3, 8.4,
and 8.7). It has a base, apex, three surfaces and margins. The
apex is located in the angle between the greater wing of the
sphenoid 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 floor of
the middle cranial fossa and its surface is grooved by the
trigeminal impression for the trigeminal ganglion; anterolat-
eral to this, it forms the roof of the carotid canal (Figs. 8.1 and
8.7). Lateral to the trigeminal impression is a shallow depres-
sion, 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 ca-
nals. 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 tympani. Opening the tegmen from above ex-
poses the heads of the malleus, incus, the tympanic segment
of the facial nerve, and the superior and lateral semicircular
canals (Fig. 8.7). 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
floor of the middle fossa toward the foramen lacerum (Figs.
8.7 and 8.8). The greater petrosal nerve can be identified
medial to the arcuate eminence as it leaves the geniculate
ganglion by passing through the facial hiatus to reach the
middle fossa floor. 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 segment 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 gan-
glion to the danger of injury during elevation of the dura from
the floor 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 to the ganglion when manip-
ulating the greater petrosal nerve (30).
The lesser petrosal nerve from the tympanic plexus passes
through the tympanic canaliculus, which is located anterior to
the facial hiatus and courses in an anteromedial direction
parallel to the greater petrosal nerve (Fig. 8.8). The cochlea lies
below the floor of the middle fossa in the angle between the
labyrinthine segment of the facial nerve and the greater petro-
sal nerve, just medial to the geniculate ganglion, anterior to
the fundus of the internal acoustic meatus, and posterosupe-
rior to the lateral genu of the petrous carotid artery. The
cochlea is separated from the petrous carotid by a 2.1 mm
(range, 0.6–10.0 mm) thickness of bone and can be injured
during exposure of the petrous carotid. The middle meningeal
artery, an important landmark when approaching the struc-
tures of the middle fossa, enters the cranial cavity through the
foramen spinosum of the sphenoid bone. The foramen spino-

Š
process, the external carotid artery, and mandibular neck. The superficial and deep heads of the masseter muscle are
exposed. This lower end of the sternocleidomastoid muscle has been reflected posteriorly by dividing its attachment to the
clavicle and sternum. The superficial 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 attachment 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 superfi-
cial 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 reflected out of the exposure to expose
the splenius capitis muscle. E, posterolateral view. The splenius capitis has been reflected downward to expose the longissi-
mus capitis, superior oblique, and semispinalis capitis. The occipital artery passes along the occipital groove on the medial
side of the digastric groove. F, the longissimus capitis has been reflected 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. A., artery; Alv.,
alveolar; Ant., anterior; Aur., auricular; Brs., branches; Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Constr.,
constrictor; 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., medi-
al; Memb., membrane; Min., minor; N., nerve; Obl., oblique; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal;
Pet., petrosal; Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; Scap., scapula;
Semispin., semispinalis; Splen., splenius; Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup., superior;
Superf., superficial; Temp., temporal, temporalis; Tens., tensor; TM., temporomandibular; Trans., transverse; Tymp., tympanic;
V., vein; Veli./Vel., veli; Vert., vertebral.

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FIGURE 8.5. G–L. 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 mandibular nerve have been removed to expose the auri-
culotemporal nerve, which splits into two roots that surround the middle meningeal artery. The levator veli palatini, 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 surface 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 pre-
served. 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 anteriorly. J, the eusta-
chian tube has been resected and the mandibular nerve divided at the foramen ovale to expose the petrous carotid. This exposes the lon-
gus capitis and rectus capitis anterior, both of which are located behind the posterior pharyngeal wall. K, the petrous carotid has been
reflected 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 anterolateral 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.

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 Temporal Bone S223

FIGURE 8.6. A–D. Translabyrinthine exposure. A, the insert shows the site of the exposure directed through the mastoid. The
spine of Henley at the posterosuperior 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 cancel-
lous 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 Trautman’s triangle. B, the mastoid
antrum opens through the aditus into the epitympanic part of the tympanic cavity, which contains the upper part of the mal-
leus and incus. The tympanic segment of the facial nerve passes between the lateral canal and the stapes in the oval window
and then turns downward 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 ves-
tibulocochlear nerve. D, the dura has been opened to expose the petrosal cerebellar surface and the structures in the cer-
ebellopontine angle. Anatomic variants that limit the exposure include an anterior position of the sigmoid sinus, a high jugu-
lar bulb, or a low middle fossa plate. The jugular bulb may extend upward into the posterior wall of the internal acoustic
meatus and be encountered as the posterior meatal wall is being removed by either the translabyrinthine or retrosigmoid
approaches. Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery; Chor., chorda; CN, cranial nerve; Coch., cochlear; Inf.,
inferior; Int., internal; Intermed., intermedius; Jug., jugular; Laby., labyrinthine; Lat., lateral; Mast., mastoid; N., nerve; Nerv.,
nervus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Seg., segment; Sig., sigmoid; Sup., superior;
Tymp., tympani, tympanic; V., vein; Vest., vestibular.

sum is an average of 4.5 mm (range, 3–6 mm) anterolateral to
the carotid canal and 14.0 mm (range, 11.0–17.0 mm) antero-
lateral to the geniculate ganglion (44).
The posterior surface of the petrosal part faces the posterior
cranial fossa and cerebellopontine angle and is continuous
with the mastoid surface (Figs. 8.1-8.3). 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

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FIGURE 8.6. E–H.

Translabyrinthine 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
foramen. 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
preparation for transposition of
the nerve for a transcochlear
approach. H, the facial nerve
has been transposed backward
and the bone anterior 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
brainstem. The cochlear nerve
has been divided. The cochlear
fibers innervating the cochlear
duct pass through the
modiolus.

divided by the vertical crest, also called Bill’s bar, which
separates the anteriorly located facial canal from the posteri-
orly 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 ar-
tery, 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 endolymphatic
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 glos-
sopharyngeal nerve enters the intrajugular part of the jugular
foramen.
The inferior surface is very irregular. The apex is connected
medially to the clivus by fibrocartilage and gives attachment
to the levator veli palatini and the cartilaginous portion of the
eustachian tube (Figs. 8.1 and 8.9). Behind this is the opening
of the carotid canal, behind which is the jugular fossa that
contains the jugular bulb. The small foramen for the tympanic

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FIGURE 8.7. A–D. Middle fossa exposure of the temporal bone. A, superolateral 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 petro-
sal 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 pre-
geniculate facial and greater petrosal nerves. C, another temporal bone drilled to expose the internal acoustic meatus,
cochlea, vestibule, semicircular canals, tympanic 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 tensor tympani muscle and eustachian tube are layered along, but are separated from, the anterior sur-
face 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. 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., tentorial; Tymp., tympani, tympanic; Vert., vertebral; Vest., vestibular.

branch of the glossopharyngeal nerve is located on the ridge
between the carotid canal and jugular foramen (Fig. 9.2). On
the lateral wall of the jugular bulb is the mastoid canaliculus
for the auricular branch of the vagus nerve. The superior
border, located along the petrous ridge, is grooved by the
superior petrosal sinus and serves as the attachment 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 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 fissure 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

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FIGURE 8.7. E–H. Middle fossa exposure of the temporal bone. E, enlarged view. The vestibule, into which the semicircular
canals open, communicates below the meatal fundus with the cochlea. The vertical crest, often called Bill’s 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 cavity to insert on the malleus. F, enlarged view. The supe-
rior canal projects upward in the floor of the middle fossa. The lateral canal is situated above the tympanic segment of the
facial nerve in the posteromedial part of the epitympanic 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 lat-
eral canals and the lower end of the posterior canal are the site of the ampullae. The posterior end of the superior 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.

transmits the inferior petrosal sinus (Fig. 9.1). The intrajugular
part, located between the sigmoid and petrosal parts, trans-
mits the glossopharyngeal, vagus, and accessory nerves. The
anterior border is joined laterally to the temporal squama at
the petrosquamosal suture and medially articulates with the
sphenoid’s 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
confluence 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. 8.3, 8.4, and 8.7).
The floor of the vestibule is separated from the apex of the
jugular bulb by a thickness of bone that averages 6 mm
(range, 4–8 mm) on the right side and 8 mm (range, 4–10 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. 8.3, 8.4, and 8.7). The anterior part of the lateral
semicircular canal is situated above the tympanic segment of

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 Temporal Bone S227

FIGURE 8.8 A, superior view of the temporal bone and

infratemporal fossa and orbit. The floor 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
trigeminal division in the infratemporal fossa. The posterior part
of the middle fossa forming the upper surface of the
temporomandibular joint has been removed to expose the
mandibular condyle. The internal acoustic meatus extends
laterally from the posterior 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 reflected 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 passing below the petrosphenoid
ligament and through Dorello’s 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 floor 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., geniculate; 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 facial nerve and can be used as a guide to locating 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 semi-
circular 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 common crus that
opens into the vestibule. The superior vestibular nerve inner-
vates 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 vesti-
bule. 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 completing 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 retrosigmoid ap-
proach (Fig. 8.3).
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. 8.2 and
8.3). In our studies, we observed that there is a constant set of
relationships among the structures around the posterior
meatal lip. The common crus of the posterior and superior
semicircular canals is located lateral to the entrance of the
subarcuate artery into the subarcuate fossa. The vestibular
aqueduct has an oblique orientation. It leaves the vesti-
bule and runs in a posterior direction to open beneath the
dura mater at a level corresponding to that of the posterior
semicircular canal. The average distance between the poste-
rior semicircular canal, at the level with the junction of the
common crus, and the lateral edge of the porus was 7 mm
(range, 5–9 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 difficult to mobilize the artery at this point (Figs. 8.9

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S228 Rhoton

FIGURE 8.9. Inferior views of an

axial section of the skull base. A, the
infratemporal fossa is surrounded by
the maxillary sinus anteriorly, the
mandible laterally, the sphenoid
pterygoid process anteromedially,
and the parapharyngeal space
posteromedially, and contains the
mandibular nerve and maxillary
artery and their branches, the
medial and lateral pterygoid
muscles, and the pterygoid 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 Rosenmüller) projects
laterally from the posterolateral
corner of the nasopharynx with its
lateral apex facing the internal
carotid artery laterally and the
foramen lacerum above. The
posterior nasopharyngeal 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 posterior part
of the sphenoid sinus floor. C, the
sphenoid pterygoid process has been
removed to expose the maxillary
nerve passing through the foramen
rotundum to enter the
pterygopalatine 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 com-
municating rami to the pterygopalatine ganglion. The vidian nerve, formed by the union of the deep petrosal nerve from the ca-
rotid 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 pterygoid and tensor veli palatini, separates the infratemporal fossa from the medially lo-
cated lateral nasopharyngeal region containing the tensor and levator veli palatini and the eustachian tube. The poststyloid 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., nasolacrimal; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal; Proc., pro-
cess; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rectus; Tens., tensor; V., vein; Vel., veli.

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 Temporal Bone S229

FIGURE 8.10. A–D. Preauricular

subtemporal-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 completed. The scalp flap has
been reflected forward while
protecting the facial nerve and its
branches. The neck dissection has
been completed 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
stylomastoid 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.

and 8.10) (38, 39). The vertical segment of the artery passes
upward in the canal toward the genu, where it curves
anteromedially to form the horizontal segment. The eusta-
chian tube and the tensor tympani muscle are located par-
allel 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 Meckel’s cave, sit in an impression on the upper surface
of the petrous apex above the medial part of the petrous
carotid (Figs. 8.1, 8.7, and 8.8). The length of the horizontal
segment of the petrous carotid that can be exposed by remov-
ing bone lateral to the trigeminal ganglion averages 8.1 mm
(range, 4.0–11.0 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, 17.5–28.0 mm) (Figs.
8.7 and 8.8) (10, 17). Gaining this added exposure can be
particularly helpful during surgical procedures that are di-
rected through the petrous apex to complete a vascular anas-
tomosis, to occlude the artery for control of bleeding, and to
allow for mobilization of the vertical and horizontal segments
of the artery (40). A venous plexus of variable size, an exten-
sion of the cavernous sinus within the periosteal covering of
the distal part of the canal, surrounds the artery.

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S230 Rhoton

FIGURE 8.10. E, a frontotemporal craniotomy has been completed and the dura of the lateral wall of the cavernous
sinus has been elevated. 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 coursing
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 continues 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. A., artery;
A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Bas., basilar; Brs., branches; Cap., capitis; Car., carotid; Cav., cavern-
ous; CN, cranial nerve; Ext., external; Front., frontal; Gl., gland; Inf., inferior; Infraorb., infraorbital; Int., internal; Jug., jugu-
lar; 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., tensor; TM.,
temporomandibular; Tymp., tympani; V., vein; Vert., vertebral.

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. 8.4, 8.5, and 8.7). 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
arises from the facial nerve at the level of the geniculate
ganglion. From there, the nerve 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 semicircular canal
above and the oval window below. As the nerve passes below
the midpoint of the lateral semicircular canal, it turns verti-
cally downward and courses through the petrous part adja-
cent 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 di-
rected 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. 8.1). From a surgical stand-
point, 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 re-
gion of the foramen magnum; 2) a middle space related to the
pons and to the structures in the prepontine and cerebel-
lopontine angle; and 3) a superior space related to the con-
tents of the interpeduncular cistern, and to the sellar and
parasellar regions.
The inferior petroclival space
The inferior petroclival space corresponds to the anterior sur-
face of the medulla and adjacent part of the clivus and anterior
margin of the foramen magnum (4). The neurovascular struc-
tures in this region are those contained in the premedullary
cistern. The superior limit is the junction of the pons and me-
dulla. The inferior limit is the rostral margin of the first 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 anterolat-
eral surface of the pons and cerebellum. Its superior limit is at
the pontomesencephalic sulcus and the lower limit is at the
pontomedullary sulcus. The lateral limits are formed by the
posterior surface of the petrous bone and by the contents of

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 Temporal Bone S231

FIGURE 8.10. G–J.

Preauricular subtemporal-
infratemporal fossa approach.
G, the floor of the middle fossa
has been resected back to the
level of the tensor tympani
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 lateral to the
foramen ovale removed. This
exposes the full length of the
petrous carotid. I, the petrous
carotid has been reflected
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
adjacent 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.

the cerebellopontine angle including the trigeminal, abdu-
cens, 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
midbrain 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
structures forming the floor of the third ventricle. The poste-
rior limit is formed by the cerebral peduncles and the posterior
perforated 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 troch-
lear 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 supraten-
torial 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 infratem-
poral fossa, and the parapharyngeal spaces.

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S232 Rhoton
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. 8.5). The muscle
attaches to the coronoid process of the mandible. The super-
ficial and the deep temporalis fasciae attach, respectively, to
the lateral and medial aspects of the upper border of the
zygomatic arch. Inferiorly, the parotid fascia invests the pa-
rotid gland and the masseter muscle and attaches to the lower
border of the zygomatic arch. The masseter muscle has two
superimposed layers. A superficial layer which attaches to the
zygomatic process of the maxilla and anterior part of the
lower border of the zygomatic arch and a deep layer which
attaches 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. 8.5, 8.9, and 8.10). 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 excessive
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 digas-
tric groove, lateral to the occipital groove in which the occip-
ital artery courses, and inserts onto the hyoid bone. The
muscles attached to the styloid process, the stylohyoid, stylo-
glossus, 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
pterygoid plate anteromedially, the mandibular ramus later-
ally, and the tympanic part of the temporal bone and the
styloid 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. 8.8-8.10). The
inferior, posteromedial, and superolateral aspects are open
without 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,
originating 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 ptery-
goid plate (Figs. 8.8-8.10). Both heads pass posterolaterally and
insert on the neck of the mandibular condylar process and the
articular disc of the temporomandibular joint. The medial ptery-
goid muscle crosses the lower part of the infratemporal fossa
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
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 superficial to the lower
head of the lateral pterygoid; and the deep head originates from
the medial surface of the lateral pterygoid plate and the ptery-
goid 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 man-
dible are the lateral pterygoid and the auriculotemporal 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: man-
dibular, pterygoid, and pterygopalatine (Figs. 8.8-8.10). 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
pterygoid, and gives rise to the deep auricular, anterior tym-
panic, middle and accessory meningeal, and the inferior alve-
olar 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, pterygoid, masseteric, and buccal arteries. The
pterygopalatine segment courses between the two heads of
the lateral pterygoid and enters the pterygopalatine fossa by
passing through the pterygomaxillary fissure. Its branching
will be described with the pterygopalatine fossa.
The pterygoid venous plexus is located in the infratemporal
fossa and has two parts: a superficial part located between
the temporalis and lateral pterygoid; and a deep part situ-
ated between the lateral and medial pterygoids anteriorly,
and between the lateral pterygoid and the parapharyngeal
space posteriorly. The deep part is more prominent and con-
nects 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. 8.8-8.10). 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 fibers, passes anterolaterally between the two heads
of the lateral 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 lingual 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 middle meningeal artery and passes postero-
laterally between the mandibular ramus and the sphenoman-
dibular ligament. The chorda tympani nerve, which con-
tains the taste fibers from the anterior two-thirds of the tongue
and the parasympathetic secretomotor fibers to the subman-
dibular and sublingual salivary glands, enters the infratem-
poral fossa through the petrotympanic fissure, descends me-
dial to the auriculotemporal and inferior alveolar nerves, and
joins the lingual nerve. The otic ganglion is situated immedi-
ately below the foramen ovale on the medial side of the
mandibular nerve. The ganglion receives the lesser petrosal
nerve, which crosses the floor of the middle fossa anterolat-
eral to the greater petrosal nerve to exit through the foramen
ovale or the more posteriorly situated canaliculus innomina-
tus and conveys parasympathetic secretomotor fibers to the
parotid gland via the auriculotemporal nerve. The medial
pterygoid nerve arises from the medial aspect of the mandib-
ular nerve close to the otic ganglion and descends to supply
the medial pterygoid and tensor veli palatini. The nervus
spinosus, a meningeal branch, also arises near the otic gan-
glion and ascends through the foramen spinosum to innervate
the middle fossa dura.
Parapharyngeal space
The parapharyngeal space is located in the lateral pharyn-
geal wall and is shaped like an inverted pyramid, with its base
on the skull base superiorly and its apex at the hyoid bone
inferiorly. The parapharyngeal space is subdivided into pre-
styloid and poststyloid compartments by the styloid dia-
phragm, a fibrous sheet that also constitutes the anterior part
of the carotid sheath (Figs. 8.5 and 8.9). The prestyloid part,
situated anteriorly between the fascia covering the opposing
surfaces of the medial pterygoid and tensor veli palatini, is a
thin fat-filled 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, in-
corporating the sphenomandibular ligament posteriorly, and
reaching the retromandibular 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 enve-
lopes 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 ptery-
goid process lateral to the origin of the tensor veli palatini,
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Temporal Bone S233
medial to the foramina ovale and spinosum to the sphenoid
spine and the posterior margin of the glenoid 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 infratem-
poral fossa by the posterolateral portion of the prestyloid part.
The glossopharyngeal nerve exits the skull through the intra-
jugular 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 ca-
rotid artery as the artery enters the carotid canal (Fig. 8.9).
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
muscle, 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. 8.9 and 8.10). It becomes
superficial 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
maxilla and pterygoid process, and opens superiorly through
the medial part of the inferior orbital fissure into the orbital
apex (Figs. 8.5, 8.9, and 8.10) (11). The fossa contains the
maxillary nerve, pterygopalatine ganglion, maxillary artery,
and their branches, all embedded in fat tissue. Its lateral
boundary, the pterygomaxillary fissure, opens into the infra-
temporal fossa and allows passage of the maxillary artery
from the infratemporal 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 communi-
cate with the oral cavity. The sphenopalatine foramen, located
in the upper part of the fossa’s 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 rotundum opens just below the superior orbital
fissure through the superior part of the posterior wall of the
fossa. The pterygoid canal opens through the sphenoid ptery-
goid process inferomedial to the foramen rotundum and con-
veys the vidian nerve carrying autonomic fibers to the ptery-
gopalatine ganglion. The maxillary nerve, after entering the
S234 Rhoton
fossa, gives off ganglionic branches to the pterygopalatine
ganglion. It then deviates laterally just beneath the inferior
orbital fissure, giving rise to, in order, the zygomatic and
posterosuperior alveolar nerves outside of the periorbita. It
then turns medially as the infraorbital nerve, passing through
the inferior orbital fissure 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 maxillary nerve, re-
ceives 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 conveys
parasympathetic fibers arising from the facial nerve at the
level of the geniculate ganglion, and the deep petrosal nerve,
which conveys sympathetic fibers from the carotid plexus, to
reach the lacrimal gland and nasal mucosa. The parasympa-
thetic fibers synapse in the pterygopalatine ganglion, whereas
the sympathetic fibers do not. The sympathetic fibers synapse
in the superior cervical sympathetic ganglion.
The third or pterygopalatine segment of the maxillary ar-
tery 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 infraor-
bital artery, which passes through the inferior orbital fissure
and courses with the infraorbital nerve; the posterosuperior
alveolar artery, which descends to pierce the posterolateral
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 cavity and is con-
sidered to be the terminal branch of the maxillary artery
because of its large diameter. The arterial structures in the
pterygopalatine fossa are located anterior to the neural
structures.
Arterial relationships
The arteries that may be involved in pathological abnor-
malities involving the temporal bone include the upper cer-
vical and petrous portions of the internal carotid artery, the
posteriorly 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. 8.9 and 8.10). Below the
digastric, it is crossed by the hypoglossal nerve and the ansa
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
cervicalis, and by the lingual and facial veins. Medial to the
digastric, it is crossed by the stylohyoid muscle and the oc-
cipital and posterior auricular arteries. Superior to the digas-
tric, 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 sepa-
rated 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 up-
ward, posterior to the external carotid artery and anterome-
dial 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 glossopharyn-
geal 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),
reaching 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 seg-
ment) toward the petrous apex (Figs. 8.8-8.10). 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.
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
superficial 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
temporal bone.
The ascending pharyngeal artery, the first branch of the
posterior 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 neighboring muscles, nerves, and lymph nodes. Its menin-
geal branches pass through the foramen lacerum to be dis-
tributed to the dura lining the middle fossa and through the
jugular foramen or the hypoglossal canal to supply the sur-
rounding dura of the posterior 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 tympanic branch of the
glossopharyngeal nerve.
The occipital artery, the second and largest branch of the
posterior group, arises from the posterior surface of the ex-
ternal 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 superficial or deep to the longissimus capitis muscle
(Fig. 8.5). 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 capi-
tis muscle, finally reaching a subcutaneous location by pierc-
ing the fascia between the attachment of the sternocleidomas-
toid 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 including the ascending pharyngeal 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 significant contribution to
tumors of the jugular foramen.
The posterior auricular artery, the last branch in the poste-
rior 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 dis-
tributed to the postauricular and the occipital regions, respec-
tively. The stylomastoid branch, which arises below the stylo-
mastoid 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 men-
ingeal artery. The posterior 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.
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. 8.5). It ascends
over the posterior root of the zygoma and divides into ante-
rior and posterior branches that run with the superficial tem-
poral vein and the auriculotemporal nerve over the superficial
temporalis fascia.
Vertebral artery
The vertebral artery and its meningeal, posterior spinal,
and posteroinferior cerebellar branches, which may be ex-
posed in approaches directed through the temporal bone, are
detailed in the chapter on the foramen magnum (4, 20, 24).
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 petro-
sal 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 fissure and drains the
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Temporal Bone S235
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 si-
nuses and from the temporal lobe through the vein of Labbé.
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
petrosal sinuses with the sinuses in the region of the foramen
magnum (10).
SURGICAL APPROACHES
The suboccipital retrosigmoid approach, the traditional
neurosurgical route to intradural pathologies arising in the
region of the cerebellopontine angle, lower clivus, and fora-
men magnum, is reviewed in the chapter on the cerebellopon-
tine angle. The approaches reviewed here are those directed
through the temporal bone.
Middle fossa approach
This section focuses on the middle fossa approach to the
internal acoustic meatus rather than on the more extensive
approaches directed through the petrous apex to the petroclival
region or the more extended approaches directed through the
temporal bone lateral to the internal acoustic meatus. The middle
fossa approach to the internal acoustic meatus is usually selected
for small tumors that are located predominantly 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 craniotomy located above the
ear and zygoma (Figs. 8.7 and 8.11) (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 remem-
ber 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 ganglion 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 covered. It also is
important to remember that the petrous segment 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
S236 Rhoton

FIGURE 8.11. 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 men-
ingeal 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 arcuate 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 anteromedial 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 petro-
sal nerve above the petrous carotid. F, enlarged view. The vertical crest (Bill’s 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, cranial 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., supe-
rior; Tens., tensor; Tymp., tympani; Vert., vertebral; Vest., vestibular.

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 Temporal Bone S237

FIGURE 8.12. A–D. Anterior petrosectomy and extended

middle fossa approach. A, the site of the bone flap is the
same as shown in Figure 8.11A. The dura has been elevated
from the floor 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 internal 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 cistern, basilar artery, and abducens nerve. A., artery; Ac.,
acoustic; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Car., carotid; Cav., cavernous; Chor., chorda; CN, cranial
nerve; Ext., external; Gang., ganglion; Gen., geniculate; Genic., geniculate; Inf., inferior; Int., internal; Laby., labyrinthine;
Lat., lateral; M., muscle; 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.

previous study, we found that a 7-mm length of petrous carotid
artery may be exposed without a bony covering in the area
below where the greater petrosal nerve passes below the lateral
margin of the trigeminal ganglion 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 mid-
dle meningeal artery at the foramen spinosum.
Two different methods are used for exposing the internal
acoustic meatus. One is to remove bone over the greater
petrosal nerve and to follow it to the geniculate 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 method is begun by drilling just in front of the petrous
ridge 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 acous-

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S238 Rhoton

FIGURE 8.12. E–H. Anterior petrosectomy and extended middle fossa approach. E, additional bone has been removed
around the internal acoustic meatus and the dura opened to expose the facial and vestibulocochlear 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 presig-
moid 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 seg-
ments of the facial nerve have been exposed. H, this extended middle fossa exposure extends from the lateral wall of the cav-
ernous 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.

tic 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 semicircu-
lar canal. The drilling is directed anterolateral 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,
which is located a few millimeters behind and oriented par-
allel to the labyrinthine segment of the facial nerve (Figs. 8.7
and 8.11). The anteromedial edge of the exposure is limited by
the cochlea, which sits only a few millimeters anterior 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 vertical crest,
which is identified at the upper edge of the meatal fundus,
provides a valuable landmark for identifying the facial nerve.
In the final 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
posterior 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.
8.12). 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

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 Temporal Bone S239

FIGURE 8.13. A–F. Subtemporal exposure of the right middle, infratemporal, and posterior fossae. A, the insert shows the side of the
scalp incision. A frontotemporal craniotomy has been completed and the dura has been elevated from the middle fossa floor and lateral
wall 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 semi-
circular 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 lateral 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. A., artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., anterior; Bas., basilar; Car., carotid; Chor.,
chorda, choroidal; CN, cranial nerve; Comm., communicating; Eust., eustachian; Gang., ganglion; Gen., geniculate; Genic., geniculate;
Gr., greater; Inf., inferior; Int., internal; Jug., jugular; Laby., labyrinthine; Lat., lateral; M., muscle; Mandib., mandibular; 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.

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S240 Rhoton

FIGURE 8.13. G–L. 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 zygomatic arch and the floor
of the middle fossa surrounding the mandibular fossa has been completed to aid in exposing the infratemporal fossa. I, the mandib-
ular 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 petrosal 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 pterygo-
palatine 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 tympani 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.

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 Temporal Bone S241

FIGURE 8.14. A–D. Presigmoid

approach. A, the insert shows the
temporo-occipital craniotomy and
the mastoid exposure. The
mastoidectomy 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.
Trautman’s 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 preserve the vein of
Labbé 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 SCA passes below the
oculomotor and trochlear nerves
and above the trigeminal nerve.
C, the semicircular canals have
been opened. The superior canal
is located under the middle fossa’s
arcuate eminence and the
posterior canal is located
immediately lateral 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 tympanic membrane and neck of the malleus. The head
of the malleus and incus are located in the epitympanic area above the level of the tympanic membrane. The mastoid
antrum communicates through the aditus with the epitympanic area and tympanic cavity. A., artery; Ac., acoustic;
A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Br., branch; Chor., chorda; Cist., cisternal; CN, cranial nerve;
Coch., cochlear; Gang., ganglion; Genic., geniculate; Inf., inferior; Int., internal; 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 cerebellar artery; Seg., segment; Sp., spine; Sup.,
superior; Tymp., tympani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.

the cerebellopontine angle by a combination of subtemporal,
translabyrinthine, and presigmoid routes, all directed through
the posterior part of the floor of the middle fossa.
Subtemporal anterior transpetrosal approach
This approach is made through a temporal craniotomy that
extends down to the floor of the middle fossa (Figs. 8.12 and
8.13) (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 pos-
teriorly. The cochlea, which is to be preserved, and the ante-
rior wall of the internal auditory canal constitute the lateral

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S242 Rhoton

FIGURE 8.14. E–H. Presigmoid

approach. E, the
labyrinthectomy has been
completed to expose the internal
acoustic meatus. F, the dura
lining the meatus has been
opened and the facial nerve has
been transposed 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
posterolateral side and the
cochlea on its anteromedial
margin. The superior and
inferior vestibular 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 meatus. G, the cochlear
nerve has been divided and
reflected and bone removed to
expose the cochlea. H, the
transcochlear exposure,
completed by removing the
cochlea and surrounding 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.

limit of the exposure through the petrous apex. The bone layer
over the superior wall of the internal auditory canal, which
averages 5 mm (range, 3–7 mm) in thickness, can be removed
with a drill to improve the exposure (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
Meckel’s 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 lateral edge of the clivus. Care is
required to prevent damage to the abducens nerve as it passes
through Dorello’s canal located at the upper edge of the petro-
clival fissure. The width of the bone resection from the trigemi-
nal impression to the posterior wall of the internal auditory canal
averages 13 mm (range, 9–14 mm) (44). The depth of the expo-
sure, from the trigeminal ganglion to the petroclival fissure,
averages 13 mm (range, 9–17 mm). The cochlea lies below the
floor of the middle fossa near the apex of the angle formed by
the greater petrosal nerve anteriorly and the internal acoustic

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 Temporal Bone S243

FIGURE 8.15. A–D. Com-

parison of the retrosig-
moid approach and the mini-
mal mastoidectomy,
retrolabyrinthine, translabyrin-
thine, and transcochlear
approach modifications of the
presigmoid approach. A, ret-
rosigmoid approach. The left
cerebellum has been elevated to
expose the cranial nerves V
through XI in the cerebel-
lopontine angle. The illustra-
tions 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 presigmoid dura
and divide the superior petro-
sal sinus and tentorium. D,
the presigmoid dura has been
opened and the sigmoid sinus
has been retracted posteri-
orly. The view is approxi-
mately the same as that seen
with the retrosigmoid expo-
sure. The retrosigmoid ap-
proach provides a better view
of the nerves entering the
jugular foramen. A., artery;
A.I.C.A., anteroinferior cere-
bellar artery; Bas., basilar;
Cist., cisternal; CN, cranial
nerve; Coch., cochlear;
Flocc., flocculus; Inf., infe-
rior; Laby., labyrinthine; Lat.,
lateral; Mast., mastoid; 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., superior; Tymp., tympanic; V., vein; Vest.,
vestibular.

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 leaflets of the tentorium are retracted
with sutures and the dural incision is carried downward 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
significant temporal lobe retraction, especially if the goal is to
reach the lower aspect of the brainstem. To reach the anterior

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S244 Rhoton

FIGURE 8.15. E–H. Comparison of the

retrosigmoid approach and the minimal
mastoidectomy, retrolabyrinthine,
translabyrinthine, and transcochlear
approach modifications 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
presigmoid approach. F, the exposure
with the retrolabyrinthine
version does not differ
significantly from that
achieved with the minimal
mastoidectomy. G, the
semicircular canals and
vestibule have been removed
and the dura lining the
internal acoustic meatus has
been opened to complete the
translabyrinthine exposure.
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.

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 frontotem-
poral craniotomy combined with zygomatic arch resection.
Translabyrinthine approach
In the translabyrinthine approach, the internal acoustic me-
atus and cerebellopontine angle are approached through a
mastoidectomy and labyrinthectomy (Fig. 8.6) (16, 29, 38)
There are two goals of bone removal in this approach. The
first is to expose the dura of Trautman’s triangle on the
posterior surface of the temporal bone facing the cerebel-
lopontine 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.
A retroauricular incision starts above the pinna and extends
inferiorly to the mastoid tip (3). A flap 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 an-
trum, the cortical bone around the labyrinth, and the digastric
ridge leading anteriorly to the mastoid segment of the facial
nerve as it exits the stylomastoid foramen and the sinodural
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

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FIGURE 8.15. I and J. Compari-
son of the retrosigmoid
approach and the minimal mas-
toidectomy, retrolabyrinthine,
translabyrinthine, and transco-
chlear approach modifications of
the presigmoid approach. I, the
labyrinthine, tympanic, and mas-
toid segments of the facial nerve
have been exposed in prepara-
tion for the posterior transposi-
tion of the nerve needed to
complete the transcochlear
exposure. J, the facial nerve has
been transposed and the cochlea
and petrous apex removed to
complete the transcochlear
exposure of the anterior aspect
of the brainstem and the basilar
artery.
structures. The lateral semicircular canal is the most laterally
projecting canal and is the first one encountered by this ap-
proach. 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 identified
inferiorly. In removing bone behind the internal acoustic me-
atus, it is important to remember that the jugular bulb may
bulge upward behind the posterior semicircular canal or in-
ternal auditory meatus. The vestibular aqueduct and the en-
dolymphatic 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 semi-
circular 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
center 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
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Temporal Bone S245
and the ampullae of the posterior canal and around the su-
perolateral margin of the vestibule.
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, pos-
terior, and inferior margins of the internal canal. Further bone
removal at the lateral end of the meatus exposes the trans-
verse and vertical crests (Fig. 8.2). 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 Bill’s 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 inci-
sion in Trautman’s 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 flap is
then reflected posteriorly to expose the structures in the me-
atus and the cerebellopontine angle. The subarcuate artery, or
the AICA, may be encountered in the dura of Trautman’s
triangle. Usually, the subarcuate artery arises from the AICA
and passes through the dura on the upper posterior wall of
the meatus as a fine stem. Occasionally, however, the subar-
cuate artery, along with its origin from the AICA, may be
incorporated into the dura on the posterior face of the tem-
poral bone. The approach may include transection of the
external canal and obliteration of the middle ear with packing
of the eustachian tube at closure.
S246 Rhoton

FIGURE 8.16. A–F. Comparison of the retrosigmoid and the various modifications of the presigmoid exposure. The modifica-
tions of the presigmoid approach include the minimal mastoidectomy, retrolabyrinthine, partial labyrinthine, translabyrin-
thine, modified 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 temporo-occipital craniotomy. A temporo-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 various modification of
the presigmoid approach. C, in the retrosigmoid exposure the vestibulocochlear nerve has been elevated and the glossopha-
ryngeal nerve depressed to expose the basilar artery at the origin of the AICA. D, subtemporal 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

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 Temporal Bone S247

Transcochlear approach
The transcochlear approach is primarily an anteromedial
extension of the translabyrinthine approach (Fig. 8.6) (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
lining the internal auditory canal, as described for the trans-
labyrinthine approach, the incus is removed and the facial
nerve is exposed from the geniculate ganglion to the stylo-
mastoid foramen. The greater superficial petrosal nerve is
transected and the facial nerve is transposed posteriorly. In
the final 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. 8.6).
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 ascend-
ing portion 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 medi-
ally into the clivus. Extending the dural opening in this area
permits visualization 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 retrofa-
cial areas extending forward to the carotid canal, thus skele-
tonizing the mastoid segment of the facial nerve and leaving
it suspended 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, retrolaby-
rinthine, and supralabyrinthine compartments. The facial
nerve is identified at its tympanic segment and at the stylo-
mastoid foramen. The inferior part of the tympanic bone is
removed to expose the infralabyrinthine compartment, the
jugular bulb, and the intrapetrous carotid artery. The retrofa-
cial 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 opera-
tive 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 infrat-
entorial craniotomy centered on the mastoid and varying
degrees of mastoid and labyrinthine resection (Fig. 8.14).
The minimal degree of mastoid resection, which we refer to as
a minimal mastoidectomy, exposes only enough of the presig-
moid dura to open the dura in front of the sigmoid sinus for
exposure of the cerebellopontine angle (Figs. 8.15 and 8.16).
The next more extensive degree of mastoid resection, the
retrolabyrinthine modification, is a more complete mastoid-
ectomy exposing the bony capsule of the semicircular canals
and skeletonizing at least a portion of the facial nerve. In the
partial labyrinthectomy, one or two of the semicircular canals,
commonly the superior and/or posterior canals, are resected
with preservation of the lateral canal. Removal of these canals
may, but not always, be associated with the loss of hearing
(37). The posterior 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
modification is the transcochlear approach, in which the co-
chlea located anteromedial to the fundus of the meatus is
removed, thus providing 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 skeletonized in a column of bone and working
both anterior and 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

Š
oculomotor and trochlear nerves. F, minimal mastoidectomy modification of the presigmoid approach. The minimal mastoid-
ectomy approach is completed by removing only enough bone in the front of the sigmoid 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 mastoid-
ectomy as it is in the retrolabyrinthine approach. The exposure shown with the minimal mastoidectomy in this figure is to be
compared with the retrosigmoid exposure shown in B. 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., petrosal; P.I.C.A., posteroinferior
cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; Sig., sigmoid; Sup., superior; Temp., tem-
poral; Tent., tentorial; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.

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 Temporal Bone S249

the same exposure as the retrolabyrinthine approach, but is
done at reduced risk since the semicircular canals and facial
nerve are not skeletonized (Figs. 8.14 and 8.15). 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 in-
creases access to the middle fossa and petrous apex and
reduces the needed retraction of the temporal lobe. The trans-
labyrinthine approach does not significantly increase the ac-
cess 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 modification, in
which bone is removed up to the edge of the clivus, does
significantly 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 mastoid-
ectomy, 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 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
suboccipital area medial to the mastoid process (Figs. 8.14,
8.15, and 8.17). The skin flap is reflected forward to the level
of the external auditory canal. The temporal muscle is ele-
vated and reflected anteriorly, and the muscles over the mas-
toid and suboccipital areas are swept inferiorly. A temporo-
occipital craniotomy is performed and the transverse sinus is
exposed. After the bone flap is elevated, a mastoidectomy is
carried out without entering the labyrinth. The sigmoid sinus
is skeletonized from the sinodural angle to the jugular bulb.
Bone is removed superiorly to expose the floor of the middle
fossa and the superior petrosal sinus. Trautman’s triangle is
exposed in the area lateral to the otic capsule.
The dura mater is then incised along the base of the tem-
poral craniotomy, while preserving the junction of the vein of
Labbé with the transverse sinus. The posterior fossa dura is
opened anterior to the sigmoid sinus in Trautman’s triangle.
The dural incision is extended across the superior petrosal
sinus to join the dural incision in the temporal dura. After
division of the superior petrosal sinus, the tentorium is in-
cised parallel to and just behind the petrous ridge and supe-
rior petrosal sinus. This dural incision is extended from the
site of division of the superior petrosal 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 cranial nerve in its course near the
tentorial margin. The posterior portion of the temporal lobe is
elevated and the sigmoid sinus is displaced posteriorly along
with the cerebellar hemisphere while preserving the junction
of the vein of Labbé with the sigmoid 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 petroclival region
can be exposed from the middle fossa and tentorial incisura to
near the foramen magnum, although access to the lower
petroclival region may be limited by the jugular bulb. The
presigmoid exposure provides a shorter working distance to
the petroclival area and provides multiple angles for dissec-
tion. The major arteries in the posterior fossa are easily acces-
sible. The exposure can also be combined with a far-lateral
approach (Fig. 8.17).
Subtemporal preauricular infratemporal fossa approach
The subtemporal preauricular infratemporal approach is
directed through the infratemporal and middle fossae to the
part of the anterior surface of the petrous bone located medial
to the cochlea and to the petroclival region (Figs. 8.10, 8.13,
and 8.18). This description outlines the full extent of the
anatomic exposure 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 down-
ward in front of the ear into the cervical region. The incision

Š
FIGURE 8.16. G–N. 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 glossopharyngeal nerves, to be com-
pared 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 cap-
sule 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 posterior canal partial labyrinthectomy is similar to that achieved with the minimal mastoidectomy. K, the partial laby-
rinthectomy has been extended by removing the superior canal in addition to removal of the posterior canal. L, the infraten-
torial exposure does not differ significantly from that achieved with the minimal mastoidectomy, as shown in F and G.
Removal of the superior canal reduces the required temporal lobe retraction and aids in the exposure 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 trans-
posed 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 per-
manent facial paralysis and loss of hearing.

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S250 Rhoton
may be extended downward only to the area just below the
tragus if only the petrous apex and upper part of the infra-
temporal 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 reflected forward.
The facial nerve and its major branches are identified distal to
the stylomastoid foramen and followed to the parotid gland.
The parotid gland is separated from the masseteric fascia to
avoid excessive stretching of the facial nerve at the stylomas-
toid foramen (33, 38, 39). The superficial temporalis fascia in
which the upper facial branches course is separated from the
temporalis muscle and is reflected 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 reflected
downward. The mandibular condyle and the capsule of the
temporomandibular joint are either dislocated downward or
excised. The temporomandibular joint can be removed in a
single piece for later replacement by dividing the mandibular
neck below the condyle and osteotomizing the middle fossa
floor around the mandibular fossa (Fig. 8.18). 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.
A frontotemporal craniotomy is then performed. The dura
is elevated from the floor of the middle fossa to expose and
obliterate the middle meningeal artery at the foramen spino-
sum and to expose the arcuate eminence, the third trigeminal
division at the foramen ovale, and the greater petrosal nerve.
The greater petrosal nerve is transected if necessary to avoid
traction on the facial nerve. The floor of the middle fossa, includ-
ing the lateral and inferior aspects of the superior orbital fissure,
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. 8.10, 8.13, and
8.18). 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 fibrocartilaginous ring encircles the artery. If mobiliza-
tion of the artery is required, care must be taken when divid-
ing 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 mobilizing 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 be-
hind 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 Meckel’s cave superiorly, by the cochlea
and internal auditory canal laterally, by the abducens nerve in
its course through the Dorello’s canal medially, and by the
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
hypoglossal canal inferiorly. If the dura is opened, the struc-
tures along the lateral and anterior aspects of the upper me-
dulla 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 inferolat-
eral portion of the cavernous sinus (17, 39). The pterygopal-
atine 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 ap-
proached by removing bone medial to the maxillary nerve at
the root of the pterygoid process.
Postauricular transtemporal approach
The postauricular transtemporal approach is most com-
monly selected for lesions that involve the mastoid and tym-
panic cavities and track along the nerves and arteries to reach
the middle and infratemporal fossa (Figs. 8.19 and 8.20). It can,
however, be tailored at its posterior margin to include a
retrosigmoid, far-lateral, or presigmoid exposure of the pos-
terior fossa or, at its anterior limits, to include exposure of the
pterygopalatine fossa and lateral parts of the maxillary orbit
or anterior cranial fossa.
A question mark incision is started behind the hairline in
the temporal region, extending behind the ear over the mas-
toid process and continuing inferiorly in front of the sterno-
cleidomastoid muscle onto the neck. The skin flap is then
reflected forward and the external auditory canal is divided at
the bone-cartilage junction and closed as a blind sac. The
sternocleidomastoid muscle is detached from the mastoid
process and reflected inferiorly. The periosteum and posterior
portion of the temporalis muscle are reflected anteriorly, thus
exposing the temporal, mastoid, and retromastoid areas. The
posterior belly of the digastric muscle is divided and reflected
inferiorly. At this point, the facial nerve is identified distal to
the stylomastoid foramen and is followed, along with its
major branches, into the substance of the parotid gland (5).
The internal jugular vein, the carotid bifurcation, and the
glossopharyngeal, 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 surrounding connective tissue attached to the
 Temporal Bone S251

FIGURE 8.17. A–D. Combined

presigmoid and far-lateral
approach. A, the insert shows
the site of the scalp incision and
mastoid tip. The scalp flap has
been reflected forward. The
mastoidectomy exposes the
dense cortical bone housing the
semicircular canals. The bone
flap is outlined. The occipital
artery courses backward
between the digastric and
superior oblique. B, enlarged
view. The tympanic segment of
the facial nerve courses below
the lateral canal. The chorda
tympani arises from the mastoid
segment of the facial nerve. The
mastoid 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 outlined. D,
the temporal and presigmoid
dura has been opened. One goal
of the procedure is to preserve
the vein of Labbé, which
empties into the transverse
sinus. 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.,
epitympanic; For., foramen;
Gang., ganglion; Genic.,
geniculate; Hypogl., hypoglossal;
Inf., inferior; Jug., jugular; 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., suboccipital; Sup., superior; Temp.,
temporal; Trans., transverse; Tymp., tympani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.

nerve, and the nerve is transposed anteriorly into the new
bony groove of the epitympanum and imbedded for its pro-
tection 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 mobi-
lization of the lower cranial nerves allows for a direct expo-
sure of the structures 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 difficult, as the lower cranial nerves
are particularly fragile and difficult to isolate from the sur-
rounding tissues.

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S252 Rhoton

FIGURE 8.17. E–H. Combined

presigmoid and far-lateral
approach. E, the dural incision has
been extended through
Trautman’s triangle and across the
superior petrosal sinus and
tentorium, taking care to preserve
the vein of Labbé and the
trochlear nerve. The semicircular
canals have been opened. F,
enlarged view. The posterior canal
faces the posterior fossa lateral to
the internal acoustic meatus. The
superior canal projects upward,
below the arcuate eminence,
toward the floor of the middle
fossa. The lateral canal is a useful
landmark for identifying 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
completed and the dura lining the
meatus opened to expose the
cisternal, meatal, labyrinthine,
tympanic, and mastoid segments
of the facial nerve. The SCA
courses 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.

Exposure of the middle clival structures requires removal of
the bony labyrinth, as described for the translabyrinthine ap-
proach. The internal auditory canal is exposed, the facial nerve
identified, and the cochlear and vestibular nerves divided. The
greater superficial 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 reflected posteriorly.
The bony portion of the external auditory canal and the tym-
panic 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
segment of the petrous carotid artery. Anterior displacement
of the carotid artery and removal of the cochlea provides a
wide exposure 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 ex-
posure may be carried medially into the clivus and retropha-
ryngeal space and anteriorly to expose the mucosa of the
sphenoid sinus.
If the approach is to be extended to the parasellar and
parasphenoidal areas, the zygomatic arch is divided and re-
flected inferiorly with the masseter muscle. The temporalis
muscle is separated from its attachment to the coronoid pro-
cess of the mandible and reflected anteriorly and superiorly.
A temporal 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

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 Temporal Bone S253

FIGURE 8.17. I–L. 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 suboccipi-
tal 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 triangle. 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.

segment after removing the cartilaginous portion of the eu-
stachian tube. The cavernous sinus can be approached and the
intracavernous carotid artery exposed by dividing the man-
dibular 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 exposure. The lateral
orbit and pterygopalatine fossa can be accessed at the anterior
limit of the exposure.
DISCUSSION
Pathologies can arise anywhere within the petroclival re-
gion and frequently are not restricted to a single anatomic
compartment of the cranial base. Involvement of multiple
cranial nerves and arteries occurs because cranial base tumors
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 advantage of these approaches directed through the
temporal bone to the petroclival area is that they reach the
area through tissue planes outside the oropharynx. They pro-
vide another route by which anterior intradural lesions situ-
ated medial to the nerves entering the internal acoustic me-
atus and jugular foramen can be approached without entering
the nasopharynx. 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

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

S254 Rhoton
approaches is frequently used to expose intra- or extradural
clival lesions that also involve the temporal and sphenoid
bones. They also provide 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 pro-
vide 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 co-
chlea, as in the translabyrinthine and transcochlear approach-
es; from above through a subtemporal middle fossa route;
from behind in the retrosigmoid suboccipital approach; or
from multiple directions using such combined supra- and
infratentorial approaches as the presigmoid approach, to
which 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 pre-
auricular 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. 8.15 and 8.16).
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
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
FIGURE 8.17. M and N, combined
presigmoid and far-lateral approach.
M, a suboccipital craniotomy has
been completed, the posterior arch
and posterior ramus of the
transverse process of the atlas
removed, and the dural incision has
been outlined. The posterior
meningeal artery arises before the
vertebral artery penetrates the dura.
The C1 nerve root adheres to the
lower margin of the vertebral
artery. N, the dura has been opened
and the nerves passing toward the
jugular foramen exposed. Bone has
been removed above the atlanto-
occipital joint to expose the
hypoglossal nerve in the hypoglossal
canal. The accessory rootlets cross
the jugular tubercle on their way
to the jugular foramen.
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
origin of the AICA from the basilar artery. The far lateral
modification of the retrosigmoid approach, described in the
chapter on the far lateral approach, was devised to provide a
better 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 Labbé with
the transverse sinus (Figs. 8.14-8.17). The amount of resection
of the petrous bone can vary from a retrolabyrinthine minimal
mastoidectomy exposure to a translabyrinthine or transco-
chlear exposure with posterior displacement 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). Preservation of the drainage of the vein of
Labbé and avoidance of excessive temporal lobe retraction are
major goals of this approach to the upper clival region. Ap-
proaching the structures 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 this 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. A major drawback to this
exposure is provided by the anatomic variants, described
below, that limit the size of the exposure through Trautman’s
triangle and the labyrinth.
 Temporal Bone S255

FIGURE 8.18. Preauricular

subtemporal-infratemporal fossa
approach. A, the scalp incision is posi-
tioned so that a frontotemporal crani-
otomy can be completed. The opera-
tion is often completed with an
incision that extends downward only
to the level of the tragus. However, it
can be extended if a neck dissection is
needed. The scalp flap has been
reflected forward, taking care to pro-
tect 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 zygo-
matic arch were removed in a single
piece, as shown in the insert, and the
middle fossa floor removed. C, expo-
sure after removal of the middle fossa
floor lateral to the foramen ovale and
before resection of the tensor tympani
muscle. The lower orifice 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 reflected forward and the
petrous apex drilled to expose the
posterior fossa dura and the inferior
petrosal sinus coursing along the pet-
roclival fissure. F, the dura facing the
petrous apex has been opened and the
vertebral arteries and AICA exposed.
This exposure is directed through the
petrous apex medial to the cochlea
and jugular foramen and does not risk
loss of facial nerve function or hear-
ing, as do the approaches directed
through the petrous apex that require
facial nerve transposition and resec-
tion 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., great-
er; Inf., inferior; Int., internal; Jug.,
jugular; M., muscle; Max., maxillary;
Men., meningeal; Mid., middle; N.,
nerve; Pet., petrosal, petrous; Post.,
posterior; Temp., temporal; Tens., ten-
sor; TM., temporomandibular; Trig.,
trigeminal; Tymp., tympani; V., vein;
Vert., vertebral; Zygo., zygomatic.

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S256 Rhoton

FIGURE 8.19. A–D. Anatomic basis of

the postauricular 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,
infratemporal, pterygopalatine, and
orbital exposure can be obtained in
front of the ear. B, the scalp flap has
been reflected forward, the external
canal transected, and the parotid gland
and superficial branches of the facial
nerve exposed. C, the
sternocleidomastoid muscle has been
reflected. The neck dissection exposes
the internal jugular vein, C1 transverse
process, and the glossopharyngeal,
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 temporomandibular joint.
The splenius capitis muscle has been
reflected 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. 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.,
infratemporal; Int., internal; Jug.,
jugular; Laby., labyrinthine; Lat., lateral; Lev., levator; M., muscle; 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.,
semicircular; Sig., sigmoid; Sphen., sphenoid; Splen., splenus; Sternocleidomast., sternocleidomastoid; Sup., superior; Superf.,
superficial; Symp., sympathetic; Temp., temporal; Tens., tensor; TM., temporomandibular; Trans., transverse; Tymp., tympani,
tympanic; V., vein; Vel., veli; Vert., vertebral; Vest., vestibular.

The translabyrinthine approach provides access to the facial
nerve from its origin at the brainstem to the stylomastoid
foramen, and exposure of the contents of the internal auditory
meatus (Fig. 8.6) (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 visual-
ized, but exposure of the region inferior to the jugular bulb,
above the trigeminal nerve, and anterior to the internal acous-
tic 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 sigmoid 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 trans-
position of the facial nerve in the transcochlear approach

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement


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 segment of the maxillary artery entering the
pterygopalatine fossa.
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 ex-
tradural resection of the anterior petrous pyramid via a tem-
poral craniotomy (Figs. 8.12 and 8.13). It may be combined
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
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Temporal Bone S257
FIGURE 8.19. E–H. 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 inferotemporal
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 pterygoid 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
infratemporal area after removal of the
mandibular condyle and lateral pterygoid
muscles. The branches of the mandibular
nerve are exposed below the foramen
ovale. The largest branches are the
lingual and superior alveolar nerves,
which are predominantly sensory. The
auriculotemporal 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
reflected or removed to expose the
internal jugular vein exiting the jugular
foramen on the medial side of the
cochlea to the petrous apex and petroclival junction, and from
the petrous ridge posteriorly to the carotid canal anteriorly. A
significant degree of temporal lobe retraction may be re-
quired. This may be reduced by using a frontotemporal cra-
niotomy 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. 8.13). The facial, vestibulocochlear,
trigeminal, and abducens nerves can be identified. The pe-
trous carotid may limit the surgeon’s line of vision and restrict
S258 Rhoton

FIGURE 8.19. I–L. Anatomic basis of the

postauricular transtemporal approach. I, a
mastoidectomy 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 structures 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
trochleiform 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
frontotemporal craniotomy has been
completed and the floor 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 tube’s
opening into the nasopharynx.

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 vestibuloco-
chlear 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 pathol-
ogies 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.
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. 8.12). The extended approaches combine different de-
grees 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. 8.12 and 8.13) (9).
The subtemporal preauricular infratemporal approach
reaches the skull base from an anterolateral direction (Figs.
8.10, 8.13, and 8.18). Division of the zygomatic arch, resection
or displacement of the mandibular condyle, and extensive

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 Temporal Bone S259

FIGURE 8.19. M–R. Anatomic basis of

the postauricular transtemporal approach.
M, a retrosigmoid craniotomy has been
completed and the nerves in the
cerebellopontine angle exposed. The
vestibulocochlear nerve has been
depressed to expose the facial nerve. N,
the facial nerve has been reflected
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
reflected backward to expose the
hypoglossal nerve exiting the hypoglossal
canal. The nerves passing through the
jugular foramen and hypoglossal canal
exit the skull on the medial side of the
internal jugular 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
inferolateral 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 ampullae 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.

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S260 Rhoton

FIGURE 8.19. S–X. Anatomic basis of the postauricular transtemporal approach. S, enlarged view of the medial wall of the tympanic cav-
ity 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 laterally, 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 handle 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 vesti-
bule 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
semicircular canals and the lateral genu of the internal carotid artery in position below the cochlea. The cochlea wraps around the modi-
olus 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.

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement


resection of the lateral part of the middle fossa floor exposes
the infratemporal fossa, the nasopharynx, the para- and ret-
ropharyngeal 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
displacement 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 intra-
dural space ventral to the brainstem (41). The exposure of the
cerebellopontine angle and foramen magnum is limited be-
cause 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 AICA and the ver-
tebrobasilar junction. The approach could be used as an alter-
Neurosurgery, Vol. 47, No. 3, September 2000 Supplement
Temporal Bone S261
FIGURE 8.19. Y and Z, anatomic
basis of the postauricular
transtemporal approach. Y,
overview before opening the dura.
The postauricular approach offers
the potential for providing
retrosigmoid, presigmoid, and far-
lateral exposures and can be used
to access the infratemporal and
pterygopalatine fossae, the orbit,
and the subtemporal areas. In this
case, the exposure extends from the
retrosigmoid area forward to the
orbit. The maxillary sinus has been
opened below the orbital floor. Z,
overview of exposure after opening
the dura.
native lateral route to vascular lesions
of the midbasilar artery or at the ver-
tebrobasilar junction, when these le-
sions cannot be exposed through ei-
ther the retromastoid or subtemporal
transtentorial approaches.
The postauricular transtemporal ap-
proach, which combines a transco-
chlear exposure with an infratemporal
approach, may be used as an alterna-
tive to the preauricular infratemporal
approach when the pathology involves
the mastoid and the infratemporal
fossa and extends to the facial recess,
hypotympanic area, and jugular bulb
(5, 6, 34) (Figs. 8.19 and 8.20). The struc-
tures 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 fora-
men. 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 lateral and anterior surfaces of the lower pons,
medulla, and cervicomedullary junction are well exposed. The ex-
tent of exposure of the major arteries is dependent on the different
anatomic variants and direction of displacement of the vessels.
Exposure of the structures of the middle clivus requires posterior
facial nerve displacement and drilling of the labyrinth with conse-
quent destruction of any residual hearing. 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 petro-
clival space requires that the transtemporal exposure be combined
with a subtemporal exposure. The transtemporal approach can
S262 Rhoton

FIGURE 8.20. A–F. 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 mus-
cle reflected to expose the maxillary artery and pterygoid muscles in the infratemporal fossa. E, enlarged view of the temporal and infra-
temporal 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 semi-
circular canal is located above the tympanic segment of the facial nerve. The promontory overlies the basal cochlear turn. A., artery; Ac.,
acoustic; Aur., auricular; Bas., basilar; Car., carotid; Chor., chorda; CN, cranial nerve; Cond., condyle; Ext., external; Gl., gland; Gr., great-
er; 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.,
sternocleidomastoid; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani, tympanic; V., vein; Vert., vertebral.

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

 Temporal Bone S263

FIGURE 8.20. G–L. 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 foramen ovale. A more extensive
exposure of the petrous carotid has been completed 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 inferior 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 segment 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 Labbé.

Neurosurgery, Vol. 47, No. 3, September 2000 Supplement

S264 Rhoton
easily be extended to the infratemporal fossa, and the same expo-
sure 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 petroclival region
(Figs. 8.19 and 8.20). 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 pterygopala-
tine 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. 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 whenever possible.
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neuro-
logical Surgery, University of Florida Brain Institute, P.O. Box 100265,
100 South Newell Drive, Building 59, L2-100, Gainesville, FL
32610-0265.
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Anatomy of the human ear, a drawing by Max Brödel using Wolff’s carbon pencil and dust on Ross stippleboard.
Courtesy, W.B. Saunders Co. (Also see pages S210 and S266.)

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