Anatomy and Surgical Appraches of The Temporal Bone PDF

INTRODUCTION
ANATOMY AND SURGICAL APPROACHES OF THE

TEMPORAL BONE AND ADJACENT AREAS
Neurosurgery 61:S4-1, 2007 DOI: 10.1227/01.NEU.0000280027.92382.2B www.neurosurgery-online.com
T
he temporal bone is the most complicated osseous struc- of the right eye and the red lens in front of the left eye. Some of
ture in the human body. Five parts participate in its for- the cardboard glasses can be bent so the red and blue are
mation. The facial and carotid canals in the temporal bone reversed with a resulting loss of 3D viewing.
are the longest canals of passage of any cranial nerve or artery This volume is dedicated to the fellows who have labored in
through the cranium. This complexity is further increased by our microsurgery laboratory beginning more than 40 years ago.
the genus, and bends in the facial nerve and carotid artery Each fellow has been challenged to improve and build upon
within the temporal bone. The presence of the delicate cochlear the efforts of the previous fellow. Several dozen fellows, begin-
and vestibular membranes within the temporal bone makes it ning with Shigeaki Kobayashi in 1966, have made contribu-
the only bone that houses the end organs of a cranial nerve. It tions to our knowledge of the temporal bone and surrounding
also houses the complicated mechanism for transmitting areas. Special thanks go to Robin Barry, who has worked with
sounds from the outward world to the inner ear. The fact that us for more than two decades and who aligned all the pictures
the temporal bone faces the middle and posterior cranial fossa for 3D images, and to Laura Dickinson, who has labored over
and also has lateral and lower surfaces yields the potential for this manuscript.
multiple complex surgical routes to the temporal bone, and Capturing 3D images of the quality presented here requires
through it to deeper areas. It is the focus of more surgical routes careful preparation of the specimen and meticulous dissection,
and approaches than any other bone in the cranium. The deli- followed by the even greater challenge of obtaining satisfactory
cate neural, vascular, and transmission systems within the bone 3D images. Obtaining excellent specimens, completing meticu-
add to the complexity of these surgical approaches and provide lous specimen preparation, and combining that with surgically
a special challenge in dealing with lesions in the area. This precise dissections, and outstanding two- and 3D photography
work, done with many of our research fellows, represents is a rare achievement. We hope this work will enhance the
knowledge gained from nearly five decades of the study of reader’s understanding of this complex area and that it will
microsurgical anatomy. We hope that the illustrations in three result in accurate, gentle, and safe operative procedures for
dimensions will aid all who deal with this complicated and patients requiring surgery in this delicate area.
delicate anatomy. This work is dedicated to the microsurgery fellows at the
Our previous article (Chapter 1) on the temporal bone was University of Florida who, for more than 40 years, have taught
included as a starting point because it provides an up-to-date me so much about microsurgical anatomy and the temporal bone.
two-dimensional description of the anatomy and approaches Hiroshi Abe, Japan
to the temporal bone (1). Additional information on the sur- Hajime Arai, Japan
rounding area will be found in the volume Cranial Anatomy and Allen S. Boyd, Jr., Tennessee
Operative Approaches published by NEUROSURGERY (2). The Robert Buza, Oregon
three-dimensional (3D) part begins with a review of the osseous Alvaro Campero, Argentina
relationships and proceeds through the anatomy and surgical Alberto C. Cardoso, Brazil
approaches directed to and through the temporal bone from Christopher C. Carver, California
the middle and posterior fossa and laterally through the mas- Patrick Chaynes, France
toid. This is followed by sections related to the exposures Chanyoung Choi, Korea
directed along the margins of the temporal bone, which include Evandro de Oliveira, Brazil
the far lateral and transcondylar approaches and the approaches Hatem El Khouly, Egypt
to the jugular foramen and fourth ventricle. Each of the latter W. Frank Emmons, Washington
sections is preceded by a short description of the approach. J. Paul Ferguson, Georgia
The pages with the 3D illustrations are to be viewed with the Juan C. Fernandez-Miranda, Spain
colored glasses. On the lower right, below the large 3D illustra- Andrew D. Fine, Florida
tion, is a two-dimensional illustration with labels guiding the Brandon Fradd, Florida
viewer to the important structures in the area. Each illustration Kiyotaka Fujii, Japan
is followed by a short legend. The 3D illustrations are to be Yutaka Fukushima, Japan
viewed with the blue lens of the colored glasses placed in front Adriano Garcia-Scaff, Brazil
NEUROSURGERY VOLUME 61 | NUMBER 4 | OCTOBER 2007 SUPPLEMENT 4 | S4-1

RHOTON
Hirohiko Gibo, Japan Shigeyuki Osawa, Japan

John L. Grant, Virginia T. Glenn Pait, Arkansas
Kristinn Gudmundsson, Iceland Wayne S. Paullus, Texas
David G. Hardy, England David Perlmutter, Florida
Frank S. Harris, Texas Mark Renfro, Texas
Tsutomu Hitotsumatsu, Japan Wade H. Renn, Georgia
Takuya Inoue, Japan Saran S. Rosner, New York
Tooru Inoue, Japan Pablo Rubino, Argentina
Yukinari Kakizawa, Japan Naokatsu Saeki, Japan
Toshiro Katsuta, Japan Shuji Sakata, Japan
Masatou Kawashima, Japan Eduardo R. Seoane, Argentina
Chang Jin Kim, South Korea Xiang-en Shi, China
Robert S. Knego, Florida Satoru Shimizu, Japan
Shigeaki Kobayashi, Japan Ryusui Tanaka, Japan
Chae Heuck Lee, South Korea Necmettin Tanriover, Turkey
Xiao-Yong Li, China Helder Tedeschi, Brazil
William Lineaweaver, California Erdener Timurkaynak, Turkey
J. Richard Lister, Florida Xiaoguang Tong, China
Qing Liang Liu, China Satoshi Tsutsumi, Japan
Jack E. Maniscalco, Florida Jay Ulm, Florida
Richard G. Martin, Alabama Hung T. Wen, Brazil
Carolina Martins, Brazil C.J. Whang, South Korea
Haruo Matsuno, Japan Isao Yamamoto, Japan
Toshio Matsushima, Japan Alexandre Yasuda, Brazil
J. Robert Mozingo, deceased
Nobutaka Yoshioka, Japan
Hiroshi Muratani, Japan
Arnold A. Zeal, Florida
Antonio C.M. Mussi, Brazil
Shinji Nagata, Japan
1. Rhoton AL Jr: The temporal bone and transtemporal approaches.
Yoshihiro Natori, Japan Neurosurgery 47 [Suppl 3]:S211–S265, 2000.
Kazunari Oka, Japan 2. Rhoton AL Jr: Cranial Anatomy and Surgical Approaches. Baltimore,
Michio Ono, Japan Lippincott Williams & Wilkins, 2003.
From Pernkopf E, Ferner H: Atlas of Topographical and Applied Human Anatomy. Philadelphia, W.B. Saunders Company, 1963.
COMMENTS
O nly a broad collection of superlatives can begin to describe

my impression of this “meisterwerk” from Professor
Rhoton. As is the case with the majority of Rhoton’s works, this
telovelar approach to the fourth ventricle. As in all of Professor
Rhoton’s work, the illustrations beautifully demonstrate this
anatomy. The far lateral and transcondylar approaches are illus-
exhibition of the temporal bone and its relationships to the sur- trated in Chapter 11. This anatomy is less frequently encoun-
rounding neuroanatomy must be viewed as required study by tered by the cranial base surgeon, and readers will find it partic-
those aspiring to master the region’s complex construction. ularly helpful. The same may be said for Chapter 12, which
For many of our colleagues, the temporal bone has essen- illustrates the complex anatomy of the jugular foramen. The
tially been the purview of our otological colleagues. Owing to relationships of the lower cranial nerves are particularly well
its intricate construction, a higher level of dedication to its sur- demonstrated.
gery and pathology has been mandated. Despite the proficiency Production of Professor Rhoton’s marvelous dissections in 3D
of our otological partners in lateral cranial base surgery, it is literally and figuratively adds a whole new dimension to the
equally important for the neurosurgeon to share this anatomical value of this wonderful work. 3D illustrations add significantly to
expertise. Such mastery on the part of the neurosurgeon is understanding the complex anatomy of this region. The surgical
essential in helping our colleagues help us by providing optimal approaches in particular are much better understood in the 3D
exposure from our perspective as the surgeon largely responsi- format. We should all be grateful to Professor Rhoton for his ded-
ble for dissection in and around critical brain and cranial nerve ication in producing these outstanding teaching tools. Everyone
structures, as well as the cerebral vasculature. Presentation of should utilize these materials not only in learning these
this material in three-dimensional (3D) format is an important approaches but for periodic review of this complex anatomy.
adjunct to our educational corpus as it brings everyone the
Derald E. Brackmann
opportunity to see the material in a fashion available to only
Neuro-otologist
those otherwise granted personal access to these phenomenal
Los Angeles, California
anatomical preparations. I can personally attest to the difficulty
of reproducing such exquisite preparations. No other laboratory
has produced relevant dissections in such painstaking, exquisite
detail. This work represents a true legacy in the continuum of
D r. Rhoton´s description of the microanatomy and operative
approaches to the temporal bone and adjacent areas is a very
worthwhile contribution to neurosurgery, particularly for the
neurosurgical education. Neurosurgeons young and mature education of those interested in cranial base approaches. The
owe Dr. Rhoton a debt of gratitude for his contributions to our presentation of these complex anatomical structures in such a 3D
most relevant science as surgeons, surgical neuroanatomy. mode helps to provide an overview of all relevant structures
within the chosen surgical corridor.
J. Diaz Day
This work is unique in the history of neurosurgery. It greatly
Burlington, Massachusetts
facilitates the detailed understanding of the microanatomy of
T his supplement continues Professor Rhoton’s wonderful

instruction of the anatomy of the head and neck. This work is
devoted to the temporal bone and adjacent areas. In addition to
the temporal bone and its surrounding structures. A variety of
very important cranial nerves and vessels runs through this rel-
atively small area. Both the normal anatomy and its variations
anatomical dissections, the supplement contains details of surgi- are presented in detail. The reader has to consider these anatom-
cal approaches. Production in 3D adds tremendously to its value. ical variations that can create complications during surgery (e.g.,
The 3D portion of the supplement is divided into 12 sections. as discussed in the supplement, 15% of the greater petrosal
The osseous relationships are described first. Following this, nerves are located directly under the dura in the middle cranial
attention is directed to the middle cranial fossa anatomy, dis- fossa). Thus, a facial palsy may occur in the case of elevation or
cussing relationships of the temporal bone as viewed from above. transection of the dura.
The next chapter details the surgical anatomy of the middle cra- For younger and less experienced neurosurgeons, this
nial fossa approach. Chapter 4 is strictly an anatomic dissection extraordinary anatomical demonstration is highly valuable for
of the temporal bone from an anterior view. This greatly helps learning the functional importance of these structures and the
one to appreciate the relationships of the various structures from spatial relationships between them. Intraoperative neurovascu-
an approach not normally seen. Next, the temporal bone is dis- lar injury can lead to significant surgical morbidity. The opera-
sected laterally; again demonstrating the intricate anatomy of tive approaches should be selected so that only minimal expo-
this structure. Chapter 6 illustrates the relationships of the soft tis- sure of important structures is required. In my 40 years of
sue of the neck and face to the temporal bone. These structures experience with cranial base surgery during which I operated
are frequently encountered in lateral cranial base surgery. on more than 8000 cases, I gradually developed my neurosurgi-
The following six chapters discuss surgical approaches. cal strategy. In the beginning, we thought we needed to expose
Chapter 7 details the retrolabyrinthine and transcochlear all cranial nerves and vessels around the lesion in order to
approaches. Stepwise dissections detail these approaches. The achieve complete removal of large tumors and to preserve the
presigmoid approach is illustrated in Chapter 8 and the ret- anatomical structures. The increased experience and knowledge
rosigmoid approach in Chapter 9. The detailed anatomic rela- of microsurgical anatomy have highlighted two important
tionships of structures in the cerebellopontine angle and poste- aspects. First, the pathological lesion displaces the structures in
rior fossa are beautifully demonstrated. Chapter 10 details the different directions. Therefore, the normal anatomy does not

COMMENTS
always completely correspond to the pathological anatomy. The only be accomplished with a profound knowledge of the
knowledge of the spatial orientation and relations of space- microanatomy, as well as of all possible approaches to this area.
occupying lesions helps the precise planning of surgeries. The Dr. Rhoton´s study of the temporal bone anatomy contains 13
second aspect is that tumor removal does not necessitate a large chapters, beginning with the description of the osseous relation-
approach and exposure of all surrounding structures. The art ships, and includes chapters on the anatomical view of the cranial
and quality of neurosurgery relate to the ability to select the base. It is valuable for its presentation of the structures viewed
simplest trajectory to the lesion that does not involve or compro- through the most frequently utilized surgical approaches, includ-
mise structures with functional importance. Another very ing the retrosigmoid, the telovelar, the far lateral, and the differ-
important and still underestimated point is the avoidance of ent petrosal approaches. The excellent 3D views of the structures
venous occlusion, which could cause excessive brain edema or allow the reader the possibility to appreciate the depth and spa-
intracerebral hematomas in certain cases. Furthermore, the vari- tial relationships, making this a great educational contribution.
ability in venous anatomy among different individuals is aston- Finally, I would like to personally thank Dr. Rhoton for his com-
ishing. The beautiful and precise description of the various mitment and effort and to congratulate him for this outstanding
venous drainage patterns performed by Dr. Rhoton will defi- achievement in modern neurosurgery.
nitely help to focus attention on this topic.
The philosophy of simple non-risky approaches to the pathol- Madjid Samii
ogy in the temporal bone, middle and/or posterior fossae can Hannover, Germany
From Pernkopf E, Ferner H: Atlas of Topographical and Applied Human Anatomy. Philadelphia, W.B. Saunders Company, 1963.
S4-4 | VOLUME 61 | NUMBER 4 | OCTOBER 2007 SUPPLEMENT 4 www.neurosurgery-online.com

PART 1
OVERVIEW OF THE
TEMPORAL BONE IN
TWO DIMENSIONS
CHAPTER 1
OVERVIEW OF TEMPORAL BONE

Albert L. Rhoton, Jr., M.D. KEY WORDS: Cranial base, Cranial nerves, Facial nerve, Internal carotid artery, Microsurgical anatomy, Skull
Department of Neurosurgery, base, Skull base neoplasm, Surgical approach, Temporal bone
University of Florida,
Gainesville, Florida Neurosurgery 61:S4-7–S4-60, 2007 DOI: 10.1227/01.NEU.0000280024.07630.65 www.neurosurgery-online.com
Reprint requests:
Albert L. Rhoton, Jr., M.D.,
University of Florida,
Osseous Relationships with exposure of the infratemporal fossa and,
if needed, the petrous carotid, petrous apex,
T
Department of Neurological Surgery, he temporal bone is divided into squa-
McKnight Brain Institute,
mosal, petrous, mastoid, tympanic, and pterygopalatine fossae, and orbit.
P.O. Box 100265, The approaches directed through the mas-
Gainesville, FL 32610–0265. styloid parts (Figs. 1-1 and 1-2). The
Email: [email protected] squamosal part helps enclose the brain. The toid in front of the sigmoid sinus vary in the
mastoid part is trabeculated and pneumatized amount of temporal bone resected. They
to a variable degree and contains the mastoid include 1) the minimal mastoidectomy vari-
antrum. The petrous part is compact and ant in which only enough presigmoid dura is
encloses the cochlea, the vestibule, and the exposed to open the dura in front of the sig-
semicircular, facial, and carotid canals (Fig. moid without exposing the labyrinth; 2) the
1-3). The tympanic part forms part of the wall retrolabyrinthine approach, which exposes the
of the tympanic cavity and the external bony capsule of the labyrinth; 3) the partial
acoustic meatus. The styloid projects down- labyrinthectomy, which includes removal of
ward and serves as the site of attachment of one or more of the semicircular canals; 4) the
several muscles. This section examines these translabyrinthine approach, which includes
parts in greater detail and defines the ana- resection of the semicircular canals and
tomic basis of the approaches directed vestibule; and 5) the transcochlear modifica-
through the temporal bone to the posterior tion, which includes removal of all the
fossa and petroclival region. The approaches labyrinth, including the cochlear and possibly
examined are the middle fossa, translab- the petrous apex. These variants of the trans-
yrinthine, transcochlear, combined supra- and mastoid approaches can all be combined, as
infratentorial presigmoid, subtemporal ante- needed, with the supra- and infratentorial pre-
rior transpetrosal, subtemporal preauricular sigmoid approaches to the middle and poste-
infratemporal, and the postauricular trans- rior fossa.
temporal approaches.
The final approach to be reviewed is the
The approaches directed through the sur-
postauricular transtemporal approach, which
face of the temporal bone forming the middle
allows lesions involving the mastoid, tym-
fossa floor include 1) the very limited middle
panic cavity, petrous apex, and jugular fora-
fossa exposure of the internal acoustic mea-
men to be followed backward to the areas
tus; 2) the anterior petrosectomy approach
directed medial to the internal acoustic mea- exposed by the retrosigmoid and far-lateral
tus through the petrous apex to access the approaches and forward to the infratemporal,
upper anterior part of the posterior fossa and pterygopalatine and middle fossae, lateral
clivus; 3) the extended middle fossa ap- maxilla, and orbit. Selecting an approach
proach, which may include not only resection directed through the temporal bone requires
of the roof of the internal acoustic meatus and an understanding of its complex anatomy and
petrous apex, but is extended lateral to the its relationship to the petroclival region, the
internal acoustic meatus to include resection, infratemporal fossa, and parapharyngeal
as needed, of the semicircular canals, vesti- space. Protecting and preserving the facial
bule, roof of the mastoid antrum and tym- nerve, the petrous carotid artery, and the sen-
panic cavity, and the posterior face of the sory organs of the inner ear that are contained
temporal bone; and 4) the subtemporal pre- within the temporal bone are important ele-
auricular infratemporal fossa approach in ments in operative approaches directed
which the middle fossa exposure is combined through the lateral aspect of the cranial base.

RHOTON
FIGURE 1-1. Temporal bone. A and B, infe-

rior views. A, the temporal bone has a
squamosal part, which forms some of the 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 tym-
panic part forms the anterior, lower, and part
of the posterior wall of the external canal, part
of the wall of the tympanic cavity, the osseous
portion of the eustachian tube, and the poste-
rior wall of the mandibular fossa. The mastoid
portion contains the mastoid air cells and
mastoid antrum. The petrous part is the site
of the auditory and vestibular labyrinth, the
carotid canal, the internal acoustic meatus,
and the facial canal. The petrous part also
forms the anterior wall and the dome of the
jugular fossa. The styloid part projects down-
ward and serves as the site of attachment of
three muscles. B, inferior view of the temporal
and surrounding bones. The squamosal and
petrous parts articulate anteriorly with the
greater wing of the sphenoid. The petrous
apex faces the foramen lacerum and is sepa-
rated from the clival part of the occipital bone
by the petroclival 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 ante-
rior and posterior roots of the zygomatic
process. C and D, superior views. C, the
medial part of the upper surface is the site of
the trigeminal impression in which Meckel’s
cave sits. Farther laterally is the prominence
of the arcuate eminence overlying the superior
semicircular canal. Anterolateral to the arcu-
ate eminences is the tegmen, a thin plate of
bone overlying the mastoid antrum and epi-
tympanic area. The temporal bone articulates
anteriorly with the sphenoid bone, above with
the parietal bone, and posteriorly with the
occipital bone. The zygomatic process of the
squamosal part has an anterior and a poste-
rior root between which, on the lower surface,
is located the mandibular canal. D, temporal
and surrounding bones. The squamosal part
of the temporal bone joins anteriorly with the
sphenoid bone to form the 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 por- Arc., arcuate; Car., carotid; Cond., condyle; Digast., digastric; Emin., emi-
tion of the occipital bone at the petroclival fissure. The sigmoid sulcus descends nence; For., foramen; Gr., greater; Impress., impression; Int., internal; Jug.,
along the posterior surface of the mastoid portion and turns forward to enter the jugular; Mandib., mandibular; N., nerve; Occip., occipital; Pet., petrosal;
jugular foramen. The foramen lacerum is located at the junction of the tempo- Post., posterior; Proc., process; Sig., sigmoid; Stylomast., stylomastoid; Trig.,
ral, sphenoid, and occipital bones. The porus of the internal acoustic meatus is trigeminal; Tymp., tympanic.
located in the central part of the posterior surface. Ac., acoustic; Ant., anterior;

FIGURE 1-2. Temporal bone. A, posterior view of a right temporal bone. The where the cochlear and inferior vestibular areas are located. The vertical crest
squamosal part forms part of the floor and lateral wall of the middle fossa. The separates the facial and superior vestibular areas. C, enlarged view of another
sigmoid sulcus descends along the posterior surface of the mastoid portion. The internal acoustic meatus. The transverse crest divides the meatal fundus into
internal acoustic meatus enters the central portion of the petrous part of the superior and inferior parts. The anterior part above the transverse crest is the
bone. The trigeminal impression and arcuate eminence are located on the upper site of the facial canal and the posterior part is the site of the superior vestibu-
surface of the petrous part. The vestibular aqueduct connects the vestibule in lar area. Below the transverse crest, the cochlear area is anterior and the infe-
the petrous part with the endolymphatic sac, which sits on the posterior petrous rior vestibular area is posterior. D, another internal acoustic meatus. The view
surface inferolateral to the internal acoustic meatus. B, enlarged view. The is directed to expose the singular foramen, for the singular branch of the inferior
transverse crest separates the meatal fundus into a superior part where the vestibular nerve that innervates the posterior ampullae. The inferior vestibular
facial canal and superior vestibular areas are situated, and an inferior part nerve also has a saccular and, occasionally, a utricular branch. (Continues)
THE TEMPORAL BONE AND point of the parietomastoid and squamous sutures is located a
few millimeters below the lateral end of the petrous ridge. The
TRANSTEMPORAL APPROACHES superior edge of the junction of the sigmoid and transverse
sinuses is located at the junction of the squamous and pari-
Lateral Surface etomastoid suture.
When the skull and temporal bone are viewed from a lateral The mastoid antrum, a pneumatized space opening into the
perspective, some landmarks useful in performing approaches tympanic cavity, is located about 1.5 cm deep to the suprameatal
directed around and through the temporal bone can be identi- triangle, a depression in the mastoid surface located between
fied (Fig. 1-2). The posterior end of the superior temporal line the posterosuperior edge of the external meatus, the supramas-
continues inferiorly as the supramastoid crest and blends into toid crest, and the vertical tangent along the posterior edge of
the upper edge of the zygomatic arch. The supramastoid crest the meatus. The suprameatal spine of Henle is located at the
is located at the level of the floor of the middle fossa. The junc- outer end of the posterosuperior edge of the external canal
tion of the supramastoid crest with the squamous suture is along the anterior edge of the suprameatal triangle and corre-
located at the lateral end of the petrous ridge. The meeting sponds to the level of the lateral semicircular canal and tym-

RHOTON
FIGURE 1-2. (Continued) E, lateral view of the temporal bone. The squamosal Henley and the anterior part of the supramastoid crest. The asterion, the junc-
part forms part of the lateral wall of the middle fossa, the posterior part of the tion of the lambdoid, parietomastoid, and occipital mastoid sutures, is usually
zygomatic arch, and the upper part of the mandibular fossa. The tympanic located over the lower half of the junction of the sigmoid and transverse sinuses.
part forms the posterior wall of the mandibular fossa and almost all of the wall The midpoint of the parietal mastoid suture is usually located at the anterior
of the external canal. The styloid process is ensheathed at its base by the tym- margin of the junction of the transverse and sigmoid sinuses, and the lateral
panic part and projects downward, serving as the attachment of several mus- edge of the petrous ridge is located at the junction of the squamosal suture and
cles. The mastoid part is located posteriorly and contains the mastoid air cells the supramastoid crest. H, the supra- and infratentorial areas have been exposed
that coalesce at the mastoid antrum. F, enlarged view of the external auditory while preserving the bone at the site of the sutures. The asterion, located at the
canal. The spine of Henley, an excellent landmark for locating the deep site of junction of the lambdoid, occipitomastoid, and parietomastoid sutures, overlies
the lateral canal and tympanic segment of the facial nerve, is located along the the lower half of the junction of the transverse and sigmoid sinuses. The junc-
posterosuperior margin of the external canal. The mastoid antrum is located tion of the supramastoid crest and the squamosal suture is located at the pos-
deep to the depressed area, called the suprameatal triangle, located behind the terior edge of the middle fossa and slightly anterior and above the junction of
spine of Henley. The view into the canal exposes the tympanic cavity, which has the transverse and sigmoid sinuses. Ac., acoustic; Arc., arcuate; CN, cranial
the promontory overlying the basal turn of the cochlea and the oval and round nerve; Coch., cochlear; Emin., eminence; Ext., external; For., foramen;
windows in its medial wall. G, lateral surface of the temporal bone in the Impress., impression; Inf., inferior; Int., internal; Mandib., mandibular;
intact skull. The tympanic part forms the anterior and lower and part of the Occipitomast., occipitomastoid; Parietomast., parietomastoid; Proc., process;
posterior wall of the external canal. The mandibular fossa is formed above and Sig., sigmoid; Sp., spine; Sup., superior; Supramast., supramastoid; Trans.,
anteriorly by the squamosal part and behind by the tympanic part. The mastoid transverse; Trig., trigeminal; Vert., vertebral; Vest., vestibular.
antrum is located posterosuperior to the spine of Henley, between the spine of
panic segment of the facial nerve at a depth of approximately the transverse and sigmoid sinuses. A burr-hole placed at this
1.5 cm. Several landmarks are also helpful in identifying the site will usually expose the lower edge of this junction. A burr-
location of the junction of the transverse and sigmoid sinuses at hole located at the junction of the supramastoid crest and the
the posterior aspect of the mastoid. The asterion located at the squamosal suture will be located at the posterior part of the
junction of the lambdoid, occipitomastoid, and parietomastoid middle fossa floor just above and anterior to the upper edge of
sutures is usually located over the junction of the lower part of the junction of the transverse and sigmoid sinuses.

FIGURE 1-3. A–D, posterior surface of the temporal bone. A, the internal vagus, and accessory nerves enter the jugular foramen. The posterior and
meatus is located near the center and the jugular foramen at the lower edge superior semicircular canals have been exposed. C, enlarged view. The upper
of the posterior surface. The sigmoid sinus descends along the posterior sur- end of the posterior canal and the posterior end of the superior canal share the
face of the mastoid and turns forward on the occipital bone to pass through common crus. The endolymphatic duct extends downward from the vestibule
the sigmoid part of the jugular foramen. The inferior petrosal sinus descends and opens into the endolymphatic sac located beneath the dura inferolateral
along the petroclival fissure and passes through the petrosal part of the jugu- to the meatus. The endolymphatic ridge, the bridge of bone forming the pos-
lar foramen. The subarcuate fossa is located superolateral and the ostium for terior lip of the vestibular aqueduct, has been preserved. The jugular bulb can
the vestibular aqueduct lateral to the internal acoustic meatus. The trigemi- be seen through the thin bone below the internal meatus. D, enlarged view of
nal impression is a shallow trough on the upper surface of the temporal bone the fundus of the meatus after removal of the posterior wall. The upper edge
behind the foramen ovale. The arcuate eminence overlies the superior semicir- of the porus has been preserved. The subarcuate artery enters the subarcuate
cular canals. B, temporal bone with the nerves preserved. The abducens nerve fossa. The inferior vestibular nerve gives rise to the singular branch to the
ascends to enter Dorello’s canal. The trigeminal nerve passes above the posterior ampullae, plus utricular and saccular branches. The superior
petrous apex to enter the porus of Meckel’s cave. The facial and vestibulo- vestibular nerve innervates the ampullae of the superior and lateral semicir-
cochlear nerves enter the internal acoustic meatus, and the glossopharyngeal, cular canals and commonly gives rise to a utricular branch. (Continues)
The Tympanic Part nal canal. The anterior surface, which is concave, forms the
The tympanic part of the temporal bone is a curved plate posterior wall of the mandibular fossa. Its lateral border forms
anterior to the mastoid process (Figs. 1-1, 1-2, and 1-4). It forms most of the margin of the external acoustic meatus. Medially, it
part of the wall of the external acoustic meatus, tympanic cav- joins the petrous part at the petrotympanic fissure through
ity, and osseous part of the Eustachian tube. Its concave poste- which the chorda tympani passes. The carotid canal and the
rior surface forms the anterior wall, floor, and part of the pos- jugular foramen are located medial to the tympanic part.
terior wall of the external acoustic meatus. The roof and upper The styloid process, a slender spicule ensheathed by the infe-
posterior wall are formed by the squamosal part. Its surface rior border of the tympanic bone, projects into the infratempo-
contains a portion of the tympanic sulcus for attachment of the ral fossa and is the site of attachment for the styloglossus, sty-
tympanic membrane, which closes the medial end of the exter- lopharyngeus, and stylohyoid muscles (Fig. 1-5). It is located

RHOTON
FIGURE 1-3. (Continued) E–H, posterior surface of the temporal bone. E, the The stapes has been removed from the oval window. The promontory in the
petrous apex medial to the internal acoustic meatus has been removed to expose medial wall of the tympanic cavity is located lateral to the basal turn of the
the petrous carotid. The lateral genu of the petrous carotid, located at the junc- cochlea. A silver fiber has been introduced into the superior canal, a red fiber
tion of the vertical and horizontal segments of the petrous carotid, is situated into the lateral canal, and a blue fiber into the posterior canal. The ampullated
below and medial to the cochlea. The jugular bulb extends upward toward the ends are located at the bulbous ends of the three fibers. The common crus of the
vestibule and semicircular canals adjacent to the posterior meatal wall. The infe- superior and posterior canals is located at the site where the tips of the blue and
rior petrosal sinus courses along the petroclival fissure and enters the petrosal silver fibers overlap. The superior vestibular nerve passes to the ampullae of the
part of the jugular foramen, and the sigmoid sinus descends in the sigmoid superior and lateral canals. The singular branch of the inferior vestibular nerve
groove and enters the sigmoid part of the foramen. The glossopharyngeal, innervates the posterior ampullae. A small black fiber has been introduced into
vagus, and accessory nerves pass through the central or intrajugular part of the the opening of the endolymphatic duct into the vestibule. A., artery; Ac.,
foramen between the sigmoid and petrosal parts. F, bone has been removed acoustic; Arc., arcuate; Car., carotid; CN, cranial nerve; Coch., cochlear;
along the anterior margin of the meatal fundus to open the cochlea, and along Emin., eminence; Endolymph., endolymphatic; Fiss., fissure; For., foramen;
the posterior margin to expose the vestibule. The jugular bulb extends upward Hypogl., hypoglossal; Impress., impression; Inf., inferior; Int., internal;
toward the semicircular canals and vestibule. G, enlarged view. The cochlear Intermed., intermedius; Jug., jugular; Lat., lateral; N., nerve; Nerv., nervus;
nerve penetrates the modiolus of the cochlea where its fibers are distributed to Pet., petrosal, petrous; Petrocliv., petroclival; Post., posterior; Semicirc., semi-
the turns of the cochlear duct. The basal turn of the cochlea communicates below circular; Sig., sigmoid; Subarc., subarcuate; Sup., superior; Trig., trigeminal;
the modiolus with the vestibule. H, enlarged view of the vestibule and cochlea. Vest., vestibular.
immediately anterior to the emergence of the facial nerve from cles downward exposes the internal jugular vein as it exits the
the stylomastoid foramen and is covered laterally by the jugular foramen and the carotid artery as it enters the carotid
parotid gland. The stylomastoid foramen, the external end of canal medial to the tympanic bone.
the facial canal, opens between the styloid and mastoid
processes. The facial nerve crosses the lateral surface of the sty- The Squamous Part
loid process, and the external carotid artery crosses the tip. The externally convex surface of the squamosal part gives
Resecting the styloid process and reflecting the attached mus- attachment to the temporalis muscle (Figs. 1-1, 1-2, and 1-5).

FIGURE 1-4. Tympanic cavity and mastoid antrum. A, the tympanic bone removed while preserving the malleus and chorda tympani. The mastoid seg-
forms the anterior, lower, and part of the posterior wall of the external canal. ment of the facial nerve descends through the facial canal and gives rise to the
The facial nerve exits the skull through the stylomastoid foramen, which is chorda tympani, which passes upward and forward across the tympanic mem-
located medial to the tympanomastoid suture. The spine of Henley approximates brane and malleus neck. D, enlarged view. The head of the incus articulates
the deep site of the tympanic facial segment and the lateral canal. The mastoid with the head of the malleus, the short process of the incus points backward
antrum is located between the posterosuperior wall of the external canal and toward the facial nerve, and the long process attaches to the stapes, which sits
middle fossa floor deep to the depression behind the spine of Henle. B, a mas- in the oval window. The stapedial muscle passes forward below the tympanic
toidectomy has been completed to expose the capsule of the posterior and lateral segment of the facial nerve and attaches to the neck of the stapes. E, the incus
canals and the tympanic and mastoid facial segments. C, the posterior and has been removed to expose the stapes sitting in the oval window. The chorda
superior wall of the external canal and the tympanic membrane have been tympani crosses the neck of the malleus. The promontory is located (Continues)

RHOTON
FIGURE 1-4. (Continued) superficial to the basal turn of the cochlea. The of the tensor tympani attaches to the upper part of the handle of the malleus.
labyrinth and fundus of the internal meatus are located medial to the tympanic The stapedial muscle is housed within the pyramidal eminence and its tendon
cavity. A line directed medially through the skull along the long axis of the inserts on the stapedial neck. Chor., chorda; CN, cranial nerve; Emin., emi-
external meatus will also approximate the site of the long axis of the internal nence; Endolymph., endolymphatic; Epitymp., epitympanic; Eust.,
meatus on the medial side of the promontory and acousticovestibular labyrinth. eustachian; Jug., jugular; Lat., lateral; Long., longus; M., muscle; Mast.,
F, the stapes has been removed from the oval window. The handle of the malleus mastoid; Memb., membrane; N., nerve; Post., posterior; Proc., process; Seg.,
attaches to the tympanic membrane, the neck is crossed by the chorda tympani, segment; Sig., sigmoid; Sp., spine; Squamomast., squamomastoid; Temp.,
and the head articulates with the incus, which has been removed. The tendon temporal; Tymp., tympani, tympanic; Tympanomast., tympanomastoid.
The supramastoid crest extends backward across its posterior that is the site of attachment, from superficial to deep, of the
part, giving attachment to the temporalis muscle and fascia. sternocleidomastoid, splenius capitis and longissimus capitis
The suprameatal triangle, a depressed area, located below the muscles, and the posterior belly of the digastric muscle (Fig.
anterior part of the crest and behind the posterosuperior mar- 1-5). The lower surface medial to the mastoid process is
gin of the external meatus, marks the deep location of the mas- grooved by the mastoid notch to which the posterior belly of
toid antrum. The cerebral surface of the squamosal part is con- the digastric attaches. Medial to the notch, the occipital groove
cave, accommodating the temporal lobe and joining the greater gives passage to the occipital artery. The fascia covering the
wing of the sphenoid anteriorly. The zygomatic process of the anterior margin of the posterior belly of the digastric is contin-
squamosal part projects forward and with the zygomatic bone uous anteriorly with the connective tissue surrounding the
completes the zygomatic arch. The attachment of the zygo- emergence of the mastoid segment of the facial nerve from the
matic process to the squama is wide giving it anterior and pos- stylomastoid foramen and can be used as a landmark for iden-
terior edges, referred to as the anterior and posterior roots. The tifying the initial extracranial segment of the nerve. After exit-
temporalis fascia attaches to the superior border of the arch ing the stylomastoid foramen, the nerve divides in the sub-
and the masseter attaches to the lower border. The posterior stance of the parotid gland into temporal, zygomatic, buccal,
root of the zygomatic process blends posteriorly into the marginal mandibular, and cervical branches (Fig. 1-5). The tem-
suprameatal crest. The anterior root is located at the anterior poral and zygomatic branches cross the zygomatic arch and the
margin of the temporomandibular joint, with the joint forming outer surface of the superficial fascia of the temporalis muscle.
a rounded fossa on the lower margin of the zygomatic process Keeping the connective tissue surrounding the nerve at the sty-
between the anterior and posterior roots. The upper margin of lomastoid foramen intact during mobilization of the facial
the zygomatic process between the two roots gives attachment nerve will reduce the risk of facial nerve damage. The posterior
to the posterior part of the temporalis muscle. The mandibular border of the mastoid process is perforated by one or more
fossa, located on the lower margin of the process between the foramina through which an emissary vein to the sigmoid sinus
two roots, is delimited in front by the articular tubercle and and a dural branch from the occipital artery pass.
posteriorly by the postglenoid tubercle adjacent to its junction The medial aspect of the mastoid process is grooved by the
with the tympanic bone. The squamotympanic fissure is sigmoid sinus (Figs. 1-1–1-4). The sinus represents the posterior
located between the medial part of the squamosal part of the limit of the mastoid cavity. The sinus meets the roof of the cav-
mandibular fossa and the medial part of the tympanic bone. ity at the level of the petrous ridge. The angle between the
The petrotympanic fissure is situated between the tympanic superior petrosal and sigmoid sinuses and the middle fossa
plate and the petrosal part and leads into the tympanic cavity; dura delimits a dural space called the sinodural angle. The sin-
it contains the anterior ligament of the malleus and the anterior odural angle is an important landmark when exposing the con-
tympanic branch of the maxillary artery. The anterior canalicu- tents of the mastoid. Inferiorly, the sigmoid sinus curves medi-
lus for the chorda tympani exits the tympanic cavity in the ally and forward, crossing the occipital bone to enter the
petrotympanic fissure. The rootlets of the temporal branch of jugular foramen. The superior aspect of the jugular foramen
the facial nerve cross the lateral aspect of the zygomatic arch corresponds to the apex of the jugular bulb and constitutes the
and course through the subcutaneous tissues on the superficial inferior limit of the mastoid cavity.
layer of the temporal fascia. During resection of the zygomatic The medial limit of the mastoid cavity is formed by the
arch, the superficial temporalis fascia should be carefully dis- block of solid bone, the otic capsule, containing the bony
sected from the underlying deep fascia, starting as close as pos- labyrinth (Figs. 1-4 and 1-6). The area of posterior fossa dura
sible to the tragal cartilage, and carried forward, reflecting the mater that can be exposed through the mastoid cavity between
superficial fascia anteriorly to avoid damage to the filaments of the sigmoid and superior petrosal sinuses, the otic capsule,
the temporal branch to the frontalis muscle, which crosses the and the jugular bulb is called Trautman’s triangle. The size of
outer surface of the superficial fascia. this dural triangle is important in surgical procedures in which
the dura delimited by the triangle must be opened medial to
The Mastoid Part the sigmoid sinus. The distance from the anterior margin of
The mastoid is the posterior part of the temporal bone (Figs. the sigmoid sinus to the otic capsule at the level of the poste-
1-1, 1-2, and 1-4). It projects downward to form the process rior semicircular canal averages 8 mm (range, 6–9 mm) on the

FIGURE 1-5. A–F, muscular and osseous relationships. A, the skin and sub- gle of the neck, located between the sternocleidomastoid and trapezius, has the
cutaneous tissues have been removed to expose the parotid gland and the facial semispinalis capitis, splenius capitis, and levator scapulae in its floor. The ter-
nerve branches that course deep to the parotid gland on their way to the facial minal branches of the occipital artery and the greater occipital nerve reach the
muscles. The masseter muscle has two heads: a more superficial anterior head, subcutaneous tissues by passing between the attachment of the trapezius and
which passes downward to the lateral surface of the angle of the jaw, and a sternocleidomastoid muscles to the superior nuchal line. B, enlarged view. The
deeper posterior head, which arises from the medial surface of the zygomatic facial nerve branches are exposed along the anterior edge of the parotid gland.
arch and passes to the mandibular body. The sternocleidomastoid attaches to the C, the parotid gland has been removed to expose the facial nerve and its
lateral part of the superior nuchal line and mastoid process, descends in an branches distal to the stylomastoid foramen. The nerve passes lateral to the sty-
anterior direction, and is crossed by the greater auricular nerve. The temporalis loid process, the external carotid artery, and mandibular neck. The superficial
fascia attaches to the upper surface of the zygomatic arch. The trapezius mus- and deep heads of the masseter muscle are exposed. This lower end of the ster-
cle attaches to the medial part of the superior nuchal line. The posterior trian- nocleidomastoid muscle has been reflected posteriorly by dividing (Continues)

RHOTON
FIGURE 1-5. (Continued) its attachment to the clavicle and sternum. The cle. E, posterolateral view. The splenius capitis has been reflected downward to
superficial temporal artery ascends in front of the ear. D, the upper part of the expose the longissimus capitis, superior oblique, and semispinalis capitis. The
mandibular ramus and the lower part of the temporalis muscle and its attach- occipital artery passes along the occipital groove on the medial side of the digas-
ment to the coronoid process have been removed while preserving the inferior tric groove. F, the longissimus capitis has been reflected downward to expose the
alveolar nerve. The infratemporal fossa is located medial to the mandible and on rectus capitis posterior minor and major, which descend from the occipital bone
the deep side of the temporalis muscle. The upper and lower heads of the lateral to attach to the spinous process of C1 and C2, respectively; the superior oblique,
pterygoid, which insert along the temporomandibular joint, and the superficial which passes from the occipital bone to the transverse process of C1; and the
head of the medial pterygoid, which extends from the lateral pterygoid plate to inferior oblique, which extends from the spinous process of C2 to the transverse
the angle of the jaw, have been exposed. The structures in the infratemporal process of C1. The vertebral artery, in its ascent from C2 to C1, is exposed
fossa include the pterygoid muscles, branches of the mandibular nerve, the medial to the attachment of the levator scapulae to the C1 transverse process.
maxillary artery, and the pterygoid venous plexus. The sternocleidomastoid The C1 transverse process is situated immediately behind the internal jugular
muscle has been reflected out of the exposure to expose the splenius capitis mus- vein and a short distance below and behind the jugular foramen. (Continues)

FIGURE 1-5. (Continued) G–L, muscular and osseous relationships. G, the tis and rectus capitis anterior, both of which are located behind the posterior pha-
mandibular condyle and ramus have been removed to expose the styloid process ryngeal wall. K, the petrous carotid has been reflected forward out of the carotid
and attached muscles. The pterygoid muscles and some branches of the mandibu- canal to expose the petrous apex medial to the carotid canal. L, the petrous apex
lar nerve have been removed to expose the auriculotemporal nerve, which splits and upper clivus have been drilled and the dura opened to expose the anterolat-
into two roots that surround the middle meningeal artery. The levator veli pala- eral aspect of the pons below the trigeminal nerve. The sigmoid sinus and the
tini, which attaches the lower margin of the eustachian tube, is in the medial part jugular bulb have been removed to expose the nerves exiting the jugular fora-
of the exposure. The longus capitis is exposed medial to the internal carotid men. A., artery; Alv., alveolar; Ant., anterior; Aur., auricular; Brs., branches;
artery in the retropharyngeal area. H, the muscles that attach to the styloid Cap., capitis; Car., carotid; CN, cranial nerve; Cond., condyle; Constr., con-
process have been divided at their origin. The facial nerve crosses the lateral sur- strictor; Eust., eustachian; Ext., external; Gl., gland; Gr., greater; Inf., inferior;
face of the styloid process. The attachment of the tensor veli palatine to the skull Int., internal; Jug., jugular; Lat., lateral; Lev., levator; Long., longus; Longiss.,
base extends between the foramen ovale and the eustachian tube. I, the external longissimus; M., muscle; Maj., major; Mandib., mandibular; Max., maxillary;
auditory canal has been removed, but the tympanic membrane and cavity have Med., medial; Memb., membrane; Min., minor; N., nerve; Obl., oblique;
been preserved. The levator veli palatine and part of the tensor veli palatine have Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal; Pet., petrosal;
been removed and the membranous part of the eustachian tube opened. The Post., posterior; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopala-
eustachian tube crosses anterior to and is separated from the petrous carotid by tine; Rec., rectus; Scap., scapula; Semispin., semispinalis; Splen., splenius;
a thin shell of bone. The jugular bulb and lateral bend of the petrous carotid are Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup., supe-
located below the osseous labyrinth. The pterygopalatine fossa is exposed anterior; Superf., superficial; Temp., temporal, temporalis; Tens., tensor; TM., tem-
riorly. J, the Eustachian tube has been resected and the mandibular nerve divided poromandibular; Trans., transverse; Tymp., tympanic; V., vein; Veli./Vel.,
at the foramen ovale to expose the petrous carotid. This exposes the longus capi- veli; Vert., vertebral.
right side, and 7 mm (range, 4–9 mm) on the left (44). The dis- The tympanic cavity is a narrow air-filled space between the
tance between the apex of the jugular bulb and the superior tympanic membrane laterally and the promontory containing
petrosal sinus is also an important determinate of the size of the auditory and vestibular labyrinth medially (Figs. 1-4, 1-6,
exposure that can be achieved by opening Trautman’s triangle. and 1-7). It communicates posteriorly with the mastoid antrum
This distance is reduced if there is a high jugular bulb. The and anteriorly through the eustachian tube with the nasophar-
jugular bulb usually lies inferior to the ampulla of the poste- ynx. It contains the malleus, incus, and stapes. The tympanic
rior semicircular canal, but it can project superiorly as far as cavity opens upward into the epitympanic recess, which con-
the level of the lateral semicircular canal (27). The average dis- tains the head of the malleus and body of the incus. The roof of
tance from the jugular bulb to the superior petrosal sinus is the tympanic cavity is formed by a thin plate, the tegmen tym-
1446p10.5mm (range, 10–19 mm) on the right side, and 16 mm pani, which separates the middle fossa and tympanic cavities,
(range, 11–21 mm) on the left (44). and also roofs the mastoid antrum and the tensor tympani.
The mastoid interior is composed of trabeculated bone, The thin floor of the tympanic cavity separates the cavity from
which coalesces to form a cavity, the mastoid antrum, that com- the jugular bulb. The medial part of the floor is perforated by
municates through an opening, the aditus, that leads forward an opening for the tympanic branch of the glossopharyngeal
to the epitympanic part of the tympanic cavity (Figs. 1-4 and nerve. The lateral wall is formed by the tympanic membrane
1-6). The lateral semicircular canal is medial to the epitympanic and the osseous ring to which the membrane attaches. The ring
recess. The medial wall of the antrum faces the posterior semi- is deficient above near the openings of the anterior and poste-
circular canal. The roof is formed by the tegmen in the floor of rior canaliculi for the chorda tympani (Figs. 1-4 and 1-6). The
the middle cranial fossa. The mastoid segment of the facial posterior canaliculus for the chorda tympani arises from the
canal courses adjacent to the anteroinferior margin of the facial canal a few millimeters above the stylomastoid foramen
antrum. The lateral wall of the mastoid antrum, through which and ascends in front of the facial canal to open into the tym-
it is usually approached surgically, is formed by the postmeatal panic cavity at the level of the upper part of the handle of the
part of the squamous temporal bone. The lateral wall of the malleus. The chorda tympani passes in close relation to the
antrum is located deep to the suprameatal triangle, which is tympanic membrane and the upper part of the handle of the
demarcated superiorly by the suprameatal crest, located at the malleus and forward to enter its anterior canaliculus at the
level of the floor of the middle fossa; anteroinferior by the pos- medial aspect of the petrotympanic fissure, and descends ver-
terosuperior margin of the acoustic meatus, which indicates tically medial to the sphenoid spine and lateral pterygoid mus-
approximately the position of the descending or mastoid part cle to join the lingual nerve.
of the facial canal; and posteriorly by a posterior vertical tan- The medial wall of the tympanic cavity, which forms the lat-
gent to the posterior margin of the external meatus. The air eral boundary of the inner ear and the petrosal part of the tem-
cells in the mastoid may extend behind the sigmoid sinus and poral bone, is the site of the promontory, the oval and round
into the squamosal part of the temporal bone, the posterior windows, and the prominence over the facial nerve (Figs. 1-2
root of the zygomatic process, the osseous roof of the external and 1-4). The tympanic nerve plexus grooves the promontory
acoustic meatus, the floor of the tympanic cavity near the jugu- overlying the lateral bulge of the basal turn of the cochlea. The
lar bulb, and the petrous apex surrounding the carotid canal, apex of the cochlea lies near the medial wall of the cavity ante-
eustachian tube, and labyrinth. rior to the promontory. The oval window is posterosuperior to

RHOTON
FIGURE 1-6. A–D, translabyrinthine exposure. A, the insert shows the site the lateral canal and the stapes in the oval window and then turns down-
of the exposure directed through the mastoid. The spine of Henley at the pos- ward as the mastoid segment. The chorda tympani arises from the mastoid
terosuperior margin of the external meatus is a superficial landmark that segment of the facial nerve and passes upward and forward along the deep
approximates the deep site of the lateral semicircular canal and the tympanic surface of the tympanic membrane crossing the neck of the malleus. The
segment of the facial nerve. The mastoidectomy has been completed. The incus, the head of which is located in the epitympanic area, has a long process
superior petrosal and sigmoid sinuses, the jugular bulb, and the facial nerve that attaches to the stapes. C, the semicircular canals and vestibule have been
are usually skeletonized in the approach, leaving a thin layer of bone over removed and the dura lining the internal acoustic meatus has been opened to
them. The semicircular canals, which are located in the cortical bone medial expose the vestibulocochlear nerve. D, the dura has been opened to expose the
to the cancellous mastoid and the mastoid antrum, have been exposed. The petrosal cerebellar surface and the structures in the cerebellopontine angle.
dura between the sigmoid and superior petrosal sinuses, the jugular bulb, and Anatomic variants that limit the exposure include an anterior position of the
the labyrinth, which faces the cerebellopontine angle, is referred to as sigmoid sinus, a high jugular bulb, or a low middle fossa plate. The jugular
Trautman’s triangle. B, the mastoid antrum opens through the aditus into the bulb may extend upward into the posterior wall of the internal acoustic mea-
epitympanic part of the tympanic cavity, which contains the upper part of the tus and be encountered as the posterior meatal wall is being removed by
malleus and incus. The tympanic segment of the facial nerve passes between either the translabyrinthine or retrosigmoid approaches. (Continues)
the promontory and connects the tympanic cavity to the located just behind the oval window and anterior to the mas-
vestibule, and is occupied by the footplate of the stapes. The toid part of the facial canal. The stapedius extends forward
round window is posteroinferior to the oval window and from the eminence to attach to the neck of the stapes. The fossa
opens under the overhanging edge of the promontory. The incudis is a small depression low and posterior in the epitym-
prominence of the facial canal is located above the oval win- panic recess; it contains the short process of the incus, which is
dow. The posterior wall of the tympanic cavity is mainly the fixed to the fossa by ligamentous fibers.
site of the aditus, the opening of the tympanic cavity, into the The anterior wall of the tympanic cavity narrows and leads
mastoid antrum. The medial wall of the aditus has a round into the eustachian tube, which communicates the nasopharynx
prominence overlying the lateral semicircular canal. The with the tympanic cavity (Figs.1-4, 1-7, and 1-8). It has bony
pyramidal eminence, which houses the stapedial muscle, is and cartilaginous parts. The bony part begins in the anterior

FIGURE 1-6. (Continued) E–H, trans-

labyrinthine exposure. E, enlarged view of the
exposure in the cerebellopontine angle. In this
case, the glossopharyngeal and vagus nerves
can be seen, although, in the translabyrinthine
exposure, the jugular bulb often obstructs the
view of the nerves entering the jugular fora-
men. F, the vestibulocochlear nerve has been
elevated to expose the facial nerve. G, the
labyrinthine, tympanic, and mastoid segments
of the facial nerve have been exposed in prepa-
ration for transposition of the nerve for a
transcochlear approach. H, the facial nerve has
been transposed backward and the bone ante-
rior to the meatal fundus has been removed to
expose the cochlea for a transcochlear approach
in which the cochlea is removed to gain access
to the side of the clivus and front of the brain-
stem. The cochlear nerve has been divided. The
cochlear fibers innervating the cochlear duct
pass through the modiolus. Ac., acoustic;
A.I.C.A., anteroinferior cerebellar artery;
Chor., chorda; CN, cranial nerve; Coch.,
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., poste-
rior; Seg., segment; Sig., sigmoid; Sup., supe-
rior; Tymp., tympani, tympanic; V., vein;
Vest., vestibular.
part of the tympanic cavity and is directed anteriorly and medi- semicanal are located above the eustachian tube, parallel to the
ally. It joins the cartilaginous part at the junction of the squa- horizontal segment of the petrous carotid. The canals for the
mous and petrous parts of the temporal bone. The cartilaginous tensor tympani superiorly and the osseous part of the
part of the tube is attached to the lower margin of the eustachian tube inferiorly open into the upper part of the ante-
sphenopetrosal groove, which is situated between the petrous rior wall of the tympanic cavity. These canals are inclined
bone and the greater wing of the sphenoid bone, and its base downward, anteriorly, and medially; they open into the angle
lies directly under the mucous membrane of the lateral wall of between the squamous and petrous parts of the temporal bone
the nasaopharynx. Both the petrous carotid and eustachian and are separated by a thin, bony septum. The canal for the ten-
tube are directed anteromedially, with the Eustachian tube sor tympani extends posterolaterally on the medial wall of the
being located along the anterior margin of the carotid canal tympanic cavity, to end above the oval window where the pos-
(Figs. 1-7 and 1-8). The tensor tympani muscle and its bony terior end of the canal curves laterally to form a pulley, the

RHOTON
FIGURE 1-7. A–D, middle fossa exposure of the temporal bone. A, super- the internal acoustic meatus, cochlea, vestibule, semicircular canals, tym-
olateral view. The tentorium, except the edge, has been removed. The dura panic cavity, and external meatus. The vestibule is located posterolateral and
has been removed from the middle fossa floor and cavernous sinus wall to the cochlea is anteromedial to the fundus of the internal meatus. The
expose the greater petrosal nerve, middle meningeal artery, and the nerves in vestibule communicates below the meatal fundus with the cochlea. The ten-
the sinus wall. B, the middle fossa floor has been opened to expose the sor tympani muscle and eustachian tube are layered along, but are separated
cochlea, semicircular canals, petrous carotid artery, and the facial, cochlear, from, the anterior surface of the petrous carotid by a thin layer of bone. The
and superior vestibular nerves in the meatus. The superior canal bulges tegmen has been opened to expose the head of the incus and malleus in the
upward into the middle fossa below the arcuate eminence. The cochlear nerve epitympanic area. The internal acoustic meatus lies directly medial to, but is
passes below the facial nerve to enter the cochlea, which is located above the separated from, the external meatus by the tympanic cavity and the
lateral genu of the petrous carotid in the angle between the pregeniculate labyrinth. D, the nerves in the meatus have been separated to expose the
facial and greater petrosal nerves. C, another temporal bone drilled to expose superior and inferior vestibular, facial, and cochlear nerves. (Continues)
trochleariform process, around which the tensor tympani ten- nial fossa and its surface is grooved by the trigeminal impres-
don turns laterally to attach to the handle of the malleus. sion for the trigeminal ganglion; anterolateral to this, it forms
the roof of the carotid canal (Figs. 1-1 and 1-7). Lateral to the
The Petrous Part trigeminal impression is a shallow depression, which partially
The petrous part of the temporal bone is wedged between roofs the internal acoustic meatus and is limited laterally by the
the sphenoid and occipital bones (Figs. 1-1 and 1-3). It contains arcuate eminence, which overlies the superior semicircular
the acoustic and vestibular labyrinth and is the site of the jugu- canal. The posterior slope of the arcuate eminence overlies the
lar fossa and the facial and carotid canals (Figs. 1-3, 1-4, and posterior and lateral semicircular canals. Farther laterally, the
1-7). It has a base, apex, three surfaces and margins. The apex roof covers the vestibule and part of the facial canal. The
is located in the angle between the greater wing of the sphe- tegmen extends laterally from here and roofs the mastoid
noid and the occipital bone and is the site of the carotid canals antrum and tympanic cavities and the canal for the tensor tym-
medial opening. It forms the posterolateral limit of the foramen pani. Opening the tegmen from above exposes the heads of
lacerum. The anterior surface faces the floor of the middle cra- the malleus, incus, the tympanic segment of the facial nerve,

FIGURE 1-7. (Continued) E–H, middle fossa exposure of the temporal bone. canals. The anterior end of the superior and lateral canals and the lower end
E, enlarged view. The vestibule, into which the semicircular canals open, com- of the posterior canal are the site of the ampullae. The posterior end of the supe-
municates below the meatal fundus with the cochlea. The vertical crest, often rior canal and the upper end of the posterior canal join to form a common crus.
called Bill’s bar, separates the superior vestibular and facial nerves at the The facial and superior vestibular nerves have been removed to expose the
meatal fundus. The tendon of the tensor tympani makes a right-angle turn cochlear and inferior vestibular nerves. The singular branch of the inferior
around the trochleariform process in the medial margin of the tympanic cav- vestibular nerve innervates the posterior ampullae. The superior vestibular
ity to insert on the malleus. F, enlarged view. The superior canal projects nerve innervates the superior and lateral ampullae. A., artery; Ac., acoustic;
upward in the floor of the middle fossa. The lateral canal is situated above the A.I.C.A., anteroinferior cerebellar artery; Car., carotid; CN, cranial nerve;
tympanic segment of the facial nerve in the posteromedial part of the epitym- Coch., cochlear; Eust., eustachian; Ext., external; Gang., ganglion; Genic.,
panic area, and the posterior canal is located lateral to the posterior wall of the geniculate; Gr., greater; Inf., inferior; Lat., lateral; M., muscle; Men.,
internal acoustic meatus. G, bone has been removed below the greater petrosal meningeal; Mid., middle; N., nerve; Pet., petrosal, petrous; Post., posterior;
nerve to expose the petrous carotid. The tensor tympani muscle above and the S.C.A., superior cerebellar artery; Sup., superior; Tens., tensor; Tent., tento-
eustachian tube below are layered along the anterior surface of the petrous rial; Tymp., tympani, tympanic; Vert., vertebral; Vest., vestibular.
carotid. H, enlarged view. Suture has been placed in the three semicircular
and the superior and lateral semicircular canals (Fig. 1-7). The the dura of the middle fossa in the sphenopetrosal groove
tympanic segment of the facial nerve begins at the geniculate formed by the junction of the petrous and sphenoid bones,
ganglion and ends at the level of the stapes, where the nerve immediately superior and anterolateral to the horizontal seg-
turns downward below the lateral semicircular canal. The ment of the petrous carotid. In a previous study, we found
tegmen anteriorly is grooved by the greater petrosal nerve that bone of the middle cranial fossa was absent over the
extending anterior and medial from the area in front of the geniculate ganglion in 16% of the specimens, thus exposing the
arcuate imminence and crossing the floor of the middle fossa facial nerve and geniculate ganglion to the danger of injury
toward the foramen lacerum (Figs. 1-7 and 1-8). The greater during elevation of the dura from the floor of the middle fossa
petrosal nerve can be identified medial to the arcuate emi- (31). Facial nerve injury can also result from damaging the
nence as it leaves the geniculate ganglion by passing through branch of the middle meningeal artery, which passes through
the facial hiatus to reach the middle fossa floor. It runs beneath the facial hiatus to supply the nerve, or from traction applied

RHOTON
to the ganglion when

manipulating 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 anterome-
dial direction parallel to
the greater petrosal nerve
(Fig. 1-8). The cochlea lies
below the floor of the
middle fossa in the angle
between the labyrinthine
segment of the facial
nerve and the greater pet-
rosal nerve, just medial to FIGURE 1-8. 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 trigemi-
the geniculate ganglion,
nal division in the infratemporal fossa. The posterior part of the middle fossa forming the upper surface of the temporomandibu-
anterior to the fundus of lar joint has been removed to expose the mandibular condyle. The internal acoustic meatus extends laterally from the poste-
the internal acoustic mea- rior surface of the temporal bone. The mastoid is located behind the external canal and lateral to the semicircular canals and
tus, and posterosuperior vestibule. B, enlarged view. The trigeminal nerve has been reflected forward and bone has been removed over the eustachian
to the lateral genu of the tube, tensor tympani muscle, petrous carotid, and internal acoustic meatus. Dura has been removed from the lateral wall of
petrous carotid artery. the cavernous sinus to expose the trochlear, trigeminal, and oculomotor nerves in the sinus wall and the abducens nerve pass-
The cochlea is separated ing below the petrosphenoid ligament and through Dorello’s canal. The greater petrosal nerve is joined by the deep petrosal
from the petrous carotid branches of the carotid sympathetic plexus to form the vidian nerve, which passes forward in the vidian canal, which has been
b y a 2 . 1 m m ( r a n g e , unroofed. The lesser petrosal nerve arises from the tympanic branch of the glossopharyngeal nerve, which passes across the
0.6–10.0 mm) thickness of 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
bone and can be injured
layered along, but are separated from, the anterior surface of the petrous carotid by a thin layer of bone. A., artery; Car.,
during exposure of the carotid; Cav., cavernous; Chor., chorda; CN, cranial nerve; Cond., condyle; Eust., eustachian; Gang., ganglion; Gen., genic-
petrous carotid. The mid- ulate; Gr., greater; Lat., lateral; Less., lesser; Lig., ligament; M., muscle; Mandib., mandibular; Max., maxillary; N.,
d l e m e n i n g e a l a r t e r y, nerve; Ophth., ophthalmic; Pet., petrosal, petrous; Pteryg., pterygoid; Semicirc., semicircular; Sphen., sphenoid; Temp.,
an important landmark temporal; Tens., tensor; Tymp., tympani, tympanic.
when approaching the
structures of the middle fossa, enters the cranial cavity which usually ends blindly in the region of the superior
through the foramen spinosum of the sphenoid bone. The semicircular canal. Inferolateral to the porus of the meatus is
foramen spino-sum is an average of 4.5 mm (range, 3–6 mm) the opening for the vestibular aqueduct, which transmits the
anterolateral to the carotid canal and 14.0 mm (range, endolymphatic duct that opens below into the endolym-
11.0–17.0 mm) anterolateral to the geniculate ganglion (44). phatic sac located between the dural layers. The opening of
The posterior surface of the petrosal part faces the poste- the cochlear aqueduct, also called the cochlear canaliculus
rior cranial fossa and cerebellopontine angle and is continu- and occupied by the perilymphatic duct, is situated inferior
ous with the mastoid surface (Figs. 1-1–1-.3). The opening to the porus of the internal meatus at the anteromedial edge
for the internal auditory meatus is situated midway between of the jugular foramen, just superior and lateral to where the
the base and the apex on the posterior surface. The lateral glossopharyngeal nerve enters the intrajugular part of the
end of the meatus is divided into superior and inferior halves jugular foramen.
by the transverse crest. The area above the transverse crest is The inferior surface is very irregular. The apex is connected
further divided by the vertical crest, also called Bill’s bar, medially to the clivus by fibrocartilage and gives attachment to
which separates the anteriorly located facial canal from the the levator veli palatini and the cartilaginous portion of the
posteriorly located superior vestibular area (29). The cochlea eustachian tube (Figs. 1-1 and 1-9). Behind this is the opening of
and inferior vestibular nerves penetrate the lateral end of the the carotid canal, behind which is the jugular fossa that con-
meatus below the transverse crest, with the cochlear nerve tains the jugular bulb. The small foramen for the tympanic
being located anteriorly. The posterior wall of the meatus, branch of the glossopharyngeal nerve is located on the ridge
lateral to the porus is the site of a small bony opening, the between the carotid canal and jugular foramen. On the lateral
subarcuate fossa, which gives passage to the subarcuate wall of the jugular bulb is the mastoid canaliculus for the auric-
artery, a branch of the anteroinferior cerebellar artery (AICA), ular branch of the vagus nerve.

FIGURE 1-9. Inferior views of an axial sec-

tion of the skull base. A, the infratemporal
fossa is surrounded by the maxillary sinus
anteriorly, the mandible laterally, the sphe-
noid pterygoid process anteromedially, and
the parapharyngeal space posteromedially,
and contains the mandibular nerve and max-
illary artery and their branches, the medial
and lateral pterygoid muscles, and the ptery-
goid venous plexus. B, part of the lateral
pterygoid muscle has been removed to expose
the branches of the trigeminal nerve coursing
in the infratemporal fossa below the greater
sphenoid wing. The pterygopalatine fossa is
located between the posterior maxillary wall
anteriorly, the sphenoid pterygoid process
posteriorly, the nasal cavity medially, and the
infratemporal fossa laterally. The pharyngeal
recess (fossa of Rosenmüller) projects later-
ally from the posterolateral corner of the
nasopharynx with its lateral apex facing the
internal carotid artery laterally and the fora-
men lacerum above. The posterior nasopha-
ryngeal wall is separated from the lower
clivus and the upper cervical vertebra by the
longus capitis, and the nasopharyngeal roof
rests against the upper clivus and the poste-
rior part of the sphenoid sinus floor. C, the
sphenoid pterygoid process has been removed
to expose the maxillary nerve passing through
the foramen rotundum to enter the ptery-
gopalatine fossa where it gives rise to the
infraorbital nerve, which courses in the roof of
the maxillary sinus. The maxillary nerve
within the pterygopalatine fossa gives off
communicating rami to the pterygopalatine
ganglion. The vidian nerve, formed by the
union of the deep petrosal nerve from the
carotid sympathetic plexus and the greater
petrosal nerve, courses forward through the
vidian canal to join the pterygopalatine gan-
glion. The terminal part of the petrous carotid
is exposed above the foramen lacerum. D,
enlarged view with highlighting of the pre-
(red) and poststyloid (yellow) compartments
of the parapharyngeal space. The styloid
diaphragm, formed by the anterior part of the
carotid sheath, separates the parapharyngeal
space into pre- and poststyloid parts. The
prestyloid compartment, a narrow fat-
containing space between the medial ptery-
goid and tensor veli palatini, separates the infratemporal fossa from the medi- gland; Gr., greater; Infraorb., infraorbital; Infratemp., infratemporal; Int.,
ally located lateral nasopharyngeal region containing the tensor and levator veli internal; Jug., jugular; Lat., lateral, lateralis; Lev., levator; Long., longus; M.,
palatini and the eustachian tube. The oststyloid compartment, located behind muscle; Mandib., mandibular; Max., maxillary; N., nerve; Nasolac., naso-
the prestyloid part, contains the internal carotid artery, internal jugular vein, lacrimal; Occip., occipital; Pal., palatini; Parapharyng., parapharyngeal;
and the cranial nerves IX through XII. A., artery; Cap., capitis; Car., carotid; Proc., process; Pteryg., pterygoid; Pterygopal., pterygopalatine; Rec., rec-
CN, cranial nerve; Cond., condyle; Eust., eustachian; For., foramen; Gl., tus; Tens., tensor; V., vein; Vel., veli.
The superior border, located along the petrous ridge, is crossed by the posterior trigeminal root. The lower posterior
grooved by the superior petrosal sinus and serves as the attach- border, located along the petroclival fissure, is the site of a
ment of the tentorium cerebelli, except medially where it is groove in which resides the inferior petrosal sinus that connects

RHOTON
the cavernous sinus and the medial wall of the jugular bulb. pleting the middle fossa approach to the internal acoustic
Behind this, the jugular fossa of the temporal bone joins with meatus. The posterior canal may be damaged in removing
the jugular notch on the jugular process of the occipital bone to the posterior wall to expose the meatal contents by the ret-
form the margins of the jugular foramen. rosigmoid approach (Fig. 1-3).
The jugular foramen is located at the lower end of the petro- During surgical approaches to the cerebellopontine angle
occipital fissure and is divided into a larger lateral opening, in which the posterior meatal lip is removed, care should be
the sigmoid part, that receives the drainage of the sigmoid taken to avoid opening the vestibular aqueduct, vestibule,
sinus, and a small medial part, the petrosal part, that transmits posterior semicircular canal, or the common crus (Figs. 1-2
the inferior petrosal sinus (Fig. 1-1). The intrajugular part, and 1-3). In our studies, we observed that there is a constant
located between the sigmoid and petrosal parts, transmits the set of relationships among the structures around the poste-
glossopharyngeal, vagus, and accessory nerves. The anterior rior meatal lip. The common crus of the posterior and supe-
border is joined laterally to the temporal squama at the pet- rior semicircular canals is located lateral to the entrance of
rosquamosal suture and medially articulates with the sphe- the subarcuate artery into the subarcuate fossa. The vestibu-
noid’s greater wing. lar aqueduct has an oblique orientation. It leaves the
The bony labyrinth consists of three parts: the vestibule, the vestibule and runs in a posterior direction to open beneath
semicircular canals, and the cochlea. The vestibule, located in the dura mater at a level corresponding to that of the poste-
the central part of the bony labyrinth, is a small cavity at the rior semicircular canal. The average distance between the
confluence of the ampullate and nonampullated ends of the posterior semicircular canal, at the level with the junction of
semicircular canals. It is situated lateral to the meatal fundus, the common crus, and the lateral edge of the porus was 7 mm
medial to the tympanic cavity, posterior to the cochlea, and (range, 5–9 mm) (44).
superior to the apex of the jugular bulb (Figs. 1-3, 1-4, and 1-7). The carotid artery, at the point where it enters the carotid
The floor of the vestibule is separated from the apex of the canal, is surrounded by a strong layer of connective tissue that
jugular bulb by a thickness of bone that averages 6 mm (range, makes it difficult to mobilize the artery at this point (Figs. 1-9
4–8 mm) on the right side and 8 mm (range, 4–10 mm) on the and 1-10) (38, 39). The vertical segment of the artery passes
left side (44). This distance is particularly important during upward in the canal toward the genu, where it curves antero-
translabyrinthine approaches since the height of the jugular medially to form the horizontal segment. The Eustachian tube
bulb is a major determinant of the size of the exposure of the and the tensor tympani muscle are located parallel to and along
cerebellopontine angle that can be achieved with this approach. the anterior margin of the horizontal segment, where they are
A high-placed jugular bulb may be the source of troublesome separated from the artery by a thin layer of bone.
bleeding and air emboli if it is opened during exposure of the The trigeminal ganglion and the adjacent part of the poste-
labyrinth or internal acoustic meatus. rior root and their surrounding dural and arachnoidal cavern,
The semicircular canals are situated posterosuperior to the called Meckel’s cave, sit in an impression on the upper surface
vestibule (Figs. 1-3, 1-4, and 1-7). The anterior part of the lat- of the petrous apex above the medial part of the petrous carotid
eral semicircular canal is situated above the tympanic seg- (Figs. 1-1, 1-7, and 1-8). The length of the horizontal segment of
ment of the facial nerve and can be used as a guide to locat- the petrous carotid that can be exposed by removing bone lat-
ing that segment of the nerve. The posterior semicircular eral to the trigeminal ganglion averages 1-1 mm (range,
canal lies parallel to and in close proximity with the posterior 4.0–11.0 mm) (44). The length that can be exposed can be
surface of the petrous bone in the area just behind and lateral increased if the mandibular branch of the trigeminal nerve is
to the lateral end of the internal acoustic meatus. The superior retracted or divided, after which the average length that can be
semicircular canal projects toward the floor of the middle exposed increases to 20.1 mm (range, 17.5–21-0 mm) (Figs. 1-7
fossa, usually in close relation to the arcuate eminence. Each and 1-8) (10, 17). Gaining this added exposure can be particu-
canal has an ampullated and a nonampullated end that opens larly helpful during surgical procedures that are directed
into the vestibule. The anterior end of the lateral and superior through the petrous apex to complete a vascular anastomosis,
canals and the inferior end of the posterior canal are the site to occlude the artery for control of bleeding, and to allow for
of the ampullae, which are innervated by the vestibular mobilization of the vertical and horizontal segments of the
nerves. The posterior ends of the superior and posterior artery (40). A venous plexus of variable size, an extension of the
canals, the ends opposite the ampullae, join to form a com- cavernous sinus within the periosteal covering of the distal
mon crus that opens into the vestibule. The superior vestibu- part of the canal, surrounds the artery.
lar nerve innervates the ampullae of the superior and lateral The facial nerve in the temporal bone, which often blocks
canals, and the singular branch of the inferior vestibular nerve access to lesions within and deep to the temporal bone, is
innervates the posterior ampulla. The vestibular nerves also divided into three segments (Figs. 1-4, 1-5, and 1-7). The first,
have branches to the utricle and saccule located within the or labyrinthine segment, which is located in the petrous part,
vestibule. The internal auditory meatus can be found medial extends from the meatal fundus to the geniculate ganglion
to the arcuate eminence at an angle of about 60 degrees and is situated between the cochlea anteromedially and the
medial from the long axis of the superior semicircular canal. semicircular canals posterolaterally. The labyrinthine segment
The superior canal is the most susceptible to damage in com- ends at the site at which the greater superficial petrosal nerve

FIGURE 1-10. A–D, preauricular subtem-

poral-infratemporal fossa approach. A, the
scalp flap has been reflected forward. The flap
is positioned so that a neck dissection as well
as a frontotemporal craniotomy can be com-
pleted. The scalp flap has been reflected for-
ward while protecting the facial nerve and its
branches. The neck dissection has been com-
pleted below the parotid gland. The facial
nerve branches passing deep to the parotid
have been preserved. B, the dissection has
been carried around the parotid gland to
expose the branches of the facial nerve. The
internal jugular vein and internal carotid
artery are exposed below the gland. C, the
parotid gland has been removed to expose the
branches of the facial nerve distal to the sty-
lomastoid foramen. D, a segment of the
mandibular ramus has been removed, leaving
the mandibular condyle in the mandibular
fossa, to expose the maxillary artery and
pterygoid muscles in the infratemporal fossa.
Branches of the third trigeminal division pass
between the lateral and medial pterygoid
muscles. The inferior alveolar nerve descends
to enter the inferior alveolar foramen and
canal. (Continues)
arises from the facial nerve at the level of the geniculate gan- Petroclival Region
glion. From there, the nerve in its canal turns laterally and These transtemporal operative approaches are often directed
posteriorly along the medial surface of the tympanic cavity, to the petroclival region located where the posterior surface of
thus giving the name tympanic segment to that part of the the petrous temporal bone meets the clival part of the occipital
nerve. The tympanic segment runs between the lateral semi- bone along the petroclival fissure. The junction of the two
circular canal above and the oval window below. As the nerve bones forms a line that extends from the jugular foramen to the
passes below the midpoint of the lateral semicircular canal, it petrous apex (Fig. 1-1). From a surgical standpoint, the
turns vertically downward and courses through the petrous intradural compartments of the petroclival region are divided
part adjacent to the mastoid part of the temporal bone; thus along this petroclival line into 1) an inferior space related to the
the third segment, which ends at the stylomastoid foramen, is medulla and to the structures around the region of the foramen
called the mastoid or vertical segment. magnum; 2) a middle space related to the pons and to the struc-

RHOTON
FIGURE 1-10. (Continued) E, a frontotemporal craniotomy has been com- made into the lateral wall of the sphenoid sinus between the first and second
pleted and the dura of the lateral wall of the cavernous sinus has been ele- divisions. The maxillary nerve passes forward to join the terminal branches
vated. In addition, the lateral orbital wall has been removed to expose the of the maxillary artery in the pterygopalatine fossa. The maxillary nerve con-
globe, extraocular muscles, and lacrimal gland. F, enlarged view of the tinues forward along the floor of the orbit as the infraorbital nerve. The
region of the cavernous sinus. The PCA and SCA have been exposed cours- superior ophthalmic vein descends across the origin of the lateral rectus
ing above and below the oculomotor and trochlear nerves, respectively. The muscle and enters the anterior portion of the cavernous sinus. (Continues)
optic nerve is exposed above the internal carotid artery. An opening has been
tures in the prepontine and cerebellopontine angle; and 3) a tures forming the floor of the third ventricle. The posterior limit
superior space related to the contents of the interpeduncular is formed by the cerebral peduncles and the posterior perfo-
cistern, and to the sellar and parasellar regions. rated substance. The inferior limit is situated above the origin
of the trigeminal nerve at the pontomesencephalic sulcus. It
The Inferior Petroclival Space includes the intradural segment of the oculomotor and
The inferior petroclival space corresponds to the anterior trochlear nerves, the basilar artery and its branching into the
surface of the medulla and adjacent part of the clivus and ante- posterior cerebral artery (PCA) and superior cerebellar artery
rior margin of the foramen magnum (4). The neurovascular (SCA), and the cavernous carotid and its intracavernous
structures in this region are those contained in the pre- branches to the dura of the upper clivus. The medial edge of
medullary cistern. The superior limit is the junction of the pons the tentorium divides the superior petroclival space into infra-
and medulla. The inferior limit is the rostral margin of the first and supratentorial compartments.
cervical nerve root, the site of the junction of the spinal cord
and the medulla. The inferior petroclival space includes the Adjacent Structures
lower four cranial nerves, lower part of the cerebellum, the The structures important in accessing the temporal bone
vertebral artery and its branches, and the structures around from posteriorly and laterally have already been reviewed. This
the occipital condyle. section reviews the structures located in front of the temporal
bone that are important in reaching lesions that involve the
The Middle Petroclival Space bone or involve both the bone and areas anterior to it. They
The middle petroclival space corresponds to the anterolateral include several muscles, like the temporalis and masseter, the
surface of the pons and cerebellum. Its superior limit is at the infratemporal fossa, and the parapharyngeal spaces.
pontomesencephalic sulcus and the lower limit is at the pon- The temporalis muscle, along with the deep temporal ves-
tomedullary sulcus. The lateral limits are formed by the poste- sels, passes between the gap formed by the zygomatic arch
rior surface of the petrous bone and by the contents of the cere- and the floor of the temporal fossa (Fig. 1-5). The muscle
bellopontine angle including the trigeminal, abducens, facial, attaches to the coronoid process of the mandible. The superfi-
and vestibulocochlear nerves, the basilar artery, and the AICA cial and the deep temporalis fasciae attach, respectively, to the
and the superior petrosal veins. lateral and medial aspects of the upper border of the zygo-
matic arch. Inferiorly, the parotid fascia invests the parotid
The Superior Petroclival Space gland and the masseter muscle and attaches to the lower bor-
The superior petroclival space is located anterior to the mid- der of the zygomatic arch. The masseter muscle has two super-
brain and corresponds to the anterior part of the tentorial imposed layers. A superficial layer which attaches to the zygo-
incisura. It extends anteriorly and laterally to the sellar and matic process of the maxilla and anterior part of the lower
parasellar regions. Its roof is formed by the diencephalic struc- border of the zygomatic arch and a deep layer which attaches

FIGURE 1-10. (Continued) G–J, preauricu-

lar subtemporalinfratemporal fossa approach.
G, the floor of the middle fossa has been
resected back to the level of the tensor tym-
pani muscle and eustachian tube, and the
petrous carotid artery. The nerves exiting the
jugular foramen and hypoglossal canal pass
laterally between the internal carotid artery
and internal jugular vein to reach their end
organs. H, the eustachian tube and tensor
tympani have been resected and the bone lat-
eral to the foramen ovale removed. This
exposes the full length of the petrous carotid. I,
the petrous carotid has been 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 adja-
cent part of the clivus medial to the jugular
foramen and cochlea have been removed and
the dura opened to expose the junction of the
vertebral and basilar arteries and the origin of
the AICA. A., artery; A.I.C.A., anteroinfe-
rior cerebellar artery; Alv., alveolar; Bas.,
basilar; Brs., branches; Cap., capitis; Car.,
carotid; Cav., cavernous; CN, cranial nerve;
Ext., external; Front., frontal; Gl., gland;
Inf., inferior; Infraorb., infraorbital; Int.,
internal; Jug., jugular; Lac., lacrimal; Lat.,
lateral; Long., longus; M., muscle; Max.,
maxillary; Med., medial; N., nerve; Ophth.,
ophthalmic; P.C.A., posterior cerebral artery;
Pet., petrosal, petrous; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Rec., rectus;
S.C.A., superior cerebellar artery; Sphen.,
sphenoid; Submandib., submandibular;
Sup., superior; Temp., temporal; Tens., ten-
sor; TM., temporomandibular; Tymp., tym-
pani; V., vein; Vert., vertebral.
to the medial aspect of the whole zygomatic arch. Inferiorly it process. The posterior digastric belly originates in the digastric
inserts onto the angle and ramus of the mandible. groove, lateral to the occipital groove in which the occipital
The parotid gland, the parotid duct, and the branches of the artery courses, and inserts onto the hyoid bone. The muscles
facial nerve are located superficial to the masseter muscle attached to the styloid process, the stylohyoid, styloglossus,
(Figs. 1-5, 1-9, and 1-10). In surgical procedures in which the and stylopharyngeus muscles, extend to the hyoid bone,
mandibular condyle is resected or displaced inferiorly, the tongue, and pharyngeal wall, respectively.
parotid gland, along with the branches of the facial nerve,
can be dissected from the underlying masseter to avoid exces- Infratemporal Fossa
sive traction on the facial nerve and to reduce the risk of facial The infratemporal fossa, a route through which some tem-
palsy (33). poral bone lesions can be reached, is a not uncommon site of
Muscles commonly encountered in operative approaches to involvement by lesions that also involve the temporal bone
the region of the temporal bone include the posterior belly of (11). The osseous boundaries of the infratemporal fossa are
the digastric muscle and the muscles attached to the styloid the posterolateral maxillary surface anteriorly, the lateral

RHOTON
pterygoid plate anteromedially, the mandibular ramus later- The pterygoid venous plexus is located in the infratemporal
ally, and the tympanic part of the temporal bone and the sty- fossa and has two parts: a superficial part located between the
loid process posteriorly. The fossa is domed anteriorly by the temporalis and lateral pterygoid; and a deep part situated
infratemporal surface of the greater sphenoid wing, the site of between the lateral and medial pterygoids anteriorly, and
the foramina ovale and spinosum, and posteriorly by the between the lateral pterygoid and the parapharyngeal space
squamous part of the temporal bone (Figs. 1-8-1-10). The infe- posteriorly. The deep part is more prominent and connects with
rior, posteromedial, and superolateral aspects are open with- the cavernous sinus by emissary veins passing through the
out bony walls. foramina ovale and spinosum, and occasionally through the
The structures located in the infratemporal fossa are the sphenoidal emissary foramen (foramen of Vesalius). The main
pterygoid muscles and venous plexus and the branches of the drainage of the pterygoid plexus is through the maxillary vein
maxillary artery and mandibular nerve. The lateral pterygoid to the internal jugular vein.
muscle crosses the upper part of the infratemporal fossa, orig- The mandibular nerve enters the infratemporal fossa by
inating from the upper and lower heads; the upper head arises passing through the foramen ovale on the lateral side of the
from the infratemporal surface of the greater sphenoid wing, parapharyngeal space, where it gives rise to several smaller
and the lower head originates from the lateral pterygoid plate branches, and then divides into a smaller anterior trunk and a
(Figs. 1-8-1-10). Both heads pass posterolaterally and insert on larger posterior trunk (Figs. 1-8-1-10). The anterior trunk gives
the neck of the mandibular condylar process and the articular rise to the deep temporal and masseteric nerves, which supply
disc of the temporomandibular joint. The medial pterygoid the temporalis and the masseter, respectively, and the nerve to
muscle crosses the lower part of the infratemporal fossa and the lateral pterygoid. The buccal nerve, which conveys sensory
arises with superficial and deep heads; the superficial head fibers, passes anterolaterally between the two heads of the lat-
arises from the lateral aspect of the palatine pyramidal process eral pterygoid, and descends lateral to the lower head to reach
and the maxillary tuberosity and passes superficial to the lower the buccinator and the buccal mucosa. The posterior trunk
head of the lateral pterygoid; and the deep head originates gives off the lingual, inferior alveolar, and auriculotemporal
from the medial surface of the lateral pterygoid plate and the nerves, which descend medial to the lateral pterygoid. The lin-
pterygoid fossa between the two pterygoid plates and passes gual and inferior alveolar nerves, the former coursing anterior
deep to the lower head of the lateral pterygoid. Both heads to the latter, pass between the lateral and medial pterygoids.
descend backward and laterally to attach to the medial surface The auriculotemporal nerve usually splits to encircle the mid-
of the mandibular ramus below the mandibular foramen. The dle meningeal artery and passes posterolaterally between the
sphenomandibular ligament, located medial to the mandibular mandibular ramus and the sphenomandibular ligament. The
condylar process, descends from the sphenoid spine to attach chorda tympani nerve, which contains the taste fibers from the
to the lingula of the mandibular foramen. The structures anterior two-thirds of the tongue and the parasympathetic
located or passing between the sphenomandibular ligament secretomotor fibers to the submandibular and sublingual sali-
and the mandible are the lateral pterygoid and the auriculotem- vary glands, enters the infratemporal fossa through the
poral nerve superiorly, and the inferior alveolar nerve, the petrotympanic fissure, descends medial to the auriculotempo-
parotid gland, the maxillary artery and its inferior alveolar ral and inferior alveolar nerves, and joins the lingual nerve.
branch inferiorly. The otic ganglion is situated immediately below the foramen
The maxillary artery is divided into three segments: ovale on the medial side of the mandibular nerve. The ganglion
mandibular, pterygoid, and pterygopalatine (Figs. 1-8-1-10). receives the lesser petrosal nerve, which crosses the floor of
The mandibular segment arises from the external carotid artery the middle fossa anterolateral to the greater petrosal nerve to
near the posterior border of the condylar process, passes exit through the foramen ovale or the more posteriorly situated
between the process and the sphenomandibular ligament, canaliculus innominatus and conveys parasympathetic secreto-
along the inferior border of the lower head of the lateral ptery- motor fibers to the parotid gland via the auriculotemporal
goid, and gives rise to the deep auricular, anterior tympanic, nerve. The medial pterygoid nerve arises from the medial
middle and accessory meningeal, and the inferior alveolar aspect of the mandibular nerve close to the otic ganglion and
arteries. The middle meningeal ascends medial to the lateral descends to supply the medial pterygoid and tensor veli pala-
pterygoid to enter the foramen spinosum, the accessory tini. The nervus spinosus, a meningeal branch, also arises near
meningeal arises from the maxillary or middle meningeal to the otic ganglion and ascends through the foramen spinosum
enter the foramen ovale, and the inferior alveolar descends to to innervate the middle fossa dura.
enter the mandibular foramen. The pterygoid segment usually
courses lateral to, but occasionally medial to, the lower head of Parapharyngeal Space
the lateral pterygoid and gives rise to the deep temporal, ptery- The parapharyngeal space is located in the lateral pharyngeal
goid, masseteric, and buccal arteries. The pterygopalatine seg- wall and is shaped like an inverted pyramid, with its base on
ment courses between the two heads of the lateral pterygoid the skull base superiorly and its apex at the hyoid bone inferi-
and enters the pterygopalatine fossa by passing through the orly. The parapharyngeal space is subdivided into prestyloid
pterygomaxillary fissure. Its branching will be described with and poststyloid compartments by the styloid diaphragm, a
the pterygopalatine fossa. fibrous sheet that also constitutes the anterior part of the

carotid sheath (Figs. 1-5 and 1-9). The prestyloid part, situated illa and pterygoid process, and opens superiorly through the
anteriorly between the fascia covering the opposing surfaces of medial part of the inferior orbital fissure into the orbital apex
the medial pterygoid and tensor veli palatini, is a thin fat-filled (Figs. 1-5, 1-9, and 1-10) (11). The fossa contains the maxillary
compartment separating the structures in the infratemporal nerve, pterygopalatine ganglion, maxillary artery, and their
fossa from the eustachian tube and the tensor and levator veli branches, all embedded in fat tissue. Its lateral boundary, the
palatini muscles in the lateral nasopharyngeal wall. The upper pterygomaxillary fissure, opens into the infratemporal fossa
portion of the prestyloid part is situated between two fascial and allows passage of the maxillary artery from the infratem-
sheets, which are oriented in a sagittal plane. The lateral sheet poral into the pterygopalatine fossa, where the artery gives rise
arises from the medial surface of the medial pterygoid, passes to its terminal branches. The lower part of the fossa is funnel-
upward, backward, and medial to the mandibular nerve and shaped, with its inferior apex opening into the greater and
the middle meningeal artery, incorporating the spheno- lesser palatine canals, which transmit the greater and lesser
mandibular ligament posteriorly, and reaching the retro- palatine nerves and vessels, and communicate with the oral
mandibular deep lobe of the parotid gland. The medial sheet is cavity. The sphenopalatine foramen, located in the upper part
formed by the fascia overlying the lateral surface of the tensor of the fossa’s medial wall, conveys the sphenopalatine nerve
veli palatini and is continuous inferiorly with the fascia over and vessels, and opens into the superior nasal meatus just
the superior pharyngeal constrictor and posteriorly with the above the root of the middle nasal concha. The foramen rotun-
thick styloid diaphragm, which envelopes the stylopharyngeus, dum opens just below the superior orbital fissure through the
styloglossus, and stylohyoid and blends into the carotid sheath. superior part of the posterior wall of the fossa. The pterygoid
The superior border is located where the two fascial sheets fuse canal opens through the sphenoid pterygoid process inferome-
together and insert in the skull base along a line extending dial to the foramen rotundum and conveys the vidian nerve
backward from the pterygoid process lateral to the origin of the carrying autonomic fibers to the pterygopalatine ganglion. The
tensor veli palatini, medial to the foramina ovale and spin- maxillary nerve, after entering the fossa, gives off ganglionic
osum to the sphenoid spine and the posterior margin of the gle- branches to the pterygopalatine ganglion. It then deviates lat-
noid fossa. The sharply angled inferior boundary is situated at erally just beneath the inferior orbital fissure, giving rise to, in
the junction of the posterior digastric belly and the greater order, the zygomatic and posterosuperior alveolar nerves out-
hyoid cornu. The poststyloid part, which contains the internal side of the periorbita. It then turns medially as the infraorbital
carotid artery, internal jugular vein, and the initial extracranial nerve, passing through the inferior orbital fissure to enter the
segment of cranial nerves IX through XII, is separated from the infraorbital groove, where the anterior and middle superior
infratemporal fossa by the posterolateral portion of the presty- alveolar nerves arise. Finally, it exits the infraorbital foramen to
loid part. The glossopharyngeal nerve exits the skull through terminate on the cheek. The pterygopalatine ganglion, located
the intrajugular part of the jugular foramen, anterior to the in front of the pterygoid canal and inferomedial to the maxil-
vagus and accessory nerves, and passes forward, medial to the lary nerve, receives communicating rami from the maxillary
styloid process in close relationship to the lateral surface of the nerve and gives rise to the greater and lesser palatine nerves
carotid artery as the artery enters the carotid canal (Fig. 1-9). from the lower surface of the ganglion, the sphenopalatine
Care is required to avoid injury to the glossopharyngeal nerve nerve and pharyngeal branch from the medial surface, and the
if the artery is to be mobilized at the carotid canal. The vagus orbital branch from the superior surface. The vidian nerve is
nerve leaves the skull through the anteromedial edge of the formed by the union of the greater petrosal nerve, which con-
intrajugular part of the foramen and courses deep within the veys parasympathetic fibers arising from the facial nerve at the
carotid sheath, between the internal carotid artery and the level of the geniculate ganglion, and the deep petrosal nerve,
jugular vein. The accessory nerve exits the intrajugular part which conveys sympathetic fibers from the carotid plexus, to
and runs backward, lateral to the jugular vein and medial to reach the lacrimal gland and nasal mucosa. The parasympa-
the styloid process and the posterior belly of the digastric mus- thetic fibers synapse in the pterygopalatine ganglion, whereas
cle, to innervate the sternocleidomastoid muscle. the sympathetic fibers do not. The sympathetic fibers synapse
The hypoglossal nerve exits through the hypoglossal canal, in the superior cervical sympathetic ganglion.
deep to the jugular vein and to the nerves emerging from the The third or pterygopalatine segment of the maxillary
jugular foramen, and runs downward, between the carotid artery enters the pterygopalatine fossa by passing through
artery and the jugular vein (Figs. 1-9 and 1-10). It becomes the pterygomaxillary fissure. This segment courses in an
superficial at the level of the angle of the jaw where it crosses anterior, medial, and superior direction and gives rise to the
the internal and external carotid arteries, close to the level of infraorbital artery, which passes through the inferior orbital
the common carotid bifurcation, to innervate the tongue. fissure and courses with the infraorbital nerve; the posterosu-
perior alveolar artery, which descends to pierce the postero-
Pterygopalatine Fossa lateral wall of the maxilla; the recurrent meningeal branches,
The pterygopalatine fossa, which opens laterally into the which pass through the foramen rotundum; and the greater
medial part of the infratemporal fossa, is bounded posteriorly and lesser palatine arteries, which descend through the
by the sphenoid pterygoid process, medially by the palatine greater and lesser palatine canals; the vidian artery to the
perpendicular plate, that bridges the interval between the max- pterygoid canal; the pharyngeal branch to the palatovaginal

RHOTON
canal; and finally the sphenopalatine artery, which passes to its terminal bifurcation into the maxillary and the superficial
through the sphenopalatine foramen to reach the nasal cav- temporal arteries, it gives rise to six branches that can be
ity and is considered to be the terminal branch of the maxil- divided into anterior and posterior groups according to their
lary artery because of its large diameter. The arterial struc- directions. The latter group is related to the region of the tem-
tures in the pterygopalatine fossa are located anterior to the poral bone.
neural structures. The ascending pharyngeal artery, the first branch of the pos-
terior group, often provides the most prominent supply to the
Arterial Relationships meninges around the jugular foramen (18). It arises either at the
The arteries that may be involved in pathological abnormal- bifurcation or from the lowest part of the external or internal
ities involving the temporal bone include the upper cervical carotid arteries. Rarely, it arises from the origin of the occipital
and petrous portions of the internal carotid artery, the posteri- artery. It courses upward between the internal and the external
orly directed branches of the external carotid artery, and the carotid arteries, giving rise to numerous branches to neighbor-
upper portion of the vertebral artery. ing muscles, nerves, and lymph nodes. Its meningeal branches
pass through the foramen lacerum to be distributed to the dura
Common Carotid Artery lining the middle fossa and through the jugular foramen or the
The common carotid artery bifurcates into the internal and hypoglossal canal to supply the surrounding dura of the pos-
external carotid arteries at the level of the upper border of the terior cranial fossa. The ascending pharyngeal artery also gives
thyroid cartilage. The internal carotid artery initially ascends rise to the inferior tympanic artery, which reaches the tympanic
relatively superficial in the carotid triangle of the neck, but cavity by way of the tympanic canaliculus along with the tym-
assumes a much deeper position after passing medial to the panic branch of the glossopharyngeal nerve.
posterior belly of the digastric (Figs. 1-9 and 1-10). Below the The occipital artery, the second and largest branch of the
digastric, it is crossed by the hypoglossal nerve and the ansa posterior group, arises from the posterior surface of the exter-
cervicalis, and by the lingual and facial veins. Medial to the nal carotid artery and courses obliquely upward between the
digastric, it is crossed by the stylohyoid muscle and the occip- posterior belly of the digastric muscle and the internal jugular
ital and posterior auricular arteries. Superior to the digastric, vein, and then medial to the mastoid process and either super-
the internal carotid artery is separated from the external carotid ficial or deep to the longissimus capitis muscle (Fig. 1-5). It
artery by the styloid process and the muscles attached to it. At courses deep to the latter muscle if it courses in the occipital
the entrance into the carotid canal, the artery is involved by a groove of the mastoid bone, which is located medial to the
dense sheath of connective tissue and is separated from the digastric groove. After passing the longissimus capitis muscle,
internal jugular vein by the hypoglossal nerve and by the the occipital artery courses deep to the splenius capitis muscle,
nerves exiting from the jugular foramen. finally reaching a subcutaneous location by piercing the fascia
The internal carotid artery passes, almost straightly upward, between the attachment of the sternocleidomastoid and the
posterior to the external carotid artery and anteromedial to the trapezius muscles to the superior nuchal line. The occipital
internal jugular vein to reach the carotid canal. At the level of artery gives rise to several muscular and meningeal branches,
the skull base, the internal jugular vein courses just posterior to anastomoses with other branches of the external carotid includ-
the internal carotid artery, being separated from it by the ing the ascending pharyngeal and superficial temporal and
carotid ridge. Between them, the glossopharyngeal nerve is also with branches of the vertebral artery. Its meningeal
located laterally and the vagus, accessory, and hypoglossal branches, which enter the posterior fossa through the jugular
nerves medially. foramen or the condylar canal, may make a significant contri-
After the internal carotid artery enters the carotid canal with bution to tumors of the jugular foramen.
the carotid sympathetic nerves and surrounding venous The posterior auricular artery, the last branch in the posterior
plexus, it ascends a short distance (the vertical segment), reach- group, arises above the posterior belly of the digastric muscle
ing the area below and slightly behind the cochlea, where it and travels between the parotid gland and the styloid process.
turns anteromedially at a right angle (the site of the lateral At the anterior margin of the mastoid process, it divides into
bend) and courses horizontally (the horizontal segment) auricular and occipital branches, which are distributed to the
toward the petrous apex (Figs. 1-8-1-10). At the medial edge of postauricular and the occipital regions, respectively. The stylo-
the foramen lacerum, it turns sharply upward at the site of the mastoid branch, which arises below the stylomastoid foramen,
medial bend to enter the posterior part of the cavernous sinus. enters the stylomastoid foramen to supply the facial nerve. Its
The petrolingual ligament, which extends from the lingual loss can lead to a facial palsy, even though it anastomoses with
process of the sphenoid bone to the petrous apex, crosses above the petrosal branch of the middle meningeal artery. The poste-
the junction of the petrous and cavernous carotid. rior auricular branch may share a common trunk with the
occipital artery, or sometimes it is absent, in which case, the
External Carotid Artery occipital artery gives rise to the stylomastoid artery. Members
The external carotid artery ascends anterior to the internal of the anterior group, whose origins may be visualized in
carotid artery on the posteromedial margin of the parotid gland exposing lesions in the region, include the superior thyroid,
and medial to the digastric and stylohyoid muscles. Proximal lingual, and facial arteries.

The superficial temporal artery arises from the external area. It consists of one or more channels that, at its lower end,
carotid artery in the substance of the parotid gland behind the course rostral or caudal to or between the nerves passing
neck of the mandible where it is crossed by the temporal and through the jugular foramen. It enters the medial wall of the
zygomatic branches of the facial nerve (Fig. 1-5). It ascends jugular bulb just anterior to where the cranial nerves descend
over the posterior root of the zygoma and divides into anterior in the anteromedial wall of the jugular bulb (18). It joins the
and posterior branches that run with the superficial temporal cavernous sinus at its upper margin. The transverse sinus
vein and the auriculotemporal nerve over the superficial tem- begins at the level of the internal occipital protuberance and
poralis fascia. passes laterally and forward to the posterolateral part of the
temporal bone where it joins the superior petrosal sinus and
Vertebral Artery continues as the sigmoid sinus. It receives drainage from the
The vertebral artery, above the transverse foramen of the tentorial surface of the cerebellum through the tentorial
axis, veers laterallt to reach the transverse foramen of the atlas, sinuses and from the temporal lobe through the vein of Labbé.
which is situated further lateral than the transverse foramen of The basilar venous plexus consists of multiple interconnecting
the axis. The artery, after ascending through the transverse channels situated between the layers of dura mater on the
process of the atlas, is located on the medial side of the rectus clivus. It forms the largest communication between the paired
capitis lateralis muscle. From here, it turns medially behind cavernous sinus and communicates through the inferior pet-
the lateral mass of the atlas and the atlanto-occipital joint and rosal sinuses with the sinuses in the region of the foramen
is pressed into the groove on the upper surface of the posterior magnum (10).
arch of the atlas. The first cervical nerve courses on the lower
surface of the artery between the artery and the posterior arch SURGICAL APPROACHES
of the atlas. After passing medially above the lateral part of the
posterior arch of the atlas, the artery enters the vertebral canal The suboccipital retrosigmoid and far lateral approaches to
by passing below the lower, arched border of the posterior intradural pathologies arising in the region of the cerebello-
atlanto-occipital membrane, which transforms the sulcus in pontine angle, lower clivus, and foramen magnum, are
which the artery courses on the upper edge of the posterior reviewed later in this volume. The approaches reviewed here
arch of the atlas into an osseofibrous casing that may ossify, are those directed through the temporal bone.
transforming it into a complete or incomplete bony canal sur-
rounding the artery. Middle Fossa Approach
Opening the dura exposes the intradural segment of the ver-
The middle fossa approach to the internal acoustic meatus
tebral artery. As the artery pierces the dura, it is encased in a
is usually selected for small tumors that are located predom-
fibrous tunnel that binds the posterior spinal artery, dentate
inantly within the internal acoustic meatus in which there is
ligament, first cervical nerve, and the spinal accessory nerve to
an opportunity to preserve hearing. With this approach, the
the vertebral artery. Care should be taken to preserve the pos-
meatus is approached from above, through a temporal cran-
terior spinal artery during the dural opening and mobilization
iotomy located above the ear and zygoma (Figs. 1-7 and 1-11)
of the vertebral artery because it may be incorporated into the
(2). The dura under the temporal lobe is elevated from the
dural cuff around the vertebral artery. The intradural segment floor of the middle cranial fossa until the arcuate eminence
of the vertebral artery, after emerging from the fibrous dural and the greater petrosal nerve are identified. The distance
tunnel, ascends in front of the rootlets of the hypoglossal nerve from the inner table of the skull to the facial hiatus, through
to reach the front of the medulla. Oblongata where it unites which the greater petrosal nerve passes, ranges from 1.3 to 2.3
near the junction of pons and medulla with its mate to form the cm (average, 1.7 cm) (42). When separating the dura from the
basilar artery. Before reaching the lower border of pons, the floor of the middle fossa, one should remember that bone
vertebral artery gives off the PICA, which courses backward may be absent over all or part of the geniculate ganglion. In
around the lateral surface of the medulla and between the our previous study of 100 temporal bones, all or part of the
rootlets of glossopharyngeal, vagus, and accessory nerves. geniculate ganglion and the genu of the facial nerve were
found to be exposed in the floor of the middle fossa in 15
Venous Relationships bones (15%) (31). In 15 other specimens, the geniculate gan-
The venous drainage of the structures of the skull base is glion was completely covered, but no bone extended over the
through the internal jugular veins, the sinuses in the dura greater petrosal nerve. The greatest length of greater petrosal
mater, and a series of emissary veins communicating the intra- nerve covered by bone was 6.0 mm. More than 50% of the
and extracranial compartments (25). The superior petrosal specimens had less than 2.5 mm of greater petrosal nerve cov-
sinus sits on the petrous ridge and connects the cavernous ered. It also is important to remember that the petrous seg-
and transverse sinuses. It receives tributaries from the inferior ment of the carotid artery may be exposed without a covering
surface of the temporal lobe and from the petrosal veins that of bone in the floor of the middle fossa deep to the greater
drain the cerebellum and brainstem. The inferior petrosal sinus petrosal nerve (17) In a previous study, we found that a 7-mm
courses along the petro-occipital fissure and drains the clival length of petrous carotid artery may be exposed without a

RHOTON
FIGURE 1-11. Middle fossa approach to the internal acoustic meatus. A, the and lateral canals and the meatal segment of the facial nerve. E, the vestibule
vertical line shows the site of the scalp incision and the stippled area outlines and semicircular canals are located posterolateral and the cochlea is located
the bone flap bordering the middle fossa floor. B, the dura has been elevated anteromedial to the meatal fundus. The tensor tympani is layered along the
to expose the middle meningeal artery, the greater petrosal nerve, and the anterior edge and the greater petrosal nerve above the petrous carotid. F,
arcuate eminence. C, bone has been removed to expose the junction of the enlarged view. The vertical crest (Bill’s bar) separates the facial and superior
greater petrosal nerve and the geniculate ganglion. A portion of the upper vestibular nerves at the meatal fundus. The superior and inferior vestibular
wall of the internal meatus has been removed. The upper surface of the arcu- nerves are located posteriorly and the facial and cochlear nerves anteriorly in
ate eminence has been drilled to expose the superior semicircular canal. In the the meatus, with the cochlear nerve passing below the facial nerve to enter the
middle fossa approach, for an acoustic neuroma, the cochlea and semicircular modiolus. The labyrinthine segment of the facial nerve courses superolateral
canal are not opened, as seen in this dissection illustrating some of the impor- to the cochlea. A., artery; Ac., acoustic; Arc., arcuate; Car., carotid; CN, cra-
tant structures that are to be avoided in opening the meatus. D, enlarged nial nerve; Coch., cochlear; Emin., eminence; Gang., ganglion; Genic.,
view. The cochlea, located below the middle fossa floor in the angle between geniculate; Gr., greater; Inf., inferior; Int., internal; Laby., labyrinthine;
the facial and greater petrosal nerves, has been opened in the area anterome- M., muscle; Meat., meatal; Men., meningeal; Mid., middle; N., nerve; Pet.,
dial to the meatal fundus. The roof of the meatus has been opened to expose petrosal, petrous; Post., posterior; Seg., segment; Sup., superior; Tens., ten-
the superior vestibular nerve, which innervates the ampullae of the superior sor; Tymp., tympani; Vert., vertebral; Vest., vestibular.

bony covering in the area below where the greater petrosal Subtemporal Anterior Transpetrosal Approach
nerve passes below the lateral margin of the trigeminal gan- This approach is made through a temporal or orbitozygo-
glion to reach the vidian canal at the anterior margin of the matic craniotomy that extends down to the floor of the middle
anterior margin of the foramen lacerum (30, 31). The foramen fossa (Figs. 1-12 and 1-13) (19). The dura is carefully elevated
spinosum and middle meningeal artery and the foramen from the floor of the middle fossa to expose the middle
ovale and third trigeminal division are situated at the anterior meningeal artery, which may be obliterated and divided at the
margin of the extradural exposure. The extradural exposure foramen spinosum. Further elevation of the dura toward the
can usually be completed without obliterating the middle petrous ridge will expose the arcuate eminence and greater
meningeal artery at the foramen spinosum. petrosal nerve posteriorly. The cochlea, which is to be pre-
Two different methods are used for exposing the internal
served, and the anterior wall of the internal auditory canal con-
acoustic meatus. One, the older method, is to remove bone
stitute the lateral limit of the exposure through the petrous
over the greater petrosal nerve and to follow it to the genic-
apex. A portion of the bone layer above the superior wall of the
ulate ganglion and the genu of the facial nerve. From here,
internal auditory canal, which averages 5 mm (range, 3–7 mm)
the labyrinthine portion of the facial nerve is followed to
in thickness, can be removed with a drill to improve the expo-
the lateral end of the internal auditory canal, after which
sure (44). The petrous carotid forms the anterior limit of the
the canal is unroofed. The other or preferred method is
exposure. The limit above the medial part of the bone resection
begun by drilling at the petrous ridge above the fundus of
is the trigeminal nerve in Meckel’s cave. Drilling is directed
the meatus in the area medial to the arcuate eminence. The
behind the petrous carotid, through the petrous apex medial to
angle between the long axis of the superior semicircular
the cochlea and under the trigeminal nerve. The petrous apex
canal or the greater petrosal nerve and the long axis of the
is removed and the bone removal is extended to the lateral
internal acoustic meatus is helpful in selecting the site for
side of the clivus, exposing the inferior petrosal sinus at the lat-
drilling. The long axis of the central part of the internal
eral edge of the clivus. Care is required to prevent damage to
acoustic meatus is located an average of 61 degrees behind
the abducens nerve as it passes through Dorello’s canal located
the long axis of the greater petrosal nerve and an average of
at the upper edge of the petroclival fissure. The width of the
37 degrees medial to the long axis of the arcuate eminence
bone resection from the trigeminal impression to the posterior
and superior semicircular canal. The drilling is directed
wall of the internal auditory canal averages 13 mm (range,
anterolateral from the meatal porus to the meatal fundus
where the vertical crest is identified. 9–14 mm) (44). The depth of the exposure, from the trigeminal
The lateral part of the bone removal near the meatal fundus ganglion to the petroclival fissure, averages 13 mm (range,
is limited posteriorly by the superior semicircular canal and 9–17 mm). The cochlea lies below the floor of the middle fossa
vestibule, which are located a few millimeters behind and ori- near the apex of the angle formed by the greater petrosal nerve
ented parallel to the labyrinthine segment of the facial nerve anteriorly and the internal acoustic meatus posteriorly. The
(Figs. 1-7 and 1-11). The anteromedial edge of the exposure is cochlea is to be avoided if hearing is to be preserved.
limited by the cochlea, which sits only a few millimeters ante- After the bone removal is completed, the superior petrosal
rior to the site of bone removal, in the angle between the sinus is obliterated and divided in the area just lateral to the
labyrinthine portion of the facial nerve and the greater petrosal trigeminal nerve, and the dural incision is extended across the
nerve. The cochlea and the semicircular canals should be tentorium. The dural leaflets of the tentorium are retracted with
avoided in this approach if hearing is to be preserved. The ver- sutures and the dural incision is carried downward below the
tical crest, which is identified at the upper edge of the meatal superior petrosal sinus to the lower margin of the opening
fundus, provides a valuable landmark for identifying the facial through the petrous apex. The approach is then directed
nerve. In the final stage of bone removal, the upper wall of the between the lower margin of the trigeminal nerve above, and
internal auditory canal is removed to expose the dura lining the the internal acoustic meatus inferiorly and laterally (20).
entire superior surface of the internal auditory canal from the The exposure is small, as described above, and may require
vertical crest to the porus. The dura is opened to expose the significant temporal lobe retraction, especially if the goal is to
pathology. reach the lower aspect of the brainstem. To reach the anterior
The extended middle fossa approach used for the removal of aspect of the pons, the view must be directed from lateral to
larger acoustic neuromas includes wider opening of the poste- medial above the internal auditory canal. The angles of view
rior part of the petrous pyramid (21, 28, 42, 43). This approach through the area of the petrousectomy can be increased if the
combines different degrees of resection of the bony labyrinth cranium is approached at a higher level through a frontotempo-
with the subtemporal transtentorial routes (Fig. 1-12). ral craniotomy combined with zygomatic arch resection.
Extending the resection of the petrous bone posteriorly over the
mastoid and the bony labyrinth exposes the whole intrapetrous Translabyrinthine Approach
course of the facial nerve, and provides access to the cerebello- In the translabyrinthine approach, the internal acoustic mea-
pontine angle by a combination of subtemporal, trans- tus and cerebellopontine angle are approached through a mas-
labyrinthine, and presigmoid routes, all directed through the toidectomy and labyrinthectomy (Fig. 1-6) (16, 29, 38) There
posterior part of the floor of the middle fossa. are two goals of bone removal in this approach. The first is to

RHOTON
FIGURE 1-12. A–D, anterior petrosectomy and extended middle fossa

approach. A, the site of the bone flap is the same as shown in Figure 1-11A. 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 inter-
nal acoustic meatus has been removed to expose the side of the clivus. C, the
exposure under the trigeminal nerve extends to the edge of the inferior petrosal
sinus. D, the posterior fossa dura has been opened to expose the prepontine cis-
tern, basilar artery, and abducens nerve. (Continues)
expose the dura of Trautman’s triangle on the posterior surface facial nerve as it exits the stylomastoid foramen and the sin-
of the temporal bone facing the cerebellopontine angle. The odural angle. Drilling is continued to expose the semicircular
second is to remove enough bone to be able to identify the canals and to skeletonize the sigmoid sinus, middle fossa dura,
nerves lateral to the tumor as they course through the internal mastoid segment of the facial nerve, and the upper surface of
auditory canal and by the transverse and vertical crests. The the jugular bulb, leaving only a thin shell of bone over these
approach may also be combined with a retrosigmoid or a structures. The lateral semicircular canal is the most laterally
supra- and infratentorial presigmoid approach. projecting canal and is the first one encountered by this
A retroauricular incision starts above the pinna and extends approach. It provides a valuable landmark in identifying the
inferiorly to the mastoid tip (3). A flap of periosteum and soft tympanic segment of the facial nerve and the other canals. The
tissues overlying the mastoid and retromastoid areas is ele- nerve is found below the lateral canal. The retrofacial air cells
vated. The cortical bone over the mastoid is drilled away and are removed and the dome of the jugular bulb is identified
the mastoid air cells are removed, exposing the mastoid inferiorly. In removing bone behind the internal acoustic mea-
antrum, the cortical bone around the labyrinth, and the digas- tus, it is important to remember that the jugular bulb may
tric ridge leading anteriorly to the mastoid segment of the bulge upward behind the posterior semicircular canal or inter-

FIGURE 1-12. (Continued) E–H, anterior petrosectomy and extended mid- exposed. H, this extended middle fossa exposure extends from the lateral wall
dle fossa approach. E, additional bone has been removed around the internal of the cavernous sinus, across the trigeminal nerve to the area lateral to the
acoustic meatus and the dura opened to expose the facial and vestibulo- internal acoustic meatus, and provides wide access to the anterior part of the
cochlear nerves. F, the exposure has been extended lateral to the internal posterior fossa. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar
acoustic meatus. The tegmen has been opened to expose the head of the incus artery; Bas., basilar; Car., carotid; Cav., cavernous; Chor., chorda; CN, cra-
in the epitympanic area. The osseous capsule of the labyrinth has been opened nial nerve; Ext., external; Gang., ganglion; Gen., geniculate; Genic., genic-
to expose the semicircular canals. The presigmoid dura behind the labyrinth ulate; Inf., inferior; Int., internal; Laby., abyrinthine; Lat., lateral; M., mus-
has been exposed and opened. G, a translabyrinthine approach directed cle; Mast., mastoid; Men., meningeal; Mid., middle; N., nerve; P.C.A.,
through the middle fossa has been completed by removing the semicircular posterior cerebral artery; Pet., petrosal, petrous; P.I.C.A., posteroinferior
canals and vestibule. The dura has been opened to give an exposure through cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg.,
the middle fossa similar to that seen with the presigmoid approach. The segment; Sup., superior; Tens., tensor; Tymp., tympani; Tent., tentorial;
labyrinthine, tympanic, and mastoid segments of the facial nerve have been Trig., trigeminal; Tymp., tympani, tympanic.
nal auditory meatus. The vestibular aqueduct and the ally, the ampullae of the lateral and superior semicircular
endolymphatic sac may be opened and removed during the canals are exposed. At this point some bleeding can occur as
bone removal between the meatus and the jugular bulb. The the subarcuate artery is encountered in the bone near the cen-
cochlear canaliculus will be seen deep to the vestibular aque- ter of the superior semicircular canal. The vestibule is an oval-
duct as bone is removed in the area between the meatus and shaped cavity located immediately lateral to the internal
the jugular bulb. The lower end of the cochlear canaliculus is acoustic meatus, which forms the communication between the
situated just above the area where the glossopharyngeal nerve semicircular canals and the cochlea. Bone is removed medial
enters the medial half of the jugular foramen. The labyrinthec- and posterior to the vestibule, completely exposing it anterior
tomy portion of the procedure involves removing the semicir- and inferior to the facial nerve. Care is required to avoid injury
cular canals and the vestibule to expose the dura lining the to the facial nerve as it courses below the lateral canal and the
internal auditory canal. The lateral and posterior semicircular ampullae of the posterior canal and around the superolateral
canals are drilled away. As the bone removal proceeds medi- margin of the vestibule.

RHOTON
FIGURE 1-13. A–F, subtemporal exposure of the right middle, infratem- the vestibule with which both ends of the semicircular canals communicate.
poral, and posterior fossae. A, the insert shows the side of the scalp incision. The vestibule contains the utricle and saccule and communicates below the
A frontotemporal craniotomy has been completed and the dura has been ele- fundus of the meatus with the cochlea. The meatal segment of the facial
vated from the middle fossa floor and lateralwall of the cavernous sinus. B, nerve courses in the internal acoustic meatus, the labyrinthine segment
enlarged view. The bony roof over the geniculate ganglion and internal between the semicircular canals and the cochlea, the tympanic segment
meatus has been removed and the dura lining the meatus opened to expose between the anterior margin of the lateral canal and the oval window on the
the facial and superior vestibular nerves. C, additional middle fossa floor medial side of the tympanic cavity, and the mastoid segment descends to
has been removed to expose the petrous carotid, the cochlea in the angle exit the stylomastoid foramen. E, the petrous apex, medial to the cochlea and
between the greater petrosal nerve and pregeniculate part of the facial nerve, extending under the trigeminal nerve, has been removed to expose the lat-
the semicircular canals and tympanic cavity. The tensor tympani muscle eral edge of the clivus and the posterior fossa dura. F, the medial tentorial
and eustachian tube are exposed in front of the petrous carotid artery. D, the edge has been divided behind the petrous ridge to expose the oculomotor,
bone between the superior and posterior canals has been removed to expose trochlear, and trigeminal nerves and the basilar artery. (Continues)

FIGURE 1-13. (Continued) G–L, subtemporal exposure of the right middle, pani have been resected, the petrous carotid reflected forward out of the carotid
infratemporal, and posterior fossae. G, the dural opening has been extended canal, the petrous apex removed, and the posterior fossa dura opened to expose
downward to expose the lateral edge of the clivus and the inferior petrosal the vertebral artery and the AICA. L, enlarged view. The right vertebral
sinus coursing along the petroclival fissure. The abducens nerve and the artery has been displaced forward to expose the left vertebral artery. The
AICA are in the lower margin of the exposure. H, an osteotomy of the zygo- AICA passes toward the nerves entering the internal acoustic meatus. A.,
matic arch and the floor of the middle fossa surrounding the mandibular artery; A.I.C.A., anteroinferior cerebellar artery; Alv., alveolar; Ant., ante-
fossa has been completed to aid in exposing the infratemporal fossa. I, the rior; Bas., basilar; Car., carotid; Chor., chorda, choroidal; CN, cranial nerve;
mandibular fossa and floor of the middle fossa, extending medially to the level Comm., communicating; Eust., eustachian; Gang., ganglion; Gen., genic-
of the foramen ovale, have been removed. Branches of the mandibular nerve ulate; Genic., geniculate; Gr., greater; Inf., inferior; Int., internal; Jug.,
and maxillary artery are exposed in the infratemporal fossa. The greater pet- jugular; Laby., labyrinthine; Lat., lateral; M., muscle; Mandib., mandibu-
rosal nerve joins the deep petrosal nerve from the carotid sympathetic plexus lar; Mast., mastoid; Max., maxillary; Meat., meatal; Men., meningeal; Mid.,
to form the vidian nerve, which passes forward in the vidian canal to reach middle; N., nerve; P.C.A., posterior cerebral artery; Pet., petrosal, petrous;
the pterygopalatine fossa. J, the upper portion of the cervical carotid is Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; Sup.,
exposed medial to the jugular foramen. The petrous carotid crosses behind the superior; Temp., temporal; Tens., tensor; Trig., trigeminal; Tymp., tym-
eustachian tube and tensor tympani. K, the eustachian tube and tensor tympani, tympanic; V., vein; Vert., vertebral; Vest., vestibular.

RHOTON
The internal auditory canal is located medial and anterior to An alternative to transposing the facial nerve is to complete
the tympanic segment of the facial nerve. The dura lining the an extensive bone removal in the hypotympanic and retrofacial
internal canal is exposed by drilling away the semicircular areas extending forward to the carotid canal, thus skeletonizing
canals and vestibule and the bone around the superior, poste- the mastoid segment of the facial nerve and leaving it sus-
rior, and inferior margins of the internal canal. Further bone pended in a shell of bone, as described by Gantz and Fisch (7).
removal at the lateral end of the meatus exposes the transverse In this approach, the external auditory canal is closed as a blind
and vertical crests (Fig. 1-2). The intrameatal portion of the sac and the tympanic membrane, incus, and body of the
facial nerve is separated from the superior vestibular nerve at malleus are removed (7). A mastoidectomy is performed,
the lateral end of the canal by the vertical crest, also called including the removal of the retrofacial, retrolabyrinthine, and
Bill’s bar, that can be used to positively identify the facial nerve supralabyrinthine compartments. The facial nerve is identified
(13, 16). The initial part of labyrinthine segment of the facial at its tympanic segment and at the stylomastoid foramen. The
nerve, which lies just in front of the vertical crest, is exposed at inferior part of the tympanic bone is removed to expose the
the meatal fundus. After identifying the facial nerve, the dura infralabyrinthine compartment, the jugular bulb, and the
lining the meatus is opened. The dural incision in Trautman’s intrapetrous carotid artery. The retrofacial dissection is carried
triangle is V-shaped with the apex of the “V” extending to the medially and superiorly, removing the semicircular canals and
incision along the meatal dura. One limb of the “V” extends vestibule. The dissection of the posterior fossa dura is carried
below the superior petrosal sinus and the other limb extends inferiorly around the internal auditory canal and under the
above the jugular bulb. The dural flap is then reflected posteri- facial canal. The cochlea is drilled away by working inferior
orly to expose the structures in the meatus and the cerebello- and anterior to the facial canal. The facial canal is then left as a
pontine angle. The subarcuate artery, or the AICA, may be bridge over the operative field and the dura is exposed
encountered in the dura of Trautman’s triangle. Usually, the between the carotid artery and the jugular bulb.
subarcuate artery arises from the AICA and passes through the
dura on the upper posterior wall of the meatus as a fine stem. Combined Supra- and Infratentorial
Occasionally, however, the subarcuate artery, along with its ori- Presigmoid Approach
gin from the AICA, may be incorporated into the dura on the The presigmoid approach combines the supra- and infraten-
posterior face of the temporal bone. The approach may include torial craniotomy centered on the mastoid and varying degrees
transection of the external canal and obliteration of the middle of mastoid and labyrinthine resection (Fig. 1-14). The minimal
ear with packing of the eustachian tube at closure. degree of mastoid resection, which we refer to as a minimal
mastoidectomy, exposes only enough of the presigmoid dura to
Transcochlear Approach open the dura in front of the sigmoid sinus for exposure of the
The transcochlear approach is primarily an anteromedial cerebellopontine angle (Figs. 1-15 and 1-16). The next more
extension of the translabyrinthine approach (Fig. 1-6) (3, 15, extensive degree of mastoid resection, the retrolabyrinthine
16). It usually includes division and closure of the external modification, is a more complete mastoidectomy exposing the
canal, resection of at least the posterior part of the osseous bony capsule of the semicircular canals and skeletonizing at
external canal, and the tympanic membrane and ossicles, and least a portion of the facial nerve. In the partial labyrinthec-
obliteration of the eustachian tube. After exposing the dura lin- tomy, one or two of the semicircular canals, commonly the
ing the internal auditory canal, as described for the superior and/or posterior canals, are resected with preserva-
translabyrinthine approach, the incus is removed and the facial tion of the lateral canal. Removal of these canals may, but not
nerve is exposed from the geniculate ganglion to the stylomas- always, be associated with the loss of hearing (37). The poste-
toid foramen. The greater superficial petrosal nerve is tran- rior canal may be removed to increase access to the posterior
sected and the facial nerve is transposed posteriorly. In the fossa, and removing the superior canal alone gives a more
final stage, the bone removal is carried through the facial canal, direct access to the petrous apex along the middle fossa. The
after nerve transposition, and the cochlea and adjacent part of next more extensive modification is the translabyrinthine
the petrous apex are drilled away (Fig. 1-6). approach, in which the semicircular canals and vestibule are
Medially, the bone removal extends to the edge of the clivus, resected uniformly, resulting in the loss of hearing. The
exposing the inferior petrosal sinus from the jugular bulb translabyrinthine approach provides excellent access to the
below to the superior petrosal sinus above. The ascending por- internal auditory canal. The next more extensive modification
tion of the petrous carotid is exposed at the anterior limit of the is the transcochlear approach, in which the cochlea located
dissection. The bone removal, which now extends to the lateral anteromedial to the fundus of the meatus is removed, thus pro-
edge of the clivus, could easily be carried medially into the viding access to the medial part of the petrous apex and the
clivus. Extending the dural opening in this area permits visu- side of the clivus. Another modification, which we call the
alization of the abducent nerve medial to the internal acoustic extended translabyrinthine approach, and is similar to the
meatus, the lower margin of the trigeminal nerve, the nerves transcochlear approach, involves drilling bone both anterior
entering the jugular foramen, a segment of the basilar artery, and posterior to the facial nerve, leaving the facial nerve skele-
and the origin and initial segment of the AICA. tonized in a column of bone and working both anterior and

FIGURE 1-14. A–D, presigmoid approach.

A, the insert shows the temporo-occipital cran-
iotomy and the mastoid exposure. The mas-
toidectomy has been completed and the dense
cortical bone around the labyrinth has been
exposed. The tympanic segment of the facial
nerve and the lateral canal are situated deep to
the spine of Henley. 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 pre-
serve 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 oculo-
motor and trochlear nerves and above the
trigeminal nerve. C, the semicircular canals
have been opened. The superior canal is located
under the middle fossa’s arcuate eminence and
the posterior canal is located immediately lat-
eral to the posterior wall of the internal acoustic
meatus. D, labyrinthine exposure in another
specimen. The tympanic segment of the facial
nerve courses below the lateral canal and turns
downward as the mastoid segment where it
gives origin to the chorda tympani, seen
ascending along the inner surface of the tym-
panic membrane and neck of the malleus. The
head of the malleus and incus are located in the
epitympanic area above the level of the tym-
panic membrane. The mastoid antrum commu-
nicates through the aditus with the epitympanic
area and tympanic cavity. (Continues)
posterior to the facial nerve to remove the cochlea and access middle fossa and petrous apex and reduces the needed retrac-
the side of the clivus. Gaining access for drilling the cochlea tion of the temporal lobe. The translabyrinthine approach does
anterior to the facial nerve commonly requires that at least part not significantly increase the access to the area medial to the
of the posterior part of the external canal be removed, that the porus of the internal acoustic meatus over that achieved with
tympanic cavity be obliterated, and that the internal carotid the minimal mastoidectomy or retrolabyrinthine approach, but
artery be exposed below the promontory. does provide access to the internal auditory canal. The
In evaluating these approaches in our laboratory, we have transcochlear modification, in which bone is removed up to the
found that the minimal mastoidectomy gives approximately the edge of the clivus, does significantly increase access to the front
same exposure as the retrolabyrinthine approach, but is done at of the brainstem and clivus over that achieved with the lesser
reduced risk since the semicircular canals and facial nerve are degrees of bony resection. The retrosigmoid, the presigmoid
not skeletonized (Figs. 1-14 and 1-15). Removing the posterior minimal mastoidectomy, and the retrolabyrinthine approaches
canal increases access to the posterior fossa, but access is only were compared and yielded nearly the same exposure of the
slightly increased over that achieved with the retrolabyrinthine cerebellopontine angle, but the retrosigmoid approach did not
approach. Removing the superior canal increases access to the provide the additional exposure of the middle fossa and petrous

RHOTON
FIGURE 1-14. (Continued) E–H, presigmoid

approach. E, the labyrinthectomy has been
completed to expose the internal acoustic mea-
tus. F, the dura lining the meatus has been
opened and the facial nerve has been trans-
posed posteriorly. The facial segments are the
cisternal segment located in the cistern medial
to the meatal porus, the meatal segment that
extends laterally from the porus to the meatal
fundus, the labyrinthine segment that is
located between the fundus and the geniculate
ganglion, the tympanic segment that arises at
the ganglion and the sharp turn, the genu, and
passes between the lateral semicircular canal
and the oval window, and the mastoid segment
that descends to exit the stylomastoid foramen.
The labyrinthine segment courses between the
semicircular canals and vestibule on its pos-
terolateral side and the cochlea on its anterome-
dial margin. The superior and inferior vestibu-
lar nerves have lost their end organs with the
drilling of the semicircular canals and
vestibule. The cochlear nerve passes laterally to
enter the cochlea, which is still preserved in
the bone anteromedial to the fundus of the mea-
tus. G, the cochlear nerve has been divided and
reflected and bone removed to expose the
cochlea. H, the transcochlear exposure, com-
pleted by removing the cochlea and surround-
ing petrous apex, provides access to the front of
the brainstem and vertebrobasilar junction, but
at the cost of loss of hearing due to the
labyrinthectomy and almost certain temporary
or permanent facial weakness associated with
the posterior transposition of the facial nerve.
A., artery; Ac., acoustic; A.I.C.A., anteroinfe-
rior cerebellar artery; Bas., basilar; Br., branch;
Chor., chorda; Cist., cisternal; CN, cranial
nerve; Coch., cochlear; Gang., ganglion;
Genic., geniculate; Inf., inferior; Int., inter-
nal; Jug., jugular; Laby., labyrinthine; Lat.,
lateral; Marg., margin; Mast., mastoid; Meat.,
meatal; Memb., membrane; N., nerve; Pet.,
petrosal; P.I.C.A., posteroinferior cerebellar
artery; Post., posterior; S.C.A., superior cere-
bellar artery; Seg., segment; Sp., spine; Sup.,
superior; Tymp., tympani, tympanic; V., vein;
Vert., vertebral; Vest., vestibular.
apex that could be achieved in the combined supra- and out entering the labyrinth. The sigmoid sinus is skeletonized
infratentorial presigmoid approach. from the sinodural angle to the jugular bulb. Bone is removed
The skin incision is started in the temporal region above the superiorly to expose the floor of the middle fossa and the supe-
zygoma, and extends above the ear and downward in the sub- rior petrosal sinus. Trautman’s triangle is exposed in the area
occipital area medial to the mastoid process (Figs. 1-14, 1-15, lateral to the otic capsule.
and 1-17). The skin flap is reflected forward to the level of the The dura mater is then incised along the base of the tempo-
external auditory canal. The temporal muscle is elevated and ral craniotomy, while preserving the junction of the vein of
reflected anteriorly, and the muscles over the mastoid and sub- Labbé with the transverse sinus. The posterior fossa dura is
occipital areas are swept inferiorly. A temporooccipital cran- opened anterior to the sigmoid sinus in Trautman’s triangle.
iotomy is performed and the transverse sinus is exposed. After The dural incision is extended across the superior petrosal
the bone flap is elevated, a mastoidectomy is carried out with- sinus to join the dural incision in the temporal dura. After divi-

sion of the superior petrosal sinus,

the tentorium is incised parallel to
and just behind the petrous ridge
and superior petrosal sinus. This
dural incision is extended from the
site of division of the superior pet-
rosal sinus through the medial edge
of the tentorium to the incisura
behind where the trochlear nerve
enters the tentorial edge. Care is
taken to avoid injury to the IVth cra-
nial nerve in its course near the ten-
torial margin. The posterior portion
of the temporal lobe is elevated and
the sigmoid sinus is displaced poste-
riorly along with the cerebellar hemi-
sphere while preserving the junction
of the vein of Labbé with the sig-
moid sinus. The sigmoid sinus limits
the ability for superior retraction of
the temporal lobe and can be ligated
to improve the exposure if bilateral
venous angiography show adequate
communication through the torcular
to the opposite side (24). The petro-
clival region can be exposed from the
middle fossa and tentorial incisura
to near the foramen magnum,
although access to the lower petrocli-
val region may be limited by the
jugular bulb. The presigmoid expo-
sure provides a shorter working dis-
tance to the petroclival area and pro-
vides multiple angles for dissection.
The major arteries in the posterior
fossa are easily accessible. The expo-
sure can also be combined with a far-
lateral approach (Fig. 1-17).
Subtemporal Preauricular
Infratemporal Fossa Approach
The subtemporal preauricular
infratemporal approach is directed FIGURE 1-15. A–D, comparison of the retrosigmoid
through the infratemporal and mid- approach and the minimal mastoidectomy, retro-
dle fossae to the part of the anterior labyrinthine, translabyrinthine, and transcochlear
surface of the petrous bone located approach modifications of the presigmoid approach.
medial to the cochlea and to the A, retrosigmoid approach. The left cerebellum has
petroclival region (Figs. 1-10, 1-13, been elevated to expose the cranial nerves V through
and 1-18). This description outlines XI in the cerebellopontine angle. The illustrations
from each step are to be compared with the views
the full extent of the anatomic expo-
from the other modifications of the approach. B, the
sure available through this approach, facial and vestibulocochlear nerves and the flocculus have been retracted to expose the side of the basilar artery.
but it can often be tailored to a C, for the minimal mastoidectomy, only enough bone is removed in front of the sigmoid sinus to open the pre-
smaller, more limited, approach. A sigmoid dura and divide the superior petrosal sinus and tentorium. D, the presigmoid dura has been opened
curvilinear incision starting in the and the sigmoid sinus has been retracted posteriorly. The view is approximately the same as that seen with
frontal region turns downward in the retrosigmoid exposure. The retrosigmoid approach provides a better view of the nerves entering the jugu-
front of the ear into the cervical lar foramen. (Continues)

RHOTON
FIGURE 1-15. (Continued) E–H, compari-

son of the retrosigmoid approach and the min-
imal mastoidectomy, retrolabyrinthine, trans-
labyrinthine, 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 presig-
moid approach. F, the exposure with the retro-
labyrinthine version does not differ signifi-
cantly from that achieved with the minimal
mastoidectomy. G, the semicircular canals and
vestibule have been removed and the dura lin-
ing the internal acoustic meatus has been
opened to complete the translabyrinthine expo-
sure. This yields an exposure of the internal
acoustic meatus but provides only minimal
improvement in the exposure of the structures
medial to the porus of the meatus. H, the
nerves have been separated beginning laterally
at the fundus of the meatus and extending the
cleavage plane medially toward the brainstem.
The superior vestibular nerve is behind the
facial nerve and the inferior vestibular nerve is
behind the cochlear nerve. (Continues)
region. The incision may be extended downward only to the muscle as the zygomatic arch is exposed. The zygomatic arch is
area just below the tragus if only the petrous apex and upper divided at its anterior and posterior ends, and the temporalis
part of the infratemporal fossa are to be exposed, but it can be muscle, with the overlying segment of the zygomatic arch, is
extended onto the upper neck if a neck dissection is needed. reflected downward. The mandibular condyle and the capsule
The skin flap is separated from the underlying tissues and of the temporomandibular joint are either dislocated down-
reflected forward. The facial nerve and its major branches are ward or excised. The temporomandibular joint can be removed
identified distal to the stylomastoid foramen and followed to in a single piece for later replacement by dividing the mandibu-
the parotid gland. The parotid gland is separated from the mas- lar neck below the condyle and osteotomizing the middle fossa
seteric fascia to avoid excessive stretching of the facial nerve at floor around the mandibular fossa (Fig. 1-18). The internal
the stylomastoid foramen (33, 38, 39). The superficial tempo- carotid artery, the internal jugular vein, and the vagus, acces-
ralis fascia in which the upper facial branches course is sepa- sory, and hypoglossal nerves may be exposed in the neck if
rated from the temporalis muscle and is reflected forward to needed. The posterior belly of the digastric muscle may be
prevent damage to the branch of the facial nerve to the frontalis divided and the styloid process resected.

FIGURE 1-15. (Continued) I and J, compar-

ison of the retrosigmoid approach and the
minimal mastoidectomy, retrolabyrinthine,
translabyrinthine, and transcochlear approach
modifications of the presigmoid approach. I,
the labyrinthine, tympanic, and mastoid seg-
ments of the facial nerve have been exposed in
preparation for the posterior transposition of
the nerve needed to complete the transcochlear
exposure. J, the facial nerve has been trans-
posed and the cochlea and petrous apex
removed to complete the transcochlear expo-
sure of the anterior aspect of the brainstem
and the basilar artery. A., artery; A.I.C.A.,
anteroinferior cerebellar artery; Bas., basilar;
Cist., cisternal; CN, cranial nerve; Coch.,
cochlear; Flocc., flocculus; Inf., inferior;
Laby., labyrinthine; Lat., lateral; Mast., mas-
toid; Meat., meatal; N., nerve; Pet., petrosal;
P.I.C.A., posteroinferior cerebellar artery;
Post., posterior; Presig., presigmoid; S.C.A.,
superior cerebellar artery; Seg., segment; Sig.,
sigmoid; Suboccip., suboccipital; Sup., supe-
rior; Tymp., tympanic; V., vein; Vest.,
vestibular.
A frontotemporal craniotomy is then performed. The dura is Meckel’s cave superiorly, by the cochlea and internal auditory
elevated from the floor of the middle fossa to expose and oblit- canal laterally, by the abducens nerve in its course through the
erate the middle meningeal artery at the foramen spinosum Dorello’s canal medially, and by the hypoglossal canal inferi-
and to expose the arcuate eminence, the third trigeminal divi- orly. If the dura is opened, the structures along the lateral and
sion at the foramen ovale, and the greater petrosal nerve. The anterior aspects of the upper medulla and lower two-thirds of
greater petrosal nerve is transected if necessary to avoid trac- the pons will be exposed (41). The tentorium can be divided to
tion on the facial nerve. The floor of the middle fossa, includ- give access to the upper clival region.
ing the lateral and inferior aspects of the superior orbital fis- Dividing the third trigeminal division above the foramen
sure, and the lateral margin of the foramina ovale may be ovale will permit exposure of the junction of the petrous and
removed to expose the structures in the infratemporal fossa. cavernous carotid along with the structures in the inferolateral
If needed, bone can be removed medial to the mandibular portion of the cavernous sinus (17, 39). The pterygopalatine
fossa to expose the eustachian tube and the tensor tympani fossa, parapharyngeal space, lateral maxilla, and orbit can be
muscle, both of which may be resected (Figs. 1-10, 1-13, and exposed farther anteriorly. The lateral aspect of the sphenoid
1-18). The bone removal is continued inferiorly, exposing the bone and the sphenoid sinus can also be approached by remov-
ascending portion of the petrous carotid. In this segment, the ing bone medial to the maxillary nerve at the root of the ptery-
carotid artery is surrounded by a periosteal sheath, which goid process.
encloses a periarterial venous plexus that is an extension of the
cavernous sinus. At the entrance of the carotid canal, a dense Postauricular Transtemporal Approach
fibrocartilaginous ring encircles the artery. If mobilizationof the The postauricular transtemporal approach is most commonly
artery is required, care must be taken when dividing the ring selected for lesions that involve the mastoid and tympanic
not to damage the IXth cranial nerve that is in close proximity cavities and track along the nerves and arteries to reach the
to the carotid canal as it exits the jugular foramen. After mobi- middle and infratemporal fossa (Figs. 1-19 and 1-20). It can,
lizing the carotid artery and displacing it forward, the petrous however, be tailored at its posterior margin to include a ret-
apex and the clival region to the level of the foramen magnum rosigmoid, far-lateral, or presigmoid exposure of the posterior
can be approached medial to and behind the artery. During fossa or, at its anterior limits, to include exposure of the ptery-
drilling, the very hard cortical bone along the petrous apex gopalatine fossa and lateral parts of the maxillary orbit or ante-
gives place to a crumbly cancellous bone in the region of the rior cranial fossa.
clivus, as the dura of the anterior and lateral aspects of the A question mark incision is started behind the hairline in the
posterior fossa is being exposed. The area exposed is limited by temporal region, extending behind the ear over the mastoid

RHOTON
FIGURE 1-16. A–F, comparison of the retrosigmoid and the various modifi- retracted to expose the nerves in the cerebellopontine angle. B, enlarged view of
cations of the presigmoid exposure. The modifications of the presigmoid the retrosigmoid exposure to compare with the exposure obtained with the var-
approach include the minimal mastoidectomy, retrolabyrinthine, partial ious modification of the presigmoid approach. C, in the retrosigmoid exposure
labyrinthine, translabyrinthine, modified transcochlear, and the full the vestibulocochlear nerve has been elevated and the glossopharyngeal nerve
transcochlear approach with facial nerve transposition. A, the scalp incision depressed to expose the basilar artery at the origin of the AICA. D, subtempo-
(insert) is positioned for a supra- and infratentorial exposure through a tem- ral exposure. The temporal lobe has been elevated to expose the optic tract and
poro-occipital craniotomy. A temporo-occipital craniotomy has been completed oculomotor nerve and the PCA, internal carotid, and anterior choroidal arter-
and the dura opened to expose the temporal lobe and the retrosigmoid area. The ies. E, the tentorium has been opened while preserving the trochlear nerve. The
transverse and sigmoid sinuses have been preserved. The cerebellum has been SCA courses below and the PCA above the oculomotor and (Continues)


RHOTON
FIGURE 1-16. (Continued) trochlear nerves. F, minimal mastoidectomy the infratentorial exposure does not differ significantly from that achieved
modification of the presigmoid approach. The minimal mastoidectomy with the minimal mastoidectomy, as shown in F and G. Removal of the supe-
approach is completed by removing only enough bone in the front of the sig- rior canal reduces the required temporal lobe retraction and aids in the expo-
moid sinus so that the presigmoid dura can be opened to expose the posterior sure along the middle fossa floor and petrous apex. M, translabyrinthine
cranial fossa. The bony capsule of the labyrinth is not exposed in the minimal exposure in which the semicircular canals and the vestibule have been
mastoidectomy as it is in the retrolabyrinthine approach. The exposure shown removed. This adds the internal auditory canal to the exposure, but does not
with the minimal mastoidectomy in this figure is to be compared with the ret- improve the exposure of the structures medial to the meatus, as compared with
rosigmoid exposure shown in B. G–N, comparison of the retrosigmoid and the minimal mastoidectomy or even the retrosigmoid approach. N, the facial
the various modifications of the presigmoid exposure. G, deep exposure with nerve has been transposed posteriorly out of the field and the cochlea has been
the minimal mastoidectomy with retraction of the vestibulocochlear and glos- removed to complete the transcochlear approach. This approach greatly
sopharyngeal nerves, to be compared with the retrosigmoid approach shown improves access to the front of the brainstem, clivus, and basilar artery, but
in C. The exposure is similar to that obtained with the retrosigmoid approach. is done at the cost of a temporary or permanent facial paralysis and loss of
H, retrolabyrinthine approach in which more extensive drilling of the mastoid hearing. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery;
has been completed to expose the osseous capsule of the semicircular canals. Ant., anterior; Bas., basilar; Car., carotid; Chor., choroidal; CN, cranial
I, the dura has been folded forward after completing the retrolabyrinthine nerve; Comm., communicating; Inf., inferior; Int., internal; Lat., lateral;
exposure. The exposure differs little from that obtained with the minimal Mast., mastoid; P.C.A., posterior cerebral artery; Ped., peduncle; Pet., pet-
mastoidectomy exposure shown in F and G. J, the exposure with the poste- rosal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; S.C.A.,
rior canal partial labyrinthectomy is similar to that achieved with the mini- superior cerebellar artery; Seg., segment; Sig., sigmoid; Sup., superior;
mal mastoidectomy. K, the partial labyrinthectomy has been extended by Temp., temporal; Tent., tentorial; Tr., trunk; Trans., transverse; V., vein;
removing the superior canal in addition to removal of the posterior canal. L, Vert., vertebral.
process and continuing inferiorly in front of the sternocleido- and the sigmoid sinus divided. Part of the wall of the sinus,
mastoid muscle onto the neck. The skin flap is then reflected bulb, and/or vein may be excised to increase the exposure.
forward and the external auditory canal is divided at the bone- This allows for dissection of the lower cranial nerves at the
cartilage junction and closed as a blind sac. The sternocleido- jugular foramen, as well as for their mobilization and posterior
mastoid muscle is detached from the mastoid process and displacement if necessary. The posterior mobilization of the
reflected inferiorly. The periosteum and posterior portion of lower cranial nerves allows for a direct exposure of the struc-
the temporalis muscle are reflected anteriorly, thus exposing tures along the lateral and anterior aspects of the medulla and
the temporal, mastoid, and retromastoid areas. The posterior lower pons without the necessity for brain retraction.
belly of the digastric muscle is divided and reflected inferiorly. Dissection in the area of the jugular foramen has proven to be
At this point, the facial nerve is identified distal to the stylo- extremely difficult, as the lower cranial nerves are particularly
mastoid foramen and is followed, along with its major fragile and difficult to isolate from the surrounding tissues.
branches, into the substance of the parotid gland (5). The inter- Exposure of the middle clival structures requires removal of
nal jugular vein, the carotid bifurcation, and the glossopharyn- the bony labyrinth, as described for the translabyrinthine
geal, vagus, accessory, and hypoglossal nerves are exposed approach. The internal auditory canal is exposed, the facial nerve
and isolated in the neck. This allows for proximal control of identified, and the cochlear and vestibular nerves divided. The
the internal carotid artery and ligation of the main feeding greater superficial petrosal nerve is sectioned at its origin from
vessels from the external carotid artery to a neoplasm early in the geniculate ganglion. The facial nerve is freed from all its
the procedure. attachments in the temporal bone and reflected posteriorly. The
After this, temporal and/or retromastoid craniotomies may bony portion of the external auditory canal and the tympanic
be performed with a simple mastoidectomy. The remaining bone are drilled away, exposing the ascending portion of the
skin of the external auditory canal, the tympanic membrane, intrapetrous carotid artery medial to the eustachian tube.
the malleus, incus, and stapes arch (leaving the footplate) are The dissection is continued by drilling away the cochlea,
removed. The facial nerve is completely skeletonized from the starting at its basal turn, to expose part of the horizontal seg-
geniculate ganglion to the stylomastoid foramen. ment of the petrous carotid artery. Anterior displacement of the
If exposure of the jugular foramen and lower clival region is carotid artery and removal of the cochlea provides a wide expo-
desired, a new facial canal is created by drilling a groove in the sure of the lateral and anterior portions of the pons and
bone of the anterior attic wall, between the geniculate ganglion medulla. This exposure extends from the inferior aspect of the
and the root of the zygoma. The facial nerve is carefully freed at trigeminal ganglion to the foramen magnum. The exposure may
the stylomastoid foramen, while leaving some of the surround- be carried medially into the clivus and retropharyngeal space
ing connective tissue attached to the nerve, and the nerve is and anteriorly to expose the mucosa of the sphenoid sinus.
transposed anteriorly into the new bony groove of the epitympa- If the approach is to be extended to the parasellar and paras-
num and imbedded for its protection into the parotid tissue (5). phenoidal areas, the zygomatic arch is divided and reflected
The dura of the middle fossa and the sigmoid sinus from the inferiorly with the masseter muscle. The temporalis muscle is
sinodural angle to the jugular bulb is skeletonized. Then the separated from its attachment to the coronoid process of the
sigmoid sinus and the jugular vein are ligated in this sequence, mandible and reflected anteriorly and superiorly. A temporal

FIGURE 1-17. 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 back-
ward between the digastric and superior
oblique. B, enlarged view. The tympanic seg-
ment of the facial nerve courses below the lat-
eral canal. The chorda tympani arises from the
mastoid segment of the facial nerve. The mas-
toid antrum, which has been drilled away,
opens through the aditus into the epitympanic
part of the tympanic cavity. C, the presigmoid
and temporal dural incisions have been out-
lined. D, the temporal and presigmoid dura
has been opened. One goal of the procedure is
to preserve the vein of Labbe, which empties
into the transverse sinus. (Continues)
craniotomy is then performed, and extensive bone is removed the suboccipital triangle for a far-lateral or transcondylar expo-
along the whole lateral aspect of the middle cranial fossa. The sure. The lateral orbit and pterygopalatine fossa can be
ascending ramus of the mandible is either displaced anteriorly accessed at the anterior limit of the exposure.
or resected, and the petrous carotid is exposed distally to the
proximal portion of the intracavernous segment after removing DISCUSSION
the cartilaginous portion of the Eustachian tube. The cavernous
sinus can be approached and the intracavernous carotid artery Pathologies can arise anywhere within the petroclival
exposed by dividing the mandibular segment of the trigeminal region and frequently are not restricted to a single anatomic
nerve. The approach can also be extended to the retrosigmoid compartment of the cranial base. Involvement of multiple cra-
area and down the vertebral artery to the C1 to C2 level, or to nial nerves and arteries occurs because cranial base tumors

RHOTON
FIGURE 1-17. (Continued) 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 Labbe and the trochlear nerve. The semicircu-
lar canals have been opened. F, enlarged view.
The posterior canal faces the posterior fossa lat-
eral to the internal acoustic meatus. The supe-
rior canal projects upward, below the arcuate
eminence, toward the floor of the middle fossa.
The lateral canal is a useful landmark for iden-
tifying the tympanic segment of the facial nerve,
which courses between the canal and the stapes
sitting in the oval window. The epitympanic
area opens through the aditus into the mastoid
antrum. G, the labyrinthectomy has been com-
pleted and the dura lining the meatus opened to
expose the cisternal, meatal, labyrinthine, tym-
panic, and mastoid segments of the facial nerve.
The 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. (Continues)
tend to achieve considerable size before producing clinical involve the temporal and sphenoid bones in addition to the
manifestation (32). The distinction between the benign or clivus. One or a combination of the lateral approaches is fre-
malignant tumors in this area is not rigid because many quently used to expose intra- or extradural clival lesions that
benign tumors can have a very invasive characteristic. The also involve the temporal and sphenoid bones. They also pro-
selection of the best surgical approach depends on the loca- vide access to the anterior aspect of the midbrain, pons, and
tion, extension, size, and nature of the pathology. An advan- medulla and to the cerebellopontine angle and nerves in the
tage of these approaches directed through the temporal bone posterior fossa. They may also provide better access to the
to the petroclival area is that they reach the area through tis- temporal bone, jugular foramen, and petrous segment of the
sue planes outside the oropharynx. They provide another internal carotid artery than the other anterior or posterior
route by which anterior intradural lesions situated medial to approaches. The area may be approached from directly lateral
the nerves entering the internal acoustic meatus and jugular through the mastoid, labyrinth, and cochlea, as in the
foramen can be approached without entering the nasophar- translabyrinthine and transcochlear approaches; from above
ynx. They also provide an avenue of exposure for lesions that through a subtemporal middle fossa route; from behind in

FIGURE 1-17. (Continued) I–L, combined presigmoid and far-lateral angle. K, the rectus capitis posterior major and the inferior oblique have been
approach. I, the insert shows the site of the additional skin incision needed reflected medially and the superior oblique laterally to expose the vertebral
to add a retrosigmoid craniotomy and far-lateral approach. The scalp flap has artery and surrounding venous plexus behind the atlanto-occipital joint. L,
been reflected to expose the suboccipital triangle located between the superior the venous plexus has been removed to expose the vertebral artery coursing
and inferior oblique and the rectus capitis posterior major and in the depths with the C1 nerve behind the atlanto-occipital joint and across the upper
of which the vertebral artery courses with a dense venous plexus. J, the edge of the posterior atlantal arch. M and N, combined presigmoid and far-
venous plexus has been removed to expose the margins of the suboccipital tri- lateral approach. (Continues)
the retrosigmoid suboccipital approach; or from multiple Removal of posterior wall of the internal auditory canal
directions using such combined supra- and infratentorial through the retrosigmoid provides access to the contents of
approaches as the presigmoid approach, to which a the meatus as far lateral as the vertical and transverse crests.
translabyrinthine or transcochlear approach may be added. The vestibule can be opened if needed to remove a tumor
Alternative or extended approaches, most of which include extending into the labyrinth. Care is required to avoid injury
some route through the mastoid and petrous parts, include to the posterior semicircular canal and common crus if there
the anterior transpetrosal, the subtemporal preauricular is the possibility of preserving hearing (29). The retrosigmoid
infratemporal, and the far-lateral transcondylar approach. approach provides easy access to the intradural part of cranial
The retrosigmoid suboccipital approach, described in the nerves V, VII, VIII, and IX through XII. It also provides access
chapter on the cerebellopontine angle, offers a wide view of to the nerve-related segments of the arteries of the posterior
the cerebellopontine angle and of the intradural structures circulation. The vertebrobasilar junction can be exposed in
behind the ipsilateral lower clivus, but the dural surface of the some cases, although the lower cranial nerves and the jugular
petrous apex, upper clivus, and tentorial incisura are not well tubercle are frequent obstacles. Retraction of the pons and
seen from this exposure (26, 35, 36, 46) (Figs. 1-15 and 1-16). working between the cranial nerves is necessary to reach the

RHOTON
FIGURE 1-17. (Continued) M, a suboccipi-

tal craniotomy has been completed, the poste-
rior arch and posterior ramus of the trans-
verse process of the atlas removed, and the
dural incision has been outlined. The poste-
rior meningeal artery arises before the verte-
bral artery penetrates the dura. The C1 nerve
root adheres to the lower margin of the verte-
bral artery. N, the dura has been opened and
the nerves passing toward the jugular fora-
men exposed. Bone has been removed above
the atlantooccipital joint to expose the hypo-
glossal nerve in the hypoglossal canal. The
accessory rootlets cross the jugular tubercle
on their way to the jugular foramen. A.,
artery; A.I.C.A., anteroinferior cerebellar
artery; Atl-Occip., atlanto-occipital; Cap.,
capitis; Car., carotid; Chor., chorda; Cist.,
cisternal; CN, cranial nerve; Epitymp., epi-
tympanic; For., foramen; Gang., ganglion;
Genic., geniculate; Hypogl., hypoglossal;
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 segment; Semicirc., semicircular; Sig., sigmoid; Sp., spine; Suboccip., suboc-
cerebral artery; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; Post., cipital; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani,
posterior; Rec., rectus; S.C.A., superior cerebellar artery; Scap., scapula; Seg., tympanic; V., vein; Vert., vertebral; Vest., vestibular.
origin of the AICA from the basilar artery. The far lateral mod- The translabyrinthine approach provides access to the facial
ification of the retrosigmoid approach, described in the chap- nerve from its origin at the brainstem to the stylomastoid fora-
ter on the far lateral approach, was devised to provide a bet- men, and exposure of the contents of the internal auditory mea-
ter exposure of the lateral and anterior aspects of the tus (Fig. 1-6) (12, 14). The lateral surface of the pons, the inferior
cervicomedullary junction (45). aspect of the origin of the trigeminal nerve, and the facial and
The presigmoid approach (1, 8, 32) combines a supra- and vestibulocochlear nerve complexes are well visualized, but
infratentorial exposure with various degrees of petrousec- exposure of the region inferior to the jugular bulb, above the
tomy, while preserving the junction of the vein of Labbé trigeminal nerve, and anterior to the internal acoustic meatus is
with the transverse sinus (Figs. 1-14-1-17). The amount of usually poor. The extent of exposure achieved with the
resection of the petrous bone can vary from a retro- translabyrinthine approach is dependent on several anatomic
labyrinthine minimal mastoidectomy exposure to a trans- factors. A high jugular bulb, an anteriorly placed or large sig-
labyrinthine or transcochlear exposure with posterior dis- moid sinus, or a low middle fossa plate may severely restrict
placement of the facial nerve. In selected cases, where the exposure (22, 27).
angiography shows patency of the communication between The transcochlear approach shares similar limitations with
the two transverse sinuses across the midline, the sigmoid the translabyrinthine exposure, although the posterior transpo-
sinus can be ligated to improve the exposure (24). Preserva- sition of the facial nerve in the transcochlear approach allows
tion of the drainage of the vein of Labbé and avoidance of better visualization of the structures anterior to the internal
excessive temporal lobe retraction are major goals of this auditory canal (15, 16). The area of exposure is very narrow and
approach to the upper clival region. Approaching the struc- restricted by the maintenance of the bony external auditory
tures in the inferior petroclival space may be restricted by canal, but can be increased by resecting the posterior part of the
the jugular bulb, which could be overcome by division of the canal. Transposition of the facial nerve may be followed by a
sigmoid sinus or by working posterior to it (36). The major transient or permanent facial palsy.
advantages of the presigmoid approach are the shorter The subtemporal anterior transpetrosal approach uses
working distance to clival lesions and the various angles for extradural resection of the anterior petrous pyramid via a
dissection that are provided. The approach provides access temporal craniotomy (Figs. 1-12 and 1-13). It may be com-
to the ipsilateral cranial nerves III through XII and to the bined with zygomatic resection to increase access to the floor
major arteries in the posterior circulation. A major drawback of the middle fossa (20). The area of the petrous apex removal
to this exposure is provided by the anatomic variants, extends from just medial to the internal auditory canal and
described below, that limit the size of the exposure through cochlea to the petrous apex and petroclival junction, and
Trautman’s triangle and the labyrinth. from the petrous ridge posteriorly to the carotid canal ante-

FIGURE 1-18. Preauricular subtemporal-infratem-

poral fossa approach. A, the scalp incision is posi-
tioned so that a frontotemporal craniotomy can be
completed. The operation is often completed with an
incision that extends downward only to the level of
the tragus. However, it can be extended if a neck dis-
section is needed. The scalp flap has been reflected
forward, taking care to protect the branches of the
facial nerve. B, the temporalis muscle has been
refracted forward and the craniotomy completed. The
mandibular condyle and fossa and a portion of the
zygomatic arch were removed in a single piece, as
shown in the insert, and the middle fossa floor
removed. C, exposure after removal of the middle
fossa floor lateral to the foramen ovale and before
resection of the tensor tympani muscle. The lower
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 pet-
rosal sinus coursing along the petroclival fissure. F,
the dura facing the petrous apex has been opened and
the vertebral arteries and AICA exposed. This expo-
sure is directed through the petrous apex medial to the
cochlea and jugular foramen and does not risk loss of
facial nerve function or hearing, as do the approaches
directed through the petrous apex that require facial
nerve transposition and resection of the labyrinth.
A., artery; A.I.C.A., anteroinferior cerebellar artery;
Brs., branches; Car., carotid; CN, cranial nerve;
Eust., eustachian; Gang., ganglion; Gl., gland; Gr.,
greater; Inf., inferior; Int., internal; Jug., jugular;
M., muscle; Max., maxillary; Men., meningeal;
Mid., middle; N., nerve; Pet., petrosal, petrous;
Post., posterior; Temp., temporal; Tens., tensor;
TM., temporomandibular; Trig., trigeminal; Tymp.,
tympani; V., vein; Vert., vertebral; Zygo., zygomatic.

RHOTON
FIGURE 1-19. A–D, anatomic basis of the postauric-

ular transtemporal approach. A, the incision sweeps
widely around the posterior margin of the ear so that a
retrosigmoid, presigmoid, and far-lateral exposure can
be obtained behind the ear, and a subtemporal, infratem-
poral, pterygopalatine, and orbital exposure can be
obtained in front of the ear. B, the scalp 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 glossopha-
ryngeal, vagus, accessory, and hypoglossal nerves. The
accessory nerve is retracted forward. D, the parotid
gland has been removed to expose the temporofacial and
cervicofacial trunks of the facial nerve and the temporo-
mandibular joint. The splenius capitis muscle has been
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. (Continues)
riorly. A significant degree of temporal lobe retraction may be anterior aspect of the brainstem and basilar artery in the area
required. This may be reduced by using a frontotemporal between the trigeminal nerve above and the facial and
craniotomy with zygomatic resection. Although only a small vestibulocochlear nerves below. In approaching the basilar
window in the petrous bone is provided, exposure can be artery through this route, the size and location of the lesion
expanded by dividing the adjacent part of the tentorium. The in relation to the petrous ridge is critical. The trigeminal
lateral and anterior surfaces of the pons and the upper clivus nerve can be mobilized to improve the exposure, although
and adjacent part of the cavernous sinus can be approached this may result in postoperative facial hypesthesia (19, 20).
through this route (Fig. 1-13). The facial, vestibulocochlear, The anterior transpetrosal approach can be used alone for
trigeminal, and abducens nerves can be identified. The extradural pathologies restricted to the petrous apex or as a
petrous carotid may limit the surgeon’s line of vision and surgical step to approaching intradural pathologies in the
restrict access to the inferior part of the petroclival region, but petroclival region. It provides a route for resecting extradural
this restriction may be overcome with anterior mobilization lesions that extend from the level of the trigeminal nerve to
of the artery (39, 41). The approach provides access to the the foramen magnum.

FIGURE 1-19. (Continued) 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 inferotempo-
ral surface of the greater sphenoid wing and the lower
head passes upward from the lateral pterygoid plate.
Both heads insert on the mandibular neck and the joint
capsule. The superficial head of the medial pterygoid
muscle passes from the maxillary tuberosity and ptery-
goid plate to the mandibular angle. The deep head of the
medial pterygoid arises from the pterygoid fossa between
the pterygoid plates. G, enlarged view of the infratem-
poral area after removal of the mandibular condyle and
lateral pterygoid muscles. The branches of the mandibu-
lar nerve are exposed below the foramen ovale. The
largest branches are the lingual and superior alveolar
nerves, which are predominantly sensory. The auricu-
lotemporal nerve arises as two roots, which often pass
around the middle meningeal artery before joining. H,
the pterygoid muscles, a segment of the maxillary
artery, and the mandibular and facial nerve branches
have been reflected or removed to expose the internal
jugular vein exiting the jugular foramen on the medial
side of the stylomastoid foramen, the internal carotid
artery ascending to enter the carotid canal, the tensor
and levator veli palatini descending from their origin
bordering the eustachian tube, and the terminal seg-
ment of the maxillary artery entering the pterygopala-
tine fossa. (Continues)
Removal of the posterior part of the petrous pyramid has or displacement of the mandibular condyle, and extensive
been used for acoustic neuroma removal as part of extended resection of the lateral part of the middle fossa floor exposes
approaches directed through the middle fossa (21, 28, 42, 43) the infratemporal fossa, the nasopharynx, the para- and
(Fig. 1-12). The extended approaches combine different degrees retropharyngeal areas, and the ethmoid, sphenoid, and maxil-
of resection of the bony labyrinth with the subtemporal lary sinuses. The approach also provides access to the upper
transtentorial routes. Extending the resection of the petrous cervical and petrous carotid. The cavernous sinus also can be
bone posteriorly over the mastoid and the bony labyrinth approached through its lateral and basal aspects. Anterior dis-
exposes the whole intrapetrous course of the facial nerve, and placement of the petrous carotid allows direct access to the
provides access to the cerebellopontine angle by a combina- clivus and for extensive resection of the petrous bone medial
tion of subtemporal, translabyrinthine, and presigmoid routes to the cochlea. This exposes the extradural clival region from
(Figs. 1-12 and 1-13) (9). the level of the trigeminal nerve to the foramen magnum (33,
The subtemporal preauricular infratemporal approach 36, 38, 39). The approach can also provide access to the
reaches the skull base from an anterolateral direction (Figs. intradural space ventral to the brainstem (41). The exposure of
1-10, 1-13, and 1-18). Division of the zygomatic arch, resection the cerebellopontine angle and foramen magnum is limited

RHOTON
FIGURE 1-19. (Continued) I–L, anatomic basis of the

postauricular transtemporal approach. I, a mastoidec-
tomy has been completed to expose the semicircular
canals and the mastoid segment of the facial canal. The
endolymphatic sac sits under the presigmoid dura. J,
the external canal has been resected to expose the struc-
tures in the tympanic cavity. The tympanic segment of
the facial nerve courses between the lateral semicircular
canal and the stapes sitting in the oval window. The
chorda tympani arises from the mastoid segment of the
facial nerve, passes forward along the inner surface of
the tympanic membrane and the neck of the malleus to
enter its anterior canaliculus, exits the skull along the
petrotympanic suture, and joins the lingual nerve in the
infratemporal fossa. The promontory overlies the basal
turn of the cochlea. The tendon of the tensor tympani
muscle makes a right-angle turn around the trochlei-
form process to insert on the malleus. K, the incus and
malleus have been removed while preserving the stapes
and the tensor tympani muscle. The petrous carotid has
been exposed. The nerves exiting the jugular foramen
have been retracted forward to expose the hypoglossal
nerve exiting the hypoglossal canal. L, a frontotempo-
ral craniotomy has been completed and the 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 nasophar-
ynx. (Continues)
because the approach is carried anterior and medial to cranial tympanic area, and jugular bulb (5, 6, 34) (Figs. 1-19 and 1-20).
nerves VII through XII and the cochlea is not resected (36). The structures of the lower and middle clivus can be exposed
Anterior transposition of the petrous carotid artery allows without the need for brain retraction. The facial nerve is dis-
unhindered exposure of the origin of the AICA and the verte- placed anterosuperiorly and the sigmoid sinus ligated and
brobasilar junction. The approach could be used as an alterna- divided. Displacement of the facial nerve from its bony canal
tive lateral route to vascular lesions of the midbasilar artery or seriously interferes with its vascular supply and temporary or
at the vertebrobasilar junction, when these lesions cannot be permanent loss of function is to be expected (33). Resection of
exposed through either the retromastoid or subtemporal the jugular bulb allows for exposure of the lower cranial
transtentorial approaches. nerves in the jugular foramen. Mobilization of the nerves in
The postauricular transtemporal approach, which combines the medial part of the jugular foramen is extremely difficult
a transcochlear exposure with an infratemporal approach, and nerve damage is likely to occur if it is attempted. The lat-
may be used as an alternative to the preauricular infratempo- eral and anterior surfaces of the lower pons, medulla, and
ral approach when the pathology involves the mastoid and cervicomedullary junction are well exposed. The extent of
the infratemporal fossa and extends to the facial recess, hypo- exposure of the major arteries is dependent on the different

FIGURE 1-19. (Continued) M–R, anatomic basis of the

postauricular transtemporal approach. M, a retrosigmoid
craniotomy has been completed and the nerves in the cerebel-
lopontine angle exposed. The vestibulocochlear nerve has been
depressed to expose the facial nerve. N, the facial nerve has
been 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 hypoglos-
sal canal exit the skull on the medial side of the internal jugu-
lar vein and descend between the internal carotid artery and
internal jugular vein. O, the bone above the occipital condyle
has been drilled to expose the hypoglossal nerve in the
hypoglossal canal. P, the posterior wall of the internal acoustic
meatus has been removed to provide this presigmoid inferolat-
eral view of the nerves in the internal meatus. The cochlear
nerve separates off the main bundle of the vestibulocochlear
nerve and penetrates the modiolus. The inferior vestibular
nerve divides into the singular nerve to the posterior ampul-
lae and a branch to the saccule. The superior vestibular nerve
innervates the superior and lateral ampullae and sends a
branch to the utricle. Q, the medial wall of the jugular fossa
has been removed and the nerves passing through the jugular
foramen have been exposed. The glossopharyngeal nerve passes
through the foramen anterior to the vagus and accessory
nerves. A large superior petrosal vein ascends to the superior
petrosal sinus. R, the glossopharyngeal, vagus, and accessory
rootlets arise behind and the hypoglossal rootlets arise anterior
to the inferior olive. (Continues)

RHOTON
FIGURE 1-19. (Continued) S–X, anatomic basis of the postauricular vestibule anteriorly and are innervated by the superior vestibular nerve.
transtemporal approach. S, enlarged view of the medial wall of the tym- Only the upper edge of the superior canal was preserved in opening the
panic cavity before mobilizing the facial nerve. The stapedial muscle passes vestibule. The ampullae of the posterior canal is located at its lower end and
forward from the pyramidal eminence below the facial nerve and attaches on is innervated by the singular branch of the inferior vestibular nerve. V, a
the neck of the stapes. The tensor tympani muscle passes backward and lat- probe is directed through the vestibule to the inner surface of the membrane
erally, giving rise to a narrow tendon that makes a sharp turn around the covering the round window, which is located behind and below the oval
trochleariform process at the lateral end of its semicanal to insert on the han- window. W, enlarged view of the labyrinth after opening the promontory to
dle of the malleus. The basal turn of the cochlea is located deep to the expose the cochlea. The jugular bulb is located below the vestibule and semi-
promontory. The tympanic segment of the facial nerve courses above the circular canals and the lateral genu of the internal carotid artery in position
stapes. T, enlarged view of the labyrinth. The semicircular canals have been below the cochlea. The cochlea wraps around the modiolus through which the
unroofed and the stapes has been removed from the oval window. The round branches of the cochlear nerve are distributed to the cochlear duct. X, the
window is located below and behind the oval window. U, the facial nerve has temporal lobe has been elevated to expose the internal carotid, PCA, and
been reflected forward out of the facial canal and the vestibule has been SCA in the basal cisterns. The dura has been elevated from the lateral wall
opened. The ampullae of the superior and the lateral canal open into the of the cavernous sinus. (Continues)

FIGURE 1-19. (Continued) Y and Z, anatomic

basis of the postauricular transtemporal approach.
Y, overview before opening the dura. The postau-
ricular approach offers the potential for providing
retrosigmoid, presigmoid, and farlateral exposures
and can be used to access the infratemporal and
pterygopalatine fossae, the orbit, and the subtem-
poral areas. In this case, the exposure extends from
the retrosigmoid area forward to the orbit. The
maxillary sinus has been opened below the orbital
floor. Z, overview of exposure after opening the
dura. A., artery; Alv., alveolar; Aur., auricular;
Br., branch; Brs., branches; Cap., capitis; Car.,
carotid; Cerv., cervical; Chor., chorda, choroid;
CN, cranial nerve; Coch., cochlear; Cond.,
condyle; Endolymph., endolymphatic; Eust.,
eustachian; Ext., external; Fac., facial; Gang.,
ganglion; Genic., geniculate; Gl., gland; Gr.,
greater; Hypogl., hypoglossal; Inf., inferior;
Infraorb., infraorbital; Infratemp., infratempo-
ral; Int., internal; Jug., jugular; Laby.,
labyrinthine; Lat., lateral; Lev., levator; M., mus-
cle; Mandib., mandibular; Mast., mastoid; Max.,
maxillary; Med., medial; N., nerve; Obl., oblique;
Occip., occipital; Pal., palatini; P.C.A., posterior
cerebral artery; Ped., peduncle; Pet., petrosal,
petrous; P.I.C.A., posteroinferior cerebellar artery;
Plex., plexus; Post., posterior; Proc., process;
Pteryg., pterygoid; Pterygopal., pterygopalatine;
Rec., rectus; S.C.A., superior cerebellar artery;
Scap., scapula; Seg., segment; Semicirc., semi-
circular; Sig., sigmoid; Sphen., sphenoid; Splen.,
splenus; Sternocleidomast., sternocleidomastoid;
Sup., superior; Superf., superficial; Symp., sym-
pathetic; Temp., temporal; Tens., tensor; TM.,
temporomandibular; Trans., transverse; Tymp.,
tympani, tympanic; V., vein; Vel., veli; Vert., ver-
tebral; Vest., vestibular.
anatomic variants and direction of displacement of the ves- clival region (Figs. 1-19 and 1-20). The retrosigmoid, far-
sels. Exposure of the structures of the middle clivus requires lateral, and transcondylar exposures can be obtained at the
posterior facial nerve displacement and drilling of the posterior margin of the exposure, and the anterior limit can be
labyrinth with consequent destruction of any residual hear- extended to include the pterygopalatine fossa and lateral part
ing. The lateral and part of the anterior surfaces of the pons of the maxilla, orbit, and anterior cranial fossa.
can be exposed up to the point of emergence of the trigeminal Extensive removal of lesions involving the skull base fre-
nerve. Exposure of the superior petroclival space requires that quently require reconstruction of the resultant bony, neural,
the transtemporal exposure be combined with a subtemporal and dural defects (Fig. 1-21). The presence of cerebrospinal
exposure. The transtemporal approach can easily be extended fluid leaks and the close proximity to contaminated spaces
to the infratemporal fossa, and the same exposure provided of the oro- or nasopharynx increases the risks of meningitis.
by the preauricular approach can be achieved. When this Opened sinuses should be obliterated, dural incisions and
approach is combined with an infratemporal fossa exposure openings should be sutured and sealed, nerves should be
and anterior displacement of the intrapetrous carotid artery, reanastomosed or grafted, and devascularized grafts of bone
the petrous part of the temporal bone can be completely or dura should be covered with vascularized tissue when-
removed, providing the widest possible exposure of the petro- ever possible.

RHOTON
FIGURE 1-20. A–F, postauricular transtemporal approach. This exposure been completed, the zygomatic arch opened, and the temporalis muscle
includes the transtemporal and infratemporal approaches in combination reflected to expose the maxillary artery and pterygoid muscles in the
with a craniotomy. A, the scalp flap has been reflected forward to expose the infratemporal fossa. E, enlarged view of the temporal and infratemporal
sternocleidomastoid, parotid gland, and the greater auricular nerve. B, the exposures. The posterior wall of the external canal has been removed. The
external canal has been divided to reflect the flap forward for a parotid and auriculotemporal branch of the mandibular nerve is often split into two
neck dissection that exposes the facial nerve and its trunks, the posterior rootlets by the middle meningeal artery. F, enlarged view of the tympanic
digastric belly, and the internal jugular vein. C, the mastoidectomy has cavity. The anterior part of the lateral semicircular canal is located above the
been completed to expose the presigmoid dura, the sigmoid sinus, and the tympanic segment of the facial nerve. The promontory overlies the basal
semicircular canals. The mandibular condyle has been resected to provide cochlear turn. (Continues)
access to the infratemporal fossa. D, a temporo-occipital craniotomy has

FIGURE 1-20. (Continued) G–L, postauricular transtemporal approach. G, ment of the sigmoid sinus and the jugular bulb have been removed to expose
the external canal has been resected in preparation for exposing the petrous the nerves passing through the jugular foramen. The dura has been opened
carotid. H, the junction of the cervical and petrous carotid has been exposed and the facial nerve displaced posteriorly. The temporal lobe has been elevated
in the area below the promontory. The lateral margin of the stylomastoid and to expose the subtemporal area while preserving the vein of Labbe. A., artery;
jugular foramina have been removed to expose the jugular bulb below the Ac., acoustic; Aur., auricular; Bas., basilar; Car., carotid; Chor., chorda;
semicircular canals. I, the mandibular nerve has been exposed below the fora- CN, cranial nerve; Cond., condyle; Ext., external; Gl., gland; Gr., greater;
men ovale. A more extensive exposure of the petrous carotid has been com- Inf., inferior; Int., internal; Jug., jugular; Lat., lateral; M., muscle; Mandib.,
pleted so that the artery can be reflected forward out of the carotid canal to mandibular; Mast., mastoid; Max., maxillary; Mid., middle; Men.,
provide access for drilling of the petrous apex. J, the petrous carotid has been meningeal; N., nerve; Pet., petrosal, petrous; Proc., process; Seg., segment;
reflected forward and the petrous apex removed to expose the clivus and infe- Semicirc., semicircular; Sig., sigmoid; Sternocleidomast., sternocleidomas-
rior petrosal sinus. K, the facial nerve has been moved out of the facial canal, toid; Sup., superior; Temp., temporal; Trans., transverse; Tymp., tympani,
and a total labyrinth and petrous apicectomy have been completed. L, a seg- tympanic; V., vein; Vert., vertebral.

RHOTON
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PART 2
THE TEMPORAL BONE IN
THREE DIMENSIONS
CHAPTER 1
OSSEOUS RELATIONSHIPS
Neurosurgery 61:S4-65–S4-84, 2007 DOI: 10.1227/01.NEU.0000280028.00006.98 www.neurosurgery-online.com
FIGURE 1-1. Temporal bone and adjacent cranial base. A, superior view of
the middle and posterior cranial base formed by the sphenoid, temporal, and
occipital bones. The temporal bone has five parts: the squamosal, petrous, mas-
toid, tympanic, and styloid parts. Only the squamosal, petrous, and mastoid
parts are seen on the upper surface. The styloid and tympanic parts are not
seen because they are on the lower surface. The upper surface of the squamosal
part forms some of the floor and lateral wall of the middle cranial fossa. The
lower surface is the site of the roof of the mandibular fossa in which the
mandibular condyle sits. The petrous part of the temporal bone houses the
internal acoustic meatus, acousticovestibular labyrinth, and the carotid and
facial canals. The mastoid part contains the mastoid air cells and mastoid
antrum. The squamosal part of the temporal bone joins anteriorly with the
greater wing of the sphenoid bone to form the floor of the middle cranial fossa.
The petrous part articulates medially with the body of the sphenoid bone and
the clival portion of the occipital bone at the petroclival fissure to form the ante-
rior wall of the posterior fossa. The sigmoid sulcus descends along the poste-
rior surface of the mastoid portion of the temporal bone and turns forward on
the upper surface of the occipital bone to enter the jugular foramen. The fora- by cartilage. The foramina spinosum and ovale of the sphenoid bone are posi-
men lacerum, which is located at the junction of the temporal, sphenoid, and tioned anterior to the petrous apex. The greater petrosal nerve courses along
occipital bones, is usually covered below the terminal part of the carotid canal the medial part of the petrosphenoid junction.

RHOTON
FIGURE 1-2. Relationships of the sphenoid, occipital, and temporal bones.

Superior view. The three bones have been separated along their sutures. The
squamosal and petrosal parts of the temporal bone articulate anteriorly with
the greater wing of the sphenoid to form the floor of the middle cranial fossa.
The petrous part articulates posteriorly with the clival part of the occipital bone
along the petroclival fissure. The mastoid part articulates with the squamosal
part of the occipital bone along the occipitomastoid suture. The part of the tem-
poral and occipital bones, between the lower ends of the petroclival fissure and
the occipitomastoid suture, forms the margins of the jugular foramen. The
petrous part of the temporal bone forms the anterior margin, and the condy-
lar part of the occipital bone forms the posterior margin of the jugular foramen.
The petrous apex is wedged into the space between the medial part of the
greater sphenoid wing and the clival and condylar parts of the occipital bone,
and faces the foramen lacerum in the area just behind the foramen ovale and
spinosum of the sphenoid bone.

FIGURE 1-3. Separate temporal and sphenoid bones have been fitted together along the
squamosal suture. The greater wing of the sphenoid bone forms the anterior wall and the
anterior part of the floor of the middle fossa. The posterior part of the floor of the middle
fossa is formed by the petrous and mastoid parts of the temporal bone. The foramen ovale
and spinosum in the greater sphenoid wing are positioned anterior to the petrous apex. The
trigeminal impression is located on the middle fossa surface of the petrous apex. The arcu-
ate eminence overlies the superior semicircular canal. The tegmen is the site of a paper-thin
layer of bone that roofs the mastoid antrum, the external acoustic meatus, and the tympanic
cavity. The mastoid part of the temporal bone is the site of the mastoid air cells and mas-
toid antrum. The sigmoid sulcus descends along the inner surface of the mastoid part. The
lingual process of the sphenoid bone extends posteriorly toward the petrous apex and par-
tially surrounds the junction of the petrous and cavernous segments of the internal carotid
artery. The petrolingual ligament extends from the lingual process to the petrous apex
above the junction of the petrous and cavernous segments of the internal carotid artery.

RHOTON
FIGURE 1-4. Separate sphenoid, temporal, and occipital bones have been fitted together,
along their adjoining sutures. The petrous apex is wedged into the area between the sphe-
noid and occipital bones. The squamosal suture extends along the lateral wall and floor of
the middle fossa and ends behind the foramen spinosum. The petrous portion of the tempo-
ral bone is separated from the clival portion of the occipital bone by the petroclival fissure.
The squamosal part of the occipital bone is separated from the mastoid part of the temporal
bone by the occipitomastoid sutures. The lower end of the occipitomastoid suture crosses the
sigmoid sulcus. The jugular foramen is situated between the petrous part of the temporal
bone and the condylar part of the occipital bone, and between the lower end of the petrocli-
val fissure and the occipitomastoid suture.

FIGURE 1-5. Oblique view of the temporal

and surrounding bones. The petrous and mas-
toid parts of the temporal bone articulate poste-
riorly with the occipital bone to form the lateral
part of the anterior wall of the posterior fossa.
Medially, the petrous part of the temporal bone
articulates along the petroclival fissure with the
clival portion of the occipital bone and the body
of the sphenoid bone to form the medial part of
the anterior wall of the posterior fossa. The
jugular foramen is positioned between the
occipital and temporal bone at the inferolateral
edge of the petroclival fissure. The petrous part
of the temporal bone forms the anterior edge,
and the condylar part of the occipital bone forms
the posterior edge of the jugular foramen. The
jugular foramen has three parts: a laterally
placed sigmoid part, through which the sigmoid
sinus drains; a smaller medial part, the petrosal
part, through which the inferior petrosal sinus
drains; and an intermediate part, the intrajugu-
lar part, through which the glossopharyngeal,
vagus, and accessory nerves pass.

RHOTON
FIGURE 1-6. Inferior view of both temporal bones and the occipital bone. The
petrous apex fits against the clival part of the occipital bone along the petro-
clival fissure. The jugular foramen is located between the lower ends of the
petroclival fissure and the occipitomastoid suture. The jugular fossa, in which
the jugular bulb resides, is on the lower surface of the petrous part of the tem-
poral bone. The stylomastoid foramen is positioned directly lateral to the jugu-
lar foramen. The external orifice of the carotid canal is located anterior to the
jugular foramen. The right jugular foramen is larger than the left, as is com-
mon. The mandibular fossa, in which the mandibular condyle sits, is located
medial to the root of the zygomatic process.

FIGURE 1-7. Inferior view of the middle

and posterior parts of the cranial base
formed by the sphenoid, temporal, and
occipital bones. The squamosal part of the
temporal bone forms the posterior part of
the floor and lateral wall of the middle
cranial fossa, the roof of the mandibular
fossa in which the mandibular condyle
sits, and the posterior part of the zygo-
matic arch. The tympanic part of the tem-
poral bone forms the anterior, lower, and
part of the posterior wall of the external
canal, part of the osseous floor of the tym-
panic cavity and Eustachian tube, and
the posterior wall of the mandibular fossa.
The mastoid part contains the mastoid air
cells and mastoid antrum. The petrous
part is the site of the auditory and
vestibular labyrinth, the carotid and facial
canals, and the internal acoustic meatus.
The external orifice of the carotid canal
opens anterior to the jugular foramen.
The jugular fossa, in which the jugular
bulb sits, is located on the lower surface of the petrous part. The stylomastoid loid process. The styloid part projects downward behind the tympanic part and
foramen opens between the anterior edge of the digastric groove and the sty- serves as the site of attachment of the three styloid muscles.

RHOTON
FIGURE 1-8. Oblique enlarged infe-

rior view of the right temporal, sphe-
noid, and occipital bones. The tym-
panic part of the temporal bone is
positioned between the squamosal part
anteriorly and the petrous and mas-
toid parts posteriorly. The petrous part
of the trigeminal bone is wedged
between the sphenoid and occipital
bones. The petrous apex faces the fora-
men lacerum and is separated from the
clival part of the occipital bone by the
petroclival fissure. The dome of the
jugular fossa, in which the jugular
bulb sits, is on the lower surface of the
petrous part. The carotid canal is posi-
tioned anterior to the jugular foramen.
The tympanic canaliculus, located
between the jugular fossa and carotid
canal, is the opening through which
Jacobson’s branch of the glossopharyn-
geal nerve passes to reach the tym-
panic cavity and, finally, the middle
fossa, where it becomes the lesser pet-
rosal nerve.

FIGURE 1-9. Anterior view of a right temporal bone. The squamosal part of the temporal bone
forms the lateral wall and floor of the middle fossa, the posterior part of the zygomatic arch, and
the roof of the mandibular fossa in which the mandibular condyle sits. The zygomatic process of
the squamosal part projects forward to join the zygomatic bone in completing the zygomatic arch.
The tympanic part forms the posterior wall of the mandibular fossa, the anterior, lower, and part
of the posterior wall of the external auditory canal and part of the floor of the tympanic cavity
and osseous part of the Eustachian tube. The petrous part, located medial to the squamosal, tym-
panic, and mastoid parts, is the site of the internal acoustic meatus, the acoustic and vestibular
labyrinth, and the facial and carotid canals. The mastoid part is located behind the lateral part
of the tympanic and squamosal parts and is the site of the mastoid air cells and mastoid antrum.

RHOTON
FIGURE 1-10. Lateral view of a right temporal bone. The squamosal

part forms part of the lateral wall and floor of the middle fossa, the pos-
terior part of the zygomatic arch, and the upper surface of the mandibu-
lar fossa. The tympanic part forms the posterior wall of the mandibular
fossa; the anterior wall, lower wall, and part of the posterior wall of the
external canal; and the floor of the tympanic cavity and adjacent osseous
portion of the eustachian tube. The styloid process is ensheathed at its
base by the tympanic part and projects downward, serving as the attach-
ment of three styloid muscles. The mastoid part is located posterior to the
external acoustic meatus and contains the mastoid air cells, which coa-
lesce into a large cavity at the mastoid antrum. The retrolabyrinthine,
translabyrinthine, and transcochlear approaches are directed through
the mastoid part. The digastric muscle attaches medial to the mastoid tip
in the digastric groove. The oval window is exposed in the medial wall
of the tympanic cavity.

FIGURE 1-11. Enlarged view of the

right external acoustic meatus. The
spine of Henle, located along the
posterosuperior margin of the exter-
nal canal, is positioned superficial
to the deep site of the lateral semicir-
cular canal and the junction of the
tympanic and mastoid segments of
the facial nerve. The mastoid
antrum is positioned deep to the
superficial depressed area, called the
suprameatal triangle, located above
and behind the spine of Henle. The
medial wall of the tympanic cavity
is the site of the promontory, which
overlies the basal turn of the cochlea
and the oval and round windows.
The footplate of the stapes sits in the
oval window. The round window is
separated from the cochlea by a thin
membrane.

RHOTON
FIGURE 1-12. Superior view of the

left and right temporal bones. The
medial part of the upper surface is the
site of the trigeminal impression in
which the trigeminal nerve and gan-
glion and Meckel’s cave sits. Farther
laterally is the prominence of the
arcuate eminence overlying the supe-
rior semicircular canal. Lateral to the
arcuate eminences is the tegmen, a
thin plate of bone roofing the mastoid
antrum, epitympanic area, and exter-
nal acoustic meatus. The temporal
bone articulates anteriorly with the
sphenoid bone, above with the pari-
etal bone, and posteriorly with the
occipital bone. The zygomatic process
of the squamosal part has an anterior
and a posterior root, between which,
on the lower surface, is located the
mandibular condyle.

FIGURE 1-13. The floor of the right

middle fossa has been drilled to
remove bone and air cells and expose
the osseous capsule of the cochlea,
semicircular canals, and internal
acoustic meatus. The cochlea is
located anteromedial to the fundus of
the meatus. The superior, lateral, and
posterior semicircular canals are sit-
uated posterolateral to the fundus of
the meatus. The transverse crest sep-
arates the fundus of the meatus into
upper and lower parts. The facial and
superior vestibular nerves course
above and the cochlear and inferior
vestibular nerves course below the
transverse crest.

RHOTON
FIGURE 1-14. Posterior view of a right temporal bone. The squamosal part forms part of the
floor and lateral wall of the middle fossa. The sigmoid sulcus descends along the inner surface of
the mastoid portion. The porus of the internal acoustic meatus opens onto the central portion of
the posterior surface of the petrous part. The trigeminal impression, trigeminal prominence,
meatal depression, and arcuate eminence are located on the upper surface of the petrous part. The
endolymphatic duct connects the vestibule in the petrous part with the endolymphatic sac, which
sits on the posterior petrous surface inferolateral to the internal acoustic meatus. The intrajugu-
lar process separates the petrosal and sigmoid parts of the jugular foramen.

FIGURE 1-15. Enlarged view of Figure

1-14. The upper edge of the petrous ridge
is the site of two shallow depressions, the
trigeminal impression and the meatal
depression, and two elevations, the
trigeminal prominence and the arcuate
eminence. The trigeminal impression, in
which Meckel’s cave and the enclosed part
of the trigeminal nerve sits, is located on
the medial part of the upper surface. The
trigeminal prominence is positioned at the
lateral edge of the trigeminal impression.
The area between the trigeminal promi-
nence and the arcuate eminence is the site
of another shallow depression, the meatal
depression, which is positioned above the
internal acoustic meatus. The tegmen, a
paper-thin area of bone that roofs the
external canal, mastoid antrum, and tym-
panic cavity, is positioned on the upper
surface lateral to the arcuate eminence.
The subarcuate fossa, through which the
subarcuate branch of the anterior inferior
cerebellar artery passes, is located supero-
lateral to and the hiatus of the endolymphatic duct is positioned inferolateral to the internal acoustic meatus.

RHOTON
FIGURE 1-16. The posterior surface of

the right temporal bone has been drilled
while preserving the bone around the
internal acoustic meatus, semicircular
canals, and cochlea. The superior canal
protrudes upward toward the arcuate
eminence in the floor of the middle fossa.
The posterior canal is exposed on the lat-
eral side of the superior canal. The poste-
rior end of the superior canal and the
upper end of the posterior canal join to
form the common crus, which opens into
the vestibule. The mastoid air cells have
been removed from the petrous apex. The
cochlea bulges upward anteromedial to
the fundus of the internal acoustic mea-
tus. Some of the mastoid air cells medial
to the sigmoid sulcus have been removed.
The cochlear aqueduct, which ends just
above the petrosal part of the jugular fora-
men, has been preserved. The endolym-
phatic sac sits on the posterior surface of
the temporal bone below the superior and
lateral canals. The intrajugular processes
of the temporal and occipital bones separates the petrosal and sigmoid parts of the cranium through the intrajugular part of the jugular foramen located
the jugular foramen. The glossopharyngeal, vagus, and accessory nerves exit between the petrosal and sigmoid parts.

FIGURE 1-17. Oblique posterior view of another right temporal

bone. The sigmoid sinus descends along the posterior surface of the
mastoid portion in the sigmoid sulcus and turns upward along the
lower surface of the petrous part to form the jugular bulb, which sits
in the jugular fossa. The internal acoustic meatus opens onto the cen-
tral portion of the posterior surface of the petrous part. The trigemi-
nal impression and arcuate eminence are located on the upper surface
of the petrous part. The porus of the internal acoustic meatus is posi-
tioned below the shallow depression, the meatal depression, posi-
tioned between the lateral edge of the trigeminal prominence and the
arcuate eminence. The endolymphatic duct connects the vestibule in
the petrous part with the endolymphatic sac, which sits on the pos-
terior surface inferolateral to the internal acoustic meatus.

RHOTON
FIGURE 1-18. View of the fundus

of the right internal acoustic meatus.
The transverse crest divides the
meatal fundus into superior and
inferior parts. Above the transverse
crest, the facial canal is anterior and
the superior vestibular area is poste-
rior. The facial canal and the supe-
rior vestibular area are separated by
the vertical crest (Bill’s Bar). Below
the transverse crest, the cochlear area
is anterior and the inferior vestibular
area is posterior. The singular fora-
men, through which the singular
branch of the inferior vestibular
nerve passes to innervate the poste-
rior canal ampullae, is located poste-
rior to the inferior vestibular area.
The inferior vestibular nerve also has
a saccular and, occasionally, a utric-
ular branch.

FIGURE 1-19. Inferior view of a left temporal bone. 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 roof of the mandibular fossa in which the mandibular condyle sits. The
tympanic part forms the anterior, lower, and part of the posterior wall of the external
canal, the posterior wall of the mandibular fossa, and part of the floor of the tympanic
cavity and osseous portion of the Eustachian tube. The mastoid portion contains the
mastoid air cells and mastoid antrum. The petrous part is the site of the auditory and
vestibular labyrinth, the internal acoustic meatus, and the carotid and facial canals. The
petrous part also forms the anterior edge of the jugular foramen and is the site of the
jugular fossa, in which the jugular bulb resides. The carotid artery enters the external
orifice of the carotid canal, which is positioned anterior to the jugular fossa. The inter-
nal orifice of the carotid canal is located at the petrous apex, where the artery turns
upward to enter the cavernous sinus. The styloid part projects downward and is par-
tially ensheathed at its base by the tympanic part. The stylomastoid foramen is located
behind the styloid process near the anterior end of the digastric groove.

RHOTON
FIGURE 1-20. Posterior inferior view of the lower surface of a right temporal bone. The jugular
fossa, the site of the jugular bulb, is positioned below the lateral part of the petrous part of the tem-
poral bone. The intrajugular ridge extends forward along the medial part of the jugular fossa to sep-
arate the petrosal and sigmoid parts of the jugular foramen. The carotid canal opens onto the lower
surface and is directed upward before turning medially toward the petrous apex. The stylomastoid
foramen, located at the anterior margin of the digastric groove, is hidden by the mastoid tip. The sty-
loid projects downward and is ensheathed along its anterior margin by the posterior edge of the tym-
panic part of the temporal bone. Ac., acoustic; Ant., anterior; Arc., arcuate; Canalic., canaliculus;
Car., carotid; Clin., clinoid; Coch., cochlear; Comm., common; Cond., condylar, condyle;
Depress., depression; Digast., digastric; Emin., eminence; Endolymph., endolymphatic; Eust.,
eustachian; Ext., external; Fiss., fissure; For., foramen; Gr., greater; Hypogloss., hypoglossal;
Impress., impression; Inf., inferior; Int., internal; Intrajug., intrajugular; Jug., jugular; Lat., lat-
eral; Ling., lingual; Mag., magnum; Mandib., mandibular; N., nerve; Occip., occipital;
Occipitomast., occipitomastoid; Orb., orbital; Pet., petrosal, petrous; Petrocliv., petroclival; Post.,
posterior; Proc., process; Prom., prominence; Pteryg., pterygoid; Semicirc., semicircular; Sig., sig-
moid; Sp., spine; Stylomast., stylomastoid; Subarc., subarcuate; Sup., superior; Trans., transverse;
Trig., trigeminal; Tymp., tympanic; Vert., vertical; Vest., vestibular.

CHAPTER 2
MIDDLE FOSSA: ANATOMIC VIEW

FIGURE 2-1. Middle fossa, anatomic view. Middle fossa surface of the tem-
poral bone. The dura has been elevated from the floor of the middle fossa. The
tentorium, except for the attachment along the petrous ridge and superior
petrosal sinus, has been removed. The petrosphenoid ligament (Gruber’s lig-
ament) forms the roof of Dorello’s canal, through which the abducens nerve
passes on the medial side of the first trigeminal division. The trigeminal
nerve sits in a depression on the upper surface of the petrous part. At the lat-
eral edge of the trigeminal impression, the floor of the middle fossa, adjacent
to the sphenoid ridge, rises upward to form the trigeminal prominence. The
posterior part of the floor then settles into another depression between the
trigeminal prominence and the arcuate eminence. The depression between the
trigeminal prominence and the arcuate eminence, the meatal depression,
roofs the majority of the internal acoustic meatus. The bone in the area lat-
eral to the arcuate eminence, referred to as the tegmen, is usually paper-thin.
The tegmen forms part of the roof of the external auditory canal, tympanic
cavity, and mastoid antrum and air cells. The greater petrosal nerve is
exposed directly under the dura of the middle fossa. In this case, the termi-
nal part of the petrous carotid artery is also exposed under the dura and ral bones. The petrous carotid artery is usually covered by bone up to the lat-
below the greater petrosal nerve, as occurs in approximately 15% of tempo- eral side of the third trigeminal division.

RHOTON
FIGURE 2-2. The bone above the internal acoustic

meatus has been removed. The meatus is situated
below the meatal depression. In the past, the drilling to
expose the internal acoustic meatus by the middle
fossa approach was begun above the greater petrosal
nerve, the geniculate ganglion, and the distal part of
the labyrinthine segment. From there, the drilling was
directed proximally from the fundus to the porus of the
meatus. It is now common practice to begin the
drilling above the porus at the level of the petrous
ridge. It is in this area that the meatus is the widest
and easiest to identify. From there, the drilling is
directed distally toward the fundus of the meatus and
the labyrinthine segment of the facial nerve. The ante-
rior wall of the meatus is usually located 6 to 9 mm
lateral to the point the trigeminal nerve crosses the
petrous ridge. Another method used to identify the
approximate site of the porus is to measure the angle
between the arcuate eminence or superior semicircular
canal and the greater petrosal nerve, and to begin the
drilling at the point that a line bisecting that angle
would cross the petrous apex. The superior semicircu-
lar canal underlies the arcuate eminence, although, as
seen here, it may not sit directly under the most prominent area and, in some the arcuate eminence, as shown here, more often than it is situated directly
cases, it may be separated from the floor of the middle fossa by a several mil- under or lateral to the most prominent part of the arcuate eminence.
limeter layer of mastoid air cells. The canal is positioned slightly medial to

FIGURE 2-3. The dura lining the internal

acoustic meatus has been opened to identify
the facial and vestibulocochlear nerves and
the nervus intermedius. The tegmen has
been opened and the mastoid air cells have
been removed to expose the semicircular
canals. The floor of the middle fossa above
the tympanic cavity has been opened to
expose the body of the incus and head of the
malleus in the epitympanic area. The exter-
nal acoustic meatus has been unroofed and
four segments of the facial nerve have been
exposed. The cisternal segment begins at
the brainstem and ends at the porus of the
meatus. The meatal segment extends from
the porus to the fundus of the meatus. The
labyrinthine segment, which is very short,
begins at the fundus of the meatus and
ends at the geniculate ganglion. The tym-
panic segment passes laterally and back-
ward from the geniculate ganglion and
below the lateral semicircular canal. The
tympanic membrane separates the external
acoustic meatus and the tympanic cavity.

RHOTON
FIGURE 2-4. Enlarged view of the internal

acoustic meatus. The cisternal segment of the
facial nerve has been retracted to expose the
nervus intermedius, which arises along the ven-
tral surface of the vestibulocochlear nerve and
jumps to the facial nerve in the cistern or mea-
tus. The nervus intermedius can be made up of
as many as four separate bundles of fibers. The
superior vestibular and facial nerves pass above
the transverse crest. The cochlear nerve courses
in the anterior-inferior quadrant of the meatus
below the transverse crest. The inferior vestibu-
lar nerve is hidden below the superior vestibular
nerve. The vestibular nerves innervate the
ampullated ends of the semicircular canals. The
superior vestibular nerve innervates the ampul-
lae positioned at the anterior end of the superior
and lateral canals. The inferior vestibular nerve
innervates the ampulla at the lower end of the
posterior semicircular canal. The nonampul-
lated posterior end of the superior canal and the
upper end of the posterior canal join to form a
single common channel, the common crus,
which opens into the vestibule.

FIGURE 2-5. Additional bone has been

removed anterior to the greater petrosal nerve
to expose the tensor tympani and eustachian
tube, which are separated from each other
and from the terminal part of petrous carotid
by a thin shell of bone. The cochlea is exposed
in the angle between the labyrinthine seg-
ment of the facial nerve and the greater pet-
rosal nerve. The vestibule into which the
semicircular canals open is positioned behind
the fundus of the meatus. The tensor tym-
pani is a long slender muscle. Its tendon
turns sharply laterally around the trochlear-
iform process to attach to the upper part of
the handle of the malleus. The temporal bone,
when viewed from above, is organized similar
to the letter “Y.” The lower single limb of the
Y is located along the external canal. The
upper two limbs of the Y are directed along
the internal acoustic meatus posteriorly and
the eustachian tube anteriorly. Thus, the
internal and external meati and the
eustachian tube together, when viewed from
above, have a configuration similar to the let-
ter “Y.” The labyrinth, which wraps around the fundus of the meatus and the tympanic cavity, is located at the junction of the three limbs of the Y.

RHOTON
FIGURE 2-6. Enlarged superior view of the

junction of the labyrinth, tympanic cavity, and
adjacent portions of the external and internal
acoustic meati and eustachian tube. The verti-
cal crest (Bill’s bar) separates the superior
vestibular area and facial canal at the fundus of
the meatus. The inferior vestibular nerve is
positioned below the transverse crest in the pos-
terior-inferior quadrant of the meatus and is
hidden by the superior vestibular nerve. The
cochlear nerve is positioned below the trans-
verse crest in the anterior-inferior quadrant of
the meatus. The superior vestibular nerve
innervates the ampulla of the superior and lat-
eral canals, which are located at the anterior
end of these canals near the fundus of the mea-
tus. The inferior vestibular nerve innervates
the ampullae of the posterior semicircular
canal, which is located at the inferior end of the
posterior canal. The tensor tympani, which is
innervated by the trigeminal nerve, has a sharp
bend around the trochleariform process, at the
site it gives rise to a narrow tendon, which
attaches to the malleus. The body and short
process of the incus are exposed posterior to the articulation of the incus with chorda tympani crosses the inner surface of the tympanic membrane and the
the malleus. The tensor tympani is separated from the roof of the eustachian upper part of the handle of the malleus.
tube, carotid canal, and floor of the middle fossa by a thin shell of bone. The


floor of the middle fossa after expos-
ing the cochlea and vestibule. The
vestibule has been exposed below the
anterior ends of the superior and lat-
eral canals. The vestibule communi-
cates, below the fundus of the mea-
tus, with the cochlea. The cochlea is
located below the floor of the middle
fossa in the angle between the
labyrinthine segment of the facial
nerve and the greater petrosal nerve.
The vertical segment of the petrous
carotid turns medially to form the
horizontal segment at its lateral
bend, which is positioned below the
cochlea. Fibers from the cervical
sympathetic ganglia ascend on the
surface of the carotid artery. The
articulation of the lenticular process
of the incus with the head of the
stapes is seen below the anterior por-
tion of the lateral semicircular canal.

RHOTON
FIGURE 2-8. Superolateral view. The

cisternal segment of the facial nerve has
been retracted to expose the nervus inter-
medius. The petrous apex, which extends
below the trigeminal nerve and up to the
side of the clivus, has been preserved. The
tympanic segment of the facial nerve
passes below the lateral semicircular
canal and turns downward to form the
mastoid (vertical or descending) seg-
ment.

FIGURE 2-9. Superolateral view. The

petrous apex medial to the internal
acoustic meatus and posterior to the
petrous segment of the internal carotid
artery has been removed, as would be per-
formed in an anterior petrosectomy
approach. The exposure extends to the lat-
eral edge of the clivus and inferior pet-
rosal sinus. The abducens nerve passes
above the anterior inferior cerebellar
artery and through the inferior petrosal
sinus. The oculomotor nerve enters the
roof of the cavernous sinus just below the
origin of the posterior communicating
artery from the internal carotid artery.
The trochlear nerve passes along the
lower margin of the tentorial edge. The
superior cerebellar artery sits on the
upper edge of the trigeminal nerve.

RHOTON
FIGURE 2-10. Another specimen with the

upper surface of the temporal bone drilled to
expose the labyrinth and internal and external
acoustic meati. The vertical crest (Bill’s bar)
separates the facial nerve and superior vestibu-
lar nerve at the fundus of the meatus. The
cochlea is positioned below the floor of the mid-
dle fossa in the angle between the labyrinthine
segment of the facial nerve and the greater pet-
rosal nerve. Both ends of the semicircular
canals communicate with the vestibule. The
semicircular canals have only five openings into
the vestibule, even though they communicate
with the vestibule at both ends. The reason is
that the posterior end of the superior canal and
the upper end of the posterior canal join to form
a common limb, or crus, before opening into the
vestibule. The body of the incus and head of the
malleus are exposed in the epitympanic area.
The tympanic segment of the facial nerve passes
below the lateral semicircular canal. The inter-
nal acoustic meatus sits below the depressed
area between the trigeminal prominence and the
arcuate eminence. The position of the internal
acoustic meatus can be approximated by bisecting the angle between the where the bisection line crosses the petrous ridge and is directed from there
greater petrosal nerve and the superior semicircular canal. The drilling to toward the fundus. Entering either the cochlea or vestibule at the fundus of
expose the internal acoustic meatus is begun above the porus of the meatus, the meatus will result in a loss of hearing.

FIGURE 2-11. Superolateral view of

the right middle fossa in another speci-
men. The bone has been removed to
expose the nerves in the internal
acoustic meatus. The cochlea is enclosed
in the bone in the angle between the
labyrinthine segment of the facial nerve
and the greater petrosal nerve. The
incus and malleus are exposed in the
epitympanic area. The superior semicir-
cular canal, which sits below the medial
side of the arcuate eminence, has been
unroofed.

RHOTON
FIGURE 2-12. Bone has been

removed to expose the semicircular
canals and the internal and external
acoustic meati. A portion of the
petrous apex has been removed and
the dura below the trigeminal nerve
has been opened to expose a tortuous
basilar artery. The tensor tympani
sits in the roof of the eustachian tube
behind the petrous carotid.

FIGURE 2-13. The trigeminal nerve has been

removed to expose the cavernous sinus. The greater
petrosal nerve passes forward and medially, where it
is joined by the deep petrosal branch of the carotid
plexus to form the Vidian nerve. The abducens nerve
passes under the petrosphenoid ligament to enter the
cavernous sinus. A portion of the petrous apex below
the trigeminal nerve has been removed. Removal of
the floor of the middle fossa exposes the pterygoid
muscles and venous complex and branches of the
mandibular nerve and maxillary artery in the
infratemporal fossa. The temporalis muscle fills the
temporal fossa. A., artery; A.I.C.A., anterior inferior
cerebellar artery; Ac., acoustic; Arc., arcuate; Bas.,
basilar; Car., carotid; Chor., chorda; Cist., cisternal;
CN, cranial nerve; Coch., cochlear; Emin., eminence;
Eust., eustachian; Ext., external; Gang., ganglion;
Gen., geniculate; Gr., greater; Inf., inferior, infero;
Infratemp., infratemporal; Intermed., intermedius;
Laby., labyrinthine; Lat., lateral; Lig., ligament;
Ling., lingual; M., muscle; Mast., mastoid; Meat.,
meatal; Memb., membrane; Men., meningeal; Mid.,
middle; N., nerve; Nerv., nervus; Pet., petro, pet-
rosal, petrous; Post., posterior; Proc., process; Prom.,
prominence; S.C.A., superior cerebellar artery; Seg., segment; Semicirc., ral; Tens., tensor; Tent., tentorial; Trig., trigeminal; Troch., trochleariform;
semicircular; Sig., sigmoid; Sphen., sphenoid; Sup., superior; Temp., tempo- Tymp., tympani, tympanic; Vert., vertical; Vest., vestibular.

CHAPTER 3
MIDDLE FOSSA: SURGICAL APPROACH

Neurosurgery 61:S4-98–S4-117, 2007 DOI: 10.1227/01.NEU.0000280013.46641.EC www.neurosurgery-online.com
FIGURE 3-1. Middle fossa. The right middle fossa with the head in the typ-
ical surgical position. The surgeon usually sits at the head of the table for mid-
dle fossa approaches. This leads to the viewing of the anatomy upsidedown,
thus placing the floor of the middle fossa in the upper part of the exposure.
The trigeminal nerve sits in the trigeminal depression on the medial part of
the petrous apex and medial to the trigeminal prominence. There is an addi-
tional depression above the internal acoustic meatus, the meatal depression,
between the trigeminal prominence and the arcuate eminence. The tegmen,
positioned lateral to the arcuate eminence, provides a paper-thin roof for the
tympanic cavity, external auditory canal, and mastoid antrum. The petrous
carotid is usually covered by bone up to the lateral edge of the trigeminal
nerve but, here, the terminal segment of the petrous carotid artery is exposed
beneath the dura and the greater petrosal nerve. The trochlear nerve passes
below the tentorial margin.

MIDDLE FOSSA SURGICAL APPROACH
FIGURE 3-2. The bone in the meatal depression

between the trigeminal prominence and the arcuate
eminence has been removed to expose the dura lining
the internal acoustic meatus. The drilling was begun
above the meatal porus at the level of the petrous
ridge. The drilling proceeds distally toward the
meatal fundus and above the labyrinthine segment of
the facial nerve. One method of identifying the porus
for the initial drilling is to begin the drilling at the
petrous ridge 5 to 7 mm lateral to the trigeminal
impression or nerve. The distance from the lateral
edge of the trigeminal impression or nerve at the
level of the petrous ridge to the anterior and posterior
walls of the porus of the meatus averages 6.4 mm
(range, 4.0–9.0 mm) and 14.2 mm (range, 12.0–18.0
mm), respectively. Care is taken to preserve the
cochlea, which is enclosed in the bone between the
labyrinthine segment of the facial nerve and the
greater petrosal nerve, and the semicircular canals
and vestibule positioned posterolateral to the fundus
of the meatus. The labyrinthine segment of the facial
nerve and the geniculate ganglion have been exposed.
The facial and vestibulocochlear nerves are exposed
in the cerebellopontine angle adjacent the flocculus.
The greater petrosal nerve passes medially above the terminal part of the petrous carotid and below the lower surface of the trigeminal nerve.

FIGURE 3-3. Additional bone ante-

rior to the terminal part of the
petrous carotid has been removed to
expose the tensor tympani muscle
and eustachian tube. Bone removal
lateral to the fundus of the internal
acoustic meatus exposes the semicir-
cular canals, tympanic cavity, and
external auditory canal. The dura lin-
ing the internal acoustic meatus has
been opened to expose the facial and
vestibulocochlear nerves. The tegmen
has been opened, and the mastoid air
cells have been removed to expose the
dura medial to the sigmoid sinus,
referred to as Trautmann’s triangle,
which faces the cerebellum. The
cochlea is exposed anteromedial and
the vestibule posterolateral to the fun-
dus of the meatus.

FIGURE 3-4. Superior view of the auditory

ossicles. The auditory ossicles are connected
to the walls of the tympanic cavity by liga-
ments, three for the malleus and one each for
the incus and stapes. The anterior ligament of
the malleus is attached at one end to the neck
and at the other end to the anterior wall of the
tympanic cavity close to the petrotympanic
fissure. The lateral ligament of the malleus
(not shown) is a triangular band passing
from the posterior part of the border of the
tympanic incisura to the head of the malleus.
The superior ligament of the malleus (not
shown) attaches the head of the malleus to
the roof of the epitympanic area. The posterior
ligament of the incus connects the end of the
short process of the fossa incudis, a shallow
depression in which the tip of the short
process sits. The superior ligament of the
incus is a small fold of mucus membrane
passing from the body of the incus to the roof
of the epitympanic area. The circumference of
the base of the stapes is attached to the mar-
gin of the oval window by a ring of elastic
fibers termed the anular ligament of the base of the stapes. The tendon of the to the upper part of the handle of the malleus. The stapedial tendon attaches
tensor makes a right angle turn around the trochleariform process to attach to the neck of the stapes.

FIGURE 3-5. The petrous apex has

been removed to expose the lateral side of
the clivus and the inferior petrosal
sinus. The layer of bone that separates
the internal acoustic meatus from the
area drilled for the anterior petrosectomy
has been preserved. The middle fossa
approach to the internal acoustic meatus
is usually selected for small tumors
within the internal acoustic meatus in
which it is possible to preserve hearing.
Preserving hearing requires that the
vestibule, semicircular canals, and
cochlea be preserved in exposing the
meatus. The approach for the anterior
petrosectomy, which exposes the lateral
edge of the clivus, upper brainstem, and
basilar artery, is directed through the
area medial to the internal acoustic mea-
tus. Care is required to avoid damaging
the cochlea, which would result in a loss
of hearing in both the middle fossa
approach to the internal acoustic meatus
and the anterior petrosectomy.

FIGURE 3-6. The petrous apex has

been removed to expose the lateral
edge of the clivus and the inferior pet-
rosal sinus. The dura has been opened
to expose the anterolateral surface of
the pons above and below the trigemi-
nal nerve and the anterior inferior
cerebellar artery crossing the abducens
nerve. Care must be taken to avoid
damage to the abducens nerve at the
medial margin of the drilling, where
the nerve passes through the inferior
petrosal sinus. The anterior petrousec-
tomy is one of our favored approaches
for exposing a low basilar bifurcation
and the portion of the basilar artery
below the trigeminal nerve.

FIGURE 3-7. Extradural right mid-

dle fossa exposure. The craniotomy is
positioned above the root of the zygo-
matic arch and extends to the middle
fossa floor. The dura has been elevated
from the floor of the right middle
fossa to expose the greater petrosal
nerve and middle meningeal artery.
The middle fossa approach to the
internal acoustic meatus is usually
directed through the extradural
space.

FIGURE 3-8. Enlarged view. The

geniculate ganglion and the distal
labyrinthine and proximal tympanic
segments of the facial nerve are exposed
directly under the dura. The ganglion is
exposed without a bony covering in
approximately 15% of temporal bones.
Trauma to the ganglion during eleva-
tion of the dura may cause a facial
palsy. The middle meningeal artery
sends a small branch along the greater
petrosal nerve to the geniculate gan-
glion and adjacent segments of the
facial nerve. Occluding this small
artery may cause facial paralysis.

FIGURE 3-9. Bone has been removed to show the two most com-
mon approaches directed through the middle fossa surface of the
temporal bone. The more medial approach, the anterior petrosec-
tomy, is directed through the petrous apex, and below the trigeminal
nerve to the lateral edge of the clivus and brainstem. The more lat-
eral channel is the middle fossa approach to the internal acoustic
meatus. In both approaches, an effort is made to avoid damaging the
cochlea, which sits in the area between the fundus of the meatus and
the greater petrosal nerves. The superior semicircular canal has been
exposed lateral to the drilling to expose the internal acoustic meatus.
This drilling to expose the internal acoustic meatus usually begins
at the level of the petrous ridge above the porus of the meatus and is
directed laterally and forward toward the fundus of the meatus,
where the exposure progressively narrows.

FIGURE 3-10. The dura lining the internal acoustic meatus has
been opened to expose the cisternal, meatal, labyrinthine, and tym-
panic segments of the facial nerve; the superior, inferior, and
cochlear nerves; two rootlets of the nervus intermedius; and the
geniculate ganglion.

FIGURE 3-11. The drilling has been

extended to expose the cochlea along the
anteromedial edge of the fundus of the meatus
and the vestibule and semicircular canals
along the posterolateral margin of the meatal
fundus. Care must be taken in the middle
fossa approach to the internal acoustic meatus
to avoid entering the cochlea and vestibule. If
either the cochlea or vestibule is entered, hear-
ing will be lost. The transverse crest divides
the fundus of the meatus into an upper and a
lower compartment. The facial and superior
vestibular nerves course above the transverse
crest and the cochlear and inferior vestibular
nerves pass below the crest. The facial nerve
passes through the anterior-superior quad-
rant, the inferior vestibular nerve passes
through the posterior-superior quadrant, the
cochlear nerve passes through the anterior-
inferior quadrant, and the inferior vestibular
nerve passes through the posterior-inferior
quadrant of the meatal fundus. The vertical
crest (Bill’s bar) separates the facial and supe-
rior vestibular nerves.

FIGURE 3-12. The anterior petro-

sectomy directed through the area
medial to the internal acoustic mea-
tus has been completed. The exposure
is directed posterior to the greater
petrosal nerve and below the trigem-
inal nerve to the lateral edge of the
clivus adjacent to the inferior petrosal
sinus, and to the posterior fossa dura
that faces the brainstem.

FIGURE 3-13. The dura below the

superior petrosal sinus and lateral to
the trigeminal nerve has been opened
to expose the anterior surface of the
pons. The dural incision crosses the
superior petrosal sinus and tento-
rium. The trochlear nerve was pre-
served in opening the tentorial edge.
The dural edges have been retracted
with sutures to expose the lower mid-
brain and the superior cerebellar
artery. The exposure extends above
and below the trigeminal nerve to the
anterolateral pons and to the lateral
edge of the clivus.

FIGURE 3-14. Drilling has been completed and

the dura opened. The exposure extends below the
trigeminal nerve and to the anterolateral surface
of the pons and lateral edge of the clivus. The
anterior inferior cerebellar artery passes next to
the abducens nerve in the lower part of the expo-
sure. The abducens nerve ascends and passes
below the petrosphenoid (Gruber’s) ligament to
reach the cavernous sinus between the cavernous
carotid artery and the first trigeminal division.
The exposure extends superiorly to the level of
the oculomotor nerve. This approach can be
directed to a basilar bifurcation located below the
level of the dorsum sellae or to selected lesions
along the trunk of the basilar artery or anterolat-
eral brainstem. The approach also provides a
pathway to the clivus that avoids going through
the oral cavity.


middle fossa. The bone above the
eustachian tube, tensor tympani
muscle, petrous carotid, and internal
acoustic meatus and below the sec-
ond trigeminal division has been
removed. Dura has been removed
from the lateral wall of the cavernous
sinus to expose the trochlear, trigem-
inal, and oculomotor nerves in the
sinus wall and the abducens nerve
passing below the petrosphenoid lig-
ament and through Dorello’s canal.
The greater petrosal nerve passes
medially above the petrous carotid
artery. The lesser petrosal nerve
arises from the tympanic branch of
the glossopharyngeal nerve, ascends
across the promontory in the tym-
panic plexus, and crosses the floor of
the middle fossa above the tensor
tympani. The lesser petrosal nerve
provides autonomic innervation
through the otic ganglion to the
parotid gland. The tensor tympani
muscle and eustachian tube are lay-
ered along but are separated from each other and from the anterior surface of the petrous carotid by a thin layer of bone.

FIGURE 3-16. The trigeminal nerve

has been reflected forward. The
petrolingual ligament extends from
the lingual process of the sphenoid
bone to the petrous apex and passes
above the junction of the petrous and
cavernous segments of the internal
carotid artery. The greater petrosal
nerve joins the deep petrosal branch
of the carotid sympathetic plexus to
form the vidian nerve. The vidian
canal has been unroofed to expose the
vidian nerve. The lesser petrosal
nerve arises from the tympanic
branch of the glossopharyngeal nerve,
passes across the promontory of the
middle ear in the tympanic nerve
plexus, crosses the floor of the middle
fossa above the tensor tympani, and
exits the cranium to provide para-
sympathetic innervation through the
otic ganglion to the parotid gland.

FIGURE 3-17. Enlarged superior view of the

junction of the eustachian tube and the internal
and external meati. The mastoid air cells on the
lateral side of the semicircular canals have been
removed. The superior vestibular, inferior
vestibular, facial, and cochlear nerves are
exposed at the fundus of the meatus. The
cochlear nerve enters the modiolus of the cochlea.
The vertical crest (Bill’s Bar) separates the facial
and superior vestibular nerves at the fundus of
the meatus. The superior vestibular nerve inner-
vates the ampullated anterior ends of the supe-
rior and lateral canals. The inferior vestibular
nerve innervates the lower or ampullated end of
the posterior canal. The chorda tympani crosses
the tympanic membrane and the upper part of
the handle of the malleus. The greater petrosal
nerve passes medially above the petrous carotid.
The cochlea sits in the angle between the
labyrinthine segment of the facial nerve and the
greater petrosal nerve. The lesser petrosal nerve
crosses above the tensor tympani and exits the
cranium near the foramen ovale to reach the otic
ganglion and innervate the parotid gland.

FIGURE 3-18. The mastoid antrum

and air cells, which are positioned
behind the external canal and lateral
to the semicircular canals and
vestibule, have been removed. Note
that the internal and external audi-
tory canals are located in a straight
line from each other. The cochlea is
exposed below the floor of the middle
fossa in the angle between the greater
petrosal nerve and the labyrinthine
segment of the facial nerve. The
petrous carotid is exposed below the
greater petrosal nerve and behind the
eustachian tube. The chorda tympani
crosses the inner surface of the tym-
panic membrane. The facial and
superior vestibular nerves pass above
and the cochlear and inferior vestibu-
lar nerves pass below the transverse
crest. The vertical crest (Bill’s Bar)
separates the facial and superior
vestibular nerves at the fundus of the
meatus. The lower segment of the
sigmoid sinus has been preserved.

FIGURE 3-19. Superior view of the temporal bone, infratemporal fossa,

and orbital apex. Aggressive lesions involving the temporal bone often
extend forward to the infratemporal fossa. The floor of the middle fossa has
been removed to expose the temporal and infratemporal fossae. The tempo-
ralis muscle fills the temporal fossa. The pterygoid muscles and venous
plexus, branches of the third trigeminal division, and the maxillary artery
are positioned in the infratemporal fossa. The posterior part of the middle
fossa formed by the squamous portion of the temporal bone, and which
forms the upper surface of the temporomandibular joint, has been removed
to expose the mandibular condyle. The posterior surface of the mandibular
condyle rests against the tympanic part of the temporal bone.

FIGURE 3-20. Lateral view. The anterior surface of the temporal

bone faces the posterior part of the infratemporal fossa, which con-
tains the branches of the maxillary artery and mandibular nerve
and the pterygoid muscles and venous plexus. The infratemporal
fossa opens medially into the pterygopalatine fossa. The maxillary
nerve passes through the foramen rotundum to enter the ptery-
gopalatine fossa and send branches along the orbital floor. The
ophthalmic nerve passes through the superior orbital fissure and
sends branches along the orbital roof. Bone has been removed to
expose the sphenoid sinus above and below the maxillary nerve,
and the vidian nerve below the maxillary nerve. A., artery;
A.I.C.A., anterior inferior cerebellar artery; Ac., acoustic; Ant.,
anterior; Arc., arcuate; Bas., basilar; Car., carotid; Cav., cav-
ernous; Chor., chorda; CN, cranial nerve; Coch., cochlear; Cond.,
condyle; Emin., eminence; Eust., eustachian; Ext., external; Fiss.,
fissure; Flocc., flocculus; Gang., ganglion; Gen., geniculate; Gr.,
greater; Inf., inferior; Int., internal; Intermed., intermedius;
Laby., labyrinthine; Lat., lateral; Lent., lenticular; Less., lesser;
Lig., ligament; Ling., lingual; M., muscle; Mandib., mandibular;
Max., maxillary; Meat., meatal; Memb., membrane; Men.,
meningeal; Mid., middle; N., nerve; Nerv., nervus; Ophth., ophthalmic; moid; Sphen., sphenoid; Stap., stapedial; Sup., superior; Temp., temporal,
Orb., orbital; Pet., petro, petrosal, petrous; Post., posterior; Proc., process; temporalis; Tens., tensor; Tent., tentorial, tentorium; Transv., transverse;
Prom., prominence; Pteryg., pterygoid; Pterygopal., pterygopalatine; S.C.A., Trig., trigeminal; Troch., trochleariform; Tymp., tympani, tympanic; Vert.,
superior cerebellar artery; Seg., segment; Semicirc., semicircular; Sig., sig- vertical; Vest., vestibular; Zygo., zygomatic.

CHAPTER 4
ANTERIOR VIEW
Neurosurgery 61:S4-118–S4-125, 2007 DOI: 10.1227/01.NEU.0000280015.54264.5E www.neurosurgery-online.com
FIGURE 4-1. Anterior view of a stepwise dissection of a cross section through

the anterior part of the temporal bone. The coronal section crosses the tempo-
ral lobe and floor of the middle fossa just anterior to the external canal and
tympanic part of the temporal bone. The mandibular condyle has been removed
from the mandibular fossa. The posterior margin of the mandibular fossa is
formed by the tympanic part of the temporal bone, which also forms the lower
and anterior wall and part of the posterior wall of the external canal. Three
muscles arise from the styloid process, which projects downward, and is
ensheathed at its base by the tympanic part of the temporal bone. The internal
carotid artery ascends medial and slightly posterior to the styloid process to
enter the carotid canal. The facial nerve exits the stylomastoid foramen postero-
lateral to the styloid process.

ANTERIOR VIEW
FIGURE 4-2. Enlarged view. The anterior

part of the tympanic part of the temporal bone
has been removed to expose the cartilaginous
and osseous parts of the external acoustic
meatus. The lateral edge of the osseous part of
the external acoustic meatus and the osseous
ring to which the tympanic membrane
attaches have been preserved. The facial nerve
is exposed posterolateral to the styloid
process. The chorda tympani arises from the
mastoid segment of the facial nerve, ascends
through its posterior canaliculus and along
the inner surface of the posterior edge of the
tympanic membrane, crosses the upper part
of the handle of the malleus, and descends
through its anterior canaliculus and the
petrotympanic fissure. A probe has been
advanced through the eustachian tube into
the tympanic cavity. The internal jugular
vein is exposed between the styloid process
and the internal carotid artery.

RHOTON
FIGURE 4-3. The tympanic membrane has been

removed to expose the tympanic cavity. Bone has
been removed below the floor of the middle fossa to
expose the epitympanic area, where the head of the
malleus and body of the incus reside. The handle of
the malleus is exposed at the lateral edge of the
tympanic cavity. The promontory overlying the
basal turn of the cochlea forms part of the medial
wall of the tympanic cavity. The tympanic cavity
opens upward into the epitympanic area. The epi-
tympanic area opens posteriorly into the mastoid
antrum.

ANTERIOR VIEW
FIGURE 4-4. Enlarged view. The handle

of the malleus and the long process of the
incus are exposed in the tympanic cavity.
The lower end of the long process of the
incus turns sharply medially to form the
lenticular process, which articulates with
the head of the stapes. The footplate of the
stapes sits in the oval window. The
chorda tympani crosses the inner surface
of the tympanic membrane and the upper
part of the handle of the malleus. The
head of the malleus and body of the incus
are exposed in the epitympanic area. The
pyramidal eminence, which houses the
stapedial muscle, is exposed to the left of
the long process of the incus. The stape-
dial muscle is innervated by the facial
nerve. The tympanic cavity opens for-
ward and medially into the eustachian
tube. The tensor tympani muscle, which
is innervated by the trigeminal nerve, is
separated from the roof of the eustachian
tube by a thin shell of bone. The niche
leading to the round window is located
below the promontory.

RHOTON
FIGURE 4-5. Enlarged view. The tendon of the stapedial muscle

extends forward from the apex of the pyramidal eminence to insert on
the neck of the stapes. The chorda tympani crosses the upper part of the
tympanic membrane and the handle of the malleus in the area lateral
to the long process of the incus. The footplate of the stapes sits in the
oval window. The promontory in the medial wall of the tympanic cav-
ity overlies the basal turn of the cochlea. The niche leading to the round
window is located below the promontory. The lenticular process of the
incus articulates with the head of the stapes.

ANTERIOR VIEW
FIGURE 4-6. Additional bone has

been removed behind the epitym-
panic area and head of the malleus
and body of the incus to expose the
superior semicircular canal. The
promontory has been drilled to
expose the basal turn of the cochlea.
The osseous spiral lamina projects
into the area between the scala tym-
pani and the scala vestibuli. The del-
icate membranes that surround and
support the cochlear duct attach to
the spiral lamina and the outer wall
of the cochlea. The scala tympani is
separated from the tympanic cavity
by a thin membrane across the round
window. The oval window, in which
the footplate of the stapes sits, leads
from the tympanic cavity to the
vestibule of the inner ear. The stapes
has been removed from the oval win-
dow. The pyramidal eminence is
exposed below the segment of the
chorda tympani ascending to reach
the upper part of the handle of the
malleus.

RHOTON
FIGURE 4-7. Enlarged view of the epi-

tympanic area anteriorly and the semi-
circular canals posteriorly. The head of
the malleus and body of the incus are
exposed in the epitympanic area. The
superior, lateral, and posterior semicir-
cular canals have been exposed by
removing some of the mastoid air cells
and mastoid antrum. The superior canal
projects upward toward the floor of the
middle fossa in the area below the arcu-
ate eminence. The medial wall of the
tympanic cavity has been drilled to
expose the tympanic segment of the
facial nerve and the geniculate ganglion.
The tympanic segment passes above the
oval window and below the lateral semi-
circular canal.

ANTERIOR VIEW
FIGURE 4-8. Anterior superior view. Additional drilling along

the floor of the middle fossa exposes the meatal segment of the
facial nerve in the internal acoustic meatus. The labyrinthine
segment of the facial nerve extends from the fundus of the mea-
tus to the geniculate ganglion. The tympanic segment of the
facial nerve arises at the level of the geniculate ganglion and
passes posteriorly below the lateral canal and above the oval
window. The tensor tympani muscle, which is innervated by the
trigeminal nerve, is enclosed in an osseous canal, which is sep-
arated by a thin shell of bone from the carotid canal and the roof
of the tympanic cavity. The tendon of the tensor tympani has a
right angle turn around the cochleaform process before attaching
to the upper part of the neck of the malleus. The chorda tympani
arises from the mastoid segment of the facial nerve, ascends in its
posterior canaliculus, crosses the tympanic membrane and the
upper part of the handle of the malleus, and descends through its
anterior canaliculus and the petrotympanic fissure. A., artery;
Ac., acoustic; Car., carotid; Chor., chorda; CN, cranial nerve;
Emin., eminence; Epitymp., epitympanic; Eust., eustachian;
Ext., external; Gang., ganglion; Gen., geniculate; Gr., greater;
Int., internal; Jug., jugular; Laby., labyrinthine; Lat., lateral;
Lent., lenticular; M., muscle; Mandib., mandibular; Meat.,
meatal; Memb., membrane; Mid., middle; N., nerve; Pet., petrosal; Post., rior; Temp., temporal; Tens., tensor; Tymp., tympani, tympanic; V., vein.
posterior; Proc., process; Seg., segment; Semicirc., semicircular; Sup., supe-

CHAPTER 5
LATERAL VIEW
Neurosurgery 61:S4-126–S4-134, 2007 DOI: 10.1227/01.NEU.0000280016.31394.A0 www.neurosurgery-online.com
FIGURE 5-1. Lateral view of the temporal bone. Stepwise dissec-

tion. The tympanic part of the temporal bone forms the anterior
and lower walls and part of the posterior wall of the external
canal, part of the floor of the tympanic cavity, and the osseous por-
tion of the eustachian tube. The facial nerve exits the cranium
through the stylomastoid foramen medial to the lower part of the
tympanomastoid suture at the anterior end of the digastric groove.
The spine of Henle, at the junction of the upper and posterior
edge of the external canal, approximates the deep site of the tym-
panic segment of the facial nerve and the lateral semicircular
canal. The suprameatal triangle, a depressed area posterosuperior
to the external canal and behind the spine of Henle, is located
superficial to the mastoid antrum. The antrum is located superfi-
cial to the semicircular canals. The squamosal and tympanic parts
of the temporal bone form the upper and posterior surfaces of the
mandibular fossa.

LATERAL VIEW
FIGURE 5-2. A mastoidectomy has

been completed to expose the osseous
capsule of the posterior and lateral
canals, the sigmoid sinus, and the
dura of the middle fossa. The jugular
bulb is medial to the cortical bone
above the digastric groove. The
chorda tympani crosses the inner
surface of the tympanic membrane.

RHOTON
FIGURE 5-3. The posterior and superior

wall of the external canal and the tym-
panic membrane have been removed while
preserving the ossicles and the chorda
tympani. The mastoid (vertical or
descending) segment of the facial nerve
descends below the lateral canal and gives
rise to the chorda tympani, which passes
upward and forward on the inner aspect of
the tympanic membrane and across the
upper part of the handle of the malleus.
The head of the malleus articulates with
the body of the incus. The short process of
the incus points backward toward the
tympanic segment of the facial nerve. The
lenticular process at the lower end of the
long process of the incus articulates with
the stapes, which sits in the oval window.
The tendon of the stapedial muscle passes
forward from the muscle’s enclosure in the
pyramidal eminence to attach to the neck
of the stapes. The dura between the sig-
moid sinus and the semicircular canals,
called Trautmann’s triangle, has been
opened. The endolymphatic sac, into which a blue piece of material has surface of the temporal bone. The jugular bulb is positioned below the semi-
been placed, sits beneath the dura of Trautmann’s triangle on the posterior circular canals and vestibule.

LATERAL VIEW
FIGURE 5-4. Enlarged view of the auditory ossicles. The

malleus, below the lateral process, attaches to the inner surface
of the tympanic membrane. The chorda tympani, a segment of
which has been preserved, crosses the upper part of the handle
or neck of the malleus. The head of the malleus and body of the
incus are situated in the epitympanic area below the floor of the
middle fossa. The short process of the incus points posteriorly
toward the tympanic segment of the facial nerve as it passes
between the lateral canal above and the stapes sitting in the
oval window below. The long process of the incus terminates in
a sharp right angle turn to form the lenticular process, which
articulates with the head of the stapes.

RHOTON

incus has been removed to expose the
stapes sitting in the oval window.
The chorda tympani crosses the upper
part of the handle of the malleus. The
promontory is located superficial to
the basal turn of the cochlea. The fun-
dus of the internal acoustic meatus is
located medial to the tympanic cavity
and acousticovestibular labyrinth. A
line directed medially through the
cranial base along the long axis of the
external meatus will, at its depth,
approximate the site of the long axis
of the internal meatus deep to the
promontory. The fibers of the tym-
panic plexus, which arise from the
tympanic (Jacobson’s) branch of the
glossopharyngeal nerve, cross the
promontory on their way to the floor
of the middle fossa, where they form
the lesser petrosal nerve.

LATERAL VIEW
FIGURE 5-6. The malleus and tym-

panic membrane have been removed.
The lateral portion of the lateral semi-
circular canal has been removed and
the vestibule is exposed deep in the
area of the ampullated end of the lat-
eral canal. A portion of the superior
and lateral canals have also been
removed. The posterior end of the
superior canal and the upper end of
the posterior canal join deep to the
bridge of bone outlined by the arrows
to form the common crus.

RHOTON
FIGURE 5-7. View directed laterally from

the oval window through the tympanic
cavity to the tympanic membrane. The
labyrinthine segment of the facial nerve
passes from the fundus of the meatus to
the geniculate ganglion. The tympanic seg-
ment arises at the geniculate ganglion and
passes above the footplate of the stapes,
which normally sits in the oval window.
The mastoid segment descends through the
facial canal medial to the mastoid part of
the temporal bone. The handle of the
malleus is attached to the tympanic mem-
brane. The chorda tympani crosses the
upper part of the handle of the malleus.
The head of the malleus articulates with
the body of the incus. The long process of
the incus ends in the medially directed
lenticular process that articulates with the
head of the stapes. The upper part of the
tympanic membrane, the pars flaccida, is
situated between the anterior and poste-
rior malleolar folds, which pass upward
from their attachment to the lateral process
of the malleus.

LATERAL VIEW
FIGURE 5-8. Medial aspect of the auditory ossicles. The head of the malleus
is the site of a facet, which articulates with the facet on the body of the incus.
The handle of the malleus, below the lateral process, is attached to the inner
surface of the tympanic membrane. The chorda tympani passes along the inner
surface of the tympanic membrane and across the upper part of the handle of
the malleus. The lateral process is the site of attachment of the lower end of the
anterior and posterior malleolar folds, between which is located the pars flac-
cida of the upper portion of the tympanic membrane. The stapedial tendon,
which has been preserved, attaches to the neck of the stapes. The long process
of the incus turns at a right angle at its lower end and gives rise to the lentic-
ular process, which articulates with the head of the stapes. The neck of the
stapes is connected by anterior and posterior limbs to join the footplate or base,
which sits in the oval window.

RHOTON
FIGURE 5-9. The medial wall of the epitympanic area

and mastoid have been exposed. The tympanic segment of
the facial nerve passes above the oval window. The semi-
circular canals are located above and behind the tym-
panic segment of the facial nerve. The oval window is
located below and the lateral canal above the tympanic
segment. The area of the promontory has been drilled to
expose the basal turn of the cochlea. A dark suture has
been placed in the basal and second turn of the cochlea.
Ant., anterior; Artic., articulate; Bas., basal; Chor.,
chorda; CN, cranial nerve; Comm., common; Digast.,
digastric; Emin., eminence; Endolymph., endolym-
phatic; Epitymp., epitympanic; Eust., eustachian;
Gang., ganglion; Gen., geniculate; Gr., greater; Jug.,
jugular; Laby., labyrinthine; Lat., lateral; Lent., lentic-
ular; M., muscle; Mandib., mandibular; Mast., mastoid;
Memb., membrane; N., nerve; Pet., petrosal; Plex.,
plexus; Post., posterior; Proc., process; Seg., segment;
Semicirc., semicircular; Sig., sigmoid; Sp., spine;
Squamomast., squamomastoid; Sup., superior;
Suprameat., suprameatal; Tens., tensor; Triang., trian-
gle; Tymp., tympani, tympanic; Tympanomast., tympa-
nomastoid.

CHAPTER 6
RELATIONSHIPS OF THE TEMPORAL BONE TO THE LATERAL CRANIAL BASE

FIGURE 6-1. Relationships of the temporal bone to the lateral cranial base.
Lateral view. Figures 6-1–6-15, stepwise dissection of left temporal area and
temporal bone. The skin and subcutaneous tissues have been removed to
expose the parotid gland and the facial nerve branches that course deep to
the parotid gland on their way to the facial muscles. The sternocleidomas-
toid attaches to the lateral part of the superior nuchal line and mastoid
process, descends in an anterior direction, and is crossed by the greater
auricular nerve. The temporalis fascia attaches to the upper surface of the
zygomatic arch. The trapezius muscle attaches to the medial part of the
superior nuchal line. The posterior triangle of the neck, located between the
sternocleidomastoid and trapezius, has the semispinalis capitis, splenius
capitis, and levator scapulae in its floor. The masseter muscle passes down-
ward from the zygomatic bone and arch to attach to the body and angle of
the mandible. The terminal branches of the occipital artery and the greater
occipital nerve reach the subcutaneous tissues by passing between the
attachment of the trapezius and sternocleidomastoid muscles to the superior
nuchal line.

RHOTON
FIGURE 6-2. Enlarged view. The facial nerve

branches are exposed along the anterior edge of the
parotid gland. The parotid duct crosses the temporalis
muscle.

LATERAL CRANIAL BASE
FIGURE 6-3. The parotid gland has been

removed to expose the facial nerve and its
branches distal to the stylomastoid foramen.
The nerve passes lateral to the styloid process,
the external carotid artery, and mandibular
neck. The masseter muscle has two heads: a
more 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 mandibular body. This
lower end of the sternocleidomastoid muscle
has been reflected backward by dividing its
attachment to the clavicle and sternum. The
superficial temporal artery ascends in front of
the ear.

RHOTON
FIGURE 6-4. The upper part of the

mandibular ramus and the lower
part of the temporalis muscle and its
attachment to the coronoid process
have been removed while preserving
the inferior alveolar and lingual
nerves. The infratemporal fossa is
located medial to the mandible on the
deep side of the temporalis muscle.
The exposure includes the upper and
lower heads of the lateral pterygoid
muscle, which insert along the tem-
poromandibular joint, and the super-
ficial head of the medial pterygoid,
which extends from the lateral ptery-
goid plate to the angle of the jaw. The
structures in the infratemporal fossa
include the pterygoid muscles,
branches of the mandibular nerve,
the maxillary artery and its
branches, and the pterygoid venous
plexus. Pathology involving the tem-
poral bone may extend to involve the
infratemporal fossa.

FIGURE 6-5. The lateral pterygoid

muscles have been removed to
expose the branches of the trigemi-
nal nerve passing through the fora-
men ovale to convey sensation from
the mandibular area and to supply
the muscles in the infratemporal
fossa. The middle meningeal artery
passes between two rootlets of the
auriculotemporal nerve to reach the
foramen spinosum. The lingual and
inferior alveolar branches of the
third division have been preserved.
Removal of the remaining part of
the ramus of the mandible exposes
the styloid process and adjacent
muscles. The deep temporal arteries
and nerves course along to the
periosteal surface of the sphenoid
and temporal bones to reach the
deep surface of the temporalis mus-
cle. Preserving the temporalis mus-
cle requires that the muscle be ele-
vated using careful subperiosteal
dissection because its nerve and
vascular supply course on the deep
periosteal surface. Loss of the deep temporal nerve and arteries will result in temporalis atrophy and a poor cosmetic result after surgery.

RHOTON
FIGURE 6-6. Posterolateral view.

The splenius capitis has been
reflected downward to expose the
longissimus capitis, superior oblique,
and semispinalis capitis. The occipi-
tal artery passes along the occipital
groove on the medial side of the
digastric groove.

FIGURE 6-7. The longissimus capitis has

been 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 site of passage of vertebral
artery behind the atlanto-occipital joint is
located deep in the suboccipital triangle
located between the superior and inferior
oblique and the rectus capitis posterior major
muscles. The C1 transverse process is situated
immediately behind the internal jugular vein
and a short distance below and behind the
jugular foramen.

RHOTON
FIGURE 6-8. The superior and infe-

rior oblique and rectus capitus poste-
rior major muscles have been removed
to expose the vertebral artery passing
behind the atlanto-occipital joint. The
rectus capitus lateralis muscle extends
upward from the transverse process of
C1 to attach to the occipital bone behind
the jugular foramen. The vertebral
artery courses in the depths of the sub-
occipital triangle located between the
inferior and superior oblique muscles
and the rectus capitus posterior major,
all of which have been removed.

FIGURE 6-9. The mandibular condyle and ramus have been

removed to expose the muscles attached to the styloid process.
The pterygoid muscles and some branches of the mandibular
nerve have been removed to expose the auriculotemporal nerve,
which splits into two roots that surround the middle
meningeal artery below the foramen spinosum. The tensor and
levator veli palatini muscles, which attach along or near the
lower margin of the eustachian tube, are in the medial part of
the exposure. The longus capitis is exposed medial to the inter-
nal carotid artery in the retropharyngeal area.

RHOTON
FIGURE 6-10. The exposure has been

extended forward by removing the lateral wall
and floor of the orbit and the medial and lat-
eral walls of the maxillary sinus. The external
auditory canal has been removed, but the
tympanic membrane and cavity have been
preserved. The mastoid segment of the facial
nerve, the semicircular canals, the sigmoid
sinus, and the presigmoid dura have been
exposed. The infraorbital branch of the sec-
ond trigeminal division courses along the
floor of the orbit. The branches of the maxil-
lary nerve and artery in the pterygopalatine
fossa have been preserved. The maxillary
artery gives rise to the middle meningeal
artery, which passes through the foramen
spinosum posterolateral to the third trigemi-
nal division exiting the foramen ovale.
Lesions involving the temporal bone may
extend forward to involve the infratemporal
fossa and, from there, they can extend into
the pterygopalatine fossa and into the anterior
cranial base.

FIGURE 6-11. The external audi-

tory canal has been removed but the
tympanic membrane and cavity have
been preserved. The levator and ten-
sor veli palatini muscles have been
removed and the membranous part of
the eustachian tube has been opened.
The eustachian tube crosses anterior
to and is separated from the petrous
carotid by a thin shell of bone. The
jugular bulb and lateral bend of the
petrous carotid are located below the
acousticovestibular labyrinth. The
second trigeminal division exits the
foramen rotundum and enters the
pterygopalatine fossa. The third divi-
sion exits the foramen ovale to reach
the infratemporal fossa.

RHOTON

vertical segment of the petrous
carotid has been exposed by remov-
ing the eustachian tube and drilling
the bone lateral to the carotid canal.
The jugular bulb is positioned below
the semicircular canals.

FIGURE 6-13. The eustachian tube

has been resected and the mandibular
nerve divided at the foramen ovale to
expose the petrous carotid. This exposes
the longus capitis and rectus capitis
anterior muscles, both of which are
located behind the posterior pharyngeal
wall. The clivus is exposed between the
longus capitis and rectus capitis anteri-
orly. The orifice of the contralateral
eustachian is exposed in the nasophar-
ynx. The accessory nerve descends pos-
teriorly on the lateral side of the inter-
nal jugular vein.

RHOTON
FIGURE 6-14. The petrous carotid

has been reflected forward out of the
carotid canal to expose the petrous
apex medial to the carotid canal.

FIGURE 6-15. The petrous apex and

upper clivus have been drilled and the
dura opened to expose the anterolat-
eral aspect of the pons below the
trigeminal nerve. The sigmoid sinus
and the jugular bulb have been
removed to expose the nerves exiting
the jugular foramen. The chorda tym-
pani, malleus, and incus have been
preserved.

RHOTON
FIGURES 6-16–6-18. Another specimen. The

cortical bone surrounding the osseous part of
the external canal, the semicircular canals, and
the incus and malleus has been preserved. The
petrous apex in front of the labyrinth has been
removed to expose the petrous carotid. A short
segment of the tensor tympani muscle has been
preserved. The facial and vestibulocochlear
nerves arise at the junction of the pons and
medulla. The labyrinthine, tympanic, and mas-
toid segments of the facial nerve and the
branches of the mandibular nerve in the
infratemporal fossa have been preserved.

FIGURE 6-17. The osseous portion of the external

acoustic meatus and the tympanic membrane have been
removed. The distal part of the tensor tympani has been
preserved. The tympanic segment of the facial nerve
passes below the lateral canal and above the stapes in
the oval window. The chorda tympani arises from the
mastoid segment of the facial nerve and ascends to cross
the upper part of the handle of the malleus.

RHOTON
FIGURE 6-18. The incus, malleus, and stapes have been

removed. Removing the stapes exposes the oval window in
which the stapes sits. The tympanic segment of the facial
nerve passes between the oval window and the lateral semi-
circular canal. A short segment of the tensor tympani mus-
cle and the tendon of the stapedial muscle have been pre-
served. The round window is exposed below the promontory.
A., artery; Ac., acoustic; Alv., alveolar; Ant., anterior; Atl.,
atlanto; Aur., auricular; Auriculotemp., auricutemporal;
Brs., branches; Cap., capitis; Car., carotid; Chor., chorda;
CN, cranial nerve; Cond., condyle; Constr., constrictor;
Contralat., contralateral; Eust., eustachian; Ext., external;
Front., frontal; Gang., ganglion; Gen., geniculate; Gl.,
gland; Gr., greater; Inf., inferior; Infraorb., infraorbital;
Infratemp., infratemporal; Int., internal; Jug., jugular;
Laby., labyrinthine; Lat., lateral, lateralis; Lev., levator;
Long., longus; Longiss., longissimus; M., muscle; Maj.,
major; Mandib., mandibular; Mast., mastoid; Max., max-
illary; Med., medial; Memb., membrane; Men., meningeal;
Mid., middle; Min., minor; N., nerve; Obl., oblique;
Occip., occipital; Pal., palatine; Pet., petrous, petrosal;
Post., posterior; Proc., process; Pteryg., pterygoid;
Pterygopal., pterygopalatine; Rec., rectus; Scap., scapulae; suboccipital; Sup., superior; Temp., temporal; Tens., tensor; TM, temporo-
Seg., segment; Semicirc., semicircular; Semispin., semispinalis; Sig., sig- mandibular; Transv., transverse; Triang., triangle; Tymp., tympani, tym-
moid; Splen., splenius; Sternocleidomast., sternocleidomastoid; Suboccip., panic; V., vein; Vert., vertebral.

CHAPTER 7
RETROLABYRINTHINE, TRANSLABYRINTHINE,
AND TRANSCOCHLEAR APPROACHES
Neurosurgery 61:S4-153–S4-168, 2007 DOI: 10.1227/01.NEU.0000280018.39017.D0 www.neurosurgery-online.com
FIGURE 7-1. Mastoidectomy and retrolabyrinthine, partial labyrinthine,

translabyrinthine, and transcochlear approaches. Right mastoid. The retroau-
ricular flap and the sternocleidomastoid muscle have been reflected forward
and the trapezius and underlying splenius capitus have been reflected back-
ward to expose the mastoid and attachment of the longissimus capitus muscle.
The posterior belly of the digastric muscle originates medial to the mastoid tip
along the digastric groove. The spine of Henle is positioned at the posterior
superior margin of the external meatus. The spine is positioned superficial to
the deep site of the lateral semicircular canal and junction of the tympanic and
mastoid segments of the facial nerve. The supramastoid crest, a continuation
of the superior temporal line, is positioned at approximately the level of the
upper margin of the transverse and sigmoid sinuses. The area below the ante-
rior part of the supramastoid crest and behind the spine of Henle, called the
suprameatal triangle, is positioned superficial to the mastoid antrum. The
semicircular canals are positioned deep to the mastoid antrum.

RHOTON
FIGURE 7-2. The superficial mastoid air cells

have been removed. The air cells coalesce in the
area deep to the suprameatal triangle to form the
mastoid antrum, which is positioned lateral to
the bone enclosing the semicircular canals.

TRANSLABYRINTHINE APPROACHES
FIGURE 7-3. The drilling has been

extended through the mastoid antrum to
expose the epitympanic area where the body
of the incus and head of the malleus reside.
The facial recess, located between the mas-
toid segment of the facial nerve and the
chorda tympani, has been opened to expose
the long process of the incus and the articu-
lation of the lenticular process of the incus
with the head of the stapes. The bridge of
bone, positioned posterior to the tip of the
short process of the incus, between the epi-
tympanic area and facial recess, is referred
to as the “buttress.” The chorda tympani
arises from the lower portion of the mastoid
segment of the facial nerve, ascends ante-
rior to the facial recess, and crosses the inner
surface of the tympanic membrane.

RHOTON
FIGURE 7-4. The drilling has been extended

to expose the middle fossa dura above, the sig-
moid sinus posteriorly, and the jugular bulb
below. The superior, lateral, and posterior semi-
circular canals are located deep to the mastoid
antrum and suprameatal triangle. The anterior
end of the superior canal projects upward below
the arcuate eminence. The posterior canal faces
the posterior fossa dura. The lateral canal is
positioned above the tympanic segment of the
facial nerve. The facial nerve passes below the
lateral canal and turns downward to form the
mastoid segment. The dura between the sig-
moid sinus and the semicircular canals, named
Trautmann’s triangle, faces the anterior surface
of the cerebellum and cerebellopontine angle. A
meningeal branch of the ascending pharyngeal
artery passes through the jugular foramen and
ascends in the dura of Trautmann’s triangle.
The jugular bulb is positioned medial to the
cortical bone overlying the digastric groove. The
sinodural angle is positioned at the junction of
the sigmoid, transverse, and superior petrosal
sinuses, and where the sigmoid sinus intersects
the middle fossa dura.

FIGURE 7-5. Enlarged view. The short

process of the incus points toward the
tympanic segment of the facial nerve
passing between the lateral semicircular
canal and the stapes sitting in the oval
window. The superior and lateral canal
ampullae, located at the anterior end of
these canals, are innervated by the supe-
rior vestibular nerve. The posterior canal
ampulla, located at the lower end of the
posterior canal, is innervated by the sin-
gular branch of the inferior vestibular
nerve. In the translabyrinthine approach,
drilling through the anterior (ampul-
lated) ends of the superior and lateral
canals exposes the superior vestibular
area and nerve at the fundus of the mea-
tus. Drilling the lower (ampullated) end
of the posterior canal exposes the infe-
rior vestibular area and nerve at the fun-
dus of the meatus. The posterior end of
the superior canal and the upper end of
the posterior canal join to form a single
channel, the common crus, which opens
into the vestibule.

RHOTON
FIGURE 7-6. The lateral edge of the

endolymphatic sac has been separated
from the dura of Trautmann’s trian-
gle. The endolymphatic sac sits
beneath the dura on the posterior sur-
face of the temporal bone above and
medial to the lower part of the sig-
moid sinus. The endolymphatic sac
communicates through the endolym-
phatic duct with the vestibule.

FIGURE 7-7. A partial labyrinthec-

tomy has been completed by remov-
ing the posterior and superior semi-
circular canals. Silver and black
sutures mark the previous position of
the superior and posterior canals.
The lateral canal has been preserved.
Removing these two canals may not
result in a total loss of hearing. The
chance of preserving some hearing
after this type of partial labyrinthec-
tomy is improved if the drilled ends
of the two canals are obliterated with
bone dust or wax or other material.
The upper end of the posterior canal
and the posterior end of the superior
canal join to form the common crus.

RHOTON
FIGURE 7-8. The lateral canal has

been removed, leaving an opening
into the vestibule. The exposure has
not been extended into the internal
meatus to complete the translaby-
rinthine exposure.

FIGURE 7-9. The translabyrinthine

exposure has been completed to expose the
vestibulocochlear and facial nerves in the
internal acoustic meatus. The meatal and
labyrinthine segments of the facial nerve
are exposed proximal to the geniculate
ganglion with the tympanic and mastoid
segments exposed distally. The short
process of the incus points toward the
tympanic segment of the facial nerve,
which passes above the stapes sitting in
the oval window. The mastoid segment of
the facial nerve descends toward the sty-
lomastoid foramen and gives rise to the
chorda tympani. The dura of Trautmann’s
triangle has been opened to expose the
trigeminal, glossopharyngeal, and vagus
nerves in the cerebellopontine angle. The
anterior inferior cerebellar artery loops
laterally into the meatus before turning
back toward the brainstem. The facial,
superior, and inferior vestibular nerves
are exposed at the fundus of the meatus.
The cochlear nerve is hidden anterior to
the inferior vestibular nerve.

RHOTON
FIGURE 7-10. The dura has been

opened to expose the Cranial Nerves in
the cerebellopontine angle. The vestibulo-
cochlear nerve has been depressed to
expose the facial nerve and the nervus
intermedius. The motor root of the
trigeminal nerve has been exposed supe-
rior and medial to the main sensory root.
The glossopharyngeal and vagus nerves
are at the lower margin of the exposure
just above the jugular bulb. The flocculus
and choroid plexus protrude from the
foramen of Luschka behind the vestibulo-
cochlear nerve. The anterior inferior cere-
bellar artery loops laterally between the
facial and vestibulocochlear nerves. A
small branch of the posterior inferior
cerebellar artery descends posterior to the
glossopharyngeal and vagus nerves.


labyrinthine, tympanic, and mastoid seg-
ments of the facial nerve. The incus has been
removed. The tympanic segment passes
above the stapes sitting in the oval window.
The junction of the labyrinthine and tym-
panic segments and the geniculate ganglion
are tethered to the floor of the middle fossa
by the greater petrosal nerve. The cochlea is
located anterior to the fundus of the meatus
and anterior to the stapes sitting in the oval
window. Completing a transcochlear
approach requires either displacing the facial
nerve posteriorly or leaving a thin shell of
bone encasing the nerve and working
around the encased nerve. Untethering the
facial nerve for a posterior transposition
requires that the greater petrosal nerve be
sectioned just medial to the geniculate gan-
glion. The lateral process and handle of the
malleus are attached to the inner surface of
the tympanic membrane.

RHOTON
FIGURE 7-12. The greater petrosal

nerve has been sectioned just distal to
the apex of the geniculate ganglion. The
facial nerve has been displaced posteri-
orly for removal of the cochlea in the
transcochlear approach. The semicircu-
lar canals and vestibule, the end organs
of the superior and vestibular nerves,
have been removed. The incus has been
removed but the malleus remains
attached to the tympanic membrane.

FIGURE 7-13. Drilling has been extended for-

ward into the cochlea. The cochlear nerve enters
the modiolus in the center of the spiral turns of the
cochlea. The scala tympani and vestibuli and the
osseous spiral crest in the auditory labyrinth have
been exposed. Drilling the cochlea often requires
that at least the posterior portion of the ring of
bone supporting the tympanic membrane be
removed and that the external canal be closed at
the end of the procedure. The malleus and tym-
panic membrane have been preserved at this stage.

RHOTON

anterior inferior cerebellar artery
loops laterally to the fundus of the
meatus. The cochlear nerve pene-
trates the modiolus at the fundus of
the meatus. The scala tympani and
vestibuli and the osseous spiral crest
in the cochlea are exposed.

FIGURE 7-15. Removal of the

cochlea opens the channel for remov-
ing the remainder of the petrous
apex. The exposure, directed below
the trigeminal nerve, extends medi-
ally to the front of the pons and
medulla and to the lateral side of the
basilar artery. The abducens nerve
ascends lateral to the basilar artery.
The tympanic membrane has been
removed. Removing the cochlea and
petrous apex exposes a short segment
of the petrous carotid artery.

RHOTON
FIGURE 7-16. Enlarged view of the com-

pleted transcochlear approach. The expo-
sure extends to the lateral edge of the clivus
and the inferior petrosal sinus. The basilar
artery and anterior surface of the pons are
at the deep end of the exposure. A high
jugular bulb may block access to the area
below the glossopharyngeal nerve. The
abducens nerve passes behind the anterior
inferior cerebellar artery and lateral to the
basilar artery. A., artery; A.I.C.A., ante-
rior inferior cerebellar artery; Asc., ascend-
ing; Bas., basilar; Br., branch; Cap., capi-
tis; Car., carotid; Chor., chorda; CN,
cranial nerve; Coch., cochlear; Comm.,
common; Endolymph., endolymphatic;
Epitymp., epitympanic; Flocc., flocculus;
Gang., ganglion; Gen., geniculate; Inf.,
inferior; Intermed., intermedius; Jug.,
jugular; Laby., labyrinthine; Lat., lateral;
Lent., lenticular; Longiss., longissimus;
M., muscle; Mast., mastoid; Meat., meatal;
Memb., membrane; Mid., middle; N.,
nerve; Nerv., nervus; Pet., petrosal,
petrous; Pharyng., pharyngeal; Post., pos-
terior; Proc., process; Seg., segment; Semicirc., semicircular; Sig., sigmoid; Suprameat., suprameatal; Triang., triangle; Tymp., tympani, tympanic;
Sp., spine; Sternocleidomast., sternocleidomastoid; Sup., superior; Vest., vestibular.

CHAPTER 8
PRESIGMOID APPROACH
Neurosurgery 61:S4-169–S4-174, 2007 DOI: 10.1227/01.NEU.0000280025.07630.2C www.neurosurgery-online.com
FIGURE 8-1. Presigmoid

approach, left presigmoid
approach. The scalp incision
is shown on the lower left.
The mastoidectomy has
been completed and the
dense cortical bone around
the semicircular canals has
been exposed. The tympanic
segment of the facial nerve
and the lateral canal are situated deep to the spine of Henle.
Trautmann’s triangle, the patch of dura in front of the sigmoid sinus,
faces the cerebellopontine angle. The endolymphatic sac sits beneath
the dura in Trautmann’s triangle.

RHOTON

presigmoid dura is opened anterior to
the sigmoid sinus. The incision, out-
lined with strips of suture, should
cross the superior petrosal sinus a few
millimeters forward of the area shown
in this illustration. The temporal
dura is opened and the tentorium is
divided, taking care to preserve the
vein of Labbé that joins the transverse
sinus and the trochlear nerve that
enters the anterior margin of the ten-
torium.

PRESIGMOID APPROACH
FIGURE 8-3. Retrolabyrinthine

presigmoid exposure in which the
semicircular canals have been pre-
served. The presigmoid dura has
been opened and the superior pet-
rosal sinus and tentorium divided.
The abducens and facial nerves are
exposed medial to the vestibulo-
cochlear nerve. The anterior inferior
cerebellar artery passes below the
vestibulocochlear nerve. The supe-
rior cerebellar artery passes above
the trigeminal nerve. The posteroin-
ferior cerebellar artery courses in the
lower margin of the exposure with
the glossopharyngeal and vagus
nerves. Choroid plexus protrudes
into the cerebellopontine angle
behind the glossopharyngeal and
vagus nerves.

RHOTON
FIGURE 8-4. The vestibulocochlear

nerve has been retracted downward
to expose the nervus intermedius and
facial nerve. The trigeminal nerve is
at the upper margin of the exposure.
The motor root of the trigeminal
nerve arises as a series of rootlets
positioned superomedial to the main
sensory root. The glossopharyngeal,
vagus, and accessory nerves are at the
lower margin of the exposure. The
flocculus protrudes into the cerebel-
lopontine angle behind the glossopha-
ryngeal nerve.

PRESIGMOID APPROACH
FIGURE 8-5. The semicircular canals and vestibule

have been removed to complete the translabyrinthine
approach to the internal acoustic meatus and cerebel-
lopontine angle and to expose the vestibulocochlear
and facial nerves in the internal acoustic meatus.
The temporal lobe has been elevated. The segment of
the trochlear nerve that passes below the medial edge
of the tentorium and the junction of the vein of Labbé
with the transverse sinus have been preserved. The
jugular bulb is at the lower margin of the exposure.

RHOTON
FIGURE 8-6. The cochlea has been removed

to complete a transcochlear exposure that
extends to the lateral margin of the clivus
and the inferior petrosal sinus. The vertical
segment of the petrous carotid is exposed
anterior to the jugular bulb. The lateral side
of the basilar artery and the anterior surface
of the pons are in the depths of the exposure.
The superior cerebellar artery passes below
the trochlear nerve and above the trigeminal
nerve. A., artery; A.I.C.A., anterior inferior
cerebellar artery; Bas., basilar; Car., carotid;
Chor., chorda, choroid; CN, cranial nerve;
Endolymph., endolymphatic; Flocc., floc-
culus; Inf., inferior; Intermed., inter-
medius; Jug., jugular; Lat., lateral; Mast.,
mastoid; Meat., meatal; Memb., membrane;
Mid., middle; N., nerve; Nerv., nervus;
P.I.C.A., posterior inferior cerebellar artery;
Pet., petrosal, petrous; Plex., plexus; Post.,
posterior; S.C.A., superior cerebellar artery;
Seg., segment; Semicirc., semicircular; Sig.,
sigmoid; Sup., superior; Temp., temporal;
Triang., triangle; Tymp., tympani, tym-
panic; V., vein.

CHAPTER 9
CEREBELLOPONTINE ANGLE AND RETROSIGMOID APPROACH

CEREBELLOPONTINE ANGLE AND sopharyngeal, vagus, accessory, and hypoglossal nerves that
RETROSIGMOID APPROACH are related to the PICA.
In summary, the upper complex includes the SCA, midbrain,
cerebellomesencephalic fissure, superior cerebellar peduncle,
Cerebellopontine Angle
tentorial surface of the cerebellum, and the oculomotor,
The cerebellopontine angle is located between the superior trochlear, and trigeminal nerves. The SCA arises in front of the
and inferior limbs of the cerebellopontine fissure, an angular midbrain, and passes below the oculomotor and trochlear
cleft formed by the petrosal cerebellar surface folding around nerves and above the trigeminal nerve to reach the cerebel-
the pons and middle cerebellar peduncle (1). The cerebellopon- lomesencephalic fissure, where it runs on the superior cerebel-
tine fissure faces the posterior surface of the temporal bone lar peduncle and terminates by supplying the tentorial surface
and has superior and inferior limbs that meet at a lateral apex. of the cerebellum.
Cranial Nerves IV through XI are located near or within the The middle complex includes the AICA, pons, middle cere-
angular space between the two limbs commonly referred to as bellar peduncle, cerebellopontine fissure, petrosal surface of
the cerebellopontine angle. The trochlear and trigeminal nerves the cerebellum, and the abducens, facial, and vestibulocochlear
are located near the fissure’s superior limb, and the glossopha- nerves. The AICA arises at the pontine level, courses in rela-
ryngeal, vagus, and accessory nerves are located near the infe- tionship to the abducens, facial, and vestibulocochlear nerves
rior limb. The facial and acousticovestibular nerve rises near to reach the surface of the middle cerebellar peduncle, where it
the central part of the fissure. The abducens nerve is located courses along the cerebellopontine fissure and terminates by
near the base of the fissure, along a line connecting the anterior supplying the petrosal surface of the cerebellum.
ends of the superior and inferior limbs. The lower complex includes the PICA, medulla, inferior cere-
Optimizing operative approaches to the cerebellopontine bellar peduncle, cerebellomedullary fissure, suboccipital sur-
angle requires an understanding of the relationship of the cere- face of the cerebellum, and the glossopharyngeal, vagus, acces-
bellar arteries to the cranial nerves, brainstem, cerebellar sory, and hypoglossal nerves. The PICA arises at the medullary
peduncles, fissures between the cerebellum and brainstem, and level, encircles the medulla, passing in relationship to the glos-
the cerebellar surfaces. When examining these relationships, sopharyngeal, vagus, accessory, and hypoglossal nerves to
three neurovascular complexes are defined: an upper complex reach the surface of the inferior cerebellar peduncle, where it
related to the superior cerebellar artery (SCA), a middle com- dips into the cerebellomedullary fissure and terminates by sup-
plex related to the anterior inferior cerebellar artery (AICA), plying the suboccipital surface of the cerebellum.
and a lower complex related to the posterior inferior cerebellar
artery (PICA). Retrosigmoid Approach
Other structures, in addition to the three cerebellar arteries, The most common operation directed to the upper neurovas-
occurring in sets of three in the posterior fossa that bear a con- cular complex is the exposure of the posterior root of the trigem-
sistent relationship to the SCA, AICA, and PICA are the parts inal nerve for a vascular decompression procedure for trigemi-
of the brainstem (midbrain, pons, and medulla), the cerebellar nal neuralgia. For a vascular decompression operation, this
peduncles (superior, middle, and inferior), the fissures between upper neurovascular complex is approached using a vertical
the brainstem and the cerebellum (cerebellomesencephalic, scalp incision crossing the asterion, which usually overlies the
cerebellopontine, and cerebellomedullary), and the surfaces of lower half of the junction of the transverse and sigmoid sinuses.
the cerebellum (tentorial, petrosal, and suboccipital). Each neu- The bone opening, a small craniotomy, located behind the upper
rovascular complex includes one of the three parts of the brain- half of the sigmoid sinus, exposes the edge of the junction of the
stem, one of the three surfaces of the cerebellum, one of the transverse and sigmoid sinuses in its superolateral margin. The
three cerebellar peduncles, and one of the three major fissures most common finding at a vascular decompression operation
between the cerebellum and the brainstem. In addition, each for trigeminal neuralgia is that a segment of the SCA com-
neurovascular complex contains a group of cranial nerves. The presses the trigeminal nerve. The AICA or basilar artery is less
upper complex includes the oculomotor, trochlear, and trigem- commonly the compressing vessel. The most common venous
inal nerves that are related to the SCA. The middle complex compression is by a tributary of a superior petrosal vein.
includes the abducens, facial, and vestibulocochlear nerves that Operations directed to the middle complex are for the
are related to the AICA. The lower complex includes the glos- removal of acoustic neuromas and other tumors and for the

RHOTON
relief of hemifacial spasm. The considerations related to The operation for hemifacial spasm is directed along the
acoustic neuromas will be dealt with first. The retrosig- inferolateral margin of the cerebellum. The craniotomy is
moid approach to an acoustic neuroma is directed through located medial to the lower half of the sigmoid sinus. It is
a vertical scalp incision that crosses the asterion. A burr not necessary to extend the bone opening downward to
hole is placed below the asterion and a craniotomy is per- the foramen magnum or upward to the transverse sinus.
formed, exposing the lower margin of the transverse sinus The inferolateral margin of the cerebellum is elevated with
superiorly, the posterior margin of the sigmoid sinus later- a small brain spatula and the arachnoid behind the glos-
ally, and the inferior portion of the squamous part of the sopharyngeal and vagus nerves is opened. This will
occipital bone inferiorly. The nerves in the lateral part of expose the tuft of choroid plexus protruding from the fora-
the internal acoustic meatus are the facial, cochlear, and men of Luschka, and sitting on the posterior surface of the
inferior and superior vestibular nerves. The position of the glossopharyngeal and vagus nerves. Commonly, the floc-
nerves is most constant in the lateral portion of the meatus, culus is seen protruding behind the nerves and blocks their
which is divided into a superior and an inferior portion by visualization at the junction with the brainstem. It may
a horizontal ridge, called either the transverse or the falci- also be difficult to see the facial nerve that is hidden in
form crest. The facial and the superior vestibular nerves front of the vestibulocochlear nerve. At this time in the
are superior to the crest. The facial nerve is anterior to the operation, it is important to recall that the facial nerve root
superior vestibular nerve and is separated from it at the exits the brainstem 2 to 3 mm rostral to the point at which
lateral end of the meatus by a vertical ridge of bone, called the glossopharyngeal nerve enters the brainstem. To
the vertical crest. The vertical crest is also called “Bill’s expose the nerve’s exit from the brainstem, the choroid
bar” in recognition of William House’s role in focusing on plexus is gently separated from the posterior margin of
the importance of this crest in identifying the facial nerve the glossopharyngeal nerve so that its junction with the
at the lateral end of the meatus. The cochlear and inferior brainstem can be seen. The brain spatula is advanced
vestibular nerves run below the transverse crest, with the upward to elevate the choroid plexus away from the pos-
cochlear nerve located anteriorly. Thus, the lateral meatus terior margin of the glossopharyngeal nerve. The expo-
can be considered to be divided into four portions, with sure is then directed several millimeters above the glos-
the facial nerve being anterosuperior, the cochlear nerve sopharyngeal nerve to where the facial nerve will be seen
anteroinferior, the superior vestibular nerve posterosupe- joining the brainstem below and in front of the vestibulo-
rior, and the inferior vestibular nerve posteroinferior. The cochlear nerve. At this point, it usually becomes obvious
facial nerve is commonly identified, even with a large which vessel is compressing the nerve.
tumor, in the anterosuperior quadrant at the lateral end of Our most common operation directed to the lower
the meatus after removing the posterior meatal lip. The complex is for glossopharyngeal neuralgia. We have usu-
cochlear nerve is identified in the anteroinferior quadrant ally treated glossopharyngeal neuralgia by dividing the
of the meatus. glossopharyngeal nerve and the upper quarter of the
There is also a consistent set of relationships on the brain- vagal rootlets. It is suggested that fewer of the rostral
stem side of an acoustic neuroma that aids in identification rootlets of the vagus nerve be cut if the diameters of the
of the facial and cochlear nerves on the medial side of the upper rootlets are large rather than small. Vascular de-
tumor. The landmarks on the medial or brainstem side that compression is an option for treating glossopharyngeal
are helpful in guiding the surgeon to the junction of the neuralgia, although we had excellent results with glos-
facial nerve with the brainstem are the pontomedullary sul- sopharyngeal and upper vagal neurectomy. A detailed
cus; the junction of the glossopharyngeal, vagus, and spinal description of these operations and others dealing with
accessory nerves with the medulla; the foramen of Luschka pathologies in the cerebellopontine angle can be found
and its choroid plexus; and the flocculus. These facial and elsewhere (1).
cochlear nerves, although distorted by the tumor, usually
can be identified on the brainstem side of the tumor at the
lateral end of the pontomedullary sulcus, just rostral to the
REFERENCES
glossopharyngeal nerve and just anterosuperior to the fora- 1. Rhoton AL Jr: The cerebellopontine angle and posterior fossa cranial
men of Luschka, the flocculus, and the choroid plexus pro- nerves by the retrosigmoid approach. Neurosurgery 47 [Suppl
truding from the foramen of Luschka. 3]:S93–S129, 2000.

CEREBELLOPONTINE ANGLE
FIGURE 9-1. Cerebellopontine angle and the retrosigmoid

approach. The petrosal surface of the cerebellum faces forward
toward the posterior surface of the temporal bone. It is the
surface that is elevated to reach the cerebellopontine angle.
The cerebellopontine fissure, a V-shaped fissure formed by the
cerebellum wrapping around the pons and middle cerebellar
peduncle, has superior and inferior limbs that define the mar-
gins of the cerebellopontine angle. Cranial Nerves V to XI
arise in, or near, the cerebellopontine fissure or angle. The
superior limb extends above the trigeminal nerve and the infe-
rior limb passes below the flocculus and the nerves that pass
to the jugular foramen. The superior and inferior limbs meet
laterally at the apex located at the anterior end of the petrosal
fissure that divides the petrosal surface of the cerebellum into
superior and inferior parts. The fourth ventricle is located
behind the pons and medulla. The midbrain and pons are sep-
arated by the pontomesencephalic sulcus and the pons and
medulla by the pontomedullary sulcus. The trigeminal nerves
arise from the mid pons. The abducens nerve arises in the
medial part of the pontomedullary sulcus, rostral to the
medullary pyramids. The facial and vestibulocochlear nerves
arise at the lateral end of the pontomedullary sulcus immedi-
ately rostral to the foramen of Luschka. The hypoglossal nerves arise ante- Luschka opens into the cerebellopontine angle below the junction of the facial
rior to the olives and the glossopharyngeal and vagus nerves arise posterior and vestibulocochlear nerves with the lateral end of the pontomedullary sul-
to the olives. The flocculus and choroid plexus protrude from the foramen of cus. The choroid plexus protrudes from the lateral recess and foramen of
Luschka behind to the glossopharyngeal and vagus nerves. The foramen of Luschka behind the glossopharyngeal, vagus, and accessory nerves.

RHOTON
FIGURE 9-2. Enlarged view of the right

cerebellopontine angle. The petrosal surface
of the cerebellum faces forward toward the
petrous bone and is the surface that is ele-
vated to expose the cerebellopontine angle
and posterior surface of the temporal bone.
The cerebellopontine fissure, which might
also be referred to as the cerebellopontine
angle, is a V-shaped fissure formed where
the cerebellum wraps around the pons and
middle cerebellar peduncle. Cranial Nerves
V through XI arise in or near the margins
of the cerebellopontine fissure. The flocculus
and choroid plexus extend laterally from the
foramen of Magendie above the lower limb
of the fissure. The abducens nerve arises in
the medial part of the pontomedullary sul-
cus rostral to the medullary pyramids. The
facial and vestibulocochlear nerves arise
just rostral to the foramen of Luschka near
the flocculus at the lateral end of the pon-
tomedullary sulcus. The hypoglossal nerves
arise anterior to, and the glossopharyngeal,
vagus, and accessory nerves arise posterior
to, the olives. The facial and vestibulocochlear nerves join the brainstem 2 or olive along the origin of the rootlets of the glossopharyngeal, vagus, and
3 mm rostral to the glossopharyngeal nerve, along a line drawn dorsal to the accessory rootlets.

FIGURE 9-3. The supratentorial

and infratentorial areas have been
exposed while preserving the bone at
the site of the sutures. The asterion,
located at the junction of the lamb-
doid, occipitomastoid, and pari-
etomastoid sutures, usually overlies
the lower half of the junction of the
transverse and sigmoid sinuses. The
vertical lateral suboccipital incision
for the retrosigmoid approach usually
crosses the asterion. The burr hole for
elevating a suboccipital bone flap is
usually placed at the lower edge of the
asterion. The junction of the supra-
mastoid crest and the squamosal
suture is located at the posterior edge
of the middle fossa and slightly ante-
rior to and above the junction of the
transverse and sigmoid sinuses. The
supramastoid crest is an inferior con-
tinuation of the superior temporal
line.

RHOTON
FIGURE 9-4. The cerebellum has

been removed in this specimen to
expose the dura covering the part of
the posterior fossa that faces the cere-
bellopontine angle and is exposed in
the retrosigmoid approach. The fourth
ventricle sits on the posterior surface
of the pons and medulla. The floccu-
lus projects laterally into the cerebel-
lopontine angle. An inferior petrosal
vein passes from the right side of the
medulla to the jugular bulb. The glos-
sopharyngeal, vagus, and accessory
nerves enter the jugular foramen. The
SCA is at the upper margin of the
exposure. The PICA courses around
the glossopharyngeal, vagus, and
accessory nerves. The endolymphatic
sac sits beneath the dura inferolateral
to the acoustic meatus.

FIGURE 9-5. Retrosigmoid exposure of the right cerebellopontine angle. The

facial nerve has been elevated and the vestibulocochlear nerve depressed to
expose both nerves entering the internal acoustic meatus. The AICA passes
between the facial and vestibulocochlear nerves and turns medially to course
above the flocculus and along the middle cerebellar peduncle and cerebellopon-
tine fissure. A large superior petrosal vein passes behind the trigeminal nerve.
The flocculus hides the junction of the facial and vestibulocochlear nerves
with the brainstem. The PICA passes between the glossopharyngeal and vagus
nerves. The posterior trigeminal root is deeper, by the retrosigmoid approach,
than the facial and vestibulocochlear nerves.

RHOTON
FIGURE 9-6. Upper part of the cerebellopontine angle. A large superior petrosal vein with multiple
tributaries, including the pontotrigeminal and transverse pontine veins and the vein of the cerebello-
pontine fissure, passes behind the trigeminal nerve. The trochlear nerve courses below the SCA. The
AICA passes between the facial and vestibulocochlear nerves and turns medially to course along the
middle cerebellar peduncle and cerebellopontine fissure.

FIGURE 9-7. The flocculus and

choroid plexus, which protrude from
the foramen of Luschka, have been
elevated to expose the junction of the
facial and vestibulocochlear nerves
with the brainstem. The facial nerve
is exposed below the vestibulo-
cochlear nerve. A branch of the AICA
gives rise to both the subarcuate and
labyrinthine arteries. The subarcuate
artery enters the dura and bone
superolateral to the meatus. The
junction of the facial nerve with the
brainstem is easier to expose from
below rather than above the floccu-
lus and vestibulocochlear nerve in an
operation for hemifacial spasm. This
approach for decompressing the facial
nerve in hemifacial spasm is referred
to as an “infrafloccular approach.” A
large PICA loops upward behind the
vestibulocochlear nerve.

RHOTON
FIGURE 9-8. The dura lining the

posterior wall of the internal acoustic
meatus has been removed and the
posterior meatal wall has been
opened to expose the dura lining the
meatus. The subarcuate artery usu-
ally has to be obliterated and divided
before removing the posterior meatal
wall. Two bundles from the nervus
intermedius are exposed above the
vestibulocochlear nerve. Care is taken
to avoid entering the semicircular
canals and vestibule during drilling
of the posterior wall of the meatus if
hearing is to be preserved.

FIGURE 9-9. The meatal dura has

been opened, the facial nerve has
been elevated, and the vestibulo-
cochlear nerve has been depressed to
expose the facial nerve coursing in
the anterior-superior quadrant of
the meatus. The nervus inter-
medius, which arises along the ante-
rior surface of the vestibulocochlear
nerve and passes laterally to join
the facial nerve, is composed of sev-
eral rootlets, as is common. The
superior vestibular nerve passes
posterior to the facial nerve, and the
cochlear nerve is hidden anterior to
the inferior vestibular nerve.

RHOTON
F I G U R E 9 - 1 0 . T he cleavage plane
between the superior and inferior vestibular
nerves has been developed. The superior
vestibular and facial nerves pass above the
transverse crest and the inferior vestibular
and cochlear nerves pass below the trans-
verse crest. The facial nerve courses anterior
to the superior vestibular nerve and the
cochlear nerve is located anterior to the infe-
rior vestibular nerve. The vertical crest sep-
arates the superior vestibular and facial
nerves at the fundus of the meatus.

FIGURE 9-11. Posterior surface of a right

temporal bone. The internal meatus is
located near the center of the posterior sur-
face and the jugular foramen at the lower
edge of the posterior surface. The sigmoid
sinus descends along the posterior surface
of the mastoid part of the temporal bone
and turns forward on the occipital bone to
pass through the sigmoid part of the jugu-
lar foramen. The inferior petrosal sinus
descends along the petroclival fissure and
passes through the petrosal part of the
jugular foramen. The glossopharyngeal,
vagus, and accessory nerves pass through
the intrajugular part of the foramen
between the sigmoid and petrosal part. The
subarcuate fossa is located superolateral to
the internal acoustic meatus and the
ostium for the endolymphatic duct is posi-
tioned lateral to the internal acoustic mea-
tus. The trigeminal impression is a shallow
trough on the upper surface of the petrous
part behind the foramen ovale. The arcuate
eminence overlies the superior semicircu-
lar canal.

RHOTON
FIGURE 9-12. The fundus of the right

internal acoustic meatus. The trans-
verse crest divides the meatal fundus
into superior and inferior parts. Above
the transverse crest, the facial canal is
anterior and the superior vestibular
area is posterior. Below the transverse
crest, the cochlear area is anterior and
the inferior vestibular area is posterior.
The singular foramen, through which
the singular branch of the inferior
vestibular nerve passes to innervate the
posterior canal ampullae, is located pos-
terior to the inferior vestibular area.
The inferior vestibular nerve also has a
saccular and, occasionally, a utricular
branch. The cochlear nerve splits into
tiny filaments as its fibers pass through
the cochlear area. These filaments are
easily torn, with a resulting loss of
hearing, with medially directed retrac-
tion of the cerebellum and nerve.

FIGURE 9-13. The trigeminal

nerve passes above the petrous apex
and through the porus of Meckel’s
cave. The facial and vestibulo-
cochlear nerves enter the internal
acoustic meatus, and the glossopha-
ryngeal, vagus, and accessory
nerves enter the jugular foramen.
The posterior and superior semicir-
cular canals have been exposed. The
superior semicircular canal is posi-
tioned below the medial edge of the
arcuate eminence. The upper end of
the posterior canal and the posterior
end of the superior canal join to
form a common channel, the com-
mon crus, which opens into the
vestibule. The endolymphatic duct
extends downward from the
vestibule and opens into the
endolymphatic sac located beneath
the dura inferolateral to the internal
acoustic meatus. The endolymphatic
ridge, the bridge of bone forming the
upper lip of the endolymphatic duct,
has been preserved. The jugular bulb can be seen through the thin bone terior portion of the superior canal, or the vestibule during drilling of the
below the internal meatus. Entering the posterior canal, common crus, pos- posterior meatal wall may result in a loss of hearing.

RHOTON

fundus of the meatus after removal of
the posterior wall. The upper edge of
the porus has been preserved. The
facial nerve and nervus intermedius
are exposed medial to the porus of the
meatus. The subarcuate artery enters
the subarcuate fossa. The inferior
vestibular nerve gives rise to the sin-
gular branch to the posterior ampul-
lae, plus utricular and saccular
branches. The superior vestibular
nerve innervates the ampullae of the
superior and lateral semicircular
canals and commonly gives rise to a
utricular branch. Care is taken to
preserve the superior and posterior
canals and the common crus, plus the
endolymphatic sac in those cases in
which there is the opportunity to pre-
serve hearing when drilling the pos-
terior wall of the meatus.

FIGURE 9-15. The petrous apex

medial to the internal acoustic mea-
tus has been partially removed to
expose the petrous segment of the
internal carotid artery. The lateral
genu of the petrous carotid, located at
the junction of the vertical and hori-
zontal segments, is situated below
and medial to the cochlea. The jugu-
lar bulb extends upward, adjacent to
the posterior meatal wall, toward the
vestibule and semicircular canals.
The inferior petrosal sinus courses
along the petroclival fissure and
enters the petrosal part of the jugular
foramen. The sigmoid sinus descends
in the sigmoid sulcus and enters the
sigmoid part of the foramen. The
glossopharyngeal, vagus, and acces-
sory nerves pass through the central
or intrajugular part of the jugular
foramen located between the sigmoid
and petrosal parts.

RHOTON
FIGURE 9-16. Bone has been removed along the anterior margin
of the meatal fundus to open the cochlea, and along the posterior
margin to expose the vestibule. The cochlear nerve penetrates the
modiolus of the cochlea, where its fibers are distributed to the turns
of the cochlear duct. The basal turn of the cochlea communicates
below the modiolus with the vestibule. The stapes has been removed
from the oval window. The promontory in the medial wall of the
tympanic cavity is located lateral to the basal turn of the cochlea. A
silver fiber has been introduced into the superior semicircular canal,
a red fiber into the lateral canal, and a blue fiber into the posterior
canal. The ampullated ends of the canals are located at the bulbous
ends of the three fibers. The common crus of the superior and pos-
terior canals is located where the tips of the blue and silver fibers
cross. The superior vestibular nerve passes to the ampullae of the
superior and lateral canals. The singular branch of the inferior
vestibular nerve innervates the posterior ampullae. A small black
fiber has been introduced into the opening of the endolymphatic
duct into the vestibule. A., artery; Ac., acoustic; Arc., arcuate;
Atl., atlanto; Car., carotid; Cer. Mes., cerebellomesencephalic; Cer.,
cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; CN, cranial
nerve; Coch., cochlear; Comm., common; Cond., condyle; Emin.,
eminence; Endolymph., endolymphatic; Fiss., fissure; Flocc., floc-
culus; For., foramen; Hypogl., hypoglossal; Impress., impression; Inf., infe- Petrocliv., petroclival; Plex., plexus; Pon. Med., pontomedullary; Pon. Mes.,
rior; Int., internal; Intermed., intermedius; Intrajug., intrajugular; Jug., jugu- pontomesencephalic; Pon. Trig., pontotrigeminal; Pon., pontine; Post., poste-
lar; Laby., labyrinthine; Lat., lateral; Med., medial; Mid., middle; N., nerve; rior; Semicirc., semicircular; Sig., sigmoid; Subarc., subarcuate; Sup., supe-
Nerv., nervus; Occip., occipital; Occipitomast., occipitomastoid; rior; Supramast., supramastoid; Trans., transverse; Trig., trigeminal; V., vein;
Parietomast., parietomastoid; Ped., peduncle; Pet., petrosal, petrous; Vert., vertebral, vertical; Vest., vestibular.

CHAPTER 10
TELOVELAR APPROACH TO THE FOURTH VENTRICLE

Neurosurgery 61:S4-193–S4-210, 2007 DOI: 10.1227/01.NEU.0000280026.15254.1F www.neurosurgery-online.com
I
n the past, operative access to the fourth ventricle that the dentate nuclei are located just rostral to the
was obtained by splitting the cerebellar vermis or superior pole of the tonsils underlying the dentate
removing part of a cerebellar hemisphere (1). In tubercles in the posterolateral part of the roof, where
e x a m i n i n g t h e c l e f t s a n d w a l l s o f t h e c e re b e l - they are wrapped around the superolateral recesses
lomedullary fissure, we found that the inferior half of near the lateral edges of the inferior medullary velum.
the roof of the fourth ventricle was formed by tela All of the cerebellar peduncles converge on the lateral
choroidea in which the choroid plexus arises, and the wall and roof, where they may be damaged. The supe-
inferior medullary velum, another paper-thin layer, rior cerebellar peduncle is more likely to be injured dur-
which attaches to the upper edge of the tela and ing operations on lesions involving the superior part of
extends from the nodule of the vermis to the flocculus. the roof above the level of the dentate tubercles; the
We also found that opening the tela alone will provide inferior peduncle is most susceptible to damage in
adequate ventricular exposure, in most cases, without exposing lesions within the lateral recess; and the mid-
splitting the vermis. The inferior medullary velum can dle cerebellar peduncle is susceptible to injury during
also be opened if opening the tela does not provide ade- procedures in the cerebellopontine angle, because the
quate exposure. Opening the tela alone provides access middle peduncle forms a major part of the cisternal sur-
to the full length of the floor and the entire ventricular face facing the cerebellopontine angle.
cavity except, possibly, the fastigium, superolateral The PICA is frequently exposed in approaches
recess, and the superior half of the roof. Opening the directed through the tela choroidea or inferior medullar
inferior medullary velum accesses the latter areas, velum. Occlusion of the branches of the PICA distal to
including the superior half of the roof. Extending the the medullary branches at the level of roof of the fourth
opening in the tela laterally toward the foramen of ventricle avoids the syndrome of medullary infarction
Luschka opens the lateral recess and exposes the sur- but produces a syndrome resembling labyrinthitis,
faces of the cerebellar peduncles bordering the recess. which includes rotatory dizziness, nausea, vomiting,
Tumors in the fourth ventricle may stretch and thin inability to stand or walk unaided, and nystagmus
these two semitranslucent membranes to a degree that without appendicular dysmetria (1). The main trunk of
one may not be aware that they are being opened in the anterior inferior cerebellar artery is infrequently
exposing a fourth ventricular tumor. exposed in opening the cerebellomedullary fissure, but
There are no reports of deficits after isolate opening it may also send choroidal branches to the tela and
of the tela and velum. However, other structures choroid plexus in the lateral recess.
exposed in the ventricle walls at risk for producing
deficits include the dentate nuclei, cerebellar pedun-
cles, the floor of the fourth ventricle, and the posterior
REFERENCES
inferior cerebellar artery (PICA). During an operation 1. Rhoton AL Jr: Cerebellum and fourth ventricle. Neurosurgery 47
on the caudal part of the roof, one should remember [Suppl 3]:S7–S27, 2000.

RHOTON
FIGURE 10-1. Telovelar approach to

the fourth ventricle and lateral recess.
The suboccipital cerebellar surface is
located below and between the sig-
moid and lateral sinuses and is the
surface that is exposed in a suboccip-
ital craniectomy. The vermis sits in a
depression, the posterior cerebellar
incisura, between the hemispheres.
The cerebellomedullary fissure
extends superiorly between the cere-
bellum and medulla along the infe-
rior half of the ventricular roof and
lateral recess. The vallecula extends
upward between the tonsils and com-
municates through the foramen of
Magendie with the fourth ventricle.
The PICAs loop above the tonsil and
exit the fissure to supply the suboc-
cipital surface.

TELOVELAR APPROACH

cerebellomedullary fissure and infe-
rior half of the fourth ventricular
roof. The lower parts of the vermis
behind the ventricle are the pyramid
and uvula. The uvula hangs down-
ward between the tonsils, thus, mim-
icking the situation in the orophar-
ynx. The tela choroidea, a paper-thin
ependymal membrane exposed below
the uvula, forms the lower part of the
fourth ventricular roof. The choroid
plexus arises on the inner surface of
the tela and extends downward in the
midline though the foramen of
Magendie and laterally through the
foramen of Luschka behind the glos-
sopharyngeal and vagus nerves.

RHOTON
FIGURE 10-3. The right tonsil has been

retracted to expose the lower half of the
roof, which is formed by the inferior
medullary velum and tela choroidea. The
cerebellomedullary fissure extends
upward between the rostral pole of the
tonsil on one side and the tela choroidea
and inferior medullary velum on the
opposite side. The segment of the PICA
passing through this fissure is called the
telovelotonsillar segment. The choroid
plexus arises on the inner surface of the
tela and extends downward in the midline
through the foramen of Magendie and lat-
erally through the foramen of Luschka.
The inferior medullary velum arises on
the surface of the nodule, drapes across
the superior pole of the tonsil, and blends
into the flocculus laterally.

TELOVELAR APPROACH
FIGURE 10-4. Both tonsils have been

re m o v e d t o e x p o s e t h e i n f e r i o r
medullary velum and tela choroidea
bilaterally. The telovelar junction is
the junction between the velum and
tela. The rhomboid lip is a sheet-like
layer of neural tissue attached to the
lateral margin of the ventricular floor,
which extends posterior to the glos-
sopharyngeal and vagus nerves and
joins the tela choroidea to form a
pouch at the outer extremity of the lat-
eral recess. The right half of the tela
has been removed to expose the ventri-
cle and the lateral recess. The inferior
medullary velum extends laterally to
form a peduncle, the peduncle of the
flocculus, which blends into the floccu-
lus at the outer margin of the lateral
recess.

RHOTON
FIGURE 10-5. The cerebellum has been sec-

tioned in an oblique coronal plane to show
the relationship of the rostral pole of the ton-
sil to the inferior medullary velum and den-
tate nucleus. The dentate nucleus is located
in the ventricular roof, near the fastigium,
where it wraps around, and is separated
from, the rostral pole of the tonsil by the infe-
rior medullary velum. The left tonsil has been
removed while preserving the left half of the
inferior medullary velum. The PICA passes
between the walls of the cerebellomedullary
f i s s u re f o r m e d a b o v e b y t h e i n f e r i o r
medullary velum and below by the upper
pole of the tonsil.

TELOVELAR APPROACH
F I G U R E 1 0 - 6 – 1 0 - 1 3 . Te l o v e l a r
approach to the fourth ventricle. The
lower part of the cerebellomedullary fis-
sure extends upward between the tonsils
posteriorly and the medulla anteriorly.
The upper part of the fissure extends
between the tonsil and the tela and
velum. The vallecula opens between the
tonsils into the fourth ventricle. The infe-
rior vermian vein ascends to enter the
sinuses in the tentorium.

RHOTON
FIGURE 10-7. Both tonsils have

been retracted laterally to expose the
inferior medullary velum and tela
choroidea that form the lower half of
the ventricular roof. The nodule of
the vermis, on which the inferior
medullary arises, is hidden deep to
the uvula.

TELOVELAR APPROACH
FIGURE 10-8. The uvula has been

retracted to the right and the tonsil
to the left to expose the inferior
medullary velum and the tela
choroidea forming the lower half of
the roof of the ventricle.

RHOTON
FIGURE 10-9. The tela choroidea

has been opened, extending from the
foramen of Magendie to the junction
with the inferior medullary velum.
The uvula has been displaced to the
right side to provide this view
extending from the obex up to the
aqueduct.

TELOVELAR APPROACH
FIGURE 10-10. The left half of the

inferior medullary velum has been
divided to expose the superolateral
recess and the ventricular surface
formed by the superior and inferior
peduncles.

RHOTON
FIGURE 10-11. The entire right

half and the medial part of the left
half of the cerebellum have been
removed to expose the lateral recess.
The right tonsil has been removed
and the tela and the inferior
medullary velum, which form the
lower part of the roof of the lateral
recess, have been retracted downward
to expose the opening into the lateral
recess. The dentate nucleus is posi-
tioned near the superolateral recess
of the roof of the fourth ventricle near
the site of attachment of the inferior
medullary velum.

TELOVELAR APPROACH
FIGURE 10-12. The cerebellar tonsil

has been elevated to expose the tela
forming the lower part of the roof of
the lateral recess.

RHOTON
FIGURE 10-13. The tela has been

opened to expose the lateral recess.
The opening extends laterally to the
foramen of Luschka. The choroid
plexus and flocculus are exposed in
the cerebellopontine angle behind the
glossopharyngeal nerve.

TELOVELAR APPROACH
FIGURES 10-14 and 10-15.

Relationships of the lateral margin of
the cerebellar tonsil to the biventral
lobule. Figure 10-14. The peduncle
of the tonsil is the bundle of white
matter, located at the superolateral
margin of the tonsil, that attaches the
tonsil to the remainder of the cerebel-
lum. All of the margins of the tonsil,
other than the site of the tonsilar
peduncle, are free margins. The left
tonsil has been retracted medially to
open the deep cleft between the tonsil
and the biventral lobule. The pedun-
cle of the tonsil is at the superolateral
margin of the tonsillobiventral fis-
sure.

RHOTON
FIGURE 10-15. The peduncle of the tonsil has been divided and the tonsil has
been lifted out of the cerebellomedullary fissure to expose the caudal surface of
the inferior medullary velum and the tela choroidea that form the lower half of
the ventricular roof.

TELOVELAR APPROACH
FIGURES 10-16 and 10-17.

Another specimen. Figure 10-16.
Both tonsils have been removed to
expose the inferior medullary velum
and tela choroidea. The inferior
medullary velum extends from the
nodule along the inferior half of the
roof of the fourth and blends later-
ally into the flocculus. The tela, in
which the choroid plexus arises, has
been removed on the left side. A dis-
sector has been placed inside the
superolateral recess to show the
paper-thin inferior medullary velum.
Opening the velum will expose the
superolateral recess. The dorsal
cochlear nucleus sits in the floor of
the lateral recess.

RHOTON
FIGURE 10-17. The velum has been

removed on the left side. Opening the
velum or removing it gives excellent
access to the cerebellar peduncles and to
the superolateral recess of the fourth
ventricle. The auditory tubercle is a
prominence in the lateral recess that
overlies the dorsal cochlear nucleus. A.,
artery; Bivent., biventral; Cer., cere-
bellar; Cer. Med., cerebellomedullary;
Cer. Mes., cerebellomesencephalic;
Coch., cochlear; Chor., choroid; CN,
cranial nerve; Dent., dentate; Dors.,
dorsal; Fiss., fissure; Flocc., flocculus;
For., foramen; Inf., inferior; Lat., lat-
eral; Med., medullary; Mid., middle;
Nucl., nucleus; Ped., peduncle; Plex.,
plexus; S.C.A., superior cerebellar
artery; Suboccip., suboccipital; Sup.,
s u p e r i o r ; Te l o v e l . , t e l o v e l a r ;
Tonsillobivent., tonsillobiventral; V.,
vein; Ve., vermian; Vel., velum; Vent.,
ventricle; Vert., vertebral.

CHAPTER 11
FAR LATERAL AND TRANSCONDYLAR APPROACHES

The basic far lateral approach is a low suboccipital approach that In the standard posterior and posterolateral approaches, an under-
extends up to, but does not include removal of, part of the atlantal or standing of the individual suboccipital muscles is not essential.
occipital condyles. The far lateral approach usually includes a suboc- However, these muscles provide important landmarks for the far lateral
cipital craniectomy or craniotomy with removal of at least half of the approach and its modifications. In this description, the muscles are
posterior arch of the atlas, dissection of the muscles along the postero- reflected separately, but, during an operation, the scalp and muscles
lateral aspect of the craniocervical junction to permit an adequate expo- superficial to the muscles forming the suboccipital triangle are reflected
sure of the Cl transverse process and the suboccipital triangle, and from the suboccipital area in a single layer, leaving a musculofascial cuff
early identification of the vertebral artery either above the posterior attached along the superior nuchal line for closure. The procedure has
arch of the atlas or in its ascending course between the transverse been performed through either a horseshoe type suboccipital flap, a C-
processes of the atlas and axis. The far lateral approach provides access shaped retroauricular incision similar to that shown in the section on the
for the following three approaches: 1) the transcondylar approach jugular foramen, or a hockey stick incision that has a vertical lateral limb
directed through the occipital condyle or the atlanto-occipital joint and behind the ear with a medial extension along the superior nuchal line.
adjoining parts of the condyles, 2) the supracondylar approach directed We prefer the horseshoe scalp flap that begins in the midline, approxi-
through the part of the occipital bone above the occipital condyle, and mately 5 cm below the external occipital protuberance, is directed
3) the paracondylar exposure directed through the area lateral to the upward to the external occipital protuberance, turns laterally just below
occipital condyle. The transcondylar extension, accomplished by the superior nuchal line, reaches the mastoid area, and turns down-
drilling the occipital condyle, allows a more lateral approach and pro- ward in front of the posterior border of the sternocleidomastoid muscle
vides access to the lower clivus and premedullary area. The supra- onto the lateral aspect of the neck below the mastoid tip and where the
condylar approach provides access to the region of and medial to the transverse process of the atlas can be palpated through the skin. The
hypoglossal canal and jugular tubercle. The paracondylar approach, scalp flap is reflected downward with the muscular layer that includes
which includes drilling of the jugular process of the occipital bone in the sternocleidomastoid, trapezius, and splenius, longissimus, and semi-
the area lateral to the occipital condyle, accesses the posterior part of spinalis capitis muscles. The three muscles, the superior and inferior
the jugular foramen, and, if needed, the posterior aspect of the facial oblique and the rectus capitis posterior, forming the suboccipital trian-
nerve and mastoid on the lateral side of the jugular foramen. gle are reflected separately to expose the vertebral artery.
The basic far lateral approach without drilling of the occipital The vertebral artery, above the transverse foramen of the axis, veers
condyle may be all that is required to reach some lesions located along laterally to reach the transverse foramen of the atlas, which is situated
the anterolateral margin of the foramen magnum. However, it also further lateral than the transverse foramen of the axis. The artery,
provides a route through which the transcondylar, supracondylar, and after ascending through the transverse process of the atlas, is located
paracondylar approaches and several modifications of these on the medial side of the rectus capitis lateralis muscle. From here, the
approaches can be completed. The transcondylar exposures can be cat- artery turns medially behind the lateral mass of the atlas and the
egorized into several variants. One variant is an atlanto-occipital atlanto-occipital joint and is pressed into the groove on the upper
transarticular approach, in which the adjacent posterior part of the surface of the posterior arch of the atlas, where it courses in the floor
occipital condyle and/or the superior articular facet of C1 is removed of the suboccipital triangle and is covered behind the triangle by the
to facilitate completion of a circular dural incision, permitting the ver- semispinalis capitis muscle. The first cervical nerve courses on the
tebral artery with the surrounding cuff of dura to be mobilized. A more lower surface of the artery between the artery and the posterior arch
extensive removal of the articular surfaces and condyles can be per- of the atlas. After passing medially above the lateral part of the pos-
formed to gain access to extradural lesions situated along the anterior terior arch of the atlas, the artery enters the vertebral canal by pass-
and lateral margins of the foramen magnum. Another variant, the ing below the lower, arched border of the posterior atlanto-occipital
occipital transcondylar variant, is directed above the atlanto-occipital membrane, which transforms the sulcus in which the artery courses
joint through the occipital condyle and below the hypoglossal canal to on the upper edge of the posterior arch of the atlas into an osseofi-
access the lower clivus and the area in front of the medulla. The supra- brous casing that may ossify, transforming it into a complete or
condylar approach directed above the occipital condyle can also be incomplete bony canal surrounding the artery.
varied, depending on the pathology to be exposed. The supracondylar The third segment of the vertebral artery, the segment located
exposure can be directed above the occipital condyle to the hypoglos- between the C1 transverse process and the dural entrance, gives rise
sal canal or both above and below the hypoglossal canal to the lateral to muscular branches and the posterior meningeal artery. The muscu-
side of the clivus. In the transtubercular variant of the supracondylar lar branches arise as the artery exits the transverse foramen of C1 and
approach, the prominence of the jugular tubercle that blocks access to courses behind the lateral mass of the atlas to supply the deep mus-
the brainstem and cistern in front of the glossopharyngeal, vagus, and cles and anastomose with the occipital and ascending and deep cer-
accessory nerves is removed extradurally to increase visualization of vical arteries. Some of the muscular branches may need to be divided
the area in front of the brainstem and to expose the origin of a poste- to mobilize and transpose the vertebral artery. The posterior
rior inferior cerebellar artery that arises from the distal part of the ver- meningeal artery arises from the posterior surface of the vertebral
tebral artery near the midline. The paracondylar approach also has artery as it passes behind the lateral mass or above the posterior arch
several variants. In the transjugular variant, the exposure is directed of the atlas or just before penetrating the dura in the region of the
lateral to the condyle through the jugular process of the occipital bone foramen magnum, but it may also have an intradural origin from the
to the posterior surface of the jugular bulb. The approach can also be vertebral artery, in which case it pierces the arachnoid over the cis-
extended lateral to the jugular foramen into the posterior aspect of the terna magna to reach the dura. Six to eight percent of posterior infe-
mastoid to access the mastoid segment of the facial nerve and the sty- rior cerebellar arteries arise extradurally and penetrate the dura with
lomastoid foramen. the vertebral artery.

RHOTON
FIGURE 11-1. Far lateral and

transcondylar approaches. The far
lateral approach involves a dissection
of the muscles along the posterolat-
eral aspect of the craniocervical junc-
tion to permit exposure of the C1
transverse process and the vertebral
artery in the suboccipital triangle.
The insert in the lower right illus-
tration shows the scalp incision. A
suboccipital horseshoe type flap is
commonly selected for the far lateral
exposure. The medial limb extends
downward in the midline so that an
upper cervical laminectomy can be
completed if needed. The lateral limb extends below the C1 transverse process, reflected muscles can be attached during the closure. The illustrations on the
which can be palpated between the mastoid tip and the angle of the jaw. The lower left in Figures 11-1 to 11-4 show the unilateral exposure on the right
lateral limb of the incision provides access to the vertebral artery as it ascends side. The scalp flap has been reflected to expose the sternocleidomastoid and
through the C1 transverse process and passes medially along the upper surface trapezius muscles, the edges of which form the margins of the posterior trian-
of the posterior arch of C1. In this section, the muscles are dissected separately gle of the neck. The splenius and semispinalis capitis are in the floor of the tri-
to show the anatomy, however, during an operation, the muscles superficial to angle. The three-dimensional illustration above and the orienting illustration
the suboccipital triangle can be reflected in a single layer with the scalp flap on the lower right show the superficial muscles bilaterally.
while leaving a cuff of fascia along the superior nuchal line, to which the

FAR LATERAL APPROACHES
FIGURE 11-2. The sternocleidomastoid and trapezius muscles have been reflected laterally and the trapezius downward to expose the splenius and semi-
detached from the superior nuchal line. The sternocleidomastoid has been spinalis capitis, which are attached just below the superior nuchal line.

RHOTON
FIGURE 11-3. The splenius capitis has been reflected downward to expose the passes deep and the right passes superficial to the longissimus capitis. The
longissimus and the semispinalis capitis muscles. The occipital artery on the left deep cervical fascia has been preserved in the illustration on the lower left.

FIGURE 11-4. The longissimus and semispinalis have been reflected to expose transverse process of C1 to the spinous process of C2; and the rectus capitis pos-
the suboccipital triangle formed by the superior and inferior oblique and rectus terior major extends from the occipital bone to the spinous process of C2. The
capitis posterior major muscles. The superior oblique extends from the occipital vertebral artery crosses behind the atlanto-occipital joint and across the upper
bone to the transverse process of C1; the inferior oblique muscle extends from the surface of the posterior arch of C1 in the depths of the suboccipital triangle.

RHOTON
FIGURE 11-5. The right superior oblique muscle has been reflected laterally. muscle extends from the C2 spinous process to the transverse process of C1. The
The rectus capitis posterior major extends from the occipital bone to the C2 occipital artery passes medial to the digastric muscle. The dense venous plexus
spinous process. The rectus capitis posterior minor extends from the occipital in the suboccipital triangle surrounds the vertebral artery as it passes behind
bone to the midline tubercle on the posterior arch of C1. The inferior oblique the atlanto-occipital joint. The lower left shows the right unilateral exposure.

FIGURE 11-6. The rectus capitis

posterior major and the adjacent part
of the rectus capitis posterior minor
have been reflected inferior and medi-
ally. The superior and inferior oblique
muscles have been reflected down-
ward. The vertebral artery passes
behind the atlantal condyle, gives rise
to a posterior meningeal branch, and
passes deep to the posterior atlanto-
occipital membrane to enter the dura.
The rectus capitis lateralis extends
from the transverse process of C1 to
the occipital bone behind the jugular
foramen.

RHOTON
FIGURE 11-7. The muscles forming

the margins of the suboccipital trian-
gle have been removed while preserv-
ing the rectus capitis posterior minor,
which extends from the part of the
occipital bone just above the foramen
magnum to the posterior tubercle on
C1. The vertebral artery gives off
muscular branches and passes medi-
ally on the upper surface of the poste-
rior arch of C1, where it is partially
encased in a bony ring. The venous
plexus around the vertebral artery
has been removed.

FIGURE 11-8. The vertebral artery

gives origin to the posterior
meningeal artery, which ascends
through the foramen magnum and
along the occipital dura. Several
muscular branches of the vertebral
artery have been divided. The C1
nerve passes between the vertebral
artery and the posterior arch of C1.

RHOTON
FIGURE 11-9. A suboccipital cran-

iotomy has been completed and the pos-
terior arch of C1 has been removed. The
vertebral artery passes behind and par-
tially hides the atlanto-occipital joint.
The facial and vestibulocochlear nerves
enter the internal acoustic meatus. The
glossopharyngeal, vagus, and accessory
nerves enter the jugular foramen. The
rootlets of the hypoglossal nerve are
stretched around the posterior surface of
the vertebral artery. The rectus capitis
lateralis muscle extends from the occip-
ital bone behind the jugular bulb to the
transverse process of C1. The posterior
inferior cerebellar artery rises just out-
side the dura and penetrates the dura
with the vertebral artery. The dentate
ligament and spinal accessory nerve
ascend through the foramen magnum.
The rostral attachment of the dentate
ligament is at the level of the foramen
magnum.

FIGURE 11-10. The vertebral artery has

been depressed to expose the atlanto-occip-
ital joint. Drilling above the occipital
condyle has exposed the hypoglossal canal
and the venous plexus accompanying the
hypoglossal nerve through the canal. The
rectus capitis lateralis has been reflected
and bone has been removed in the para-
condylar area to expose the posterior surface
of the jugular bulb. The occipital artery and
facial nerve are exposed below the stylomas-
toid foramen in the paracondylar region lat-
eral to the jugular bulb. A posterior condy-
lar vein connects the venous plexus around
the vertebral artery to the jugular bulb and
venous plexus in the hypoglossal canal.

RHOTON
FIGURE 11-11. The dural incision com-

pletely encircles the vertebral artery, leaving a
narrow dural cuff on the artery, thus, allow-
ing the artery to be mobilized. The drilling in
the supracondylar area exposes the hypoglos-
sal nerve in the hypoglossal canal and can be
extended extradurally to the level of the jugu-
lar tubercles to increase access to the front of
the brainstem and clivus.

FIGURE 11-12. Comparison of expo-

sure with the far lateral and transcondy-
lar approaches. The far lateral exposure
on the right side extends to the posterior
margin of the atlantal and occipital
condyles and the atlanto-occipital joint.
The prominence of the condyles on the
right side limits the exposure along the
anterolateral margin of the foramen
magnum. On the left side, a transcondy-
lar exposure has been completed by
removing the upper part of the occipital
condyle. The dura can be reflected fur-
ther laterally with the transcondylar
approach than with the far lateral
approach. The condylar drilling provides
an increased angle of view and addi-
tional space for exposure and dissection.
The dentate ligament and accessory
nerve ascend through the foramen mag-
num. The rostral attachment of the den-
tate ligament is at the level of the fora-
men magnum.

RHOTON
FIGURE 11-13. The part of the left occipital condyle above the atlanto-occipital joint has been
drilled to expose the hypoglossal nerve in the hypoglossal canal. The glossopharyngeal and
vagus nerves descend behind the jugular tubercle. Drilling the condyle above and below the
hypoglossal canal provides entry into the lower part of the clivus medial to the condyle. A cuff
of dura has been left on the vertebral artery.

FIGURE 11-14. The right occipital condyle and bone above the atlanto-occipital condyle joint
have been drilled to expose the hypoglossal nerve in the hypoglossal canal. The C1 nerve root
passes laterally between the vertebral artery and the posterior arch of C1.

RHOTON
FIGURE 11-15. Another specimen with the brainstem removed. The bone
above the occipital condyle has been removed to expose the hypoglossal nerve
in the hypoglossal canal. The glossopharyngeal, vagus, and accessory nerves
cross the jugular tubercle. The jugular bulb is located lateral to the occipital
condyle and can be exposed by drilling the occipital bone in the paracondylar
area.

FIGURE 11-16. The medial part of the right occipital condyle and the poste-
rior arch of C1 have been removed. The extradural segment of the right verte-
bral artery, which normally courses above the C1 nerve root, has been retracted
below the level of the C1 nerve root. The intradural segment of the right ver-
tebral artery has been retracted posteriorly to provide access to the cervi-
comedullary region. The contralateral vertebral artery is exposed anterior to
the medulla. The hypoglossal nerve passes behind the vertebral artery. The
drilling has provided wide access to the lower clivus adjacent to the occipital
condyle and also to the lateral and anterior aspects of the brainstem.

RHOTON
FIGURE 11-17. The bone lateral to the occipital condyle has been
removed to expose the jugular bulb. The occipital and atlantal condyles
have been drilled to provide access to the clivus. The condylar emissary
vein connects the jugular bulb and vertebral venous plexus. The hypoglos-
sal nerve, in the hypoglossal canal, has been exposed. A., artery; Atl.,
atlanto; Bas., basilar; Br., branch; Cap., capitis; Cerv., cervical; CN, cra-
nial nerve; Cond., condylar, condyle; Dent., dentate; Digast., digastric;
Dors., dorsal; Flocc., flocculus; Gr., greater; Hypogloss., hypoglossal;
Inf., inferior; Int., internal; Jug., jugular; Lat., lateralis; Lev., levator;
Lig., ligament; Longiss., longissimus; M., muscle; Maj., major; Memb.,
membrane; Men., meningeal; Min., minor; Musc., muscular; N., nerve;
Obl., oblique; Occip., occipital; P.I.C.A., posterior inferior cerebellar
artery; Plex., plexus; Post., posterior; Proc., process; Rec., rectus; Scap.,
scapulae; Semispin., semispinalis; Sig., sigmoid; Splen., splenius;
Sternocleidomast., sternocleidomastoid; Suboccip., suboccipital; Sup.,
superior; Trans., transverse; Triang., triangle; V., vein; Vent., ventral,
ventricle; Vert., vertebral.

CHAPTER 12
JUGULAR FORAMEN
Neurosurgery 61:S4-229–S4-250, 2007 DOI: 10.1227/01.NEU.0000280041.55157.E0 www.neurosurgery-online.com
The jugular foramen is located between the temporal and the occip- canal is either preserved or transected, depending on the anterior
ital bones. It can be regarded as a hiatus between the temporal and the extent of the pathological abnormality. The neck dissection is com-
occipital bones (1). The right foramen is usually larger than the left. The pleted initially to gain control of the major vessels and the branches
foramen is configured around the sigmoid and inferior petrosal supplying the tumor. The internal carotid artery, branches of the exter-
sinuses. The jugular foramen is divided into three compartments: two nal carotid artery, internal jugular vein, and lower cranial nerves are
venous compartments and a neural or intrajugular compartment. The exposed in the carotid sheath. A mastoidectomy with extensive drilling
venous compartments consist of a larger posterolateral venous channel, of the infralabyrinthine region accesses the jugular bulb. A limited mas-
the sigmoid part, which receives the flow of the sigmoid sinus, and a toidectomy confined to the area behind the stylomastoid foramen and
smaller anteromedial venous channel, the petrosal part, which receives mastoid segment of the facial nerve, combined with removal of the
the drainage of the inferior petrosal sinus. The petrosal part forms a adjacent part of the jugular process of the temporal bone, will provide
characteristic venous confluens by also receiving tributaries from the access to the posterior and posterolateral aspect of the jugular foramen.
hypoglossal canal, petroclival fissure, and vertebral venous plexus. The Three obstacles to exposure of the full lateral half of the jugular fora-
petrosal part empties into the sigmoid part through an opening men, the facial nerve, styloid process, and rectus capitis lateralis mus-
between the glossopharyngeal and the vagus nerves in the medial wall cle are dealt with by transposing the facial nerve, removing the styloid
of the jugular bulb. The intrajugular or neural part, through which the process, and dividing the rectus capitis lateralis muscle. Anterior exten-
glossopharyngeal, vagus, and accessory nerves course, is located sions of the pathological abnormality are reached by sacrificing the
between the sigmoid and petrosal parts. The junction of the sigmoid external and the middle ear structures. Sensorineural hearing can be
and petrosal parts of the foramen, when viewed from above, is the site preserved by maintaining the footplate of the stapes in the oval win-
of bony prominences on the opposing surfaces of the temporal and dow to avoid opening the labyrinth. Intracranial extensions of the
occipital bones, called the intrajugular processes, which are joined by lesion are reached by the retrosigmoid or presigmoid approaches after
a fibrous, or, less commonly, an osseous bridge, the intrajugular sep- adding a suboccipital craniectomy. Some lesions can be removed by a
tum, separating the sigmoid and petrosal part of the foramen. The transtemporal infralabyrinthine approach directed through the tem-
glossopharyngeal, vagus, and accessory nerves penetrate the dura on poral bone below the labyrinth without a neck dissection, if the
the medial margin of the intrajugular process of the temporal bone to extracranial extension of the lesion is not prominent. The exposure can
reach the medial wall of the jugular bulb and internal jugular vein. be extended by opening the otic capsule (translabyrinthine approach).
The jugular foramen is difficult to access surgically. The difficulties
in exposing this foramen are created by its deep location and the sur- Retrosigmoid Approach
rounding structures, such as the carotid artery anteriorly, the facial A lesion located predominantly intradurally above the jugular fora-
nerve laterally, the hypoglossal nerve medially, and the vertebral artery men can be resected by the retrosigmoid approach. A lateral suboccip-
inferiorly, all of which block access to the foramen and require careful ital craniectomy exposes the dura behind the sigmoid sinus. The dura
management. is opened, and the cerebellum is gently elevated away from the poste-
The structures that traverse the jugular foramen are the sigmoid rior surface of the temporal bone to expose the cisterns in the cerebel-
sinus and jugular bulb, the inferior petrosal sinus, meningeal branches lopontine angle and the intracranial aspect of the cranial nerves enter-
of the ascending pharyngeal and occipital arteries, the glossopharyn- ing the jugular foramen, hypoglossal canal, and internal acoustic
geal, vagus, and accessory nerves with their ganglia, the tympanic meatus. Lesions can be followed into only the upper part of the fora-
branch of the glossopharyngeal nerve (Jacobson’s nerve), the auricular men by this approach.
branch of the vagus nerve (Arnold’s nerve), and the cochlear aqueduct.
Tumors involving the jugular foramen can extend as follows: 1) along Far Lateral Approach
the eustachian tube into the nasopharynx and through the foramina at An extended modification of the retrosigmoid approach, the far lat-
the base of the cranium, 2) along the carotid artery to the middle fossa, eral approach, may be selected if the tumor extends down to the fora-
3) through the intracranial orifice of the jugular foramen or along the men magnum in front of or lateral to the lower brainstem. In this
hypoglossal canal to the posterior fossa, 4) through the tegmen tym- approach, the jugular foramen is opened from behind by completing a
pani to the floor of the middle fossa, 5) through the round window and paracondylar modification of the far lateral approach. In this modifica-
the internal acoustic meatus to the cerebellopontine angle, and 6) tion, the rectus capitis lateralis is detached from the occipital bone at
through the extracranial orifice of the jugular foramen to the upper cer- the posterior margin of the foramen and the posterior margin is
vical region. removed. The dura is opened and the cerebellum elevated to expose
the intracranial extension of the pathological abnormality at the lower
Surgical Approaches clivus and at the foramen magnum. In another variant of the approach,
The most common operative approaches used to access various depending on the location and extent of the pathological abnormality,
aspects of the foramen and adjacent areas are the postauricular the jugular tubercle is removed extradurally to minimize the retraction
transtemporal, retrosigmoid, and far lateral approaches. of the brainstem needed to reach the area anterior to the medulla and
pontomedullary junction. Most jugular foramen tumors cannot be
Postauricular Transtemporal Approach reached by this route because they extend forward beyond the limits of
The postauricular transtemporal approach, the most common this approach to the posterior part of the foramen.
approach selected for a lesion in the jugular foramen, accesses the
region from laterally, through the mastoid, and from below, through the REFERENCES
neck. A C-shaped postauricular skin incision provides the exposure
for a mastoidectomy and the neck dissection. The external auditory 1. Rhoton AL Jr: Jugular foramen. Neurosurgery 47 [Suppl 3]:S267–S285, 2000.

RHOTON
FIGURE 12-1. Jugular foramen.

Posterior view of the cranial base with
the cranial nerves and arteries pre-
served. The jugular foramen is posi-
tioned below the internal acoustic
meatus and superolateral to the
hypoglossal nerves entering the
hypoglossal canal. The glossopharyn-
geal, vagus, and accessory nerves
enter the dural roof of the jugular
foramen. The superior cerebellar arter-
ies arise at the midbrain level and pass
below the oculomotor and trochlear
nerves and above the trigeminal
nerve. The anterior inferior cerebellar
arteries arise at the pontine level and
course by the abducens, facial, and
vestibulocochlear nerves. The poste-
rior inferior cerebellar arteries arise
from the vertebral artery at the
medullary level and course near the
glossopharyngeal, vagus, accessory,
and hypoglossal nerves.

JUGULAR FORAMEN
FIGURE 12-2. The dural roof of the left jugular foramen has been exposed below the facial and
vestibulocochlear nerves. There is a dural septum between the glossopharyngeal and vagus
nerves at the roof of the jugular foramen. The glossopharyngeal nerve is often adherent to the
rootlets of the vagus nerve in the cistern, however, at the roof of the jugular foramen, there is
consistently a dural septum separating the glossopharyngeal from the vagus nerve. The glos-
sopharyngeal nerve enters a shallow meatus, the glossopharyngeal meatus, in the dural roof of
the foramen. The glossopharyngeal dural fold passes above the glossopharyngeal nerve at the
entrance to the glossopharyngeal meatus. The vagus nerve enters the vagal meatus, which is
broader than, but not as deep, as the glossopharyngeal meatus, at the roof of the jugular fora-
men. There is also a dural fold around the upper and lateral margin of the vagal meatus. The
accessory nerve ascends to enter the lower part of the vagal meatus.

RHOTON
FIGURE 12-3. The left sigmoid and infe-

rior petrosal sinuses have been unroofed.
The glossopharyngeal, vagus, and acces-
sory nerves are exposed at the roof of the
jugular foramen. The jugular foramen has
three parts: sigmoid, petrosal, and intra-
jugular. The sigmoid sinus descends and
turns forward to pass through the sigmoid
part of the jugular foramen. The inferior
petrosal sinus descends and passes
through the petrosal part of the jugular
foramen. The glossopharyngeal, vagus,
and accessory nerves exit the cranium
through the intrajugular part of the fora-
men, which is located between the sigmoid
and petrosal parts. Two bundles of
hypoglossal rootlets enter a bifid hypoglos-
sal canal above the occipital condyle and
join after exiting the hypoglossal canal.

JUGULAR FORAMEN
FIGURE 12-4. The jugular bulb has

been removed to expose the jugular
fossa on the lower surface of the tem-
poral bone. The glossopharyngeal
nerve enters the jugular foramen
above and medial to the vagus nerve.
The tympanic branch (Jacobson’s
nerve) of the glossopharyngeal nerve
arises in the medial part of the jugular
fossa, ascends to cross the promontory
in the tympanic cavity, and gives rise
to the lesser petrosal nerve. The auric-
ular branch (Arnold’s nerve) of the
vagus nerve arises in the intrajugular
part of the foramen and passes later-
ally across the anterior margin of the
jugular fossa. The bone above the
hypoglossal canal has been drilled to
expose a bifid hypoglossal canal. The
two bundles of hypoglossal rootlets
join at the extracranial end of the
hypoglossal canal and descend in the
carotid sheath with the glossopharyn-
geal, vagus, and accessory nerves.

RHOTON
FIGURES 12-5 AND 12-6. Inferior view of the temporal bone

and jugular foramen. Figure 12-5, the internal jugular vein is
exposed below the jugular foramen and descends on the medial
side of the facial nerve and styloid process. The glossopharyngeal,
vagus, accessory, and hypoglossal nerves descend in the carotid
sheath with the internal carotid artery and internal jugular vein.
The occipital condyle has been drilled to expose the passage of the
hypoglossal nerve behind the vertebral artery and through the
hypoglossal canal. The mandibular head, which sits in the
mandibular fossa, is exposed anterolateral to the jugular foramen.
The middle meningeal artery and branches of the third trigemi-
nal division are exposed below the greater sphenoid wing in the
infratemporal fossa. Bone has been removed to expose the
eustachian tube and the petrous segment of the internal carotid
artery. The Vidian nerve, which arises from the union of the
greater and deep petrosal nerves, continues forward in the Vidian
canal. The rectus capitis lateralis muscle attaches to the occipital
bone behind the jugular foramen. The auriculotemporal branch of
the third trigeminal division conveys autonomic fibers from the
lesser petrosal nerve to the otic ganglion, which provides auto-
nomic innervation to the parotid gland.

JUGULAR FORAMEN
FIGURE 12-6. The rectus capitis lateralis muscle has been resected
and the part of the occipital bone forming the posterior margin of the
jugular foramen has been removed to expose the lower part of the
sigmoid sinus as it hooks forward to form the jugular bulb. The
venous plexus in the hypoglossal canal has been removed. The infe-
rior petroclival vein, which courses along the extracranial surface of
the petroclival fissure, has been removed to expose the petrous apex
articulating with the lateral edge of the clivus along the petroclival
fissure.

RHOTON
FIGURE 12-7. Lateral view of the left tympanic cavity and mastoid area. The tympanic part
of the temporal bone, which forms the lower and anterior margin of the external meatus, has
been removed, but the tympanic sulcus and osseous ring to which the tympanic membrane
attaches has been preserved. The carotid ridge separates the carotid canal and jugular foramen.
Meningeal branches of the ascending pharyngeal and occipital arteries enter the jugular fora-
men. The glossopharyngeal, vagus, and accessory nerves pass through the jugular foramen on
the medial side of the jugular bulb. The malleus, incus, and stapes are exposed in the tympanic
cavity. The stylomastoid branch of the occipital artery joins the facial nerve at the stylomas-
toid foramen. The surface of the temporal and occipital bones surrounding the jugular foramen
and carotid canal has an irregular surface that serves as the site of attachment of the upper end
of the carotid sheath. The mastoid segment of the facial nerve and the stylomastoid foramen are
situated lateral to the jugular bulb. The chorda tympani arises from the mastoid segment of the
facial nerve and courses along the deep surface of the tympanic membrane and crosses the upper
part of the handle of the malleus.

JUGULAR FORAMEN
FIGURE 12-8. Lateral view of the

left tympanic cavity, mastoid area,
and adjacent part of the infratempo-
ral fossa. The tympanic segment of
the facial nerve passes below the lat-
eral semicircular canal and turns
downward to form the mastoid seg-
ment, which exits the stylomastoid
foramen. The stylomastoid foramen
and the mastoid segment are posi-
tioned lateral to the jugular bulb.
The semicircular canals are located
above the jugular bulb. The third
trigeminal division exits the fora-
men ovale to enter the infratemporal
fossa. The chorda tympani arises
from the mastoid segment of the
facial nerve, courses along the deep
surface of the tympanic membrane,
crosses the upper part of the handle
of the malleus, exits the cranium by
passing through the petrotympanic
fissure, and joins the lingual branch
of the mandibular nerve in the
infratemporal fossa.

RHOTON
FIGURE 12-9. The floor of the mid-

dle fossa and the tympanic ring have
been removed to expose the jugular
bulb and petrous carotid. The jugular
bulb is positioned below the semicir-
cular canals. The junction of the ver-
tical and horizontal segments of the
petrous carotid is positioned below
the cochlea. The malleus and medial
wall of the tympanic cavity have
been preserved. The eustachian tube
extends downward and medially
across the anterior surface of the
petrous carotid. The third trigeminal
division has been elevated out of the
foramen ovale.

JUGULAR FORAMEN
FIGURE 12-10. A short segment of the

Eustachian tube has been removed to expose
more of the horizontal segment of the
petrous carotid. The greater petrosal nerve
courses along the floor of the middle fossa
on the upper surface of the petrous carotid.
The deep petrosal nerves arise from the sym-
pathetic nerves accompanying the internal
carotid artery. The deep and greater petrosal
nerves join to form the vidian nerve, which
passes forward through the vidian canal to
join the maxillary nerve and pterygopala-
tine ganglion in the pterygopalatine fossa.
The pharyngobasilar fascia has been opened
to expose the upper part of the longus capi-
tis muscle.

RHOTON
FIGURE 12-11. The internal carotid artery has been displaced forward out of the carotid
canal to expose the carotid nerves, which arise in the cervical sympathetic ganglia and ascend
with the artery. The glossopharyngeal, vagus, accessory, and hypoglossal nerves exit the cra-
nium on the medial side of the internal carotid artery and jugular vein. The hypoglossal nerve
passes forward along the lateral surface of the internal carotid artery, and the accessory nerve
descends posteriorly across the lateral surface of the internal jugular vein. The vagus nerve
descends in the carotid sheath. The glossopharyngeal nerve descends along the medial side of
the internal carotid artery.

JUGULAR FORAMEN
FIGURE 12-12. The jugular bulb, positioned below the

vestibule and semicircular canals, has been removed. The
vertical segment of the petrous carotid has been removed
while preserving the horizontal segment. The cochlea,
which has been opened, is located above the lateral genu of
the petrous carotid artery. The tympanic segment of the
facial nerve passes between the lateral semicircular canal
and oval window. The mastoid segment of the nerve
descends lateral to the jugular fossa.

RHOTON
FIGURE 12-13. Posterior view of the nerves in the jugular foramen with the venous struc-
tures removed. The posterior wall of the jugular foramen and hypoglossal canal have been
opened. The glossopharyngeal nerve enters the jugular foramen caudal to the cochlear aqueduct.
The vagus nerve enters the jugular foramen behind the glossopharyngeal nerve. The auricu-
lar branch of the vagus nerve (Arnold’s nerve) arises at the level of the superior ganglion and
passes across the anterior wall of the jugular bulb. The accessory nerve is formed by multiple
rootlets that arise from the medulla and cervical spinal cord and collect together to form a bun-
dle that blends into the lower margin of the vagus nerve at the level of the jugular foramen. The
vagal and accessory rootlets cross the surface of the jugular tubercle. The glossopharyngeal
nerve expands at the site of the superior and inferior ganglia. The superior ganglion of the
vagus nerve is located at the level of or just below the dural roof of the foramen, and the infe-
rior ganglion is located below the foramen at the level of the atlanto-occipital joint.

JUGULAR FORAMEN
FIGURE 12-14–12-21. Postauri-

cular approach to the jugular fora-
men. Figure 12-14, the C-shaped
retroauricular incision (lower left)
provides access for the mastoidec-
tomy, neck dissection, and reflecting
the parotid gland forward. The scalp
flap and superficial muscles have
been reflected forward to expose the
posterior part of the parotid gland,
the posterior belly of the digastric
muscle, the internal jugular vein
and longissimus capitis, and the superior and inferior oblique muscles.

RHOTON
FIGURE 12-15. A mastoidectomy

has been completed to expose the
facial nerve, sigmoid sinus, jugular
bulb, and the osseous capsule of the
semicircular canals. The facial nerve
and styloid process block access to the
extracranial orifice of the jugular
foramen. The facial nerve crosses the
lateral surface of the styloid process.
The stylomastoid artery arises from
the postauricular artery and joins the
facial nerve at the stylomastoid fora-
men. The superior and inferior
oblique and levator scapulae muscles
attach to the transverse process of
C1.

JUGULAR FORAMEN
FIGURE 12-16. The tympanic

membrane and the posterior part of
the tympanic sulcus and ring have
been removed while preserving the
ossicles. A cuff of tissues around the
facial nerve has been preserved at the
stylomastoid foramen to avoid dissec-
tion directly on the surface of the
nerve and also to preserve the vascu-
lar supply to the nerve from the sty-
lomastoid artery. It will be necessary
to resect the tympanic ring if the
pathology must be followed into the
Eustachian tube or along the petrous
carotid artery. Some hearing will be
preserved if the stapes remains in the
oval window.

RHOTON
FIGURE 12-17. The external audi-

tory canal has been transected and the
middle ear structures have been
removed, except the stapes, which has
been left in the oval window. The lat-
eral edge of the jugular foramen has
been exposed by completing the mas-
toidectomy, transposing the facial
nerve anteriorly, and fracturing the
styloid process across its base and
reflecting it caudally. The rectus capi-
tis lateralis muscle has been detached
from the jugular process of the occip-
ital bone. The petrous carotid is sur-
rounded in the carotid canal by a
venous plexus.

JUGULAR FORAMEN
FIGURE 12-18. The dura behind

the sigmoid sinus has been opened to
expose the facial and vestibulo-
cochlear nerves entering the internal
acoustic meatus and the glossopha-
ryngeal and vagus nerves entering
the jugular foramen. The vertebral
artery is exposed medial to the
nerves.

RHOTON
FIGURE 12-19. A segment of the

sigmoid sinus, jugular bulb, and
internal jugular vein have been
removed. The lateral wall of the
jugular bulb has been removed while
preserving the medial wall and the
opening of the inferior petrosal sinus
into the lower part of the bulb. The
glossopharyngeal, vagus, accessory,
and hypoglossal nerves are exposed
below the jugular bulb. The likeli-
hood of preserving these nerves in
exposing a jugular foramen lesion is
greatly enhanced if the medial
venous wall can be preserved. The
main inflow from the inferior pet-
rosal sinus is directed between the
glossopharyngeal and vagus nerves.

JUGULAR FORAMEN
FIGURE 12-20. The medial venous wall of

the jugular bulb has been removed. The
intrajugular ridge extends forward from the
intrajugular process of the temporal bone
along the medial side of the jugular bulb. The
glossopharyngeal, vagus, and accessory
nerves enter the dura on the medial side of
the intrajugular process, but only the glos-
sopharyngeal nerve courses through the fora-
men entirely on the medial side of the intra-
jugular ridge.

RHOTON
FIGURE 12-21. The intrajugular process and ridge have been removed to expose the passage
of the glossopharyngeal, vagus, and accessory nerves through the jugular foramen. The tip of a
right-angle probe identifies the lower end of the cochlear aqueduct just above where the glossopha-
ryngeal nerve penetrates the dura. A., artery; Ac., acoustic; A.I.C.A., anterior inferior cerebel-
lar artery; Asc., ascending; Atl., atlanto; Aur., auricular; Auriculotemp., auriculotemporal;
Bas., basilar; Br., branch; Cap., capitis; Car., carotid; Chor., chorda, choroid; Cliv., clival; CN,
cranial nerve; Coch., cochlear; Cond., condyle; Eust., eustachian; Ext., external; Fiss., fissure;
Flocc., flocculus; For., foramen; Gang., ganglion; Gl., gland; Glossopharyng., glossopharyn-
geal; Gr., greater; Hypogl., hypoglossal; Inf., inferior; Int., internal; Intrajug., intrajugular;
Jug., jugular; Lat., lateral, lateralis; Long., longus; Longiss., longissimus; M., muscle;
Mandib., mandibular; Mast., mastoid; Max., maxillary; Med., medial; Men., meningeal;
Mid., middle; N., nerve; Obl., oblique; Occip., occipital; Pet., petro, petrosal, petrous; Pharyng.,
pharyngeal; Plex., plexus; P.I.C.A., posterior inferior cerebellar artery; Post., posterior; Proc.,
process; Pterygopal., pterygopalatine; Rec., rectus; S.C.A., superior cerebellar artery; Seg., seg-
ment; Semicirc., semicircular; Sig., sigmoid; Stylomast., stylomastoid; Sup., superior; Tens.,
tensor; Trans., transverse; Tymp., tympanic, tympani; V., vein; Vert., vertebral.

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What are the main structures contained within the temporal bone?

What are the main structures contained within the temporal bone?

What surgical approaches are described for accessing the temporal bone and surrounding areas?

What surgical approaches are described for accessing the temporal bone and surrounding areas?

INTRODUCTION

ANATOMY AND SURGICAL APPROACHES OF THE

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

Hirohiko Gibo, Japan Shigeyuki Osawa, Japan

O nly a broad collection of superlatives can begin to describe

T his supplement continues Professor Rhoton’s wonderful

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OVERVIEW OF TEMPORAL BONE

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FIGURE 1-1. Temporal bone. A and B, infe-

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FIGURE 1-6. (Continued) E–H, trans-

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to the ganglion when

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FIGURE 1-9. Inferior views of an axial sec-

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FIGURE 1-10. A–D, preauricular subtem-

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FIGURE 1-10. (Continued) G–J, preauricu-

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FIGURE 1-12. A–D, anterior petrosectomy and extended middle fossa

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FIGURE 1-14. A–D, presigmoid approach.

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FIGURE 1-14. (Continued) E–H, presigmoid

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sion of the superior petrosal sinus,

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