Middle Fossa Craniotomy and Approach to the Internal Auditory Canal or Petrous Apex

2011 ◽  
pp. 117-121
Author(s):  
Michael E. Sughrue ◽  
Andrew T. Parsa
Keyword(s):  
Internal Auditory Canal ◽  
Petrous Apex ◽  
Middle Fossa

Maturation of the anterior petrous apex: surgical relevance for performance of the middle fossa transpetrosal approach in pediatric patients

2021 ◽  
pp. 1-7
Author(s):  
Robert C. Rennert ◽  
Michael G. Brandel ◽  
Jeffrey A. Steinberg ◽  
David D. Gonda ◽  
Rick A. Friedman ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Internal Carotid ◽  
Age Groups ◽  
Internal Auditory Canal ◽  
Petrous Bone ◽  
Growth Patterns ◽  
Ct Scans ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Region Growth

OBJECTIVE The middle fossa transpetrosal approach to the petroclival and posterior cavernous sinus regions includes removal of the anterior petrous apex (APA), an area well studied in adults but not in children. To this end, the authors performed a morphometric analysis of the APA region during pediatric maturation. METHODS Measurements of the distance from the clivus to the internal auditory canal (IAC; C-IAC), the distance of the petrous segment of the internal carotid artery (petrous carotid; PC) to the mesial petrous bone (MPB; PC-MPB), the distance of the PC to the mesial petrous apex (MPA; PC-MPA), and the IAC depth from the middle fossa floor (IAC-D) were made on thin-cut CT scans from 60 patients (distributed across ages 0–3, 4–7, 8–11, 12–15, 16–18, and > 18 years). The APA volume was calculated as a cylinder using C-IAC (length) and PC-MPB (diameter). APA pneumatization was noted. Data were analyzed by laterality, sex, and age. RESULTS APA parameters did not differ by laterality or sex. APA pneumatization was seen on 20 of 60 scans (33.3%) in patients ≥ 4 years. The majority of the APA region growth occurred by ages 8–11 years, with PC-MPA and PC-MPB increasing 15.9% (from 9.4 to 10.9 mm, p = 0.08) and 23.5% (from 8.9 to 11.0 mm, p < 0.01) between ages 0–3 and 8–11 years, and C-IAC increasing 20.7% (from 13.0 to 15.7 mm, p < 0.01) between ages 0–3 and 4–7 years. APA volume increased 79.6% from ages 0–3 to 8–11 years (from 834.3 to 1499.2 mm3, p < 0.01). None of these parameters displayed further significant growth. Finally, IAC-D increased 51.1% (from 4.3 to 6.5 mm, p < 0.01) between ages 0–3 and adult, without significant differences between successive age groups. CONCLUSIONS APA development is largely complete by the ages of 8–11 years. Knowledge of APA growth patterns may aid approach selection and APA removal in pediatric patients.

scholarly journals Transzygomatic extended middle fossa approach for upper petroclival skull base lesions

2008 ◽  
Vol 25 (6) ◽  
pp. E5 ◽  
Author(s):  
Jin-cheng Zhao ◽  
James K. Liu
Keyword(s):  
Skull Base ◽  
Internal Auditory Canal ◽  
Direct Access ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Trigeminal Root ◽  
Skull Base Lesions ◽  
Anterior Petrosectomy ◽  
Surgical Corridor

Central skull base lesions in the upper retroclival and petroclival regions can be challenging to access because of their location anterior to the brainstem. Several transpetrosal approaches have been developed to access the petroclival junction, including anterior petrosal (anterior petrosectomy), posterior petrosal (retrolabyrinthine, translabyrinthine, transcochlear), and combined petrosal approaches. The anterior petrosal approach is best suited for upper petroclival lesions located anterior and superior to the internal auditory canal and superior to the inferior petrosal sinus. This approach provides direct access to the anteromedial cerebellopontine angle, petrous apex, Meckel cave, and ventrolateral brainstem between the trigeminal root and the facial nerve. The authors describe their modification of an anterior petrosal approach, the so-called transzygomatic extended middle fossa approach, which incorporates a zygomatic osteotomy, anterior mobilization of the V3, and extensive middle fossa drilling. This exposure provides a wider surgical corridor for direct view of the clivus and ventral brainstem.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

Microsurgical Anatomy of the Endoscopy-Assisted Retrosigmoid Intradural Suprameatal Approach to the Meckel's Cave

2021 ◽  
Author(s):  
Yuanzhi Xu ◽  
Benjamin K Hendricks ◽  
Maximiliano Alberto Nunez ◽  
Ahmed Mohyeldin ◽  
Juan C Fernandez-Miranda ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Internal Auditory Canal ◽  
Semicircular Canals ◽  
Petrous Apex ◽  
Microsurgical Anatomy ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Trigeminal Root

Abstract BACKGROUND Understanding the microsurgical anatomical features of the endoscopy-assisted retrosigmoid intradural suprameatal approach (RISA) is critical for surgeons treating petroclival tumors or lesions in the cerebellopontine region that extend into Meckel's cave. OBJECTIVE To evaluate increased exposure for Meckel's cave in the RISA and assess the surgical landmarks for this approach. METHODS A standard retrosigmoid craniotomy to the cerebellopontine region was performed in 4 cadaveric specimens (8 hemispheres) with microscope-assisted endoscopy. The length and depth of the drilling region from the suprameatal tubercle to the petrous apex were analyzed. After opening Meckel's cave and mobilizing the trigeminal root completely, the landmarks for this approach were investigated. RESULTS The endoscopy-assisted RISA facilitates mobilization of the trigeminal root and enhances surgical exposure in the region of Meckel's cave and the petrous apex with increases of 10.1 ± 1.3 mm in depth, 21.4 ± 3.2 mm in length, and 6.4 ± 0.6 mm in height. The posterior and superior semicircular canals, internal auditory canal, superior petrous sinus, and internal carotid artery (petrous segment) served as important landmarks for this approach. One case illustration is presented to describe the application of this approach. CONCLUSION The RISA is suitable mainly for lesions in the posterior fossa that extend into Meckel's cave. The endoscopy-assisted reach optimizes accessibility to the petrous apex region, obviates the need for extensive drilling, and decreases the risk of internal carotid artery injury. Better realization and recognition of microsurgical landmarks and parameters of this approach are crucial for successful outcomes.

scholarly journals Resection of a Dumbbell-Shaped Facial Nerve Schwannoma With Preservation of Facial Nerve Function Through the Extended Middle Fossa Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kaith K Almefty ◽  
Wenya Linda Bi ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Facial Nerve ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Growth Patterns ◽  
Geniculate Ganglion ◽  
Nerve Function ◽  
Middle Fossa ◽  
Facial Nerve Function ◽  
Large Tumor ◽  
Middle Fossa Approach

Abstract Facial nerve schwannomas are rare and can arise from any segment along the course of the facial nerve.1 Their location and growth patterns present as distinct groups that warrant specific surgical management and approaches.2 The management challenge arises when the facial nerve maintains good function (House-Brackmann grade I-II).3 Hence, a prime goal of management is to maintain good facial animation. In large tumors, however, resection with facial nerve function preservation should be sought and is achievable.4,5  While tumors originating from the geniculate ganglion grow extradural on the floor of the middle fossa, they may extend via an isthmus through the internal auditory canal to the cerebellopontine angle forming a dumbbell-shaped tumor. Despite the large size, they may present with good facial nerve function. These tumors may be resected through an extended middle fossa approach with preservation of facial and vestibulocochlear nerve function.  The patient is a 62-yr-old man who presented with mixed sensorineural and conductive hearing loss and normal facial nerve function. Magnetic resonance imaging (MRI) revealed a large tumor involving the middle fossa, internal auditory meatus, and cerebellopontine angle.  The tumor was resected through an extended middle fossa approach with a zygomatic osteotomy and anterior petrosectomy.6 A small residual was left at the geniculate ganglion to preserve facial function. The patient did well with hearing preservation and intact facial nerve function. He consented to the procedure and publication of images.  Image at 1:30 © Ossama Al-Mefty, used with permission. Images at 2:03 reprinted from Kadri and Al-Mefty,6 with permission from JNSPG.

Extended middle fossa approach to lateralized pontine cavernomas in children

2018 ◽  
Vol 21 (4) ◽  
pp. 384-388 ◽  
Author(s):  
Robert C. Rennert ◽  
Reid Hoshide ◽  
Mark Calayag ◽  
Joanna Kemp ◽  
David D. Gonda ◽  
...  
Keyword(s):  
Trigeminal Nerve ◽  
Internal Auditory Canal ◽  
Csf Leak ◽  
Geniculate Ganglion ◽  
Gasserian Ganglion ◽  
Middle Fossa ◽  
Cavernous Malformations ◽  
Middle Fossa Approach ◽  
Cerebellar Artery ◽  
Mandibular Branch

OBJECTIVETreatment of hemorrhagic cavernous malformations within the lateral pontine region demands meticulous surgical planning and execution to maximize resection while minimizing morbidity. The authors report a single institution’s experience using the extended middle fossa rhomboid approach for the safe resection of hemorrhagic cavernomas involving the lateral pons.METHODSA retrospective chart review was performed to identify and review the surgical outcomes of patients who underwent an extended middle fossa rhomboid approach for the resection of hemorrhagic cavernomas involving the lateral pons during a 10-year period at Rady Children’s Hospital of San Diego. Surgical landmarks for this extradural approach were based on the Fukushima dual-fan model, which defines the rhomboid based on the following anatomical structures: 1) the junction of the greater superficial petrosal nerve (GSPN) and mandibular branch of the trigeminal nerve; 2) the lateral edge of the porus trigeminus; 3) the intersection of the petrous ridge and arcuate eminence; and 4) the intersection of the GSPN, geniculate ganglion, and arcuate eminence. The boundaries of maximal bony removal for this approach are the clivus inferiorly below the inferior petrosal sinus; unroofing of the internal auditory canal posteriorly; skeletonizing the geniculate ganglion, GSPN, and internal carotid artery laterally; and drilling under the Gasserian ganglion anteriorly. This extradural petrosectomy allowed for an approach to all lesions from an area posterolateral to the basilar artery near its junction with cranial nerve (CN) VI, superior to the anterior inferior cerebellar artery and lateral to the origin of CN V. Retraction of the mandibular branch of the trigeminal nerve during this approach allowed avoidance of the region involving CN IV and the superior cerebellar artery.RESULTSEight pediatric patients (4 girls and 4 boys, mean age of 13.2 ± 4.6 years) with hemorrhagic cavernomas involving the lateral pons and extension to the pial surface were treated using the surgical approach described above. Seven cavernomas were completely resected. In the eighth patient, a second peripheral lesion was not resected with the primary lesion. One patient had a transient CN VI palsy, and 2 patients had transient trigeminal hypesthesia/dysesthesia. One patient experienced a CSF leak that was successfully treated by oversewing the wound.CONCLUSIONSThe extended middle fossa approach can be used for resection of lateral pontine hemorrhagic cavernomas with minimal morbidity in the pediatric population.

Microsurgical Resection of Trigeminal Schwannomas: 3-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E18-E18
Author(s):  
Duarte N C Cândido ◽  
Marcio S Rassi ◽  
Guilherme Henrique Weiler Ceccato ◽  
Jean Gonçalves de Oliveira ◽  
Luis A B Borba
Keyword(s):  
Trigeminal Nerve ◽  
Senior Author ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
3 Dimensional ◽  
History Of ◽  
Nerve Paresis ◽  
Microsurgical Resection ◽  
The Right

Abstract Trigeminal schwannomas are benign lesions arising from the Schwann cells of the trigeminal nerve. This is an unusual tumor that accounts for less than 0.4% of intracranial pathologies, even though they are the second most frequent schwannoma after the vestibular schwannoma. The tumor spreads along the natural course of the V nerve at its cisternal portion, along the ganglion inside Meckel's cave or through its peripheral division. Even though the tumor can reach great size and become multicompartmental. We present a 51-yr-old woman, with an history of 3 mo of incapacitating facial pain, that was found on examination to be on the territory of the third division of the trigeminal nerve on the right side. The MRI depicted a large homogeneous enhancing lesion at the base of the right middle fossa with extension through the petrous apex to the most superior and medial part of the posterior fossa. The patient was operated by the senior author, through a middle fossa approach, dissecting between the two layers of the middle fossa dura (the apparent inner and the true outer layer of the cavernous sinus), the so called middle fossa “peeling”. We achieved total resection of the tumor, but the patient presented after surgery with facial nerve paresis. This is thought to be related to geniculate ganglion manipulation, as it was unprotect by bone at the middle fossa and the patient maintained lacrimal function (post-geniculate alteration). It resolved completely after 6 mo. The patient consented to publication of her images.

scholarly journals Anterior Petrosal Approach for the Resection of a Petrous Apex Meningioma with Tentorial Infiltration

2019 ◽  
Vol 80 (S 03) ◽  
pp. S304-S304
Author(s):  
Diego Mendez-Rosito
Keyword(s):  
Trigeminal Neuralgia ◽  
Free Edge ◽  
Gross Total Resection ◽  
Petrous Apex ◽  
Anatomical Landmarks ◽  
Middle Fossa ◽  
Total Resection ◽  
Middle Fossa Approach ◽  
Anterior Petrosectomy ◽  
Surgical Corridor

Objective The anterior petrosal approach is an extension of the middle fossa approach, characterized by drilling of the posteromedial triangle of the middle fossa. Drilling the Kawase's rhomboid creates a surgical corridor to the posterior fossa after splitting the tentorium. We present a case of a petrous apex meningioma invading the tentorium and causing trigeminal neuralgia. Results The patient was positioned in a Mayfield with the head rotated. A frontotemporal incision was done. A basal craniotomy was done to allow epidural dissection. The anatomical landmarks were identified. The surgical video is analyzed together with cadaveric dissections to highlight landmarks when doing an anterior petrosectomy. The tentorium was identified and the infiltrated region was coagulated and removed. The tentorium was sharply sectioned until the free edge of the tentorium was opened. The tumor in the petrous apex was identified and removed. The trigeminal nerve was decompressed and a gross total resection was achieved with resolution of the symptoms. Conclusion The anterior petrosal approach is a useful corridor to remove tumors in the petrous apex that infiltrate the tentorium. A thorough knowledge of the anatomical landmarks is crucial to identify and delineate the limits of the Kawase's rhomboid. After evaluating different surgical corridors, the anterior petrosal approach allows a gross total resection including the removal of the infiltrated tentorium and a resolution of the symptoms.The link to the video can be found at: https://youtu.be/p4KPUnM_bww.

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