Middle Fossa

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The Middle Fossa Approach

! / For Physicians & Researchers / Education / Grand Rounds, Publications, & Media / Barrow Quarterly / Volume 16, No. 4, 2000 / The
Middle Fossa Approach
Authors
Fernando L. Gonzalez, MD
Mauro A. T. Ferreira, MD
Joseph M. Zabramski, MD
Robert F. Spetzler, MD
Pushpa Deshmukh, PhD
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital

and Medical Center, Phoenix, Arizona
Abstract
The internal auditory canal can be approached through the middle fossa by
following anatomic landmarks. Cadaveric dissections are used to illustrate the
anatomy relevant to this surgery. The middle fossa approach is a useful option for
small lesions when hearing might be preserved. The approach is versatile because it
can be extended anteriorly by drilling the petrous apex (Kawase’s triangle) and
gaining access to the posterior fossa and petroclival area.
Key Words: acoustic neuromas, facial nerve, middle fossa approach, petrosectomy
The middle fossa approach, as popularized by William House, provides excellent

exposure to the internal auditory canal (IAC) for the removal of small acoustic
tumors with the potential for hearing preservation. The anterior extension of this
approach described by Kawase enhances the surgical exposure provided by this

route to the upper clivus and petrous apex. This article focuses on the most relevant
anatomical and technical aspects involved with accessing the IAC and with
removing the petrous apex when greater exposure is needed.
https://www.barrowneuro.org/for-physicians-researchers/education/gra…row-quarterly/volume-16-no-4-2000/the-middle-fossa-approach/?print= Page 1 of 16
In 1904 Parry[16] `rst described the middle fossa approach for vestibular nerve
section. At that time exposure of this nerve was associated with a high rate of
morbidity. In 1961 William House, an eye, nose, and throat surgeon working with Dr.
Theodore Kurze, a neurosurgeon, revisited this surgical approach. They performed
14 cadaveric dissections and described the approach for decompression of the IAC
for the treatment of otosclerosis.[8] The technique was abandoned, but its utility for
removing acoustic neuromas was evident.[9]
Compared to other approaches to the IAC, the middle fossa approach adequately
exposes the facial (CN VII) and superior vestibular nerves within the IAC. It permits
exposure of the subarachnoid, intracanalicular, and labyrinthine segments, and the
`rst portion of the horizontal (tympanic) segment of CN VII. It is useful for removing
small lesions (up to 2 cm in diameter), primarily intracanalicular, with minimal
extension into the posterior fossa. Depending on the size of a lesion, the possibility
for preserving hearing with the middle fossa approach is good. It is useful whenever
the above segments of CN VII need to be decompressed. Because the approach is
from the superior surface of the temporal bone, the risk of inadvertently opening the
posterior semicircular canal is less than that associated with the retrosigmoid
approach, which involves drilling the posterior wall of the IAC.
Figure 1. Primary anatomic structures of the middle fossa. The right cerebral hemisphere is removed and the dura
of the middle fossa is peeled away. The middle meningeal artery (MMA) is exposed where it emerges from the
foramen spinosum. The greater superior petrosal nerve (GSPN) is visible from the geniculate ganglion to the point
where it courses below the mandibular branch of CN V. The geniculate ganglion is shown as well as the
labyrinthine, tympanic, and subarachnoid portions of the facial nerve. A1, A2=segments of anterior cerebral
artery, CN=cranial nerve, ICA=internal carotid artery, PCoA=posterior communicating artery, SC=semicircular
canals, SS=sigmoid sinus, TS=transverse sinus, V1, V2, V3=branches of CN V,VA=vertebral artery.
The suboccipital retrosigmoid and the translabyrinthine approaches can also be

used to expose the IAC. When the suboccipital approach is used, the ability to
preserve hearing depends on the size of the lesion. If the tumor is less than 2 cm,
the chance to preserve hearing is 53% but increases to 83% if the lesion is 1 cm or
less.[17] The most important advantage of the suboccipital approach is that it can
be used for lesions of different sizes. The trans labyrinthine approach is useful for
intracanalicular lesions.
Its main drawback is that hearing must be sacri`ced. A partial labyrinthectomy (that
removes the superior and posterior semicircular canals), however, may preserve
hearing.[18] In a recent study,[7] hearing was preserved in 100% of patients who
underwent a “transcrusal” approach, in which only the superior and posterior
semicircular canals, starting at the common crus, were removed. Bone removal to
expose the IAC is also time consuming and requires in depth knowledge of the
anatomy of the temporal bone. If a cerebrospinal iuid `stula occurs, it is harder to
treat than with other approaches. The IAC can also be exposed by combining these
three approaches (Table 1).
Relevant Anatomic Structures
The ultimate goal of the middle fossa approach is to expose the IAC from above,
from the roof of the petrous temporal bone. Although the IAC is not a middle fossa
structure, its location (Fig. 1) is easily identièd by the following important
landmarks.
The internal maxillary artery, one of the two terminal branches of the external carotid
artery, gives rise to the middle meningeal artery. The middle meningeal artery enters
the cranium through the foramen spinosum and has two branches, the anterior and
the posterior. The middle fossa approach involves the posterior branch.
The foramen spinosum is the outermost lateral structure in the middle fossa.
According to de Oliveira et al.,5 the foramen spinosum is 4.7 mm in diameter and
2.5 to 8.0 mm anterolateral to the carotid canal. The third branch of the trigeminal
nerve, the mandibular nerve (V3), is 2 to 3 mm medial to the foramen.
Typically, the tensor tympani muscle is roofed by bone. The muscle originates from
the cartilaginous part of the eustachian tube and inserts via a tendon on the handle
of the malleus. It is innervated by a tympanic branch of V3. When the muscle
contracts, it tenses the tympanic membrane (hence its name), facilitating the ability
to hear high-frequency tones.
The greater superior petrosal nerve (GSPN) is the `rst branch of CN VII and is
composed of the latter’s preganglionic parasympathetic `bers. Originating from the
geniculate ganglion, the GSPN travels in the ioor of the middle fossa under the dura
in the sphenopetrosal groove and can be either partially covered or not covered at all
by bone. It is medial to the lesser petrosal nerve and could easily be mistaken for
the latter.19 Hence, nerve stimulation can help identify the GSPN.[2]
Distal to the Gasserian ganglion, the GSPN lies at the anterior part of the foramen
lacerum. There, it is joined by the deep petrosal nerve, which is composed of the
sympathetic `bers from the pericarotid plexus. The deep petrosal nerve unites with
the GSPN to become the vidian nerve. From the vidian canal, the vidian nerve
courses to the sphenopalatine ganglion in the pterygopalatine fossa,[1] supplying
post ganglionic `bers to the lacrimal glands.
The lesser petrosal nerve is com posed of parasympathetic `bers that originate in
the inferior salivatory nucleus. It is a branch of the glossopharyngeal (CN IX) nerve
and travels lateral to the GSPN in the same direction in the ioor of the middle fossa
under the dura.[19] It exits the foramen ovale directly to the otic ganglion where it
joins a branch of V3, the auriculotemporal nerve, which innervates the parotid gland.
The petrosal segment (C3) of the internal carotid artery (ICA) enters the skull base
through the carotid canal. The tympanic muscle is the landmark for identifying the
genu of the ICA. After its genu, the ICA courses horizontally toward the petrous
apex. A venous plexus and a network of sympathetic `bers surround the artery, from
which exit two inconsistent branches. The caroticotympanic branch goes to the
tympanic region (anterior and lateral to the genu of the petrosal ICA), and the vidian
or pterygoid branch typically arises from the middle meningeal artery.[5]
Figure 2. Skin incision for the middle fossa approach (dashed line). The patient’s head is rotated 90º to the
contralateral side. A vertical incision begins anterior to the ear at the level of the zygomatic arch. A question mark
incision (dotted line) is preferred when anterior extension is desired (e.g., transKawase approach) and reaching
the petrous apex is the goal.
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EducationGrand Rounds, Publications, & MediaBarrow QuarterlyVolume 16, No. 4,

2000The Middle Fossa Approach
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The Middle Fossa
Approach
Authors
Fernando L. Gonzalez, MD
Mauro A. T. Ferreira, MD
Joseph M. Zabramski, MD
Robert F. Spetzler, MD
Pushpa Deshmukh, PhD
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital

and Medical Center, Phoenix, Arizona
Abstract
The internal auditory canal can be approached through the middle fossa by
following anatomic landmarks. Cadaveric dissections are used to illustrate the
anatomy relevant to this surgery. The middle fossa approach is a useful option for
small lesions when hearing might be preserved. The approach is versatile because it
can be extended anteriorly by drilling the petrous apex (Kawase’s triangle) and
gaining access to the posterior fossa and petroclival area.
Key Words: acoustic neuromas, facial nerve, middle fossa approach, petrosectomy
The middle fossa approach, as popularized by William House, provides excellent

exposure to the internal auditory canal (IAC) for the removal of small acoustic
tumors with the potential for hearing preservation. The anterior extension of this
approach described by Kawase enhances the surgical exposure provided by this
route to the upper clivus and petrous apex. This article focuses on the most relevant
anatomical and technical aspects involved with accessing the IAC and with
removing the petrous apex when greater exposure is needed.
In 1904 Parry[16] `rst described the middle fossa approach for vestibular nerve
section. At that time exposure of this nerve was associated with a high rate of
morbidity. In 1961 William House, an eye, nose, and throat surgeon working with Dr.
Theodore Kurze, a neurosurgeon, revisited this surgical approach. They performed
14 cadaveric dissections and described the approach for decompression of the IAC
for the treatment of otosclerosis.[8] The technique was abandoned, but its utility for
removing acoustic neuromas was evident.[9]
Compared to other approaches to the IAC, the middle fossa approach adequately
exposure of the subarachnoid, intracanalicular, and labyrinthine segments, and the
`rst portion of the horizontal (tympanic) segment of CN VII. It is useful for removing
small lesions (up to 2 cm in diameter), primarily intracanalicular, with minimal
extension into the posterior fossa. Depending on the size of a lesion, the possibility
for preserving hearing with the middle fossa approach is good. It is useful whenever
the above segments of CN VII need to be decompressed. Because the approach is
from the superior surface of the temporal bone, the risk of inadvertently opening the
posterior semicircular canal is less than that associated with the retrosigmoid
approach, which involves drilling the posterior wall of the IAC.
Figure 1. Primary anatomic structures of the middle fossa. The right cerebral
hemisphere is removed and the dura of the middle fossa is peeled away. The middle
meningeal artery (MMA) is exposed where it emerges from the foramen spinosum.
The greater superior petrosal nerve (GSPN) is visible from the geniculate ganglion to
the point where it courses below the mandibular branch of CN V. The geniculate
ganglion is shown as well as the labyrinthine, tympanic, and subarachnoid portions
of the facial nerve. A1, A2=segments of anterior cerebral artery, CN=cranial nerve,
ICA=internal carotid artery, PCoA=posterior communicating artery, SC=semicircular
canals, SS=sigmoid sinus, TS=transverse sinus, V1, V2, V3=branches of CN
V,VA=vertebral artery.
The suboccipital retrosigmoid and the translabyrinthine approaches can also be

used to expose the IAC. When the suboccipital approach is used, the ability to
preserve hearing depends on the size of the lesion. If the tumor is less than 2 cm,
the chance to preserve hearing is 53% but increases to 83% if the lesion is 1 cm or
less.[17] The most important advantage of the suboccipital approach is that it can
be used for lesions of different sizes. The trans labyrinthine approach is useful for
intracanalicular lesions.
Its main drawback is that hearing must be sacri`ced. A partial labyrinthectomy (that
removes the superior and posterior semicircular canals), however, may preserve
hearing.[18] In a recent study,[7] hearing was preserved in 100% of patients who
underwent a “transcrusal” approach, in which only the superior and posterior
semicircular canals, starting at the common crus, were removed. Bone removal to
expose the IAC is also time consuming and requires in depth knowledge of the
anatomy of the temporal bone. If a cerebrospinal iuid `stula occurs, it is harder to
treat than with other approaches. The IAC can also be exposed by combining these
three approaches (Table 1).
Relevant Anatomic Structures
The ultimate goal of the middle fossa approach is to expose the IAC from above,
structure, its location (Fig. 1) is easily identièd by the following important
landmarks.
The internal maxillary artery, one of the two terminal branches of the external carotid
the cranium through the foramen spinosum and has two branches, the anterior and
the posterior. The middle fossa approach involves the posterior branch.
The foramen spinosum is the outermost lateral structure in the middle fossa.
According to de Oliveira et al.,5 the foramen spinosum is 4.7 mm in diameter and
2.5 to 8.0 mm anterolateral to the carotid canal. The third branch of the trigeminal
nerve, the mandibular nerve (V3), is 2 to 3 mm medial to the foramen.
Typically, the tensor tympani muscle is roofed by bone. The muscle originates from
the cartilaginous part of the eustachian tube and inserts via a tendon on the handle
of the malleus. It is innervated by a tympanic branch of V3. When the muscle
contracts, it tenses the tympanic membrane (hence its name), facilitating the ability
to hear high-frequency tones.
The greater superior petrosal nerve (GSPN) is the `rst branch of CN VII and is
composed of the latter’s preganglionic parasympathetic `bers. Originating from the
geniculate ganglion, the GSPN travels in the ioor of the middle fossa under the dura
in the sphenopetrosal groove and can be either partially covered or not covered at all
by bone. It is medial to the lesser petrosal nerve and could easily be mistaken for
the latter.19 Hence, nerve stimulation can help identify the GSPN.[2]
Distal to the Gasserian ganglion, the GSPN lies at the anterior part of the foramen
lacerum. There, it is joined by the deep petrosal nerve, which is composed of the
sympathetic `bers from the pericarotid plexus. The deep petrosal nerve unites with
the GSPN to become the vidian nerve. From the vidian canal, the vidian nerve
courses to the sphenopalatine ganglion in the pterygopalatine fossa,[1] supplying
post ganglionic `bers to the lacrimal glands.
The lesser petrosal nerve is com posed of parasympathetic `bers that originate in
the inferior salivatory nucleus. It is a branch of the glossopharyngeal (CN IX) nerve
and travels lateral to the GSPN in the same direction in the ioor of the middle fossa
under the dura.[19] It exits the foramen ovale directly to the otic ganglion where it
joins a branch of V3, the auriculotemporal nerve, which innervates the parotid gland.
The petrosal segment (C3) of the internal carotid artery (ICA) enters the skull base
through the carotid canal. The tympanic muscle is the landmark for identifying the
genu of the ICA. After its genu, the ICA courses horizontally toward the petrous
apex. A venous plexus and a network of sympathetic `bers surround the artery, from
which exit two inconsistent branches. The caroticotympanic branch goes to the
tympanic region (anterior and lateral to the genu of the petrosal ICA), and the vidian
or pterygoid branch typically arises from the middle meningeal artery.[5]
Figure 2. Skin incision for the middle fossa approach (dashed line). The patient’s
head is rotated 90º to the contralateral side. A vertical incision begins anterior to the
ear at the level of the zygomatic arch. A question mark incision (dotted line) is
preferred when anterior extension is desired (e.g., transKawase approach) and
reaching the petrous apex is the goal.
reaching the petrous apex is the goal.
The cochlea is located in the axilla between the GSPN and facial nerve just below
the geniculate ganglion.
The arcuate eminence is a bony prominence, formed by the superior semi circular
canal in the ioor of the middle fossa. Its location is too inconsistent to serve as an
accurate landmark for localizing the superior semicircular canal.
The superior petrosal vein, also known as Dandy’s vein, is a part of the super`cial
draining system of the cerebellum on its petrosal surface and drains into the
superior petrosal sinus. It is formed by the transverse pontine vein, the
pontotrigeminal vein, the vein of the middle cerebellar peduncle, and the
Find vein of the
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cerebellomedullary `ssure.[15] The superior petrosal vein is not a structure
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middle fossa, but is important during surgery of the cerebellopon tine Portal
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the middle fossa approach must be extended anteriorly, surgeons must be aware of
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Surgical Technique
The long axis of the head is positioned parallel to the ioor with the ear facing the
ceiling and the neck slightly extended. A vertical incision, 5 to 6 cm long, is made
anterior to the tragus and perpendicular to the zygomatic arch (Fig. 2). Fascia and
temporal muscle are exposed and split with the Bovie electrocautery device and
then retracted with a self-retaining retractor or `shhooks. A square-shaped
craniotomy is performed. The squamous suture, which is a good landmark for
identifying the superior limit of the craniotomy, is exposed.
Figure 3. Craniotomy for the middle fossa approach. (A) The skin incision and temporalis muscle have been
retracted with Tshhooks to expose the temporalis squama and the root of the zygomatic arch. (B) The craniotomy
is approximately a 3.5-cm square. The superior limit is the temporal squama while the inferior limit is the
zygomatic arch.
A third of the craniotomy is positioned posterior and two-thirds of it anterior to the
external auditory canal (Fig. 3) This con`guration adequately exposes the ioor of
the middle fossa. Sometimes part of the temporal rim must be removed to obtain a
iat exposure and thus minimize retraction of the temporal lobe (Fig. 4).
Figure 4. Coronal view showing the angle of the operative approach. The temporal bone must be trimmed to
minimize retraction of the temporal lobe.
The dura is elevated posteriorly to anteriorly to prevent injury to the GSPN (Fig. 5).
The GSPN and lesser petrosal nerve are just beneath the dura and become visible
once it is elevated. Both nerves are delicate and the operating microscope must be
used to identify them. The two nerves can be distinguished by electrical stimulation
as mentioned earlier. When the dura is retracted medially, the middle meningeal
artery, with its anterior and posterior branches, can be seen emerging from the
foramen spinosum. The middle meningeal artery is sectioned just after it exits the
foramen spinosum, which is then exposed along with V3.
In the posterior part of the exposure near the petrous ridge, the arcuate eminence
becomes visible. The angle between the arcuate eminence and the GSPN is
approximately 120º. After the GSPN, arcuate eminence, and petrous ridge are
identièd, the IAC can be localized by any of the following three techniques.
https://www.barrowneuro.org/for-physicians-researchers/education/gr…row-quarterly/volume-16-no-4-2000/the-middle-fossa-approach/?print= Page 10 of 16
Figure 5. Extradural exposure of important landmarks shown in surgical

orientation. The temporal dura has been elevated posteriorly to
anteriorly. A retraction blade is placed beneath the dura of the temporal
lobe. The arcuate eminence in the ]oor of the middle fossa helps to
identify the remaining structures. The major axis of the arcuate
eminence must be recognized to identify the internal auditory canal
posteriorly. The anterior limit is the middle meningeal artery (MMA)
immediately after it emerges from the foramen spinosum. The greater Figure 6. Options for exposing the internal auditory canal (IAC). (A) Fisch
superior petrosal nerve (GSPN) and the anterior and posterior branches technique: A line traced 60Þ anterior to the long axis of the arcuate
of the MMA are identiTed with the dura elevated. In some cases the eminence shows the anterior lip of the IAC. (B) Garcia-Ibañez technique:
geniculate ganglion is not encased in bone. The greater superior petrosal nerve (GSPN) and the long axis of the
arcuate eminence are identiTed by tracing two imaginary lines over these
structures. At their bisection, another line is drawn over the anterior lip
of the IAC. Drilling proceeds along this line to expose the IAC. (C) House
technique: The GSPN is followed until the geniculate ganglion is
exposed. The labyrinthine portion of the facial nerve is traced until it
reaches the IAC. It is unnecessary to expose the arcuate eminence,
thereby reducing retraction of the temporal lobe.
Fisch Technique. A line is drawn over the long axis of the arcuate eminence (Fig.
6A). Another line is drawn 60º to the `rst line away from the arcuate eminence. The
second line provides the location of the IAC, which typically is 3 to 4 mm below the
petrous ridge.[4] It has, however, been reported to be as much as 7 mm below the
ioor of the middle fossa.[11]
Garcia-Ibañez Technique. This technique (Fig. 6B) relies on the important

relationship between the GSPN and the arcuate eminence, which are separated by
120º. Bisecting this angle provides the site at which to start drilling the temporal
bone to expose the IAC.[6]
House Technique. House proposed that once the GSPN has been identièd, it is
possible to drill the ioor of the middle fossa (2 to 3 mm), to identify the geniculate
ganglion, and to follow the facial (labyrinthine portion) nerve medially until the IAC is
reached (Fig. 6C).[6,8] The junction between the geniculate ganglion and the facial
nerve is not on the same plane as the IAC but rather is slightly posterior. Therefore,
most of the geniculate ganglion must be unroofed to expose the facial nerve
medially.
After the roof of the IAC has been drilled (3 to 4 mm below the ioor of the middle
fossa), the vertical bar of bone (also known as Bill’s bar in honor of Dr. William
House) is easily identièd. This bar separates the facial nerve from the superior
vestibular nerve. Adjacent to the IAC is the meatal portion of the anterior inferior
vestibular nerve. Adjacent to the IAC is the meatal portion of the anterior inferior
cerebellar artery (AICA), which forms an important loop, sometimes enters the IAC,
and then passes through the nerves. The anatomy of the AICA in this region is quite
variable as is the percentage of its loop located inside the IAC. According to Martin
et al.,14 54% of meatal segments protrude into the IAC.
The internal auditory artery sends branches to the bone and dura lining the IAC.
According to Martin et al. the internal auditory artery emerged from the premeatal
segment in 77% of their anatomical specimens, from the meatal segment in 21%,
and from the post meatal segment in 2%. This artery also can emerge outside or at
the meatus.14 Its patency is a prerequisite to the preservation of hearing.
The recurrent artery is also important because it supplies blood to the pons, middle
cerebellar peduncle, and the entry zone of the trigeminal nerve (CN V). It can be
found between or anterior, anteroinferior, or superior to the facial and vestibular
nerves.14 Early identi`cation and preservation of these arterial branches inside the
IAC are fundamental to the preservation of hearing during the resection of acoustic
neuromas.
Extended Middle Fossa Approach to the IAC and Clivus
Despite the excellent exposure of the IAC afforded by the traditional middle fossa
approach, it is inadequate for the removal of tumors that extend into the posterior
fossa or lesions in the petroclival region. To resect tumors with such medial
extensions, a wider approach is needed.
Kawase’s group[10] `rst described an area of the temporal bone that can be
removed with impunity. For the treatment of low-neck basilar tip aneurysms
(between the sellar ioor and IAC on a lateral projection), they described an
approach that later proved useful for resecting meningiomas of the petroclival
region.[3,12,13] In 1986 Day et al.[4] developed a geometric construct by
compartmentalizing structures in and adjacent to the cavernous sinus. They named
the area described by Kawase as the posteromedial triangle and its limits were as
follows: the porustrigeminus, cochlea, and posterior border of the mandibular
branch (Fig. 7).[6] The triangle is devoid of any vascular or nerve branches and
limited by the margin of V3, the petrous ridge, the GSPN laterally, and the nerves
inside the IAC posteriorly. The principle of this approach is the same as for the
middle fossa. Hence, early identi`cation of the IAC is important.
Figure 7. The transKawase approach requires exposing the internal Figure 8. Operative exposure achieved with the transKawase approach.
auditory canal (IAC). After the middle meningeal artery (MMA) is The dura is opened and the superior petrosal sinus is ligated anterior to
sectioned, the third branch of the trigeminal nerve is identiTed (V3). The the point where the petrosal vein reaches the superior petrosal sinus.
greater superior petrosal nerve (GSPN) was exposed during the previous The trigeminal nerve is exposed from its origin at the pons to its
step. The Kawase area, delimited by V3 anteriorly, by the GSPN laterally, entrance into Meckel’s cave. The subarachnoid and labyrinthine portions
by the IAC posteriorly, and by the insertion of the tentorium in the of the facial nerve (CN VII) are exposed. Posterior to CN VII in the
petrous bone medially, deTnes the location of the superior petrosal internal auditory canal (IAC), the superior vestibular nerve and, inferior to
sinus. The cochlea is in the angle formed by the GSPN and the facial it, the inferior vestibular nerve, are visible. The cochlear nerve is anterior
nerve (CN VII, labyrinthine portion). The posterolateral triangle and inferior to CN VII. Three tributaries (i.e., the transverse pontine vein,
(Glasscock’s triangle) is limited by V3 anteriorly, the GSPN medially, and pontotrigeminal vein, and vein of the cerebellopontine Tssure) of the
an imaginary line from the origin of the MMA (foramen spinosum) to the superior petrosal vein are exposed. The premeatal and meatal segments
origin of the GSPN from the geniculate ganglion. This triangle is an of the branch inside the IAC and the anterior inferior cerebellar artery
important landmark for exposing the petrous portion of the internal (AICA) are visible. GSPN=greater superTcial petrosal nerve, ICA=internal
carotid artery. V1, V2=branches of CN V. carotid artery, MMA=middle meningeal artery, V1, V2, V3=branches of
CN V.
Surgical Technique
The head is positioned as described for the traditional middle fossa approach. The
incision is in the shape of an inverted question mark big enough to include the
squamous portion of the temporal bone and part of sphenotemporal bone (Fig. 2).
Below the skin incision, the fascia is incised in a semicircular fashion. The
craniotomy must include the sphenotemporal junction, and its position varies
depending on if it needs to be extended anteriorly enough to include the posterior
part of cavernous sinus.
The petrous apex is exposed extradurally until the petrous ridge is identièd. The
dura is again elevated posteriorly to anteriorly, and the foramen spinosum is
identièd. The middle meningeal artery is coagulated so that the dura can be
elevated and V3 visualized. The petrosal nerves are located medially, just under the
dura.
To expose the IAC, the superior petrosal sinus and petrous ridge must be identièd.
An incision is made above and below the ridge so that the sinus can be ligated just
posterior to the porus trigeminus. The sinus must be ligated before the entry point
of the superior petrosal vein so that it will drain normally into the transverse sinus.
Utmost care must be exercised to protect the trochlear nerve (CN IV), which courses
Utmost care must be exercised to protect the trochlear nerve (CN IV), which courses
just below the tentorium and can be easily damaged. After V3, GSPN, and CN VII
and the vestibulocochlear nerve (CN VIII) have been identièd in the IAC and the
superior petrosal sinus has been ligated, this piece of bone, which is devoid of
important structures, can be drilled until the dura of the posterior fossa becomes
visible (Fig. 8).
In this exposure the basilar trunk, the emergence of the AICA, and abducens nerve
are visible medially (Fig. 9) and the nerves inside the IAC are visible posteriorly. The
brain stem is exposed from the pontomedullary sulcus, and the anterolateral portion
of the pons between CN V and CN VII is also visible.
Figure 9. Exposure of the origin of the anterior inferior cerebellar artery (AICA) from the midbasilar trunk. The
abducent nerve (CN VI) lies over the pons and is traversed by the proximal AICA.
Conclusions
The middle fossa approach is an option for the removal of small acoustic neuromas
(inside the internal auditory canal). It is adequate for the decompression of CN VII
and provides the landmarks associated with exposure of the petrous portion of the
ICA when a bypass (C3-C5) is needed. The anterior extension (transKawase)
provides an excellent option for petroclival lesions, lesions of the middle third of the
clivus, and AICA aneurysms. This complicated anatomy must be mastered by
practicing anatomical dissection and drilling of the temporal bone.
References
1. Brazis PW, Masdeu JC, Biller J: The localization of lesions affecting cranial nerve
VII (the facial nerve), in Brazis PW, Masdeu JC, Biller J (eds): Localization in
Clinical Neurology. Boston: Little, Brown and Company, 1996, pp 271-291
2. Chicoine MR, van Loveren HR: Surgical approaches to the cavernous sinus, in
Robertson JT, Coakham HB, Robertson JH (eds): Cranial Base Surgery. London:
Churchill Livingstone, 2000, pp 171-185
3. David CA, Spetzler RF: Petroclival meningiomas. BNI Quarterly 15(2):4-14, 1999
4. Day JD, Fukushima T, Giannotta SL: Microanatomical study of the extradural

middle fossa approach to the petroclival and posterior cavernous sinus region:
Description of the rhomboid construct. Neurosurgery 34:1009-1016, 1994
5. de Oliveira E, Tedeschi H, Rhoton AL, Jr., et al: Microsurgical anatomy of the

internal carotid artery: Intrapetrous, intracavernous, and clinoidal segments, in
Carter LP, Spetzler RF (eds): Neuro vascular Surgery. New York: McGraw-Hill,
1995, pp 3-10
6. Fukushima T, Day JD: Manual of Skull Base Dissection. Pittsburgh: AF

NeuroVideo, 1996
7. Horgan MA, Anderson GJ, Schwartz MS, et al: Classi`cation and quanti`cation of
the petrosal approach (abst). Skull Base Surgery 10(suppl 1): 11, 2000
8. House WF: Surgical exposure of the internal auditory canal and its contents
through the middle cranial fossa. Laryngoscope 71:1363-1385, 1961
9. House WF, Shelton C: Middle fossa approach for acoustic tumor removal.
Otolaryngol Clin North Am 25:347-359, 1992
10.Kanzaki J, Kawase T, Sano K, et al: A modièd extended middle cranial fossa

approach for acoustic tumors. Arch Otorhinolaryngol 217:119-121, 1977
11.Kawase T, Shiobara R: Extended middle cranial fossa approaches to the clivus

and acoustic meatus, in Torrens M, Al-Mefty O, Kobayashi S (eds): Operative Skull
Base Surgery. New York: Churchill Livingstone, 1997, pp 263-278
12.Kawase T, Shiobara R, Toya S: Anterior transpetrosal-transtentorial approach for

sphenopetroclival meningiomas: Surgical method and results in 10 patients.
Neurosurgery 28:869-876, 1991
13.Kawase T, Toya S, Shiobara R, et al: Transpetrosal approach for aneurysms of the

lower basilar artery. J Neurosurg 63:857-861, 1985
14.Martin RG, Grant JL, Peace D, et al: Microsurgical relationships of the anterior
inferior cerebellar artery and the facial-vestibulocochlear nerve complex.
15.Matsushima T, Rhoton AL, Jr., de Oliveira E, et al: Microsurgical anatomy of the

veins of the posterior fossa. J Neurosurg 59:63-105, 1983
16.Parry RH: A case of tinnitus and vertigo treated by division of the auditory nerve.
J Laryngol 19:402-406, 1904
17.Post KD, Eisenberg MB, Catalano PJ: Hearing preservation in vestibular

schwannoma surgery: What factors iniuence outcome? J Neurosurg 83:191-196,
1995
18.Sekhar LN, Schessel DA, Bucur SD, et al: Partial labyrinthectomy petrous
apicectomy approach to neoplastic and vascular lesions of the petroclival area.
apicectomy approach to neoplastic and vascular lesions of the petroclival area.

19.Wilson-Pauwels L, Akesson EJ, Stewart PA: Glossopharyngeal nerve, in Wilson-

Pauwels L, Akesson EJ, Stewart PA (eds): Cranial Nerves. Anatomy and Clinical
Comments. Toronto: B.C. Decker, 1988, pp 114-123
About Barrow Neurological Institute
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The Middle Fossa Approach | Barrow Neurological Institute 14/06/21, 3:23 PM

The Middle Fossa Approach

Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital

The middle fossa approach, as popularized by William House, provides excellent

approach described by Kawase enhances the surgical exposure provided by this

Middle Fossa Approach

The suboccipital retrosigmoid and the translabyrinthine approaches can also be

three approaches (Table 1).

Relevant Anatomic Structures

PATIENT PORTALTRANSFER A PATIENTGET A SECOND OPINIONTHE BARROW

EducationGrand Rounds, Publications, & MediaBarrow QuarterlyVolume 16, No. 4,

The Middle Fossa

Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital

The middle fossa approach, as popularized by William House, provides excellent

Middle Fossa Approach

The suboccipital retrosigmoid and the translabyrinthine approaches can also be

Relevant Anatomic Structures

reaching the petrous apex is the goal.

A third of the craniotomy is positioned posterior and two-thirds of it anterior to the

Figure 5. Extradural exposure of important landmarks shown in surgical

Garcia-Ibañez Technique. This technique (Fig. 6B) relies on the important

Extended Middle Fossa Approach to the IAC and Clivus

Clinical Neurology. Boston: Little, Brown and Company, 1996, pp 271-291

4. Day JD, Fukushima T, Giannotta SL: Microanatomical study of the extradural

5. de Oliveira E, Tedeschi H, Rhoton AL, Jr., et al: Microsurgical anatomy of the

6. Fukushima T, Day JD: Manual of Skull Base Dissection. Pittsburgh: AF

10.Kanzaki J, Kawase T, Sano K, et al: A modi`ed extended middle cranial fossa

11.Kawase T, Shiobara R: Extended middle cranial fossa approaches to the clivus

12.Kawase T, Shiobara R, Toya S: Anterior transpetrosal-transtentorial approach for

13.Kawase T, Toya S, Shiobara R, et al: Transpetrosal approach for aneurysms of the

15.Matsushima T, Rhoton AL, Jr., de Oliveira E, et al: Microsurgical anatomy of the

17.Post KD, Eisenberg MB, Catalano PJ: Hearing preservation in vestibular

apicectomy approach to neoplastic and vascular lesions of the petroclival area.

19.Wilson-Pauwels L, Akesson EJ, Stewart PA: Glossopharyngeal nerve, in Wilson-

About Barrow Neurological Institute

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