OBJECTIVE

The objective of neurotologic skull base surgery is exposure of the skull base through precise management of the temporal bone. In subsequent chapters, procedures are presented that accomplish ample surgical exposure and minimize brain retraction in posterior, medial, and lateral skull base lesions.

The modern era of neurotologic transtemporal skull base surgery began in 1961, when House introduced the operating microscope and multidisciplinary surgery for removal of acoustic neuromas. The conceptual advantage of this transtemporal technique was a wide exposure of the lesion with substantially less cerebellar retraction than the techniques available at that time, in addition to direct facial nerve preservation. With its low mortality rate and enhanced facial nerve preservation rate, House established the translabyrinthine procedure as a technique with which all other microsurgical approaches to the cerebellopontine angle are compared.¹ The emphasis on functional preservation has increased over the years from the initial enthusiasm with ablative skull base approaches.^2,3 As surgeons and patients are demanding better outcomes, such strategies as the fallopian bridge technique⁴ to avoid facial nerve mobilization, partial labyrinthine occlusion to preserve hearing,^5–7 and endoscopic strategies⁸ to minimize incisions have decreased the morbidity of surgery.

Neurotologic skull base surgery includes various techniques that permit the surgeon to tailor the procedure to a particular patient’s pathology and physiologic status. An array of neurotologic procedures provide safe exposure of the midbrain, clivus, cerebellopontine angle, vertebrobasilar junction, petrous apex, and infratemporal fossa. The modern skull base surgeon has an expanding armamentarium of treatments, including surgery, stereotactic radiosurgery, and advanced imaging. New strategies combining observation, surgery, and stereotactic radiation are part of modern patient management. This chapter presents an anatomic framework for organizing and planning transtemporal neurotologic skull base approaches. In addition, the difficulties of terminology and classification of approaches are discussed. The emphasis is on anatomic descriptions rather than eponyms.

Figure 43-1 presents an organizational framework for transtemporal surgery based on management of the otic capsule. The otic capsule is selected as the organizational center based on its function and location. Functionally, anatomic preservation of the otic capsule is the requirement for preservation of audiovestibular function (although exceptions to this principle are developing). Anatomically, the paired petrous pyramids encompass the center of lateral skull base exposure. The approaches presented in Figure 43-1 can be used individually; however, in certain cases, combinations of these approaches offer the ideal exposure.

FIGURE 43-1

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