Neurosurgery 1992-98 posterior petrosectomy, for lesions of the

September 1993, Volume 33, Number 3 cerebellopontine angle and petroclival area.
461 Transpetrosal Approach: Surgical Anatomy and Combining either of these procedures with existing
Technique conventional techniques accurately describes all
Surgical Anatomy previously reported transpetrosal operations
(Table 2). Renaming transpetrosal operations in this
AUTHOR(S): Miller, Christopher G., M.D.; fashion will greatly facilitate understanding of the
van Loveren, Harry R., M.D.; operations and eliminate confusion over
Keller, Jeffrey T., Ph.D.; Pensak, Myles, M.D.; El- nomenclature.
Kalliny, Magdy, M.D.; Tew, John M., Jr., M.D. In addition, previous reports have lacked the
detailed description of surgical anatomy and
Department of Neurosurgery, University of technique needed to perform these transpetrosal
Cincinnati College of Medicine and Mayfield procedures. In this report, we describe a step-by-step
Neurological Institute, Cincinnati, Ohio method for each of these two approaches that allows
excellent exposure while sparing nearby vital
Neurosurgery 33; 461-469, 1993 structures, and that provides the detail needed to
perform transpetrosal surgery safely.
ABSTRACT: TRANSPETROSAL OPERATIONS
HAVE been shown to offer distinct advantages over ANTERIOR PETROSECTOMY
traditional operations in approaching lesions of the Positioning and opening
petroclival area. Confusion about these approaches The anterior petrosectomy is performed with the
exists due to the variety of names given to these patient supine and the shoulder elevated; the head
procedures and the lack of detailed descriptions should be horizontal. Spinal drainage improves
needed to perform them. After extensive review of exposure and helps postoperatively in preventing
the literature, we have determined that all cerebrospinal fluid leakage. The anterior
transpetrosal techniques fall into one of two petrosectomy is performed through a subtemporal
categories: anterior petrosectomy or posterior craniotomy. A zygomatic osteotomy helps improve

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petrosectomy. Combining one of these procedures exposure but is not always necessary. We prefer an
with existing conventional procedures accurately inverted "question-mark" incision that preserves the
describes all existing transpetrosal operations and main trunk of the superficial temporal artery (Fig. 1).
eliminates confusion over nomenclature. In addition,
through a series of cadaveric dissections and Step 1: Petrous carotid artery
operative experience, we have detailed each of these The middle meningeal artery is identified
procedures as a series of steps that will enable the extradurally at the foramen spinosum and sacrificed.
surgeon to understand the unfamiliar anatomy of the Medially, the foramen ovale and both the lesser
temporal bone and to perform these transpetrosal superficial petrosal nerve and the greater superficial
techniques. petrosal nerve (GSPN) are identified and sacrificed to
prevent traction injury to the facial nerve. The petrous
KEY WORDS: Anterior petrosectomy; carotid artery lies within the posterolateral triangle
Petrous bone; Posterior petrosectomy; (Glasscock's triangle) and is identified by drilling
Surgical technique; Transpetrosal technique along the course of the GSPN with a diamond drill
(32)
(Figs. 2 and 3A).
Tumors of the cranial base and vascular lesions in the
petroclival region are notoriously difficult to Step 2: Geniculate ganglion
approach surgically. Transpetrosal approaches offer The GSPN is followed posteriorly from the facial
distinct advantages over traditional approaches to the hiatus to the geniculate ganglion (GG). Although it is
petroclival area (1,8-10,12-14,17,19,20,23-28,30-31). These not always necessary, opening the epitympanum can
approaches were initially used to improve access to facilitate identification of the GG. The epitympanum
the cerebellopontine angle, mainly for acoustic lies posterolateral to the GG. When opened, the
neuromas (2-5,7,11,15-16,18,21,29), but have subsequently tympanic portion of the facial nerve is easily
been refined to expand exposure of the basilar artery, identified and can be followed back to the GG (Fig. 3,
anterior brain stem, and clivus for a variety of lesions A-C).
(1,8-10,12-13,19,24-28)
. However, the plethora of titles and
descriptions applied to transpetrosal approaches can Step 3: Superior semicircular canal
be confusing. A partial list of the titles given to The superior semicircular canal (SSC) lies beneath
transpetrosal operations appears in Table 1. Despite the arcuate eminence, although the precise position of
the varied nomenclature, these operations simply the canal is frequently difficult to appreciate. The
consist of conventional procedures combined with SSC lies perpendicular to the petrous ridge and forms
one of two types of transpetrosal procedure. an angle of approximately 120 degrees with the
At the University of Cincinnati Medical Center, we GSPN. The meatal plane (Fig. 2B), the flat area of
have determined that all previously described bone that overlies the internal auditory canal, lies in
transpetrosal techniques can be divided into two basic the angle between the GG and the arcuate eminence
(6)
types: anterior petrosectomy, for lesions of the . In locating the bony SSC, drilling begins anterior
petrous apex and superior half of the clivus, and to the arcuate eminence in the soft bone of the meatal
plane and continues posteriorly until the compact the temporal lobe. The tentorium is opened posterior
bone of the anterior border of the bony SSC is to the trochlear nerve and incised laterally to the
identified (Fig. 3B) (5). superior petrosal sinus. A second incision extends
perpendicularly from the middle fossa incision across
Step 4: Internal auditory canal the superior petrosal sinus (sacrificed) and inferiorly
The internal auditory canal (IAC) lies beneath the into the posterior fossa (Fig. 3, C and F).
meatal plane and forms an angle of approximately 60
degrees with the SSC (6). Its location can also be POSTERIOR PETROSECTOMY
judged by bisecting the angle between the course of Position and opening
the GSPN and the SSC. The IAC is exposed in the The posterior petrosectomy is performed with the
meatal plane anterior to the SSC along the expected patient in the lateral position with the head rotated
course of the canal (Fig. 3B). Once the midportion of horizontally to minimize torsion to the contralateral
the IAC is identified, the exposure is broadened and jugular vein. Spinal drainage aids exposure and is
extended medially to expose the internal auditory crucial in preventing postoperative cerebrospinal
meatus and posterior fossa dura. fluid leakage. We use an inverted J-shaped incision
that extends anteriorly and posteriorly as needed
Step 5: Bill's bar (Fig. 4A). A free bone flap is raised using four burr
The labyrinthine segment of the facial nerve holes (Fig. 4B) located at the junction of the inferior
(Fig. 3C) is the portion between the GG and the temporal line and parietomastoid suture, asterion, and
lateral end of the IAC (fundus). This segment runs both sides of the superior nuchal line.
between the cochlea anteriorly and the ampulla of the The posterior petrosectomy is derived from the
SSC posteriorly. As the facial and superior vestibular basic mastoidectomy that has long been performed by
nerves exit the IAC, they are separated by a bony otolaryngologists. The following steps represent a
spicule, the vertical crest, known as Bill's bar. Bill's distillation of the mastoidectomy as described by
bar is an important landmark for identification of the Nelson (22) and Fisch and Mattox (6) to optimize
cochlea, and it is exposed by following the IAC neurosurgical exposure of the petroclival region.
laterally (Fig. 3D). To minimize risk to the cochlea,

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facial nerve, and ampulla of the SSC, only the tip of Step 1: Decortication
Bill's bar needs to be exposed. All of the cortical bone overlying the mastoid is
removed superiorly to the supramastoidal crest
Step 6: Cochlea (infratemporal line) (Fig. 4B), inferiorly into the
The cochlea lies largely beneath the GG. However, mastoid tip, and anteriorly to the posterior wall of the
superior portions of the basal and middle turns of the external auditory canal (posterior canal wall). The
cochlea extend into the corner between the GG and compact plate of the sigmoid (sigmoid plate) and
the IAC (Figs. 2A and 3C). The cochlea represents sinodural angle are delineated (Fig. 5A).
the posterolateral limit of bony exposure through
Kawase's triangle. It need not always be exposed, but Step 2: Antrum
for maximal exposure, the cochlea must be located. The antrum is identified by following the middle
The bone surrounding the membranous cochlea is fossa plate and posterior canal wall through the
formed by the otic capsule, which is compact and remaining superior mastoid air cells. The antrum is
always devoid of pneumatization. The otic capsule is located posterior to the spine of Henle deep in
distinctly dense and lighter in color than the Macewen's triangle (Fig. 4B). On close inspection,
remaining bone in the petrous apex. Locating the the incus can be seen through the antrum. Medially,
cochlea within the otic capsule can be difficult. We the cortical floor of the antrum is the lateral
determined that a line extending from the tip of Bill's semicircular canal (LSC). To prevent hearing loss, the
bar to the junction of the petrous carotid artery and buttress should be carefully preserved (Fig. 5E).
the mandibular branch of the trigeminal nerve passes
through the superior portion of the basal turn of the Step 3: Digastric ridge
cochlea. The shadow (blue line) of the cochlea can be Inferior mastoid air cells are removed to expose the
seen by gently removing bone along this line cortical indentation of the digastric muscle called the
(Figs. 2A, 3C, and 7A). digastric ridge. Anteriorly, the digastric ridge leads to
the facial nerve at the stylomastoid foramen (Fig. 5).
Step 7: Kawase's triangle
The remaining bone that lies between the third Step 4: Lateral semicircular canal
branch of the facial nerve anteriorly, the carotid The LSC, already partially exposed anteriorly, is
artery and cochlea laterally, and the SSC and IAC followed posteriorly through the remaining mastoid
posteriorly can now be safely removed (Fig. 3D). air cells (Fig. 5B). Exposure of the inferior surface of
This portion of the petrous apex is known as the LSC is unnecessary and risks injury to the
Kawase's triangle (Fig. 2B). The exposure can be external genu of the facial nerve.
continued inferiorly along the posterior fossa dura to
the inferior petrosal sinus (Fig. 3C). Step 5: Posterior semicircular canal
The posterior semicircular canal (PSC) is bisected
Dural opening by the LSC and runs approximately parallel to the
The middle fossa dura is opened inferiorly along posterior fossa plate. The PSC originates inferiorly,
just medial to the facial nerve below the external petrosal sinus. This incision will likely divide the
genu, and ends superiorly in the common crus with endolymphatic sac; however, to preserve hearing,
the SSC. It is located between the LSC and the care should be taken to spare the endolymphatic duct
posterior fossa plate. As the LSC is exposed located posterior to the inferior portion of the PSC. A
posteriorly, the PSC will be identified crossing it second limb extends superiorly across the posterior
(Fig. 5, C-E). temporal lobe and may cross the vein of Labbé. The
third limb, perpendicular to the first and second,
Step 6: Fallopian canal extends anteriorly beneath the inferior temporal lobe.
The vertical segment (i.e., the vertical, mastoid, or After division of the superior petrosal sinus, the
descending segment) of the facial nerve runs between tentorium is incised posterior to the trochlear nerve
the external genu at the inferior edge of the LSC to (Fig. 6B). The temporal lobe is gently retracted with
the stylomastoid foramen located just anterior to the the retractor blade placed beneath the tentorium to
digastric ridge (Fig. 5F). The facial nerve is protect the cortical surface of the temporal lobe (25). If
embedded in the thick cortical bone of the fallopian needed, the vein of Labbé can be partly mobilized by
canal. By removing the remaining inferior mastoid dissecting it from the cortical surface (1). To continue
and retrofacial air cells between the antrum and the exposure inferiorly, an opening may also be made
digastric ridge, the fallopian canal is exposed posterior to the sigmoid sinus, as is standard for a
(Fig. 5, C and D). There is no need to skeletonize the suboccipital retrosigmoid exposure.
facial nerve unless improved exposure of the jugular
foramen is needed. CLOSURE FOR ANTERIOR AND POSTERIOR
PETROSECTOMY
Step 7: Jugular bulb To prevent cerebrospinal fluid leakage, the defect
The sigmoid plate is followed inferiorly through created in the anterior petrous ridge should be filled
the infralabyrinthine air cells to expose the jugular with muscle or fascia and held in place with fibrin
bulb (Fig. 5, E and F). Generally, only the beginning thrombin glue. If opened, the epitympanum should be
of the jugular bulb is exposed during posterior covered with bone. In the posterior petrosectomy, the
petrosectomy. However, if needed, exposure of the antrum must also be sealed with a layer of fascia and

Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
jugular bulb and foramen can usually be improved by fibrin thrombin glue. The dura is reapproximated.
skeletonizing the facial nerve. The large space created by the posterior petrosectomy
is filled with a piece of autologous fat. Additionally,
Step 8: Superior semicircular canal a posterior temporal muscle flap can also help cover
The SSC is oriented perpendicular to the LSC and the posterior petrosectomy defect. Spinal drainage
approximately parallel to the floor (Fig. 5C). It continues for 3 to 5 days postoperatively.
originates deep to the LSC and arches posteriorly to
join with the PSC at the common crus (Fig. 5F). The DISCUSSION
SSC is exposed by following the sinodural angle Anterior petrosectomy with a subtemporal
through the supralabyrinthine air cells and through transtentorial dural opening provides access to the
the dense cortical bone (hard angle) located along the upper half of the clivus. The anterior petrosectomy
petrous ridge at the juncture of the posterior and provides a corridor to the posterior fossa between the
middle fossa plates (Fig. 5D). Exposure may be internal carotid artery, trigeminal root, and facial
facilitated by removing the middle fossa plate and nerve (Figs. 3C and 7A). Access to the posterior face
identifying the arcuate eminence from a more of the petrous bone is limited to the area between the
subtemporal trajectory (Step 9) (Fig. 5E). IAC, trigeminal nerve, and inferior petrosal sinus.
Sacrifice of the cochlea is rarely necessary because it
Step 9: Trautmann's triangle adds little or no exposure to the posterior fossa.
Trautmann's triangle is the area bordered by the However, cochlear sacrifice will improve access to
posterior fossa dura, middle fossa dura, and posterior the lateral end of the IAC, medial wall of the
canal wall; the triangle represents much of the area tympanic cavity, and jugular foramen. Additional
resected in the posterior petrosectomy. The middle exposure of the posterior fossa can be obtained by
fossa plate, posterior fossa plate, and sigmoid plate sacrifice of the labyrinth and extension of the anterior
have been left in place to guide the dissection and to petrosectomy posterior to the SSC, as originally
protect the dura and sinuses. Removing these plates described for the extended middle fossa approach (15,
27,28)
completes the petrosectomy (Fig. 5E). In addition, . However, lesions posterior to the IAC are
the medial portion of the petrous ridge remains deep frequently better approached through a posterior
to the SSC and PSC. The size of the ridge varies from petrosectomy or a suboccipital craniotomy without
insignificant to large and can be drilled off as needed sacrifice of hearing.
(Fig. 5D). Following the ridge forward leads across The steps for the anterior petrosectomy provide the
the IAC into the petrous apex. maximal exposure obtainable without sacrificing vital
structures. However, it is technically difficult and
Dural opening carries considerable risk to the facial nerve and
The dural opening for the posterior petrosectomy hearing. Many lesions can be adequately exposed
has three limbs (Fig. 6A). The first limb is the through a slightly smaller anterior petrosectomy with
presigmoid incision described by Al-Mefty et al. (1) much less risk by skipping Steps 2, 5, and 6. In this
that extends from the jugular bulb to the superior case, lateral exposure during Step 4 continues along
the IAC only as far as the otic capsule. This illustration, Alexis Rostoker for medical
modification compromises only the extreme lateral transcription, and Mary Kemper Chanin for editorial
inferior portions of the posterior fossa exposure. assistance.
Posterior petrosectomy, combined with a
suboccipital-subtemporal craniotomy, provides Received, February 3, 1993.
excellent access across the posterior face of the Accepted, April 6, 1993.
petrous bone, the upper two thirds of the clivus, Reprint requests: Christopher G. Miller, M.D.,
anterior cerebellum, and brain stem (Fig. 7). Editorial Office, Department of Neurosurgery,
Exposure is approximately at the level (coronal University of Cincinnati Medical Center, 231
plane) of the origin of cranial nerves V and VII-X. Bethesda Avenue, Cincinnati, OH 45267-0515.
Inferiorly, the anterior lip of the foramen magnum
can be exposed. However, the lower ipsilateral REFERENCES: (1-32)
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11. Hitselberger WE, House WF: A combined
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ACKNOWLEDGMENTS 15. King TI: Combined translabyrinthine-
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Figure 1. Position and skin incision used for
subtemporal craniotomy, zygomatic osteotomy, and
anterior petrosectomy.

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 Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Figure 2. A, illustration of significant neurovascular
structures usually obscured beneath the bone of the
middle fossa and petrous ridge. B, illustration of
Glasscock's and Kawase's triangles on the floor of the
middle fossa. The boundaries of Glasscock's triangle
are laterally, a line from the foramen spinosum
toward the arcuate eminence ending at the facial
hiatus; medially, the GSPN; and at the base, the
mandibular division of the trigeminal nerve. The
boundaries of Kawase's triangle are laterally, the
GSPN; medially, the petrous ridge; and at the base,
the arcuate eminence. The meatal plane is the flat area
of bone in the posterior aspect of Kawase's triangle
overlying the IAC. Key: AE, arcuate eminence; Ca,
carotid artery; Coc, cochlea; Epi, epitympanum; FH,
facial hiatus; FSp, foramen spinosum; FOv, foramen
ovale; GG, geniculate ganglion; GSPN, greater
superficial petrosal nerve; IAC, internal auditory
canal; LSC, lateral semicircular canal; LSPN, lesser
superficial petrosal nerve; PSC, posterior
semicircular canal; SSC, superior semicircular canal;
V, fifth cranial nerve.
 Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Figure 3. Surgical steps of the anterior petrosectomy:
A, the carotid artery is exposed in Glasscock's
triangle. With a diamond drill, the residual GSPN is
followed toward the GG. B, the GG is unroofed; after
identification of the SSC beneath the arcuate
eminence, the IAC is exposed. C, photomicroscopic
view of the GG, the labyrinthine and canalicular
segments of the facial nerve, the superior vestibular
nerve separated from the facial nerve by Bill's bar,
and the cochlea; the epitympanum has been opened in
this dissection to expose the tympanic segment of the
facial nerve. D, the cochlea is exposed by "blue
lining" the cortical bone of the basal turn; the
remaining bone of Kawase's triangle is removed to
complete the anterior petrosectomy. E,
photomicroscopic view of the intradural exposure of
both the middle and posterior fossae achieved with
the anterior petrosectomy. F, illustration of the
intradural exposure of both the middle and posterior
fossae achieved with the anterior petrosectomy.
AICA, anterior inferior cerebellar artery; Amp SSC,
ampulla of the superior semicircular canal; BA,
basilar artery; BB, Bill's bar; Ca, carotid artery; Coc,
cochlea; Epi, epitympanum; GG, geniculate
ganglion; IAC, internal auditory canal; IPS, inferior
petrosal sinus; Lab, LS, labyrinthine segment of the
facial nerve; PCA, posterior cerebral artery; PFD,
posterior fossa dura; PV, petrosal vein; SCA, superior
cerebellar artery; SSC, superior semicircular canal;
SPS, superior petrosal sinus; Tent, tentorium
cerebelli; Tym, tympanic segment of the facial nerve;
III, IV, V, VII, VIII--third, fourth, fifth, seventh, and
eighth cranial nerves, respectively.
 Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Figure 4. A, position and skin incision for the
posterior (--) and the combined anterior-posterior (- -
-) petrosectomies. B, bony landmarks utilized to
identify the underlying sigmoid and transverse
sinuses for appropriate placement of burr holes for
craniotomy
 Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Figure 5. Surgical steps of the posterior
petrosectomy: A, decortication of the mastoid with
exposure of the antrum and digastric ridge; the high-
speed air drill is manufactured by the Midas Rex
Institute, Inc., (Fort Worth, TX). B, the LSC is
exposed; drilling continues inferiorly between the
LSC and the digastric ridge to identify the fallopian
canal. C, exposure of the labyrinth, LSC, PSC, and
SSC. D, drilling of residual bone medial to the PSC.
E, exposure of the jugular bulb after removing the
remaining bone of Trautmann's triangle. F, structures
of the labyrinth, middle ear, and facial nerve. A,
antrum; AE, arcuate eminence; But, buttress; Crus,
common crus; DR, digastric ridge; EAC, external
auditory canal; FC, fallopian canal; FN, facial nerve;
I, incus; JB, jugular bulb; LSC, lateral semicircular
canal; M, malleus; MFD, middle fossa dura; MFP,
middle fossa plate; MTip, mastoid tip; PCW,
posterior canal wall; PFD, posterior fossa dura; PR,
petrous ridge; PSC, posterior semicircular canal;
SDA, sinodural angle; SH, spine of Henle; Sig,
sigmoid sinus; SmF, stylomastoid foramen; SPI,
sigmoid plate; SPS, superior petrosal sinus; SSC,
superior semicircular canal.
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Figure 6. Dural incisions (A) and tentorial incision
(B) in the posterior petrosectomy. Sig, sigmoid sinus;
SPS, superior petrosal sinus; Tent, tentorium
cerebelli; IV, fourth cranial nerve.
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Figure 7. Intradural exposure achieved with a
combined anterior-posterior petrosectomy. The
surgical perspectives shown are through the middle
fossa (A) and the posterior fossa (B). AICA, arterior
inferior cerebellar artery; Ca, carotid artery; Coc,
cochlea; FSp, foramen spinosum; GG, geniculate
ganglion; lA, labyrinthine artery; IPS, inferior
petrosal sinus; LSC, lateral semicircular canal; PICA,
posterior inferior cerebellar artery; PSC, posterior
semicircular canal; SSC, superior semicircular canal;
Tent, tentorium cerebelli; VA, vertebral artery; V, VI,
VII, VIII, IX, X, XI, XII--fifth through the twelfth
cranial nerves, respectively.
Table 1. Partial List of Names Given to Operations
That Are Variations of Transpetrosal Procedures

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Table 2. Examples of Renaming Transpetrosal