Extended middle fossa approach: Quantitative analysis of petroclival exposure and surgical freedom as a function of successive temporal bone removal by using frameless stereotaxy

Object. Conventional wisdom regarding skull base surgery says that more extensive bone removal equals greater exposure. Few researchers have quantitatively examined this assertion, however. In this study the authors used a frameless stereotactic system to measure quantitatively the area of petroclival exposure and surgical freedom for manipulation of instruments with successive steps of temporal bone removal. Methods. With the aid of high-power magnification and a high-speed drill, 12 cadaveric specimens were dissected in four predetermined, successive bone removal steps: 1) removal of the Kawase triangle; 2) removal of the Glasscock triangle; 3) removal of the cochlea together with skeletonization of the anterior internal auditory canal; and 4) inferior displacement of the zygoma. Step 1 offered 62 ± 43 mm ² of exposed petroclival area, with 84 ± 69 mm² of surgical freedom; Step 2, 61 ± 22 and 76 ± 58 mm²; Step 3, 128 ± 47 and 109 ± 87 mm²; and Step 4, 135 ± 38 and 102 ± 69 mm², respectively. Conclusions. The middle fossa approach provided a means surgically to expose the petroclival area. When examined quantitatively by using a frameless stereotactic device, the authors determined that the removal of the cochlea and skeletonization of the anterior internal auditory canal (Step 3) provided the most significant increase in both exposure and surgical freedom. Removal of the zygoma improved neither exposure nor surgical freedom.