Middle Cranial Fossa Approach: Pathologies and Complications

Introduction: The middle cranial fossa approach is an established surgical technique used mainly for vestibular schwannoma resection. We present our institution's experience with the approach, including the range of pathologies treated and the morbidity associated with it.

Methods: The electronic records of all the patients that have undergone a craniotomy with middle fossa approach in our institution from 2005 to 2010 were retrospectively reviewed.

Results: Forty-one patients (22 men) with a mean age of 51.7 years (range, 21–74 years) underwent middle fossa approaches in our institution. Immediately preoperatively 36 patients (88%) underwent lumbar drain placement for brain relaxation. Eight patients additionally had orbitozygomatic craniotomies and seven had extended middle fossa approaches (with drilling of the petrous apex) to enhance exposure. Pathologies treated include vestibular schwannomas, tegmen tympani defects with spontaneous CSF leaks, petroclival meningiomas, middle fossa meningiomas, nasopharyngeal carcinomas, trigeminal schwannomas, chordomas, giant pituitary adenoma with cavernous sinus extension, myopericytoma, cholesterol granuloma, synovial sarcoma, temporal bone fracture with facial nerve compression, basilar apex aneurysm, facial nerve schwannoma, and epidermoid. There were no postoperative CSF leaks or GSPN injuries. Two patients had complications related to the postoperative approach, with one developing an epidural hematoma necessitating reoperation and evacuation, and one requiring laminectomy for removal of a retained lumbar drain fragment. The mean hospital stay was 7.1 days (range, 3–23 days).

Conclusions: The middle fossa approach, with orbitozygomatic extension or drilling of the petrous apex, when needed, can be used to provide exposure to a wide range of pathologies with acceptable morbidity and complication rate.