Space, or the lack of it, always seems to be the problem here. Certainly, at the beginning of most procedures, visualization of the important structures is difficult.
The principle of the approach is similar to the translabyrinthine route, but combined with a temporal craniotomy and division of the tento-rium all the way down to the tentorial hiatus.
The procedure starts, therefore, with the patient in a park-bench position. Diuretics, antibiotics and anticonvulsants should be given. A question-mark-shaped incision is made, extending from just above the zygomatic process of the temporal bone down to below the mastoid process. The skin flap is reflected, leaving the temporalis fascia intact and extended all the way forward to the external auditory meatus.
Incisions are then made to elevate the tem-poralis muscle forwards on its blood supply, and to reflect the sub-occipital muscles inferi-orly. This then allows a posterior fossa craniotomy to expose the straight and sigmoid sinuses, and a temporal craniotomy to expose the temporal lobe above the straight sinus and above the petrous bone. Great care must be taken to avoid injury to the sinuses.
The translabyrinthine exposure is then performed as previously described (see chapter on cerebellopontine angle tumors). This should be taken as far forward as possible and as low as possible towards the jugular bulb, to expose as much of the presigmoid dura as can be achieved. The exposure must include the undersurface of the temporal dura. Clearly, the
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