Middle Fossa

Infratemporal-Middle Cranial Fossa Approach

This technique, pioneered by Fisch [22] and further developed by Sekhar [23] and Schramm [24], provides excellent access to regions previously characterized by difficult dissection and poor exposure. The entire middle cranial fossa, from the petrous ridge to the lesser wing of the sphenoid, can be exposed (see Fig. l5.5). Patients who require this approach present with a wide variety of disease processes. Tumors may be benign or malignant, and may originate intracranially from dura or calvarial bone or extracranially from the soft tissues that occupy the subcranial area. Most common among the intracranial neoplasms that extend extracra-nially are meningioma, chordoma, chondroma and chondrosarcoma. Among the extracranial tumors that extend intracranially are schwannoma (often of the trigeminal nerve); parotid tumors, especially of the deep lobe; and squa-mous cell carcinomas from the paranasal sinuses, nasopharynx and temporal bone.

Surgical Steps

The approach is attained through a long incision, extending from the calvarial vertex to in front of the ear, then curving posteriorly under the lobule and into the neck, similar to the modified Blair incision for parotidectomy. The cutaneous flap is elevated anteriorly to a point from

Fig. 15.5. Infratemporal fossa/middle cranial fossa approach. Removal of zygomatic arch (and possibly mandibular condylec-tomy), allowing access for craniotomy.
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