Retrosigmoid Approach

Historically, this approach was favored for the removal of acoustic neuromas. However, cere-bellar retraction, which in large lesions may be considerable, and difficult access to the lateral internal auditory canal have reduced the utility of the approach in favor of the translabyrinthine exposure in the majority of patients. Furthermore, headache appears to be more persistent than after a translabyrinthine approach. We use the retrosigmoid approach in an attempt to preserve hearing in patients with socially useful hearing (Gardner-Robertson Grade I). We also use this approach in patients with Grade II hearing accompanied by contralateral hearing loss.

The patient is positioned supine with the head turned 80° to the contralateral side, with the neck flexed and the ear uppermost. Brain relaxation is achieved by inducing an osmotic diuresis during exposure. A curvilinear incision commencing posterior to the auricle and descending 2 cm behind and below the mastoid process is used. The sub-occipital muscles and fascia are divided in the line of the incision in separate layers. Care is taken to avoid cutting the occipital artery. The periosteum is then retracted to expose the mastoid tip and the superior nuchal line. A sub-occipital, retrosig-moid craniectomy is performed, exposing the transverse and sigmoid sinuses. The latter is followed inferiorly for about 4 cm. The foramen

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