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Neurosurgery
Preauricular Transzygomatic Subtemporal Approach to the Sk
Built from Feldman — Neurosurgical Operative Atlas: Neuro-Oncology
What’s inside
12 sections · 69 slides
Overview
- What you will learn
The Target Region
Why the middle cranial and infratemporal fossae are so hard to reach
- First, the words: what are these two fossae?
- Why surgery here is genuinely difficult
- What lesions turn up in this region
- What the approach reaches once the bone is removed
Patient Selection
When to operate, and who needs to be in the room
- Tumor spread across the two fossae
- Surgery is the mainstay, but the bar is high
- Why it takes a whole team
- Choosing preauricular over other routes
Preoperative Assessment
Cranial-nerve exam first, then imaging
- Start by mapping the existing deficits
- Trigeminal nerve (CN V): the chewing nerve
- Lower nerves (IX, X, XII): speech and swallowing
- Protecting the airway before it fails
- Accessory nerve (CN XI) and hearing
- Preoperative imaging: the surgical map
Relevant Anatomy
Three axes, two bony frameworks, and the soft tissue between
- Think of the field in three axes
- The lateral (outer) osseous framework
- The medial (deep) osseous framework
- The soft tissue and vascular contents
- Anatomical corridors: how removing bone helps
- Tailoring the craniotomy to the goal
Positioning and Set-Up
Securing the airway, the head, and the monitoring
- Supine positioning with three-point head fixation
- Airway and head fixation
- Intraoperative monitoring and prophylaxis
- Hair and incision preparation
Exposing the Osseous Framework
Lifting soft tissue while protecting the facial nerve
- The coronal incision and scalp flap
- Scalp flap elevated to the supraorbital rim
- Freeing the supraorbital bundle and temporalis
- Incising the deep temporal fascia
- The two fascial layers and the facial nerve
- Temporalis muscle detached and rotated inferiorly
- Exposure of the orbitozygomatic complex
- Skeletonizing the zygoma and orbit
Module 1: Superolateral Orbit
Removing orbital wall to see the medial middle fossa
- The three modules, and why they are 'modular'
- What the superolateral orbit module adds
- Making and removing the orbital osteotomies
- Inside the dura: relaxing and reaching the brainstem
- Going medial to the tentorial notch
Module 2: Transzygomatic
Removing the cheekbone to gain superior-inferior reach
- What removing the zygoma buys
- Exposing the middle fossa floor and its foramina
- The angles that tell the foramina apart
- Exposing the horizontal petrous carotid artery
- Inside the dura: the transtentorial extension
Glenoid Fossa and Combined
Removing the jaw joint, then assembling the full approach
- Removal of the orbitozygomatic complex
- The glenoid fossa module: reaching the vertical carotid
- The combined module: the full orbitozygomatic approach
Postoperative Management
Monitoring, and the complications to anticipate
- The first hours after surgery
- Intracranial complications
- Orbital and cranial-nerve complications
- Trismus and cosmetic sequelae
Summary and Self-Test
- Modular philosophy
- Key takeaways
- Why is the temporalis muscle dissected off the skull and pedicled inferiorly rather than simply cut across?
- How does the surgeon protect the facial nerve while exposing the zygomatic arch?
- References (1/2)
- References (2/2)
- Neurosurgical Operative Atlas: Neuro-Oncology