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Transmastoid Retrosigmoid Approach to the Cerebellopontine Angle: Surgical Technique

Abolfotoh, Mohammad MD, PhD*,‡; Dunn, Ian F. MD*; Al-Mefty, Ossama MD*

doi: 10.1227/NEU.0b013e31827fc87b
Operative Technique

BACKGROUND: The traditional suboccipital craniotomy in the retrosigmoid approach gives limited exposure to the cerebellopontine angle (CPA) structures and necessitates cerebellar retraction, whereas the addition of drilling of the mastoid process with reflection of venous sinuses offers wider exposure of the CPA and avoids cerebellar retraction. We describe the details of the surgical technique and provide radiological measurements substantiating the advantages of this approach.

OBJECTIVE: To validate the usefulness of partial mastoidectomy in the retrosigmoid approach and to evaluate the complications of this maneuver.

METHODS: Radiological CPA measurements on computed tomography bone window films were made on the last consecutive 20 patients who underwent CPA surgery via the transmastoid retrosigmoid approach. We measured the distance and angle of work by this approach and compared the measurements with those using the traditional retrosigmoid approach if that would have been used in each case. We also reviewed 432 patients from the records of the senior author to evaluate possible complications of this approach.

RESULTS: The mean working distance for the transmastoid approach was 23.06 mm, whereas the working distance in the traditional approach was 46.44 mm. The mean increase in the angle of work after drilling of the mastoid was 25.39 degrees, and the simple average of increased distance in lateral exposure was 26.66 mm.

CONCLUSION: The transmastoid retrosigmoid approach increases the exposure and gives better access to the CPA targets. This approach alleviates cerebellar retraction, facilitates surgery in the supine position, promotes the use of the endoscope, and is associated with negligible complications.

ABBREVIATIONS: CPA, cerebellopontine angle

IAM, internal auditory meatus

LSS, lateral edge of sigmoid sulcus

OM, occipitomastoid

P-IAM, posterior wall of the internal auditory meatus

*Neurosurgery Department, Brigham and Women's Hospital, Harvard Medical School, Boston Massachusetts;

Neurosurgery Department, Ain Shams University, Cairo, Egypt

Correspondence: Mohamad Abolfotoh, MD, Department of Neurosurgery, 15 Francis Street, Boston MA, 02115. E-mail:,

Received May 18, 2012

Accepted November 7, 2012

Copyright © by the Congress of Neurological Surgeons