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the middle cranial fossa approach

Samy, Ravi N.

Current Opinion in Otolaryngology & Head and Neck Surgery: October 2018 - Volume 26 - Issue 5 - p 275
doi: 10.1097/MOO.0000000000000483

Division of Otology/Neurotology, Department of Otolaryngology, University of Cincinnati/Cincinnati Children's Hospital Medical Center, UC Gardner Neuroscience Institute, Cincinnati, Ohio, USA

Correspondence to Ravi N. Samy, MD, FACS, Chief, Division of Otology/Neurotology, Department of Otolaryngology, University of Cincinnati/Cincinnati Children's Hospital Medical Center, UC Gardner Neuroscience Institute, 231 Albert Sabin Way, Cincinnati, OH 45267-0528. Tel: +1 513 475 8458; e-mail:

It has been a pleasure and an honor reading all of the articles on the middle cranial fossa (MCF) approach for this edition of the journal. All of the senior authors enlisted to write about the MCF approach have extensive experience with arguably the hardest approach to master in all of otology and neurotology. I fondly remember my days as a fellow at the University of Iowa (2000–2002). It seemed as though I spent the entire 1st year of my fellowship just attempting to understand how to place the MCF retractor properly and then dealing with the bleeding, while safely retracting the temporal lobe (and all this before even trying to understanding the anatomy of the MCF floor!). I hope that the readers glean the tips and tricks that each senior author has learned over many years of laborious dissection in the temporal bone lab as well as in the operating theater. The MCF approach is ideal for a variety of intradural or extradural diseases within the temporal bone or surrounding regions.

The first article, by Drs Wilkinson and Peng (pp. 276–279), discusses pearls to improve the outcomes of the MCF approach in acoustic neuroma surgery. This includes removing the retractor blade after opening the internal auditory canal (IAC) and allowing for egress of cerebrospinal fluid. The removal of the blade allows one to work much easier in the IAC or cerebellopontine angle, while performing tumor removal and preserving facial nerve and cochlear nerve function, which are incredibly challenging feats of surgical prowess. The second article, by Dr Hansen (pp. 280–285), elucidates how to decompress the facial nerve via the MCF approach. Although this approach is not used as often as it one was for Bell's palsy (due to the improved utilization of corticosteroids), the MCF approach, either alone or in combination with the transmastoid approach, is still a valuable procedure for the practicing neurotologist in dealing with temporal bone trauma and facial nerve injury. The final two articles, one by my team and the other by Dr Gluth (pp. 293–301), discuss the uses of the extended MCF and/or combined approaches to tackle such challenging diseases such as petroclival meningomas or vascular lesions (e.g., basilar artery aneurysm or brainstem cavernoma).

Finally, although this journal focuses on the newest updates and current literature regarding the MCF approach, it behooves the reader to learn more about the history of the MCF approach. Monfared et al.[1] elegantly discuss the early days of the MCF approach (which begin in the late 1800s to treat temporal lobe infections and trigeminal neuralgia) as well as the seminal work by Dr William F. House on the use of the MCF approach to treat pathology of the IAC (initially used for cochlear otosclerosis in 1959!).

I hope the readers of this issue enjoy and learn from the articles as much as I have.

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Conflicts of interest

There are no conflicts of interest.

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1. Monfared A, Mudry A, Jackler R. The history of the middle cranial fossa approach to the cerebellopontine angle. Otol Neurotol 2010; 31:691–696.
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