Temporal craniotomy for surgical access to the infratemporal fossa

Abstract

We propose a surgical approach for select patients that minimizes morbidity while allowing gross total resection of lesions in the anterior portion of the infratemporal fossa. The approach we describe is an extradural approach through a subtemporal craniectomy or craniotomy with the possible addition of a zygomatic osteotomy. Lesions that have a well-defined capsule and a texture that permits manipulation are ideal for this less invasive approach. We retrospectively reviewed six cases from the primary author (C.B.H.) using a temporal craniectomy or craniotomy alone to resect lesions in the infratemporal fossa. All six cases had good clinical outcomes with no unexpected neurological deficits while achieving gross total resections. The only complication included one cerebrospinal fluid leak that was sealed endoscopically. For select lesions, a less morbid surgical approach via an extradural window through a subtemporal craniectomy or small craniotomy may be preferable to transfacial approaches. Adjuvant use of endoscopic techniques may facilitate surgical exposure and resection of large lesions.

Keywords: Infratemporal fossa; lateral skull base; subtemporal; temporal craniotomy.

Figure 1

Intraoperative image displaying linear incision ~1 cm anterior to tragus extending from the zygomatic root to the superior temporal line.

Figure 2

Intraoperative image showing the divided temporalis muscle and an arrow highlighting the root of the zygoma prior to the craniotomy or craniectomy.

Figure 3

Intraoperative image showing the surgical window after craniectomy and drilling of the superior edge of the zygomatic root. The temporal lobe is retracted slightly to increase the operative window and the temporal dura is identified by the arrow.

Figure 4

Preoperative T1-weighted coronal magnetic resonance imaging after gadolinium administration displaying the enhancing lesion in the infratemporal fossa and arrows highlighting the operative corridor. The arrowhead points to the zygoma.

Figure 5

Operative corridor with slight retraction of the temporal lobe and dura mater overlying the tumor.

Figure 6

Operative view of the anterior infratemporal fossa after resection of the lesion with the medial pterygoid muscle as the deep boundary.

Figure 7

Cadaveric dissection of the infratemporal fossa identifying the medial pterygoid, branches of the mandibular division, and middle meningeal artery.

Figure 8

Postoperative T1-weighted coronal magnetic resonance image with gadolinium displaying muscle enhancement and gross total resection of the lesion. The arrowheads highlight the enhancing muscle tissue.

Figure 9

Follow-up T1-weighted coronal magnetic resonance imaging after gadolinium injection showing partial resolution of the muscle enhancement. The arrowheads identify the diminished enhancement of the muscle.