Operative Techniques in Otolaryngology (2013) 24, 179–183

Temporal bone resection

Brian Ho, MD,a C. Arturo Solares, MD, FACS,a Benedict Panizza, MBBS, MBA, FRACSb

From the aCenter for Skull Base Surgery, Georgia Regents University, Augusta, Georgia; and the bQueensland Skull Base
Center, Department of Otolaryngology - Head and Neck Surgery, University of Queensland and Princess Alexandra Hospital,
Brisbane, Australia

KEYWORDS The temporal bone can be affected by primary or secondary malignancies. The latter are far more
Temporal bone cancer; common. The complex anatomy of this region requires a thorough understanding in order to manage
Temporal bone these lesions safely. Herein we present a brief description of the techniques used to resect malignant
resection; temporal bone lesions.
Lateral skull base r 2013 Elsevier Inc. All rights reserved.

Introduction petrous portion of the temporal bone interjects between the

Primary malignant lesions of the temporal bone are rare.
Malignant locoregional spread from adjacent anatomical
locations is more common. Traditionally, attempts were
made to use a “desleeving” technique in the external
auditory canal (EAC) or to treat with a single-modality
radiation therapy. These yielded historically poor results in
patient's life expectancy.1 This led to the advent of
aggressive lateral skull base surgery and resection for
comprehensive treatment.
The complex anatomy of the temporal bone and its
adjacent structures requires the otolaryngologist to have a
thorough command of the anatomy and experience in open
and microscopic surgical skills to safely and effectively
manage these tumors. This paper describes the operative
technique for surgically resecting primary malignant tumors
of the temporal bone or lesions that extend into the temporal
bone, or both.
Anatomy and patterns of spread
The medial portion of the squamosa forms a portion of the
middle cranial fossa. On the lateral surface, the mandibular
fossa is located just inferior to the zygomatic root. The
Address reprint requests and correspondence: C. Arturo Solares,
Center for Skull Base Surgery, Georgia Regents University, 1120 15th St,
BP 4109, Augusta, GA 30912.
E-mail address: csolares@gru.edu
1043-1810/$ - see front matter r 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.otot.2013.04.013
angular union of the sphenoid and occipital bones. This
marks the border between the middle and posterior cranial
fossas. The temporal bone also houses cranial nerves VII-
XI, the sigmoid sinus, and the internal carotid artery (ICA).
Because of the dense anatomical nature of the head and
neck, adjacent structures are prone to malignant spread.
These tumors can invade in the following ways:
(1) Anteriorly: parotid gland, infratemporal fossa, glenoid
fossa, or facial skin.
(2) Posteriorly: bony EAC, mastoid, and posterior fossa.
(3) Inferiorly: soft tissue neck structures, jugular foramen,
foramen magnum, or cervical spine.
(4) Superiorly: epitympanum, tegmen, and middle cranial
fossa.
Lymphatic spread occurs in the following ways:
(1) Anteriorly: parotid and preauricular nodes.
(2) Posteriorly: postauricular nodes.
(3) Inferiorly: upper deep cervical and deep internal
jugular nodes.
(4) Middle ear or mastoid lymphatics drain to the
Eustachian tube area, then into deep upper jugular and
retropharyngeal nodes.2,3
The collateral invasion dictates any additional surgical
procedures (eg, neck dissection, parotidectomy, or man-
dibular condylectomy).2,3
180 Operative Techniques in Otolaryngology, Vol 24, No 3, September 2013
Pathology
The primary pathology can range from cutaneous skin
squamous cell carcinoma to adenocarcinomas, and adenoid
cystic carcinomas. Because cutaneous skin squamous cell
carcinoma has a predilection to bone invasion, patients
typically undergo fine-cut temporal bone computed tomog-
raphy scans. Magnetic resonance imaging of the head and neck
is also advisable. If there is suspected ICA involvement, a poor
prognostic indicator, angiography utilizing trial ipsilateral
balloon occlusion should be performed. This should also then
be followed up with xenon diffusion analysis to evaluate for
contralateral cerebral blood flow. The venous outflow phase
should also be analyzed to evaluate for contralateral venous
drainage, in the instance where the surgeon is required to
occlude the sigmoid sinus or internal jugular vein.
Lesions that invade the following structures are generally
not surgical candidates4:
 cavernous sinus,
 carotid artery,
 infratemporal fossa, and
 paraspinous musculature.
Principles of temporal bone resection
As with any traditional oncologic resection, this chapter
advocates an en bloc resection of malignant tumors
involving the temporal bone when feasible. This can be
completed by a lateral temporal bone resection (LTBR) or a
near-total temporal bone resection (NTTBR) (Figure 1).
Adjacent involved tissue should also be included with the
resection specimen. In standard practice, this typically
involves a parotidectomy and, less frequently, the tempor-
omandibular joint (TMJ) with capsule. LTBRs can be
performed with facial nerve preservation if the tumor is
located lateral to the tympanic membrane (TM). If the
malignant lesion invades medially to the TM, the resection
then escalates to a NTTBR.
Figure 1 Diagram illustrating which structures are removed
with each variation of temporal bone resection.
Intraoperative evaluation of the middle ear space is
performed via a posterior tympanotomy. It becomes difficult
to distinguish mucosal inflammation owing to mass effect
from gross tumor involvement. The senior authors
(C.A.S., B.P.) advocate for the use of frozen section
whenever questions arise.
Surgical technique
LTBR
(1) Several operative exposures can be used. A postaur-
icular C-shaped incision (1 cm posterior to the
postauricular sulcus). A preauricular incision may be
used if a large parotidectomy is to be performed. This
can be carried inferiorly to the neck if neck dissection
is also planned. The incision should be tailored toward
the pathology and individual. Attention should be paid
to the blood supply to the pinna at the conclusion of the
case and plan accordingly.
(2) Skin flaps are elevated anteriorly to the parotidomasse-
teric and temporalis fascia, and posteriorly above the
temporalis, mastoid bone, and sternocleidomastoid
fascia. Typically, the pinna can be retracted forward
with a wide-based postauricular incision.
(a) If necessary, the tragus and conchal cartilage may
be resected.
(b) If the retromandibular area is included, the anterior
skin flap depth is extended deep to the temporalis
fascia at the zygomatic root to preserve the facial
nerve's temporal branches.
(3) If the lateral canal is free of disease, the EAC is closed
off into a “blind sac” (tragal to conchal skin). This is
reinforced medially with an anteriorly based muscu-
loperiosteal flap.
(a) If the lateral canal is involved, it is resected and the
defect is repaired with local rotation or free flaps.
(4) A typical cortical mastoidectomy is performed expos-
ing sigmoid sinus and middle cranial fossa dura
(Figure 2).
Figure 2 Cortical mastoidectomy.
Ho et al. Temporal Bone Resection
Figure 3 Posterior tympanotomy.
(5) A posterior tympanotomy is performed for inspection
of the middle ear space and the incudostapedial joint is
disarticulated (Figure 3).
(6) Mastoidectomy is then extended to the zygomatic root
and the epitympanum is then opened.
(7) The tympanotomy is extended to the hypotympanum
inferiorly. The chorda tympani is sharply transected
(Figure 4).
(8) To reach the superior portion of the TMJ, the anterior
epitympanic region is drilled and extended antero-
inferiorly and medially.
(9) The hypotympanic opening is then extended antero-
laterally to the jugular bulb and ICA to reach the TMJ.
(a) It may be necessary to lift the facial nerve (portion
between the second genu and stylomastoid fora-
men) to gain access for drilling the hypotympanum.
(10) Pressure is applied to the specimen in an anterior direction.
(a) If the specimen does not freely fracture, a 2-mm
osteotome can be used via the posterior tympanot-
omy (Figure 5).
Figure 4 Posterior tympanotomy extended inferiorly into the
hypotympanum.
181
Figure 5 Removal of the specimen with an osteotome.
(b) In the case of a narrow posterior tympanotomy
(facial nerve to the tympanic annulus), the temporal
bone can be fractured anteriorly, which allows for
the space to further enlarge by several millimeters,
facilitating anterior drilling and clean excision of
the specimen.
(11) A plug is fashioned, out of muscle and fascia, and
utilized to obliterate the eustachian tube.
(12) Mastoid cavity obliteration is also advocated to prevent
osteoradionecrosis after radiation therapy.
(13) The wound is then closed in multilayered fashion and a
padded compression dressing is then applied.
NTTBR and total temporal bone resection (TTBR)
NTTBR is a resection of the medial aspect of the
mesotympanum, exposing air cells of the petrous apex.
This is a resection reserved for patients with malignancies
extending medially to the TM and not the petrous apex
A TTBR, as the name implies, is a total en bloc resection
of the temporal bone. This includes the petrous apex along
with the sigmoid sinus. The petrous ICA may also be
included in the final specimen. TTBR has not been shown to
be of added benefit3-5 and will not be discussed.
(1) The skin incision should provide adequate access to the
middle cranial fossa and mastoid, parotid, and retro-
mandibular fossa.
(a) A C-shaped incision: frontotemporal region (6-8 cm
superior to the auricle) and extended 4-5 cm
postauricularly and 4 cm below the angle of the
mandible into the submental region (Figure 6).
(b) It again can be extended inferiorly to include a
neck dissection.
(2) The superior flap is elevated along with elevation of
the temporal muscle.
(3) A midposterior temporal craniotomy is performed.
A burr hole is performed at the asterion to locate
182 Operative Techniques in Otolaryngology, Vol 24, No 3, September 2013
Figure 6 C-shaped incision for NTTBR.
the junction between the lateral and sigmoid
sinuses.
(a) Typically, the craniotomy measures 6  4 cm
extending to the zygomatic root.
(4) Middle cranial fossa dura is then dissected free from
the anterosuperior petrous bone. This is further
inspected to confirm that the tumor is indeed resectable.
(a) If there is dural involvement, this may be excised
and included with the specimen.
(5) Expose the sigmoid sinus and jugular bulb regions
(utilizing a cutting burr and then a diamond burr to
assist with hemostasis)
(a) Dura anterior to the sigmoid is exposed and this
allows dissection of the dura along the posterior
aspect of the petrous bone.
(b) The dissection is carried toward the internal
auditory meatus and pars nervosa (jugular fora-
men). In addition, this area is also inspected for
gross tumor involvement.
(6) Ancillary procedures can be performed at this stage:
(a) total parotidectomy,
(b) neck dissection, and
(c) resection of additional tissue anterior to the EAC.
(7) The sigmoid sinus is collapsed after opening and
packing it off with a hemostatic plug. This is
performed with proximal and distal vascular control
(toward the jugular bulb).
(8) Open the jugular bulb
(a) Inferior petrosal sinus openings are packed.
(b) A preoperative magnetic resonance venography
should be performed to ensure adequate contrala-
teral drainage.
(9) An osteotomy (via the middle cranial fossa) is created
across the petrous bone (lateral to the porus acousticus)
to reach the carotid canal anteriorly and the preserved
posteromedial wall of the jugular fossa (inferiorly).
Figure 7 Removal of the specimen after NTTBR.
This is best performed with a diamond drill.
(a) Careful attention should be directed here to prevent
cranial nerve injury.
(10) A finishing cut is made (medial to lateral) to complete
the joining of the glennoid fossa or zygomatic root
(across the middle cranial fossa floor) to lie posterior to
the foramen ovale toward the carotid canal. The
specimen is usually mobile at this stage (Figure 7).
(11) Pressure is applied anteroinferiorly (from the posterior
surface of the petrous bone) to free the specimen.
(a) There may be persistent soft tissue attachments
(eg, internal auditory canal nerves), which can be
divided.
(b) If there is bleeding from the inferior petrosal sinus,
this can be managed with hemostatic packing.
(12) Close any residual dural defects primarily. Larger
defects may require fascial grafts.
Facial nerve rehabilitation options include the following:
 Cross-face cable graft,
 split VII-XII (which can also be utilized as a temporizing
graft in cases where a cross-face anastomosis is
performed. This helps prevent degeneration of motor
end plates), and
 static reanimation via slings and gold weights.
Defect reconstruction
Generally, temporal bone resection combined with paro-
tidectomy is best served with free-tissue transfer. These
flaps can provide robust amounts of tissue to prevent
cerebrospinal fluid leakage and protect the carotid. This
last point is of paramount importance, given that some of
these patients are radiation failures and some will require
postoperative radiotherapy. In previously irradiated tissue
Ho et al. Temporal Bone Resection
fields, free-flap repair is ideal. The defect can also be
repaired with local or regional myocutaneous flaps.
The important note is to reconstruct with the goal of
providing proper soft tissue envelope for the underlying
vasculature, dura, bone, and obliterated dead spaces.
Cosmesis is often a second consideration, but proper
contouring of the patient's cranial silhouette is also an
important point.
Complications
Patients with head and neck cancer often suffer from
significant morbidity and in-hospital complications, owing to
their numerous underlying comorbidities. These patients can
often present with significant cardiovascular risk and, given
the anatomy involved, can suffer intracranial complications.
One study noted that hematoma was more likely in free-flap
repairs, probably due to aggressive postoperative anticoagu-
lation associated with microvascular reconstruction protocols.
Myocutaneous reconstruction perfusion is least reliable to the
distal (superior) point, which may increase the risk of
183
dehiscence.6 Patients may also experience vertigo (middle
ear surgery), trismus (TMJ excision), and facial nerve injury.
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