Infratemporal approach for skull base lesions

Abstract

Tumors of the infratemporal fossa constitute a diverse group of pathology with similar surgical considerations. Access to the infratemporal fossa is possible through a variety of surgical approaches including anterior, lateral, and inferior approaches. Fisch has provided excellent descriptions of the lateral approach and his works stress the need for facial nerve and internal carotid identification and preservation. Many technological enhancements have furnished the modern skull base team with sophisticated tools for preoperative assessment and intraoperative assistance, improving the outcome and reducing operative morbidity. These have included the use of preoperative balloon occlusion, magnetic resonance imaging (MRI) three-dimensional computed tomography and MRI reconstructions, intraoperative nerve monitoring and navigational systems, and safe and reliable reconstructive and anesthesia methods. Proper interpretation of preoperative studies and translation to careful selection of technique require surgical experience and maturity. Various aspects of infratemporal surgery, based on the author's experience with 93 patients, are discussed in this article. The lateral approaches are broadly classified into preauricular and postauricular approaches. Indications, advantages, and descriptions of each technique are presented with regard to avoidance of complications. The need for internal carotid artery exposure and/or reconstruction and facial nerve transposition determines preference of preauricular or postauricular exposure. Management of the eustachian tube, middle ear, and temporomandibular joint is an important additional consideration. The management of the temporalis muscle may also vary. Intracranial extensions of infratemporal fossa tumors can be quite varied, and precise calculation is necessary to determine appropriate craniotomy exposure. The need for a dural/mucosal barrier is paramount, and therefore appropriate planning and assiduous attention to closure are important. Injuries to important neurovascular structures are best avoided by careful identification of these structures and appropriate surgical manipulations.