Acta Neurochirurgica

, Volume 159, Issue 6, pp 1023–1026 | Cite as

Middle fossa approach for resection of vestibular schwannoma

  • Gmaan Alzhrani
  • Clough Shelton
  • William T. CouldwellEmail author
How I Do it - Brain Tumors



Surgical approaches for removal of vestibular schwannoma are done through retrosigmoid, translabyrinthine, or middle fossa approaches, depending on the tumor size, preoperative hearing status, surgical team experience, and patient preference. The middle fossa approach (MFA) for the vestibular schwannoma (VS) route preserves hearing and can be done with minimal morbidity and mortality.


The authors discuss the surgical anatomy of the middle fossa, internal auditory canal localization techniques, MFA indications and the procedure for VS removal, and outcome.


Unlike otolaryngologists, who use the MFA to treat various pathological processes that involve the inner or middle ear, many neurosurgeons are unfamiliar with the MFA. Nevertheless, learning the technical nuances of the MFA adds to the neurosurgeon’s armamentarium, especially for treatment of small intracanalicular VSs in young patients who wish to preserve hearing.


Middle fossa approach Vestibular schwannoma Resection Hearing 

Supplementary material

Video 1

Video illustrating the middle fossa approach technique used by the authors for resection of the vestibular schwannoma. In this case, a right middle fossa approach was used for resection of intracanalicular vestibular schwannoma. (MP4 231,994 kb)


  1. 1.
    Anagnostopoulou S, Diamantopoulou P (2004) Topographic relationship between the cochlea and the middle fossa floor: the anatomical basis for an alternative approach to the cochlear turns. Surg Radiol Anat: SRA 26:82–85CrossRefPubMedGoogle Scholar
  2. 2.
    Fisch U (1970) Transtemporal surgery of the internal auditory canal. Report of 92 cases, technique, indications and results. Adv Otorhinolaryngol 17:203–240PubMedGoogle Scholar
  3. 3.
    Garcia-Ibanez E, Garcia-Ibanez JL (1980) Middle fossa vestibular neurectomy: a report of 373 cases. Otolaryngol Head Neck Surg 88:486–490CrossRefPubMedGoogle Scholar
  4. 4.
    House WF (1961) Surgical exposure of the internal auditory canal and its contents through the middle, cranial fossa. Laryngoscope 71(11):1363–1385CrossRefPubMedGoogle Scholar
  5. 5.
    Lan M-Y, Shiao J-Y (2010) Using greater superficial petrosal nerve and geniculate ganglion as the only two landmarks for identifying internal auditory canal in middle fossa approach. Eur Arch Otorhinolaryngol 267:1867–1871CrossRefPubMedGoogle Scholar
  6. 6.
    Liu JK, Fukushima T, Sameshima T, Al-Mefty O, Couldwell WT (2006) Increasing exposure of the petrous internal carotid artery for revascularization using the transzygomatic extended middle fossa approach: a cadaveric morphometric study. Neurosurgery 59:ONS309-318 discussion ONS318-319CrossRefGoogle Scholar
  7. 7.
    Mortini P, Mandelli C, Gerevini S, Giovanelli M (2001) Exposure of the petrous segment of the internal carotid artery through the extradural subtemporal middle cranial fossa approach: a systematic anatomical study. Skull Base 11:177–187CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Raheja A, Bowers CA, MacDonald JD, Shelton C, Gurgel RK, Brimley C, Couldwell WT (2016) Middle fossa approach for vestibular schwannoma: good hearing and facial nerve outcomes with low morbidity. World Neurosurg 92:37–46CrossRefPubMedGoogle Scholar
  9. 9.
    Tanriover N, Sanus GZ, Ulu MO, Tanriverdi T, Akar Z, Rubino PA, Rhoton AL Jr (2009) Middle fossa approach: microsurgical anatomy and surgical technique from the neurosurgical perspective. Surg Neurol 71:586–596 discussion 596CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2017

Authors and Affiliations

  • Gmaan Alzhrani
    • 1
  • Clough Shelton
    • 2
  • William T. Couldwell
    • 1
    Email author
  1. 1.Department of Neurosurgery, Clinical Neurosciences CenterUniversity of UtahSalt Lake CityUSA
  2. 2.Department of Surgery, Division of OtolaryngologyUniversity of UtahSalt Lake CityUSA

Personalised recommendations