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Objective?To establish a consistent surface bony landmark for a middle fossa approach (MFA) lateral craniotomy represented by the squamosal suture (SS). Methods?In 60 dried skulls, we assessed the relation between the SS and the external auditory canal (EAC). The lateral portion of the middle cranial fossa floor was also assessed for a possible relation with the anteroposterior diameter (APD) of the squama temporalis (ST). Clinically, we applied our findings on the SS in MFA for different lesions. Results?A vertical line at the EAC divided the ST into the anterior part constituting 61% of the APD (i.e., two thirds) and the posterior part forming 39% (i.e., one third). The average ST height was 35.92 mm. The SS posterior limit at the supramastoid crest was located just anterior to the external projection of the petrous ridge in 35 skulls (58%) and exactly corresponded to it in 25 skulls (42%). The APD of the ST equals on average 97% of the APD of the lateral middle cranial fossa. Optimum exposure of the middle fossa was obtained without any further craniotomy extension. Conclusion?The SS serves as a consistent natural surface bony landmark for MFA. Optimum craniotomy, two thirds anterior to the EAC and one third posterior, is obtained following SS as a landmark.

Background:Retromastoid craniectomy (RSC) is a cardinal surgical approach used to access the posterior fossa. Hydroxyapetite bone cement (HBC) is frequently employed for cranioplasty in efforts to prevent cerebrospinal fluid (CSF) leak, whilst maintaining low complication rates and good cosmetic satisfaction. The authors aim to determine the safety and effectiveness of HBC for reconstruction RSC used for treatment of various cranial nerves disorders.Methods:The authors conducted a retrospective one-center two surgeons review of 113 patients who underwent RSC filled with HBC for the treatment of cranial nerve disorders. The study period extended from January 2011 through April 2016. Charts were reviewed for documentation of descriptors pertinent to the endpoints described above. Revisions and reoperations were excluded from analysis.Results:Ninety-three patients met the inclusion criteria; there was one case of postoperative pseudomeningocele, which was considered as CSF leak (1%), 3 (3,2%) superficial infections, and no deep infections. Cosmetic satisfaction was obtained in all but one case (98.9% satisfaction) and long-term incisional pain was problematic in 1 (1.1%) patient. Other complications (serous drainage, headache, ear pain) accounted for three cases (3.2%).Conclusions:The application of HBC in the reconstruction of RSC for the treatment of cranial nerves disorders is an effective method, yielding good cosmetic results whilst eliminating CSF leak. Additionally, it is safe due to the lack of deep-seated wound infections with low incidence of chronic incisional pain.

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