have stimulated a widespread interest in the subject of suppuration of the petrous pyramid during the past few years. As far back as 1904 Mouret1 carried out systematic anatomic studies on the petrous pyramid. At that time he evidenced his understanding of infection of the petrous tip. He stated that "if the cellular arrangement favors an infection of the mastoid process in the presence of suppuration of the middle ear and facilitates the retention of pus in that part of the temporal bone, it is easy to understand how the pus can be extended into the perilabyrinthine cells and cause necrosis of the petrous pyramid."A series of 200 temporal bones were studied in 100 autopsies. These bones were studied in their normal position and relationship within the skull with the brain intact and also after they were excised. A better understanding of the cell groupings or arrangements of the petrous pyramid can be obtained by studying this part of the bone both in situ and after removal and by means of roentgenography and gross sections after removal. The cellular structure of both the mastoid and the petrous portions was noted. In addition dyes were introduced into the apex of the removed petrous bones to ascertain whether the dye would pass through one or more groups of cells. Sodium iodide and iodized poppy-seed oil 40 per cent were used with the roentgenographic studies but were found to be of no special value. The channels of pneumatization were further studied and in many instances recorded by means of photographs. The nerves and vessels in proximity to the petrous apex were studied. It was hoped thus to secure a better understanding of the various clinical pictures and syn¬ dromes which have been observed in involvement of the petrous pyramid as a complication of mastoiditis. At the same time various operations From the Department of Otolaryngology, Kings County Hospital. 1. Mouret, J.: Nouvelle recherches sur les cellules petreuses, Rev. hebd. de laryngol. 25:753 (Dec. 24) 1904. Downloaded From: http://archotol.jamanetwork.com/ by a Western University User on 06/09/2015
We propose an improved operative technic for the approach to the apex of the petrous portion of the temporal bone by way of the middle fossa. Several operators have approached this region by this route, but in their procedures landmarks and instrumentation have not been stressed so as to clarify and simplify the technic. In most instances the petrous apex was exposed but not entered. When the area of the apex was entered, a hook or a curet was used. The operation which we describe is an attempt to simplify and, if possible, to define the technic so that it will be readily available to the otologic surgeon.In one of his excellent articles Kopetzky has reviewed the various technics which have been used or advocated and has rendered his critique. Our review of the literature on this subject and our understanding of the pathologic nature of suppuration of the petrous pyramid lead us to incline toward the policy that a radical mastoidectomy should be avoided, whenever possible, so as to preserve the hearing. This applies especially to children, whose hearing is so essential to a proper mental development. Thus far two operations have been described which propose a well defined technic, that of Kopetzky and Almour and that of Eagleton. By the procedure of Kopetzky and Almour an attempt is made to enter the apex by circumventing the labyrinth. Their operation requires an approach through the middle ear and a preliminary radical mastoidec¬ tomy. The other operation is that of Eagleton. He removes what he terms the anterior and posterior buttresses ; this affords an exposure of the middle and posterior fossae, in their relation with the petrous pyramid. He carries his exposure of the anterior surface as far as the apex, while posteriorly the exposure goes as far as the internal auditory meatus after the saccus endolymphaticus has been severed. A radical mastoidectomy is required as a part of this operation. We are mindful of the existence of a fistula from the region of the petrous apex into From the
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