Improved Operative Technic for Suppuration of the Petrous Apex

Abstract

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

I. The Cellular Character of One Hundred Temporal Bones: Clinical and Surgical Significance

“…Lange is of the same opinion. 26 Streit, 32 Eagleton,33 Myerson and his co-workers 34 have advised a subtemporal approach. Its value in comparison with the peritubal technic in empyematous lesions of the tip must be questioned, chiefly upon the basic principles of drainage.…”