Extradural middle fossa approach. Proposal of a learning method: the "rule of two fans." Technical note

The extradural middle fossa approach is used to access lesions of the petroclival and cavernous sinus regions. It may be included in combined petrosal and anterolateral transcavernous approaches. Technically, it is a demanding exposure that provides a wide extradural corridor between the 5th, 7th, and 8th cranial nerves. Its major advantages are that it offers extradural dissection, limits temporal lobe retraction, and avoids the transposition of nerves or vessels. Its disadvantages are primarily related to the complicated anatomy of the petrous apex from the middle fossa trajectory, which can be unfamiliar to neurosurgeons. To facilitate the first attempts with this relatively uncommon approach during dissections of human cadaveric injected heads and isolated temporal bones, we developed a simple learning method useful for localizing all anatomical structures. Using this "rule of two fans," vascular, nervous, fibrous, and osseous structures are localized within two bordering fans with a 90-degree relationship to each other.