The Versatility of the Retrolabyrinthine Approach: Anatomical Study, Indications, and Review of the Literature

The retrolabyrinthine (RLB) approach, first described in the 1970s, has been largely forgotten due to its technical complexity and longer operative time. Despite this, it remains the only extradural route that allows access to internal auditory canal (IAC) without compressing the brain or cerebellum, while aiming to preserve hearing. Its versatility and safety are often underestimated.

The authors conducted a retrospective analysis of 121 patients operated via the RLB approach or its variants between 1995 and 2024. The study aimed to assess hearing preservation, facial nerve outcomes, and complication rates and to describe the surgical technique and its variations. A systematic literature review was also performed to compare outcomes.

Among the 121 cases included, the main indications were vestibular neurotomy (55), vestibular schwannoma (36), and cerebellopontine angle meningioma.17 Overall hearing preservation was achieved in 67% of cases, and normal facial nerve function (House-Brackmann Grade I/II) was preserved in 95.8%. Cerebrospinal fluid leak occurred in only 2.4% of the patients and was managed conservatively. No cases of mortality or meningitis were reported. Comparative statistical analysis confirmed that outcomes varied mainly according to indication but not according to the specific RLB variant. The approach demonstrated flexibility, allowing adaptation to different anatomical situations and pathologies through multiple variations and extensions.

The RLB approach is a safe and effective extradural technique with low complication rates and excellent functional outcomes. Its ability to preserve hearing and facial nerve function, combined with its adaptability to various skull base pathologies, supports its inclusion as a valuable tool in lateral skull base surgery.