title: A Percutaneous Transtubular Middle Fossa Approach for Intracanalicular Tumors.
abstract: OBJECTIVE
  In cases of small intracanalicular tumors (≤ 1.5 cm), the middle fossa approach (MFA) provides the ability for adequate tumor removal with preservation of existing auditory function. Application of a minimally invasive tubular retractor in this approach may help mitigate the risk of postoperative seizures, aphasia, and venous complications by minimizing intraoperative retraction of the temporal lobe. We propose a minimally invasive microscopic and/or endoscopic percutaneous transtubular MFA for the management of intracanalicular tumors.
  
  
  METHODS
  Subtemporal keyhole craniectomies were performed on 5 preserved cadaveric heads (10 sides), with 6 sides previously injected with a synthetic tumor model. A ViewSite Brain Access System tubular retractor (Vycor Medical, Inc., Boca Raton, Florida, USA) was used to provide minimal temporal retraction and protection of the surrounding anatomy. An extradural dissection of the internal auditory canal was performed under microscopic and endoscopic visualization with a minimally invasive surgical drill and tube shaft instruments, the intracanalicular tumors were removed, and degree of resection was assessed.
  
  
  RESULTS
  All 10 approaches were completed successfully through the tubular retractor with minimal retraction of the temporal lobe. Excellent visualization of the structures within the internal auditory canal was achieved with both the microscope and 3-dimensional endoscope. On the 6 synthetic intracanalicular tumors resected, 5 gross total (Grade I) and 1 near total (Grade II) resections were achieved.
  
  
  CONCLUSIONS
  A percutaneous transtubular MFA is a feasible minimally invasive option for resection of small intracanalicular tumors with potential preservation of auditory function, reduced temporal retraction, and enhanced protection of surrounding structures.
authors.affiliation: Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA. Electronic address: anb2029@med.cornell.edu.
authors.forename: Antonio
authors.initials: A
authors.lastname: Bernardo
authors.affiliation: Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
authors.forename: Alexander I
authors.initials: AI
authors.lastname: Evins
authors.affiliation: Department of Neuroradiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
authors.forename: Apostolos J
authors.initials: AJ
authors.lastname: Tsiouris
authors.affiliation: Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
authors.forename: Philip E
authors.initials: PE
authors.lastname: Stieg
mesh_terms: D002102:Cadaver; D003399:Craniotomy / Q000009:adverse effects / Q000379:methods*; D004424:Ear Canal / Q000601:surgery*; D005240:Feasibility Studies; D006309:Hearing; D006801:Humans; D008866:Microsurgery; D044583:Neuroendoscopy; D013701:Temporal Bone / Q000601:surgery*; D013702:Temporal Lobe / Q000601:surgery
keywords: Endoscopic; Internal auditory canal; Middle fossa; Minimally invasive; Transtubular; Tubular retractor