Combined Middle Fossa and Transmastoid Approach for Resection of Petrous Temporal Meningioma With Facial Nerve Reanimation by Interposition Grafting: 2-Dimensional Operative Video

Meningiomas affecting the facial nerve along its course within the petrous temporal bone are exceptionally rare, with less than 20 cases reported in the literature.1 We present a case of a 44-year-old woman presenting with progressive facial palsy and an enhancing lesion within the petrous temporal bone in the area of the geniculate ganglion. On presentation, she had House-Brackmann grade 5 facial palsy with incomplete eye closure and barely perceptible left-sided facial movement, as well as normal hearing bilaterally. The lesion was believed to likely be a facial nerve hemangioma given its imaging characteristics and location, with facial nerve schwannoma, meningioma, and lymphoma as additional diagnostic considerations. Given her severe facial nerve palsy, she was recommended to undergo surgical resection and facial nerve reanimation. This surgical video demonstrates a middle fossa approach and anterior petrousectomy combined with a mastoidectomy for resection of the lesion, isolation and excision of the involved facial nerve segments, and reanimation using a greater auricular nerve interposition graft. The patient provided informed consent to the procedure. A gross total resection with hearing preservation was achieved without any perioperative complications. Final pathology was consistent with a World Health Organization grade 1 meningioma. At 9 months after surgery, the patient showed some evidence of facial muscle reinnervation on electromyography but no clinical evidence of facial nerve recovery. This video contains the key surgical steps of both the middle fossa and transmastoid approaches and also demonstrates the technical nuances of interposition grafting for facial nerve reanimation.