laboratory investigation

J Neurosurg 125:1094–1104, 2016

The cochlea in skull base surgery: an anatomy study

Jian Wang, MD, PhD,1 Fumitaka Yoshioka, MD,4 Wonil Joo, MD,2 Noritaka Komune, MD, PhD,3,4
Vicent Quilis-Quesada, MD,4 and Albert L. Rhoton Jr., MD4
1
Department of Neurosurgery/Neuro-Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People’s
Republic of China; 2Department of Neurosurgery, Catholic University of Korea, Uijeongbu St. Mary’s Hopsital, Gyeonggi-do,
Korea; 3Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; and
4
Department of Neurosurgery, University of Florida, Gainesville, Florida

Objective  The object of this study was to examine the relationships of the cochlea as a guide for avoiding both co-
chlear damage with loss of hearing in middle fossa approaches and injury to adjacent structures in approaches directed
through the cochlea.
Methods  Twenty adult cadaveric middle fossae were examined using magnifications of ×3 to ×40.
Results  The cochlea sits below the floor of the middle fossa in the area between and below the labyrinthine segment
of the facial nerve and greater petrosal nerve (GPN) and adjacent to the lateral genu of the petrous carotid. Approxi-
mately one-third of the cochlea extends below the medial edge of the labyrinthine segment of the facial nerve, geniculate
ganglion, and proximal part of the GPN. The medial part of the basal and middle turns are the parts at greatest risk in
drilling the floor of the middle fossa to expose the nerves in middle fossa approaches to the internal acoustic meatus and
in anterior petrosectomy approaches. Resection of the cochlea is used selectively in extending approaches through the
mastoid toward the lateral edge of the clivus and front of the brainstem.
Conclusions  An understanding of the location and relationships of the cochlea will reduce the likelihood of cochlear
damage with hearing loss in approaches directed through the middle fossa and reduce the incidence of injury to adjacent
structures in approaches directed through the cochlea.
http://thejns.org/doi/abs/10.3171/2015.8.JNS151325
Key Words  cochlea; facial nerve; internal acoustic meatus; internal carotid artery; microsurgical anatomy; skull base
surgery

T
he cochlea is the most anterior and medial part of
the vestibulocochlear labyrinth. It lies anteromedial
to the vestibule and semicircular canals, where it is
embedded in the petrous part of the temporal bone adjacent
to the petrous segment of the internal carotid artery, facial
nerve, geniculate ganglion, internal acoustic meatus, and
semicircular canals. The middle fossa surgical approaches
directed through the temporal bone to the internal acous-
tic meatus, cerebellopontine angle, and petroclival region
pass near but usually spare the cochlea. One goal of the
middle cranial approaches to the internal acoustic meatus
and anterior petrous apex is to preserve the cochlea togeth-
er with hearing. The basal cochlear turn bulges laterally
toward the tympanic cavity where it underlies the promon-
tory, and its medial part lies below the floor of the middle
fossa just posterior and medial to the geniculate ganglion
in the angle between the labyrinthine segment of the facial
nerve and the greater petrosal nerve (GPN).1,3,23 Few stud-
ies have examined the exact location of the cochlea and
its relationships with surround structures.1,7 This study ex-
amined the relationships important in avoiding damage to
the cochlea during approaches directed through the middle
fossa and injury to adjacent structures in approaches di-
rected through the cochlea (Fig. 1).

Abbreviations  GPN = greater petrosal nerve.

submitted  June 8, 2015.  accepted  August 7, 2015.
include when citing  Published online January 29, 2016; DOI: 10.3171/2015.8.JNS151325.

1094 J Neurosurg  Volume 125 • November 2016 ©AANS, 2016

 Cochlea in skull base surgery

Fig. 1. A: Superior view of the right middle fossa exposing the trigeminal nerve, GPN, and middle meningeal artery.  B: The floor
of the middle fossa has been drilled to expose the internal acoustic meatus. The basal turn of the cochlea has been exposed in the
angle between the facial nerve and the GPN. Superior view, stepwise dissection of another right middle fossa (C–F).  C: Bone has
been removed to expose the meatal and labyrinthine segments of the facial nerve and the geniculate ganglion.  D: Additional bone
has been removed to expose the cochlea in the bone in the angle between the facial nerve and the GPN, the nerves in the internal
acoustic meatus, and the tympanic cavity and eustachian tube.  E: Additional drilling exposes the cochlea in the angle between
the facial nerve and the GPN. The second turn of the cochlea is exposed below the GPN, and the apical turn is exposed pos-
terolateral to the trochleariform process. The lateral edge of the basal and middle turns of the cochlea extends below the medial
edge of the labyrinthine segment of the facial nerve and geniculate ganglion.  F: The meatal segment of the facial nerve has been
retracted to expose the cochlear nerve proximal to the cochlea. A. = artery; Ac. = acoustic; Arc. = arcuate; Car. = carotid; CN =
cranial nerve; Coch. = cochlear; Depress. = depression; Emin. = eminence; Eust. = eustachian; Ext. = external; Gang. = ganglion;
Gen. = geniculate; Gr. = greater; Int. = internal; Intermed. = intermedius; Laby. = labyrinthine; Lat. = lateral; Less. = lesser; M. =
muscle; Memb. = membrane; Men. = meningeal; Mid. = middle; N. = nerve; Nerv. = nervus; P.C.A. = posterior cerebellar artery;
Pet. = petrosal, petrous; Post. = posterior; Proc. = process; Seg. = segment; Sup. = superior; Tens. = tensor; Troch. = trochleari-
form; Tymp. = tympani, tympanic.

Methods which the vessels were injected with colored silicon were
examined using magnifications of ×3 to ×20. The cochlea
Twenty temporal bones from cadaveric specimens in was exposed from laterally through the mastoid and tym-

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J. Wang et al.

TABLE 1. Relationships of the cochlea as illustrated in Fig. 3

Measurements Average Range
Angles in Fig. 3A & B (°)
a Modiolar axis & sagittal plane 26.5 22.2–32.4
b Modiolar axis & coronal plane 58.4 53.6–67.3
c Axis along outer diameter of basal turn & long axis of superior semicircular canal 104 95–112
d Axis along outer diameter of basal turn & long axis of internal acoustic meatus 58.9 51.2–63.3
Lines in Fig. 3C & D (mm)
a Anterior edge of basal turn to GPN 3.9 3.4–4.4
b Medial edge of basal turn to trigeminal nerve 8.4 7.2–11.2
c GPN to petrous ridge 14.9 12.7–17.4
d Posterior edge of basal turn to petrous ridge 9.7 7.8–11.3
e Medial edge of basal turn to medial side of labyrinthine segment of facial nerve 4.3 3.7–5.1
f Distance btwn horizontal (axial) planes passing through lower edge of basal turn & upper edge of jugular bulb 5.3 3.9–7.4
g Shortest distance btwn basal turn & posterior genu of petrous carotid 1.9 1.1–3.2
Not shown in Fig. 3
— Labyrinthine segment of facial nerve to superior edge of basal turn (mm) 0.4 0.2–0.5
— Trochleariform process to modiolar apex (mm) 4.7 4.5–5.1
— Superficial edge of basal turn to middle fossa floor (mm) 3.9 3.4–4.6
— Modiolar axis & degrees below horizontal (axial) plane (°) 8.6 5.5–10.3
— = not applicable.

panic cavity, from anteriorly through the pterygopalatine
and infratemporal fossae, from above through the floor of
the middle fossa, and from posteriorly through the posteri-
or surface of the temporal bone. Blue lined or skeletonized
structures in which the bone was carefully removed with a
high-speed drill to a thinness at which the structures could
be seen through the thinned bone were used in examining
the relationship of the cochlea to the facial nerve, vestibu-
locochlear nerve, GPN, chorda tympani, geniculate gan-
glion, internal and external acoustic meati, tensor tympani
muscle, eustachian tube, and petrous carotid. Finally, the
cochlear turns were identified with meticulous drilling.
Selective distances and angles were measured (Table 1).
Results
The central cochlear axis is directed along the modio-
lus, the osseous cone-shaped central pillar of the cochlea
from which the osseous spiral lamina projects into the
bony canal of the cochlea to give the modiolus a screw-
like appearance. The osseous cochlear canal spirals for
about 2.5–2.75 turns around its central bony core, the mo-
diolus, and is approximately 35 mm in length (Figs. 1 and
2).4 The cochlea, from base to apex, measures 5 mm along
the axis of the modiolus and 9 mm across the outer diam-
eter of the basal turn.27 It is through the modiolus that the
cochlear nerve fibers are distributed to the cochlear duct.
The modiolus is not oriented in a strictly vertical or hori-
zontal axis. The modiolus, from base to apex, is directed
anterolaterally and slightly caudal. The angles between the
long axis of the modiolus, from basal turn to apex, and the
sagittal and coronal planes were 26.5° (range 22.2°–32.4°)
and 58.4° (range 53.6°–67.3°), respectively. The modiolar
axis projected an average of 8.6° (range 5.5°–10.3°) below
the horizontal (axial) plane (Table 1 and Fig. 3).
Lateral and Anterior View
As viewed from laterally in the transmastoid approach-
es through the facial recess, the round window, located
between the mastoid segment of the facial nerve posteri-
orly and the chorda tympani anteriorly, is the most lateral
part of the cochlea (Fig. 4). The round window is located
inferior to the oval window and opens in a posterolateral
direction under the overhanging edge of the promontory.
The oval window, in which the footplate of the stapes sits,
is located posterosuperior to the promontory and, in the
dry bone with the stapes removed, connects the tympanic
cavity to the vestibule. The cochlea is hidden anterome-
dial to the semicircular canals, vestibule, facial nerve, and
auditory ossicles in the lateral view through the mastoid
(Figs. 1 and 4).
The semicircular canals are positioned above the jugu-
lar bulb (Fig. 4A and D). The tympanic segment of the fa-
cial nerve passes below the lateral semicircular canal and
turns downward to form the mastoid (descending or verti-
cal) segment of the facial nerve, which exits the stylomas-
toid foramen. The labyrinthine and tympanic segments of
the facial nerve and the geniculate ganglion have an inti-
mate relationship with the basal turn of the cochlea. The
shortest distance between the facial nerve and cochlea is
between the labyrinthine segment and the superior edge
of the basal turn (average 0.4 mm, range 0.2–0.5 mm), in
agreement with reports by Wigand et al.29 and Wysocki
and Skarzyñski.30 The distance between the lower edge of
the basal turn of the cochlea and the jugular bulb averaged
5.3 mm (range 3.9–7.4 mm; Table 1 and Fig. 3). The apex
of the cochlea underlies the medial wall of the tympanic
cavity in the area anterior and superior to the promontory
(Fig. 4D and F).
The tympanic branch (Jacobson’s nerve) of the glosso-

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 Cochlea in skull base surgery

Fig. 2. A: The superior surface of a right temporal bone has been drilled, leaving a thin shell of bone around the internal acoustic
meatus, the basal turn of the cochlea, and the semicircular canals. The eustachian tube and mastoid have been opened.  B: The
internal acoustic meatus has been opened, and the air cells in the petrous apex and in the mastoid have been partially re-
moved.  C: The upper edge of the petrous ridge and middle fossa floor is the site of the trigeminal and meatal depressions and
the trigeminal prominence and arcuate eminence. The meatal depression is positioned above and medial to the internal acoustic
meatus. The hiatus of the endolymphatic duct is inferolateral to the porus of the internal acoustic meatus.  D: The posterior surface
of the right temporal bone has been drilled while preserving the bone around the cochlea, internal acoustic meatus, endolymphatic
duct, cochlear aqueduct, and semicircular canals. The basal turn of the cochlea bulges upward anteromedial to the fundus of the
internal acoustic meatus and semicircular canal. The endolymphatic sac sits on the posterior surface of the temporal bone below
the superior and lateral canals. Ac. = acoustic; Arc. = arcuate; Car. = carotid; Coch. = cochlear; Comm. = common; Depress. =
depression; Emin. = eminence; Endolymph. = endolymphatic; Eust. = eustachian; Gr. = greater; Int. = internal; Lat. = lateral; N. =
nerve; Pet. = petrosal, petrous; Post. = posterior; Prom. = prominence; Subarc. = subarcuate; Sup. = superior; Transv. = trans-
verse; Trig. = trigonal.

pharyngeal nerve arises in the medial part of the jugular
fossa, ascends in the medial wall of the tympanic cavity
where it splits into fascicles that groove the promontory,
and collects again to form the lesser petrosal nerve (Figs.
1F and 4C). The orientation of the modiolar axis of the co-
chlea results in the basal turn passing closer to the prom-
ontory than the apical turn.
The tensor tympani is a long slender muscle enclosed
in an osseous canal, positioned above and parallel to the
eustachian tube and anterior to the petrous carotid artery
from which it is separated by a thin shell of bone (Figs.
1 and 4). The tendon of the tensor tympani turns sharply
lateral around the trochleariform process, also known as
the “cochleariform process,” to reach its attachment near
the neck of the malleus. The trochleariform process is an
angular bony process positioned at the upper edge of the
promontory, above the anterior edge of the oval window,
and just below the tympanic segment of the facial nerve
(Figs. 1F and 4E). The cochlear apex lies anteroinferior
to the trochleariform process. The distance between the
trochleariform process and the modiolar apex was rela-
tively constant (average 4.7 mm, range 4.5–5.1 mm; Table
1 and Fig. 3). The trochleariform process can be used as a
landmark to locate the cochlea in the anterior and lateral
view. The cochlea is exposed inferior and medial to the
trochleariform process in the transmastoid-transcochlear
approach through the petrous apex. The relationship be-
tween the trochleariform process and the tympanic seg-
ment of the facial nerve is important in avoiding damage
to the tympanic segment, which courses just above the
trochleariform process (Fig. 4C, E, and F).
Superior and Posterior View
The cochlea is positioned below the middle fossa floor
in the cochlear angle, the angle between the long axis of
the labyrinthine segment of the facial nerve and the initial
segment of the GPN (Figs. 1, 5, and 6).8,18,23,25 The GPN,
an essential landmark in estimating the position of the
cochlea below the middle fossa floor, can be identified
medial to the arcuate eminence as it exits the geniculate
ganglion by passing through the facial hiatus to reach the
middle fossa floor. The GPN passes anteromedial beneath
the dura of the middle fossa in the sphenopetrosal groove,
which runs along the junction of the petrous apex and
sphenoid bones, superior and slightly anterolateral to the
horizontal segment of the petrous carotid (Figs. 1 and 6).
The axis across the outer diameter of the basal turn paral-

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J. Wang et al.
Fig. 3. This figure accompanies Table 1. A. = artery; Car. = carotid; CN = cranial nerve; Gang. = ganglion; Gen. = geniculate; Gr.
= greater; Jug. = jugular; Lat. = lateral; M. = muscle; N. = nerve; Pet. = petrosal; Post. = posterior; Sup. = superior; Tens. = tensor;
Tymp. = tympani.
lels the GPN in most temporal bones. However, in 15% of
temporal bones examined for this study, the medial side of
this axis was tilted slightly away from the GPN. The aver-
age distance between the anterior edge of the basal turn
and the posterior edge of the GPN averaged 3.9 mm (range
3.4–4.4 mm). The distance between the most medial point
of the basal turn and the lateral edge of the trigeminal
nerve averaged 8.4 mm (range 7.2–11.2 mm; Table 1 and
Fig. 3). The lateral part of the basal and middle turns ex-
tends below the medial edge of the labyrinthine segment
of the facial nerve, and the lateral part of the apical turn
extends below the geniculate ganglion. The apical turn of
the cochlea extends below the junction of the GPN and
geniculate ganglion (Fig. 4D and F). The labyrinthine
segment of the facial nerve begins at the fundus of the
internal acoustic meatus where the nerve turns anteriorly
and medially above the lateral part of the basal turn to
reach the geniculate ganglion.1,12 The distance between
the medial edge of the basal turn and the medial edge of
the labyrinthine segment averaged 4.3 mm (range 3.7–5.1
mm). The lateral third of the cochlea frequently underlies
the labyrinthine segment, geniculate ganglion, and GPN.
The most superficial part of the basal turn of the co-
chlea sits an average of 3.9 mm (range 3.4–4.6 mm) below
the floor of the middle fossa (Table 1 and Fig. 3). Anag-
nostopoulou and Diamantopoulou1 noted that the average
depth of the superficial edge of the basal turn is greater
than the depth of the apical turn because the upper surface
of petrosal bone forming the middle fossa floor and over-
lying the cochlea has a downward inclination from poste-
rior to anterior. The petrous ridge is oriented perpendicu-
lar to the long axis of the cochlear modiolus. The posterior
aspect of the basal turn sits below the middle fossa floor,
an average of 9.7 mm (range 7.8–11.3 mm) anterior to the
petrous ridge. The distance between the GPN and the pe-
1098 J Neurosurg  Volume 125 • November 2016
trous ridge averages 14.9 mm (range 12.7–17.4 mm). The
cochlea lies in the anterior one-third and lateral part of the
area between the GPN and the petrous ridge.
The eustachian tube, tensor tympani muscle, and pe-
trous carotid artery lie side by side and parallel to the GPN
in the part of the middle fossa area between the trigeminal
nerve medially and the cochlea laterally (Fig. 1D–F). The
lateral genu of the petrous carotid is the sharp turn where
the carotid artery changes from a vertical to a horizontally
anteromedial course.20 The cochlea is positioned below
the floor of the middle fossa slightly superior, posterior,
and lateral to the posterior genu of the petrous carotid.
The shortest distance, an average of 1.9 mm (range 1.1–3.2
mm), between the posterior genu of the petrous carotid
and the cochlea is along the inferomedial side of the basal
turn (Table 1 and Fig. 3). There may be a dehiscence of the
bone separating the basal turn from the posterior genu.19
The semicircular canals are located superior, pos-
terior, and lateral to the cochlea (Figs. 1E, 2B, and 5C).
The superior canal projects upward toward the floor of the
middle fossa and underlies the area of the arcuate emi-
nence. However, the most prominent area of the arcuate
eminence does not correspond exactly to the upper part
of the superior semicircular canal.16 The arcuate eminence
was located lateral to the superior semicircular canal in
48% of specimens, directly above or intersecting the ca-
nal in 23%, and medial in 12%; in 17% of specimens an
arcuate eminence could not be identified.26 The basal turn
is positioned medial to the anterior portion of the supe-
rior semicircular canal. The angle between a line directed
through the outer diameter of the basal turn and the long
axis of the superior canal averaged 104° (range 95°–112°;
Table 1 and Fig. 3).
The internal acoustic meatus is located below the lat-
eral part of the meatal depression, a shallow depression in
 Cochlea in skull base surgery

Fig. 4. Lateral view of a stepwise exposure of the left cochlea.  A: A mastoidectomy has been completed to expose the semicir-
cular canals and facial nerve. The tympanic membrane has been removed to expose the tympanic cavity.  B: Another specimen
oriented as in A. The tympanic membrane has been removed. The cochlea is positioned anterior and superior to the round window
and deep to the promontory. The tensor tympani muscle passes posterolateral above the eustachian tube and gives rise to a
tendon that turns sharply laterally around the trochleariform process to attach to the malleus.  C: Some bone has been removed to
define the bony capsule around the cochlea. The tympanic branch (Jacobson’s nerve) of CN IX is exposed below the promontory.
The lateral genu of the petrous carotid sits slightly anterior, inferior, and medial to the cochlea. The incus and malleus have been
removed while preserving the stapes in the oval window. The round window is located below the oval window and the overhanging
edge of the promontory. The stapedius muscle is housed in the pyramidal eminence and gives rise to a tendon that attaches to the
neck of the stapes. The trochleariform process around which the tendon of the tensor tympani bends is located anterosuperior to
the oval window in which the stapes sits.  D: The promontory has been drilled to skeletonize the cochlea. The tensor tympani has
been retracted anteriorly. The cochlea lies in the area between the geniculate ganglion, labyrinthine and tympanic segments of the
facial nerve, posterior genu of the petrous carotid, and jugular bulb. The modiolus of the cochlea, from basal to apical turn, is di-
rected anterior and lateral and has a slightly caudal inclination in relation to the axial plane. Another specimen (E and F).  E: Later-
al view through the left tympanic cavity. The tympanic membrane and the malleus and incus have been removed. The promontory
is positioned anterior to the round window and stapes. The tendon of the tensor tympani bends around the trochleariform process
and attaches to the malleus (removed).  F: Posterolateral view. The cochlea has been skeletonized, leaving a thin shell of bone
around the cochlea with careful drilling. The semicircular canals are exposed posterolateral to the cochlea. The cochlea is posi-
tioned between the tympanic and mastoid segments of the facial nerve and petrous carotid. The basal turn proceeds downward
and forward below the oval window in which the stapes sits. The petrous carotid has been exposed anteroinferior to the cochlea.
The tympanic segment of the facial nerve passes below the lateral semicircular canal and above the trochleariform process and
the stapes in the oval window. A. = artery; Car. = carotid; Chor. = chorda; CN = cranial nerve; Cond. = condylar; Emin. = eminence;
Eust. = eustachian; Gang. = ganglion; Gen. = geniculate; Gr. = greater; Int. = internal; Jug. = jugular; Lat. = lateral; M. = muscle;
Mast. = mastoid; N. = nerve; Pet. = petrosal, petrous; Plex. = plexus; Post. = posterior; Proc. = process; Pyram. = pyramidal; Seg.
= segment; Staped. = stapedial; Sup. = superior; Tens. = tensor; Troch. = trochleariform; Tymp. = tympani, tympanic; V. = vein; V3
= third division of trigeminal nerve.

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Fig. 5. Posterior view of the fundus of the left internal acoustic meatus and cochlea. Bone has been removed along the posterior
and superior wall of the internal acoustic meatus.  A: Posterosuperior view. The transverse crest separates the meatal fundus into
a superior part where the superior vestibular and facial nerves are situated, and an inferior part where the cochlear and inferior
vestibular nerves pass. The singular branch of the inferior vestibular nerve that innervates the posterior canal ampullae has been
exposed. The inferior vestibular nerve also has a saccular and, occasionally, a utricular branch.  B: Posterior view of the fundus of
the meatus and basal turn of the cochlea. The cochlear nerve penetrates the modiolus of the cochlea where its fibers are distrib-
uted to the turns of the cochlear duct. The basal turn of the cochlea communicates below the modiolus with the vestibule.  C: The
medial part of the cochlea is positioned in the bone below the area between the GPN and the labyrinthine segment of the facial
nerve. The latter courses just above the lateral part of the cochlea.  D: Posterosuperior view. The cochlea, the most anterior and
medial part of the labyrinth, is positioned anteromedial to the semicircular canal and vestibule. A small opening has been made
into the cochlea.  E: Another specimen. The fundus of the right meatus has been exposed. The posterior meatal wall has been
removed while preserving the upper edge of the meatal porus. Additional drilling is required to expose the cochlea.  F: The petrous
apex medial to the internal acoustic meatus has been partially removed to expose the cochlea. The facial nerve has been elevated
to expose the cochlear nerve entering the modiolus. The cochlea communicates below the meatal fundus with the vestibule. It is
rare to enter the cochlea in a retrosigmoid approach. A. = artery; Car. = carotid; CN = cranial nerve; Coch. = cochlear; Endolymph.
= endolymphatic; Gang. = ganglion; Gen. = geniculate; Gr. = greater; Inf. = inferior; Intermed. = intermedius; Jug. = jugular; Laby.
= labyrinthine; M. = muscle; N. = nerve; Nerv. = nervus; Pet. = petrosal, petrous; Post. = posterior; Seg. = segment; Subarc. =
subarcuate; Sup. = superior; Tens. = tensor; Transv. = transverse; Tymp. = tympani; Vert. = vertical; Vest. = vestibular.

the posterior part of the floor of the middle fossa between
the trigeminal prominence medially and the arcuate emi-
nence laterally (Figs. 1A and 2C). The average distance
between the meatal porus and meatal fundus is 8 mm.28
The angle between the long axis of the central part of the
internal acoustic meatus and the line along the outer diam-
1100 J Neurosurg  Volume 125 • November 2016
eter of the basal turn averaged 58.9° (range 51.2°–63.3°;
Table 1 and Fig. 3). The cochlea bulges upward anterome-
dial to the fundus of the internal acoustic meatus (Figs.
1B and 2B–E). The transverse crest divides the lateral end
of the meatus (meatal fundus) into superior and inferior
halves (Figs. 2B, 5B and C, and 6B). The area above the
 Cochlea in skull base surgery

Fig. 6. Extradural right middle fossa exposure.  A: Inset shows the extradural exposure and the GPN. The roof of the internal
acoustic meatus has been removed and the dura opened to expose the nerves in the meatus. Drilling to expose the internal
acoustic meatus usually begins at the level of the petrous ridge above the porus of the meatus and is directed laterally and forward
toward the fundus of the meatus, where the exposure progressively narrows. The cochlea is positioned in the bone below the angle
between the junction of the GPN and the labyrinthine segment of the facial nerve.  B: Drilling has been extended to open and show
the position of the cochlea along the anteromedial edge of the meatal fundus and the vestibule along the posterolateral margin
of the meatal fundus. The lateral edge of the cochlea extends below the labyrinthine segment of the facial nerve, and the apical
turn extends below the greater petrosal nerve. Care must be taken in the middle fossa approach to the internal acoustic meatus to
avoid entering the cochlea and vestibule because if either the cochlea or the vestibule is entered hearing will be lost.  C: An ante-
rior petrosectomy approach directed through the area medial to the internal acoustic meatus has been completed. The exposure is
directed posterior to the GPN and below the trigeminal nerve to the lateral edge of the clivus adjacent to the inferior petrosal sinus
and to the posterior fossa dura that faces the brainstem.  D: The dura below the superior petrosal sinus and lateral to the trigemi-
nal nerve has been opened to expose the anterior surface of the pons. The dural incision crosses the superior petrosal sinus and
tentorium. The dural edges have been retracted to expose the lower midbrain and upper pons and the superior cerebellar artery.
The exposure extends above and below the trigeminal nerve to the anterolateral pons and to the lateral edge of the clivus. A.I.C.A.
= anterior inferior cerebral artery; CN = cranial nerve; Coch. = cochlear; Gang. = ganglion; Gen. = geniculate; Gr. = greater; Inf. =
inferior; Intermed. = intermedius; Laby. = labyrinthine; N. = nerve; Nerv. = nervus; Pet. = petrosal, petrous; Post. = posterior; S.C.A.
= superior cerebellar artery; Seg. = segment; Sup. = superior; Temp. = temporal; Tent. = tentorium; Transv. = transverse; Tymp. =
tympanic; Vert. = vertical; Vest. = vestibular; V3 = third division of trigeminal nerve; Zygo. = zygomatic.

transverse crest is further divided by the vertical crest, also Discussion

called “Bill’s bar,” which separates the anteriorly located
facial canal from the posteriorly located superior vestibu-
lar area (Fig. 6B).21 The cochlea and inferior vestibular
nerves penetrate the lateral end of the meatus below the
transverse crest, with the cochlear nerve being located an-
teriorly. Djalilian et al.8 examined the relationship between
the internal and the external acoustic meati by using axial
and coronal CT and found that the anterior wall of the ex-
ternal acoustic meatus was always anterior to the anterior
wall of the internal acoustic meatus. However, in our dis-
sections, after exposing the external acoustic meatus from
above, the medial extension of the long axis of the central
part of the external acoustic meatus approximated the long
axis of the internal acoustic meatus.
The cochlea is not seen when viewing any surface of
the temporal bone. An understanding of its location and
relationships is crucial to its preservation in middle fossa
approaches to the internal acoustic meatus and anterior
petrosectomy and for locating and preserving adjacent
structures including the petrous carotid and facial nerve
in approaches directed through the cochlea. Locating the
cochlea is based on familiarity with the orientation of the
modiolar axis and turns of the cochlea and the distance
between the cochlea and adjacent structures (Table 1 and
Fig. 3).
Three methods have been applied to the investigation
of the anatomy of the cochlea and its relationship with
J Neurosurg  Volume 125 • November 2016 1101
J. Wang et al.
surrounding structures. Dimopoulos and Muren7 and Er-
ixon et al.9 elegantly displayed the cochlea using corrosion
casts of human inner ears. In this method, the specimens
were placed in a wax form, and polyester resin or rubber-
ized silicone rubber was injected into the wax form from
the orifices of the inner ear canals. Thereafter, the bone
was dissolved with hydrochloric acid to expose the co-
chlea, semicircular canals, and facial nerve for study. In
our study, the geniculate ganglion, adjacent segment of the
GPN, labyrinthine and tympanic segments of the facial
nerve, and petrous carotid were landmarks used in esti-
mating the position of the cochlea, and all may be exposed
to a variable degree by spontaneous dehiscence in the
bone of the floor of the middle fossa.6,24 High-resolution
CT has also been used to locate the cochlea.8,22 There is
a high correlation between anatomical and CT measure-
ments in middle cranial fossa anatomy.25
Middle Cranial Fossa Approach
The middle fossa approach was developed by House
and Crabtree14 to remove tumors in the internal acoustic
meatus and has been modified to include removal of the
petrous bone lying within the Kawase rhomboid demar-
cated by the GPN anteriorly, the trigeminal nerve and in-
ferior petrosal sinus medially, and the superior semicircu-
lar canal laterally (Fig. 6).17 The latter approach, referred
to as the “anterior transpetrosal approach,” “Kawase’s
approach,” or “anterior petrosectomy,” has been used to
reach lesions in the ipsilateral upper anteromedial part of
the cerebellopontine angle and the clivus.17 Hearing loss
caused by cochlear damage during drilling is a poten-
tial complication of the middle fossa approach. Although
it was reported that the second turn and the apex of the
cochlea are more superficial than the basal turn, it is the
basal turn that is most commonly damaged in the middle
cranial fossa approach, with a resultant loss of hearing,
because the second turn and the cochlear apex are more
concealed below the geniculate ganglion and GPN in the
middle fossa approach.1
Multiple methods have been devised to estimate the lo-
cation of the internal acoustic meatus in the area below the
middle fossa floor. House and Crabtree14 described a meth-
od of following the GPN and the labyrinthine segment of
the facial nerve medially to the internal acoustic meatus.
Sennaroglu and Slattery25 suggested that the cochlea will
not be encountered if drilling is confined to the area supe-
rior to the labyrinthine segment. We found that the super-
ficial edge of the basal turn may extend below the middle
fossa floor on the medial side of the labyrinthine segment
to the level of the superior edge of the labyrinthine seg-
ment. Drilling medial to the labyrinthine segment risks
penetrating the cochlea. Fisch et al.10 described an imagi-
nary line drawn 60° medial to a line directed along the
long axis of the arcuate eminence and superior semicir-
cular canal that approximates the location of the internal
acoustic meatus, although there is controversy about the
size of this angle.5 This method may require some drilling
of the arcuate eminence to locate the superior semicircu-
lar canal. Garcia-Ibanez and Garcia-Ibanez11 described a
method of locating the internal acoustic meatus that com-
bines the methods described by House and Crabtree14 and
1102 J Neurosurg  Volume 125 • November 2016
Fisch et al.10 In their method, the internal acoustic meatus
is located below an imaginary line that bisects the angle
between the long axis of the superior semicircular canal
and the GPN. Tanriover et al.28 estimated the position of
the internal acoustic meatus by extending a line 61° pos-
teromedial to the long axis of the GPN. The meatal drill-
ing and exposure was begun where the imaginary line
along the middle part of the external acoustic meatus in-
tersected the petrous ridge rather than over the GPN and
labyrinthine segment of the facial nerve.
The following points may also help in locating the co-
chlea. First, the axis along the outer diameter of the basal
turn roughly parallels the GPN. The average distance be-
tween the GPN and anterior edge of the basal turn was 3.9
mm. Second, the basal turn is in the anterior one-third of
the area between the GPN and petrous ridge. Third, ap-
proximately one-third of the lateral part of the cochlea
underlies the labyrinthine segment of the facial nerve
and geniculate ganglion. The mean distance between the
medial edge of the basal turn and the medial side of the
labyrinthine segment of the facial nerve, which is located
above the lateral edge of the basal turn, was 4.3 mm (range
3.7–5.1; Table 1 and Fig. 3). The extensive anatomical vari-
ation in dimension, height, shape, and number of the turns
of the human cochlea will also influence the location of
the cochlea.4,9
Transmastoid-Transcochlear Approach
The transmastoid-transcochlear approach encompasses
the removal of the entire otic capsule including the co-
chlea, vestibule, and semicircular canals to gain access
to the anteromedial posterior fossa, brainstem, and clivus
through the petrous apex (Fig. 7).2,13,15 The transcochlear
approaches may involve transposing or rerouting the facial
nerve posteriorly or skeletonizing the nerve and working
around it, followed by removal of the cochlea and petrous
apex.
After completing the mastoidectomy, the tympanic and
labyrinthine segments of the facial nerve, which course
adjacent to the lateral and superior semicircular canals, re-
spectively, are exposed after removal of these canals. The
inferior surface of the labyrinthine segment of the facial
nerve sits near the superior aspect of the basal turn of the
cochlea. The labyrinthine segment is positioned an aver-
age of only 0.4 mm superior to the cochlea (Table 1 and
Fig. 3). Care is taken to preserve the facial nerve when re-
moving the inferior part of the semicircular canals and the
superior portion of the cochlea. The trochleariform pro-
cess, located just below the tympanic segment of the facial
nerve, is an important landmark for avoiding injury to this
part of the facial nerve during removal of the cochlea. The
cochlea is positioned medial to the promontory, inferior
and medial to the trochleariform process, and between the
labyrinthine and tympanic segments and the geniculate
ganglion and posterior genu of the petrous carotid artery.
The distances between the cochlear turns and the facial
nerve and carotid artery in the elderly are greater than
those in younger children.30
Retrosigmoid Approach
The cochlea is rarely at risk of being entered or dam-
 Cochlea in skull base surgery

Fig. 7. Transmastoid-transcochlear approach.  A: A right retrolabyrinthine approach with exposure of the superior, lateral, and
posterior semicircular canals, facial nerve and recess, and chorda tympani has been completed.  B: The GPN has been sectioned
just distal to the apex of the geniculate ganglion, and the facial nerve has been displaced posteriorly to allow removal of the
cochlea in the transcochlear approach. The semicircular canals and vestibule have been removed. Drilling has been extended into
the petrous apex, and the cochlea has been opened. The cochlear nerve penetrates the modiolus at the fundus of the meatus. The
osseous spiral crest in the cochlea has been exposed. Drilling the cochlea often requires that at least the posterior portion of the
ring of bone supporting the tympanic membrane be removed.  C: Enlarged view. The anterior inferior cerebellar artery loops later-
ally to the fundus of the meatus.  D: Completed transcochlear approach. The exposure extends to the lateral edge of the clivus
and the inferior petrosal sinus. The basilar artery and anterior surface of the pons are at the deep end of the exposure. A. = artery;
A.I.C.A. = anterior inferior cerebral artery; Bas. = basilar; Chor. = chorda; CN = cranial nerve; Coch. = cochlear; Flocc. = flocculus;
Inf. = inferior; Jug. = jugular; Lat. = lateral; Mast. = mastoid; Memb. = membrane; N. = nerve; Pet. = petrosal; Post. = posterior;
Seg. = segment; Sup. = superior; Tymp. = tympani, tympanic.

aged in the retrosigmoid approach because it is located Acknowledgments

anteromedial to the meatal fundus (Fig. 5E and F). The
greater risk to hearing in the retrosigmoid approach is
damage to the semicircular canals and vestibule located
posterolateral to the fundus of the meatus and the cochlea.
The greatest risk is to the posterior canal, posterior half of
the superior and lateral canals, common crus, and vesti-
bule. Drilling below the meatal fundus may reach the level
of the communication between the vestibule and cochlea,
but hearing has already been lost at this point because of
damage to the part of the labyrinth lateral to the cochlea
(Fig. 5F).
Conclusions
An understanding of the location and relationships of
the cochlea will reduce the likelihood of cochlear dam-
age and hearing loss in approaches directed through the
middle fossa and reduce the incidence of injury to adjacent
structures in approaches directed through the cochlea.
We thank Robin Barry, MA, for her assistance with the prepa-
ration of the illustrations and Jessica Striley, BS, for her editorial
assistance. This work was supported by the University of Florida
Foundation.
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Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: Rhoton, Wang. Acquisition of data: Rho-
ton, Wang, Yoshioka, Joo, Quilis-Quesada. Analysis and interpre-
tation of data: Rhoton, Wang. Drafting the article: Rhoton, Wang.
Critically revising the article: Rhoton, Wang, Komune. Reviewed
submitted version of manuscript: Rhoton, Wang, Komune, Quilis-
Quesada. Approved the final version of the manuscript on behalf
of all authors: Rhoton. Statistical analysis: Wang. Administrative/
technical/material support: Rhoton. Study supervision: Rhoton.
Correspondence
Albert L. Rhoton Jr., Department of Neurosurgery, University
of Florida, P.O. Box 100265, Gainesville, FL 32610. email:
rhoton@neurosurgery.ufl.edu.