The jugular foramen is located at the skull base and formed by bones of the temporal and occipital bones. It contains nerves IX-XI and often the inferior petrosal sinus. Approaches to access the jugular foramen include posterior, lateral, and anterior. The posterior approach uses a suboccipital retrosigmoid, transcondylar, or supracondylar route. Lateral approaches are juxtacondylar or lateral skull base. Anterior approaches use a postauricular transtemporal or preauricular subtemporal route. Surgical techniques aim to expose the jugular foramen while preserving nearby structures like cranial nerves and vessels.

1. JUGULAR FORAMEN ANATOMY
AND APPROACHES
Dr Dikpal

2. Anatomy
• located at the posterolateral skull base
• long axis obliquely directed in the
posterolateral to anteromedial
• formed by the petrous temporal bone
anterolaterally and by the jugular process of
the condylar part of the occipital bone
posteromedially

8. • The jugular foramen is traditionally divided
into a large posterolateral compartment (pars
venosa) and a smaller anteromedial
compartment (pars nervosa)
• three compartments: two venous
compartments and one neural intrajugular
compartment in between

9. • The venous compartments include a large
posterolateral sigmoid part and a small
anteromedial petrosal part.
• At the junction : two bony prominences
(intrajugular processes), arising from the
temporal and occipital bones: intrajugular
septum

10. • The dura over the intrajugular septum has two
characteristic perforations:
• (1) The glossopharyngeal meatus for the IX
nerve and
• (2) A larger vagal meatus for X and XI nerves

13. • The inferior petrosal sinus (IPS) joins the
jugular bulb in 90%, passing between the IX
nerve superolaterally and the X and XI nerves
inferomedially
• In 10% it drains directly into the internal
jugular vein

14. Condylar emissary vein
• The occipital condyle (OC) contains a condylar
emissary vein in 70% of cases.
• This posterior condylar vein enters the jugular
foramen at its posteromedial part and serves
as a landmark to the foramen for the posterior
approaches
• The hypoglossal canal contains a venous
plexus, called anterior condylar vein in
addition to the XII nerve

15. Relations at skull base

18. Classification of JF lesions
• Fisch’s and Glasscock and Jacobson’s
classification for glomus jugular tumours
• Keye’s and Franklin’s classification for
schwannoma.
• The one proposed by Bertalanffy and Ulrich is
applicable to any type of lesion

19. Bertalanffy and Ulrich classification

20. difficulties in exposing
• its deep location
• the carotid artery anteriorly,
• the facial nerve laterally,
• the hypoglossal nerve medially,
• The vertebral artery inferiorly,

21. Surgical approaches
• Posterior
• Lateral
• Anterior

22. Posterior approach
• Sub occipital (SO) retrosigmoid
• SO transcondylar
• SO supracondylar

23. SO retrosigmoid
• One component of more extensive exposure
• Main indication (intradural)
type A schwannoma, acoustic schwannoma
epidermoid cyst
• Intracranial part of JF exposed by dissecting
arachnoid around 9,10,11
• Disadv: extradural and intrajugular

24. Suboccipital Transcondylar
• More extended lateral and inferior exposure
Bony resection includes
• Post and medial occipital condyle
• Jugular tubercle to expose hypoglossal canal
• Jugular foramen dorsally and inferiorly (post
emissary vein landmark)
• Risk : Injury (VA, CN)

25. Supracondylar app
• Small lesion limited to hypoglossal canal and
medial rim of JF
• SOC extended down to supracondylar fossa
• OC and FM preserved
• Jugular tubercle drilled extradurally
• Disadv : radical resection not possible

26. Anterolateral Approach
• Postauricular transtemporal
• Preauricular subtemporal – infratemporal
approach
• The skin incision: pre- or retroauricular, and
starts above the level of the pinna
• extends in a curvilinear fashion inferiorly into
the neck superficial to the SCM

28. Postauricular transtemporal
• Key component : mastoidectomy and neck
dissection
• Mastoidectomy : involve the intralabyrinthine
region with exposure of the sigmoid sinus,
jugular bulb, and mastoid portion of the facial
nerve
• Facial nerve mobilsed
• Rectus capitis lateralis ms detached
• Hearing does not sacrificed

29. Preauricular subtemporal –
infratemporal approach
• Preauricular incision across zygoma
• FT craniotomy
• Mobilisation of TM joint
• Middle cranial fossa removed , until carotid canal is
reached
• eustachian tube and tensor tympani muscle sacrificed
• removal styloid process allows anterior mobilization of
the internal carotid artery and access to the clivus.
• Drilling of Kawase's triangle gains access to the
posterior cranial fossa.

30. Fisch description
• Type A allows access to the temporal bone in
its infralabyrinthine and apical compartments
• Postauricular incision
• EAC transected
• Neck dissection : identification of CN , vessels
• Radical mastoidectomy and subtotal
petrosectomy
• Facial N anterior transposition

31. • Both middle and posterior cranial fossa dura in
front (Trautmann's triangle) and behind of the
sigmoid sinus are exposed.
• The petrous internal carotid artery is identified
and the eustachian tube is obliterated at its bony
isthmus.
• The mandibular condyle is resected, and the
temporal root of the zygoma and lateral orbital
rim are removed for additional exposure

33. Lateral approaches
• Juxtacondylar
• Lateral skull base

34. Juxtacondylar app
• Extradural, confined to jugular F
• Incision : superior nuchal line to medial border
of SCM below mastoid
• Transverse process of atlas removed and VA
transposed
• PL aspect of OA and AA joint exposed
• Post belly of digastric resected and occipital
artery ligated

35. • Partial mastoidectomy done distal SS exposed
• Post inf wall of jugular bulb drilled to expose
JF
• Adv : wide exposure of post inf JF without
petrous drilling : preserves hearing
• Extradural : no csf leak
• Risk : VA injury , venous bleed

36. Lateral Skull base
• Conserving Otic capsule
infratemporal fossa type A
Petro Occipital Trans Sigmoid (POTS)
• Sacrificing Otic Capsule
Translabyrinthine
transcochlear

37. Infratemporal fossa type A
• Incision : post auricular extending superiorly
to temporal region
• Inferiorly along ant border of SCM

39. • EAC closed
• VII CN exposed by neck dissection
• Lower CN , ICA, ECA, IJV exposed
• SCM and Digastric divided
• ECA ligated beyond Lingual br
• TM , malleus incus removed
• Radical mastoidectomy done

40. • VII CN freed from geniculate ganglion to
stylomastoid foramen and transposed
anteriorly
• Mandibular condyle is resected
• SS is packed or ligated
• Lateral wall of SS is opened to bulb and IPS
and entry of condylar vein packed
• ADV : wide exposure of anterior of JF till
petrous apex

41. Petro Occipital Trans Sigmoid
• Infralabyrinthine lateral skull base
• Indicated for :
• lower cranial nerve schwannomas with
intracranial extensions
• meningioma of the jugular bulb small
petroclival meningiomas lying anterio to the
internal auditory canal (IAC) with preserved
hearing.

42. • Technique: c shaped post auricular incision
• U shaped musculoperiosteal flap raised
• SCM retracted post
• IJV ant to lateral process of atlas identified &
ligated
• Radical mastoidectomy
• VII CN and JB identified

43. • Bone over SS and JB and posterior fossa dura
in front of the SS are removed
• suboccipital craniotomy
• The infralabyrinthine petrous bone is drilled
away taking care not to injure the posterior
semicircular canal or VII nerve.
• The occipital condyle is partially drilled up to
the hypoglossal canal

44. • SS is then opened and packed distally and
proximally
• A horizontal dural incision is made starting
posterior to the SS, coursing anteriorly traversing
the medial wall of the SS
• The removal of the lateral wall of the JB and, if
necessary, its medial wall, fully exposes the
intracranial part of IX−XI nerves.
• The dura over the drilled part of the OC is
excised exposing the hypoglossal canal

45. • ADV: hearing preserved
• Disadv: limited control over ICA , so
involovemet of ICA is contraindication