Pediatric Middle Fossa Craniotomy: Institutional Experience and Surgical Outcomes

Introduction: Middle fossa craniotomy (MFC) with exposure of the internal auditory canal and/or petrous apex (anterior petrosectomy) is an uncommon operation in the pediatric population. We report our institution’s experience and surgical outcomes with pediatric MFC. Methods: We conducted a retrospective review for MFC with exposure of the internal auditory canal and/or petrous apex performed at our institution from 2018-2024 in patients aged 18 and under. Data collected included demographics, office visits, surgery and inpatient stay, audiometrics, and imaging. Results: Sixteen patients met our inclusion criteria. Median age was 12 years (range 1-18), 10 (63%) were male. The pathology treated was: 9 (56%) VS, of which 7 were neurofibromatosis 2 (NF2); and 1 (6%) each of grade I meningioma, clear cell meningioma, epidermoid cyst, cavernous malformation, atypical teratoid rhabdoid tumor, anaplastic ependymoma, prepontine abscess. On preoperative MRI, median tumor size was 12.5 mm (range 3-63). Gross total resection was achieved in 11 (69%) cases, near total in 1 (6%), and subtotal in 4 (25%). There was 1 (6%) case of CSF leak. Median length of stay was 3 days. Sixth nerve palsy was sustained in 3 (19%) cases. Facial nerve outcomes were favorable: of 11 patients with preoperative House-Brackmann (HB) I, 10 (91%) maintained HB1 postoperatively. For VS, hearing outcomes were evaluated: Preoperatively, all patients had class A hearing. At first postoperative follow-up (median 8 days), 5 (56%) maintained class A hearing and 4 (44%) were class D. At latest follow-up (median 678 days), of the 5 patients with preserved hearing, 4 maintained class A hearing, and the other one progressed to class B. On follow-up MRI (median 172 days), 7 (50%) had no evidence of disease, 1 (7%) had linear enhancement, and 6 (43%) had nodular enhancement. Of the 6 with nodular enhancement, 5 had NF2. Conclusion: Pediatric MFC can be used to approach a variety of intracranial pathologies. VS in NF2 is the most common indication and has favorable facial nerve outcomes and hearing preservation rates similar to those in adult NF2. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany