Transpterygoid approach, step by step. The pterygoid process has been further drilled to completely skeletonize the vidian nerve as it reaches the inferolateral aspect of the foramen lacerum. The pterygosphenoidal fissure ends up at the inferomedial aspect of the foramen lacerum. Vidian nerve and pterygosphenoidal fissure converge on the lower aspect of the foramen lacerum, and the bone that remains in between is called the pterygoid tubercle. The bone on the medial wall of the middle cranial fossa, lateral to the paraclival ICA, has been removed just leaving the lingual process that forms the lateral wall of the upper aspect of the foramen lacerum. (Image courtesy of JC Fernandez-Miranda)