A, The scalp flap has been reflected forward to expose the sternocleidomastoid, parotid gland, and the greater auricular nerve. B, The external canal has been divided to reflect the flap forward for a parotid and neck dissection that exposes the facial nerve and its trunks, the posterior digastric belly, and the internal jugular vein. C, The mastoidectomy has been completed to expose the presigmoid dura, the sigmoid sinus, and the semicircular canals. The mandibular condyle has been resected to provide access to the infratemporal fossa. D, A temporo-occipital craniotomy has been completed, the zygomatic arch opened, and the temporalis muscle reflected to expose the maxillary artery and pterygoid muscles in the infratemporal fossa. E, Enlarged view of the temporal and infratemporal exposures. The posterior wall of the external canal has been removed. The auriculotemporal branch of the mandibular nerve is often split into two rootlets by the middle meningeal artery. F, Enlarged view of the tympanic cavity. The anterior part of the lateral semicircular canal is located above the tympanic segment of the facial nerve. The promontory overlies the basal cochlear turn. G, The external canal has been resected in preparation for exposing the petrous carotid. H, The junction of the cervical and petrous carotid has been exposed in the area below the promontory. The lateral margin of the stylomastoid and jugular foramina have been removed to expose the jugular bulb below the semicircular canals. I, The mandibular nerve has been exposed below the foramen ovale. A more extensive exposure of the petrous carotid has been completed so that the artery can be reflected forward out of the carotid canal to provide access for drilling of the petrous apex. J, The petrous carotid has been reflected forward and the petrous apex removed to expose the clivus and inferior petrosal sinus. K, The facial nerve has been moved out of the facial canal, and a total labyrinth and petrous apicectomy have been completed. L, A segment of the sigmoid sinus and the jugular bulb have been removed to expose the nerves passing through the jugular foramen. The dura has been opened and the facial nerve displaced posteriorly. The temporal lobe has been elevated to expose the subtemporal area while preserving the vein of Labbe´. (Images courtesy of AL Rhoton, Jr.)