Jugular Foramen

Albert L. Rhoton, Jr., M.D.

Department of Neurological Surgery, University of Florida, Gainesville,
Florida
-------------------------------------------------------------------------------The jugular foramen is difficult to understand and to access surgically (3, 11,
15, 19, 24, 28). It is difficult to conceptualize because it varies in size and
shape in different crania, from side to side in the same cranium, and from its
intracranial to extracranial end in the same foramen, and because of its
complex irregular shape, its curved course, its formation by two bones, and
the numerous nerves and venous channels that pass through it (Fig. 9.1 A-D,
9.1 E-H). The difficulties in exposing this foramen are created by its deep
location and the surrounding structures, such as the carotid artery anteriorly,
the facial nerve laterally, the hypoglossal nerve medially, and the vertebral
artery inferiorly, all of which block access to the foramen and require careful
management.
The jugular foramen is divided into three compartments: two venous and a
neural or intrajugular compartment. The venous compartments consist of a
larger posterolateral venous channel, the sigmoid part, which receives the flow
of the sigmoid sinus, and a smaller anteromedial venous channel, the petrosal
part, which receives the drainage of the inferior petrosal sinus. The petrosal
part forms a characteristic venous confluens by also receiving tributaries from
the hypoglossal canal, petroclival fissure, and vertebral venous plexus. The
petrosal part empties into the sigmoid part through an opening in the medial
wall of the jugular bulb between the glossopharyngeal nerve anteriorly and the
vagus and accessory nerves posteriorly. The intrajugular or neural part,
through which the glossopharyngeal, vagus, and accessory nerves course, is
located between the sigmoid and petrosal parts at the site of the intrajugular
processes of the temporal and occipital bones, which are joined by a fibrous or
osseous bridge. The glossopharyngeal, vagus, and accessory nerves penetrate
the dura on the medial margin of the intrajugular process of the temporal bone
to reach the medial wall of the internal jugular vein. The operative approaches
that access various aspects of the foramen and adjacent areas are the
postauricular transtemporal, retrosigmoid, extreme lateral transcondylar, and
preauricular subtemporal-infratemporal approaches.

OSSEOUS RELATIONSHIPS
The jugular foramen is located between the temporal bone and the occipital
bone (Figs. 9.1 A-D, 9.1 E-H and 9.2). The right foramen is usually larger than
the left. In a previous study, we observed that the right foramen was larger
than the left in 68% of the cases, equal to the left in 12%, and smaller than the
left in 20% (24). The foramen is configured around the sigmoid and inferior
petrosal sinuses. It can be regarded as a hiatus between the temporal and the
occipital bones. The structures that traverse the jugular foramen are the
sigmoid sinus and jugular bulb, the inferior petrosal sinus, meningeal branches
of the ascending pharyngeal and occipital arteries, the glossopharyngeal,
vagus, and accessory nerves with their ganglia, the tympanic branch of the
glossopharyngeal nerve (Jacobson's nerve), the auricular branch of the vagus
nerve (Arnold's nerve), and the cochlear aqueduct.
The foramen is situated so that its long axis is directed from posterolateral
to anteromedial, giving it an anterolateral margin formed by the temporal bone
and a posteromedial margin formed by the occipital bone. From the
intracranial end, it is directed forward, medially, and downward. One cannot
see through the foramen when viewing the skull from directly above or below
because of its roof, formed by the lower surface of the petrous part of the
temporal bone. The foramen, when viewed from the intracranial side in a
posterior to anterior direction, has a large oval lateral component, referred to
as the sigmoid part, because it receives the drainage of the sigmoid sinus, and
a small medial part, called the petrosal part, because it receives the drainage of
the inferior petrosal sinus. The view through the foramen from directly below
reveals the part of the temporal bone forming the dome of the jugular bulb,
rather than a clear opening.
The junction of the sigmoid and petrosal parts is the site of bony
prominences on the opposing surfaces of the temporal and occipital bones,
called the intrajugular processes, which are joined by a fibrous, or less
commonly, and osseous bridge, the intrajugular septum, separating the
sigmoid and petrosal part of the foramen.
Although the margins of the jugular foramen are formed by the petrosal part
of the temporal bone and the condylar part of the occipital bone, the other
parts of these bones also have important relationships to the jugular foramen.
The petroclival fissure, the fissure between the lateral edge of the clival part of
the occipital bone and the petrous part of the temporal bone, intersects the
anteromedial edge of the foramen, and the occipitomastoid suture, the suture

between the mastoid portion of the temporal bone and the condylar part of the
occipital bone, intersects its posterolateral edge.
The intrajugular processes of the temporal and occipital bones divide the
anterior and posterior edges of the foramen between the sigmoid and petrosal
parts. The intrajugular process of the temporal bone protrudes farther into the
jugular foramen than the opposite process from the occipital bone, and may
infrequently reach the smaller intrajugular process of the occipital bone,
dividing the jugular foramen into two bony foramina. A ridge, the intrajugular
ridge, extends forward from the intrajugular process of the temporal bone
along the medial edge of the jugular bulb (Fig. 9.1 A-D, 9.1 E-H). The
glossopharyngeal nerve courses along its medial edge. Occasionally, the edge
of this ridge extends medially toward the adjacent part of the temporal bone to
create a deep groove in which the nerve courses or it may reach the temporal
bone to form a canal, which surrounds the glossopharyngeal nerve as it passes
through the jugular foramen.
The drainage of the sigmoid sinus is directed forward into the sigmoid
portion of the foramen, where a high domed recess, the jugular fossa, forms a
roof over the top of the jugular bulb (Figs. 9.1 A-D, 9.1 E-H and 9.3). This
recess, which has its summit slightly lateral to the entrance of the sigmoid
sinus, is usually larger on the right side of the skull, reflecting the larger
sigmoid sinus on that side. The dome of the recess is usually smooth as it
conforms to the jugular bulb, but the summit may also be ridged and irregular.
A small triangular recess, the pyramidal fossa, extends forward on the medial
side of the intrajugular process of the temporal bone along the anterior wall of
the petrosal part of the foramen. The external aperture of the cochlear
canaliculus, which houses the perilymphatic duct and a tubular prolongation
of the dura mater, opens into the anterior apex of the pyramidal fossa. The
glossopharyngeal nerve enters this fossa below the point at which the cochlear
aqueduct joins its apex.
The jugular process of the condylar portion of the occipital bone, which
extends behind the jugular foramen and connects the clival and squamosal
parts of the occipital bone, forms the posteromedial wall of the foramen. This
process extends laterally from the area above the posterior half of the occipital
condyle and is penetrated by the hypoglossal canal. The upper surface of the
jugular process of the occipital bone in the area superomedial to the foramen
presents an oval prominence, the jugular tubercle, which is located above the
hypoglossal canal. The jugular tubercle often has a shallow furrow marking
the site of passage of the glossopharyngeal, vagus, and accessory nerves
across its surface. The terminal end of the sigmoid sinus courses forward on

the superior surface of the jugular process in a deep hook-like groove, the
sigmoid sulcus, which is directed medially into the sigmoid portion of the
jugular foramen.
On the lateral wall of the jugular foramen, a few millimeters inside the
external edge, just behind the point at which the occipitomastoid suture
crosses the lateral edge of the foramen, is a small foramen, the mastoid
canaliculus, and a shallow groove leading from medial to lateral across the
anterior wall of the sigmoid part to the mastoid canaliculus (Figs. 9.2 and 9.3).
The auricular branch of the vagus nerve (Arnold's nerve) courses along the
groove and enters the canaliculus. The nerve passes through the mastoid and
exits the bone in the inferolateral part of the tympanomastoid suture. At the
site where the intrajugular ridge of the temporal bone meets the carotid ridge,
a small canal, the tympanic canaliculus, is directed upward, leading the
tympanic branch arising from the inferior glossopharyngeal ganglion
(Jacobson's nerve) to the tympanic cavity (Figs. 9.2). Looking from below at
the extracranial orifice of the jugular foramen, it can be recognized that the
glossopharyngeal nerve courses along the medial side of the intrajugular
process and ridge to reach the area below the tympanic canaliculus.
ADJACENT BONY STRUCTURES
On the intracranial side, the petrosal part of the foramen is located
approximately 5 mm below the porus of the internal canal and 5 mm above the
intracranial orifice of the hypoglossal canal (Figs. 9.2 and 9.4 A-D, 9.4 E-H,
9.4 I-N). The lateral edge of the foramen is located below and in
approximately the sagittal plane through the lateral end of the internal acoustic
meatus. The jugular tubercle, a rounded prominence located at the junc tion of
the basal and condylar parts of the occipital bone, is situated approximately 8
mm medial to the medial edge of the jugular foramen. The otic capsule, which
is situated in the petrous part of the temporal bone and which contains the
semicircular canals and cochlea, is located superior to the dome of the jugular
bulb.
The occipital condyle is located along the lateral margin of the anterior half
of the foramen magnum in the area below and medial to the jugular foramen.
The hypoglossal canals, which pass through the condylar part of the
occipital bone in the area above the occipital condyles, are located medial to
the jugular foramina (Figs. 9.1 A-D, 9.1 E-H and 9.3). The intracranial end of
the hypoglossal canal is situated below the jugular tubercle approximately 5
mm inferomedial to the petrosal part of the jugular foramen and several

millimeters below the lower part of the petroclival fissure. A more detailed
review is included in the chapter on the far-lateral approach.
The anterior margin of the jugular foramen, when viewed extracranially, is
formed by the narrow ridge of temporal bone, the carotid ridge, which
separates the foramen and the carotid canal (Figs. 9.1 A-D, 9.1 E-H and 9.2).
The tympanic canaliculus opens on or near the medial part of the carotid ridge.
The styloid process and the stylomastoid foramen are located lateral to the
outer orifice of the jugular foramen, with the styloid process being located
slightly anteromedial to the stylomastoid foramen. The facial nerve exits the
stylomastoid foramen approximately 5 mm lateral to the lateral edge of the
jugular foramen. The anterior margin of the jugular foramen is located just
behind the part of the tympanic bone that forms the posterior wall of the
temporomandibular joint and the anterior and inferior wall of the external
auditory canal. The vaginal process of the tympanic bone, which separates
both the carotid canal and sigmoid part of the foramen from the glenoid fossa,
is the site of attachment of the styloid process to the skull base. The styloid
process projects downward from the vaginal process of the tympanic bone,
lateral to the foramen. The digastric groove is directed posteriorly from the
styloid process along the medial margin of the mastoid process. Access to the
jugular foramen is blocked laterally by mastoid and styloid processes, the
transverse process of the atlas, and the mandibular ramus (Figs. 9.3 and 9.4 AD, 9.4 E-H, 9.4 I-N).
The tympanic cavity, which is located medial to the tympanic membrane, is
situated above and lateral to the jugular bulb and the sharp right-angled curve,
called the lateral bend, at the junction of the vertical and horizontal segments
of the petrous carotid artery (Figs. 9.4 A-D, 9.4 E-H, 9.4 I-N). Several
structures that may be exposed during surgery for lesions in the jugular
foramen are the vertical and horizontal segments of the petrous portion of the
internal carotid artery, the eustachian tube, and the tensor tympani muscle.
Both the cochlea and semicircular canals are located in the petrous part of the
temporal bone above the dome of the jugular bulb (Figs. 9.4 A-D, 9.4 E-H, 9.4
I-N). The facial nerve in the temporal bone, which often blocks access to
lesions in the jugular foramen, descends through the mastoid lateral to the
jugular bulb. The endolymphatic sac is situated on the posterior surface of the
petrous bone between the two layers of the dura in the corner at which the
sigmoid sinus changes its course from a vertical direction to a horizontal one
(Figs. 9.3 and 9.5).
Dural architecture

At the intracranial orifice, the jugular foramen is divided into three

compartments by the dura mater: the petrosal compartment situated
anteromedially, the sigmoid compartment situated posterolaterally, and the
intrajugular or neural compartment situated between the petrosal and sigmoid
parts at the site of the intrajugular processes of the temporal and occipital
bones, the intrajugular septum, and the glossopharyngeal, vagus, and
accessory nerves (Figs. 9.3 and 9.5). The dura over the intrajugular part of the
foramen, which is located anteromedial to the sigmoid part, has two
characteristic perforations, a glossopharyngeal meatus, through which the
glossopharyngeal nerve passes, and a vagal meatus, through which the vagus
and accessory nerves pass (Figs. 9.5 and 9.6) (24). Both meatus are located on
the medial side of the intrajugular processes and septum. The
glossopharyngeal and vagal meatus are consistently separated by a dural
septum ranging in width from 0.5 to 4.9 mm (13). The only intradural site at
which the glossopharyngeal nerve is consistently distinguishable from the
vagus nerve is just proximal to this dural septum. The close origins of the
glossopharyngeal and vagus nerves at the brainstem, and the arachnoidal
adhesions between the two in their course through the subarachnoid space
may make separation difficult except in the area just proximal to the dural
septum. The superior glossopharyngeal ganglion is easily visible intracranially
in about one-third of nerves. The superior ganglion of the vagus can be seen
intracranially in only one-sixth of nerves. Although the cranial and spinal
portions of the accessory nerve most frequently enter the vagal meatus
together, a dural septum may separate them.
The upper and lateral margins of the intrajugular part of the foramen are the
site of a characteristic thick dural fold that forms a roof or lip that projects
inferiorly and medially to partially cover the glossopharyngeal and vagal
meatus (Figs. 9.5 and 9.6). This structure, called the jugular dural fold, was
ossified on both sides in one specimen (13, 16, 17, 24, 31). The lip projects
most prominently over the glossopharyngeal meatus and is comparable to, but
smaller than, the posterior lip of the internal acoustic meatus. It is either
predominantly bony or fibrous and may project a maximum of 2.5 mm over
the margin of the glossopharyngeal meatus. The vagal lip is less prominent,
projecting a maximum of 1 mm over the lateral margin of the vagal meatus.

Neural relationships

The glossopharyngeal, vagus, and accessory nerves arise from the medulla
as a line of rootlets situated along the posterior edge of the inferior olive in the
postolivary sulcus (Figs. 9.3 and 9.5). The hypoglossal nerve arises as a line of
rootlets that exit the brainstem along the anterior margin of the lower twothirds of the olive in the preolivary sulcus, a groove between the olive and
medullary pyramid.
The glossopharyngeal nerve, at the point at which it penetrates the dural
glossopharyngeal meatus, turns abruptly forward and then downward and
courses through the jugular foramen in the groove leading from the pyramidal
fossa below the opening of the cochlear aqueduct and along the medial side of
the intrajugular ridge. After the nerve exits the jugular foramen, it turns
forward, crossing the lateral surface of the internal carotid artery deep to the
styloid process. As the nerve transverses the jugular foramen, it expands at the
site of its superior and inferior ganglia (Fig. 9.5). At the external orifice of the
jugular foramen, it gives rise to the tympanic branch (Jacobson's nerve), which
traverses the tympanic canaliculus to enter the tympanic cavity where it gives
rise to the tympanic plexus, the fibers of which course in shallow grooves on
the promontory and regroup to form the lesser petrosal nerve, providing
parasympathetic innervation by way of the otic ganglion to the parotid gland.
The vagal rootlets enter the dural subcompartment, called the vagal meatus,
inferior to the glossopharyngeal meatus from which it is separated by a dural
septum (Figs. 9.5 and 9.6). It is joined by the accessory nerve as it enters the
dura. After its rootlets gather in the intracranial orifice of the foramen, the
vagus nerve expands at the superior ganglion, which is about 2.5 mm in
length, and ends below the extracranial orifice of the foramen. It sits on the
dura, covering the jugular foramen, and there, along the medial side of the
intrajugular process of the temporal bone, it turns downward. At the superior
ganglion, the vagus nerve communicates with the accessory nerve, a portion
of which blends into the ganglion. The auricular branch (Arnold's nerve) arises
at the level of the superior vagal ganglion and is joined by a branch from the
inferior glossopharyngeal ganglion (Fig. 9.3). The auricular branch passes
laterally in a shallow groove on the anterior wall of the jugular bulb to reach
the lateral wall of the jugular fossa, where it enters the mastoid canaliculus
and ascends toward the vertical (mastoid) segment of the facial canal, giving
off an ascending branch to the facial nerve as it crosses lateral to it before
turning downward to exit the temporal bone through the tympanomastoid
fissure.

The main trunk of the vagus nerve (or, more accurately, the superior
ganglion) courses anterior and inferior as it crosses below the midportion of
the intrajugular process of the temporal bone (Figs. 9.3 and 9.5). At the
intracranial orifice of the foramen, the intrajugular process of the temporal
bone separates the ganglion from the sigmoid sinus. In most cases, in the area
immediately below the dura at the level of the intrajugular processes, there are
no fibrous bands between the glossopharyngeal nerve and the vagal ganglion.
The vagus nerve exits the jugular foramen vertically, retaining an intimate
relationship to the accessory nerve (Figs. 9.3, 9.4 A-D, 9.4 E-H, 9.4 I-N, 9.5).
At the level the two nerves exit the jugular foramen, they are located behind
the glossopharyngeal nerve on the posteromedial wall of the internal jugular
vein. As the vagus nerve passes lateral to the outer orifice of the hypoglossal
canal, it is joined by the hypoglossal nerve medially. The vagus nerve begins
to expand at the site of the inferior vagal ganglion just below the foramen and
is approximately 2.5 cm in length.
Accessory nerve
Although the cranial and spinal portions of the accessory nerve most
frequently enter the vagal meatus together, they may infrequently be separated
by a dural septum. The spinal portion ascends toward the foramen magnum by
crawling along the surface of the dura and may even be buried in the dura
below the foramen magnum (Figs. 9.3, 9.5, and 9.6). At the dural orifice of the
jugular foramen, the nerve is often indistinguishable from the vagus nerve.
The accessory nerve usually enters the same dural subcompartment as the
vagus nerve and often adheres and blends into the vagus nerve at the level of
the superior vagal ganglion. The accessory nerve departs the vagal ganglion
after it exits the jugular foramen and descends obliquely laterally between the
internal carotid artery and internal jugular vein and then backward across the
lateral surface of the vein to reach its muscles. Approximately 30% of nerves
descend along the medial, rather than the lateral, surface of the internal jugular
vein (8).
Hypoglossal nerve
The hypoglossal nerve does not traverse the jugular foramen (Figs. 9.3, 9.4
A-D, 9.4 E-H, 9.4 I-N, 9.5). However, it joins the nerves exiting the jugular
foramen just below the skull and runs with them in the carotid sheath. The
nerve exits the inferolateral part of the hypoglossal canal and passes adjacent

to the vagus nerve, descends between the internal carotid artery and the
internal jugular vein to the level of the transverse process of the atlas, where it
turns abruptly forward along the lateral surface of the internal carotid artery
toward the tongue, leaving only the ansa cervicalis to descend with the major
vessels.
ARTERIAL RELATIONSHIPS
The arteries that may be involved in pathological abnormalities at the
jugular foramen include the upper cervical and petrous portions of the internal
carotid artery, the posteriorly directed branches of the external carotid artery,
and the upper portion of the vertebral artery (9.4 A-D, 9.4 E-H, 9.4 I-N).
Internal carotid artery
The internal carotid artery passes, almost straightly upward, posterior to the
external carotid artery and anteromedial to the internal jugular vein, to reach
the carotid canal (9.4 A-D, 9.4 E-H, 9.4 I-N). At the level of the skull base, the
internal jugular vein courses just posterior to the internal carotid artery, being
separated from it by the carotid ridge. Between them, the glossopharyngeal
nerve is located laterally and the vagus, accessory, and hypoglossal nerves
medially.
After the internal carotid artery enters the carotid canal with the carotid
sympathetic nerves and surrounding venous plexus, it ascends a short distance
(the vertical segment), reaching the area below and slightly behind the
cochlea, where it turns anteromedially at a right angle (the site of the lateral
bend) and courses horizontally (the horizontal segment) toward the petrous
apex (9.4 A-D, 9.4 E-H, 9.4 I-N). At the medial edge of the foramen lacerum,
it turns sharply upward at the site of the medial bend to enter the posterior part
of the cavernous sinus.

External carotid artery

The external carotid artery ascends anterior to the internal carotid artery.
Proximal to its terminal bifurcation into the maxillary and the superficial
temporal arteries, it gives rise to six branches, which can be divided into

anterior and posterior groups according to their directions. The latter group is
related to the jugular foramen.
The ascending pharyngeal artery, the first branch of the posterior group,
often provides the most prominent supply to the meninges around the jugular
foramen (9.4 A-D, 9.4 E-H, 9.4 I-N) (18). It arises either at the bifurcation or
from the lowest part of the external or internal carotid arteries. Rarely it arises
from the origin of the occipital artery. It courses upward between the internal
and the external carotid arteries, giving rise to numerous branches to
neighboring muscles, nerves, and lymph nodes. Its meningeal branches pass
through the foramen lacerum to be distributed to the dura lining the middle
fossa and through the jugular foramen or the hypoglossal canal to supply the
surrounding dura of the posterior cranial fossa. The ascending pharyngeal
artery also gives rise to the inferior tympanic artery, which reaches the
tympanic cavity by way of the tympanic canaliculus along with the tympanic
branch of the glossopharyngeal nerve.
The occipital artery, the second and largest branch of the posterior group,
arises from the posterior surface of the external carotid artery and courses
obliquely upward between the posterior belly of the digastric muscle and the
internal jugular vein (9.4 A-D, 9.4 E-H, 9.4 I-N). Its meningeal branches,
which enter the posterior fossa through the jugular foramen or the condylar
canal, may make a significant contribution to tumors of the jugular foramen.
The posterior auricular artery, the last branch in the posterior group, arises
above the posterior belly of the digastric muscle and travels between the
parotid gland and the styloid process. At the anterior margin of the mastoid
process, it divides into auricular and occipital branches, which are distributed
to the postauricular and the occipital regions respectively. The stylomastoid
branch, which arises below the stylomastoid foramen, enters the stylomastoid
foramen to supply the facial nerve. Its loss can lead to a facial palsy even
though it anastomoses with the petrosal branch of the middle meningeal artery.
The posterior auricular branch may share a common trunk with the occipital
artery, or sometimes it is absent, in which case, the occipital artery gives rise
to the stylomastoid artery. Members of the anterior group, whose origins may
be visualized in exposing lesions of the jugular foramen, include the superior
thyroid, lingual, and facial arteries.
Vertebral artery
The vertebral artery, as it ascends to reach and pass through the transverse
foramen of the atlas, is located below and behind the jugular foramen (9.4 A-

D, 9.4 E-H, 9.4 I-N). Branches encountered in approaches to lesions of the

jugular foramen include the meningeal, posterior spinal, and posteroinferior
cerebellar artery.
VENOUS RELATIONSHIPS
The jugular bulb and adjacent part of the internal jugular vein receives
drainage from both intracranial and extracranial sources, which include the
sigmoid and inferior petrosal sinuses, the vertebral venous plexus, the venous
plexus of the hypoglossal canal, the posterior condylar emissary vein, and the
vein coursing along the inferior aspect of the petroclival fissure (9.4 A-D, 9.4
E-H, 9.4 I-N and 9.5).
Sigmoid sinus and jugular bulb
The sigmoid sinus is the largest channel emptying into the jugular foramen
(Figs. 9.1 A-D, 9.1 E-H and 9.3, 9.4 A-D, 9.4 E-H, 9.4 I-N, 9.5). After
coursing down the sigmoid sulcus, the sinus turns anteriorly toward the
jugular foramen, crossing the occipitomastoid suture immediately proximal to
the foramen. From there, the sinus is directed forward below the petrous
temporal bone at the site of the jugular bulb. The upward bulging of the
superior margin of the jugular bulb creates a rounded fossa in the lower
surface of the temporal bone below the internal auditory canal. The dome of
the jugular bulb may extend upward in the posterior wall of the internal
auditory canal to the level of the upper margin of the canal. The bulb is
usually larger on the right side, reflecting the larger diameter of the sigmoid
sinus on that side. From the level of the jugular bulb, flow is directed
downward behind the tympanic bone and the carotid canal into the internal
jugular vein.
Inferior petrosal sinus and venous confluens
The foramen also receives the inflow from the inferior petrosal sinus and
the venous confluens in the petrosal part of the foramen. The inferior petrosal
sinus, which courses on the intracranial surface of the petroclival fissure,
communicates the cavernous sinus and basilar venous plexus at its upper end
and with the jugular bulb at its lower end (Figs. 9.3 and 9.5). The inferior
petrosal sinus, as it enters the petrosal part of the jugular foramen, forms a
plexiform confluens with the venous plexus of the hypoglossal canal, the

inferior petroclival vein, and tributaries from the vertebral venous plexus and
posterior condylar emissary vein. This confluens, which fills the petrosal part
of the foramen, usually consists of a main channel, 2 to 3 mm in diameter, and
several smaller channels, less than 1 mm in diameter. It empties into the
medial aspect of the jugular bulb through one or two openings in the venous
walls between the glossopharyngeal and vagus nerves or into the internal
jugular vein below the extracranial orifice.
The inferior petroclival vein courses along the extracranial surface of the
petroclival fissure and is a mirror image of the inferior petrosal sinus, which
courses along the intracranial surface of the fissure (Fig. 9.5). It empties into
the venous confluens at the lower end of the inferior petrosal sinus at or just
below the extracranial orifice of the jugular foramen or even above it, through
bony clefts between the temporal and occipital bones.
Bridging veins
A bridging vein, which courses posterior to the glossopharyngeal, vagus,
and accessory nerves from the dorsolateral medulla to the lower end of the
sigmoid sinus, is present in about one-third of cerebellopontine angles (Fig.
9.5, also see Fig. 3.12). Infrequently, a bridging vein extends from the ventral
medulla to the lower margin of the inferior petrosal sinus in front of the
nerves.
MUSCULAR RELATIONSHIPS
Several muscles that are encountered in the surgical approaches to the
jugular foramen and that provide important landmarks in the approach are
reviewed in detail in the chapters on the foramen magnum and temporal bone
(9.4 A-D, 9.4 E-H, 9.4 I-N). These include the sternocleidomastoid, situated
superficially in the lateral neck, and the splenius capitis, longissimus capitis,
levator scapulae, and scalenus medius muscles in a deeper muscular layer.
More anteriorly is the posterior belly of the digastric muscle, which arises
in the digastric groove located medial to the mastoid process and the
longissimus capitis. The styloid process and its attached muscles appear in the
triangular zone bounded by the posterior belly of the digastric, the external
auditory canal, and the mandibular ramus. Reflecting the digastric muscle
exposes the transverse process of the atlas, which is covered by the
attachments of numerous muscles, including the superior and inferior
obliques, which form the upper and lower margin of the suboccipital triangle.

The rectus capitis lateralis muscle is the muscle most intimately related to the
jugular foramen. It extends vertically behind the internal jugular vein from the
transverse process of the atlas to the jugular process of the occipital bone.
On the posterior neck are the trapezius muscle, splenius capitis, and
semispinalis capitis. Beneath the semispinalis capitis muscle, three muscles
arise between the inferior nuchal line and the margin of the foramen magnum:
the rectus capitis posterior major and minor and the superior oblique muscle.
The suboccipital triangle, an area defined by the opposing margins of the
rectus capitis posterior major and the superior and inferior oblique muscles, is
the site at which the vertebral artery courses along the upper posterior surface
of the atlas.
SURGICAL APPROACHES
Postauricular transtemporal approach
The postauricular transtemporal approach accesses the region from laterally,
through the mastoid, and from below, through the neck (Fig. 9.7 A-D, Fig. 9.7
E-H) (2, 4, 5). A C-shaped postauricular skin incision provides the exposure
for a mastoidectomy and the neck dissection. The external auditory canal is
either preserved or transected, depending on the anterior extent of the
pathological abnormality. The neck dissection is completed initially to gain
control of the major vessels and the branches supplying the tumor. The
internal carotid artery, branches of the external carotid artery, internal jugular
vein, and lower cranial nerves are exposed in the carotid sheath. A
mastoidectomy with extensive drilling of the infralabyrinthine region accesses
the jugular bulb. A limited mastoidectomy confined to the area behind the
stylomastoid foramen and mastoid segment of the facial nerve, combined with
removal of the adjacent part of the jugular process of the temporal bone, will
provide access to the posterior and posterolateral aspect of the jugular
foramen. Three obstacles to exposure of the full lateral half of the jugular
foramen, the facial nerve, styloid process, and rectus capitis lateralis muscle
are dealt with by transposing the facial nerve, removing the styloid process,
and dividing the rectus capitis lateralis muscle. Anterior extensions of the
pathological abnormality are reached by sacrificing the external and the
middle ear structures. Sensorineural hearing can be preserved by maintaining
the foot plate of the stapes in the oval window to avoid opening the labyrinth.
Intracranial extensions of the lesion are reached by the retrosigmoid or
presigmoid approaches after adding a suboccipital craniectomy. The lesion can

be removed by a transtemporal infralabyrinthine approach directed through

the temporal bone below the labyrinth without the neck dissection, if the
extracranial extension of the lesion is not prominent. The exposure can be
extended by opening the otic capsule (translabyrinthine approach).
Retrosigmoid approach
A pathological abnormality located predominantly intradurally can be
resected by the retrosigmoid approach (Fig. 9.6). A lateral suboccipital
craniectomy exposes the dura behind the sigmoid sinus. The dura is opened,
and the cerebellum is gently elevated away from the posterior surface of the
temporal bone to expose the cisterns in the cerebellopontine angle and the
intracranial aspect of the cranial nerves entering the jugular foramen,
hypoglossal canal, and internal acoustic meatus.
Far-lateral approach
An extended modification of the retrosigmoid approach, the far-lateral
approach, the subject of another chapter in this issue, may be selected if the
tumor extends down to the foramen magnum in front of or lateral to the lower
brainstem (10, 30, 32, 33). In this approach, the jugular foramen is opened
from behind. The dura is opened and the cerebellum elevated to expose the
intracranial extension of the pathological abnormality at the lower clivus and
at the foramen magnum. Several variations, depending on the location and
extent of the pathological abnormality, include drilling the jugular tubercle
extradurally and removing bone above without disturbing the condyle (21,
33). The extradural reduction of the jugular tubercle aids in minimizing the
retraction of the brainstem needed to reach the area anterior to the medulla and
pontomedullary junction.

Preauricular subtemporal-infratemporal approach

The preauricular subtemporal-infratemporal approach, reviewed in detail in
the chapter on the temporal bone (see Figs. 8.10 A-D, 8.10 E-F, 8.10 G-J and
8.18), exposes the jugular foramen anteriorly. It may be selected for tumors

that extend along the petrous portion of the internal carotid artery, through the
eustachian tube, or through the cancellous portion of the petrous apex (29). A
preauricular hemicoronal scalp incision is extended down to at least the level
of the tragus and possibly into the cervical region, depending on the extent of
the pathological finding and whether a neck dissection is needed. The
zygomatic arch is removed or reflected downward with the temporalis muscle,
taking care to preserve the frontal branch of the facial nerve. A frontotemporal
bone flap, which may include the superior or lateral orbital rim, is elevated,
and the glenoid fossa and the mandibular condyle with the joint capsule are
either dislocated inferiorly or removed. The dura is elevated, and the bone of
the middle fossa medial to the glenoid fossa is removed until the carotid canal
is opened. The eustachian tube and the tensor tympani muscle, which course
anterior to the carotid canal, are sacrificed during this procedure, taking care
to protect the lower cranial nerves as they exit the jugular foramen. The
styloid process is divided at its base, and the internal carotid artery is reflected
anteriorly to gain access to the clivus and anterior aspect of the jugular
foramen. Drilling can be extended to the posterior fossa through Kawase's
triangle or through the clivus to the contralateral internal carotid artery (14).
DISCUSSION
Pathologies
Tumors are the most common lesions to affect the jugular foramen; the
majority are chemodectomas (glomus jugulare tumor), neurinomas, and
meningiomas, with a small percentage of other tumors, such as
chondrosarcomas and chordomas (12, 25). The glomus jugulare tumor arises
either in the adventitia of the jugular dome or from the intumescences along
the tympanic branch of the glossopharyngeal nerve or the auricular branch of
the vagus nerve in the jugular foramen (9). Tumors of the same nature that
arise in the tympanic cavity or in the mastoid on branches of these nerves are
referred to as glomus tympanicum tumors. Small glomus jugulare tumors
remain confined within the jugular foramen. However, the tumor can extend
as follows: 1) along the eustachian tube into the nasopharynx and through the
foramina at the base of the skull, 2) along the carotid artery to the middle
fossa, 3) through the intracranial orifice of the jugular foramen or along the
hypoglossal canal to the posterior fossa, 4) through the tegmen tympani to the
floor of the middle fossa, 5) through the round window and the internal

acoustic meatus to the cerebellopontine angle, and 6) through the extracranial

orifice of the jugular foramen to the upper cervical region.
Neuromas arise either from the glossopharyngeal, vagus, or the accessory
nerves, and meningiomas from arachnoid granulations in the jugular bulb or
venous sinuses. Although each tumor has characteristic patterns of invasion
and destruction, the basic anatomic environment is similar to that of the
glomus jugulare tumor.
Selection of surgical approach
The approaches to the jugular foramen can be categorized into three groups:
1) a lateral group directed through the mastoid bone, 2) a posterior group
directed through the posterior cranial fossa, and 3) an anterior group directed
through the tympanic bone. This categorization is based on the anatomic fact
that the block of the temporal bone, excluding the squamous part, is regarded
as an irregular pyramid, having its base on the mastoid surface. In addition,
the middle fossa approaches could be categorized as in the "superior group"
and the neck dissection upward to the jugular foramen as in the "inferior
group". However, the latter approaches are usually not suitable when used
alone for pathological abnormalities of the jugular foramen.
Lateral approach
The lateral approach directed through a mastoidectomy, used alone or in
combination with other approaches, is the route most commonly selected for
lesions extending through the jugular foramen (7, 12, 22). Because the jugular
foramen is situated under the otic capsule, the approach basic to this group is
called the infralabyrinthine approach. The facial nerve is frequently transposed
anteriorly to drill the bone inferior to the labyrinth. Avoiding injury to the
facial nerve is one of the key points in the lateral approaches (1). Even with
special care, some degree of transient facial palsy is common, possibly
because of disturbance to the nerve's vasculature. The surgical field can be
widened anteriorly by sacrificing the external auditory canal and middle ear
structures or medially by drilling away the otic capsule (translabyrinthine
approach) or cochlea (transcochlear approach).
The postauricular transtemporal approach, when combined with a neck
dissection, provides satisfactory exposure of the jugular foramen, mastoid air
cells, tympanic cavity, and the extracranial structures in and around the carotid
sheath. Removal of the styloid process along with transposition of the facial

nerve facilitates wide opening of the extracranial orifice of the jugular

foramen and provides access to the lower part of the petrous portion of the
internal carotid artery. A wider exposure for the extracranial tumor can be
obtained by removing the transverse process of the atlas or dislocating or
resecting the mandibular condyle. The intracranial extension of the tumor is
approached either retrosigmoidally or presigmoidally after adding a lateral
suboccipital craniectomy or craniotomy (4, 6, 10, 26, 27).
Posterior approach
This group includes the retrosigmoid approach and its more extensive farlateral and transcondylar variants. These approaches are suited to the
intracranial portion of the tu mors. The conventional retrosigmoid approach
provides access to the cerebellopontine angle and the intracranial orifice of the
jugular foramen. However, extensions of the tumor through the foramen
magnum or medially into the clivus are beyond the reach of this approach. The
far-lateral and transcondylar modifications access these areas, providing an
upward view from below by opening the posterolateral quarter of the foramen
magnum and removing the posterior part of the occipital condyle. The
posterior and posterolateral margin of the jugular foramen can be accessed by
removing the part of the jugular process of the occipital bone located behind
the jugular foramen and the portion of the mastoid located behind the mastoid
segment of the facial nerve and stylomastoid foramen. A flatter view toward
the midline clivus is obtained by additional extradural drilling of the jugular
tubercle, although drilling in front of these nerves risks damaging the nerves
as they cross the jugular tubercle (21, 23).
Anterior approach
The preauricular subtemporal-infratemporal approach is a major variant of
this group of approaches. It uses the pathway anterior to the external auditory
canal and through the tympanic bone, which are exposed by removal or
displacement of the glenoid fossa and the temporomandibular joint. The
approach alone can access the anterior part of the jugular foramen after
reflecting the petrous portion of the internal carotid artery anteriorly. Further
extensive drilling will expose the middle to upper clivus anteriorly. However,
this approach is most often combined with a lateral approach to access an
anterior extension of the pathology (22). Fisch et al. call this combined

approach the infratemporal fossa approach, Type B or C according to the

anterior extension of the exposure (4).
The selection of the optimal approach requires an understanding of the
nature and the extension of the lesion. The combination of two or three
approaches may be needed either in stages or in combination in one operative
procedure (4, 25). Preoperative embolization will often reduce the blood loss
with a vascular tumor. Intraoperative electrophysiological monitoring is of
great help in avoiding nerve injury, in locating the neural trajectory in and
around the tumor, or in predicting postoperative neural function (3, 20).
Carefully planned reconstruction is required to reduce postoperative
complications, especially leakage of cerebrospinal fluid, and to achieve a
satisfactory cosmetic result.
Reprint requests: Albert L. Rhoton, Jr., M.D., Department of Neurological
Surgery, University of Florida Brain Institute, P.O. Box 100265, 100 S. Newell
Drive, Building 59, L2-100, Gainesville, FL 32610-0265.
REFERENCES: 1-33

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