Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus

Abstract

A transmaxillosphenoidal approach was used to remove sellar tumors invading the cavernous sinus. This procedure, a widening of the standard transsphenoidal approach to the sella turcica, uses the sublabial or transnasal route in which the medial wall of the maxillary sinus is laterally dislocated. This method provides good exposure of the prominences of bone above the carotid artery which lies on the posterolateral wall of the sphenoid sinus. This bone area is the key to opening the cavernous sinus inferomedially and removing lesions within its medial compartment. The inferomedial approach takes an entirely extracerebral route so that tumors invading the cavernous sinus through its medial wall are approached inferomedially following the direction of tumor growth. It also allows direct visualization of the intracavernous carotid artery during tumor removal, thus sparing the cranial nerves, which run on the opposite side. Adequate surgical exposure of a pituitary adenoma is achieved with a custom-made sphenoidal retractor with asymmetric blades, the shorter blade holding aside the thin medial wall of the maxillary sinus. Between October, 1989, and July, 1993, 11 patients with tumors invading the cavernous sinus underwent surgery via this approach; 10 had pituitary adenomas and one had a craniopharyngioma. Eight tumors were treated by primary operation: four tumors were totally and four subtotally (> 80%) removed; one tumor already operated on elsewhere was totally removed; and of two tumors already operated on and irradiated, one was subtotally removed and the other only partially (approximately 40%) removed owing to marked postirradiation scarring. None of the patients suffered permanent cranial nerve deficit and all but one showed marked clinical improvement.

The surgical treatment of pituitary adenomas in the eighth decade

“…We especially recommend the supine position for aged patients [17]. Owing to tumoral right cavernous sinus invasion, the unilateral inferomedial transmaxillosphenoidal approach was performed in Case 9 [11].…”

Skull base chordomas: overview of disease, management options, and outcome

“…A detailed analysis of the advantages and disadvantages of each approach proposed for resection of skull base chordomas is beyond the scope of this article, and excellent reports have already been published on this topic. 1,11,17,23,26,27,33,36,37,45,47,51,55,57,58,76,[86][87][88][89]94 Careful study of the preoperative neuroradiological studies is essential when planning the surgical approach to these challenging lesions. In recent years, continuous refinements of frameless stereotactic systems have come to provide the surgeon with intraoperative feedback regarding surgical orientation.…”

Transsphenoidal removal of huge pituitary adenomas with marked suprasellar extension: Results with modified surgical technique

“…It is explicable because we are not use, after a significant experience of cavernous sinus surgery [12], to overmanipulate the eventual para-or intracavernous component of pituitary adenomas, except for particular cases in which the main tumoral component is located into the cavernous sinus itself.…”