Lateral orbital wall approach to the cavernous sinus

Laboratory investigation

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Object

Lesions of the cavernous sinus remain a technical challenge. The most common surgical approaches involve some variation of the standard frontotemporal craniotomy. Here, the authors describe a surgical approach to access the cavernous sinus that involves the removal of the lateral orbital wall.

Methods

To achieve exposure of the cavernous sinus, a lateral canthal incision is performed, and the lateral orbital rim and anterior lateral wall are removed, for later replacement at closure. The posterior lateral orbital wall is removed to the region of the superior and inferior orbital fissures. With reflection of the dural covering of the lateral cavernous sinus and removal of the anterior clinoid process, the cavernous sinus is exposed.

Results

Exposure and details of the procedure were derived from anatomical study in cadavers. After the approach, with removal of the anterior clinoid process, the entire cavernous sinus from the superior orbital fissure anteriorly to the Meckel cave posteriorly is exposed. More exposure to the lateral middle fossa, foramen spinosum, and petrous carotid artery is obtained by further removal of the lateral sphenoid wing. An illustrative case example for approaching a cavernous sinus meningioma is presented.

Conclusions

The translateral orbital wall approach provides a simple, rapid approach for lesions with primary or secondary involvement of the cavernous sinus. Advantages of this simple, extradural approach include the lack of brain retraction and no interruption of the temporalis muscle.

Abbreviations used in this paper:GSPN = greater superficial petrosal nerve; ICA = internal carotid artery.

Article Information

Address correspondence to: William T. Couldwell, M.D., Ph.D., Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, Utah 84132. email: neuropub@hsc.utah.edu.

Please include this information when citing this paper: published online January 13, 2012; DOI: 10.3171/2011.12.JNS111251.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Left: Illustration showing the lateral orbital rim and wall to be removed for the translateral orbital approach to the cavernous sinus. Right: Illustration showing the parasellar area and middle fossa structures after removal of the lateral orbital rim and wall in the translateral orbital approach. Printed with permission from KTB Studios, LLC.

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    Cadaver dissection demonstrating the surgical incision (A), exposure of the lateral orbital rim (B), and removal of the lateral orbital rim and anterior lateral orbital wall (C). Note the gentle retraction of the temporalis muscle and the orbital structures.

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    Cadaver dissection after lateral orbital removal, demonstrating initial exposure of the anterior cavernous sinus and anterior clinoid process (ACP). III = oculomotor nerve; IV = trochlear nerve.

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    After removal of the anterior clinoid process, the intradural carotid artery is exposed after opening the distal dural ring (DDR). The temporal dura mater is dissected off the lateral wall of the cavernous sinus. Then, the dura is opened and the distal dural ring is excised.

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    A more inferior exposure enables clear visualization of the trigeminal nerve.

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    Cadaver dissection (left) and illustration (right) showing exposure of the intradural carotid artery with the posterior communicating artery takeoff after exposure of the cavernous sinus. The oculomotor and trochlear nerves are exposed. Both clinoid and intradural segments of the ICA are also seen. CN = cranial nerve. Illustration used with permission from KTB Studios, LLC.

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    A more inferior trajectory demonstrates the lateral aspects of all 3 branches of the trigeminal nerve and gasserian ganglion. Illustration used with permission from KTB Studios, LLC.

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    Cadaver dissection (left) and illustration (right) depicting the entrance to the cavernous sinus through its lateral wall between V1 and V2. The V1 segment is retracted to expose the proximal part of the cavernous carotid artery and the abducent nerve coursing lateral to it. Illustration used with permission from KTB Studios, LLC.

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    Cadaver dissection (left) and illustration (right) of the “extended version” of the translateral orbital approach. The medial temporal fossa is followed as far back as the Meckel cave and the petrous ridge. The posterior fossa dura is opened above the superior petrosal sinus, revealing the superior cerebellar artery in the posterior fossa. Illustration used with permission from KTB Studios, LLC.

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    Axial (left) and coronal (right) MR images demonstrating an enhancing lesion of the right cavernous sinus with optic canal involvement.

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    Postoperative axial (left) and coronal (right) CT scans showing the extent of bone removal.

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