Lateral orbital wall approach to the cavernous sinus

Laboratory investigation

Restricted access


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.


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.


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.


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

Contributor Notes

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: 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.

  • 1

    Al-Mefty O: Supraorbital-pterional approach to skull base lesions. Neurosurgery 21:4744771987

  • 2

    Al-Mefty OAnand VK: Zygomatic approach to skull-base lesions. J Neurosurg 73:6686731990

  • 3

    Andaluz NRomano AReddy LVZuccarello M: Eyelid approach to the anterior cranial base. Technical note. J Neurosurg 109:3413462008

    • Search Google Scholar
    • Export Citation
  • 4

    Browder J: Treatment of carotid artery-cavernous sinus fistula. Report of a case. Arch Ophthalmol 18:951021937

  • 5

    Couldwell WTSabit IWeiss MHGiannotta SLRice D: Transmaxillary approach to the anterior cavernous sinus: a microanatomic study. Neurosurgery 40:130713111997

    • Search Google Scholar
    • Export Citation
  • 6

    Delashaw JB JrTedeschi HRhoton AL: Modified supraorbital craniotomy: technical note. Neurosurgery 30:9549561992

  • 7

    Dolenc V: Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58:8248311983

  • 8

    Dolenc VV: A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg 62:6676721985

  • 9

    Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 41:5425521997

  • 10

    Dollinger J: Die Druckentlastung der Augenhöhle durch Entfernung der äusseren Orbitalwand bei hochgradigem Exophthalmus (Morbus Basedowii) und konsekutiver Hornhauterkrankung. Dtsch Med Wochenschr 37:188818901911

    • Search Google Scholar
    • Export Citation
  • 11

    Fujitsu KKuwabara T: Zygomatic approach for lesions in the interpeduncular cistern. J Neurosurg 62:3403431985

  • 12

    Golshani KJLalwani KDelashaw JB JrSelden NR: Modified orbitozygomatic craniotomy for craniopharyngioma resection in children. Clinical article. J Neurosurg Pediatr 4:3453522009

    • Search Google Scholar
    • Export Citation
  • 13

    Hakuba ANishimura SShirakata STsukamoto M: [Surgical approaches to the cavernous sinus. Report of 19 cases.]. Neurol Med Chir (Tokyo) 22:2953081982. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 14

    Hakuba ATanaka KSuzuki TNishimura S: A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 71:6997041989

    • Search Google Scholar
    • Export Citation
  • 15

    Knosp EPerneczky AKoos WTFries GMatula C: Meningiomas of the space of the cavernous sinus. Neurosurgery 38:4344441996

  • 16

    Krönlein R: Zur Pathologie und operativen Behandlung der Dermoidzysten der Orbita. Beitr Klin Chir 4:1491631889

  • 17

    Mariniello GMaiuri Fde Divitiis EBonavolontà GTranfa FIuliano A: Lateral orbitotomy for removal of sphenoid wing meningiomas invading the orbit. Neurosurgery 66:6 Suppl Operative2872922010

    • Search Google Scholar
    • Export Citation
  • 18

    Parkinson DRamsay RM: Carotid cavernous fistula with pulsating exophthalmus: a fortuitous cure. Can J Surg 6:1911951963

  • 19

    Pellerin PLesoin FDhellemmes PDonazzan MJomin M: Usefulness of the orbitofrontomalar approach associated with bone reconstruction for frontotemporosphenoid meningiomas. Neurosurgery 15:7157181984

    • Search Google Scholar
    • Export Citation
  • 20

    Pelton RWPatel BC: Superomedial lid crease approach to the medial intraconal space: a new technique for access to the optic nerve and central space. Ophthal Plast Reconstr Surg 17:2412532001

    • Search Google Scholar
    • Export Citation
  • 21

    Perneczky AKnosp EMatula C: Cavernous sinus surgery. Approach through the lateral wall. Acta Neurochir (Wien) 92:76821988

  • 22

    Pieper DRAl-Mefty O: Cranio-orbito-zygomatic approach. Oper Tech Neurosurg 2:291999

  • 23

    Sekhar LNSchramm VL JrJones NF: Subtemporal-preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg 67:4884991987

    • Search Google Scholar
    • Export Citation
  • 24

    Sekhar LNSen CNJho HDJanecka IP: Surgical treatment of intracavernous neoplasms: a four-year experience. Neurosurgery 24:18301989

    • Search Google Scholar
    • Export Citation
  • 25

    Stallard HB: A plea for lateral orbitotomy: with certain modifications. Br J Ophthalmol 44:7187231960

  • 26

    Yaşargil MG: Microneurosurgery Vol IVB: Microneurosurgery of CNS Tumors New YorkThieme1996

  • 27

    Yaşargil MGAntic JLaciga RJain KKHodosh RMSmith RD: Microsurgical pterional approach to aneurysms of the basilar bifurcation. Surg Neurol 6:83911976

    • Search Google Scholar
    • Export Citation
  • 28

    Yaşargil MGFox JL: The microsurgical approach to intracranial aneurysms. Surg Neurol 3:7141975



All Time Past Year Past 30 Days
Abstract Views 289 287 86
Full Text Views 182 113 5
PDF Downloads 167 82 3
EPUB Downloads 0 0 0
Google Scholar