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

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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.