Peer-Review Reports
Endoscopic Anatomy of the Skull Base Explored Through the Nose
Domenico Solari1, Carmela Chiaramonte1, Alberto Di Somma1, Giovanni Dell’Aversana Orabona2, Matteo de Notaris3,
Filippo Flavio Angileri4, Luigi Maria Cavallo1, Stefania Montagnani5, Manfred Tschabitscher6, Paolo Cappabianca1
Key words
- Anatomy
- Endoscopic endonasal
- Skull base
- Suprasellar area
- Transsphenoidal surgery
Abbreviations and Acronyms
ICA: Internal carotid artery
From the 1Department of
Neurosciences
Reproductive and Odontostomatological Sciences, Division of
Neurosurgery, Università degli Studi di Napoli Federico II,
Naples, Italy; 2Department of Neurosciences Reproductive
and Odontostomatological Sciences, Division of Maxillo-
Facial surgery, Università degli Studi di Napoli Federico II,
Naples, Italy; 3Department of Human Anatomy and
Embryology, Faculty of Medicine, Universitat de Barcelona,
Barcelona, Spain; 4Department of Neurosciences, Division of
Neurosurgery, Università degli Studi di Messina, Italy;
5
Department of Public Health, Università degli Studi di
Napoli Federico II, Naples, Italy; and 6Centre for Anatomy
and Cell Biology, Department of Systematic Anatomy,
Medical University of Vienna, Vienna, Austria
To whom correspondence should be addressed:
Domenico Solari, M.D.
[E-mail: domenico.solari@unina.it]
Citation: World Neurosurg. (2014) 82, 6S:S164-S170.
http://dx.doi.org/10.1016/j.wneu.2014.08.005
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2014 Elsevier Inc.
All rights reserved.
INTRODUCTION
The skull base is one of the most attractive
and complex areas of the human body,
from both an anatomical and surgical
standpoint. It lies in a frontline position,
between the brain and extracranial
compartment, being itself constituted of
many different anatomical structures. It
could be involved by a variety of lesions,
either neoplastic or not, or primarily
arising from this area, whose surgical
management can be very difficult. In the
last few decades, a variety of innovative
skull base craniofacial approaches have
been adopted to access the whole skull
base in its different parts, including
several transcranial and/or nasofacial
routes, such as anterior, anterolateral, and
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- OBJECTIVE: Different surgical approaches have been used over the years in
order to access skull base. The endoscopic endonasal approach represents a
direct and minimally invasive approach to the suprasellar, retrosellar, and ret-
roclival space, with the advantage of avoid brain retraction and visualize safely
and effectively the surgical target. The present contribution aims to provide
anatomical details of the skull base as seen from below (i.e., via an endoscopic
endonasal approach).
- METHODS: Five human cadaver heads were dissected. The anatomical neu-
rovascular structures within the skull base were visualized and carefully
described from an endoscopic endonasal view. The advantages and limitations
of the endoscopic endonasal route were discussed as well.
- RESULTS: The entire skull base region, as seen from the endoscopic endo-
nasal viewpoint, has been divided in 4 main regions: anterior skull base, middle
skull base, posterior skull base and parasellar area.
- CONCLUSION: The development of endoscopic techniques has opened
different perspectives over the skull base surgery. Endonasal surgery provides
access to a wide range of skull base lesions via a natural surgical corridor (i.e.,
the nasal cavities).
posterolateral (1, 18, 22, 28, 29, 31, 32, 34, procedures and, finally, as the sole visu-
36, 38, 41-45, 47, 48). These approaches alizing instrument during the whole pro-
often are characterized by tissue disrup- cedure (5, 8, 15, 23). The wider and
tion, brain retraction, and neurovascular panoramic view offered by the endoscope
manipulation, eventually resulting in pushed the development of a variety of
aesthetically harms and/or greater rate of modifications to this approach, targeted
morbidity and mortality. mainly to the entire midline of the skull
The continuous technological in- base, from the anterior skull base to the
novations and surgical advances of the last craniovertebral junction and adjacent
few years have lead to a progressive areas. Different from the standard endo-
reduction of the invasiveness of these ap- scopic approach, in which the sphenoid
proaches, culminating in the idea to ac- sinus creates itself a surgical space to gain
cess the skull base from a different access to the sellar region, the extended
surgical corridor, the nose. This route is approach requires the creation of a new
extremely versatile and provides the pos- surgical corridor to expose and to work
sibility to expose mostly the entire midline around the sella.
skull base through the nose, allowing the The endoscopic endonasal approach
surgeon to gain access through a natural represents a direct and minimally invasive
cavity, the sphenoid sinus. Referring to approach to the suprasellar, retrosellar,
Perneczky’s “keyhole” theory, the sphe- and retroclival space, obviating brain
noid sinus cavity could be defined as the retraction, visualizing safely and effectively
“main entrance” to many areas of the skull the surgical field, and granting the least
base (39). rates of morbidity and mortality in a safe
The endoscope was introduced in and effective way. The endoscopic endo-
transsphenoidal surgery (20, 21), first in nasal technique, however, requires spe-
the so-called endoscope-assisted cific endoscopic skills and the use of
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DOMENICO SOLARI ET AL.
Figure 1. Endoscopic endonasal wide
exposure of the anterior, middle, and
posterior skull base. OP, optic protuberance;
ICAs, parasellar segment of the internal
carotid artery; Pg, pituitary gland; C, clivus;
ICAc, paraclival segment of the internal
carotid artery; ET, Eustachian tube; RPhx,
rhinopharynx. *Second branch of the
trigeminal nerve; **suprasellar notch.
different instrumentation: the endoscope,
the fiberoptic cable, the light source, the
camera, the monitor, and the video
recording system, related one to another
as a “clock mechanism.”
ENDOSCOPIC ANATOMY OF THE SKULL
BASE
The entire skull base region, as seen from
the endoscopic endonasal viewpoint, can
be divided in 4 areas, whose exposure re-
quires tailored surgical approach
(Figure 1):
1. The anterior midline skull base, from the
frontal sinus to the posterior ethmoidal
arteries, accessed through an endo-
scopic endonasal trancribriform
approach;
2. The middle skull base, from the planum
sphenoidale to the sellar floor, unlocked
via different corridors, i.e., the endo-
scopic endonasal transplanum-trans-
tuberculum approach to the
suprasellar area and the standard endo-
scopic endonasal approach to the sellar
region;
3. The posterior midline skull base, from the
clivus to the craniovertebral junction,
exposed by mean of the endoscopic
endonasal transclival approach; and
4. The parasellar region, namely the
cavernous sinuses and Meckel’s cave
areas, gained with the endoscopic
endonasal transpterygoid approach.
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ENDOSCOPIC ANATOMY OF THE SKULL BASE THROUGH THE NOSE
Basic Concepts
According to the area to deal with, the
head can be extended to reach in a more
direct trajectory the anterior skull base, or
slightly flexed in cases of approaches tar-
geted to posterior fossa. The first surgeon
stands in front, on the right side, with the
endoscopic equipment and the neuro-
navigation system positioned behind the
head of the patient.
Dedicated surgical instrumentation is
necessary to ensure safe and effective
maneuverability in such a narrow surgical
field; a rigid 0-degree endoscope, 18 cm in
length and 4 mm in diameter (Karl Storz
Endoscopy, Tuttlingen, Germany), is used
as the sole visualizing tool along the
procedure.
The endoscope is introduced through
the patient’s right nostril, close to the
floor of the nasal cavity. The first structure
to be identified is the inferior turbinate,
then the middle turbinate and the nasal
septum. The head of the middle turbinate
is dislocated laterally to widen the space
between the middle turbinate and the
nasal septum and to create an optimum
surgical route in the posterior nasal cavity
to reach the anterior wall of the sphenoid
sinus. Following the tail of the inferior
turbinate, the endoscope reaches the
choana limited medially by the vomer,
which is a midline marker and, superiorly,
by the floor of the sphenoid sinus; laterally
to the choana, the tail of the inferior
turbinate lies.
The endoscope is then angled rostrally,
along the roof of the choana and the
sphenoethmoid recess, until it reaches the
sphenoid ostium, which is usually located
approximately 1.5 cm above the roof of the
choana.
To enlarge the surgical corridor when
performing endoscopic approach to the
skull base, according to the principles
defined by Pittsburgh school (24, 25), one
should perform: 1) a middle turbinectomy
on one side; 2) middle turbinate lateral
luxation in the other nostril; 3) posterior
ethmoidectomy in one or in both nostrils;
and 4) removal of the posterior portion of
the nasal septum. These maneuvers
should be completed carefully, although it
may be useful to highlight several tech-
nical aspects and anatomical details in the
paragraphs to follow.
The head of the middle turbinate
should be cut and carefully pushed
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PEER-REVIEW REPORTS
downward, with the surgeon aware not to
injure the sphenopalatine artery and/or its
branches, which lie at this level on
crossing the roof of the choana (30).
A wide anterior sphenoidotomy is
essential and bony spurs require to be
flattened to create an adequate wide space
also in the deeper part of the surgical field
and, moreover, to identify the bony pro-
tuberances and depressions molded by the
main neurovascular structures over the
sphenoid sinus posterior wall.
According to the grade of sinus pneu-
matization (6), one can recognize the
sellar floor at the center, the clival inden-
tation below, the optic nerve, and the ca-
rotid prominences laterally with the
optocarotid recess in between. A compre-
hensive understanding of the anatomy and
spatial relationships between such
anatomical landmarks is of paramount
importance to define a correct surgical
strategy for lesion removal via endoscopic
endonasal approach.
Anterior Skull Base
Coming from an endoscopic endonasal
corridor, the most anterior view of the
skull base, seen from below, is repre-
sented by the nasal cavities roof. After the
removal of the middle turbinates together
with the bulla ethmoidalis, the anterior
and posterior ethmoid cells complexes
and the most superior part of the posterior
portion of the nasal septum, a rectangular
area become visible. This appears to be
limited anteriorly by the frontal recesses,
laterally by the lamina papyracea (orbital
walls) and posteriorly by the planum
sphenoidale.
The rectangular area is symmetrically
split into 2 compartments by the lamina
perpendicularis of the ethmoid, coming
out of the lamina cribrosa to continue with
nasal septum.
On both sides the nasal cavities are
laterally occupied by the ethmoidal laby-
rinth, which is divided, by the basal
lamella of the middle turbinate, in 2 por-
tions: the anterior ethmoidal complex
(which includes the bullar and suprabullar
recesses) and the posterior complex (46).
In the foremost position, the frontal re-
cesses represent a virtual space defined by
the anterior part of the middle turbinate
medially, the lamina papyracea laterally,
and agger nasi cells anteriorly. The lamina
cribrosa lies at the center of the anterior
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DOMENICO SOLARI ET AL.
Figure 2. Endoscopic endonasal anatomical
view of the anterior skull base. AEA, anterior
ethmoidal artery; LC, lamina cribrosa; O,
orbit; PEA, posterior ethmoidal artery; OP,
optic protuberance; PS, planum
sphenoidale; ocr, lateral opto-carotid recess;
CPs, parasellar segment of the carotid
protuberance; SF, sellar floor. *Posterior
attachment of the sphenoid septum;
**suprasellar notch; ***frontal sinus.
skull base floor. It consists of a thin
osseous layer pierced by the small olfac-
tory phila coming from the olphactory
bulbs, placed on it, and entangled be-
tween the anterior and posterior
ethmoidal arteries. These latter represent
2 branches of the ophthalmic artery, which
provide the arterial supply of the dura of
the ethmoidal planum and send many
small feeders to the cribriform plate,
where they anastomize with the nasal
branches of the sphenopalatine artery.
The anterior ethmoidal artery runs
medially to the optic nerve, sliding in be-
tween the lateral surfaces of the medial
and superior rectus muscles to pass into
the anterior ethmoidal foramen of the
lamina papyracea: it bends twice before
entering the anterior ethmoidal canal and,
Figure 3. Endoscopic endonasal anatomical
view of the olfactory groove. LC, lamina
cribrosa; O, orbit; dm, dura mater. **Frontal
sinus.
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ENDOSCOPIC ANATOMY OF THE SKULL BASE THROUGH THE NOSE
thereafter, moves in a slight anteromedial
direction inside it, toward the lamina cri-
brosa. The anterior ethmoidal artery can
occupy a variable position within the
ethmoidal planum: it can run within or
below it, in its bony canal, between the
second and third ethmoidal lamellae,
representing, therefore, a crucial point to
be clearly identified during the approach
to the anterior skull base (17, 35, 49).
The posterior ethmoidal artery runs
between the superior rectus and superior
oblique muscles and exit the orbit via the Figure 4. Endoscopic endonasal anatomical
posterior ethmoidal canal, which, crossing view of the posterior wall of the sphenoid
horizontally the ethmoidal roof, defines sinus. PS, planum sphenoidale; OP, optic
protuberance; ocr, lateral opto-carotid
the posterior rim of the olphactory groove,
recess; CPs, parasellar segment of the
only few millimeters from the anterior carotid protuberance; SF, sellar floor; CPc,
margin of the planum sphenoidale. These paraclival segment of the carotid
anatomical landmarks are very important protuberance; C, clivus. *Posterior
attachment of the sphenoid septum;
to be considered when one is performing **suprasellar notch.
an endoscopic endonasal approach to the
olphactory groove or an approach to the
suprasellar area (transplanum-trans-
and below with the clivus; the optic nerve
tuberculum route) (Figures 2 and 3).
prominences, above, formed by the bony
In the endoscopic endonasal approach
covering of the optic nerves and the ca-
to the anterior skull base, is recommended
rotid prominences, below, covering the
that one remove the superior portion of
internal carotid artery with the optocarotid
the lamina papyracea and to isolate, on
recess in between them (47) (Figure 4).
both sides, the anterior and posterior
The lateral optocarotid recess is molded by
ethmoidal arteries. The removal of the
the pneumatization of the optic strut of
bone of the anterior skull base enclosed
the anterior clinoid process (18). Its su-
between the 2 orbits.
perior boundary attaches to a thickening
Upon the dural opening, the olphactory
of the dura mater and periosteum.
bulbs appears at the bottom of the gyri
recta; with a careful retraction of the brain
tissue, it is possible to expose the 2 fron-
topolar and fronto-orbital arteries with
their branches, exploring the interemi-
spheric scissure.
Middle Skull Base
As seen through the endoscopic endonasal
corridor, the middle skull base corre-
sponds to the posterior and lateral walls of
the sphenoid sinus. A wider opening of
the anterior wall of the sphenoid sinus,
with the removal of the superior and/or
supreme turbinates and the posterior Figure 5. Endoscopic endonasal anatomical
ethmoid cells, is crucial to gain an view of the posterior wall of the sphenoid
sinus after the removing of the bone of the
adequate exposure of this area. Particular
sellar floor and the planum sphenoidale. PS,
attention must be paid to avoid injuries to planum sphenoidale; OP, optic
the posterior ethmoidal artery and to not protuberance; ocr, lateral optocarotid
extend the bone removal in the forefront recess; ICAs, parasellar segment of the
internal carotid artery; CPc, paraclival
skull base to avoid damaging the olfactory segment of the carotid protuberance; C,
nerve and/or the lamina cribrosa. clivus; *, dura mater covering the pituitary
The sellar floor lies at the center on the gland. **Dura mater covering the
suprasellar area; dotted line, proximal dural
posterior sphenoid sinus wall and con- ring.
tinues above with the planum sphenoidale
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DOMENICO SOLARI ET AL.
Representing the internal carotid artery
(ICA) distal dural ring, it divides the optic
nerve from the clinoidal segment of the
ICA. The inferior margin of the lateral
optocarotid recess, on its intracranial
aspect, attaches to the thickening of the
dura mater and periosteum, known as ICA
proximal dural ring. Although rarely
visible in the cavity of the sphenoid sinus,
it is important to define the position of the
medial optocarotid recess because it rep-
resents a key entry into the suprasellar
area.
Once the sellar dura is opened, the
anterior lobe of the pituitary gland comes
into view. Its inferior surface usually con-
forms to the shape of the sellar floor, but
its lateral and superior margins vary in
shape because these walls are composed
of soft tissue rather than bone. Posteriorly,
the neurohypophyseal part of the pituitary
gland can be observed, which is softer,
almost gelatinous, and is more densely
adherent to the sellar wall, i.e., dorsum
sellae. Above, the diaphragma sellae can
be seen, which covers the pituitary gland,
except for a small central opening in its
center transmitting the pituitary stalk.
Laterally, the internal carotid artery within
the cavernous sinus can be appreciated at
this level.
Immediately above the sella, the
tuberculum sellae can be seen as an indent
represented by the angle formed by the
convergence of the sphenoid planum with
the sellar floor; recently, according to the
identification of this shape, we renamed
Figure 6. Endoscopic endonasal intradural
view of the subchiasmatic region, in the
suprasellar area. GR, gyri recta; A2,
post-communicating tract of anterior
cerebral artery; ON, optic nerve; Ch, chiasm;
Ps, pituitary stalk; sha, superior hypophyseal
artery; ICA, internal carotid artery; Pg,
pituitary gland. *Anterior communicating
artery.
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ENDOSCOPIC ANATOMY OF THE SKULL BASE THROUGH THE NOSE
this structure as the “suprasellar notch”
(16). At this level, the superior inter-
cavernous sinus lies: as well, it should be
closed and coagulated upon the dural
opening, if a suprasellar approach is
intended (Figure 5).
The removal of the upper half of the
sellar the tuberculum sellae and the pos-
terior portion of the planum sphenoidale
offers the possibility to explore the supra-
sellar region. The entire suprasellar region
has been divided in 4 areas by 2 ideal
Figure 7. Endoscopic endonasal intradural
planes, one passing through the inferior view of the superior third of the retroclival
surface of the chiasm and the mammillary area (or retrosellar area). PCA, posterior
bodies and another passing through the cerebral artery; BA, basilar artery; SCA,
posterior margin of chiasm and the dorsum superior cerebellar artery. *Posterior
communicating artery; **floor of the third
sellae: the supra-chiasmatic region, the ventricle.
subchiasmatic region, the retrosellar, and
the ventricular region (11).
In the supra-chiasmatic region, the chias-
massa intermedia, the foramina of Monro
matic and the lamina terminalis cisterns
anteriorly, the bulging of mammillary
with relative contents are accessible. The
bodies and the beginning of the aqueduct,
anterior margin of the chiasm and the
posteriorly can be seen.
medial portion of the optic nerves, the
anterior cerebral arteries, the anterior
communicating artery, and the recurrent
Heubner arteries, together with the gyri Posterior Skull Base
recti of the frontal lobes can be identified. The midline posterior cranial fossa could
In the subchiasmatic space, the pituitary be accessed via the endoscopic endonasal
stalk is encountered, below the chiasm, route through the anterior surface of the
with the superior hypophyseal artery and clivus upward to the dorsum sellae and
its perforating branches, supplying the downward to the craniovertebral junction
inferior surface of the chiasm and the (Figure 8).
optic nerves. The superior aspect of the The clivus can be divided in an upper
pituitary gland and the dorsum sellae are part (sphenoidal portion) and in a lower part
also visible. The superior hypophyseal ar- (rhino-pharyngeal portion) by the floor of the
teries supply the optic chiasm, the floor of sphenoid sinus. Laterally, on the sphenoid
the hypothalamus, and the median portion of the clivus, the ascending tract
eminence. Each inferior hypophyseal ar-
tery divides into a medial and a lateral
branch, which anastomose with the cor-
responding vessels of the opposite side,
forming an arterial ring around the hy-
pophysis (Figure 6).
The retrosellar area, explored passing with
the endoscope between the pituitary stalk
and the internal carotid artery, above the
dorsum sellae, encloses the upper third of
the basilar artery, the pons, the superior
cerebellar arteries, the oculomotor nerves,
the posterior cerebral arteries and lastly to Figure 8. Endoscopic endonasal picture
the mammillary bodies and the floor of showing the sellar and clival area. Ch,
the third ventricle (Figure 7). chiasm; Ps, pituitary stalk, ICAs, parasellar
segment of the internal carotid artery; Pg,
The third ventricle could be opened at pituitary gland; VI, sixth cranial nerve; V2,
level of tuber cinereum and the endoscope second branch of trigeminal nerve; ICAc,
could be advanced inside the ventricular paraclival segment of the internal carotid
artery; C, clivus. *Floor of the sphenoid
cavity, obtaining a panoramic view of the sinus.
ventricular area: the thalami and the
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DOMENICO SOLARI ET AL.
Figure 9. Endoscopic endonasal intradural
view of the posterior skull base. PCA,
posterior cerebral artery; SCA, superior
cerebellar artery; ICA, internal carotid artery;
BA, basilar artery; VI, sixth cranial nerve;
AICA, anterior inferior cerebellar artery; VA,
vertebral artery. *Third cranial nerve; **floor
of the third ventricle.
of the carotid arteries can be seen, which
represent the lateral limit of the access.
The vomer and the inferior wall of the
sphenoid sinus have to be removed
completely to permit the exposure of both
the sphenoidal and rhinopharyngeal part
of the clivus (7, 17).
The periostium-dural layer is exposed
after the surgeon removes the bone of the
sphenoid portion of the clivus, enclosed be-
tween the carotid bony protuberances.
This permits one to identify the sixth
cranial nerve, running in a medial-to-
lateral direction together with the dorsal
meningeal artery—a branch of the
meningohypophyseal artery, that supply to
the dura of the clival region—to cross
posteriorly the paraclival carotid artery and
enter the cavernous sinus.
To access to the rhino-pharyngeal portion
of the clivus, the nasal mucosa is detached
from the vomer, along the inferior wall of
the sphenoid sinus, up to identify the
vidian nerves, representing the lateral
limits of the surgical corridor at this lower
level. The vidian nerve should be identi-
fied while removing the bone in this area,
to avoid the risk of injury of the intra-
petrous carotid artery (27, 37).
The clival bone contains the most
extensive series of intercavernous venous
connections across the midline, i.e., the
basilar plexus; as soon it is removed, the
dural layer is visible. Once the dura has
been opened, the basilar artery, its
branches (posterior cerebral artery, supe-
rior cerebellar artery and anterior inferior
cerebellar artery), and the upper cranial
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ENDOSCOPIC ANATOMY OF THE SKULL BASE THROUGH THE NOSE
nerves (mainly the III and the VI cranial
nerves), are well seen along their courses
in the posterior cranial fossa (Figure 9).
Extending inferiorly the bone removal
to the lower third of the clivus, both the
foramina lacera are identified, which
represent the lateral limit of the approach
at this level. It is possible to further
enlarge this opening by removing the
anterior third of the occipital condyles
without entering in the hypoglossal canal,
which is located at the junction of the
anterior and middle third of each occipital
condyle. It should be noted that the
articular surface of the condyles lies on its
lateral portion; hence, the removal of the
anterior inner aspect does not affect the
joint functionalities (10, 12, 48).
The mucosa of the rhinopharynx is then
carried away, and the atlanto-occipital
membrane, the longus capitis and longus colli
muscles, the atlas, and axis are seen. After
one dissects the muscular structures, the
anterior arch of the atlas could be removed
to expose the dens, which can be sepa-
rated from ligaments and finally dissected
(33). At the craniocervical junction, the
dentate ligament is located behind the
vertebral artery and the ventral rootlets of
C1 and C2. The opening of the dura offers
the possibility for the surgeon to observe
all the neurovascular structures running
through the anterior part of the foramen
magnum.
The first vascular structures to be iden-
tified are the vertebral arteries, which can
be explored from their entrance in the
vertebral canal up to the basilar artery. The
intradural segment of the vertebral artery,
after emerging from the fibrous dural ca-
nal, ascends in front of the rootlets of the
hypoglossal nerve to reach the anterior
aspect of the medulla oblongata, where it
unites near the junction of the pons and
medulla with its homologous to form the
basilar artery. During its intradural course,
2 arterial branches can be identified
through an anterior approach: the poste-
rior inferior cerebellar artery, which cour-
ses backward around the lateral surface of
the medulla and between the rootlets of
glossopharyngeal, vagus, and accessory
nerves, and the anterior spinal artery.
Above and behind the vertebral artery, the
lower cranial nerves (IX-X-XI-XII) and the
acoustic-facial bundle (VII-VIII) with the
anterior inferior cerebellar artery (AICA)
are visible.
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Parasellar Region
Thanks to the sphenoid sinus chamber,
the endoscopic endonasal corridor also
provides the access to the lateral sellar
compartment (38), represented mainly by
the cavernous sinuses (2, 19, 26, 32, 40).
Various endoscopic endonasal surgical
corridors have been described to get ac-
cess to different areas of the cavernous
sinus (11, 23), being related to the position
of the intracavernous carotid artery, i.e.,
corridor to medial and lateral
compartments.
To allow a better exposure of such
areas, as already described, the anterior
sphenoidotomy has to be extended more
laterally to remove posterior ethmoidal
cells. The first structure to be removed is
the uncinate process; then, the bulla eth-
moidalis is opened and finally the access
is gained through anterior and posterior
ethmoid cells (7, 9, 14, 19). To expose
widely the lateral recess of the sphenoid
sinus through the pterygopalatine fossa (1,
4, 32), the portion of the medial pterygoid
process enclosed between the pterygoid
canal and the foramen rotundum has to be
removed (3, 13, 27, 45).
Once anatomical landmarks have been
identified, the bone covering the lateral
wall of the sphenoid sinus and the carotid
protuberances is removed. The medial
wall of the cavernous sinus is composed
of a fibrous trabecular frame that sepa-
rates this sinus from the outer periosteum
layer of the pituitary gland. The opening
of such structure immediately shows the
Figure 10. Endoscopic endonasal view of the
right cavernous sinus after the medial
displacement of the internal carotid artery.
III, third cranial nerve; ICAs, parasellar
segment of the internal carotid artery; IV,
fourth cranial nerve; VI, sixth cranial nerve;
V1, first branch of trigeminal nerve; V2,
second branch of trigeminal nerve; ICAc,
paraclival segment of the internal carotid
artery. *Superior orbital fissure.

DOMENICO SOLARI ET AL.
C-shaped segment of the intracavernous
carotid artery. Indeed, the cavernous sinus
envelops a portion of the ICA extending
forward in a groove called the carotid
sulcus.
The arteries to the pituitary gland arise
from the ICA as the superior and inferior
hypophyseal arteries. The superior hypo-
physeal arteries supply the optic chiasm,
the floor of the hypothalamus, and the
median eminence. Each inferior hypo-
physeal artery divides into a medial and a
lateral branch, which anastomose with the
corresponding vessels of the opposite
side, forming an arterial ring around the
hypophysis.
Displacing the carotid artery laterally, it
is possible to visualize the meningohypo-
physeal artery and its branches of the
dorsal meningeal, inferior hypophyseal,
and tentorial arteries; on the contrary, the
inferolateral trunk, with its branches to
the intracavernous cranial nerves, lies
laterally to the carotid artery, embedded in
the lateral wall of the cavernous sinus.
Furthermore, moving upward the endo-
scope, the oculomotor and trochlear nerve
are seen coming up from the C shaped
toward the superior orbital fissure.
Lateral to the intracavernous carotid
artery, the oculomotor, the abducent, and
the maxillary nerves can be detected
lying on a closer plane as compared to
that occupied by the trochlear and the
ophthalmic nerves (Figure 10). The ocu-
lomotor, trochlear, and ophthalmic nerves
lie between the 2 dural leaves of the lateral
sinus wall while the abducens courses
within the sinus on the medial side of the
ophthalmic nerve and is adherent to the
carotid artery medially and the ophthalmic
nerve laterally.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 23 July 2014; accepted 1 August 2014
Citation: World Neurosurg. (2014) 82, 6S:S164-S170.
http://dx.doi.org/10.1016/j.wneu.2014.08.005
Journal homepage: www.WORLDNEUROSURGERY.org
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