The Laryngoscop e
Li ppincott Wil lia ms & Wilkins, Inc., Philadelphia
© 2000 The America n Laryng ological,
Rhinologicsl a nd Otologica l Society, Inc.
Extradural Extranasal Combined
Transmaxillary Transsphenoidal Approach
to the Cavernous Sinus: A Minimally
Invasive Microsurgical Model
Ibrahim Sabit, MD; Steven D. Schaefer, MD; William T. Couldwell, MD, PhD
The authors have previously described an extra-
dural transmaxillary approach to the anterior com·
partment of the cavernous sinus. In an effort to ex-
pand the surgical access to that area without
n cessitating a craniotomy or wide transfacial dissec·
tion, they present a modification of the transmaxil-
lary approach to the sellar region and cavernous si-
nus. Methods: The approach was developed on 12
fresh and 12 embalmed cadaveric specimen, and 2 dry
skulls. The initial sublabial incision is followed by a
maxillotomy to expose the course of the infraorbital
nerve (terminal branch of maxillary branch of the
trigeminal n erve) on the roof of the maxillary sinus.
The route of the infraorbital n erve is traced to the
pterygopalatine fossa a s a guide to the foramen rotun-
d um. Superomedial drilling of the foramen rotund um
is then p erformed to r eveal the contents of the supe-
rior orbital fissure. After the n erves are safely identi·
fled in the superior orbital fi ssure, m edial enlarge-
m ent of the window into the cavernous sinus is made
possible by drilling the lateral and posterior wall and
septum of the sphenoid sinus. R esults: The combined
transmaxillary transsphenoidal approach offers an
excellent exposure of the sellar and infrasellar r egion.
The approach offer s clear visualization of the ipsilat·
eral loop of the carotid artery, the pituitaryfossa, and
the cranial n erves of the ipsilateral cavernous sinus.
Mean operative reach is 38 mm from the posterior
wall of the maxillary sinus to the ipsilateral carotid
loop and 56 mm to the contralateral loop. The width of
the operative window is 26 mm at the base within the
cavernous sinus. Conclusion: The model offer s a min-
imally invasive approach that avoids the n eed for era·
niotomy or violating the nasal cavity. It may be safely
From the Departments of Neurological S urgery (1.s., w.r .c.), New
York Medical ollege, Valhall a a nd New York, N ew York, and the Depart-
ment of Otolaryngology (s.o.s.), New York Eye a nd Ea r Infirmary, New
York, New York.
Editor's Note: This Manuscript was accepted for publication November
18, 1999.
Send Correspondenc to WiHia m T. Couldwell, MD , PhD, Professor
and Chairma n, Department of Neurological Surgery, New York Medical
Coll ege, Mun g r Pavill ion, Valhalla, NY 10595, U .S.A. E-mail:
wi lliam_ couldwell@nymc.edu
Laryngoscope 11 O: February 2000
286
employed to access vascular as well as invasive le-
sions of the sellar and infrasellar region. The ap-
proach offers excellent visualization of the ipsilateral
intracavernous carotid artery with both proximal
and distal control, a s well as cranial nerves ill, IV, VI,
V2, the hypophyseal r egion, and the medial a spect of
the contralateral cavernous sinus. Key Words: Mini-
mally invasive, maxillary sinus, sphenoid sinus, cav-
ernous sinus. ·
Laryngoscope, 110:286-291, 2000
INTRODUCTION
Despite the variety of approaches the n eurosurgeon
may employ to expose lesions in the cavernous sinus,
surgical access to this a rea remains a formidable task. The
variations in the basic frontal, frontotemporal , and infra-
te mporal appr oaches documented in the liter ature for cav-
ernous sinus surgery attest to the complexity of the anat-
omy of the area.
Advances in microsurgical technique and instrumenta-
tion have offered better access to the skull base through
combined neurosurgical and otolaryngological team ap-
proaches. This collaboration has yielded advances in ante-
rior transfacial approaches to the skull base including the
transbasal, transnasal transsphenoidal, lateral rhinotomy,
transmaxillary transnasal, transoral, transcervical, and
midfacial degloving approaches.1- 10 These anterior ap-
pr oaches are popular because they avoid the need for crani-
otomy and brain retraction and offer better cosmetic out-
come. However, the variable access to the clivus and
infrahypophyseal region that these approaches offer re-
mains limited primarily to exposure of midline structures
with limited lateral access. For more aggressive lesions with
skull base invasion from the middle fossa or the paranasal
sinuses, more invasive variations of the Caldwell-Luc
approach are warranted.s,11-13
The authors have recently described an extradural
transmaxillary model for access to lesions limited to the
anterior cavernous sinus.14 However, minimal medial reach
to the subhypophyseal region and insufficient control of the
Sabit et al: Minimally Invasive Approach to the Cavernous Sinus

Fig . 1. A. Bony specimen depicting the osseous landmarks of the
approach. The right maxilla has been osteomized to open the max-
illary sinus (MS). SOF = superior orbital fissure, OC = optic canal.
B. Right sublabial incision extending beyond the second molar and
superiorly to the infraorbital foramen (IOF). The lnfraorbital nerve
and artery are reflected superiorly with the skin.
intracavemous carotid artery limit its application for resec-
tion oflarge lesions.15 To facilitate access to the more m.idline
structures without violating the nasal cavity, we present an
extradural modified transmaxillary transsphenoidal ap-
proach to the cavernous sinus.
MATERIALS AND METIIODS
The dissections were carried out on 12 fresh an d 12 em-
balmed cadaveric specimens and two dried bone specimens. Mi-
crosurgical techniques and metric measurements were conducted
under a Zeiss OPMI 1 FC (Carl Zeiss, Oberkochen, Germany) and
documented using a Nikon FE camera with Kodak Ektachrome
200 film . A Midae Rex 3 drill was used for all bone drilling (Midas
Rex, Fort Worth, TX).
SURGICAL APPROACH
The approach is conceptually divided into two stages: an ex-
tracranial stage that utilizes the course of the infraorbital nerve, the
Laryngoscope 110: February 2000
Fig. 2. After stripping of the mucosa, the course of the infraorbital
nerve (ION) and artery within the infraorbital canal is displayed In the
roof of the maxillary antrum. A thin layer of periosteum covers the
nerve inside the maxillary sinus (MS).
terminal branch of the V2, as a guide to the foramen rotundum, and
a cranial stage that begins at the level of the fora.men rotundum.
Extracranial Stage
A sublabial incision is made at the level of the lateral incisors
and extended posterolaterally to the third molar. Soft tissue eleva-
tion to expose the maxilla is then performed up to the level of the
infraorbital foramen to expose the infraorbital nerve and artery. The
surgical widow is afforded by a 2 X 2-cm osteotomy of the maxilla
extending to the frontal process of the maxilla, exercising care not to
damage the blood supply of the canine roots at the inferior aspect of
the field (Fig. 1). After the maxillotomy removal of the mucosa of the
maxillary sinus displays the course of the infraorbital nerve and
artery encased in the very thin bone of the infraorbital canal within
the roof of the maxillary antrum (Fig. 2).
After identification of the infraorbital nerve in the sinus, the
posterior maxillary antrum is removed with a high-speed drill. This
allows access to the extracranial course of V2 from its exit in the
foramen rotundum through the pterygopalatine fossa. With the
course ofV2 in view, enlargement of the osteotomy in the posterior
wall of the maxillary sinus is carried out safely to expose the con-
tents of the pterygopalatine fossa (Fig. 3A). The internal maxillary
artery and its terminal branch, the sphenopalatine artery, are iden-
tified in their retroantral course. The sphenopalatine artery enters
the sphenopalatine foramen to supply the nasopharynx. The supe-
rior aspect of the lateral pterygoid plate and V2 exiting the cranial
base from the foramen rotundum are clearly identified (Fig. 3B). The
window in the posterior antral space is enlarged superiorly by thin-
ning the bone of the orbital floor without entering the orbital fat pad.
Inferior extension of the osteotomy allows for mobilization of the
Sabit et al: Minimally Invasive Approach to the Cavernous Sinus
287

Fig. 3. A. Dissection of a dried bone specimen to reveal the rela-
tionship between the foramen rotundum, the superior orbital fissure
(SOF), the superior aspect of the lateral pterygoid plate (LPP), and
the sphenopalatine foramen (SPF), which emits the sphenopaiatine
artery to the nasopharynx. B. Contents of the pterygopalatine fossa
are displayed after a 2 x 2-cm osteotomy of the posterior wall of the
maxillary sinus. The maxillary division of the trlgeminai nerve (V2)
exits the foramen rotundum, and courses immediately Inferior to the
orbital floor (OF) in the infraorbltal canal. it gives Its first extracranlal
sensory branch, the posterior superior alveolar nerve (PSAN), which
supplies sensory endings to the molars. Coursing inferior and per-
pendicular to the nerve Is the Internal maxillary artery (IMA) whose
terminal branch is the sphenopalatine artery (SPA). The lateral wall
of the sphenoid sinus (SS) has been partially opened to reveal the
mucosa. The nasopharynx mucosa (NM) is reflected anteromedially.
sphenopalatine artery that otherwise would need to be embolized
before surgery to minimi ze the risk of accidental rupture. However,
the artery is routinely sacrificed in various procedures owing to the
extensive a.n astomosis around the nasopharynx and can be safely
ligated during surgery. Furthermore, as the mucosa) branch of the
sph nopalatine artery is a common source of postoperative epistaxis
when the sphenoid rostrum is opened, it is recommended that the
internal maxillary arte1y be ernboli zed before surgery. 1a.11
Finally, an osteotomy of the superomedial aspect of the ptery-
goid plate is carried out to expand the medial extent of the approach,
Laryngoscope 11O: February 2000
288
Fig. 4. A. Magnified view of a bony specimen displaying the trajec-
tory afforded after osteotomy of the lateral wall of the sphenoid
sinus (SS) and enlargement of the medial aspect of the foramen
rotundum (FR) and superior orbital fissure (SOF) to access the
parasellar and infrasellar regions. The posterior limit of the approach
is the upper third of the ventral surface of th e clivus. B. After the
osteotomy described in panel A, the thin sellar floor is removed and
periosteum removed to facilitate access to the vascular and neural
structures of the cavernous sinus and sellar region. The anterior
loop of the intracavernous portion of the internal carotid artery (ICA)
laterally borders the pituitary gland, which is seen in its entirety (pit).
The cranial nerves of the right cavernous cavity are visualized in
their course toward the superior orbital fiss ure (Ill, IV, VI = oculo-
motor, trochlear, and abducens nerve, respectively). The abducens
nerve has been reflected laterally to facilitate visualization of IV
mth care not to enter the nasal cavity. The extent of the osteotomy
of the superomedial pterygoid plate (above the attachment of the
pterygoid muscles) will be the limiting factor in determining the
medial reach of the approach and is crucial to enabling adequate
exposure of the medial cavernous compartment.
Cranial Stage
With the foramen rotundum and V2 clearly identified, the
cranial aspect of the microdissection commences by exposing the
anterolateral triangle of the cavernous sinus from below. Using a
high-speed drill with a 2-mm diamond burr, the course of V2 in
Sabit et al: Minimally Invasive Approach to the Cavernous Sinus
th e foram en rotundum is exposed by drilling around the medial
course of the nerve. With adequate mobilization of V2, th e extra-
dural cranial base window is safely enlarged superiorly to trans-
form the foramen rotundum and superior orbital fi ssure into a
single fora men (Fig. 4A). The bone of th e floor of th e middle fossa
inferior to the anterolateral triangle of the cavernous sinus is
thicker on the lower aspect (28 mm for the course of the foramen
rotundum) but thins out markedly below the superior orbital
fi ss ure, which lies only 4 to 5 mm superior to the foram en rotun-
dum. Great care must be exercised during superior enl arge ment
of the window to include the superior orbita l fi ssure in order avoid
injury to the neural structures coursing through it (III, IV, Vl,
and VI).
After th e bone window is enlarged to encompass the superior
orbital fissure, the periosteum of the middle cranial floor is removed
and the contents of the superior orbital fissure are identified. Only
after the vital neura l structures of the superior orbital fissure are
safely visualized can medi al enlargement of the window into the
cavernous sinus be performed to gain access to the medial cavernous
compartment. This is effectuated by fi rst thinning the lateral wall of
the ipsilateral sphenoid sinus with a high-speed drill using a 2-mm
diamond burr, followed by carefully removing the remnant of the
lateral and posterior walls using microdissection tecluuques. The
variation in the anatomic architecture of the sphenoid sinus man-
dates a particular order of bone removal in the lateral sphenoidec-
tomy so as to avoid injury to the anterior loop of the carotid artery.
The artery lies in an impression on the superior part of the postero-
lateral wall of the sinus and,..in 66% of cadaveric specimens the
artery is covered by less than 1 mm of bone and by only the mucosa
of the sphenoid sinus in 4%. 18 Consequently, starting at the thick
bone of the floor of the middle fossa medial to the enlarged foram en
rotundum, the bone is drilled safely and propagated med.ially to-
ward the lateral sphenoid wall. After the anterior aspect of the
lateral wall is removed and the sinus opened, the mucosa is stripped
from the sphenoid sinus and the major septum extracted using
pituitary forceps. With the extent of carotid artery protection as-
sessed, more extensive bone drilling can safely be conducted to
medially extend the superior orbital fissure osteotorriy into the
opened sphenoid sinus. It is crucial to note that the inferior medial
wall of the optic canal protrudes into the superior lateral aspect of
the sphenoid sinus. The osseous shielding of the optic nerve in this
location may be very thin or absent, leaving the nerve vulnerable to
injury from both surgical manipulation and thermal damage. 18· 19
With the i.nfrasellar bone removed using microsurgical dissec-
tion techniques, the dural sac covering the pituitary gland is opened
to access the entire ipsilateral cavernous sinus and infrasellar re-
gion, as well as gain good visualization of the intracavernous carotid Fig. 5. A. With the sellar floor and anterior sphenoid wall removed,
artery (Fig. 4B). Finally, the anterior sphenoid wall is extracted with access to the contralateral cavernous sinus is obtained. The thin
lateral wall of the contralateral sphenoid sinus is removed around
pituitary forceps, and the nasopharyngeal mucosa anterior to the
the carotid impression to reveal the medial aspect of the extradural
sphenoid sinus is refl ected anteriorly to avoid its violation and to intracavernous internal carotid artery (ICA). B. lntradural exposure of
enhance viewing of the cavernous sinus. The lateral wall of the the medial contralateral cavernous sinus. The horizontal portion and
contralateral sphenoid wall is removed exercising the same care anterior loop of the lCA (C4 and CS segments) are seen inferior to
previously mentioned to access the contralateral cavernous sinus the proximal dural ring. The inferior hypophyseal trunk (IHT) arises
(Fig. 5a). The dura covering the medi al aspect of the contralateral from the medial aspect of the intracavernous ICA and supplies the
internal carotid artery OCA) is incised to open the cavernous cavity pituitary gland . The intracavernous course of VI is demonstrated in
and access its vascular and neural structures (Fig. 5B). this dissection , lateral and inferior to the ICA, and Inferior to Ill. A
medial view of trigeminal ganglion (TG) is seen on the lateral wall of
the contralateral cavernous sinus.
DISCUSSION
Traditionally, surgical access to the cavernous sinus
has been gained through some variation of the Dalene
approach, thus necessitating a craniotomy and brain re- base and sellar region in 1897. Modifications of that route
traction. Des pite the variety of permutations of the s tan- were quick to follow but still required extensive facial soft
dard approaches to the cavernous sinus, they all r emain tissue dissection and radical osteotomies. Among these,
highly invasive in nature, ranging from the s tandard fron- Schloffer's approach is the most popular. 2 1 Kanave122 pro-
totemporal to the radical midfacial degloving. Giordano20 posed a less invasive model in 1909 entailing a combined
first described the trans facial approaches to the cranial subnasal lateral rhinotomy approach. Also in 1909,

Laryngoscope 110: February 2000 Sabit et al: Minimally Invasive Approach to the Cavernous Sinus
289
 TABLE I.
Measurements Between Bony Landmarks in the Transmaxillary Transsphenoidal Approach.
Average
Distance
{mm) SD{mm)

Posterior antral wall --> foremen rotundum 9.7 0.87

Foremen rotundum --> pterygoid plate 4.2 0.26
Depth of foramen rotundum (thickness) 23.1 3.17
Foremen rotundum --> superior orbital fissure 4.6 0.34
Foremen rotundum --> lateral wall of sphenold sinus 7.3 0.87
Superior orbital fissure --> lateral wall of sphenoid 3.7 1.09
sinus
Foremen rotundum --> clivus 49 5.88

Hirsch23 refined the technique to a strictly endonasal
route without a need for a lateral rhinotomy. One year
later, Halstead.24 introduced the sublabial transnasal ap-
proach, which was adopted by Cushing26 in his early pi-
tuitary adenoma operations and reported a 5.2% mortality
r te. However, the transf: cial route was abandoned owing
to poor illumination and high incidence of meningitis.
In more r cent years the introduction of the operating
microscope and advances in microsurgical instrumentation
as well as the use of antibiotics have led to the reexamina-
tion of transfacial approaches. Anterior approaches to the
skull base have offered various degrees of exposure to pri-
marily midline lesions of the hypophysis, clivus, or poste-
rior circulating vascular lesions, and include the trans-
basal, xtended transfrontal, transseptal transsphenoidal,
facial translocation, transmaxillary, transmaxillary trans-
nasal, midfacial degloving, transoral, mandible splitting
transoral, transcervical transclival, and anterior cervi-
cal.4,5,7,9,10,12,2s-s2 For large or local extensions of the various
lesions to the parasellar region, petrous bone, or cavernous
sinus, the limited lateral access and difficulty in attaining
proximal control of the ICA confines the usefulness of these
approaches. 8·19·18
The proposed combined transmaxillary transsphenoi-
dal approach offers a safe, minimally invasive extradural
extranasal route to the entire cavernous sinus and provides
adequate lateral-to-medial reach in.to the parasellar region.
Owing to the satisfactory medial reach of the approach, an
important feature of this model is the adequate exposure of
both the ipsilateral and medial contralateral intracavernous
carotid arteries. Visualization of the contralateral cavernous
ICA extends to the entire C4-C5 segments (Fig. 5B). In
addition, the lack of any contact with vital neural or vascular
structures before the opening of the cavernous window offers
a clear advantage for this microsurgical model. The course of
the infraorbital nerve provides a clear and uncomplicated
course to follow, leading into the cranial base and the floor of
the middle fossa. Furthermore, clear exposure of the fore-
men rotundum provides good orientation for the bony land-
marks of the inferior skull base and infratemporal fossa.
(Table I)
Previous authors have noted the direct access and short
operative range afforded by transfacial approaches to gain
ac ess to the infrasellar region and clivus. 6 •27 •33 However,
unlike most previously published efforts, this approach re-
quires no extensive osteotomies of the facial bones or exter-
nal facial incisions, thus maintaining excellent cosmetic out-
come. The ability of this approach to avoid violation the
nasopharynx and oropharynx is a further demonstration of
its minimally invasive nature. Closure and reconstruction of
the base of the skull would be a clear advantage for this
approach.
The operative reach afforded by this approach allows
adequate access to the ipsilateral cavernous sinus, medial
aspect of the contralateral cavernous sinus, infrasellar and
subdiaphragmatic region, and ventral surface of the upper
third of the clivus (Table II). The adjoining of the foramen
rotundum and superior orbital fissure into a single foramen
at the onset of the cranial course of the dissection allows
adequate and prompt visualization of cranial nerves III, IV,
V2, and VI lying lateral to the intracavernous carotid artery.
During the approach, venous bleeding encountered from the
cavernous sinus is controlled by gentle packing with oxidized
regenerated cellulose (Surgical, Johnson & Johnson Medical,
Arlington, TX), a technique routinely used in transcranial
cavernous sinus dissection. By identifying the neural and
vascular contents of the cavernous sinus early, more medial
exposure can be performed with decreased risk of iatrogenic
injury to the carotid artery when opening the sphenoid sinus
to expose the infrasellar region and contralateral ICA. Renn
and Rhotonl8 noted that the distance between the intracav-
ernous carotid arteries ranged from 4 to 18 mm. For large
invasive midline lesions of the cavernous sinus, approaching
TABLE II.
Distances Between Key Structures in the Transmaxillary
Transsphenoidal Approach.
Average
Distance
{mm) SD{mm)
Course of V2 in pterygopalatlne fossa 9.7 0.87
Course of V2 in foramen rotundum 23.1 2.17
Foramen rotundum --> anterior loop of 27.7 3.27
ICA
ICA (ipsllateral) <- --> ICA (contralateral) 12.6 1.21
Foramen rotundum --> contralateral ICA 36.4 4.59
ICA = Internal carotid artery.

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290
the lesions from the inferolateral orientation afforded by this
procedure offers more lateral exposure than a standard
transsphenoidal approach. With a width 26 mm at the base
of the operative field within the cavernous sinus, adequate
proximal and distal control of the ipsilateral carotid artery is
easily established by the u se of aneurysm clips, as well as
visualization of the medial aspect of the contralateral carotid
artery. The approach can be a safe alternative route
for gaining access to locally aggressive lesions with signifi-
cant lateral extension and involvement of the intra-
cavemous carotid artery: lesions that otherwise would re-
quire both a transsphenoidal and pterional approach for
resection. 11
CONCLUSION
The transmaxillary transsphenoidal approach can be
u seful to neurosurgical and otolaryngological teams in
a ddressing disease of the infrasellar and cavernous region
with lateral extension. Potential complications of this ap-
proach include delayed postoperative epistaxis from the
mucosa! branches of the sphenopalatine artery, and anes-
thesia of the upper lips and anterior maxillary teeth seen
with the employment of the sublabial incision and re-
moval of the maxillary spine.a4 .as The decreased sen sa-
tion, however, is temporary in 90% of cases and delayed
epistaxis can be avoided b preoperative embolization of
the maxillary artery.17 •28 In addition, with exposure of the
carotid artery within the cavernous sinus or sphenoid,
clos ure of the wound should include fas cia! or muscle
covering to the region to decrease the exposure of the
artery and reduce the risk of erosion. The approach can be
tailored to provide access to the desired target area and
can be attained by a purely extradural extranasal route.
This approach minimizes the need for the more invasive
trans facial approaches of the mid facial degloving, or use of
an external facial incision of the lateral rhinotomy opera-
tion . It can be u sed in combination with supratentorial
approaches to provide complete access to disease of the
cavernous sinus.
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