Minim Invasive Neurosurg 2004; 47(1): 9-15
DOI: 10.1055/s-2004-818346
Original Article
© Georg Thieme Verlag Stuttgart · New York

Endoscopic Endonasal Skull Base Surgery: Part 2 - The Cavernous Sinus

H.-D.  Jho1 , H.-G.  Ha1
  • 1Center for Minimally Invasive Innovative Microneurosurgery, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
Further Information

Publication History

Publication Date:
18 July 2005 (online)


Objective: An endoscopic endonasal approach to the cavernous sinus was developed with cadaver study and, subsequently, has been used in patient treatment.

Methods: The endoscopic anatomy, surgical approaches, and ideal head positioning were studied with six cadaver head specimens in order to develop endoscopic endonasal surgery of the cavernous sinus. Three illustrative patient cases are also reported.

Results: Horizontal placement of the forehead-chin line of head specimens provided the ideal head positioning for endoscopic endonasal cavernous sinus surgery. Three different surgical approaches were developed to access the cavernous sinus: the paraseptal, middle meatal and middle turbinectomy approaches. While the ipsilateral middle meatal approach provided straight anterior exposure, the contralateral paraseptal approach provided anteromedial exposure at the cavernous sinus. The middle turbinectomy approach rendered straight anterior exposure ipsilaterally and anteromedial exposure contralaterally. The sympathetic nerve climbed up on the surface of the carotid artery. When the dura mater was opened at the anterior wall of the cavernous sinus, the S-shaped carotid siphon was exposed. Cranial nerves III and IV were located inside the C-shaped carotid siphon. Cranial nerve VI was just lateral to the inferior arch of the carotid siphon. The ophthalmic branch of the trigeminal nerve was lateral to cranial nerve VI. When used in patient treatment, this technique was observed to be minimally invasive.

Conclusion: Endonasal endoscopy for cavernous sinus surgery was studied in cadaver dissection, and subsequently, was used in patient treatment with satisfactory outcomes.


  • 1 Dolenc V V. Transcranial epidural approach to pituitary tumors extending beyond the sella.  Neurosurgery. 1997;  41 542-552
  • 2 Matsuno A, Sasaki T, Saito N, Mochizuki T, Fujimaki T, Kirino T, Takakura K. Transcavernous surgery: an effective treatment for pituitary macroadenomas.  European Journal of Endocrinology. 1995;  133 156-165
  • 3 Sekhar L N, Burgess J, Akin O. Anatomical study of the cavernous sinus emphasizing operative approaches and related vascular and neural reconstruction.  Neurosurgery. 1987;  21 806-816
  • 4 Fujii K, Chambers S M, Rhoton Jr A L. Neurovascular relationships of the sphenoid sinus. A microsurgical study.  J Neurosurg. 1979;  50 31-39
  • 5 Rhoton A L, Hardy D G, Chambers S M. Microsurgical anatomy and dissection of the sphenoid bone, cavernous sinus and sellar region.  Surg Neurol. 1979;  12 63-104
  • 6 Fraioli B, Esposito V, Santoro A, Iannetti G, Giuffre R, Cantore G. Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus.  J Neurosurg. 1995;  82 63-69
  • 7 Hashimoto N, Kikuchi H. Transsphenoidal approach to infrasellar tumors involving the cavernous sinus.  J Neurosurg. 1990;  73 513-517
  • 8 Ludecke D K. Value of transcavernous surgery in the treatment of pituitary adenomas.  European Journal of Endocrinology. 1995;  133 147-148
  • 9 Jho H D. Endoscopic endonasal pituitary surgery: Technical aspects.  Contemporary Neurosurgery. 1997;  19 1-7
  • 10 Jho H D, Carrau R L, Ko Y. Endoscopic pituitary surgery. In: Wilkins RH, Rengachary SS (eds). Neurosurgical Operative Atlas. Baltimore: Williams & Wilkins 1996 Vol. 5 (1): pp 1-12
  • 11 Jho H D, Carrau R L. Endoscopy assisted transsphenoidal surgery for pituitary adenoma. Technical note.  Acta Neurochir (Wien). 1996;  138 1416-1425
  • 12 Jho H D, Carrau R L. Endoscopic endonasal transsphenoidal surgery: Experience with 50 patients.  J Neurosurg. 1997;  87 44-51
  • 13 Jho H D, Carrau R L, Mclaughlin M L, Somaza S C. Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa.  Acta Neurochir (Wien). 1997;  139 343-348
  • 14 Jho H D, Carrau R L, Ko Y, Daly M. Endoscopic pituitary surgery: An early experience.  Surg Neurol. 1997;  47 213-223
  • 15 Jho H D, Ha H G. Endoscopic endonasal skull base surgery: Part I - The midline anterior fossa skull base.  Minim Invas Neurosurg. 2004;  47 1-8

H.-D. Jho, M. D. Ph. D. 

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