Endoscopic Endonasal Surgery for Biopsy of Cavernous Sinus Lesions

Abstract

Introduction: The etiology of cavernous sinus (CS) lesions remains difficult to determine due to the wide range of pathological processes and in spite of the development of neuroimaging techniques. Microsurgery is still not appropriate to take a biopsy of CS lesions for diagnostic purposes while biopsy was rarely attempted by fine-needle aspiration guided by computed tomography. The authors present a new application to endoscopic endonasal surgery for the biopsy of lesions arising from or invading the cavernous sinus.

Methods: Ten patients diagnosed with cavernous sinus lesions, 5 male and 5 female, whose ages ranged from 20 to 58 years (mean±SD: 38.4±11.8 years) underwent an endoscopic biopsy via the endonasal transphenoid approach by using 0° and 30° lens endoscopes. Nine of the 10 patients experienced headache, 6 presented with visual disturbances, and 2 presented with a decrease in facial sensation. Preoperative MRI identified 6 patients with CS lesions on right side, 3 on the left and 1 on both sides.

Results: The accuracy of the diagnosis with this technique was 100%. The pathological diagnosis of the cavernous sinus lesions showed 3 patients with nasopharyngeal carcinoma, 2 patients with meningioma, 1 patient with esthesioneuroblastoma, 1 giant cell tumor of bone, 1 small cell carcinoma from the lungs, 1 fungal granuloma, and 1 schwannoma. Postoperatively 6 patients received radiotherapy, 1 patient received antifungal treatment, and the others did not receive any treatment, but were followed up in the clinic. The course of one patient was complicated by an internal carotid artery injury which was treated by interventional balloon occlusion, and another with transient cerebrospinal leakage cured within a week by subarachnoid drainage.

Conclusion: The authors present an alternative surgical approach for the diagnostic biopsy of CS under a direct endoscopic visualization. The technique is safe, effective and accurate for biopsy and provides a surgical route that can be added to the armamentarium for the management for pathological conditions in this region.

Key words

endoscope - cavernous sinus - skull base - surgery - tumor

References

• 1 Fernández S, Godino O, Martínez-Yélamos S. et al . Cavernous sinus syndrome: a series of 126 patients.  Medicine (Baltimore). 2007;  86 278-281
• 2 Sekhar LN, Sen CN, Jho HD. et al . Surgical treatment of intracavernous neoplasm: a four-year experience.  Neurosurgery. 1989;  24 18-30
• 3 Jho HD, Ha HG. Endoscopic endonasal skull base surgery: Part 1 – The middle anterior fossa skull base.  Minim Invas Neurosurg. 2004;  47 1-8
• 4 Jho HD, Ha HG. Endoscopic endonasal skull base surgery: Part 2 – The cavernous sinus.  Minim Invas Neurosurg. 2004;  47 9-15
• 5 Jho HD, Ha HG. Endoscopic endonasal skull base surgery: Part 3 – The clivus and posterior fossa.  Minim Invas Neurosurg. 2004;  47 16-23
• 6 Alfieri A, Jho HD. Endoscopic endonasal approaches to the cavernous sinus: surgical approaches.  Neurosurgery. 2001;  49 354-362
• 7 Heth JA, Al-Mefty O. Cavernous sinus meningiomas.  Neurosurg Focus. 2003;  14 ((6)) e3
• 8 Rhoton AL. The cavernous sinus, the cavernous venous plexus and the carotid collar.  Neurosurgery. 2002;  51 ((4 Suppl)) S375-S410
• 9 Rhoton AL. The sellar region.  Neurosurgery. 2002;  51 ((4 Suppl)) S335-S374
• 10 Couldwell WT, Sabit I, Weiss MH. et al . Transmaxillary approach to the anterior cavernous sinus: a microanatomic study.  Neurosurgery. 1997;  40 1307-1311
• 11 Sindou M, Chavez JM, Saint Pierre G. et al . Percutaneous biopsy of cavernous sinus tumors though the foramen ovale.  Neurosurgery. 1997;  40 106-111
• 12 Olmos PR, Falko JM, Rea GL. et al . Fibrosing pseudotumor of the sella and parasellar area producing hypopituitarism and multiple cranial nerve palsies.  Neurosurgery. 1993;  32 1015-1021
• 13 Supler ML, Friedman WA. Acute bilateral ophthalmoplegia secondary to cavernous sinus metastasis: a case report.  Neurosurgery. 1992;  31 783-786
• 14 Liu HS, Qu QY, Ni ZL. The endoscopic cavernous sinus surgery via the extended transsphenoidal approach: An anatomic study.  Chinese Journal of Minimally Invasive Neurosurgery. 2004;  9 549-552
• 15 Liu HS, Zhao CH, Yin W. The supraorbital “keyhole” approach: a study of endoscopic anatomy.  Chinese Journal of Clinical Anatomy. 2002;  20 38-40
• 16 el-Kalliny M, Loveren H Van, Keller JT. et al . Tumors of the lateral wall of the cavernous sinus.  J Neurosurg. 1992;  77 508-514
• 17 Alfieri A, Jho HD. Endoscopic endonasal cavernous sinus surgery: an anatomic study.  Neurosurgery. 2001;  48 827-836 , discussion 836–837

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