Transnasal Endoscopic Surgery of the Cavernous Sinus

Objectives: Head and neck cancer metastases to the cavernous sinus have been rarely reported. Tissue diagnosis and surgical management present unique challenges, given the proximity to the critical cavernous sinus structures. We describe a transnasal endoscopic approach to the cavernous sinus for tissue diagnosis, ultimately guiding treatment and management. Study Design: Retrospective case study Methods: A review of the medical records of two patients who presented to a tertiary medical center with symptoms of cavernous sinus syndrome was done. Radiographic images, videographic demonstration of the operative technique, and pathology slides are presented. Results: Both patients presented with ophthalmologic symptoms consistent with cavernous sinus syndrome. Imaging demonstrated a lesion in the cavernous sinus. Videographic demonstration of the operative technique shows that a transnasal endoscopic approach to the cavernous sinus is feasible and safe. A dual surgeon approach was utilized, with the otolaryngologist providing wide exposure of the cavernous sinus through the lateral wall of the sphenoid, and the neurosurgeon taking down the dura to enter the cavernous sinus and collect tissue. The tissue diagnosis was metastatic adenoid cystic carcinoma in one patient and metastatic squamous cell carcinoma in the second. Postoperatively, both patients recovered well without new vision changes, cranial neuropathies or bleeding. Conclusions: A transnasal endoscopic approach to the cavernous sinus is a safe and efficacious method to obtain tissue specimens of cavernous sinus lesions. Pathologic diagnoses in patients presenting with cavernous sinus syndrome is critical for guiding further treatment and management.