The patient came to the clinic 19-May-2013 complaining of right ophthalmalgia, diplopea, decreased vision right eye, photophobia and numbness right side of the face for 4 months. Right otalgia for 2 months. She was operated and radiated for adnocarcinoma of the nasal cavity during the last three months of 2009. Radiation dose was 3300 rad during October-2009. The patient in Rivotril 1 mg twice daily for several years for right trigeminal neuralgia.

On examination: The patient has hypalgesia I-II-III divisions of the right V nerve. Blepharospasm of the right eye due to photophobia. Decreased vision right eye. The oculomotor and the trochlear nerves are functioning well. The uvula shifts to the left and there is scareous changes in the right side of the soft palate.

The patient sent for new MRI of the brain with contrast with MRA of the brain with special sella protocol, which were done 20-May-2013 showing the mass involving the right cavernous sinus pushing the arterial compartment medially and reaching the right optic canal, compressing the optic nerve. CT-scan of the chest and abdomino-pelvic cavities done 10 days ago were normal, so the bone scan done 20-May-2013 showing only the high uptake at the mentioned lesion of the cavernous sinus.

Right extended pterional approach with reflection of the bone flap to the right ear. The dura was opened parallel to the anterior and middle fossa. The right cavernous sinus, the right optic nerve. the supraclinoid right ICA and the olfactory tracts were seen after opening of the sylvian cistern. The tumor was invading the lateral wall of the cavernous sinus. 8 mm under the superior edge of the cavernous sinus, a dural incision was done to expose the tumor. Piece meal resection of the tumor was carried out and fresh frozen section confirmed the presence of malignant adnocarcinoma. Considering that the tumor was invading all the branches of the right trigeminal nerve, the incision was widened to expose most of the tumor leaving the above mentioned zone of 8 mm to avoid injury to the right oculomotor and trochlear nerves. A bundle of nerves, which mostly is a division of the ophthalmic division of the trigeminal nerve was violated. A wide cavity was created at the tumor bed and the dura was seen at the bed of the resected tumor. The CSF flow started to come from the posterior parts of the cavity, mandating no residual at the posterior aspect. At the anterior part of the cavity, further resection of the mass revealed that the tumor is transforming to nerve bundles, for what the resection was limited. Inspection of the right optic nerve and supraclinoid and the space between them revealed no tumor at these angles. Surgicele was inserted at the tumor bed cavity and routine closure of the wound.

Routine closure of the wound. Smooth postoperative recovery. The patient was sent to the ICU.

The patient has adnocarcinoma treated 4 years ago and has spread to the right cavernous sinus. Surgical resection, followed by radiotherapy is the best option at this time.

The tumor was diffusely invading the neural structure of the trigeminal nerve. They were included in the resection to obtain maximum resection.