Skip to main content

Advertisement

Log in

Open and Endoscopic Skull Base Approaches

  • Skull Base Surgery (CH Synderman and EW Wang, Section Editors)
  • Published:
Current Otorhinolaryngology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Surgical approaches to the skull base have been evolving at an incredible rate in the past 30 years. The advent of the endoscope has multiplied the available approaches while reducing morbidity. Otolaryngologists and neurosurgeons performing these operations must stay updated in recent trends and techniques to determine the best options for patients.

Recent Findings

Twenty years have passed since the adoption of the endoscope in skull base surgery but new techniques are still being introduced on an annual basis. Most notably are the “cross court” techniques utilizing the contralateral transmaxillary (CTM) approach and transorbital neuroendoscopic surgery (TONES). Both approaches allow the surgeon increased angulation and access to lateral structures limited by the endonasal approach.

Summary

Surgeons must understand the patient factors, pathology, and available resources as well as the armamentarium of approaches to the skull base to offer the best option for individual patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Hirschmann A. Endoscopy of the nose and its accessory sinuses. Laryngoscope. 1903;13(10):810. https://doi.org/10.1288/00005537-190310000-00015.

    Article  Google Scholar 

  2. Tajudeen BA, Kennedy DW. Thirty years of endoscopic sinus surgery: what have we learned? World J Otorhinolaryngol - Head Neck Surg. 2017;3(2):115–21. https://doi.org/10.1016/j.wjorl.2016.12.001.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Linder TE, Simmen D, Stool SE. Revolutionary inventions in the 20th century: the history of endoscopy. Arch Otolaryngol Head Neck Surg. 1997;123(11):1161–3. https://doi.org/10.1001/archotol.1997.01900110011001.

    Article  CAS  PubMed  Google Scholar 

  4. Messerklinger W. Diagnosis and endoscopic surgery of the nose and its adjoining structures. Acta Otorhinolaryngol Belg. 1980;34(2):170–6.

    CAS  PubMed  Google Scholar 

  5. Frazier CH. I. An approach to the hypophysis through the anterior cranial fossa. Ann Surg. 1913;57(2):145–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Derome P. Spheno-ethmoidal tumors. Possibilities for exeresis and surgical repair. Neurochirurgie. 1972;18(1 Suppl 1):1–164.

    Google Scholar 

  7. Tessier P, Guiot G, Rougerie J, Delbet JP, Pastoriza J. Cranio-naso-orbito-facial osteotomies. Hypertelorism. Ann Chir Plast. 1967;12(2):103–18.

    CAS  PubMed  Google Scholar 

  8. Raveh J, Vuillemin T. Advantages of an additional subcranial approach in the correction of craniofacial deformities. J Craniomaxillofac Surg. 1988;16(8):350–8.

    Article  CAS  PubMed  Google Scholar 

  9. Kawakami K, Yamanouchi Y, Kubota C, Kawamura Y, Matsumura H. An extensive transbasal approach to frontal skull-base tumors Technical note. J Neurosurg. 1991;74(6):1011–3.

    Article  CAS  PubMed  Google Scholar 

  10. Sekhar LN, Nanda A, Sen CN, Snyderman CN, Janecka IP. The extended frontal approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg. 1992;76(2):198–206.

    Article  CAS  PubMed  Google Scholar 

  11. Liu JK, Wong A, Eloy JA. Combined endoscopic and open approaches in the management of sinonasal and ventral skull base malignancies. Otolaryngol Clin N Am. 2017;50(2):331–46.

    Article  Google Scholar 

  12. Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus. 2006;19(3):164–71.

    Article  CAS  PubMed  Google Scholar 

  13. McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery. 2012;71(5):916–24 discussion 924-926.

    Article  PubMed  Google Scholar 

  14. healthpolicy. Position statement: intra-operative use of computer aided surgery. American Academy of Otolaryngology-Head and Neck Surgery. https://www.entnet.org/content/intra-operative-use-computer-aided-surgery. Published March 20, 2014. Accessed November 6, 2019.

  15. Elia AEH, Shih HA, Loeffler JS. Stereotactic radiation treatment for benign meningiomas. Neurosurgical Focus. 2007;23(4):E5. https://doi.org/10.3171/foc-07/10/e5.

    Article  PubMed  Google Scholar 

  16. Castelnuovo P, Turri-Zanoni M, Battaglia P, Antognoni P, Bossi P, Locatelli D. Sinonasal malignancies of anterior skull base: histology-driven treatment strategies. Otolaryngol Clin N Am. 2016;49(1):183–200.

    Article  Google Scholar 

  17. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882–6.

    Article  PubMed  Google Scholar 

  18. Abu-Ghanem S, Fliss DM. Surgical approaches to resection of anterior skull base and paranasal sinuses tumors. Balkan Med J. 2013;30(2):136–41.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lee KJ KJ Lee’s essential otolaryngology, 12th Edition. McGraw Hill Professional; 2019.

  20. Ganly I, Patel SG, Singh B, et al. Craniofacial resection for malignant paranasal sinus tumors: report of an international collaborative study. Head Neck. 2005;27(7):575–84.

    Article  PubMed  Google Scholar 

  21. Gil Z, Fliss DM. Pericranial wrapping of the frontal bone after anterior skull base tumor resection. Plast Reconstr Surg. 2005;116(2):395–8 discussion 399.

    Article  CAS  PubMed  Google Scholar 

  22. Gil Z, Fliss DM. Skull Base surgery in the twenty-first century. Tumours Skull Base Paranasal Sinuses. 2012:1-4. https://doi.org/10.1007/978-81-322-2583-6_1.

    Chapter  Google Scholar 

  23. Mehta RP, Cueva RA, Dale Brown J, et al. What’s new in skull base medicine and surgery? Skull base committee report. Otolaryngol Head Neck Surg. 2006;135(4):620–30. https://doi.org/10.1016/j.otohns.2006.04.018.

    Article  PubMed  Google Scholar 

  24. Fliss DM, Abergel A, Cavel O, Margalit N, Gil Z. Combined subcranial approaches for excision of complex anterior skull base tumors. Arch Otolaryngol Head Neck Surg. 2007;133(9):888–96.

    Article  PubMed  Google Scholar 

  25. Kutlay M, Durmaz A, Özer İ, et al. Extended endoscopic endonasal approach to the ventral skull base lesions. Clin Neurol Neurosurg. 2018;167:129–40.

    Article  PubMed  Google Scholar 

  26. Schroeder HWS. Indications and limitations of the endoscopic endonasal approach for anterior cranial base meningiomas. World Neurosurg. 2014;82(6 Suppl):S81–5.

    Article  PubMed  Google Scholar 

  27. Shetty SR, Ruiz-Treviño AS, Omay SB, Almeida JP, Liang B, Chen YN, et al. Limitations of the endonasal endoscopic approach in treating olfactory groove meningiomas. A systematic review. Acta Neurochir. 2017;159(10):1875–85.

    Article  PubMed  Google Scholar 

  28. Youssef AS, Sampath R, Freeman JL, Mattingly JK, Ramakrishnan VR. Unilateral endonasal transcribriform approach with septal transposition for olfactory groove meningioma: can olfaction be preserved? Acta Neurochir. 2016;158(10):1965–72.

    Article  PubMed  Google Scholar 

  29. Liu JK, Christiano LD, Patel SK, Tubbs RS, Eloy JA. Surgical nuances for removal of olfactory groove meningiomas using the endoscopic endonasal transcribriform approach. Neurosurg Focus. 2011;30(5):E3.

    Article  PubMed  Google Scholar 

  30. Majmundar N, Kamal NH, Reddy RK, Eloy JA, Liu JK. Limitations of the endoscopic endonasal transcribriform approach. J Neurosurg Sci. 2018;62(3):287–96.

    PubMed  Google Scholar 

  31. Kasemsiri P, Carrau RL, Ditzel Filho LFS, et al. Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg. 2014;82(6 Suppl):S12–21.

    Article  PubMed  Google Scholar 

  32. Flint PW, Haughey BH, Niparko JK, et al. Cummings otolaryngology - head and neck surgery e-book: head and neck surgery, 3-volume set. Elsevier Health Sciences; 2010.

  33. de Lara D, Ditzel Filho LFS, Prevedello DM, et al. Endonasal endoscopic approaches to the paramedian skull base. World Neurosurg. 2014;82(6 Suppl):S121–9.

    Article  PubMed  Google Scholar 

  34. Moe KS, Bergeron CM, Ellenbogen RG. Transorbital neuroendoscopic surgery. Neurosurgery. 2010;67(3 Suppl Operative):ons16–28.

    PubMed  Google Scholar 

  35. • Ramakrishna R, Kim LJ, Bly RA, Moe K, Ferreira M. Transorbital neuroendoscopic surgery for the treatment of skull base lesions. J Clin Neurosci. 2016;24:99–104. https://doi.org/10.1016/j.jocn.2015.07.021This study reports the largest number of patients treated with the relatively new TONES for treatment of skull base lesions.

    Article  PubMed  Google Scholar 

  36. Patel CR, Fernandez-Miranda JC, Wang W-H, Wang EW. Skull base anatomy. Otolaryngol Clin N Am. 2016;49(1):9–20.

    Article  Google Scholar 

  37. Graffeo CS, Dietrich AR, Grobelny B, et al. A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors. Pituitary. 2014;17(4):349–56.

    Article  PubMed  PubMed Central  Google Scholar 

  38. de Almeida JR, Witterick IJ, Gullane PJ, et al. Physical morbidity by surgical approach and tumor location in skull base surgery. Head Neck. 2013;35(4):493–9.

    Article  PubMed  Google Scholar 

  39. Wong AK, Stamates MM, Bhansali AP, Shinners M, Wong RH. Radiographic assessment of the presigmoid retrolabyrinthine approach. Surg Neurol Int. 2017;8:129.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Jankowski R, Auque J, Simon C, Marchai JC, Hepner H, Wayoff M. Endoscopic Pituitary Tumor Surgery. Laryngoscope. 1992;102(2):198–202. https://doi.org/10.1288/00005537-199202000-00016.

    Article  CAS  PubMed  Google Scholar 

  41. Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007;106(3):400–6.

    Article  PubMed  Google Scholar 

  42. Cavallo LM, Messina A, Gardner P, et al. Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations. Neurosurg Focus. 2005;19(1):E5.

    PubMed  Google Scholar 

  43. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. 2005;19(1):E6.

    PubMed  Google Scholar 

  44. Lee JT, Suh JD, Carrau RL, Chu MW, Chiu AG. Endoscopic Denker’s approach for resection of lesions involving the anteroinferior maxillary sinus and infratemporal fossa. Laryngoscope. 2017;127(3):556–60. https://doi.org/10.1002/lary.26237.

    Article  PubMed  Google Scholar 

  45. Little AS, Nakaji P, Milligan J. Endoscopic endonasal transmaxillary approach and endoscopic sublabial transmaxillary approach: surgical decision-making and implications of the nasolacrimal duct. World Neurosurg. 2013;80(5):583–90.

    Article  PubMed  Google Scholar 

  46. Truong HQ, Sun X, Celtikci E, et al. Endoscopic anterior transmaxillary “transalisphenoid” approach to Meckel’s cave and the middle cranial fossa: an anatomical study and clinical application. J Neurosurg. 2018;130(1):227–37. https://doi.org/10.3171/2017.8.jns171308.

    Article  PubMed  Google Scholar 

  47. Verillaud B, Bresson D, Sauvaget E, et al. Exposure techniques in endoscopic skull base surgery: posterior septectomy, medial maxillectomy, transmaxillary and transpterygoid approach. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(5):284–8.

    Article  CAS  PubMed  Google Scholar 

  48. Sheehan P, Debnath I, Schlosser R. Transseptal approach for extended endoscopic resections of the maxilla and infratemporal fossa. Am J Rhinol Allergy. 2009;23(4):426–32.

    Article  PubMed  Google Scholar 

  49. Eloy JA, Kuperan AB, Friedel ME, Choudhry OJ, Liu JK. Modified hemi-Lothrop procedure for supraorbital frontal sinus access: a case series. Otolaryngol Head Neck Surg. 2012;147(1):167–9.

    Article  PubMed  Google Scholar 

  50. •• Patel C, Fernandez-Miranda J, Wang E, Gardner P, Snyderman C. Contralateral transmaxillary corridor as an extension to the endoscopic endonasal approach to the petrous apex. J Neurol Surg Part B: Skull Base. 2016;77(S 01). https://doi.org/10.1055/s-0036-1579949. This study describes a new corridor to allow access to the petrous apex with decreased manipulation of the petrous ICA.

  51. Zanation AM, Snyderman CH, Carrau RL, Gardner PA, Prevedello DM, Kassam AB. Endoscopic endonasal surgery for petrous apex lesions. Laryngoscope. 2009;119(1):19–25.

    Article  PubMed  Google Scholar 

  52. Paluzzi A, Gardner P, Fernandez-Miranda JC, et al. Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients: clinical article. J Neurosurg. 2012;116(4):792–8.

    Article  PubMed  Google Scholar 

  53. Pamias-Portalatin E, Mahato D, Rincon-Torroella J, Vivas-Buitrago T, Quiñones-Hinojosa A, Boahene KO. Endoscope-assisted contralateral transmaxillary approach to the clivus and the hypoglossal canal: technical case report. J Neurosurg. 2018:1-7.

  54. Lavigne P, Wang EW, Fernandez-Miranda JC. Supratotal resection of residual clival chordoma with combined endoscopic endonasal and contralateral transmaxillary approaches: 2-dimensional operative video. Oper Neurosurg (Hagerstown). 2019;16(3):E88–9.

    Article  Google Scholar 

  55. Park HH, Hong SD, Kim YH, et al. Endoscopic transorbital and endonasal approach for trigeminal schwannomas: a retrospective multicenter analysis (KOSEN-005). J Neurosurg. 2019:1-10.

  56. Jeon C, Hong C-K, Woo KI, et al. Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results. J Neurosurg. 2018:1-10.

  57. Lee MH, Hong SD, Woo KI, et al. Endoscopic endonasal versus transorbital surgery for middle cranial fossa tumors: comparison of clinical outcomes based on surgical corridors. World Neurosurg. 2019;122:e1491–504.

    Article  PubMed  Google Scholar 

  58. Chen HI, Bohman L-E, Loevner LA, Lucas TH. Transorbital endoscopic amygdalohippocampectomy: a feasibility investigation. J Neurosurg. 2014;120(6):1428–36.

    Article  PubMed  Google Scholar 

  59. Gerges MM, Godil SS, Younus I, Rezk M, Schwartz TH. Endoscopic transorbital approach to the infratemporal fossa and parapharyngeal space: a cadaveric study. J Neurosurg. 2019:1–12.

  60. Di Somma A, Andaluz N, Cavallo LM, et al. Endoscopic transorbital route to the petrous apex: a feasibility anatomic study. Acta Neurochir. 2018;160(4):707–20.

    Article  PubMed  Google Scholar 

  61. Bly RA, Ramakrishna R, Ferreira M, Moe KS. Lateral transorbital neuroendoscopic approach to the lateral cavernous sinus. J Neurol Surg B Skull Base. 2014;75(1):11–7.

    PubMed  Google Scholar 

  62. Priddy BH, Nunes CF, Beer-Furlan A, Carrau R, Dallan I, Prevedello DM-S. A side door to Meckel’s cave: anatomic feasibility study for the lateral transorbital approach. Oper Neurosurg. 2017;13(5):614–21. https://doi.org/10.1093/ons/opx042.

    Article  Google Scholar 

  63. Hakuba A, Nishimura S, Jang BJ. A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol. 1988;30(2):108–16. https://doi.org/10.1016/0090-3019(88)90095-x.

    Article  CAS  PubMed  Google Scholar 

  64. Lanzino G, Paolini S, Spetzler RF. Far-lateral approach to the craniocervical junction. Operative Neurosurgery. 2005;57:367–71. https://doi.org/10.1227/01.neu.0000176848.05925.80.

    Article  Google Scholar 

  65. Flores BC, Boudreaux BP, Klinger DR, Mickey BE, Barnett SL. The far-lateral approach for foramen magnum meningiomas. Neurosurg Focus. 2013;35(6):E12.

    Article  PubMed  Google Scholar 

  66. Kassam AB, Prevedello DM, Thomas A, et al. Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery. 2008;62(3 Suppl 1):57–72 discussion 72-74.

    PubMed  Google Scholar 

  67. Shkarubo AN, Koval KV, Shkarubo MA, Chernov IV, Andreev DN, Panteleyev AA. Endoscopic endonasal transclival approach to tumors of the clivus and anterior region of the posterior cranial fossa: an anatomic study. World Neurosurg. 2018;119:e825–41.

    Article  PubMed  Google Scholar 

  68. Funaki T, Matsushima T, Peris-Celda M, Valentine RJ, Joo W, Rhoton AL Jr. Focal transnasal approach to the upper, middle, and lower clivus. Neurosurgery. 2013;73(2 Suppl Operative):ons155–90 discussion ons190-ons191.

    PubMed  Google Scholar 

  69. Vaz-Guimaraes F, Nakassa ACI, Gardner PA, Wang EW, Snyderman CH, Fernandez-Miranda JC. Endoscopic endonasal approach to the ventral jugular foramen: anatomical basis, technical considerations, and clinical series. Oper Neurosurg (Hagerstown). 2017;13(4):482–91.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Chirag Patel.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical collection on Skull Base Surgery

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tadokoro, K., Domack, A., Germanwala, A.V. et al. Open and Endoscopic Skull Base Approaches. Curr Otorhinolaryngol Rep 8, 136–146 (2020). https://doi.org/10.1007/s40136-020-00283-w

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40136-020-00283-w

Keywords

Navigation