Endoscopic Endonasal Approaches for Treatment of Craniovertebral Junction Tumours

  • Davide Locatelli
  • Apostolos Karligkiotis
  • Mario Turri-Zanoni
  • Frank Rikki Canevari
  • Fabio Pozzi
  • Paolo Castelnuovo
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 125)


Tumours involving the craniovertebral junction (CVJ) are challenging because of their local invasiveness and high recurrence rates, as well as their proximity to critical neurovascular structures and the difficulty of reconstructing the resulting skull base defect at this site. Several surgical techniques are currently available to access these lesions, including the far lateral, extreme lateral, direct lateral, transcervical, transoral and transnasal approaches. In this paper, application of the endoscopic endonasal approach (EEA) in the treatment of CVJ tumours is analysed. The indications, contraindications, preoperative workup, step-by-step surgical technique, skull base reconstruction options and postoperative management are described. The advantages and limitations of the EEA are also discussed. Finally, a systematic review of the literature is provided to elucidate the levels of evidence supporting the use of the EEA in this field. Employment of this approach to the CVJ has contributed to high success rates in achieving gross total resection of tumours and improvement in neurological symptoms. Intraoperative and postoperative complication rates are acceptable, with cerebrospinal fluid leakage being the major concern (with a 17–25% incidence). Moreover, in comparison with traditional approaches to the CVJ, the EEA provides lower rates of postoperative dysphagia and respiratory complications. Use of the EEA for treatment of CVJ tumours appears to be a rational alternative to the conventional transoral, transcranial and transcervical approaches in selected cases. Multidisciplinary teamwork including different specialists—such as medical and radiation oncologists, radiologists, otorhinolaryngologists and neurosurgeons—is strongly recommended for the purpose of offering the best treatment strategy for the patient.


Chordomas Meningiomas Craniovertebral junction Clivus Posterior cranial fossa Endoscopic transnasal approaches Multiportal endoscopic approaches Radiotherapy 


Competing Interests

The authors declare that they have no competing interests.

Compliance with Ethical Standards

 No financial support was received for this work.


  1. 1.
    Kshettry VR, Thorp BD, Shriver MF, Zanation AM, Woodard TD, Sindwani R, Recinos PF. Endoscopic approaches to the craniovertebral junction. Otolaryngol Clin N Am. 2016;49:213–26.CrossRefGoogle Scholar
  2. 2.
    Mangussi-Gomes J, Beer-Furlan A, Balsalobre L, Vellutini EA, Stamm AC. Endoscopic endonasal management of skull base chordomas: surgical technique, nuances, and pitfalls. Otolaryngol Clin N Am. 2016;49:167–82.CrossRefGoogle Scholar
  3. 3.
    Singh H, Harrop J, Schiffmacher P, Rosen M, Evans J. Ventral surgical approaches to craniovertebral junction chordomas. Neurosurgery. 2010;66:96–103.CrossRefGoogle Scholar
  4. 4.
    Fang CH, Friedman R, Schild SD, Goldstein IM, Baredes S, Liu JK, Eloy JA. Purely endoscopic endonasal surgery of the craniovertebral junction: a systematic review. Int Forum Allergy Rhinol. 2015;5:754–60.CrossRefGoogle Scholar
  5. 5.
    Vellutini Ede A, Balsalobre L, Hermann DR, Stamm AC. The endoscopic endonasal approach for extradural and intradural clivus lesions. World Neurosurg. 2014;82:S106–15.CrossRefGoogle Scholar
  6. 6.
    Beer-Furlan A, Vellutini EA, Balsalobre L, Stamm AC. Endoscopic endonasal approach to ventral posterior fossa meningiomas: from case selection to surgical management. Neurosurg Clin N Am. 2015;26:413–26.CrossRefGoogle Scholar
  7. 7.
    Lund V, Stammberger H, Nicolai P, Castelnuovo P, et al. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl. 2010;22:1–143.PubMedGoogle Scholar
  8. 8.
    Chibbaro S, Cornelius JF, Froelich S, Tigan L, Kehrli P, Debry C, Romano A, Herman P, George B, Bresson D. Endoscopic endonasal approach in the management of skull base chordomas—clinical experience on a large series, technique, outcome, and pitfalls. Neurosurg Rev. 2014;37:217–24.CrossRefGoogle Scholar
  9. 9.
    Jahangiri A, Jian B, Miller L, El-Sayed IH, Aghi MK. Skull base chordomas: clinical features, prognostic factors, and therapeutics. Neurosurg Clin N Am. 2013;24:79–88.CrossRefGoogle Scholar
  10. 10.
    Fossati P, Vavassori A, Deantonio L, Ferrara E, Krengli M, Orecchia R. Review of photon and proton radiotherapy for skull base tumours. Rep Pract Oncol Radiother. 2016;21:336–55.CrossRefGoogle Scholar
  11. 11.
    Kooshkabadi A, Choi PA, Koutourousiou M, Snyderman CH, Wang EW, Fernandez-Miranda JC, Gardner PA. Atlanto-occipital instability following endoscopic endonasal approach for lower clival lesions: experience with 212 cases. Neurosurgery. 2015;77:888–97.CrossRefGoogle Scholar
  12. 12.
    Perez-Orribo L, Little AS, Lefevre RD, Reyes PR, Newcomb AG, Prevedello DM, Roldan H, Nakaji P, Dickman CA, Crawford NR. Biomechanical evaluation of the craniovertebral junction after anterior unilateral condylectomy: implications for endoscopic endonasal approaches to the cranial base. Neurosurgery. 2013;72:1021–9.CrossRefGoogle Scholar
  13. 13.
    Kasemsiri P, Carrau RL, Ditzel Filho LF, Prevedello DM, Otto BA, Old M, de Lara D, Kassam AB. Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg. 2014;82:S12–21.CrossRefGoogle Scholar
  14. 14.
    Prevedello DM, Ditzel Filho LF, Solari D, Carrau RL, Kassam AB. Expanded endonasal approaches to middle cranial fossa and posterior fossa tumors. Neurosurg Clin N Am. 2010;21:621–35. viCrossRefGoogle Scholar
  15. 15.
    Stippler M, Gardner PA, Snyderman CH, Carrau RL, Prevedello DM, Kassam AB. Endoscopic endonasal approach for clival chordomas. Neurosurgery. 2009;64:268–77.CrossRefGoogle Scholar
  16. 16.
    La Corte E, Aldana PR, Ferroli P, Greenfield JP, Härtl R, Anand VK, Schwartz TH. The rhinopalatine line as a reliable predictor of the inferior extent of endonasal odontoidectomies. Neurosurg Focus. 2015;38:E16.CrossRefGoogle Scholar
  17. 17.
    Dlouhy BJ, Dahdaleh NS, Menezes AH. Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update. Neurosurg Focus. 2015;38:E8.CrossRefGoogle Scholar
  18. 18.
    Seker A, Inoue K, Osawa S, Akakin A, Kilic T, Rhoton AL Jr. Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction. World Neurosurg. 2010;74:583–602.CrossRefGoogle Scholar
  19. 19.
    Turri-Zanoni M, Battaglia P, Dallan I, Locatelli D, Castelnuovo P. Multiportal combined transnasal transoral transpharyngeal endoscopic approach for selected skull base cancers. Head Neck. 2016;38:E2440–5.CrossRefGoogle Scholar
  20. 20.
    Neligan PC, Mulholland S, Irish J, Gullane PJ, Boyd JB, Gentili F, Brown D, Freeman J. Flap selection in cranial base reconstruction. Plast Reconstr Surg. 1996;98:1159–66.CrossRefGoogle Scholar
  21. 21.
    Anand VK, Murali RK, Glasgold MJ. Surgical decisions in the management of cerebrospinal fluid rhinorrhoea. Rhinology. 1995;33:212–8.PubMedGoogle Scholar
  22. 22.
    Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116:1882–6.CrossRefGoogle Scholar
  23. 23.
    Fortes FS, Carrau RL, Snyderman CH, Kassam A, Prevedello D, Vescan A, Mintz A, Gardner P. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope. 2007;117:970–6.CrossRefGoogle Scholar
  24. 24.
    Murakami CS, Kriet D, Ierokomos A. Nasal reconstruction using the inferior turbinate mucosal flap. Arch Facial Plast Surg. 1999;1:97–100.CrossRefGoogle Scholar
  25. 25.
    Fortes FS, Carrau RL, Snyderman CH, Prevedello D, Vescan A, Mintz A, Gardner P, Kassam AB. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope. 2007;117:1329–32.CrossRefGoogle Scholar
  26. 26.
    Oliver CL, Hackman TG, Carrau RL, Snyderman CH, Kassam AB, Prevedello DM, Gardner P. Palatal flap modifications allow pedicled reconstruction of the skull base. Laryngoscope. 2008;118:2102–6.CrossRefGoogle Scholar
  27. 27.
    Gun R, Oyama K, Kapucu B, Wang L, Al Qahtani AA, Otto BA, Prevedello DM, Carrau RL. Salpingopharyngeus myomucosal flap. J Craniofac Surg. 2014;25:1967–70.PubMedGoogle Scholar
  28. 28.
    Aviv JE, Sultan MR. Free flaps in skull base surgery. In: Donald PJ, editor. Surgery of the skull base. Philadelphia: Lippincott-Raven; 1998. p. 607–21.Google Scholar
  29. 29.
    Leng LZ, Brown S, Anand VK, Schwartz TH. Gasket-seal watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery. 2008;62(5 Suppl 2):ONSE342–3.PubMedGoogle Scholar
  30. 30.
    Nyquist GG, Anand VK, Singh A, Schwartz TH. Janus flap: bilateral nasoseptal flaps for anterior skull base reconstruction. Otolaryngol Head Neck Surg. 2010;142:327–31.CrossRefGoogle Scholar
  31. 31.
    McCoul ED, Anand VK, Singh A, Nyquist GG, Schaberg MR, Schwartz TH. Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg. 2014;81:136–43.CrossRefGoogle Scholar
  32. 32.
    Shah RN, Surowitz JB, Patel MR Huang BY, Snyderman CH, Carrau RL, Kassam AB, Germanwala AV, Zanation AM. Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects. Laryngoscope. 2009;119:1067–75.CrossRefGoogle Scholar
  33. 33.
    Harvey RJ, Nogueira JF, Schlosser RJ, Patel SJ, Vellutini E, Stamm AC. Closure of large skull base defects after endoscopic transnasal craniotomy. Clinical article. J Neurosurg. 2009;111:371–9.CrossRefGoogle Scholar
  34. 34.
    El-Sayed IH, Roediger FC, Goldberg AN, Parsa AT, McDermott MW. Endoscopic reconstruction of skull base defects with the nasal septal flap. Skull Base. 2008;18:385–94.CrossRefGoogle Scholar
  35. 35.
    Terranova P, Karligkiotis A, Gallo S, Gallo S, Meloni F, Bignami M, Castelnuovo P. A novel endoscopic technique for long-term patency of cholesterol granulomas of the petrous apex. Laryngoscope. 2013;123:2639–42.CrossRefGoogle Scholar
  36. 36.
    Karligkiotis A, Bignami M, Terranova P, Ciniglio-Appiani M, Shawkat A, Verrilaud B, Meloni F, Herman P, Castelnuovo P. Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex. Int Forum Allergy Rhinol. 2015;5:747–53.CrossRefGoogle Scholar
  37. 37.
    Rivera-Serrano CM, Snyderman CH, Gardner P, et al. Nasoseptal rescue flap: a novel modification of the nasoseptal flap technique for pituitary surgery. Laryngoscope. 2011;121:990–3.CrossRefGoogle Scholar
  38. 38.
    Otto BA, Bowe SN, Carrau RL, Prevedello DM, Ditzel Filho LF, de Lara D. Transsphenoidal approach with nasoseptal flap pedicle transposition: modified rescue flap technique. Laryngoscope. 2013;123:2976–9.CrossRefGoogle Scholar
  39. 39.
    Agarwal CA, Mendenhall SD, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125:532–7.CrossRefGoogle Scholar
  40. 40.
    Zide BM, Jelks GW. Forehead, temporal region and cheek. In: Zide BM, Jelks GW, editors. Surgical anatomy of the orbit. New York: Raven; 1988. p. 13–9.Google Scholar
  41. 41.
    Bolzoni Villaret A, Nicolai P, Schreiber A, Bizzoni A, Farina D, Tschabitscher M. The temporo-parietal fascial flap in extended transnasal endoscopic procedures: cadaver dissection and personal clinical experience. Eur Arch Otorhinolaryngol. 2013;270:1473–9.CrossRefGoogle Scholar
  42. 42.
    Saito K, Toda M, Tomita T, Ogawa K, Yoshida K. Surgical results of an endoscopic endonasal approach for clival chordomas. Acta Neurochir. 2012;154:879–86.CrossRefGoogle Scholar
  43. 43.
    Koutourousiou M, Gardner PA, Tormenti MJ, Henry SL, Stefko ST, Kassam AB, Fernandez-Miranda JC, Snyderman CH. Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery. 2012;71:614–24.CrossRefGoogle Scholar
  44. 44.
    Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta PE. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery. 2006;59:ONS50–7.PubMedGoogle Scholar
  45. 45.
    Carrabba G, Dehdashti AR, Gentili F. Surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach. Neurosurg Focus. 2008;25:E7.CrossRefGoogle Scholar
  46. 46.
    Tan NC-W, Naidoo Y, Oue S, Alexander H, Robinson S, Wickremesekera A, Floreani S, Vrodos N, Santoreneos S, Ooi E, McDonald M, Wormald PJ. Endoscopic surgery of skull base chordomas. J Neurol Surg B Skull Base. 2012;73:379–86.CrossRefGoogle Scholar
  47. 47.
    Zhang Q, Kong F, Yan B, Ni Z, Liu H. Endoscopic endonasal surgery for clival chordoma and chondrosarcoma. ORL J Otorhinolaryngol Relat Spec. 2008;70:124–9.CrossRefGoogle Scholar
  48. 48.
    Messerer M, Cossu G, Pasche P, Ikonomidis C, Simon C, Pralong E, George M, Levivier M, Daniel RT. Extended endoscopic endonasal approach to clival and paraclival tumors: indications and limits. Neurochirurgie. 2016;62:136–45.CrossRefGoogle Scholar
  49. 49.
    Alexander H, Robinson S, Wickremesekera A, Wormald PJ. Endoscopic transsphenoidal resection of a midclival meningioma. J Clin Neurosci. 2010;17:374–6.CrossRefGoogle Scholar
  50. 50.
    Prosser JD, Vender JR, Alleyne CH, Solares CA. Expanded endoscopic endonasal approaches to skull base meningiomas. J Neurol Surg B Skull Base. 2012;73:147–56.CrossRefGoogle Scholar
  51. 51.
    Simal Julian JA, Sanromán Álvarez P, Miranda Lloret P, Plaza Ramirez E, Pérez Borreda P, Botella Asunción C. Full endoscopic endonasal transclival approach: meningioma attached to the ventral surface of the brainstem. Neurocirugia (Astur). 2014;25:140–4.CrossRefGoogle Scholar
  52. 52.
    Iacoangeli M, Di Rienzo A, di Somma LG, Moriconi E, Alvaro L, Re M, Salvinelli F, Carassiti M, Scerrati M. Improving the endoscopic endonasal transclival approach: the importance of a precise layer by layer reconstruction. Br J Neurosurg. 2014;28:241–6.CrossRefGoogle Scholar
  53. 53.
    Gardner PA, Tormenti MJ, Pant H, Fernandez-Miranda JC, Snyderman CH, Horowitz MB. Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosurgery. 2013;73:ONS261–70.PubMedGoogle Scholar
  54. 54.
    Morales-Valero SF, Serchi E, Zoli M, Mazzatenta D, Van Gompel JJ. Endoscopic endonasal approach for craniovertebral junction pathology: a review of the literature. Neurosurg Focus. 2015;38:E15.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Davide Locatelli
    • 1
    • 2
  • Apostolos Karligkiotis
    • 2
    • 3
  • Mario Turri-Zanoni
    • 2
    • 3
  • Frank Rikki Canevari
    • 4
  • Fabio Pozzi
    • 1
    • 2
  • Paolo Castelnuovo
    • 2
    • 3
  1. 1.Division of Neurological Surgery, Department of Biotechnology and Life SciencesUniversity of Insubria–Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione MacchiVareseItaly
  2. 2.Head and Neck Surgery & Forensic Dissection Research Centre, Department of Biotechnology and Life SciencesUniversity of Insubria–Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione MacchiVareseItaly
  3. 3.Division of Otorhinolaryngology, Department of Biotechnology and Life SciencesUniversity of Insubria–Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione MacchiVareseItaly
  4. 4.Department of OtorhinolaryngologyAzienda Ospedaliera SS Antonio e Biagio e Cesare ArrigoAlessandriaItaly

Personalised recommendations