Peer-Review Reports
Endonasal Endoscopic Approaches to the Paramedian Skull Base
Danielle de Lara1, Leo F. S. Ditzel Filho1, Daniel M. Prevedello1, Ricardo L. Carrau2, Pornthep Kasemsiri2,
Bradley A. Otto2, Amin B. Kassam3
Key words
- Endoscopy
- Endonasal approach
- Infratemporal fossa
- Middle cranial fossa
- Posterior fossa
- Pterygopalatine fossa
- Skull base
Abbreviations and Acronyms
CN: Cranial nerve
CSF: Cerebrospinal fluid
EEA: Endoscopic endonasal approach
ET: Eustachian tube
ICA: Internal carotid artery
V2: Second branch of the trigeminal nerve
V3: Third branch of the trigeminal nerve
From the Departments of
1
Neurosurgery and
2
OtolaryngologyeHead & Neck Surgery, The Ohio State
University Medical Center, Columbus, Ohio, USA; and
3
Division of Neurological Surgery, University of Ottawa,
Ottawa, Ontario, Canada
To whom correspondence should be addressed:
Ricardo L. Carrau, M.D.
[E-mail: carraurl@gmail.com]
Citation: World Neurosurg. (2014) 82, 6S:S121-S129.
http://dx.doi.org/10.1016/j.wneu.2014.07.036
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2014 Elsevier Inc.
All rights reserved.
INTRODUCTION
Endoscopic endonasal approaches (EEAs)
have become a feasible option for the
management of benign and malignant
cranial base pathologies, bringing a new
perspective to the treatment of skull base
disorders (1, 10). Expanded endoscopic
approaches can be classified according to
the orientation of the surgical field (target
area) under 2 main categories: 1) ap-
proaches to the median skull base (access
to structures in the sagittal plane) and 2)
approaches to the paramedian skull base
(access to more lateral structures, located
in the coronal plane) (5, 9, 12).
Traditionally, middle and posterior
cranial fossa pathologies have been
treated through lateral routes, such as
transpterional, transpetrosal (anterior and
WORLD NEUROSURGERY 82 [6S]: S121-S129, DECEMBER 2014
- OBJECTIVE: To describe the technical and anatomic nuances related to
endoscopic endonasal approaches (EEAs) to the paramedian skull base.
- METHODS: Surgical indications, limitations, and technical aspects pertaining
to EEAs designed to access areas oriented in the coronal plane are systemati-
cally reviewed with special attention to caveats, pitfalls, and common compli-
cations and how to avoid them. Case examples are presented.
- RESULTS: The paramedian skull base may be divided into anterior (corre-
sponding to the orbit and its contents), middle (corresponding to the middle
cranial, pterygopalatine, and infratemporal fossae), and posterior (includes the
craniovertebral junction lateral to the occipital condyles and the jugular fora-
men) segments. EEAs to the anterior segment offer access to the intraconal
orbital space and the optic canal. A transpterygoid corridor typically precedes
EEAs to the middle and posterior paramedian approaches. EEAs to the middle
segment provide wide exposure of the petrous apex, middle cranial fossa
(including cavernous sinus and Meckel cave), and infratemporal and pter-
ygopalatine fossae. Finally, EEAs to the posterior segment access the hypo-
glossal canal, occipital condyle, and jugular foramen.
- CONCLUSIONS: Approaches to the paramedian skull base are the most
challenging and complex of all endoscopic endonasal techniques. Because of
their technical complexity, it is recommended that surgeons master endoscopic
endonasal anatomic approaches oriented to median structures (sagittal plane)
before approaching paramedian (coronal plane) pathologies.
posterior), and retrosigmoid/far lateral distinct landmarks (Table 1) (10, 12).
approaches. These approaches are well Additional important anatomic landmarks
established, and they are effective in well- include the pterygoid plates, the vidian
selected patients, especially in patients canal, and foramina rotundum and ovale
whose lesions extend to the lateral aspect (with the second and third branches of the
of the middle and posterior fossae. How- trigeminal nerve [V2 and V3], respectively)
ever, when lateral approaches are used for (15, 22).
lateral lesions that extend medially to the
ventral brainstem, they may require un-
desirable manipulation and retraction of PARAMEDIAN EEAS
neural tissue (16). Under these circum- Paramedian EEAs must be considered in 3
stances, paramedian EEAs can be a great different depths as the working corridor
alternative to avoid neural tissue and advances from an anterior to posterior. In
vascular retraction (10, 20). general, the anterior coronal plane relates
Modular EEAs are defined based on the to the anterior cranial fossa and orbits,
anatomy of the corridor and their target the middle coronal plane relates to the
areas and their relationship with critical middle cranial fossa and temporal lobe,
structures. In the coronal plane, the most and the posterior coronal plane relates to
critical and defining structure is the in- the posterior cranial fossa (1, 10). Based
ternal carotid artery (ICA). The ICA can be on their relationship to different segments
divided into segments that have their own of the ICA, the middle and posterior
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DANIELLE DE LARA ET AL.
Table 1. Endoscopic Landmarks to
Segments of the ICA
Segment Anatomic Landmark
Parasellar mOCR
Vertical ICA Medial pterygoid
Horizontal ICA Vidian nerve
Carotid canal ET (bony)
Ascending ICA ET (cartilaginous)
ICA, internal carotid artery; mOCR, medial opticocarotid
recess; ET, eustachian tube.
paramedian approaches may be classified
as follows: zone 1 or medial petrous apex
approach (posterior to the paraclival ICA),
zone 2 or infrapetrous approach (inferior
to the petrous ICA), zone 3 or supra-
petrous approach (superior to the petrous
ICA and lateral to the paraclival ICA), zone
4 or lateral cavernous sinus approach
(superior to Meckel cave approach, i.e.,
Meckel cave), zone 5 or middle fossa/
infratemporal fossa approach (lateral to
the petrous ICA and anterior to the para-
pharyngeal ICA), zone 6 or occipital
transcondylar approach (posterior to the
eustachian tube [ET] and medial to the
parapharyngeal ICA), and zone 7 or jugu-
lar foramen approach (posterior and
lateral to the parapharyngeal ICA) (9, 10,
12). A transpterygoid corridor is the initial
step to gain endonasal access to most of
the zones in the middle and posterior
coronal plane (9).
Anatomic Considerations
As with any other surgical technique, a
flawless EEA is based on a profound un-
derstanding of the ventral skull base
anatomy. A complex group of bones, fis-
sures, foramina, and neurovascular struc-
tures must be taken into consideration.
The sphenoid bone is located in the center
of the cranial base in intimate contact with
many important arterial, venous, and
neural structures, such as the internal ca-
rotid and basilar arteries, the cavernous
sinuses, and associated cranial nerves
(CNs). Pneumatization of the sphenoid
bone and sphenoid sinus creates a
natural corridor, allowing the surgeon to
approach various neurovascular structures
with minimal drilling or manipulation of
intracranial structures (1, 16).
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ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE
The body of the sphenoid bone forms
part of the medial wall of the orbital apex
and superior orbital fissure. The medial
wall of the orbit is also formed by the
ascending process of the palatine bone,
the lamina papyraceae of the ethmoid
bone, the lacrimal bone, and the frontal
process of the maxilla (from posterior to
anterior). The orbital medial wall is
extremely thin at the level of the lamina
papyraceae, which separates the ethmoid
sinus cells and the orbit. At the junction of
the roof and the medial wall of the orbit is
the frontoethmoidal suture. This suture
represents an important landmark as
the anterior and posterior ethmoidal
foramina, in which the respective anterior
and posterior ethmoidal arteries and
nerves traverse (7, 14).
The greater wing of the sphenoid bone
forms a large part of the lateral wall of the
orbit, the floor of the middle fossa, and the
roof of the infratemporal fossa. The infra-
temporal fossa is an anatomic space located
under the floor of the middle cranial fossa
and posterior to the maxilla that contains
the parapharyngeal and masticator spaces.
It communicates medially with the pter-
ygopalatine fossa through the pter-
ygomaxillary fissure, which is continuous
with the inferior orbital fissure (3, 5). These
fissures form a half-mooneshaped
pathway and can be used as a surgical
landmark because they delimit surgical
boundaries between the pterygopalatine
(medially) and the infratemporal fossae
(laterally) (3, 6).
The pterygopalatine fossa is bound by
the pterygoid process posteriorly, the pal-
atine bone anteromedially, and the maxilla
anterolaterally (Figure 1) (3, 15, 18). It con-
tains a superficial (i.e., anterior) vascular
compartment that contains the maxillary
artery (also known as internal maxillary ar-
tery) and its terminal branches. A posterior
neural compartment includes the pter-
ygopalatine ganglion, which receives para-
sympathetic and sympathetic fibers
through the vidian nerve, and sensory fibers
from the descending palatine nerve and the
maxillary nerve (V2).
The vidian nerve, formed by the union
of the greater superficial petrosal nerve
and the deep petrosal nerve, is one of the
most important surgical landmarks when
navigating on the coronal plane. It
consistently marks the level of the hori-
zontal ICA in the petrous bone.
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Figure 1. Endoscopic view of a cadaveric
dissection of the pterygopalatine fossa. ET,
eustachian tube; IMAx, internal maxillary
artery; LPP, lateral pterygoid plate; MPP,
medial pterygoid plate; VC, vidian canal
(sectioned).
Intraoperatively, the nerve can be followed
posteriorly up to the level of the foramen
lacerum allowing the surgeon to identify
the ICA safely (12, 16, 17, 22).
Pneumatization of the sphenoid sinus
extending into the greater sphenoid wing
bears a lateral sphenoid recess (i.e.,
pterygoid recess), which projects under
the middle fossa. The anteromedial
portion corresponds to Meckel cave,
containing the trigeminal (gasserian)
ganglion (4, 7, 16). Removal of the lateral
wall of the sphenoid sinus exposes the
periosteum of the middle fossa. CN VI is
the most vulnerable structure intradurally.
Understanding its anatomy is paramount
to avoid an accidental injury. CN VI exits
the brainstem at the level of the verte-
brobasilar junction (level of the sphenoid
sinus floor), pierces the clival dura mater
posterior to the paraclival ICA, and ad-
vances between the dural layers super-
olaterally toward Dorello’s canal; it
angulates anteriorly under Gruber liga-
ment to enter the cavernous sinus
immediately lateral to the parasellar ICA.
CN VI goes into the superior orbital
fissure running parallel to the horizontal
segment of the cavernous ICA and first
branch of the trigeminal nerve. CN VI
must be monitored, carefully identified,
or avoided to prevent postoperative palsy
(8, 10).
Anterior Coronal Plane
Transorbital Approach. Transorbital EEAs
are designed to reach both extraconal and
intraconal lesions. The most common

DANIELLE DE LARA ET AL.
indications for extraconal approaches are
sinonasal lesions that displace, erode, or
invade the medial wall of the orbit and for
decompression of the orbit or optic nerves
in the presence of Graves disease, trauma,
or unresectable intraconal pathology (19).
Intraconal approaches are designed to
address intraorbital benign space-occu-
pying lesions, such as schwannomas,
hemangiomas, and meningiomas.
A transorbital EEA begins with com-
plete anterior and posterior ethmoidec-
tomies to expose the medial wall of the
orbit. Removal of the lamina papyraceae
and decompression of the medial aspect
of the optic canal follow. If needed, the
approach can be extended into the intra-
conal compartment opening the periorbita
and exposing the medial and inferior
rectus muscles. The gap between these 2
extraocular muscles represents the win-
dow for intraconal access (10, 19).
Important anatomic landmarks include
the optic nerves, the anterior and poste-
rior ethmoidal arteries, and the
ophthalmic artery with its branches.
Because the ophthalmic arteries and the
optic nerves cannot be mobilized, they
constitute the lateral limits of the
approach (Figure 2).
Middle Coronal Plane
As previously addressed, the approaches
to the middle coronal plane can be divided
into 5 different zones, according to their
relationship with specific segments of the
ICA. With the exception of zone 1, the
approach to all zones starts with a trans-
pterygoid approach using the maxillary
sinus as the working corridor (9). When
studying the middle coronal plane, it is
also useful to divide its 5 modular ap-
proaches further into 2 general categories
based on whether they are below the
horizontal segment of the petrous ICA
(infrapetrous approaches) or above it
(suprapetrous approaches) (9, 10). EEAs
may be combined whenever necessary to
resect lesions involving more than 1 of the
zones described.
Basic Transpterygoid Approach. A trans-
pterygoid approach starts with an unci-
nectomy, anterior ethmoidectomy, and
enlargement of the maxillary ostium to
obtain a wide middle meatus antrostomy.
The sphenopalatine and posterior nasal
arteries are identified at the
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ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE
sphenopalatine foramen, and their
branches are coagulated. The infraorbital
canal is visualized superiorly, and the
posterior wall of the maxillary sinus is
removed (i.e., anterior wall of the sphe-
nopalatine foramen), exposing the soft
tissue contents of the pterygopalatine
fossa.
Sacrifice of the pharyngeal artery and
nerve that run medially through the pala-
tovaginal canal on the superomedial
aspect of choana allows the lateral retrac-
tion of the soft tissues of the pter-
ygopalatine (7). The vidian foramen and
foramen rotundum are identified posteri-
orly in the sphenoid bone. Whenever
possible, the vidian nerve and artery are
transposed from the vidian canal and
preserved (17). After the vidian nerve is
transposed or sectioned, the soft contents
of the pterygopalatine fossa are lateral-
ized, and the base of the pterygoid plate is
drilled. The lateral sphenoid recess is
opened, and the base of the pterygoid
plates is drilled. This exposure allows
direct access to the medial infratemporal
fossa (1, 3, 9).
Infrapetrous Approaches. A zone 1 or petrous
apex approach is indicated for lesions
affecting or expanding the medial petrous
apex, such as chondrosarcomas and
cholesterol granulomas. As an approach,
it essentially requires a lateral extension of
the middle third transclival approach
(Figure 3). The approach is initiated with
wide bilateral sphenoidotomies, removal
of the sphenoid sinus floor, and removal
of the basopharyngeal fascia from the
undersurface of the sphenoid sinus floor.
Complete drilling of the sphenoid sinus
floor is carried back until the floor is flush
with the clival recess and the area of the
foramen lacerum is defined (9).
It is important to define the position of
the ICA, and the paraclival ICA canal oc-
casionally is removed to allow the lateral-
ization of the vessel to access a lesion
extending laterally behind the ICA. In
these situations, the vidian nerve is fol-
lowed posteriorly leading directly to the
lacerum segment of the ICA. It is impor-
tant to remove the bone medial and lateral
to the ICA to enhance lateralization; this
provides direct access to the petrous apex
(9). It is important to remember that CN
VI is adjacent to this area as it passes
through Dorello canal, immediately
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PEER-REVIEW REPORTS
behind and above the petrous apex. The
main anatomic structures at risk during
performance of this approach are the ICA
and CN VI (8, 16).
A zone 2 or petroclival approach is most
commonly indicated for the treatment of
chondrosarcomas and chordomas. The
approach is initiated as described previ-
ously for a zone 1 petrous apex approach,
with an extension of the working corridor
to the medial maxilla (anterior) and the
fossa of Rosenmüller (posterior) (9). The
relationship between the vidian nerve,
vidian artery, and ICA serves as the most
important anatomic landmark for this
approach (Figure 4) (17, 22); the pter-
ygopalatine fossa is exposed removing the
posterior wall of the maxilla, and the
vidian nerve and canal are identified (22).
The vidian nerve is followed posteriorly
(removing its surrounding bone) to the
point where it encounters the lacerum
segment of the ICA (vidian artery is not
always present).
After the foramen lacerum is exposed,
the corridor is expanded into the infrape-
trous area. The ICA does not need to be
exposed; however, its full dissection is
usually necessary in cases of malignancies,
such as chondrosarcomas. To expose the
inferior aspect of the petrous bone, the
foramen lacerum is disconnected from the
superior aspect of the ET cartilage. Hori-
zontal cuts are performed at that level, and
the dense fibrocartilaginous tissue is
retracted inferiorly allowing for direct
visualization of the petrous apex below the
ICA. If necessary, the ET is completely
removed to allow full exposure of the
petroclival synchondrosis (Figure 5).
Suprapetrous Approaches. A zone 3 approach
is indicated to access lesions located in
Meckel cave through the quadrangular
space. The most common pathologies in
this location are invasive adenoid cystic
carcinomas, meningiomas, schwannomas,
and invasive pituitary adenomas.
The quadrangular space is limited by
the horizontal petrous ICA inferiorly,
ascending vertical cavernous/paraclival
ICA medially, CN VI superiorly (in the
cavernous sinus), and maxillary division of
the trigeminal nerve (V2) laterally (1, 9).
Exposure is initiated with a transpterygoid
approach isolating the maxillary nerve and
following it superiorly until the foramen
rotundum is identified and following the
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DANIELLE DE LARA ET AL. ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE

Figure 2. Transorbital approach. A previously healthy, 35-year-old man presented with complaints of progressive visual loss in the right
eye. Preoperative magnetic resonance imaging was performed, and an intraconal meningioma was diagnosed. The patient underwent
an endoscopic endonasal transorbital approach, and the tumor was completely resected. Preoperative T1-weighted and T2-weighted
coronal (A), sagittal (B), and axial (C and D) images of an intraconal meningioma. (E) Surgical specimen.

vidian canal to identify the anterior genu
of the ICA. To expose the ICA and the
anterior face of Meckel cave better, the
bone separating V2 and the vidian canal is
drilled away exposing the petrous, lac-
erum, and paraclival segments of the ICA
(3). The bone of the middle fossa is dril-
led, and the periosteal dura mater is
exposed and opened into the quadran-
gular space.
A dural opening into the quadrangular
space is performed from a medial-to-
lateral direction—from the genu of the
ICA toward V2. It is important to stay
below the level of CN VI and lateral to the
ICA to avoid the superior portion of the
cavernous sinus and consequently damage
to the CNs within the cavernous sinus.
The key anatomic landmarks in this
approach are V2, CN VI, and the ICA (10).
A zone 4 approach accesses the superior
cavernous sinus. This approach is rarely
indicated, and its use is limited to patients
with an existing CN deficit (CNs III, IV,
VI), such as patients with a cavernous si-
nus syndrome secondary to an apoplectic
pituitary adenoma. This approach is a
continuation of a zone 3 approach,
extending the dural opening above the
quadrangular space. Minimal venous

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DANIELLE DE LARA ET AL. ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE

Figure 4. Endoscopic view of a cadaveric

dissection of the infratemporal fossa. The
infratemporal fossa and the dura mater of
Meckel cave are exposed. The vidian nerve
is followed posteriorly to the anterior genu
of the internal carotid artery. ICA, internal
carotid artery; IMAx, internal maxillary
artery; LOCR, lateral opticocarotid recess;
VN, vidian nerve; VI, abducens nerve; V1,
first branch of trigeminal nerve; V2, second
branch of trigeminal nerve; V3, third branch
of trigeminal nerve.

bleeding on opening the space is the norm

because the tumor typically thromboses
the sinus. Copious venous bleeding is
encountered when the tumor is removed
(10). The incision is performed on the
periosteum of the superior orbital fissure
and the cavernous ICA at the level of the
siphon, and the dissection is performed
immediately lateral to the ICA. The
inferolateral trunk of the ICA is a good
landmark for the caudal extent of the
exposure. Structures at risk during this
approach are CNs III, IV, V, and VI and the
ICA with its sympathetic fibers (2).
The zone 5 approach is designed to reach
the middle cranial and infratemporal
fossae. Common pathologies in this re-
gion include invasive carcinomas extend-
ing from the sinonasal tract or
nasopharynx, cerebrospinal fluid (CSF)
leaks, encephaloceles, schwannomas, and
meningiomas (3, 5, 6). During a zone 5
approach, full exposure of the pter-
ygopalatine fossa is necessary. The poste-
rior wall of the maxilla is removed, and the
periosteum of the pterygopalatine fossa
Figure 3. Preoperative axial computed tomography scan (A) and axial (B), coronal (C), and
can be incised to dissect its soft tissue
sagittal (D) T1-weighted magnetic resonance imaging scans of a lesion at the petrous apex.
The sharply marginated expansive lesion with increased signal intensity on T1-weighted contents. In the event that a full exposure
images is strongly suggestive of a cholesterol granuloma. The patient underwent an expanded of the infratemporal fossa is needed, the
endoscopic endonasal petrous apex approach for tumor removal. Postoperative axial maxillary artery and its branches should be
computed tomography scans (E and F) show the tumor resection and working corridor.
controlled early in the dissection.

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DANIELLE DE LARA ET AL. ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE

Figure 5. A 57-year-old woman with a history of double vision and a sixth
cranial nerve palsy in the left eye presented to the Neurological Surgery
Department. Magnetic resonance imaging scan obtained on admission
revealed a petroclival lesion, compatible with a chondrosarcoma. Complete
tumor removal was achieved via an expanded endonasal approach
petroclival approach. Preoperative axial (A), coronal (B), and sagittal (C)
T1-weighted contrast-enhanced magnetic resonance imaging scans show
the lesion arising from the petroclival region. Postoperative axial (D),
coronal (E), and sagittal (F) T1-weighted contrast-enhanced magnetic
resonance imaging scans show complete tumor resection.

As previously mentioned, the nerves are
located in a posterior compartment of the
pterygopalatine fossa, and a decision to
lateralize or medialize the soft tissues of
the pterygopalatine fossa is made to
approach the disease. Intensive bleeding
from the pterygopalatine venous plexus is
expected and can be controlled with bi-
polar electrocautery or hemostatic paste.
The pterygoid process (base and pterygoid
plates) can be drilled and reduced as
needed for the approach. The dissection
continues lateral to the lateral pterygoid
plate to reach the infratemporal fossa. The
posterosuperior aspect of the lateral pter-
ygoid plate is an important landmark for
the identification of the mandibular nerve
(V3), which is immediately posterior.
When the middle cranial fossa needs to be
approached, the pterygoid base is drilled
posteriorly preserving V2 and the vidian
nerve in the direction of the middle cranial
fossa. The lateral wall of the lateral recess
of the sphenoid is drilled, and the peri-
osteal dura mater is exposed and incised
between the first branch of the trigeminal
nerve and V2 (anteromedial triangle of the
middle cranial fossa) or in between V2 and
V3 (anterolateral triangle of the middle
cranial fossa) (Figure 6) (5). Relevant
structures in this approach include the soft
tissue contents of the pterygomaxillary
fissure, such as the internal maxillary ar-
tery with its branches, the vidian nerve,
and the trigeminal nerve (V2 and V3)
branches.
Posterior Coronal Plane. A zone 6 approach is
an inferior extension of a zone 2 approach
and comprises the region immediately
posterior to the ET and medial to the
parapharyngeal ICA. Common pathologies
in this location are paragangliomas,
schwannomas, nasopharyngeal malig-
nancies, chordomas, and meningiomas.
The working corridor for this approach is
the inferior aspect of the medial maxilla and
nasopharynx. The ET helps as an important

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DANIELLE DE LARA ET AL.
Figure 6. Preoperative contrast-enhanced T1-weighted axial (A and B) and coronal (C) magnetic
resonance imaging scans. An extensive nasopharyngeal and skull base tumor involving the left
pterygopalatine fossa and middle fossa is shown, consistent with the diagnosis of adenocarcinoma.
(D) Intraoperative navigation image shows the working corridor to the infratemporal and temporal
fossae.
landmark to identify safely the ICA para-
pharyngeal segment (cartilaginous ET) and
the carotid canal in the petrous bone (bony
ET) (5, 18).
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ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE
The medial aspect of the occipital
condyle is just lateral to the foramen
magnum, and the hypoglossal canal is
positioned superolateral inside the
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PEER-REVIEW REPORTS
condyle (lateral limit of this approach).
Stability is maintained if the occipital-C1
joint is not transgressed (10, 19). The
supracondylar area can also be drilled, and
it yields access to the jugular tubercle of
the occipital bone immediately medial to
the inferior petrosal sinus and jugular
foramen.
The superior limit of this approach is
the petroclival synchondrosis. Above this
area is considered part of the infrapetrous
area (zone 2). The lateral limits of the
approach are the hypoglossal canal (inside
the condyle) and the parapharyngeal ICA.
The most important structures in this
approach are the parapharyngeal and
petrous segments of the ICA and the hy-
poglossal nerve (CN XII) exiting the hy-
poglossal canal inferiorly and laterally.
The zone 7 approach is a lateral exten-
sion of a zone 6 approach to access the
parapharyngeal ICA and the jugular
foramen. Indications for this approach are
invasive carcinomas, paragangliomas,
schwannomas, and certain skull base
meningiomas. The ET is an important
landmark because it allows direct identi-
fication of the ICA. The ET runs parallel
and anterior to the petrous ICA, and it
enters the petrous bone just medial to the
ascending parapharyngeal ICA before it
enters into the petrous canal (5). With rare
exceptions, the ET is removed to allow
exposure of the parapharyngeal ICA
and petroclival synchondrosis, which lead
to the jugular foramen. An endonasal
Doppler acoustic ultrasound probe is
valuable when dissecting the soft tissue
lateral to the ET to avoid an ICA injury.
After localizing the ICA, the jugular fora-
men may be found just lateral and poste-
rior. To facilitate the tumor resection, an
endoscopic Denker approach (i.e., Stur-
man-Canfield approach) and anterior
maxillotomy is frequently performed (10).
The parapharyngeal ICA, jugular foramen,
jugular vein, and lower CNs (CNs IX, X,
XI) are the most important anatomic
structures in this approach (Figure 7).
COMPLICATIONS
EEAs involve multiple technical challenges
to the surgeon regarding tumor removal
and complication avoidance. Neurophysi-
ologic monitoring (somatosensory evoked
potentials) and CN electromyography are
used routinely because they are helpful in
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DANIELLE DE LARA ET AL. ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE

Figure 7. A 40-year-old woman presented with a sixth cranial nerve palsy in infratemporal fossae. The patient underwent endoscopic endonasal
the right eye. Preoperative magnetic resonance imaging scans (AeC) removal of the tumor, which was confirmed to be a chordoma. (DeF)
revealed an extensive mass lesion, involving the middle, posterior, and Postoperative images are shown. The patient’s recovery was uneventful.

preventing vascular and neural injuries.
Computer-assisted navigation, using pre-
operative computed tomography angiog-
raphy fused with magnetic resonance
imaging, confirms the surgeon’s anatomic
assessment of the field.
During endoscopic endonasal surgery, 2
tasks are crucial to avoid complications,
hemostasis and water-sealed skull base
reconstruction. Postoperative CSF leaks
are the most common complication. Skull
base reconstruction after a paramedian
endoscopic approach is performed as
previously described. The main objective
is to restore the natural isolation of the
intracranial structures from the sinonasal
cavity, avoiding a CSF leak and secondary
complications, such as infection or men-
ingitis. In cases in which there is no
intraoperative CSF leak but there is
vascular exposure, we still favor a vascu-
larized reconstruction (often the naso-
septal flap) to cover and protect the ICA.
The introduction and refinement of the
vascularized nasoseptal mucosal flap for
the reconstruction of the ventral skull base
are important advancements that dramat-
ically reduced the incidence of CSF leaks
(10, 11). The selected corridor correlates
with the type and incidence of complica-
tions. In general, paramedian approaches
are associated with higher rates of vascular
complications (3.8%) (10), probably asso-
ciated with the intimate relationship to the
various segments of the ICA.
Internal tumor debulking and extrac-
apsular tumor dissection are strongly
advocated because this facilitates the
visualization and dissection of the sur-
rounding vessels and nerves. Hemostasis
is paramount to adequate endoscopic
visualization. Low-flow venous or capillary
bleeding is controlled by irrigation with
warm saline (40 Ce42 C). Drilling with a
diamond burr and judicious use of bone
wax are useful to control bleeding from
bone surfaces. Venous bleeding from the
cavernous sinus, basilar plexus, or ptery-
goid plexus can be copious and is best
controlled with hemostatic material gently
applied with cottonoids or pastelike he-
mostatic agents (13).
Applying direct compression, compres-
sive packing, suture repair, and endovas-
cular reconstruction can control arterial
high-flow bleeding, similar to that from
the ICA. More recent studies have

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DANIELLE DE LARA ET AL.
elucidated effective maneuvers to control
catastrophic ICA bleeding intraoperatively,
including use of large-bore suctions,
placement of the scope through the side of
less bleeding, use of a lens cleansing de-
vice, and use of a muscle patch or packing.
It is also important to maintain cerebral
perfusion with adequate resuscitation,
maintaining blood pressure and providing
anticoagulation to avoid embolic phe-
nomena. The patient can be taken to
interventional radiology to complete the
permanent sacrifice of the vessel or to
insert a stent in the area of injury. Some
rare situations require permanent occlu-
sion of the vessel (10, 21). For these
reason, we strongly recommend that the
team performing endoscopic skull base
surgery, particularly in the coronal plane,
is also proficient in cerebrovascular
techniques.
CONCLUSIONS
EEAs have become an important option
for the treatment of ventral skull base le-
sions because they offer the possibility of
tumor resection with minimal manipula-
tion of brain and CNs. Approaches in the
coronal plane represent the most chal-
lenging and complex of all endoscopic
endonasal skull base surgery techniques.
Detailed understanding of the ventral skull
base anatomy, extensive training in
endonasal endoscopic surgery, and proper
microsurgical technique are the key ele-
ments to achieve a successful paramedian
endoscopic approach.
REFERENCES
1. Bhatki AM, Carrau RL, Snyderman CH,
Prevedello DM, Gardner PA, Kassam AB: Endo-
nasal surgery of the ventral skull base—endo-
scopic transcranial surgery. Oral Maxillofac Surg
Clin North Am 22:157-168, 2010.
2. Cavallo LM, Cappabianca P, Galzio R,
Iaconetta G, de Divitiis E, Tschabitscher M:
Endoscopic transnasal approach to the cavernous
sinus versus transcranial route: anatomic study.
Neurosurgery 56 (2 Suppl):379-389 [discussion
379-389], 2005.
3. Cavallo LM, Messina A, Gardner P, Esposito F,
Kassam AB, Cappabianca P, de Divitiis E,
Tschabitscher M: Extended endoscopic endonasal
approach to the pterygopalatine fossa: anatomical
WORLD NEUROSURGERY 82 [6S]: S121-S129, DECEMBER 2014
ENDONASAL ENDOSCOPIC APPROACHES TO PARAMEDIAN SKULL BASE
study and clinical considerations. Neurosurg
Focus 19:E5, 2005.
4. Dallan I, Lenzi R, Bignami M, Battaglia P, Sellari-
Franceschini S, Muscatello L, Seccia V,
Castelnuovo P, Tschabitscher M: Endoscopic
transnasal anatomy of the infratemporal fossa and
upper parapharyngeal regions: correlations with
traditional perspectives and surgical implications.
Minim Invasive Neurosurg 53:261-269, 2010.
5. Falcon RT, Rivera-Serrano CM, Miranda JF,
Prevedello DM, Snyderman CH, Kassam AB,
Carrau RL: Endoscopic endonasal dissection of
the infratemporal fossa: anatomic relationships
and importance of eustachian tube in the endo-
scopic skull base surgery. Laryngoscope 121:31-41,
2011.
6. Hartnick CJ, Myseros JS, Myer CM 3rd: Endo-
scopic access to the infratemporal fossa and skull
base: a cadaveric study. Arch Otolaryngol Head
Neck Surg 127:1325-1327, 2001.
7. Hofstetter CP, Singh A, Anand VK, Kacker A,
Schwartz TH: The endoscopic, endonasal, trans-
maxillary transpterygoid approach to the pter-
ygopalatine fossa, infratemporal fossa, petrous
apex, and the Meckel cave. J Neurosurg 113:
967-974, 2010.
8. Iaconetta G, Fusco M, Cavallo LM,
Cappabianca P, Samii M, Tschabitscher M: The
abducens nerve: microanatomic and endoscopic
study. Neurosurgery 61 (3 Suppl):7-14 [discussion
14], 2007.
9. 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 19:E6, 2005.
10. Kassam AB, Prevedello DM, Carrau RL,
Snyderman CH, Thomas A, Gardner P,
Zanation A, Duz B, Stefko ST, Byers K,
Horowitz MB: Endoscopic endonasal skull base
surgery: analysis of complications in the authors’
initial 800 patients. J Neurosurg 114:1544-1568,
2011.
11. Kassam AB, Thomas A, Carrau RL,
Snyderman CH, Vescan A, Prevedello D, Mintz A,
Gardner P: Endoscopic reconstruction of the cra-
nial base using a pedicled nasoseptal flap.
Neurosurgery 63 (1 Suppl 1):ONS44-ONS52 [dis-
cussion ONS52-53], 2008.
12. Kassam AB, Vescan AD, Carrau RL,
Prevedello DM, Gardner P, Mintz AH,
Snyderman CH, Rhoton AL: Expanded endonasal
approach: vidian canal as a landmark to the
petrous internal carotid artery. J Neurosurg 108:
177-183, 2008.
13. Kassam A, Snyderman CH, Carrau RL, Gardner P,
Mintz A: Endoneurosurgical hemostasis tech-
niques: lessons learned from 400 cases. Neuro-
surg Focus 19:E7, 2005.
www.WORLDNEUROSURGERY.org
PEER-REVIEW REPORTS
14. Kassam A, Snyderman CH, Mintz A, Gardner P,
Carrau RL: Expanded endonasal approach: the
rostrocaudal axis. Part I. Crista galli to the sella
turcica. Neurosurg Focus 19:E3, 2005.
15. Mousa Sadr Hosseini S, Razfar A, Carrau RL,
Prevedello DM, Fernandez-Miranda J, Zanation A,
Kassam AB: Endonasal transpterygoid approach to
the infratemporal fossa: correlation of endoscopic
and multiplanar CT anatomy. Head Neck 34:
313-320, 2012.
16. Prevedello DM, Ditzel Filho LF, Solari D,
Carrau RL, Kassam AB: Expanded endonasal ap-
proaches to middle cranial fossa and posterior
fossa tumors. Neurosurg Clin N Am 21:621-635,
2010.
17. Prevedello DM, Pinheiro-Neto CD, Fernandez-
Miranda JC, Carrau RL, Snyderman CH,
Gardner PA, Kassam AB: Vidian nerve trans-
position for endoscopic endonasal middle fossa
approaches. Neurosurgery 67 (2 Suppl Operative):
478-484, 2010.
18. Rivera-Serrano CM, Terre-Falcon R, Fernandez-
Miranda J, Prevedello D, Snyderman CH,
Gardner P, Kassam A, Carrau RL: Endoscopic
endonasal dissection of the pterygopalatine fossa,
infratemporal fossa, and post-styloid compart-
ment. Anatomical relationships and importance of
eustachian tube in the endoscopic skull base
surgery. Laryngoscope 120 (Suppl 4):S244, 2010.
19. Snyderman CH, Pant H, Carrau RL, Prevedello D,
Gardner P, Kassam AB: What are the limits of
endoscopic sinus surgery? The expanded endo-
nasal approach to the skull base. Keio J Med 58:
152-160, 2009.
20. Theodosopoulos PV, Guthikonda B, Brescia A,
Keller JT, Zimmer LA: Endoscopic approach to
the infratemporal fossa: anatomic study. Neuro-
surgery 66:196-202 [discussion 202-203], 2010.
21. Valentine R, Wormald PJ: Controlling the surgical
field during a large endoscopic vascular injury.
Laryngoscope 121:562-566, 2011.
22. Vescan AD, Snyderman CH, Carrau RL, Mintz A,
Gardner P, Branstetter BT, Kassam AB: Vidian
canal: analysis and relationship to the internal
carotid artery. Laryngoscope 117:1338-1342, 2007.
Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 19 September 2013; accepted 25 July 2014
Citation: World Neurosurg. (2014) 82, 6S:S121-S129.
http://dx.doi.org/10.1016/j.wneu.2014.07.036
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
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