Techniques and challenges of the expanded endoscopic endonasal access to the ventrolateral skull base during the “far-medial” and “extreme medial” approaches

  • Giuliano Silveira-BertazzoEmail author
  • Sunil Manjila
  • Nyall R. LondonJr
  • Daniel M. PrevedelloEmail author
How I Do it - Neurosurgical Anatomy
Part of the following topical collections:
  1. Neurosurgical anatomy



Expanding the ventrolateral skull base corridor from the midline of lower clivus to the petroclival fissure is a challenging endonasal surgical task. Resection of lytic lesions like chondrosarcoma can cause cranial nerve morbidities and injury of ICA, necessitating accurate knowledge of correlative endoscopic anatomy with stereotactic landmarks.


We describe an extended endoscopic endonasal approach (EEA) for a right petroclival chondrosarcoma with the demonstration of ipsilateral surgical landmarks with contralateral normal correlates, using a stepwise comparative image-guided cadaveric dissection study.


EEA for lytic lesions like chondrosarcomas needs to address brain shift and displacement of ICA, posing a chance for cranial nerve morbidities and ICA injury. Meticulous utilization of intraoperative stereotactic landmarks can help avoid and mitigate surgical complications.


Far-medial Extreme medial Expanded endonasal Transclival approach Lower clivus Skull base Sublacerum corridor Endoscopic landmarks 



Expanded endoscopic endonasal approaches


Endoscopic far-medial approach


Craniocervical junction


Supracondylar groove


Lateral pharyngeal tubercle


Atlanto-occipital joint


Atlanto-occipital membrane


Image guidance system


Hypoglossal canal


Endoscope-integrated indocyanine green fluorescence


Internal carotid artery


Expanded endonasal approach


Somato-sensory evoked potential


Jugular foramen



We thank Ricardo L. Carrau, MD, for his invaluable guidance and intellectual contribution during this project.

Compliance with ethical standards

Conflict of interest

This study was performed at ALT-VISION at The Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical. Dr. Prevedello is a consultant for Stryker Corp., Medtronic Corp., and Integra; he has received an honorarium from Mizuho and royalties from KLS- Martin. N. London holds stock in Navigen Pharmaceuticals currently of no value and was a consultant for Cooltech Inc., both of which are unrelated to this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ohio State University Wexner Medical Center institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

701_2019_4204_MOESM1_ESM.mp4 (217.9 mb)
Video 1 A 27-year-old woman presented with diplopia during pregnancy. The neurological exam revealed no cranial nerve dysfunction. Preoperative and postoperative MRI is presented in Fig. 1a and b. There were no postoperative complications, and the patient improved her referred diplopia after the procedure. Postop MRI shows a gross total resection of the petroclival lesion. (Fig. 1e and f) (MP4 223092 kb)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of Neurological SurgeryThe Ohio State University, Wexner Medical CenterColumbusUSA
  2. 2.Department of Neurological SurgeryMcLaren HospitalBay CityUSA
  3. 3.Department of Otolaryngology-Head and Neck SurgeryThe Ohio State University, Wexner Medical CenterColumbusUSA
  4. 4.Department of Otolaryngology-Head and Neck SurgeryJohns Hopkins School of MedicineBaltimoreUSA
  5. 5.National Institute on Deafness and Other Communication DisordersNIHBethesdaUSA

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