Authors of section

Authors

S Fusetti, B Hammer, R Kellman, C Matula, EB Strong, A Di Ieva

General Editor

Daniel Buchbinder

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Endoscopic approach to the central skull base

1. Introduction

The whole central compartment of the skull base, from the crista galli to the clivus and anterior craniocervical junction, can be accessed by means of the endonasal transsphenoidal endoscopic approach.

Endoscopic approach to the central skull base

2. Endonasal endoscopy

The endoscope is introduced in the nostrils and the main anatomical landmark should be identified. The 2 nostrils – 4 hands techniques is highly recommended: the collaboration of two surgeons (ENT and neurosurgeon) insure the best therapeutic option for the patients.
In the endonasal step, the main landmarks are: the middle turbinate (MT), the nasal septum (NS), the choana (Ch).

Endoscopic approach to the central skull base

3. Finding of the ostium sphenoidalis

The roof of the choana (Ch) is a good anatomical landmark to find the ostium sphenoidalis (OS), which is located superiorly to it.

Endoscopic approach to the central skull base

4. Opening of the ostium sphenoidalis

Once the ostium sphenoidalis (OS) has been identified, ...

Endoscopic approach to the central skull base

... it is enlarged using a diamond tipped burr and circular cutting punch.

According to the needs, the two openings of the right and left ostium sphenoidalis can be connected in order to get more space for surgical instrumentation.

Endoscopic approach to the central skull base

5. Sphenoidal step

The introduction of the endoscope in the enlarged ostium sphenoidalis allows the visualization of additional anatomical landmarks: sellar floor (SF), clivus (C), planum sphenoidalis (PS), internal carotid artery (ICA), and optic nerve (ON).

Endoscopic approach to the central skull base

6. Visualization of the optic-carotid recess

The optic-carotid recess (OCR) is a very important landmark for the identification of the internal carotid artery (ICA) and the optic nerve (ON).

Endoscopic approach to the central skull base

High-speed drills are used to open the floor of the sella (as in the photograph) and the planum sphenoidalis, to allow for decompression of the optic nerve and/or to allow for reduction of bony fragments, etc.

Endoscopic approach to the central skull base

7. Extended endoscopic transbasal approach

The anterior cranial fossa can be reached removing the planum sphenoidalis (PS) between the optic nerves (II), visualizing the dura mater (DM) of the basal frontal lobes. The endoscopic visualization shown here ...

Endoscopic approach to the central skull base

... is compared to the transcranial visualization of the same region. The area which has to be opened is outlined.

C: Clivus
III: oculomotor nerve

Endoscopic approach to the central skull base

8. Duroplasty

In cases of dural injuries, the closure technique is strictly related to the individual patient‘s anatomy, the size of the CSF leak, and its anatomical location. Underlay, overlay, combined, and obliterative techniques have been described.
The illustration shows a combined three layer technique in which are evident:

  • Subdural intracranial underlay graft (dark green)
  • Extradural intracranial underlay graft (blue)
  • Extracranial overlay graft (purple)

Fibrin glue can be used to keep the layers together or to fill the dead-space.

Endoscopic approach to the central skull base