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Resection of the cavernous sinus (CS) lesions has been a surgical challenge because the anatomy of the CS presents a high grade of complexity. This report describes the feasibility of the purely endoscopic endonasal approach to the CS. Twenty-five patients with intracavernous sinus tumors were treated with a purely endoscopic endonasal approach. The indications, efficacy, surgical techniques, and complications of this approach were discussed. Gross total resection occurred in 19 cases (76%), subtotal resection occurred in 2 cases (8%), and partial resection occurred in 4 cases (16%) including pituitary adenoma in 10 cases (total 70%; subtotal 10%; partial 20%), meningioma in 6 cases (total 66.6%; subtotal 16.7%, partial 16.7%), schwannoma in 5 cases (100%, total 5), malignant tumor in 4 cases (total 75%; subtotal 25%). All patients experienced resolution or improvement of symptoms. No patient experienced intraoperative complication and new neurological deficit. Only 1 case of postoperative cerebrospinal fluid leakage repaired via endoscopic endonasal approach on the 14th day after the surgery. The purely endoscopic endonasal approach to the CS in appropriately evaluated patients can be used to address a wide variety of benign and malignant tumor pathology with favorable outcomes and a low incidence of complications.

Study design Clinical study. Objective To investigate the feasibility of the transoral endoscopic odontoidectomy without occipitocervical fusion. Summary of background data Endoscopic transnasal resection of the odontoid process is less invasive than the conventional transoral odontoidectomy. However, the endonasal approach has a much longer working distance compared with the transoral approach to the craniovertebral junction and usually the endonasal approach needs a previous occipitocervical posterior fusion. Methods From July 2007 to June 2010, 5 patients (3 males and 2 females, age range, 25-41 yr) with irreducible cervicomedullary junction compression were subjected to endoscopic transoral odontoidectomy without occipitocervical posterior fixation and bone fusion. Results A purely endoscopic transoral odontoidectomy for decompression of the cervicomedullary junction without the occipitocervical fusion was achieved successfully in 5 patients. None of the patients underwent tracheotomy and postoperative gastrostomy tube placement. The patients were started on liquids on the third postoperative day and advanced to a regular diet on the fourth postoperative day. There was no postoperative velopharyngeal insufficiency, cerebrospinal fluid leakage, regional infection, or meningitis. The patients were discharged in 10 to 12 days after the surgery. There were no evidence of instability at the craniovertebral junction at 12 to 47 months of follow-up and remarkable improvement in neurological function was observed in each patient. Conclusion The endoscopic transoral approach may be a more direct route to C1 and the odontoid than the endoscopic endonasal approach. This approach allows complete resection odontoid to decompress the cervicomedullary junction without increasing the risk of complications such as wound infection, meningitis, and velopharyngeal insufficiency. Usually, the occipitocervical posterior fusion and tracheotomy is less necessary in this approach.

Lesions at the cavernous sinus and brainstem can be detected by radiologic studies, but a definitive diagnosis depends on histopathologic analysis. We present the case of a 75-year-old woman with symptoms including cranial nerve palsy, hydrocephalus,seizures, and long-term coma caused by squamous cell carcinoma at the cavernous sinus and ventral pons, which was confirmed by an endoscopic endonasal biopsy.

The endoscopic endonasal approach (EEA) has been reported to be an efficient approach for treating lesions of the petrous apex. However, there have been only limited anatomic studies for the EEA. Furthermore, most of the relevant distances for EEA cannot be measured easily on a cadaveric skull. Two fresh adult cadaver heads and five formalin-fixed adult cadaver heads were dissected using the EEA to identify groups of landmarks for safe guidance during this approach. The distances between these landmarks were then measured by CT angiography by using three-dimensional software. The EEA to the petrous apex can be divided into five phases. In each phase, a group of landmarks, rather than a single landmark, can be identified easily for guiding the next phase of the approach. There was no significant difference between males and females in any of the distances reported in the present study. The EEA can be performed to manage a petrous apex lesion more safely by referring to multiple landmarks and the distances between them.

We report a patient with a tiny intradural clival chordoma, which was identified following presentation with cerebrospinal fluid (CSF) rhinorrhea as the initial symptom. The transclival dural defect and the intradural tumor were successfully localized by both radiological investigation and intraoperative endoscopic inspection. The tumor was totally resected and the CSF fistula was repaired by an endoscopic endonasal approach. The diagnosis, possible mechanisms and management of this rare condition are discussed. The role of endoscopy in identifying and treating the clival CSF rhinorrhea is emphasized. To our knowledge, this is the first report of a clival fistula secondary to a tiny intradural chordoma.