Combined endoscopic endonasal and trans-oral approach for excision of lower clival chordoma and stabilization

Clival chordoma surgery is a challenging surgery for skull-base surgeons. Access to the tumour site is the most challenging factor [1] for gross total resection of tumor which is recommended for this kind of tumor and frequently results in incomplete removal and recurrence. Another dimension is added by direct anterior access by the endoscopic expanded endonasal approach in the literature [2,3] for maximum tumour resection with minimum complications and morbidity. The endonasal endoscopic panoramic view can expose the surgically classified [4] upper, middle and lower clivus and with the assistance of the endo-oral corridor it can reach till craniovertebral junction and upper cervical vertebrae [3]. We present a case of a 31-year-old female patient with clival chordoma involving the middle and lower clivus, reaching up to the upper border of the C-3 vertebral body and laterally extending to occipital condyles. This patient underwent combined endoscopic endonasal and transoral excision of tumor followed by stabilization of the craniovertebral joint. The operative video highlights the techniques of elevation of various pedicled mucoperiosteal flaps (reverse rotation flap [2], Hadad- Bassagasteguy nasoseptal flap [5] and posterior nasopharyngeal mucosal flap [3]), inferior turbinectomy to widen the exposure, maxillary antrostomy for parking of flaps, use of red rubber catheter for the intermittent soft palate and uvula retraction [3] away from the field which will prevent velopharyngeal insufficiency due to palatal split, posterior pharyngeal wall incision technique, angled endoscopes to resect tumor from difficult access areas and reconstruction for the large skull base defect. The patient underwent stabilization of the craniovertebral junction by occipital-cervical fusion in the same setting. The patient had no new onset deficit and an uneventful course postoperatively. The use of combined endoscopic endonasal and endo-oral approaches for large lower clival chordomas, spending time more patiently in harvesting mucosal flaps and adequate exposure, makes the resection of tumors more feasible and to the maximal extent.