Commentary

Combining endoscopic and open craniotomy techniques to improve visualization deep within the operative field and around tight angles is not new. The strategy is most commonly used in the resection of pituitary and acoustic tumors. These authors demonstrate yet another instance in which the endoscope improves operative exposure and visualization, which translates to improved access and to safe and complete tumor removal. In this particular case, the blind spots that had impaired visualization were the dorsum sellae, posterior and lateral vertical segments of the carotid artery, and the area superior and lateral to the clinoid.

The benefits of the extended subfrontal approach are well documented: decreased retraction on the frontal lobe and the ability to reach the anterior clivus, anterior cranial fossa, and nasal ethmoid regions. To further improve access to these areas, we use a level III transfacial approach, which involves a bifrontal craniotomy and bifrontal nasal orbital osteotomy. Osteotomies extend down to the lateral orbits and the nasal bone, leaving a frontal orbital bandeau for a plastic surgeon to remove. The addition of a circumferential cribriform plate osteotomy preserves olfaction. The lateral orbital osteotomies allow lateral retraction of the globes without risk of impairing vision. When a lesion of the clivus must be resected, other approaches should be considered based on the size, location, and extent of the tumor, including the transoral, trans-sphenoidal, infratemporal fossa, and transfacial approaches. Overall, this manuscript is excellent, and the authors should be congratulated for their contributions to the skull base literature.