Mononostril Endoscopic Endonasal Chopstick Technique for Low Petroclival Meningioma With Sphenoidal Sinus Cranialization and Rostral Mucosal Closure.

Abstract

Background and importance: Lower petroclival meningiomas (PCMs) and jugular tubercle meningiomas are among the most challenging tumors in neurosurgery, with the optimal approach still debated. Traditional posterior and lateral open approaches are still commonly employed but are invasive and carry significant risks due to brain retraction and neurovascular manipulation. The extended endonasal transclival approach has emerged as a less invasive alternative for midline lesions, offering direct access with early tumor devascularization and reduced manipulation of critical structures. However, limitations include lateral tumor extension, challenging skull base reconstruction, and nasal morbidity, especially when using a nasoseptal flap, which may negatively affect quality of life. To minimize both intracranial and nasal morbidities, we propose a right mononostril contralateral endonasal approach using the chopstick technique with angled scopes and instruments, combined with sphenoid sinus cranialization and rostral mucosal suturing for reconstruction.

Clinical presentation: A 33-year-old man presented with progressive headaches. Neuroimaging revealed a 29 × 39-mm PCM centered in the lower petroclival junction. Preoperative embolization was followed by tumor resection using a right mononostril endoscopic endonasal approach. Closure involved cranialization of the sphenoid sinus with rostral mucosa suturing. Postoperatively, lumbar punctures for cerebrospinal fluid depletion were conducted. No cerebrospinal fluid leakage or new neurological deficits were observed.

Conclusion: The mononostril endoscopic endonasal chopstick technique provides direct access to the petroclival region, enabling total resection of selected low-lying PCMs or jugular tubercle meningiomas. This minimally invasive technique, combined with rostral mucosal closure, may reduce surgical morbidity and improve postoperative quality of life.