The challenge: operating through the nose without damaging it

Endoscopic endonasal surgery is now the gold standard for reaching deep skull base tumors — chordomas, craniopharyngiomas, meningiomas — without opening the skull, by passing directly through the nasal cavities.

However, this approach has long required removing certain nasal structures to widen the working corridor, and harvesting a nasoseptal flap — a vascularized mucosal pedicle used to reconstruct the skull base at the end of the procedure. While this technique represented a major advancement, it can leave lasting nasal side effects: crusting, dryness, obstruction, and olfactory disturbances.

The solution: navigating around obstacles rather than removing them

The team led by Pr Sébastien Froelich and Dr Thibault Passeri developed an alternative approach based on two combined innovations:

• The mononostril chopsticks technique: the endoscope and suction are held in a single hand like chopsticks, freeing the other hand for the surgical instrument. This configuration allows working in a confined space without removing nasal structures, using angled endoscopes to navigate around corners rather than cutting them away.
• Sphenoid sinus cranialization with septal mucosa suturing: at the end of the procedure, instead of using a nasoseptal flap, the nasal mucosa is simply sutured like a skin incision. The cavity left by the tumor is filled with fat, and skull base reconstruction is achieved without sacrificing the nasoseptal mucosa.

The study: 82 patients, compelling results

The team compared 82 consecutive patients who underwent surgery for paraclival and craniovertebral junction lesions:

Both groups were broadly comparable in terms of demographic characteristics. The most common tumor was skull base chordoma (70.7% in the SSCT group vs 58.5% in the NSFT group), followed by chondrosarcomas, craniopharyngiomas, and meningiomas.

Results: equally effective, better tolerated

• Equivalent surgical efficacy: gross-total or subtotal resection was achieved in 97.6% of patients in the SSCT group compared to 85.4% in the traditional group — a non-significant difference, confirming that the new technique is non-inferior in terms of oncological outcomes.
• Comparable CSF leak risk: 12.2% in the SSCT group vs 9.8% in the traditional group — no significant difference between the two groups.
• Significantly improved quality of life: patients in the SSCT group reported significantly better overall scores (p = 0.004) on the EES-Q questionnaire dedicated to quality of life after endonasal surgery, with improvements in both the physical (p < 0.001) and psychological (p = 0.006) domains.

What this means for patients

This study confirms that complex, deep skull base tumors can be removed without sacrificing nasal anatomy, with improved postoperative recovery and a lower impact on daily life. For patients with chordomas, craniopharyngiomas, or skull base meningiomas, this technique represents a concrete advancement in terms of postoperative comfort.

These results are part of a broader approach championed by the Lariboisière team: improving tumor control while preserving quality of life — two goals that are no longer mutually exclusive.

Reference

1. Passeri T, Alcântara T, Fava A, Watanabe N, Jiang T, Justo J, Vu TH, Bernat A-L, Abbritti R, Baussart B, Chainey J, Froelich S. Chopsticks mononostril approach with sphenoid sinus cranialization and septal mucosa suturing: a new minimally invasive concept and closure technique for endoscopic endonasal approaches. Journal of Neurosurgery. 2025. doi:10.3171/2025.8.JNS251403. View on PubMed ➤