Chopsticks mononostril approach with sphenoid sinus cranialization and septal mucosa suturing: a new minimally invasive concept and closure technique for endoscopic endonasal approaches

OBJECTIVE: The extended approach and the development of pedicled flaps represented major advancements of the endoscopic endonasal approach (EEA) for skull base lesion removal. However, resection of normal nasal structures to expand the working corridor and harvesting such flaps can result in significant nasal morbidity, prompting the exploration of less invasive strategies. The authors aimed to evaluate their experience with the minimally invasive chopsticks mononostril technique using sphenoid sinus cranialization with septal mucosa suturing for skull base lesions. Outcomes were compared with those of the traditional extended EEA using the nasoseptal flap (NSF). METHODS: The authors conducted a retrospective cohort study involving 82 consecutive patients who underwent EEA for paraclival and craniovertebral junction lesions. Forty-one consecutive patients were treated using the chopsticks mononostril approach using the sphenoid sinus cranialization technique (SSCT) and septal mucosa suturing and were compared with 41 consecutive patients treated previously using the extended EEA with the NSF technique (NSFT). Surgical outcomes and postoperative results were compared between the groups, with a particular focus on health-related quality of life (HRQOL), assessed using the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q). RESULTS: Demographics of the two groups were broadly similar. Skull base chordoma was the most common indication (70.7% in the SSCT group vs 58.5% in the NSFT group), followed by chondrosarcoma located at the petrosphenoidal suture (14.6% vs 22.0%), craniopharyngioma (4.9% vs 12.2%), and meningioma (7.3% vs 2.4%). The incidence of postoperative CSF leaks (12.2% [n = 5] in the SSCT group vs 9.8% [n = 4] in the NSFT group) was not significantly different between the groups. Gross-total resection or subtotal resection was achieved in 97.6% of SSCT patients compared with 85.4% in the NSFT group (p = 0.11). Importantly, patients who underwent SSCT reported significantly lower EES-Q scores overall (p = 0.004), with better outcomes in both the physical (p < 0.001) and psychological (p = 0.006) domains. CONCLUSIONS: The chopsticks mononostril approach with SSCT and septal mucosa suturing provides a valuable minimally invasive alternative to the traditional extended EEA, which typically relies on a pedicled flap for skull base reconstruction. By using angled endoscopes to navigate around corners rather than removing them, this technique preserves the endonasal anatomy and provides a less invasive option, ultimately contributing to the preservation of the patient's HRQOL.