A modified transfacial approach to the clivus

Anterior approaches to the clivus must provide excellent visualization of the lesion, give adequate access for dural repair, and be cosmetically acceptable. Most current approaches enter through the nasopharynx or oropharynx, with either palatal, maxillary, or mandibular splitting for greater exposure. We have modified the transfacial approach described by others, which provides excellent access to the clivus along its rostrocaudal extent. A lateral rhinotomy incision is used and carried along the base of the right alae nasi and columella. The nasal bones are osteotomized bilaterally, and the nose is rotated on a pedicle flap, thus opening the entire nasal cavity to view. The septum and medial maxillary walls are removed. This provides excellent visualization of the ethmoid, sphenoid, posterior nasopharynx, and upper oropharynx. At the conclusion of the procedure, the nasal incision is closed, with good cosmesis. A case of recurrent chordoma of the middle and lower clivus is presented to exemplify this technique. The approach has since been used to approach clivus tumors and midline aneurysms of the vertebrobasilar system.