BACKGROUND: The clivus is a region characterized by complex anatomy, with 
vascular and neural structures that are located in close proximity. Different 
pathologies can affect this area, and traditional surgical approaches were open 
approaches. Recently, the endoscopic transnasal technique has been introduced, 
and currently represents a good alternative for the surgical management of these 
lesions. This is a preliminary report on patients treated endoscopically for 
clival lesions by the authors' Skull Base Team.
PATIENTS AND METHODS: This was a retrospective chart review of patients who 
underwent an endoscopic exclusive transnasal approach (EEA) or a transoral one 
(TO) for clival lesions between June 2015 and November 2017 at our Skull Base 
Referral Center. Patient characteristics and symptoms, preoperative 
neuroradiological evaluation, surgical approach, complications, and 
postoperative results were evaluated.
RESULTS: Nine patients (6 females and 3 males; age range 6-82 years, mean 
50.8 years) underwent EEA or TO. From histological analysis, we found chordomas 
(6/9 subjects), chondrosarcoma (1/9), craniopharyngioma (1/9), and eosinophilic 
granuloma (1/9). Three patients had previously been operated for a parasellar 
chondrosarcoma (1/9), a pituitary macroadenoma (1/9), or a chondroid chordoma 
(1/9). The lesions were totally (2/9) or sub-totally (5/9) resected, debulked 
(1/9), or analyzed with a biopsy (1/9). Reconstruction was accomplished with a 
multilayer technique (7/9), or with a gasket-seal (1/9), using a 
mucoperichondrial graft, a single/double nasoseptal flap, a middle turbinate 
flap, a fascia lata, or a synthetic fascia. One patient (11.1%) was re-operated 
on due to cerebrospinal leakage, without further complications. Two patients 
(22.2%) were re-operated on due to chordoma regrowth. Adjuvant chemotherapy was 
administered to 1/9 patient with progressive healing. All of the other patients 
underwent proton-beam radiotherapy with no documented tumor growth (median 
follow-up: 20 months; range 5.1-29.9 months).
CONCLUSIONS: Clival lesions represent a heterogeneous group of lesions located 
in a very complex and difficult area. EEA and TO approaches are safe and 
mini-invasive, with lower morbidity and with postoperative complications when 
compared to the traditional open approaches, according to the extent and type of 
pathology.