LABORATORY INVESTIGATION

J Neurosurg 137:1124–1134, 2022

Morphometric comparison of Fisch type A and endoscopic

endonasal far-medial supracondylar approaches to the
jugular foramen
Takuma Hara, MD,1,3 Mohammad Salah Mahmoud, MD, PhD,2 Rafael Martinez-Perez, MD, PhD,1
Ben G. McGahan, MD,1 Douglas A. Hardesty, MD,1 Thiago Albonette-Felicio, MD, PhD,1
Ricardo L. Carrau, MD, MBA,1,2 and Daniel M. Prevedello, MD1,2
Department of Neurological Surgery, and 2Otolaryngology–Head and Neck Surgery, Wexner Medical Center, The Ohio State
1

University, Columbus, Ohio; and 3Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan

OBJECTIVE The jugular foramen (JF) is one of the most complex and challenging skull base regions to approach surgi-
cally. The extreme medial approach to access the JF provides the approach angle from an anterior direction and does
not require dissection and sacrifice of the jugular bulb (JB) to reach the pars nervosa. The authors compared the Fisch
type A approach to the extreme medial approach to access the JF and evaluated the usefulness of the extreme medial
approach.
METHODS This study was performed at the Anatomical Laboratory for Visuospatial Innovations in Otolaryngology and
Neurosurgery of The Ohio State University. For the comparison of surgical maneuverability and visualization, two angles
were measured: 1) the angle of attack (AoA), defined as the widest angle of movement achieved with a straight dissector;
and 2) the angle of endoscopic exposure (AoEE), defined as the widest angle of movement in the nasal cavity. The dif-
ferences in eustachian tube (ET) management, approach angle, surgical maneuverability, and surgical application of the
Fisch type A approach to the extreme medial approach were compared.
RESULTS There was no difference between ET mobilization and transection regarding cranial-caudal (CC) or medial-
lateral (ML) AoA (p = 0.646). The CC-AoA of the Fisch type A approach was significantly wider than the CC-AoA of the
extreme medial approach (p = 0.001), and the CC-AoEE was significantly wider than the CC-AoA of the extreme medial
approach (p < 0.001). There was no significant difference between the CC-AoA of the Fisch type A approach and the
CC-AoEE. The ML-AoA of the Fisch type A approach was significantly wider than the ML-AoA of the extreme medial ap-
proach (p = 0.033), and the ML-AoEE was significantly wider than ML-AoA in the extreme medial approach (p < 0.001).
The ML-AoEE was significantly wider than the ML-AoA in the Fisch type A approach (p = 0.033).
CONCLUSIONS The surgical maneuverability of the extreme medial approach was not inferior to that of the Fisch
type A approach. The extreme medial approach can provide excellent surgical field visualization, while preserving the
JB. Select cases of chordomas, chondrosarcomas, and JF schwannomas should be considered for an extreme medial
approach. These two approaches are complementary, and a case-by-case detailed analysis should be conducted to
decide the best approach.
https://thejns.org/doi/abs/10.3171/2021.11.JNS212065
KEYWORDS jugular foramen; jugular tubercle; pars nervosa; schwannoma; eustachian tube; surgical technique;
anatomy

T
he jugular foramen (JF) is one of the most complex
skull base regions to approach surgically. The deep
location and surrounding critical structures make
any JF approach challenging. The internal carotid artery
(ICA) is located anterolaterally, the hypoglossal canal
(HC) is located inferomedially, and the labyrinth is located
superiorly. Furthermore, the JF harbors the jugular bulb
(JB) and the inferior cranial nerves. The JF encompasses
two different parts: 1) the pars nervosa (PN) is located
anteromedially and contains the glossopharyngeal nerve

ABBREVIATIONS AoA = angle of attack; AoEE = angle of endoscopic exposure; CC = cranial-caudal; ECA = external carotid artery; EES = endoscopic endonasal surgery;
ET = eustachian tube; FL = foramen lacerum; HC = hypoglossal canal; ICA = internal carotid artery; IJV = internal jugular vein; IPS = inferior petrosal sinus; JB = jugular
bulb; JF = jugular foramen; JT = jugular tubercle; ML = medial-lateral; PN = pars nervosa; PPF = pterygopalatine fossa; PV = pars venosa; SCM = sternocleidomastoid
muscle; SS = sigmoid sinus; VC = vidian canal.
SUBMITTED August 28, 2021. ACCEPTED November 8, 2021.
INCLUDE WHEN CITING Published online January 21, 2022; DOI: 10.3171/2021.11.JNS212065.

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(cranial nerve IX), the tympanic branch of the glosso-
pharyngeal nerve (Jacobsen’s nerve), the inferior petrosal
sinus (IPS), and the anterior meningeal branch of the as-
cending pharyngeal artery; and 2) the pars venosa (PV) is
located posterolaterally and contains the vagus nerve (cra-
nial nerve X), the accessory nerve (cranial nerve XI), the
auricular branch of the vagus nerve (Arnold’s nerve), the
sigmoid sinus (SS), and the posterior meningeal branch of
the ascending pharyngeal artery.
The classic approaches to the JF are the Fisch type A
approach1–3 from the anterolateral direction, the far-lat-
eral approach4,5 from posteriorly, and the far-medial ap-
proach6–8 from anteriorly. The Fisch type A approach is
described as the approach to the infratemporal fossa and
petrous apex3 and can provide useful anterolateral access
to the JF. However, this approach requires extensive ma-
nipulation of critical neurovascular structures. The anteri-
or translocation of the facial nerve may cause facial palsy,
and sacrifice of the external auditory canal and mid-ear
structures will cause hearing impairment. Moreover, the
SS needs to be ligated to expose the PN from a posterolat-
eral approach, which may lead to venous infarction. The
far-lateral direction can provide useful intradural posterior
access to the JF. However, the approach from this direc-
tion is not sufficient to remove JF tumors extending ante-
riorly beyond the limit of this approach.9
There have been reports of using the endoscopic en-
donasal far-medial approach to access the JF.6,8 This ap-
proach has been used mainly to manage extracranial
petroclival lesions, such as chordomas and chondrosarco-
mas.6,10
The classic approaches to the JF, including the Fisch
type A, far-lateral, and retrosigmoid approaches, provide
the approach angle from posteriorly or laterally and often
require sacrificing the JB to adequately access the JF. In
comparison, the extreme medial approach provides the
approach angle from the anterior direction and does not
require dissection and sacrifice of the JB or SS or manipu-
lation of the facial nerve. Moreover, the extreme medial
approach is more beneficial for exposing the PN because
there is no obstruction into the corridor for endoscopic
endonasal surgery (EES). The endoscopic endonasal far-
medial approach avoids many critical neurovascular struc-
tures, leading to potential use for a trans–jugular tubercle
(JT) approach for JF schwannomas. There are few quanti-
tative analysis reports on this approach.11
The main goal of the present study is to compare the
Fisch type A approach to the endoscopic endonasal far-
medial trans-JT approach (extreme medial approach6) to
access the JF and evaluate the usefulness of the extreme
medial approach. We compare the differences in approach
angle, surgical maneuverability, and surgical application.
Additionally, we describe how to maximize the exposure
and surgical maneuverability of the extreme medial ap-
proach.
Methods
Study Design
Five embalmed human cadaveric heads were injected
with red silicone through the common carotid artery and
Hara et al.
prepared for dissection at the Anatomical Laboratory for
Visuospatial Innovations in Otolaryngology and Neu-
rosurgery at The Ohio State University. All experiments
were performed in the laboratory.
The Fisch type A approach was performed under mi-
croscopic visualization (Carl Zeiss Co.) with a standard
craniotomy, microsurgical instruments (KLS Martin
Group), and drills (Stryker-Leibinger Corp/Medtronic).
The extreme medial approach was performed under en-
doscopic visualization with 0°, 30°, and 45° rod-lens en-
doscopes coupled to a high-definition camera and moni-
tor (Storz Endoscopy). The endoscopic dissections were
performed using skull base neurosurgical endoscopic in-
struments (Storz Endoscopy), a high-speed drill, and both
diamond (3- and 4-mm) and cutting (3- and 4-mm) burrs
(Midas Rex Stylus, Medtronic).
Surgical Technique
Fisch Type A Approach
The Fisch type A approach was performed based on
previous reports.12,13 A standard C-shaped postauricular
incision that extended down to the neck was made. The
external auditory canal was transected. Sharp dissection
was used to disconnect the sternocleidomastoid muscle
(SCM) from the mastoid tip. The dissection continued in
the neck until there was adequate exposure of the ICA,
external carotid artery (ECA), internal jugular vein (IJV),
and cranial nerves IX–XII. The external auditory canal,
tympanic membrane, malleus, and incus were all removed.
Under microscopic visualization, a subtotal petrosectomy
exposed the skeletonized fallopian canal. After anterior
mobilization of the facial nerve, the lateral aspects of the
JF and SS were entirely exposed by drilling the mastoid
bone, and the styloid process was resected (Fig. 1A and B).
The IJV and SS were ligated and cut, and the JB was then
opened for exposure of the PN and PV (Fig. 1C).
Extreme Medial Approach
Under endoscopic visualization, a posterior nasal sep-
tectomy, bilateral sphenoidotomies, ethmoidectomies, and
middle turbinectomy were performed. Uncinectomy and
medial maxillectomy were performed for exposure to the
posterior wall of the maxillary sinus.14 The pterygopala-
tine fossa (PPF) was exposed by resecting the posterior
wall of the maxillary sinus. Lateralization of the PPF con-
tents was performed after cutting the palatovaginal artery.
The vidian canal (VC) was identified, and the bone was
drilled under the VC and foramen rotundum in a poste-
rior direction, providing access to the fibrocartilaginous
component of the foramen lacerum (FL). The medial and
lateral pterygoid plates were removed, and fibrocartilage
of the FL connecting to the eustachian tube (ET)15 was
exposed (Fig. 2A). According to the anatomical study by
Labib et al.,15 the exposure of the petroclival synchondro-
sis, including the lower clivus, infrapetrous region, JF, and
HC, can be maximized by the transection or anterolateral
mobilization of the ET. Thus, ET anterolateral mobiliza-
tion was performed. After exposure of the PN, the ET was
transected for measurements of angles of attack (AoAs).
The AoA was defined as the widest angle of movement
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FIG. 1. A: Microscopic view of the Fisch type A approach from the lateral direction. After anterior mobilization of the facial nerve,
the lateral aspects of the JF and SS were exposed by drilling the mastoid bone. Cranial nerves IX–XII, the ICA, and the IJV were
exposed. B: The IJV was ligated and lifted to the JB. C: The IJV and SS were removed, and the JB was then opened for exposure
of the PN and PV. © Takuma Hara, published with permission. Figure is available in color online only.

achieved with a straight dissector held in place with the
tip at the PN.16 The nasopharyngeal mucosa, basopharyn-
geal fascia, longus capitis major muscle, and rectus capitis
anterior muscle were identified and resected to optimize
lateral exposure (Fig. 2B).
The exposed clivus bone was drilled inferolaterally to
identify the HC. The HC is known as a landmark for iden-
tifying the JT and occipital condyle. The JT is above the
HC and can be drilled without occipital condyle compro-
mise. Atlantooccipital joint instability caused by drilling
of the occipital condyle can be avoided by identifying the
HC. Before drilling the JT, the petrous bone of the sublac-
erum area was drilled.6 The removal of the petrous apex
above the petroclival synchondrosis and optimal manage-
ment of the ET were essential to allow proper maneuver-
ability in the superolateral compartments of the JT and JF.
Drilling of the JT was then started from the cancellous
bone. If maneuverability was sufficient, then drilling the
JT toward the lateral, medial, and superior directions can
be freely performed (Fig. 2C).
However, drilling toward the inferior direction was re-
stricted anatomically by the HC, and the drill head itself
obstructed posterior visualization through the narrow cor-
ridor. Drilling the JT was performed carefully. After drill-
ing the JT and lower clivus bone, the dura was exposed
and the connection of the IPS into the ventromedial part
of the JF was identified. Additionally, the lower cranial
nerves (IX and X) and cranial nerve XII were identified
by opening the dura, and the PN and PV were directly
identified posterolateral to the IPS using a 30° or 45° en-
doscope (Fig. 2D and E). Next, transection of the ET was
performed after exposure of the PN for measurement, as
noted above.
Morphometric Analysis
Each stereotactic point was measured using a neuro-
navigation system and coordinates were calculated for
each angle. For the comparison of surgical maneuverabil-
ity and visualization we measured the following angles.
The AoA was defined as the widest angle of movement
achieved with a straight dissector held in place with the
tip at the PN16 through each surgical approach (Fig. 3A).

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FIG. 2. A: Endoscopic view of the left-sided extreme medial approach. The medial and lateral pterygoid plates were removed, and
fibrocartilage of the FL connecting to the ET was identified. The lateral infrapetrous supra-eustachian area was exposed. FO =
foramen ovale. B: Comparison of the mobilization of the ET side (left) and preservation side (right). RCA = rectus capitis anterior.
C: After resection of the ET, drilling of the JT was started from the cancellous bone. The HC and condyle were identified inferior
to the JT. D: JF exposure using a 30° endoscope. The lower cranial nerves (IX and X) and cranial nerve XII were identified by the
opening of the dura. The extracranial part of the cranial nerves was also exposed. ACC = anterior condylar confluence. E: The
PN and PV were directly identified posterolateral to the IPS using a 45° endoscope. © Takuma Hara, published with permission.
Figure is available in color online only.

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Hara et al.
The surgical maneuverability was compared between ET
transection and anterolateral mobilization by measuring
the cranial-caudal (CC) and medial-lateral (ML) AoA of
ET transection and anterolateral mobilization.
Endoscopic endonasal approaches are limited by the
nasal cavity because the maximum movement of the
straight dissector is always restricted by the nostril. If we
simply compared the AoA of craniotomy and that of EES,
the AoA of craniotomy would always be superior to that
of EES. Therefore, the AoA alone does not provide suf-
ficient information to compare surgical maneuverability
at the target tissue. As such, the angle of endoscopic ex-
posure (AoEE) was also measured in the extreme medial
approach. The AoEE was defined as the widest angle of
movement within the nasal cavity centered at the target
point (PN). The AoEE was calculated as the angle made
by the three following points: the superior (or lateral) re-
striction point of movement located on the critical struc-
ture, the inferior (or medial) restriction point located on
the critical structure, and the target point (Fig. 3B). The
AoEE of the Fisch type A approach was not described be-
cause the AoEE is equal to the AoA.
The AoA was measured in both the CC and ML angles
of the Fisch type A and extreme medial approaches (Fig.
3C and D), whereas the AoEE was in the CC and ML an-
gles of only the extreme medial approach (Fig. 3E).
Statistical Analysis
The median angle values were illustrated as a scatter-
plot, with some values overlapping each other. Nonpara-
metric statistical techniques were used due to the small
sample size. Differences between continuous variables
were evaluated using the Wilcoxon signed-rank test (ET
management) and Kruskal-Wallis test (angles). The Dunn-
Bonferroni test was used for post hoc testing following
any significant differences noted with the Kruskal-Wallis
test. The level of statistical significance was set at p < 0.05.
All statistical analyses were performed using SPSS (ver-
sion 26, IBM Corp.).
Results
Comparison of ET Management
The AoA of ET transection and anterolateral mobili-
zation was measured on 10 sides of the 5 cadaver heads.
The median CC-AoAs of ET transection and mobilization
were 5.5° and 5.6°, respectively. There was no significant
difference between the CC-AoAs of ET transection and
mobilization (p = 0.646; Fig. 4A). The median ML-AoAs
of ET transection and mobilization were both 11.0°. There
was no significant difference between the ML-AoAs of
ET transection and mobilization (p = 0.646; Fig. 4B).
Angle Comparisons
The AoA of the Fisch type A approach and extreme
medial approach and the AoEE of the extreme medial ap-
proach were measured using 10 sides of 5 cadaver heads.
The median CC-AoAs of the Fisch type A and extreme
medial approaches were 101.2° and 5.5°, respectively, and
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the CC-AoEE was 105.3°. The CC-AoA of the Fisch type
A approach was significantly wider than the CC-AoA of
the extreme medial approach (p = 0.001), and the CC-
AoEE was significantly wider than the CC-AoA of the
extreme medial approach (p < 0.001). There was no sig-
nificant difference between the CC-AoA of the Fisch type
A approach and the CC-AoEE (Fig. 4C).
The median ML-AoAs of the Fisch type A and extreme
medial approaches were 69.6° and 11.0°, respectively, and
the ML-AoEE was 134.1°. The ML-AoA of the Fisch type
A approach was significantly wider than the ML-AoA of
the extreme medial approach (p = 0.033), and the ML-
AoEE was significantly wider than the ML-AoA in the
extreme medial approach (p < 0.001). The ML-AoEE was
significantly wider than the ML-AoA of the Fisch type A
approach (p = 0.033; Fig. 4D).
Illustrative Cases
Fisch Type A Approach
A 21-year-old woman with no past medical history
presented with headaches and a dull throbbing sensa-
tion behind her right ear. On examination she had mild
right-sided hearing loss. MRI revealed a right-sided 1-cm
enhancing mass consistent with a JF schwannoma (Fig.
5A–D). She was followed with serial imaging that dem-
onstrated growth, and she continued to have worsening
symptoms. The patient underwent a complete resection
using the Fisch Type A approach. At the 4-year follow-up,
she expressed no complaints and there were no signs of
tumor recurrence on MRI (Fig. 5E–H).
Extreme Medial Approach
A 69-year-old man with a history of a left-sided pet-
roclival chondrosarcoma after undergoing retromastoid
resection 20 years prior and Gamma Knife surgery pre-
sented with worsening phonation and a dysphagia. He was
neurologically intact on examination. MRI demonstrated
recurrence of the left-sided petroclival chondrosarcoma
with extension intradurally and into the jugular vein. He
underwent an endoscopic endonasal extreme medial ap-
proach with a complete resection (Video 1).
VIDEO 1. Clip showing a case example of the extreme medial
approach for resection of a petroclival chondrosarcoma. Hx = his-
tory; s/p = status post. © Takuma Hara, published with permission.
Click here to view.
Postoperatively, the patient was neurologically intact, but
suffered from pneumonia that was treated with antibiot-
ics, and a myocardial infarction that was treated with a
coronary artery stent. At the 5-year follow-up, the patient
had no complaints and MRI demonstrated no recurrence.
Discussion
Fisch Type A Approach
The Fisch type A approach can provide a wide surgical
exposure of the posterolateral aspect to the JF. This clas-
sic approach is used for the treatment of huge and inva-
sive tumors such as glomus tumors and dumbbell-shaped
schwannomas. There is high risk of cranial nerve IX and
X palsies given the location of these procedures.17 This
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FIG. 3. A: Schematic illustration of the AoA of the EES. The AoA was calculated as the angle made by the following 3 points: the
superior edge of the nostril, the target point, and the inferior edge of the nostril. B: Schematic illustration of the CC-AoEE. The
AoEE was calculated as the angle made by 3 points: the superior restriction point of movement located on the critical structure, the
target point, and the inferior restriction point located on the critical structure. C: The concept of AoA in the CC (dotted line) and ML
(red line) directions of the Fisch type A approach is shown by a microscopic lateral view. The PN was defined as an interest point
(yellow dot). D: The concepts of AoA in the CC (white dotted line) and ML (red line) directions of the extreme medial approach and
AoA in the CC (yellow dotted line) and ML (yellow line) directions of the Fisch type A approach are shown by axial and sagittal CT
images. The PN was defined as an interest point (yellow). E: The AoEEs in the CC (white dotted line) and ML (red line) directions
of the extreme medial approach are shown by a 30° endoscopic view. The PN was defined as an interest point (yellow dot). ©
Takuma Hara (panels C and E), published with permission. Figure is available in color online only.

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FIG. 4. A: Scatterplot comparing the CC-AoAs of the ET transection and anterolateral mobilization in the extreme medial
approach. Values are presented as medians. B: Scatterplot comparing the ML-AoAs of the ET transection and anterolateral
mobilization in the extreme medial approach. Values are presented as medians. C: Scatterplot comparing the CC-AoA in the Fisch
type A and extreme medial approaches, and the CC-AoEE. *p < 0.05, **p < 0.01. Values are presented as medians. D: Scatterplot
comparing the ML-AoA in the Fisch type A and extreme medial approaches, and the ML-AoEE. *p < 0.05; **p < 0.01. Values are
presented as medians. Figure is available in color online only.

approach usually requires mobilization of the facial nerve
to expose the maximum surgical field and achieve excel-
lent maneuverability. The mobilization of the facial nerve
risks the morbidity of a facial palsy, although Russo et al.18
have reported good outcomes of anterior rerouting (mobi-
lization of the facial nerve). Additionally, this classic ap-
proach often requires manipulation of the SS and JB for
exposing the PN and PV. Ligation and transection of the
JB are needed for approaching the JF (especially the PN),
because the PN is located behind the JB from the postero-
lateral aspect. This procedure risks venous congestion and
infarction. The balance between the risk of morbidity with
this approach and the benefit of gross-total resection of
these tumors19 must be considered.
Extreme Medial Approach
The endoscopic endonasal extreme medial approach to
the JF has been growing in popularity.6,8 This approach
provides excellent exposure and direct access to the me-
dial and anterior aspects of the PN and PV without ma-
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nipulation and sacrifice of critical neurovascular struc-
tures. However, in contrast to the classic approach, access
behind the lower cranial nerves (the posterior side of the
JF) using the extreme medial approach is challenging. The
direction of tumor extension should be considered when
planning the surgical approach to tumors of the JF. The
extreme medial approach is performed in the deep and lat-
eral infrapetrous6 and supra-eustachian region. Visualiza-
tion of the JF can be achieved without manipulation of the
ET. However, to obtain the maximum surgical field and
angle15 for maneuvering around the JF, which is critical
for tumor resection, displacement of the ET and sublac-
erum structures is needed.20,21 Additionally, resection of
the ET in the extreme medial approach can provide ac-
cess to the extracranial lower cranial nerves and ICA (Fig.
6A–C). The resection or anterolateral mobilization of the
ET can be beneficial to this approach, but risks causing
middle ear effusion, mastoid opacification, and conductive
hearing loss.8 This approach is one of the most challenging
EES procedures due to the depth of the JF and the narrow
surgical field.

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FIG. 5. Case example of the Fisch type A approach. A–D: Preoperative MR images of a right-sided 1-cm enhancing mass con-
sistent with a JF schwannoma (A, axial T1-weighted with contrast; B, axial T2-weighted without contrast; C, sagittal T1-weighted
with contrast; and D, coronal T1-weighted with contrast). E–H: Postoperative MR images showing no residual tumor or recurrence
(E, axial T1-weighted with contrast; F, axial T2-weighted without contrast; G, sagittal T1-weighted with contrast; and H, coronal
T1-weighted with contrast).

Comparison of Angles
Labib et al.15 found that the exposure of the petroclival
synchondrosis, including the lower clivus, infrapetrous re-
gion, JF, and HC, was maximized by the transection or
anterolateral mobilization of the ET. In the present study,
we compared the AoA of the transection to the anterolat-
eral mobilization of the ET, and there was no significant
difference (Fig. 6D and E). According to our analysis, the
surgical corridor made by these two procedures has the
same effectiveness. There have been no published data on
the complication rate of either ET management strategy.
Further investigation is needed regarding clinical data of
these ET manipulations.
Komune et al.22 provided an analysis of different ap-
proaches to the JF and regarded the lower invasiveness of
the extreme medial approach as an advantage. However,
this study was descriptive and had no quantitative data.
Youssef et al.11 described a quantitative analysis of the ap-
proach angle and volume of exposure with a combined
staged endonasal far-medial and open postauricular ap-
proach to the JF and concluded that it may constitute a
less invasive alternative to the more extensive open ap-
proaches.11 Comparing the extreme medial with the Fisch
type A approach is difficult because one is an endoscopic
endonasal approach, and the other is an open craniotomy
approach. It is unavoidable that the AoA of the EES is
more restricted than in an open approach. However, only
comparing AoAs is not sufficient to evaluate the dif-
ference between the two approaches. The two essential
concepts of EES are access and visualization through the
narrowest practical corridor, and providing maximum
effective action at the target with minimal disruption of
normal tissue.23
The AoA alone is not sufficient for a useful comparison
of the Fisch type A approach and the extreme medial ap-
proach. In EES, the maximum movement of the straight
dissector is regulated by the width and height of the nos-
tril, as well as the depth and distance from the midline of
the target point. EES is essentially a keyhole surgery, in
which the nostril is the keyhole. Similar to keyhole sur-
gery, EES is based on the use of many types of angled in-
struments and endoscopes. The use of angled instruments
and endoscopes can compensate for the narrowed AoA in
EES. If we simply compared the AoA of craniotomy and
that of EES, that of craniotomy would always be superior
to that of EES. Given the use of angled instruments and
endoscopes in EES, the angle of movement within the na-
sal cavity centered at the target point is more important
than the AoA. For example, when dissecting a tumor at the
JF with a 45° or 70° endoscope, the surgeon is utilizing
the AoEE.
This led to our use of the AoEE as an indicator of sur-
gical maneuverability, in addition to the AoA, to compare
and evaluate the surgical maneuverability at the target tis-
sue. There was no significant difference between the AoA
of the Fisch type A approach and the AoEE in the extreme
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FIG. 6. A: A 0° endoscopic view of the clivus area. The right-sided ET was preserved and the left side was resected. The lateral
infrapetrous supra-eustachian area was exposed on the left side. B: A 30° endoscopic right-sided view of the lower clivus area.
The lateral infrapetrous supra-eustachian area (dotted circle) restricts lateral manipulation. C: A 30° endoscopic left-sided view
of the lower clivus area. The lateral infrapetrous supra-eustachian area (dotted circle) was dissected and does not restrict lateral
manipulation. D: A 0° endoscopic view of the lateral infrapetrous supra-eustachian area by the anterolateral ET mobilization.
E: A 0° endoscopic view of the lateral infrapetrous supra-eustachian area by the ET transection. © Takuma Hara, published with
permission. Figure is available in color online only.

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medial approach. Although these metrics are not a direct
comparison, they can serve as a useful tool in comparing
surgical maneuverability between an open approach and
an endoscopic approach. As such, the surgical maneuver-
ability of the extreme medial approach would not be infe-
rior to that of the Fisch type A approach. Of course, these
angles should be considered as only one indicator of surgi-
cal maneuverability, and they do not convey the difficulty
or usefulness of these approaches. There is an inherent
learning curve to operate at different angles in EES, and
for the AoEE rather than the AoA of an open craniotomy.
The AoA of the extreme medial approach is significantly
narrower than the Fisch type A approach (Fig. 4C and D).
However, in well-selected cases, the extreme medial ap-
proach can be a useful alternative.
Approach Selection
Certain pathologies lend themselves to consideration
for use of the extreme medial approach. Our group agrees
with the conclusion of Vaz-Guimaraes et al.6 that chordo-
mas and chondrosarcomas with extension into the JF are
good candidates for the extreme medial approach. Addi-
tionally, JF schwannomas may be considered for this ap-
proach as well. The benefit of the extreme medial approach
for the treatment of JF schwannomas is that the SS and JB
do not need to be sacrificed, even with tumor extending
extracranially through the JF. The sacrifice of the IPS and
anterior condylar confluence depends on the anatomy of
each individual case. Using the Fisch type A approach, the
JB and SS are usually sacrificed when approaching the JF.
The risks of the extreme medial approach have been pre-
viously reported.6,24 The extreme medial approach to the
PN and PV is an expert-level approach and requires dural
opening, which involves a high risk of CSF leak. CSF leak
must be managed by multilayer closure using vascularized
flaps.25,26 A recent clinical series reported that the extreme
medial approach is safe and effective for chordomas and
chondrosarcomas with extension into the JF.6 Additionally,
our group has reported on techniques and challenges of
the extreme medial approach.24
Limitations
This study is a cadaveric morphometric analysis and is
limited by lack of clinical data and the small sample size
of cadavers analyzed. Further clinical studies are required
to assess the usefulness and safety of the extreme medi-
al approach. Surgical cases involving use of the extreme
medial approach are rare. Both the extreme medial and
Fisch type A approaches require an extremely high level
of skull base surgery skills in a setting with multidisciplin-
ary teams, which may limit the applicability of this study.
Conclusions
The Fisch type A and extreme medial approaches pro-
vide excellent surgical field visualization and maneuver-
ability in our morphometric study. Select cases of chor-
domas, chondrosarcomas, and JF schwannomas may be
considered for an extreme medial approach. These two ap-
proaches require a high level of skill and having the abil-
ity to perform either is complementary. A case-by-case
Hara et al.
detailed analysis should be performed to decide the best
approach.
References
1. Leoncini E, Ricciardi W, Cadoni G, et al. Adult height and
head and neck cancer:​a pooled analysis within the IN-
HANCE Consortium. Eur J Epidemiol. 2014;​29(1):​35-48.
2. Fisch U. Infratemporal fossa approach for glomus tumors of
the temporal bone. Ann Otol Rhinol Laryngol. 1982;​91(5 Pt
1):​474-479.
3. Fisch U. Infratemporal fossa approach for lesions in the
temporal bone and base of the skull. Adv Otorhinolaryngol.
1984;​34:​254-266.
4. Rhoton AL Jr. The far-lateral approach and its transcondylar,
supracondylar, and paracondylar extensions. Neurosurgery.
2000;​47(3)(suppl):​S195-S209.
5. Matsushima T, Natori Y, Katsuta T, Ikezaki K, Fukui M,
Rhoton AL. Microsurgical anatomy for lateral approaches to
the foramen magnum with special reference to transcondylar
fossa (supracondylar transjugular tubercle) approach. Skull
Base Surg. 1998;​8(3):​119-125.
6. Vaz-Guimaraes F, Nakassa ACI, Gardner PA, Wang EW,
Snyderman CH, Fernandez-Miranda JC. Endoscopic endona-
sal approach to the ventral jugular foramen:​anatomical basis,
technical considerations, and clinical series. Oper Neurosurg
(Hagerstown). 2017;​13(4):​482-491.
7. Liu JK, Sameshima T, Gottfried ON, Couldwell WT, Fuku-
shima T. The combined transmastoid retro- and infralabyrin-
thine transjugular transcondylar transtubercular high cervical
approach for resection of glomus jugulare tumors. Neurosur-
gery. 2006;​59(1)(suppl 1):​ONS115-ONS125.
8. Morera VA, Fernandez-Miranda JC, Prevedello DM, et al.
“Far-medial” expanded endonasal approach to the inferior
third of the clivus:​the transcondylar and transjugular tuber-
cle approaches. Neurosurgery. 2010;​66(6)(Suppl Operative):​
211-220.
9. Jugular foramen. Neurosurgery. 2007;​61(Suppl 4):​229-250.
10. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R.
Expanded endonasal approach:​fully endoscopic, completely
transnasal approach to the middle third of the clivus, petrous
bone, middle cranial fossa, and infratemporal fossa. Neuro-
surg Focus. 2005;​19(1):​E6.
11. Youssef AS, Arnone GD, Farell NF, et al. The combined
endoscopic endonasal far medial and open postauricular
transtemporal approaches as a lesser invasive approach to
the jugular foramen:​anatomic morphometric study with case
illustration. Oper Neurosurg (Hagerstown). 2020;​19(4):​471-
479.
12. Slattery WH, Kutz JW. The Fisch infratemporal fossa ap-
proach:​Type A. In:​Friedman RA, ed. Lateral Skull Base
Surgery:​The House Clinic Atlas. Thieme;​ 1978:​107-118.
13. Sanna M, Saleh EA, Russo A, et al. TK-A of microsurgery of
the lateral skull base-T (2008). In:​Atlas of Microsurgery of
the Lateral Skull Base. Thieme;​2014.
14. Fortes FSG, Sennes LU, Carrau RL, et al. Endoscopic
anatomy of the pterygopalatine fossa and the transpterygoid
approach:​development of a surgical instruction model. La-
ryngoscope. 2008;​118(1):​44-49.
15. Labib MA, Belykh E, Cavallo C, et al. The endoscopic en-
donasal eustachian tube anterolateral mobilization strategy:​
minimizing the cost of the extreme-medial approach. J Neu-
rosurg. 2020;​134(3):​831-842.
16. Martinez-Perez R, Albonette-Felicio T, Hardesty DA, Carrau
RL, Prevedello DM. Same viewing angle, minimal crani-
otomy enlargement, extreme exposure increase:​the extended
supraorbital eyebrow approach. Neurosurg Rev. 2021;​44(2):​
1141-1150.
17. Sedney CL, Nonaka Y, Bulsara KR, Fukushima T. Microsur-
J Neurosurg Volume 137 • October 2022 1133
Unauthenticated | Downloaded 04/04/24 12:32 AM UTC
Hara et al.
gical management of jugular foramen schwannomas. Neuro-
surgery. 2013;​72(1):​42-46.
18. Russo A, Piccirillo E, De Donato G, Agarwal M, Sanna M.
Anterior and posterior facial nerve rerouting:​a comparative
study. Skull Base. 2003;​13(3):​123-130.
19. Ivan ME, Sughrue ME, Clark AJ, et al. A meta-analysis of
tumor control rates and treatment-related morbidity for pa-
tients with glomus jugulare tumors. J Neurosurg. 2011;​114(5):​
1299-1305.
20. Wang WH, Lieber S, Mathias RN, et al. The foramen lac-
erum:​surgical anatomy and relevance for endoscopic endo-
nasal approaches. J Neurosurg. 2018;​131(5):​1-12.
21. Taniguchi M, Akutsu N, Mizukawa K, Kohta M, Kimura H,
Kohmura E. Endoscopic endonasal translacerum approach
to the inferior petrous apex. J Neurosurg. 2016;​124(4):​1032-
1038.
22. Komune N, Komune S, Matsushima K, Rhoton AL Jr. Com-
parison of lateral microsurgical preauricular and anterior
endoscopic approaches to the jugular foramen. J Laryngol
Otol. 2015;​129(suppl 2):​S12-S20.
23. Cinalli G, Cappabianca P, de Falco R, et al. Current state and
future development of intracranial neuroendoscopic surgery.
Expert Rev Med Devices. 2005;​2(3):​351-373.
24. Silveira-Bertazzo G, Manjila S, London NR Jr, Prevedello
DM. Techniques and challenges of the expanded endoscopic
endonasal access to the ventrolateral skull base during the
“far-medial” and “extreme medial” approaches. Acta Neuro-
chir (Wien). 2020;​162(3):​597-603.
25. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic recon-
struction of the cranial base using a pedicled nasoseptal flap.
Neurosurgery. 2008;​63(1)(suppl 1):​ONS44-ONS53.
1134 J Neurosurg Volume 137 • October 2022
26. Hara T, Akutsu H, Yamamoto T, et al. Cranial base repair
using suturing technique combined with a mucosal flap for
cerebrospinal fluid leakage during endoscopic endonasal
surgery. World Neurosurg. 2015;​84(6):​1887-1893.
Disclosures
Dr. Prevedello reports being a consultant for Integra and Stryker;
receiving an honorarium from Storz and BK Medical; receiv-
ing royalties from KLS Martin, Mizuho, and ACE Medical; and
receiving support of non–study-related clinical or research effort
from Stryker, Storz, and Integra.
Author Contributions
Conception and design: Prevedello, Hara. Acquisition of data:
Hara, Mahmoud. Analysis and interpretation of data: Hara, Mar-
tinez-Perez, Albonette-Felicio. Drafting the article: Prevedello,
Hara. Critically revising the article: all authors. Reviewed submit-
ted version of manuscript: all authors. Approved the final version
of the manuscript on behalf of all authors: Prevedello. Statistical
analysis: Hara. Administrative/technical/material support: Preve-
dello. Study supervision: Prevedello.
Supplemental Information
Videos
Video 1. https://vimeo.com/646866747.
Correspondence
Daniel M. Prevedello: Wexner Medical Center, The Ohio State
University, Columbus, OH. daniel.prevedello@osumc.edu.
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