Endoscopic endonasal skull-base surgery is now standard for many lesions that once required an open approach, and it has shifted the burden of operative planning onto imaging. The region cannot be assessed on clinical examination in any useful way, so the choice of corridor, the intended extent of resection and the reconstruction plan are all built from high-resolution CT and MRI before the patient reaches theatre.
This review sets out what that means for the person reporting the scan. It covers the normal and variant anatomy along the endonasal corridors, the surgical landmarks a surgeon navigates by, the red-flag findings that should be stated explicitly as cautions, and the common pathologies encountered along each route. Its argument is that the interpreting radiologist is part of the operative planning team rather than a supplier of descriptions, and that a report which catalogues findings without relating them to the approach has not done the job.
The practical consequence is in how these studies get reported. A skull-base report that names the lesion and its size but leaves the surgeon to work out the relationship to the internal carotid artery, the optic nerve, and the sphenoid septations forces a second read in the planning meeting. Reporting against the approach - which corridor, which landmarks, which structures are at risk, what reconstruction the defect will need - is what turns the study into a plan.
- State the lesion's relationship to the internal carotid artery and optic nerve explicitly, not by implication
- Describe sphenoid sinus pneumatisation and septation, including where a septum inserts onto the carotid canal
- Flag anatomical variants as cautions rather than incidental observations
- Comment on the likely defect and what it implies for reconstruction where the pathology makes that predictable
- Report against the intended approach when the request names one; if it does not, ask
Why it matters
The operative plan for this region is made from the scan, which puts the reporting radiologist inside the decision rather than upstream of it.
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