Basically, three different surgical approaches, transoral, endonasal and transcervical, have been defined for anterior excision and decompression for craniocervical junction (CCJ) lesions. The choice of surgical method and appropriate patient is significantly affected by the location of the lesion according to the palatine or nasoaxial line and the surgeon's experience. In recent years, the endonasal endoscopic approach has been increasingly used as an alternative to the more traditional transoral approach, due to its many advantages such as shorter intubation times, early initiation of oral intake, shorter recovery and hospital stay, and less risk of CSF fistula and related infection. As a result, it is a surgical method that is used more and more frequently. The most important advantage of this method is that the anterior arch of the atlas can be preserved and thus the craniovertebral instability can be prevented. Endonasal endoscopic approach is used nowadays as a very safe and effective method.