Skull base approaches, including both microscopic and endoscopic techniques, offer critical access to complex tumors and vascular pathologies while minimizing trauma to surrounding neurologic and vascular structures. Intraoperative neurophysiological monitoring (IONM) has played a pivotal role in skull base surgeries for nearly three decades, significantly reducing morbidity and mortality by providing real-time feedback on at-risk structures. The successful implementation of IONM requires a collaborative team involving neurosurgeons, otolaryngologists, neurophysiologists, and neuroanesthesiologists. Preoperative planning considers the patient’s neurological status, surgical approach, and the structures at risk, determining the optimal IONM modalities. This review explores the use of IONM in skull base surgery, emphasizing the endoscopic endonasal approach (EEA) for tumor resection. It highlights the potential risks to neurologic and vascular structures and reviews the literature supporting the role of IONM in mitigating these risks during surgery.