title: Combined transnasal and transoral endoscopic approaches to the craniovertebral junction.
abstract: OBJECTIVE
  To describe and evaluate a new technique of a combined endoscope-assisted transnasal and transoral approach to decompress the craniovertebral junction.
  
  
  METHODS
  A retrospective cohort of patients requiring an anterior decompression at the craniovertebral junction over a 12-month period was studied. Eleven patients were identified and included in the study. Eight of the patients had an endoscopic approach [endonasal (2), endooral (2), and combined (4)]. Four of the 8 patients in the endoscopic group had a prior open transoral procedure at other institutions. These 8 patients were compared with a contemporary group of 3 patients who had an open, transoral-transpalatal approach. Charts, radiographic images, and pathologic diagnosis were reviewed. We evaluated the following issues: airway obstruction, dysphagia, velopharyngeal insufficiency (VPI), length of hospital stay (LOS), adequate decompression, and the need for revision surgery.
  
  
  RESULTS
  Adequate anterior decompression was achieved in all the patients. The endoscopic cohort had a reduced LOS (P = 0.014), reduced need for prolonged intubation/tracheotomy (P =0.024) and a trend toward reduced VPI (P = 0.061) when compared with the open surgery group. None of the patients required a revision surgery.
  
  
  CONCLUSIONS
  Proper choice of endoscopic transnasal, transoral, or combined approaches allows anterior decompression at the craniovertebral junction, while avoiding the need to split the palate. A combined transnasal-transoral approach appears to reduce procedure-related morbidity compared with open, transoral, and transpalatal surgeries.
authors.affiliation: Department of Otololaryngology-Head and Neck Surgery, UCSF Spine Center, University of California, San Francisco, San Francisco, USA.
authors.forename: Ivan H
authors.initials: IH
authors.lastname: El-Sayed
authors.forename: Jau-Ching
authors.initials: JC
authors.lastname: Wu
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Ames
authors.forename: Gopalakrishnan
authors.initials: G
authors.lastname: Balamurali
authors.forename: Praveen V
authors.initials: PV
authors.lastname: Mummaneni