title: The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding.
abstract: OBJECTIVE
  The gold-standard surgical approach to the odontoid is via the transoral route. This approach necessitates opening of the oropharynx and is associated with risks of infection, and swallowing and breathing complications. The endoscopic endonasal approach has the potential to reduce these complications as the oral cavity is avoided. There are fewer than 25 such cases reported to date. The authors present a consecutive, single-institution series of 9 patients who underwent the endonasal endoscopic approach to the odontoid.
  
  
  METHODS
  The charts of 9 patients who underwent endonasal endoscopic surgery to the odontoid between January 2005 and August 2013 were reviewed. The clinical presentation, radiographic findings, surgical management, complications, and outcome, particularly with respect to time to extubation and feeding, were analyzed. Radiographic measurements of the distance between the back of the odontoid and the front of the cervicomedullary junction (CMJ) were calculated, as well as the location of any residual bone fragments.
  
  
  RESULTS
  There were 7 adult and 2 pediatric patients in this series. The mean age of the adults was 54.8 years; the pediatric patients were 7 and 14 years. There were 5 females and 4 males. The mean follow-up was 42.9 months. Symptoms were resolved or improved in all but 1 patient, who had concurrent polyneuropathy. The distance between the odontoid and CMJ increased by 2.34 ± 0.43 mm (p = 0.03). A small, clinically insignificant fragment remained after surgery, always on the left side, in 57% of patients. Mean times to extubation and oral feeding were on postoperative Days 0.3 and 1, respectively. There was one posterior cervical wound infection; there were 2 cases of epistaxis requiring repacking of the nose and no instances of breathing or swallowing complications or velopharyngeal insufficiency.
  
  
  CONCLUSIONS
  This series of 9 cases of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.
authors.affiliation: Departments of Neurosurgery.
authors.forename: Tony
authors.initials: T
authors.lastname: Goldschlager
authors.forename: Roger
authors.initials: R
authors.lastname: Härtl
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Greenfield
authors.forename: Vijay K
authors.initials: VK
authors.lastname: Anand
authors.forename: Theodore H
authors.initials: TH
authors.lastname: Schwartz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D060666:Airway Extubation / Q000706:statistics & numerical data*; D016208:Databases, Factual; D004435:Eating; D004724:Endoscopy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009296:Nasal Cavity / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D009809:Odontoid Process / Q000601:surgery*; D011184:Postoperative Period; D011446:Prospective Studies; D019291:Skull Base / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: CMJ = cervicomedullary junction; POD = postoperative day; anatomy; cervicomedullary junction; endonasal; endoscopy; extubation; feeding; odontoid; odontoidectomy; transnasal; transsphenoidal