The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding

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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.


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.


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.


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.

ABBREVIATIONSCMJ = cervicomedullary junction; POD = postoperative day.

Article Information

Correspondence Theodore H. Schwartz, Department of Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E. 68th St., Box 99, New York, NY 10065. email:

INCLUDE WHEN CITING Published online October 31, 2014; DOI: 10.3171/2014.9.JNS14733.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Dr. Härtl is a consultant for DePuy-Synthes, Lanx, AOSpine, and Brainlab.

© AANS, except where prohibited by US copyright law.



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    A: Illustration showing the endoscopic endonasal approach to the odontoid along the hard palate. Note the absence of trauma to the oropharynx, which facilitates early extubation and feeding. Inset: View of the odontoid, after removal of the anterior ring of C-1. B: Staged views of operation. Upper Left: The nasopharyngeal fascia between the eustachian tubes overlies the bottom of the clivus and the top of the odontoid. The sphenoid sinus is opened here for orientation purposes but does not need to be opened in this operation. Upper Right: Anterior arch of C-1 after removal of nasopharyngeal fascia and longus colli muscles. Lower Left: Odontoid process following removal of anterior arch of C-1. Lower Right: Ventral dura in front of CMJ following odontoid removal. Copyright Holt Medical Illustration. Published with permission. Figure is available in color online only.

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    Case 7. Example of pre- and postoperative midline sagittal T2-weighted MR images. Note the increased T2 signal and CSF space ventral to the CMJ, indicating successful radiological decompression.

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    Graph showing the measurement of the distance between the back of odontoid and front of CMJ before and after decompression based on MRI findings. Each line represents 1 patient. Images were not available in 1 patient.

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    Illustrative example of pre- and postoperative axial, coronal, and sagittal CT images demonstrating small residual fragment of bone on the left.


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