Hi, my name is Raj Iyer, I'm the pediatric neurosurgery fellow at Primary Children's Hospital in Salt Lake. I'm going to talk today about endoscopic transoral and transnasal odontoid resection in children and the results of a 10-year protocolized institutional approach. So as we all know, odontogenic brainstem compression due to craniosurficial junction pathology can cause significant morbidity in the pediatric population. In some cases, odontoid resection is warranted, and techniques for removal include transoral, transnasal, and transcervical approaches. At our institution, we adopted a multidisciplinary approach with the combined benefits of the transoral and transnasal routes. This was a retrospective review of patients under 18 years of age undergoing odontoid resection at our institution. Various data points were collected, including procedure duration, day of extubation postoperatively, and any procedure associated complications. Our general approach for triaging patients with significant ventral brainstem compression is for extensive preoperative evaluation by both neurosurgery and otolaryngology. The preoperative ENT evaluation is quite important and includes evaluation for obstructive sleep apnea, anatomical features that are relevant for surgery, and airway risk assessment for general anesthesia. If there's a strong snoring history or concern for OSA, a preoperative polysomnogram is performed. Inspection of the oral cavity for aperture size, tonsil and tongue size, and neck range of motion is also evaluated. Otolaryngoscopy is also conducted in the office to look at the endoscopic view of the surgical field. If the tonsils or adenoids are large, the decision is made to perform a tonsillectomy and adenoidectomy at the time of surgery in conjunction with the odontoid resection. Many of these patients have undergone a prior OC fusion, classifying them as difficult airway patients. Preoperatively and in the OR, discussion is held between ENT and anesthesia about specific roles in airway management, making sure all equipment is present, and having an algorithm for airway securement, with the final step, if all other attempts fail, being a tracheostomy. Clear endpoints are established for trach placement, and this is discussed with the family prior to surgery and with the airway teams prior to ENT. The entirety of the procedure is performed endoscopically. The endoscope is inserted through the cingulinaire into the posterior nasopharynx, and a suction is inserted through the other one. Other instrumentation in this procedure is then triangulated to the posterior nasopharynx from a transoral route, be it a bayoneted monopolar cautery, the drill, or other instrumentation. A key feature of this procedure is the pharyngeal flap, which allows access to the ventral cranial cervical junction. This is performed as a trapdoor, U-shaped flap, with the base being inferior. Fluoroscopy can also be used to ensure the correct location of this. During the pharyngeal opening, special care is taken to avoid the torus tuberius, which is the funnel-shaped entrance to the eustachian tube. Additionally, careful attention is paid to the inferior extent of the flap, such that it doesn't extend below passavant's ridge, which is an elevated point where the soft palate contacts the pharynx. Keeping the flap above this level prevents oral contamination of the flap and also prevents valopharyngeal insufficiency. Finally, it was found that the height of the flap should not be too long in its craniocaudal dimensions with respect to its base. Postoperatively, all patients are extubated in the OR immediately after surgery. They are placed on a clear liquid diet and advanced to soft foods at 24 hours post-op. At one month, in-office nasopharyngoscopy is performed and a speech evaluation as well. And at three months, an MRI is obtained. Thirteen patients were analyzed in our series over the course of 10 years. The mean age was 12 years. There were various etiologies of ventral brainstem compression, such as the ones listed here. In our series, all patients were able to be extubated immediately following surgery. There was no need for any re-intubation. There were also no tracheostomies inserted. The mean procedural duration was 203 minutes, for which there was an increased efficiency as the series progressed. Average hospital length of stay was close to a week. There were no instances of valopharyngeal insufficiency. And in the series, there were two re-operations. One was for an incomplete odontoid resection requiring completion odontoidectomy, which was the first case in the series. The other one was a dehiscent flap, which was not infected. It was thought to have dehisced due to the height of the flap being out of proportion to its width. We found that morbidity could be minimized in this procedure by evaluating patients from the perspective of several different providers. Extensive preoperative evaluation allowed for a more streamlined intraoperative and postoperative course. The careful airway management by ENT and anesthesia led to no re-intubations and no tracheoplacements. Importantly, thoughtful pharyngeal flap placement and morphology, we feel, led to the avoidance of valopharyngeal insufficiency and no infections. And it was through our experience with one dehiscence that we feel that the flap should have a similar ratio between its base and its height. The combined transoral and transnasal approach provided versatile access to the craniosurficial junction. We did not need to make palatal incisions and were not limited inferiorly by the rhinopalatine line, thereby taking advantage of the merits of both approaches and minimizing sinus nasal and pharyngeal morbidity. In conclusion, a multidisciplinary protocolized approach has allowed for iterative improvement in the safety and efficacy of odontoid resection in children. Careful considerations of the neurosurgical, otolaryngologic, and anesthetic aspects of treatment minimizes morbidity and increases efficiency of this procedure. Thank you very much.

pediatric neurosurgery

endoscopic transoral

transnasal odontoid resection

multidisciplinary approach

craniosurficial junction