Transtubular Transoral Approach for Irreducible Ventral Craniovertebral Junction Compressive Pathologies: Surgical Technique and Outcome

@#Introduction: To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods: Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results: All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions: A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.

Clinical analysis of gasless transoral vestibular robotic resection of thyroglossal duct cysts / 临床耳鼻咽喉头颈外科杂志

Objective:This study aimed to explore the safety and feasibility of gasless transoral vestibular robotic resection of thyroglossal duct cysts. Methods:The clinical data of patients who underwent gasless transoral vestibular robotic resection of thyroglossal duct cysts at the Department of otolaryngology, Sun Yat-sen Memorial Hospital, Sun yat-sen university from September 2020 to May 2022 were analyzed. The operative time, blood loss, postoperative complications, postoperative pain score, postoperative aesthetic score, and recurrence were prospectively evaluated. Results:All patients completed the operation successfully and no case conversed to an open operation. The operation time was 104.00（95.00, 131.25） minutes, and the surgical blood loss was 15.00（10.00, 16.25） mL. The drainage volume was（59.71±9.20） mL. Postoperative pathology was consistent with thyroglossal duct cysts. There was no local reswelling, subcutaneous hematoma, emphysema, skin flap necrosis, infection and other complications. The postoperative hospital stay was 3.00（2.00, 3.00） days. Six patients had mild sensory abnormalities of the lower lip 3 months after surgery, and all patients were satisfied with the cosmetic outcomes. No recurrence was found during the 5-26 months follow-up. Conclusion:gasless transoral vestibular robotic resection of thyroglossal duct cysts is safe and feasible, with hidden postoperative scars and good cosmetic outcomes. It can provide a new choice for patients with thyroglossal duct cysts.

Abordaje Transoral para la Extracción de un Diente Supernumerario Intranasal. Presentación de un Caso y Revisión de la Literatura

RESUMEN: El diente supernumerario de ubicación nasal es una patología de baja prevalencia en la población con diferentes formas y sintomatología clínica. Es importante establecer un diagnóstico respecto a sus características clínicas y radiológicas para realizar una planificación de tratamiento quirúrgica adecuada, con nula o escasas complicaciones post intervención. Presentación del caso: En el presente estudio se reporta el caso de un niño de 10 años de edad, sin antecedentes mórbidos, que recurre al servicio por presentar un diente supernumerario en la línea media hallado radiográficamente. El CBCT demuestra un mesiodens en el septum nasal, palatal inclinado e invertido, parcialmente erupcionado cubierto por mucosa nasal, con su corona en sentido a la cavidad nasal en relación a las fosas nasales. El diente fue extraído con anestesia general mediante un abordaje transoral a través de una vestibulotomía. El diente supernumerario nasal es una patología poco prevalente. Es importante conocer sus características clínicas y radiográficas ya que determinarán el tipo de abordaje a realizar. El grado de erupción, la distancia a la espina nasal anterior y su sintomatología asociada son fundamentales para determinar si el abordaje quirúrgico es intraoral o extraoral.

ABSTRACT: The supernumerary tooth of nasal location is a pathology of low prevalence in the population with different forms and clinical symptoms. It is important to establish a diagnosis regarding its clinical and radiological characteristics in order to carry out adequate surgical treatment planning, with few or no post-intervention complications. Case presentation: This study reports the case of a 10-year-old boy, with no morbid history, who presented a supernumerary tooth, found radiographically in the midline. CBCT showed a mesiodens in the nasal septum, tilted and inverted palatal, partially erupted covered by nasal mucosa, with its crown facing the nasal cavity in relation to the nostrils. The tooth was extracted under general anesthesia using a transoral approach through a vestibulotomy. The nasal supernumerary tooth is a rare pathology. It is important to know its clinical and radiographic characteristics since they will determine the type of approach to be used. The degree of eruption, the distance to the anterior nasal spine and its associated symptoms are essential to determine whether the surgical approach is intraoral or extraoral.

Cauterización transoral de la arteria maxilar interna en la fosa infratemporal: informe de un caso / Transoral cauterization of the internal maxillary artery in the infratemporal fossa: case report

Se describe el caso clínico de una paciente de 84 años que tuvo epistaxis recidivante por padecer enfermedad de Rendu-Osler-Weber. Tuvo antecedentes de diversos tratamientos quirúrgicos que incluyeron el cierre de la fosa nasal izquierda (operación de Young). Por la persistencia de epistaxis izquierda se indicó una angiografía y embolización. Esta última no se hizo porque se diagnosticaron anastomosis entre el sistema carotídeo externo y el interno. Se realizó un abordaje intraoral paramaxilar asistido con endoscopios para cauterizar la arteria maxilar interna en la fosa infratemporal y un abordaje externo para cauterizar la arteria etmoidal anterior solucionando la epistaxis. (AU)

The clinical case of an 84-year-old patient who had recurrent epistaxis due to Rendu-Osler- Weber disease is described. She had a history of various surgical treatments including closure of the left nostril (Young's operation).Due to the persistence of left epistaxis, angiography and embolization were indicated. The latter was not done because anastomosis between the external and internal carotid system was diagnosed. An intraoral paramaxillary approach assisted with endoscopes was performed to cauterize the internal maxillary artery in the infratemporal fossa and an external approach to cauterize the anterior ethmoidal artery solving the epistaxis. (AU)

An observation on risk of infection in treatment of craniovertebral junction disorders by transoral approach operation / 中国修复重建外科杂志

Objective: To study the changes of bacterial flora after a series of preoperative oral disinfection and the postoperative recovery of patients with craniovertebral junction disorders who were treated with transoral approach operations. And to provide a theoretical basis for the prevention of postoperative complications such as infection. Methods: The clinical data of 20 cases with craniovertebral junction disorders and treated with transoral approach operations between October 2009 and May 2010 were analyzed. There were 8 males and 12 females, aged 2-66 years (median, 34.5 years). According to the classification of American Spinal Injury Association (ASIA)，there were 4 cases of grade B, 8 of grade C, 6 of grade D, and 2 of grade E. The Japanese Orthopedic Association (JOA) score was 10.3±3.0. The mucosa samples of the posterior pharyngeal wall were sent for bacteria culture. These samples were collected by sterile cotton swabs at four crucial points including 3 days before operation/before gargling (T1), 3 days after continuous gargling by chlorhexidine acetate/after anesthesia intubation on the day of operation (T2), after intraoperative cleaning and washing of the mouth (T3), and after intraoperative iodophor immersion for 5-10 minutes (T4). The microflora was stained by means of smear and further counted after an investigation by microscope. The ASIA classification and the JOA scores were applied to evaluate the postoperative nerve function of the patients. A regular reexamination of cervical vertebra with X-ray film, CT, and MRI was conducted after operation to evaluate the reduction of atlantoaxial dislocation, internal fixation position, bone graft fusion, inflammatory lesion, and tumor resection in the craniovertebral junction. Results: After a series of oral disinfection, the mucosa of the posterior pharyngeal wall of all the patients was in a sterile state, which was considered as type Ⅰ incision. All these 20 patients were treated with successful operations, without any intraoperative injury in vertebral artery and spinal cord, or any postoperative complications such as plate loosening, incision infection, or intracranial infection. All the patients were followed up 3-23 months, with an average of 5.15 months. The symptoms such as neck pain, limb numbness and weakness, neural symptoms, etc. were improved to different degrees after operation. The JOA score was improved to 13.4±1.9 at 3 months after operation, showing significant difference when compared with preoperative score ( t=8.677, P=0.000); and the atlantoaxial joints had been fused. At last follow-up, the ASIA grades were improved when compared with those before operation. Conclusion: It is safe and effective to cut the posterior pharyngeal muscle layer and implant internal fixation by means of transoral approach in the treatment of craniovertebral junction disorders.

An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction / 中国修复重建外科杂志

Objective: To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction (CVJ) and its effectiveness. Methods: The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ, which collected between September 2010 and April 2019, were retrospectively analyzed. There were 5 males and 2 females, aged 23 to 75 years (median, 56 years). All patients were diagnosed as chordoma in 4 cases, plasmacytoma in 2 cases, and fibrosarcoma in 1 case. The disease duration ranged from 0.7 to 36.0 months, with an average of 12.2 months. Lesion location: 1 case of C 0, 1, 3 cases of C 2, 1 case of C 1, 2, 1 case of C 2, 3, and 1 case of C 0-2. Preoperative visual analogue scale (VAS) score was 6.7±2.1, the Japanese Orthopaedic Association (JOA) score was 15.6±2.4. According to American Society of Spinal Cord Injury (ASIA) grading system, there was 1 case of grade C, 1 case of grade D, and 5 cases of grade E. According to Enneking stage of spinal malignant tumor, there was 1 case of stage ⅠB, 2 cases of stage ⅡB, and 4 cases of stage Ⅲ. According to Weinstein-Boriani-Biagini (WBB) stage, there was 1 case of 5-8/A-D, 1 case of 4-9/A-D, 1 case of 6-7/B-D, 1 case of 6-7/A-D, 2 cases of 1-12/A-D, and 1 case of 3-10/A-D. All these patients were treated with tumor extended resection, bone graft fusion, and internal fixation via posterior cervical approach, as well as tumor (stage Ⅰ or stage Ⅱ) boundary resection via transoral or submandibular approach. Meanwhile, anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation. Results: The operation time was 307-695 minutes (mean, 489.57 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 1 107.14 mL). There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications, including incision infection, intracranial infection, and pulmonary infection. All the patients were followed up 3-57 months (mean, 21 months). Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position, and the bone graft was fused at 3-6 months after operation. Symptoms such as neck pain, limb numbness, and fatigue relieved to different degrees after operation. At 3 months after operation, the VAS score improved to 1.7±0.8 ( t=7.638, P=0.000); while the JOA score improved to 16.1±1.5, but no significant difference was found when compared with preoperative score ( t=1.549, P=0.172). According to ASIA grading system, 1 patient with grade C had upgraded to grade D after operation, while the remaining patients had no change. There were 4 cases of recurrence after operation, in which those patients were with high malignancy of tumors before the first surgery. Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed. Among the 4 cases, 1 patient underwent transoral tumor removal operation again, while the other 3 cases gave up further treatment. There was no recurrence among the remaining 3 cases. Conclusion: Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach. Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen. These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.

Single-Staged Transoral Intra-Lesional Excision of Aneurysmal Bone Cyst of Axis (C2) Vertebra and Temporary Stabilization of Upper Cervical Spine in an Adolescent: A Case Report

@#Aneurysmal bone cyst (ABC) infrequently occurs within the upper cervical vertebrae. Various therapeutic options have been reported in the literature. We would like to share our experience in managing a case of a 16-year-old girl diagnosed with ABC at the body of axis (C2) vertebra. Serious attention had to be given on the stability of the cervical spine following tumour resection, which can be affected by the mode of treatment chosen. Instability can have a detrimental effect on the cervical spine, in which case may necessitate further surgery. We performed a single-staged intra-lesional curettage via a transoral approach and temporary non-fusion posterior stabilization of C1 lateral mass screw and C2 pedicle screw. The implants were removed after six months once ossification of C2 has taken place to regain full motion of the neck. There was no evidence of recurrence or instability of the cervical spine three years following surgery.

Endoscopic Endonasal Odontoidectomy: Nuances of Neurosurgical Technique / Odontoidectomia endoscópica endonasal: nuances da técnica cirúrgica

Odontoidectomy is the treatment of choice for some diseases that cause irreducible ventral compression of the brainstem. In this study, we present our series emphasizing the technical nuances of endoscopic endonasal odontoidectomy

Odontoidectomia é o tratamento de escolha para algumas doenças que cursam com compressão irredutível do tronco encefálico. Neste trabalho, apresentamos nossa série enfatizando as nuances da técnica cirúrgica da odontoidectomia por via endonasal endoscópica.

Research progress on reatment of unstable atlas fracture with single-segment fixation by transoral approach / 中国骨伤

As a common type of fracture in cervical, atlas fracture is frequently unstable due to its special anatomical structure. In a previous treatment, external fixation was likely to bring low bony union rate and long-term neck pain, while occipito-cervical fusion and atlantoaxial fusion sacrifice range of motion in cervical spine. Reduction and single section fixation of atlas by anterior lateral mass screws through the transoral approach were reported by some scholars, and the retrospective study demonstrated the high healing rate, reservation of cervical ROM and less bleeding. But it also has high risks of cervical spinal cord and vertebral artery damage, as well as the post-operation infection. Moreover, the indication and fixation strength require further evidences. As a result, this surgical option provides a new way for spinal surgeons to deal with unstable atlas fractures.

Transbuccal versus transoral approach for management of mandibular angle fractures: a prospective, clinical and radiographic study

OBJECTIVES: We compared the transbuccal and transoral approaches in the management of mandibular angle fractures. MATERIALS AND METHODS: Sixty patients with mandibular angle fractures were randomly divided into two equal groups (A, transoral approach; group B, transbuccal approach) who received fracture reduction using a single 2.5 mm 4 holed miniplate with a bar using either of the two approaches. Intraoperatively, the surgical time and the ease of surgical assess for fixation were noted. Patients were followed at 1 week, 3 months, and 6 months postoperatively and evaluated clinically for post-surgical complications like scarring, infection, postoperative occlusal discrepancy, malunion, and non-union. Radiographically, the interpretation of fracture reduction was also performed by studying the fracture gap following reduction using orthopantomogram tracing. The data was tabulated and subjected to statistical analysis. A P-value less than 0.05 was considered significant. RESULTS: No significant difference was seen between the two groups for variables like surgical time and ease of fixation. Radiographic interpretation of fracture reduction revealed statistical significance for group B from points B to D as compared to group A. No cases of malunion/non-union were noted. A single case of hypertrophic scar formation was noted in group B at 6 months postsurgery. Infection was noted in 2 patients in group B compared to 6 patients in group A. There was significantly more occlusal discrepancy in group A compared to group B at 1 week postoperatively, but no long standing discrepancy was noted in either group at the 6 months follow-up. CONCLUSION: The transbuccal approach was superior to the transoral approach with regard to radiographic reduction of the fracture gap, inconspicuous external scarring, and fewer postoperative complications. We preferred the transbuccal approach due to ease of use, minimal requirement for plate bending, and facilitation of plate placement in the neutral mid-point area of the mandible.

Evaluation of the treatment of unfavourable mandibular angle fracture by internal fixation via two different approaches / 实用口腔医学杂志

Objective:To evaluation of the treatment of unfavourable mandibular angle fracture by internal fixation with two different approachs.Methods:46 patients with unfavourable mandibular angle fracture were treated by internal fixation with titanium miniplate through transoral approach group(n =20)and extraoral approach group(n =26)respectively.Postoperative clinical and radiological data including wound healing,difficulty in function and malocclusion were analysed 1 0 days,3 months and 6 months after operation. Results:Postoperative infection occurred in 2 cases in extraoral group,and 1 of them developed as ostomylitis which recovered gradu-ally in 1 year.Surgical site infection was observed in 2 cases in transoral approach group,which was resolved with appropriate course of antibiotics and wound care.Conclusion:Unfavourable mandibular angle fracture can be effectively treated by titanium miniplate via intraoral or extraoral approach.

Atlantoaxial lesions treated with internal fixation：Advantages of transoral approach / 中国组织工程研究

10.3969/j.issn.2095-4344.2013.26.025

The Anatomic Study on Replacement of Artificial Atlanto-odontoid Joint through Transoral Approach / 华中科技大学学报（医学）（英德文版）

In order to provide anatomical basis for transoral approach (TOA) in dealing with the ventro lesions of craniocervical junction, and the design and application of artificial atlanto-odontoid joint, microsurgical dissecting was performed on 8 fresh craniocervical specimens layer by layer through transoropharyngeal approach. The stratification of posterior pharyngeal wall, course of vertebral artery, adjacent relationship of atlas and axis and correlative anatomical parameters of replacement of artificial atlanto-odontoid joint were observed. Besides, 32 sets of atlanto-axial joint in adults' fresh bony specimens were measured with a digital caliper and a goniometer, including the width of bony window of anterior arch of atlas, the width of bony window of axis vertebra, the distance between superior and inferior two atlas screw inserting points, the distance between two axis screw inserting points etc. It was found that the width of atlas and axis which could be exposed were 40.2±3.5mm and 39.3±3.7mm respectively. The width and height of posterior pharyngeal wall which could be exposed were 40.1±5.2mm and 50.2±4.6mm respectively. The distance between superior and inferior two atlas screw inserting points was 28.0±2.9mm and 24.0±3.5mm respectively, and the distance of bilateral axis screw inserting points was 18.0±1.2mm. The operative exposure position through TOA ranged from inferior part of the clivus to the superior part of the C3 vertebral body. Posterior pharyngeal wall consisted of 5 layers and two interspaces: mucosa, submucosa, superficial muscular layer, anterior fascia of vertebrae, anterior muscular layer of vertebrae and posterior interspace of pharynx, anterior interspace of vertebrae. This study revealed that it had the advantages of short operative distance, good exposure and sufficient decompression in dealing with the ventro lesions from the upper cervical to the lower clivus through the TOA. The replacement of artificial atlanto-odontoid joint is suitable and feasible. The design of artificial atlanto-odontoid joint should be based on the above data.

Transoral approach to the craniovertebral junction

The transoral approach provides a safe exposure to lesions in the midline and the ventral side of the craniovertebral junction. The advantages of the transoral approach are 1) the impinging bony pathology and granulation tissue are accessible only via the ventral route; 2) the head is placed in the extended position, thus decreasing the angulation of the brainstem during the surgery; and 3) surgery is done through the avascular median pharyngeal raphe and clivus. We analyzed the clinical effects of odontoidectomy after treating 38 patients with basilar invagination. The anterior transoral operation to treat irreducible ventral compression in patients with basilar invagination was performed in 38 patients. The patientsÆ ages ranged from 34 to 67 years. Fourteen patients had associated Chiari malformation and eight had previously undergone posterior decompressive surgery. The main indication for surgery was significant neurological deterioration. Symptoms and signs included neck pain, myelopathy, lower cranial nerve dysfunction, nystagmus and gait disturbance. Extended exposure was performed in 24 patients. The surgery was beneficial to the majority of patients. There was one death within 10 days of surgery, due to pulmonary embolism. Postoperative complications included two cases of pneumonia, three cases of oronasal fistula with regurgitation and one cerebrospinal fluid leak. In patients with marked ventral compression, the transoral approach provides direct access to the anterior face of the craniovertebral junction and effective means for odontoidectomy.

O acesso transoral é uma via direta e segura às lesões situadas na linha média e na face anterior da junção craniocervical. As vantagens do acesso transoral são as seguintes:1) a compressão óssea e o tecido de granulação localizam-se anteriormente e são accessíveis pela via anterior; 2) a cabeça do paciente é colocada em extensão, diminuindo a angulação do tronco cerebral durante a cirurgia; e 3) a cirurgia é feita através de um plano avascular na linha média faríngea e clivo. Analisamos os resultados obtidos após odontoidectomia por via transoral em 38 pacientes portadores de invaginação basilar. Trinta e oito pacientes com compressão ventral da junção craniocervical foram submetidos a odontoidectomia por via transoral. A idade dos pacientes variou de 34 a 67 anos. Quatorze pacientes apresentavam associação com malformação de Chiari tipo I e 8 já haviam sido submetidos à cirurgia descompressiva por via posterior. A maioria dos pacientes apresentou nucalgia, mielopatia, déficits dos nervos cranianos baixos, nistagmo, e distúrbio da marcha. Em 24 pacientes foi necessário ampliar o acesso transoral através de miotomia do palato mole, ou osteotomia do palato duro ou maxilotomia. A cirurgia proporcionou melhora dos sintomas na maioria dos pacientes. Um paciente faleceu no pós-operatório imediato por causa de embolia pulmonar. Dois pacientes tiveram pneumonia, três apresentaram fístula oronasal com regurgitação, e um teve fístula liquórica. Em pacientes com compressão ventral irredutível da junção craniocervical, a via transoral proporcionou uma abordagem direta e ampla ao processo odontoide.

Biomechanical study of atlas odontoid process replacement / 中国矫形外科杂志

[Objective] To investigate the stability and function of atlantoaxial segment after atlas odontoid process artificial joint replacement.[Method]Ten fresh adult human head and neck specimens were chosen for biomechanical models.The range of motion(ROM),neutral zone(NZ)and stiffness under intact state,post-decompression,post-replacement surgery and post-fatigue were measured respectively.[Result]After decompression,ROM,NZ and stiffness in flexion,extension,right and left lateral bending,and right and left axial rotation increased significantly(P0.05)than that in intact state group.[Conclusion]Artificial atlantoaxial joint in this study has been proved to have biomechanical significance in morphology and dynamic.It has advantages of stable replacement,simple operation,less injury and low wear characteristics.It provides a new choice for the atlantoaxial fusion of anterior or posterior approach.

Adequate Management of Retropharyngeal Abscess / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The incidence of retropharyngeal abscess has been decreased with use of antibiotics, but it still causes critical complications such as airway obstruction, aspiration pneumonia, mediastinitis, or sepsis. For this reason, early diagnosis and proper management of retropharyngeal abscess should be undertaken as soon as possibile. The treatment includes maintaining airway, performing surgical drainage, and administering antibiotics; but there are no definite guidelines for treating patients with retropharyngeal abscess, nor a golden rule for the correct surgical approach. SUBJECTS AND METHOD: A retrospective analysis of patients with retropharyngeal abscess who were treated at the Chungbuk University Hospital from 1993 to 2003 was performed. We analized general symptoms, signs, causing factors, and causing bacteria. We also analized the treatment outcome and selected approaches from the surgically treated patients. RESULTS: The general symptoms of retropharyngeal abscess were sore throat, fever, dyspnea, with the most common cause being the upper airway infection. Bacteriologically, hemolytic streptococcus was the most common bacteria among aerobes and bacteroides was the most common bacteria among anaerobes. However, in most cases, both aerobe and anaerobes were cultured at the same time. Among 18 cases, 6 cases were treated conservatively with antibiotics and surgical interventions were performed in 12 cases, which included 11 cases of transoral and 1 case of transcervical approach. CONCLUSION: Retropharyngeal abscess can be treated with either conservative or surgical treatment according to initial abscess size. The abscess size which is greater than 3 cm is prefered to be treated surgically, and transoral approach is a useful way of dealing with less invasive procedure.

Surgical Treatment of Klippel-Feil Syndrome with Cervical Spondylosis

We report a case of Klippel-Feil syndrome. The patient was a 37-year-old man who developed progressive motor weakness and on C4-5 and C6-7 segments combined with severe cervical stenosis, basilar impression and C1 assimilation. He showed progressive quadriparesis and respiratory difficulty. He had combined congenital anomaly of right side facial palsy of peripheral type and right side sensorineural hearing loss. In May 2002, we performed, via transoral approach, anterior fusion with Harm's mesh and hydroxyapatite from the clivus to the C3. But, one month after the operation, Harm's mesh with hydroxyapatite slipped anteriorly due to non-union. So, we removed the mesh and reoperated with fibular bone graft from the clivus to the C3. Simultaneously, posterior approach was performed with on-lay autologous rib bone graft and wiring from the occiput to the C2, 3, 4. One year after the operation, his motor weakness has been gradually improved and there is minimal difficulty in self-respiration.

Reduction malarplasty with bone ostectomy & repositioning only using intraoral approach

Transoral Approach for the Lesion of Cranio-vertebral Junction and Atlantoaxial Dislocation

Although the operation for the ventral lesion of craniovrtebral junction and atlantoaxial area is considered difficult to perform, the transoral approach made it safer and easier. The authors report 10 cases(9 patients) treated by the transoral approach for the lesion of craniovertebral junction over the past 13 years at the Ajou University Hospital and the Presbyterian Medical Center. Of these 10 cases, there were 4 odontoid type II fractures, 1 atlantoaxial dislocation, 1 os odontoideum, 1 chordoma at lower clival area, 1 rheumatoid arthritis, 1 epidural abscess and 1 wound revision due to slippage of grafted bone after clivoaxial fusion. The surgical methods included 4 cases of anterior decompression and clivoaxial fusion, 2 cases of anterior decompression and C1-2 interarticular joint fusion, 1 case of anterior decompression and clivoaxial fusion followed by posterior fusion, and 3 cases of anterior decompression and posterior fusion. In nonreducible atlantoaxial dislocation or ventral cord compression le sion, if the clivoaxial angle was less than 120 degree, the transoral approach was selected. The appropriate surgical approach must be selected according to the degree of compression of the neural tissue involving the craniovertebral junction and atlantoaxial dislocation.

Transoral Approach of Atlanto-Axial Pyogenic Abscess

A case of atlanto-axial dislocation caused by a pyogenic abscess was presented. A pyogenic abscess in the cervical region is rare and surgical treatment is indicated if the sign of spinal cord compression is present. The lesion was removed by transoral approach and effective decompression was obtained. We reviewed the literatures and discussed the advantage and applications of transoral approach in detail.