Overall survival, disease-free survival and quality of life in patients affected by HPV mediated p16+ oropharyngeal squamous cell carcinoma treated with upfront trans-oral robotic surgery vs radiotherapy or chemoradiotherapy.

PURPOSE: Treatment de-intensification for p16 + oropharyngeal squamous cell carcinoma (OPSCC) is an area of active research to reduce the side effects and improve patients' quality of life (QoL). In this paper we evaluated the Overall Survival (OS), the Disease-Free Survival (DFS) and the QoL of patients affected by p16 + OPSCC according to their prognostic stage group (PSG) and different treatments. METHODS: Patients were selected retrospectively through our Electronic Tumor Board Database according to prespecified inclusion criteria. Basic data of eligible patients were recorded and analyzed. Then, OS and DFS were evaluated according to the PSG and the treatments performed. Patients alive completed three questionnaires: the QoL Questionnaire Core 30 (QLQ-C30), the QoL Questionnaire Head & Neck 43 (QLQ-HN43) and the MD Anderson Dysphagia Inventory (MDADI) questionnaire. RESULTS: Sixty-one patients were included in this study. Eight patients died from the disease and the remaining 53 patients completed the 3 questionnaires. Fifteen (25%) patients were treated with upfront surgery, 6 (10%) patients with definitive radiotherapy and 40 (65%) patients with concomitant chemoradiotherapy. Comparing the DFS and the OS of PSG I patients by the different treatments performed, no statistically significant difference was identified. Patients treated with upfront surgery showed better outcomes in some aspects of their QoL. CONCLUSION: For p16 + OPSCC PSG I patients, upfront surgery can be considered a valid alternative to radiotherapy or chemoradiotherapy while maintaining a comparable DFS and OS and giving patients better results in terms of specific aspects of their QoL.

Component-Resolved Diagnosis for Endotyping Patients with Chronic Rhinosinusitis with Nasal Polyps.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2 inflammation-mediated disease of the nasal mucosa and paranasal sinuses that often coexists with asthma. The role of atopy in the development and severity of CRSwNP is still a controversial issue. OBJECTIVE: The aim of our study was to propose a systematic allergy workup to identify atopic patients in the context of CRSwNP and to characterize their allergen sensitization profile (sources/molecules). METHODS: Patients with a diagnosis of CRSwNP (n = 97) were studied in the otorhinolaryngologist and allergy settings. Demographic and clinical data were collected for each patient. Different allergen sensitization profiles (sources/molecules) were evaluated in atopic CRSwNP patients by using component-resolved diagnosis (CRD). RESULTS: In our cohort of patients, the CRSwNP was frequently diagnosed during adulthood with significant impact on health-related quality of life. Asthma and atopy were the most common comorbidities with a prevalence of asthma in the atopic group. In CRSwNP patients sensitized to grass pollens and/or to house dust mites, the CRD analysis revealed a prevalence of sensitization to species-specific allergens of Phleum pratense (Phl p1, Phl p2, and Phl p5) or Dermatophagoides pteronyssinus (Der p1 and Der p2) rather than to cross-reactive ones. CONCLUSION: To define the allergen sensitization profile in atopic CRSwNP patients by CRD, it may be useful to better characterize type 2 inflammation, thus providing a personalized endotype-driven treatment.

Functional outcomes and complications in refractory dysthyroid optic neuropathy management: Experience with 3 different surgical protocols.

INTRODUCTION: Dysthyroid optic neuropathy (DON) is the most severe complication of Graves' orbitopathy (GO) and its management may require decompression surgery. Clear recommendations do not exist about which surgery should be performed and how extended the decompression should be. In this paper we present our experience regarding the management of DON via 3 different surgical protocols: a modified extended orbital apex decompression, a 2 walls decompression (inferior and lateral) and a 3 walls decompression (inferior, lateral and medial) and evaluate the functional outcomes. METHODS: Retrospective evaluation of subjects affected by DON not responding to medical therapy has been performed. All patients were submitted to pre- and post-operative ophthalmologic evaluations and orbital and sinuses CT scan in order to evaluate functional and surgical outcomes. RESULTS: 27 patients were enrolled in the study. Surgical procedures were performed on 42 orbits. A statistically significant post-operative improvement was recorded in visual acuity, proptosis, color vision and fundus oculi evaluation for all groups. No patient developed major or minor complications after surgery. CONCLUSIONS: Extended endonasal approach and 3 walls decompression have been proved effective in the management of DON. The choice between them is done according to degree of proptosis, general status and eye-surface damages.

Incidence and types of laryngotracheal sequelae of prolonged invasive ventilation in COVID-19 patients.

PURPOSE: The COVID-19 outbreak has led to an increasing number of acute laryngotracheal complications in patients subjected to prolonged mechanical ventilation, but their incidence in the short and mid-term after ICU discharge is still unknown. The main objective of this study is to evaluate the incidence of these complications in a COVID-19 group of patients and to compare these aspects with non-COVID-19 matched controls. METHODS: In this cohort study, we retrospectively selected patients from November 1 to December 31, 2020, according to specific inclusion and exclusion criteria. The follow-up visits were planned after 6 months from discharge. All patients were subjected to an endoscopic evaluation and completed two questionnaires (VHI-10 score and MDADI score). RESULTS: Thirteen men and three women were enrolled in the COVID-19 group while nine men and seven women were included in the control group. The median age was 60 [56-66] years in the COVID-19 group and 64 [58-69] years in the control group. All the patients of the control group showed no laryngotracheal lesions, while five COVID-19 patients had different types of lesions, two located in the vocal folds and three in the trachea. No difference was identified between the two groups regarding the VHI-10 score, while the control group showed a significantly worse MDADI score. CONCLUSIONS: COVID-19 patients subjected to prolonged invasive ventilation are more likely to develop a laryngotracheal complication in the short and medium term. A rigorous clinical follow-up to allow early identification and management of these complications should be set up after discharge.

Acinic cell carcinoma of the parotid gland: Timeo Danaos et dona ferentes? A multicenter retrospective analysis focusing on survival outcome.

OBJECTIVES: To analyze the demographic data, surgical and adjuvant treatment data and the survival outcomes in adult patients affected by acinic cell carcinoma of the parotid gland (AciCC). METHODS: A retrospective multicenter analysis of patients treated for AciCC of the parotid gland from 2000 to 2021 was performed. Exclusion criteria were pediatric (0-18 years) patients, the absence of follow-up and patients with secondary metastatic disease to the parotid gland. Multivariable logistic regression was used to determine factors associated with survival. RESULTS: The study included 81 adult patients with AciCC of the parotid gland. The median age was 46.3 years (SD 15.81, range 19-84 years), with a gender female prevalence (F = 48, M = 33). The mean follow-up was 77.7 months (min 4-max 361, SD 72.46). The 5 years overall survival (OS) was 97.5%. The 5 years disease-free survival (DFS) was 60%. No statistical differences have been found in prognosis for age (< 65 or ≥ 65 years), sex, surgery type (superficial vs profound parotid surgery), radicality (R0 vs R1 + Rclose), neck dissection, early pathologic T and N stages and adjuvant therapy (p > 0.05). CONCLUSION: This study did not find prognostic factor for poorest outcome. In contrast with the existing literature, our results showed how also high-grade tumours cannot be considered predictive of recurrence or aggressive behaviour.

Correction to: Multiple spontaneous skull base cerebrospinal fluid leaks: some insights from an international retrospective collaborative study.

In the original publication of the article, the following affiliation "Medical school, University of Nicosia, Nicosia, Cyprus" of the author "Christos Georgalas" was missed and included in this correction.

Multiple spontaneous skull base cerebrospinal fluid leaks: some insights from an international retrospective collaborative study.

PURPOSE: Spontaneous skull base cerebrospinal fluid leaks occurring without any apparent cause are rare. But those patients that present such leaks simultaneously, or successively, in multiple locations are even rarer. Given the rarity of this condition, we collected data from other groups in a multicentre study to reach an adequate number of patients and draw some preliminary considerations. METHODS: We carried out a multicentre retrospective study on a cohort of patients treated at third level hospitals in Italy, Spain, United Kingdom and Greece for multiple spontaneous-CSF leaks and we compared them with a control group of patients treated for recurrent spontaneous-CSF leaks. Data regarding clinical aspects, radiological findings, surgical techniques and outcome were collected and preliminary considerations on the results were discussed. RESULTS: A total of 25 patients presented multiple simultaneous spontaneous CSF leaks while 18 patients fit with the criteria of recurrent spontaneous CSF leaks. Data analysis was conducted separately. CONCLUSIONS: Our understanding of the pathogenesis of this condition is currently very limited. A causative role of IIH may be present but the differences that emerged from the comparison with patients with recurrent fistulas seem to promote the possible role of other cofactors. A longer follow-up period is needed, and, in our opinion, prospective and multicentre studies are the only solution to seriously deal with such a complex topic.

Transoral robotic tongue base reduction and supraglottoplasty combined with maxillomandibular advancement: a new option for selected sleep apnea patients? Preliminary report.

PURPOSE: Transoral robotic surgery (TORS) and maxillo-mandibular advancement (MMA) are effective options for obstructive sleep apnea patients. Identification of the correct candidate is by far the most important item in achieving a succesful outcome. As a consequence, not all patients can be managed successfully via one or the other procedure. To overcome the limits of any single procedure we have combined, in a very selected population of patients, TORS tongue base reduction and MMA. Preliminary data are encouraging, in terms of both AHI and ESS. METHODS: A retrospective cohort study was conducted on five patients treated with combined TORS-MMA surgery. Demographic and clinical data, pre-operative and post-operative PSG and ESS were collected. RESULTS: Three of five patients were recruited. All patients presented severe OSAHS. Mean AHI and ESS went respectively from 48 and 12 pre-operatively to 19 and 4 post-operatively. Minor bleeding occurred in two patients. No significant sequelae have been reported. CONCLUSIONS: Combined TORS and MMA is feasible and safe. Our very preliminary data are encouraging, in terms of both AHI and ESS. Long-term follow-up and a larger amount of subjects are needed to confirm this surgical approach as a valuable option for selected OSAHS patient.

Focus on the Involvement of the Nose and Paranasal Sinuses in Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome): Nasal Cytology Reveals Infiltration of Eosinophils as a Very Common Feature.

BACKGROUND: Eosinophilic granulomatosis with polyangiitis (EGPA) is a necrotizing vasculitis that predominantly affects small- to medium-sized vessels. It is characterized by a wide spectrum of extrapulmonary symptoms, including sinonasal and paranasal sinus abnormalities. These are the most common features of this disease, constituting diagnostic criteria for EGPA. However, the actual clinical features, cellular mechanisms and impact on patients' quality of life (QoL) are still a matter of study. METHODS: Thirty-nine EGPA patients underwent multidimensional rhinological evaluations, including rhinofibroscopy, nasal cytology, and QoL questionnaires. This was coupled with respiratory and rheumatological assessments. RESULTS: Twenty-eight patients were diagnosed with chronic rhinosinusitis (CRS). Of these, 18 had nasal polyposis (NP). Chronic rhinitis was diagnosed in 10 patients. Of these, 3 had allergic rhinitis (AR) and seven had non-AR (NAR). Overall, only 1 patient (2.6%) was normal. Nasal cytology showed that hypereosinophilia was present in 17/28 patients with CRS, 4/7 patients with NAR and all patients with AR. SNOT-22 and SF-36 showed a severe impact of nasal symptoms on QoL. No differences in asthma control or rheumatological patterns for EGPA were observed among patients with or without NP. CONCLUSIONS: Even when the rheumatological assessment scored EGPA "under control" according to the Birmingham Vasculitis Activity Score and Vasculitis Damage Index, sinonasal diseases and related nasal inflammatory processes were not controlled. Therefore, there is a need for clinical monitoring and targeted treatment to control the inflammatory processes and improve the QoL of EGPA patients.

Multimodal use of indocyanine green endoscopy in neurosurgery: a single-center experience and review of the literature.

During the last 10 years, microscope-integrated indocyanine green fluorescence (m-ICG) has been widely used for assessing real-time blood flow during aneurysm surgery. More recently, an endoscope-integrated indocyanine green fluorescence (e-ICG) has been adopted as a versatile tool during different endoscopic neurosurgical procedures. The purpose of the present report is to evaluate multimodal applications of e-ICG during different endonasal, intraventricular, aneurysm and brain tumor surgeries and provide technical nuances. In addition, we reviewed the literature and identified and compare several overlapping case series of patients treated via an endoscopic integrated indocyanine green fluorescence technique. A total of 40 patients were retrospectively evaluated. Patients were divided into four main groups: (1) endoscopic endonasal approaches (n = 14); (2) ventricular endoscopic approach including patients undergoing third ventriculostomy (n = 8) and tumor biopsy (n = 1); (3) aneurysms surgery (n = 9); and (4) brain parenchymal tumors (n = 8). All patients were successfully treated using the e-ICG dynamic endoscopic visualization, and there were no perioperative complications. Such unique features open up a promising field of applications beyond the use of m-ICG in different surgical field due to the longer duration of e-ICG fluorescence up to 35 ± 7 min. E-ICG represents a new and effective technique for longer real-time visualization of vascular structures preserving normal tissues and functions during different transcranial and endonasal approaches. As the technology and e-ICG resolution improves, the technique has the potential to become a critical tool for different applications in neurosurgery.

Frey Syndrome, First Bite Syndrome, great auricular nerve morbidity, and quality of life following parotidectomy.

PURPOSE: Parotidectomy may be burdened by numerous complications that may worsen subjects' quality of life (QoL). These include paresis or paralysis of the facial nerve, face profile asymmetry, keloids, salivary fistula, Frey Syndrome (FS), First Bite Syndrome (FBS), and hypo-anaesthesia of the skin. This study is an effort to assess the incidence of complications following parotidectomy and their impact on subjects' QoL. METHODS: Subjects undergoing parotidectomy for benign neoplasms from 2012 to 2015 were selected and invited to attend our outpatient clinic. After a brief anamnesis, the medical examiners tested their tactile perception and performed the Minor test for FS. Depending on the complications showed, subjects were asked to complete from 1 to 4 questionnaires about their QoL. RESULTS: 76 subjects completed the medical examination. The most frequent complication was the hypo-anaesthesia of the skin (71%). 21 subjects (28%) were positive to the Minor test, while 8 subjects (11%) reported FBS-compatible symptoms. Two subjects (3%) showed a facial nerve paralysis. Free abdominal fat graft was used in 16 subjects (21%) and it was associated with a lower incidence of FS. Surgery of the deep lobe of the parotid was associated with FBS. CONCLUSIONS: FBS appears to have a greater influence on subjects' QoL than FS and hypo-anaesthesia of the skin. Moreover, this work confirms that surgery of the deep lobe of the parotid is a risk factor for developing FBS and the free abdominal fat graft is a reliable technique to prevent FS.

Surgical and pathogenetic considerations of frontal sinus fungus ball.

Fungus ball (FB) is an non-invasive form of mycosis, that generally affects immunocompetent and non-atopic subjects. Involvement of the frontal sinus is extremely rare. We report two cases with frontal sinus fungus ball that underwent endoscopic endonasal frontal Draf type IIb or III sinusotomy with complete removal of the cheesy clay-like material. There were no intra-operative or postoperative complications, and no recurrence of disease was evident during the follow-up of 51 and 26 months, respectively. The Draf type IIb or type III frontal sinusotomy seems to be highly effective for the treatment of frontal sinus FB and can represent a valid alternative to the traditional external approaches.

Transoral robotic-assisted tongue base resection in pediatric obstructive sleep apnea syndrome: case presentation, clinical and technical consideration.

Pediatric obstructive sleep apnea syndrome (OSAS) is primarily caused by adenotonsillar hypertrophy. However, tongue base hypertrophy is increasingly being recognized as a cause, even after adenotonsillectomy. We report three cases of pediatric OSAS successfully treated by transoral robotic reduction of the tongue base. In all children, we were able to achieve improved retrolingual patency while avoiding significant procedure-related morbidity. In conclusion, tongue base reduction by transoral robotic surgery appears to be a feasible solution for the base of tongue obstruction due to lingual tonsil hypertrophy in pediatric patients.

The use of a three-dimensional endoscope for different skull base tumors: results of a preliminary extended endonasal surgical series.

BACKGROUND: The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions. METHODS: From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma. RESULTS: Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6-72 months). CONCLUSIONS: In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand-eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.

Endoscopic-assisted transoral-transpharyngeal approach to parapharyngeal space and infratemporal fossa: focus on feasibility and lessons learned.

The parapharyngeal space (PPS) is a challenging anatomical region, rich in vascular and nervous vital structures. Surgery is considered the treatment of choice for the majority of PPS lesions. Herein, we present a retrospective evaluation on ten patients with various types of lesions of the parapharyngeal and infratemporal fossa (ITF) regions operated on via an endoscopic-assisted transoral-transpharyngeal approach (EATTA), focusing on feasibility and safety. A retrospective evaluation of patients treated by means of EATTA to PPS and/or ITF lesions was carried out. The clinical records of patients who were operated on with EATTA for PPS and/or ITF lesions between March 2009 and October 2015 at two referral centres were reviewed and the intra-operative and post-operative complications were analysed. Ten patients who underwent EATTA on the PPS and ITF were included in this series. The procedure was performed in six patients for tumour removal, in three patients for diagnostic purposes and in one patient for pain control. No major complications occurred. No conversion to external approach was required. We observed only two minor complications which were promptly solved. No dysphagia or other problems during the food intake were observed in our series. One day after surgery all patients, except one, referred a value of VAS minor than 4. To date, no evidence of disease recurrence has been assessed in all six oncological cases. Although preliminary, our experience seems to demonstrate the feasibility and safety of EATTA when properly planned and performed.

Transorbital endoscopic assisted resection of a superior orbital fissure cavernous haemangioma: a technical case report.

OBJECTIVES: Superior orbital fissure and orbital apex lesions are challenging to manage, regardless of the approach chosen, due to the potential morbidity. The objectives of this study are to describe an innovative, minimally invasive surgical approach addressing this critical area and to discuss its indications and outcomes. SUBJECT: A young patient presented with visual disturbances (reduction of color discrimination, central scotoma) and mild exophthalmos owing to the presence of a right orbital apex cavernous haemangioma with superior orbital fissure invasion. METHODS: The lesion was removed via a minimally invasive, neuronavigated, transorbital superior eyelid endoscopic-assisted approach. MAIN OUTCOME MEASURES: Technical feasibility and safety, early and late complications, length of hospitalization time and follow-up data were collected and analyzed. RESULTS: The lesion was radically resected minimizing the surgical morbidity and hospitalization time for the patient and with encouraging functional and cosmetic outcomes. No recurrences were observed 1 year after surgery. CONCLUSIONS: The endoscopic-assisted transorbital approach should be considered a safe and effective option that can be applied in the treatment of lesions affecting such complex anatomical regions, as it offers excellent visualization of the surgical field, acceptable sequelae and reduced morbidity in relation to the traditional transcranial/transfacial approaches. Further studies and larger case series are needed in order to validate the reproducibility and range of applications of this surgical technique.

Quantitative study on endoscopic endonasal approach to the posterior sino-orbito-cranial interface: implications and clinical considerations.

The posterior sino-orbito-cranial interface is a critical area in the skull base since it represents a gateway to deeper vital regions. Quantification of the surgical freedom for any given point/area is an objective method for comparing in a reproducible way different surgical approaches. Three freshly injected cadaver heads (six sides) were dissected under the magnetic navigation control system. The surgical freedom (SF) and the angle of attack of fixed target points were determined from the ipsilateral nasal fossa, from the contralateral nasal fossa (after posterior septectomy), and after an anteromedial maxillotomy (according to the Denker procedure). The mean pre-operative SF value resulted to be 403.07 ± 102.73 mm(2) for the ipsilateral nostril, increasing by 126.97 % for the binostril approach, by 118.45 % for the monolateral nostril approach after anteromedial maxillotomy, and by 310.48 % for the binostril approach after bilateral anteromedial maxillotomy. Laterally extended lesions require an anteromedial maxillotomy, while more medially located lesions can be managed by means of a posterior septectomy. When addressing the posterior sino-orbito-cranial interface, the transnasal binostril approach and anteromedial maxillotomy both increase the SF. The choice between them depends on exact position, relationship and clinical behaviour of the lesion to treat.

Successful application of transoral robotic surgery in failures of traditional transoral laser microsurgery: critical considerations.

AIMS: To assess the role of transoral robotic surgery (TORS) in managing failures of conventional transoral laser microsurgery (TLM) in cases with difficult laryngeal exposure. METHODS: Retrospective analysis of 3 patients with difficult laryngeal exposure treated with TORS. All 3 cases failed to be managed by conventional TLM after repeated attempts by experienced surgeons. In 2 cases, the initial disease was laryngeal cancer treated by a cricohyoidoepiglottopexy, with an obstructing residual epiglottis. The last case was a bilateral Reinke disease submitted to repeated TLM procedures, producing multiple supraglottic and glottic scars. In all cases, the difficult exposure was produced by a combination of concurrent elements including insufficient mouth opening, short and stiff neck, macroglossia and high-positioned larynx. RESULTS: Two patients were exposed by means of a Davis Meyer mouth gag. The other patient was managed by a Feyh-Kastenbauer device. The key of the success was the possibility to work 'around the corner' (30° angle view) where straight alignment of the larynx was impossible. CONCLUSIONS: Where possible, a TORS approach should be considered complementary to TLM in cases of very difficult or even impossible conventional transoral laryngoscopic approach.

Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease.

BACKGROUND: The aim of this study was to create benchmarks for evaluating clinical outcomes and complications of transoral robotic surgeries (TORS) in a multicenter setting. METHODS: 243 TORS for obstructive sleep apnea/hypopnea syndrome (OSAHS) operations, carried out between 2008 and 2012, were analyzed at 7 different centers. The average hospitalization was 3.5 days. The mean patient age was 50 ± 12 years, the average BMI at the time of the procedure was 28.53 ± 3.87 and the majority of the patients were men (81%). RESULTS: The mean preoperative and postoperative apnea/hypopnea index was 43.0 ± 22.6 and 17.9 ± 18.4, respectively (p < 0.001). The mean preoperative and postoperative Epworth Sleepiness Scale score was 12.34 ± 5.19 and 5.7 ± 3.49, respectively (p < 0.001). The mean pre- and postoperative lowest O2 saturation was 79.5 ± 8.77 and 83.9 ± 6.38%, respectively (p < 0.001). CONCLUSIONS: Patients undergoing TORS as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation of success with minimal long-term morbidity.

Combined Endoscopic Endonasal Transclival and Contralateral Transmaxillary Approach to the Petrous Apex and the Petroclival Synchondrosis: Working "Around the Corner" of the Internal Carotid Artery-Quantitative Anatomical Study and Clinical Applications.

The endoscopic contralateral transmaxillary (CTM) approach has been proposed as a potential route to widen the corridor posterolateral to the internal carotid artery (ICA). In this study, we first refined the surgical technique of a combined multiportal endoscopic endonasal transclival (EETC) and CTM approach to the petrous apex (PA) and petroclival synchondrosis (PCS) in the dissection laboratory, and then validated its applications in a preliminary surgical series. The combined EETC and CTM approach was performed on three cadaver specimens based on four surgical steps: (1) the nasal, (2) the clival, (3) the maxillary and (4) the petrosal phases. The CTM provided a "head-on trajectory" to the PA and PCS and a short distance to the surgical field considerably furthering surgical maneuverability. The best operative set-up was achieved by introducing angled optics via the endonasal route and operative instruments via the transmaxillary corridor exploiting the advantages of a non-coaxial multiportal surgery. Clinical applications of the combined EETC and CTM approach were reported in three cases, a clival chordoma and two giant pituitary adenomas. The present translational study explores the safety and feasibility of a combined multiportal EETC and CTM approach to access the petroclival region though different corridors.