Round 1

Reviewer 1 Report

Thank your for let me review the present article. The authors present a case series of 9 patients who underwent endoscopic assisted transoral approach for parapharingeal space tumors. The article is interesting but the manuscript has to be improoved:

- English editing by a native speaking proofreader

-Materials and methods:

 1) Why you avoid to perform FNAC in these tumours? in the preoperative setting is fundamental to know if these tumours are benign or malign neoplasm. In the case of schwannoma and lipoma RMN can be sufficient for the preoperative workup, but for adenomas the risk of malignancy in particular for minor salivary gland neoplasm is always present, and in those case an external transcervical approac could be preferred and a neck dissection can be evaluated.

2) in the operative technique explain better the use of the endoscope. Is an operative tool (i.e. FESS for nasal surgery) or only for check? is the first surgeon that holds the endoscope or the second operator? Please provide a photo of the OR setting.

3) Figures can be improved. In Figure 1 the focus is not on the incision, please change it with a better photo. You suggest that endoscope is a fundamental tool for this surgery, but no pictures of the endoscopic view are provided. I think it would be of interest a panel also with the endoscopic steps of the procedure and a comparison of the transoral view with and without the endoscope in order to compare the different view of the surgical field that you can achieve with the endoscope.

 

Results:

I think that a table can be more simple and better for understand the results.

 

- Discussion.

In my opinion the real comparison that has to be done is the comparison of the techinque that authors descibed in the present article with the transoral robotic surgery that has spread all over the world in the last years and is now becoming the gold standard technique for selected cases in referral centers.

I think that a review of the literature comparing classical transoral approach- endoscopic transoral approach and Robotic surgery is mandatory. A revision of the discussion and a table comparing these techniques can be useful to improve the overall quality of the present article.

Author Response

Dear Reviewer,

We have addressed, point by point, all the critical issues that were made. Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

hello

dear Authors, thank you for an interesting topic of endoscopic PPS tumors

at the current form of the paper is not suitable for publication in any form, neither a case report nor an original study

a diagram presenting the scope of retro/ante styloid tumors operated by Authors should be more widely addressed

endoscopic surgery is very much discussable world wide, and some strict indications for their usage are known and described

in presented material the inclusion criteria for endoscopic surgery are missing - not each schwannoma nor each tumor mixtus can be operated endoscopically! - same: both inclusion and exclusion criteria for surgery with endoscopic approach are not described. secondly, it is now known what exact cases should be only scheduled for PPS endoscopic surgery? 

tumors situated between jugular vein/artery would be troublesome to remove from intraoral approach, same as styloid surgery in Eagles syndrome - there is very limited control of possible bleeding if it occurs - again, does the position of the tumor decide on the endoscopic approach?

is there any other tumors within a capsule that can be operated endoscopically? what if a tumor in CT/MT will have a possibe capsule, but clinically, the capsule is not so tight and tumor cells will spread outside of the cystic cavity- what then?

figure 5 shows a lesion close to the midline - maybe an indication for endoscopic approach?

lipomas can be removed from the endoscopic approach, but a conservative parotidectomy is a treatment of choice when pleomorphic adenomas occur - whats author comment why only capsulated tumors should be removed without any salivary gland???? what if a whartin tumor would be present in PPS - since whartin tumors are known of more % re-occurrence ratio?

honestly, I think that Authors should rather write an article, where they are trying to investigate what lesions from PPS can be operated endoscopically via intraoral approach based on their cases and briefly describe how those tumors/pathologies can be  evaluated to schedule them for an endoscopic approach

 

 

Author Response

Dear Reviewer,

We have addressed, point by point, all the critical issues that were made. Please see the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

REVIEW REPORT

This is a unicentric study of the Transoral Approach to Parapharyngeal Space Tumours. The study was done in retrospect using data available in university hospital records from 2003 to 2021. The authors conclude that the endoscopically assisted transoral approach (EATA) is a good technique to treat benign capsulated tumors of the true Parapharyngeal Space.

There is no mention of the Hospital or University Ethical(of review board) committee approval for using the patient data records. The study sample size of 9 is relatively small to offer any real clinical insights or recommendations. Thirdly, a heterogeneous population of patients has been studied without any stratification into age, sex or tumor types, etc. these reduce the validity of the research.

Despite its shortcoming, the study does offer a piece of new evidence to the clinician and gives advice that the Transoral Endoscopic Approach is a valid method to treat benign tumors of the Parapharyngeal Space, hence has high significance and must be given the due credit.

 

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

thank you for the comments