Purpose

Transorbital neuroendoscopic surgery (TONES) is a minimally invasive approach to the skull base through advanced interdisciplinary teamwork. Recent studies suggest narrowing of gender gaps in skull base workforce and research. This study aims to quantify contributions of authors by gender, specialty, and country in the TONES literature over time.

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Methods

This retrospective observational study analyzed all original human research articles published on TONES in PubMed. Data reviewed included article type, year, gender, specialty, and country of each article’s first and senior author.

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Results

Of 377 articles reviewed, 253 articles from years 2001 to 2025 met criteria. Overall, females were underrepresented in the TONES literature (40, 15.8% of first authors and 14, 5.5% of senior authors. Female first authorship consistently increased over time from 2015 (first, 7.7%; senior, 0.0%) to 2025 (first, 18.3%; senior, 5.1%). The rate of male/male authorship dropped while female/male authorship rose from 7.7% (2015) to 16.0% (2025). Ophthalmologists were underrepresented (18, 7.1% first authors and 20, 7.9% senior authors), though did have the highest proportion of females. Neurosurgery was the majority (174, 68.8% first authors and 179 70.7% senior authors), with neurosurgery rising from 27% (2015) to 77% (2025). The United States (US) was the most represented (70, 27.7% first authors and 82 (32.4% senior authors), followed by Italy. US authorship dropped from 69% (2015) to 21% (2025) as more countries contributed.

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Conclusion

Despite a notable increase in female authorship over the history of TONES research, females remain underrepresented, particularly in senior authorship. The highest female representation was in Ophthalmology. Neurosurgeons are increasingly involved, and US representation is decreasing as more countries contribute over time. Strides toward gender parity were seen in females as first authors and more mixed gender teams. These findings suggest a need for greater attention to promoting diversity in TONES research.

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Additional Authors

First name	Last name	Base Hospital / Institution
Daniel	Azzam	University of California Irvine
Samuel	Korouri	University of California Irvine
Yosur	Alsulaiman	University of California Irvine
Edward	Kuan	University of California Irvine
Lilangi	Ediriwickrema	University of California Irvine
Jeremiah	Tao	University of California Irvine
Seanna	Grob	University of California Irvine

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