Background: Endonasal endoscopic odontoidectomy (EEO) is a well-established method for treating symptomatic ventral compression at the cranio-cervical junction (CCJ). This study aims to review the clinical outcomes of patients undergoing EEO, focusing on clinical presentation, progression, and prognostic factors. Methods: We retrospectively analyzed data from patients who underwent EEO between October 2001 and October 2023. Information was collected on demographics, indications, reconstruction techniques, complications, fusion requirements, readmission rates, and outcomes. Results: Fifteen patients were included, with 60% classified as ASA class III. The majority presented with myelopathy (80%). Indications for surgery included basilar invagination, Chiari malformation, and rheumatoid arthritis. The mean blood loss was 317 ml. No perioperative lumbar drains were used, and 26.7% of patients had intraoperative CSF leaks, though no postoperative leaks were noted. A pedicled nasal flap was required in 66.7% of cases. Fourteen patients needed occipitocervical fusion, and six were readmitted within 30 days due to bulbar deficits. At the last follow-up, 86.6% of patients experienced symptom improvement. A significant association was found between decompression extent and symptomatic improvement (p=0.003). Conclusions: EEO is a safe and effective method for CCJ decompression, often accompanied by posterior cervical stabilization, with most patients showing symptomatic improvement and a low complication rate.