Margins in oncologic nasopharyngeal surgery: a systematic review with meta-analysis

Objective

Nasopharyngeal malignancies are rare heterogenous histologies (nasopharyngeal carcinoma [NPC], minor salivary glands carcinomas, and low-grade papillary nasopharyngeal adenocarcinoma) and a significant proportion of patients experience loco-regional recurrence after primary treatment. Resection margin status is a key prognostic factor that influences recurrence and survival, although definitions and criteria for negative, close, and positive margins remain inconsistent. This systematic review with meta-analysis aimed to summarise the existing definitions of resection margins in the literature and evaluate their impact on clinical outcomes in patients undergoing nasopharyngectomy with a specific focus on NPC.

Methods

A systematic literature review was conducted according to PRISMA guidelines. Electronic databases (Scopus, PubMed, and Web of Science) were searched up to November 2024. Studies reporting on surgical margins and survival outcomes in patients with NPC treated with endoscopic or open nasopharyngectomy were included. Pooled odds ratios (OR) for overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were calculated using a random-effects model.

Results

A total of 45 studies met the inclusion criteria, with 12 included in the meta-analysis. Positive surgical margins were associated with worse 5-year DFS (OR 2.21, 95% CI 1.55-3.14, p < 0.001), while no significant impact was observed on 3-year DFS (OR 2.3, p = 0.239), 3-year OS (OR 2, p = 0.167), 5-year OS (OR 2.98, p = 0.115), 3-year DSS (OR 1.25, p = 0.761), or 5-year DSS (OR 2.57, p = 0.265). Margin positivity rates were 16.9% for endoscopically-treated NPC, 20.6% for open-surgery NPC, and 20.6% for mixed histology, with no significant difference between surgical approaches (p = 0.995).

Conclusions

Positive resection margins significantly impact DFS in recurrent NPC. Standardised margin definitions are needed to improve prognostication and guide decisions on adjuvant therapy.

Salvage surgery in nasopharyngeal Cancer: Unraveling the efficacy of transnasal endoscopic nasopharyngectomy for advanced stage recurrent tumors

OBJECTIVE

This systematic review evaluates the efficacy and morbidity of transnasal endoscopic nasopharyngectomy as a salvage treatment for advanced-stage recurrent nasopharyngeal carcinoma (rNPC).

METHODS

Following PRISMA guidelines, we conducted a systematic search in Medline, Scopus, and PubMed, identifying studies on transnasal endoscopic nasopharyngectomy for rNPC. Inclusion criteria encompassed histologically confirmed rT3 and rT4 NPC patients previously treated with radiotherapy or chemoradiotherapy. Data on overall survival (OS), disease-free survival (DFS), and complications were extracted and analyzed.

RESULTS

Nine studies, including a total of 429 patients, met the inclusion criteria. Five studies reported 2-year overall survival (OS) rates ranging from 34.6 % to 88.7 %. Three studies reported 3-year OS rates between 50 % and 63.5 %. Long-term 5-year survival varied widely from 0 % to 100 % across three studies. One study detailed 1-year disease-free survival (DFS) and OS at 93 % and 98 %, respectively. The pooled analysis included 429 patients with a median follow-up of 26.1 months. Complications were predominantly minor and transient. Major complications included necrosis, hemorrhage, cranial nerve palsy, and death. Advanced surgical techniques and pre-treatment measures, such as internal carotid artery embolization, improved resection outcomes and reduced complication rates.

CONCLUSION

Transnasal endoscopic nasopharyngectomy emerges as a viable salvage option for advanced rNPC, offering favorable survival outcomes and manageable complication profiles. Future research should focus on refining surgical techniques and improving patient selection criteria to further enhance treatment efficacy.

Vidian Canal in Chiari Type I Malformation: A Computed Tomography Study

OBJECTIVE

To evaluate the position and dimension of the Vidian canal (VC) in Chiari type I malformation (CIM).

MATERIALS AND METHODS

Radiologic views of 49 CIM (mean age: 23.58±15.62 y, sex: 23 males/26 females) and 51 healthy subjects (mean age: 42.50±20.12 y, sex: 21 males/30 females) were included in this computed tomography study.

RESULTS

In comparison with controls, the VC angle and the distance of the round foramen to VC were greater in CIM, but VC length and the distances of the superior wall of the bony sphenoidal sinus, midsagittal plane, and vomerine crest to VC were smaller in CIM. Relative to the sphenoid bone, the position of VC in CIM was determined as type 1 (59.2%) >type 2 (28.6%) >type 3 (12.2%), whereas in controls as type 1 (54.9%) >type 3 (25.5%) >type 2 (19.6%). Relative to the medial pterygoid plate, the position of VC in CIM was determined as type A (63.3%) >type B (20.4%) >type C (16.3%), while in controls as type B (43.1%) >type A (40.2%) >type C (16.7%).

CONCLUSION

VC size and position correlated with CIM. Compared with controls, CIM patients had more partially protruded VC into the bony sphenoidal sinus and more medially located VC according to the medial pterygoid plate.

Nasopharyngeal mucoepidermoid carcinoma with mastermind-like transcriptional coactivator 2 translocation: A case report and comprehensive literature review of a rare entity

Mucoepidermoid carcinoma is one of the most common malignant tumors in salivary glands and is usually associated with mastermind-like transcriptional coactivator 2 (MAML2) rearrangement. Primary nasopharyngeal mucoepidermoid carcinoma is extremely rare, and MAML2 status was reported in only two studies. Herein, we present a 70-year-old male patient with incidentally found nasopharyngeal mucoepidermoid carcinoma. MAML2 translocation was detected by fluorescence in situ hybridization test. Additionally, we conducted a comprehensive literature review and summarized the clinicopathological features of this rare condition. Nasopharyngeal mucoepidermoid carcinoma shows a similar mean age at diagnosis and gender ratio to those of mucoepidermoid carcinoma in salivary glands. More than half of the patients exhibit high histologic grade at the time of diagnosis. As MAML2 status is unreported in almost all published cases, further studies are needed to explore the incidence and prognostic value of MAML2 rearrangement in nasopharyngeal mucoepidermoid carcinoma.

Radiologic evaluation of the Vidian canal in the pediatric population

PURPOSE

This examination aimed to display the size and topographic position of the Vidian canal (VC) in normal children.

METHODS

180 pediatric subjects aged 1-18 years were included this computed tomography examination. The distances of VC to certain landmarks, and VC length were measured. The locations of VC according to the sphenoid sinus, and the medial plate of pterygoid process were classified as three types, separately.

RESULTS

The distances of VC to the vomerine crest, midsagittal plane, round foramen, and the superior wall of sphenoid sinus were measured as 12.68 ± 3.17 mm, 10.76 ± 2.52 mm, 8.62 ± 2.35 mm, and 14.16 ± 5.00 mm, respectively. The length and angle of VC were measured as 12.00 ± 2.52 mm, and 16.60 ± 9.76°, respectively. According to the sphenoid bone, VC location was identified as Type 1 in 113 sides (47.5%), as Type 2 in 70 sides (29.4%), and as Type 3 in 55 sides (23.1%). According to the medial plate of pterygoid process, VC location was identified as Type A in 274 sides (76.1%), as Type B in 55 sides (15.3%), and as Type C in 31 sides (8.6%). VC location types correlated with pediatric ages, but not sex or side.

CONCLUSION

With advancing pediatric age, the protrusion of VC into the sphenoid sinus increases, and VC shifts from medial to lateral side of the medial plate of pterygoid process.

Adenoid Cystic Carcinoma of the Nasopharynx: A Retrospective Study of 12 Cases

Objective: This study aimed to describe the experience of a single institution in China in treating adenoid cystic carcinoma of the nasopharynx. Methods: We reviewed the previous literature and conducted a retrospective analysis of 12 patients who diagnosed with nasopharyngeal adenoid cystic carcinoma (NACC) in clinical data, treatment, and follow-up data during 2019 to 2021. Results: Patients ranged in age from 32 to 68 years (mean 40.7 years, median 48.5 years), with a male to female ratio of 5:7. Most of our patients have T4a and T4b diseases (50% and 25%, respectively). A quarter of patients develop distant metastases. Among the 12 patients, 7 of them have positive margins under the microscope (7/12, 58.3%). The chief clinical manifestations were epistaxis, facial swelling, facial pain, headache ear stuffy, and hearing loss. If the tumors involved with cavernous sinus, brain stem infiltrated, and internal carotid artery circumvented, patients will undertake routine enhanced magnetic resonance imaging with Magnetic Resonance Angiography/Magnetic Resonance Venogram (MRA/MRV) to clearly show the lesion region. All patients underwent endoscopic endonasal approach. Fifty percent of patients received radiotherapy and 25% of patients received chemotherapy. None of the patients was lost and the follow-up time ranged from 16 to 45 months. The mean and median follow-up were 2.08 and 1.58 years. Two patients were dead of distant metastasis within 18 and 20 months after the surgery, and another patient with recurrent NACC died of hemorrhage. Conclusion: NACC is a rare malignant tumor that occurs in the nasopharynx, which can grow along the nerve, destroy the bone of the skull base, and metastasize to other organs. Up to now, there is no standard treatment. Our results show that endoscopic sinus surgery is a better choice for advanced or recurrent NACC.

Endoscopic endonasal transpterygoid nasopharyngectomy: Anatomical considerations and technical note

BACKGROUND

The study was designed to identify new landmarks in the parapharyngeal segment of the internal carotid artery (ICA) for nasopharyngectomy and describe a surgical procedure of endoscopic endonasal transpterygoid nasopharyngectomy (EETPN).

METHODS

Four cadaveric specimens were injected with colored silicone and subjected to CT scanning before dissection. The nasopharyngeal skull base was exposed using the endoscopic endonasal transpterygoid approach. The clinical data of four patients with nasopharyngeal malignances who underwent EETPN were reviewed.

RESULTS

The lateral edge of the longus capitis muscle medially; the foramen lacerum, petrous apex spine and the stump of the levator veli palatini muscle superior laterally; and the upper parapharyngeal ICA laterally constitute the ICA-longus capitis muscle-petrous apex spine triangle which was a novel landmark for the upper parapharyngeal segment of the ICA.

CONCLUSION

The ICA-longus capitis muscle-petrous apex spine triangle are important landmarks of the upper parapharyngeal segment of the ICA.

An endoscopic transnasal prelacrimal recess transmaxillary approach to the pterygopalatine fossa and infratemporal fossa

Objective

In this paper, the goal of the authors is to present the anatomic nuances and their clinical experience with lesions of the pterygopalatine fossa and infratemporal fossa using an endoscopic transnasal prelacrimal recess transmaxillary approach (PLRMA).

Methods

An endoscopic anatomical dissection of three fresh cadaveric heads was performed bilaterally to evaluate the feasibility of the PLRMA. Prior to dissection, stereotactic computed tomography scans were obtained for each head to obtain anatomical measurements. The area of exposure on the posterior wall of the maxillary sinus was determined using stereotaxis. The cases of six patients with schwannomas or epidermoid cysts who underwent the transnasal PLRMA were illustrated.

Results

The mean area of exposure on the posterior wall of the maxillary sinus was 9.55 cm2. Total resection was achieved in all six patients. The mean follow-up time was 16 months, and one patient complained of postoperative facial numbness, which resolved gradually. No cases of chronic sinusitis were reported.

Conclusions

The endoscopic transnasal PLRMA provides efficient operative exposure to the pterygopalatine fossa and infratemporal fossa. Preserving the integrity of the mucosa on the nasal lateral wall is an advantage of this approach.

Maximal exposure of the parapharyngeal internal carotid artery via transnasal and transoral corridors

BACKGROUND

The parapharyngeal internal carotid artery (pICA) could be surgically exposed through the transnasal and transoral corridors. However, their potential degree of exposure has not been established sufficiently. This study aims to elucidate the maximal exposure of the pICA via the transnasal and transoral corridors.

METHODS

An endonasal transpterygoid nasopharyngectomy for exposure of the pICA was performed on eight cadaveric specimens (16 sides), while a transoral approach for exposure of the pICA was performed on six additional specimens (12 sides). In addition, the CT angiography of 60 consecutive patients (120 sides) was analyzed to establish the potential maximal exposure of the pICA through each corridor.

RESULTS

The hard palate becomes a restricting factor for the inferior exposure of the pICA via the transnasal approach, whereas the entire pICA segment could be adequately displayed through the transoral corridor. The maximal exposed length of the pICA for a transnasal and transoral approach was 3.08 ± 0.30 cm and 6.56 ± 0.57 cm, respectively. This difference was statistically significant (p < 0.001).

CONCLUSION

An endonasal exposure of the pICA seems limited to its superior aspect, whereas the transoral corridor could provide adequate exposure of the entire length of pICA.

Schwannoma Arising in Nasopharynx: A Case Report and Literature Review

Schwannoma in paranasal sinus has been known as a rare tumor in this origin. This study reports on primary schwannoma arising in the nasopharynx, which is an uncommon location. A 36-year-old female presented with nasal obstruction for one month. Physical examination revealed a nasopharyngeal mass totally occluding bilateral posterior choanae and extended downward to the oropharynx. Magnetic resonance image showed heterogeneous enhancing mass at the nasopharynx extending inferiorly to the oropharynx. The tumor was excised via endoscopic combined trans-nasal/trans-oral approach under general anesthesia. The pathologic diagnosis was consistent with schwannoma. The tumor was successfully excised with en-block resection and the patient was discharged the next day after the operation, without any postoperative complications. There was no tumor recurrence at 12-months follow-up. Schwannoma primarily arising in the nasopharynx is uncommon. Minimally-invasive surgery via the endoscopic approach can be applied for tumor removal with fewer complications and reduced risk of morbidity.

Exploration of anatomical landmarks for performing an endoscopic transoral nasopharyngectomy

BACKGROUND

Performing a nasopharyngectomy via a transoral approach has been reported; however, defining landmarks to facilitate this approach has not been addressed. This study aims to explore anatomical landmarks to aid in performing a nasopharyngectomy via the transoral corridor.

METHODS

An endoscopic transoral nasopharyngectomy was performed on six cadaveric specimens (12 sides). Related anatomical landmarks were defined, and the strategy to preserve the parapharyngeal internal carotid artery (pICA) was explored.

RESULTS

An endoscopic transoral nasopharyngectomy was successfully achieved in all 12 sides. Utilizing the pterygoid hamulus as a landmark, the cartilaginous ET and attachments could be adequately exposed. Identification of the pICA is a prerequisite prior to Eustachian tube (ET) transection. The sphenoidal spine and the petrotympanic fissure could be sufficiently revealed in all 12 sides, which aided in transection of the cartilaginous ET without pICA injury. The ET and the prevertebral contents could be adequately removed via the transoral corridor.

CONCLUSION

The pterygoid hamulus, sphenoidal spine and petrotympanic fissure serve as reliable landmarks for performing a transoral nasopharyngectomy. Identification of the pICA is a prerequisite prior to transection of the ET to avoid pICA injury.

Long-term results of robotic-assisted nasopharyngectomy for recurrent nasopharyngeal carcinoma

BACKGROUND

We have previously reported our early experience in robotic-assisted nasopharyngectomy. The current case series is a report of our experience in 33 robotic-assisted nasopharyngectomy.

METHODS

Prospective series of patients who underwent robotic-assisted nasopharyngectomy for local recurrent nasopharyngeal carcinoma from January 2010 to March 2019.

RESULTS

Thirty-one patients underwent robotic-assisted nasopharyngectomy with two additional second procedure for positive margin. Median age is 55 years (29-85). Twenty-five patients had rT1 disease and six patients had tumor invaded sphenoid floor (rT3). Median operative time was 227 min and median blood loss was 200 ml. The median follow-up period for all patients were 38 months. Four patients had local recurrence. Five-year local control rate, overall survival, and disease-free survival are 85.1%, 55.7%, and 69.1%, respectively.

CONCLUSION

Robotic-assisted nasopharyngectomy for recurrent nasopharyngectomy was showed to have a high local control rate. The operating time was comparable to open surgery.

Transoral Approach to the Jugular Foramen Region with Preservation of the Eustachian Tube

OBJECTIVES/HYPOTHESIS

Transnasal exposure of the jugular foramen region (JFR) often requires transection of the Eustachian tube (ET). This study aims to propose a transoral corridor for access to the JFR with preservation of the ET.

STUDY DESIGN

Cadaveric dissection and case illustration.

METHODS

An endoscopic transoral approach for exposure of the JFR was performed on 5 cadaveric specimens (10 sides). Six patients who underwent a transoral resection of schwannoma within the JFR were retrospectively analyzed.

RESULTS

Direct exposure of the JFR with a 0° scope via a transoral approach was feasible, and the internal carotid artery and lower cranial nerves could be adequately exposed, and preservation of the ET was achieved in all 10 sides of the cadaveric specimens. For six patients with JFR tumors, the transoral approach provided adequate access to achieve a gross total resection with ET preservation. Intraoperative cerebral spinal fluid (CSF) leak was encountered in one patient, and a multilayer reconstruction was employed for reconstruction. No operative field or intracranial infection, persistent CSF leak, or emergent airway issues occurred. No recurrence occurred in this cohort with an average follow-up of 12 months.

CONCLUSIONS

The transoral approach provided a reliable corridor for access into the JFR with preservation of the ET. For select lesions with expansion into the posterior cranial fossa, a transoral corridor may serve as an alternative for tumor extirpation.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Postoperative Pharynx and Larynx

Cancers of the pharynx and larynx are treated using a combination of chemotherapeutic, radiation, and surgical techniques, depending on the cancer type, biology, location, and stage, as well as patient and other factors. When imaging in the postsurgical setting, the knowledge of the type of tumor, preoperative appearance, and type of surgery performed is essential for accurate interpretation. Surgical anatomic changes, surgical implants/devices, and potential postsurgical complications must be differentiated from suspected recurrent tumors.

An Endoscopic Endonasal Nasopharyngectomy with Posterolateral Extension

Background Invasion depth influences the choice for extirpation of nasopharyngeal malignancies. This study aims to validate the feasibility of endoscopic endonasal resection of lesions with a posterolateral invasion. As a secondary goal, the study intends to propose a classification system of endoscopic endonasal nasopharyngectomy determined by the depth of posterolateral invasion.

Methods Eight cadaveric specimens (16 sides) underwent progressive nasopharyngectomy using an endoscopic endonasal approach. Resection of the torus tubarius, Eustachian tube (ET), medial pterygoid plate and muscle, lateral nasal wall, and lateral pterygoid plate and muscle were sequentially performed to expose the fossa of Rosenmüller, petroclival region, parapharyngeal space (PPS), and jugular foramen, respectively.

Results Technical feasibility of endonasal nasopharyngectomy toward a posterolateral direction was validated in all 16 sides. Nasopharyngectomy was classified into four types as follows: (1) type 1: resection restricted to the posterior or superior nasopharynx; (2) type 2: resection includes the torus tubarius which is suitable for lesions extended into the petroclival region; (3) type 3: resection includes the distal cartilaginous ET, medial pterygoid plate, and muscle, often required for lesions extending laterally into the PPS; And (4) type 4: resection includes the lateral nasal wall, pterygoid plates and muscles, and all the cartilaginous ET. This extensive resection is required for lesions involving the carotid artery or extending to the jugular foramen region.

Conclusion Selected lesions with posterolateral invasion into the PPS or jugular foramen is amenable to a resection via expanded endonasal approach. Classification of nasopharyngectomy based on tumor depth of posterolateral invasion helps to plan a surgical approach.

Carotid Sacrifice via Endonasal Clipping to Treat Carotid Injury in Extended Endoscopic Endonasal Surgery

ABSTRACT

Internal carotid artery (ICA) injury is a rare but disastrous complication during extended endoscopic endonasal surgery. The method of ICA sacrifice via endonasal clipping has only been reported in a few cases to treat ICA injury. To provide some technical experience of this method, here the authors present 2 cases of ICA injury during extended endoscopic endonasal surgery with 2-year follow-up. The 2-nostrils/4-hands technique was used to control the active bleeding. Based on the good collateral circulation status and the normal results of intraoperative electrophysiological monitoring, we sacrificed the injured ICAs via endonasal clipping. Both cases had a satisfying tumor resection rate and a good clinical outcome.

The endoscopic endonasal eustachian tube anterolateral mobilization strategy: minimizing the cost of the extreme-medial approach

OBJECTIVE

The ventral jugular foramen and the infrapetrous region are difficult to access through conventional lateral and posterolateral approaches. Endoscopic endonasal approaches to this region are obstructed by the eustachian tube (ET). This study presents a novel strategy for mobilizing the ET while preserving its integrity. Qualitative and quantitative comparisons with previous ET management paradigms are also presented.

METHODS

Ten dry skulls were analyzed. Four ET management strategies were sequentially performed on a total of 6 sides of cadaveric head specimens. Four measurement groups were generated: in group A, the ET was intact and not mobilized; in group B, the ET was mobilized inferolaterally; in group C, the ET underwent anterolateral mobilization; and in group D, the ET was resected. ET range of mobilization, surgical exposure area, and surgical freedom were measured and compared among the groups.

RESULTS

Wide exposure of the infrapetrous region and jugular foramen was achieved by removing the pterygoid process, unroofing the cartilaginous ET up to the level of the posterior aspect of the foramen ovale, and detaching the ET from the skull base and soft palate. Anterolateral mobilization of the ET facilitated significantly more retraction (a 126% increase) of the ET than inferolateral mobilization (mean ± SD: 20.8 ± 11.2 mm vs 9.2 ± 3.6 mm [p = 0.02]). Compared with group A, groups C and D had enhanced surgical exposure (142.5% [1176.9 ± 935.7 mm2] and 155.9% [1242.0 ± 1096.2 mm2], respectively, vs 485.4 ± 377.6 mm2 for group A [both p = 0.02]). Furthermore, group C had a significantly larger surgical exposure area than group B (p = 0.02). No statistically significant difference was found between the area of exposure obtained by ET removal and anterolateral mobilization. Anterolateral mobilization of the ET resulted in a 39.5% increase in surgical freedom toward the exocranial jugular foramen compared with that obtained through inferolateral mobilization of the ET (67.2° ± 20.5° vs 48.1° ± 6.7° [p = 0.047]) and a 65.4% increase compared with that afforded by an intact ET position (67.2° ± 20.5° vs 40.6° ± 14.3° [p = 0.03]).

CONCLUSIONS

Anterolateral mobilization of the ET provides excellent access to the ventral jugular foramen and infrapetrous region. The surgical exposure obtained is superior to that achieved with other ET management strategies and is comparable to that obtained by ET resection.

Repair of internal carotid artery injury with aneurysm clip during endoscopic endonasal surgery: illustrative case

BACKGROUND

One of the most feared and dangerous scenarios that can appear during an endoscopic endonasal surgery (EES) is the iatrogenic injury of the internal carotid artery (ICA). Several methods, along with a variety of outcomes, have been described to deal with this complication. To the authors’ knowledge, this is the first report on the use of a Yasargil-type aneurysm clip to solve an ICA injury, preserving the artery’s patency and having a long-term follow-up. The authors discuss the advantages and disadvantages of other vessel preservation techniques compared with clipping.

OBSERVATIONS

A visually impaired 56-year-old woman was diagnosed with a giant nonfunctional pituitary tumor that invaded the sphenoidal sinus, anterior and posterior ethmoidal cells, and both cavernous sinuses, with suprasellar extension and optochiasmatic compression. The patient underwent EES, and during the final resection phase her left ICA was injured, with massive hemorrhage.

LESSONS

ICA injury during endoscopic skull base surgery carries high mortality and morbidity; it is essential to maintain carotid flow when possible to avoid short-term and long-term consequences. There are several techniques depicted in the literature to deal with this situation. The authors report the use of a Yasargil mini-clip to deal with the injury for a positive outcome: primary hemostasis, vessel preservation, and no postoperative complications.

Infratemporal fossa surgical approaches to primary/recurrent malignancies of salivary origin: paradigm surgical shift, patient selection, and oncologic outcomes

PURPOSE OF REVIEW

To review, the surgical approaches available on diagnosing a patient with salivary gland malignancy in the infratemporal fossa (ITF). To comment on patient evaluation and method of treatment selection. To identify and report on patient outcome data and make recommendations on future needs.

RECENT FINDINGS

There is a need to define the anatomic boundaries contents of the ITF, masticator space, parapharyngeal space (PPS), pterygopalatine fossa, ventral skull base, and paramedian skull base, as evidence from publications. The pathological subtypes identified mainly include adenoid cystic and mucoepidermoid carcinomas. The source of these tumours originates from primary disease in the sinonasal tract and nasopharynx superiorly, and the PPS/deep lobe of parotid inferiorly. Current surgical options available, in suitable selected patient, available in tertiary head and neck cancer hospitals, which have available facilities and staffing is the endoscopic endonasal approach. This approach offers patients a 'complete margin-free surgical excision', minimal complications, shorter hospital stay, and no delay with commencement of any adjuvant treatment compared with the traditional 'open transcutaneous' approach.

SUMMARY

The current evidence specifically to the surgical management of salivary gland malignancy involving the ITF is sparse, with great difficult identifying treated patients and their details among a heterogeneous group of patients with many lesions. There is a need for patient data that have specific pathologic conditions to be amalgamated from such centers and publish on outcome events.

Endoscopic transoral nasopharyngectomy

BACKGROUND

A minimal access technique for the management of nasopharyngeal tumors extending below the palatal plane and laterally beyond the pterygoid musculature is yet to be developed. In this study we demonstrate the feasibility of endoscopic transoral nasopharyngectomy (ETON) for resection of large nasopharyngeal lesions as a natural orifice alternative to traditional approaches.

METHODS

ETON was completed in three latex-injected specimens. Surgical freedom (SF) and angles of attack (AoA) were calculated along the internal carotid artery (ICA).

RESULTS

An endoscopic transoral approach was successfully used to identify the parapharyngeal ICA and subsequently perform a complete nasopharyngeal resection. SF and AoA (sagittal) were found to be the greatest at the anterior genu of the ICA.

CONCLUSIONS

ETON is feasible. It provides wide exposure of the skull base and proximal control of the ICA. It may be indicated for the management of nasopharyngeal tumors with inferolateral extension, involving the ICA.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity

Multiple anterior surgical approaches are available to obtain access to the nasopharynx, clivus, and craniocervical junction. These include the direct and transoral robotic surgery transpalatal, maxillary swing, and endoscopic endonasal approaches. In this article, we describe the indications for these techniques, surgical steps, and associated morbidities. This article is a PubMed literature review. A review of the literature was conducted to assess the techniques, surgical steps, and associated morbidities with transpalatal approaches to the skull base and nasopharynx. The transpalatal approach has been traditionally utilized to obtain surgical access to the nasopharynx, clivus, and craniocervical junction. Morbidity includes velopalatine insufficiency due to shortening of the soft palate from scar contraction or neuromuscular damage, thus leading to hypernasal speech and dysphagia. Middle ear effusion and oronasal or oronasopharyngeal palatal fistula are additional potential morbidities. The choice of surgical approach depends on a variety of factors including the disease location and extent, surgeon experience, and available resources.

Endoscopic Nasopharyngectomy Combined with a Nerve-sparing Transpterygoid Approach

OBJECTIVES/HYPOTHESIS

Surgical management of nasopharyngeal tumors has evolved in the endoscopic era. Lateral exposure remains difficult especially near the petrous internal carotid artery and bony Eustachian tube (ET). Our study examines the need to sacrifice the vidian and greater palatine nerves in order to successfully perform en bloc endoscopic nasopharyngectomy.

METHODS

Four cadaveric specimens (eight sides) were dissected bilaterally using a binarial, extended, endoscopic endonasal approach (EEA). Nasopharyngectomy was completed including an extended transptyergoid approach for resection of the cartilaginous ET at its junction with the bony ET. Dissection was attempted without sacrifice of the vidian or palatine nerves.

RESULTS

Successful en bloc nasopharyngectomy combined with a nerve-sparing transpterygoid approach was achieved in all specimens with successful preservation of the palatine and vidian nerves. The approach provided exposure of foramen lacerum, the petrous carotid, foramen spinosum, and foramen ovale as well as all segments of the cartilaginous Eustachian tube, Meckel's cave and the parapharyngeal carotid. There was no inadvertent exposure or injury of the internal carotid artery.

CONCLUSION

Endoscopic nasopharyngectomy combined with a nerve-sparing transpterygoid approach allows for en bloc resection of the cartilaginous Eustachian tube and nasopharyngeal contents with broad skull base exposure and preservation of the internal carotid artery, vidian and palatine nerves.

LEVEL OF EVIDENCE

VI Laryngoscope, 130:2343-2348, 2020.

Cervical-transoral robotic nasopharyngectomy: A preclinical study

BACKGROUND

We performed a preclinical study to assess the feasibility of the cervical-transoral robotic pharyngectomy procedure in surgery for nasopharyngeal cancer, where deep margins and vascular safety are key issues.

MATERIALS AND METHODS

Four cadaveric dissections were performed with the da Vinci Xi system. The first step was a robotic parapharyngeal dissection along the internal carotid artery (ICA). The second step was a type 3 transoral robotic nasopharyngectomy.

RESULTS

In each procedure, a comprehensive dissection of the parapharyngeal space was performed along the ICA up to the foramen lacerum. A type 3 nasopharyngectomy was performed transorally with an "en-bloc" removal of the parapharyngeal space, and with complete removal of the eustachian tube up to its bony part.

CONCLUSION

A comprehensive cervical-transoral robotic type 3 nasopharyngectomy with "en-bloc" removal of the parapharyngeal space and the eustachian tube proved to be technically feasible in a preclinical study.

Endoscopic endonasal transpterygoid transnasopharyngeal management of petroclival chondrosarcomas without medial extension

Chondrosarcomas of the skull base are malignant tumors for which surgery is the primary therapeutic option. Gross-total resection has been demonstrated to improve survival in patients with these tumors. Chondrosarcomas arising from the petroclival synchondrosis harbor particularly unique anatomical considerations that have long been a barrier to achieving such a resection. Endoscopic endonasal transpterygoid approaches have been recently used to gain improved access to such lesions; however, these approaches have classically relied on a medial to lateral transclival trajectory, which provides limited exposure for complete resection of lateral disease. In this paper the authors describe an endoscopic endonasal transpterygoid transnasopharyngeal approach that provides comprehensive access to the petroclival region through dissection of the eustachian tube with resection of the cartilaginous torus tubarius. Of note, the authors have previously demonstrated the superior outcomes and validity of this approach relative to other cranial base techniques for petroclival chondrosarcomas. Surgical outcomes in 5 cases of chondrosarcoma without medial extension are detailed. Gross-total resection was achieved in 4 of 5 patients. Postoperative complications included transient palatal numbness in all patients and eustachian tube dysfunction due to the approach. With tympanostomy tube placement, no patient had persistent hearing loss. Overall, this approach appears to be a safe and effective technique for resection of petroclival chondrosarcomas.

A 4-year review of surgical and oncological outcomes of endoscopic endonasal transpterygoid nasopharyngectomy in salvaging locally recurrent nasopharyngeal carcinoma

PURPOSE

To study the surgical and oncological outcomes of endoscopic endonasal transpterygoid nasopharyngectomy (EETN) in salvaging locally recurrent nasopharyngeal carcinoma (NPC).

METHOD

This was a retrospective clinical record review study carried out at a tertiary centre from June 2013 until May 2017. A total of 55 locally recurrent NPC patients (rT1-rT4) underwent EETN performed by single skull base surgeon with curative intention with postoperative adjuvant chemotherapy but without postoperative radiotherapy.

RESULTS

There were 44 (80.0%) males and 11 (20.0%) females, with mean age of 52.5 years. The mean operating time was 180 min (range 150-280 min). 85% (47/55) of patients achieved en bloc tumour resection. 93% (51/55) of patients obtained negative microscopic margin based on postoperative histopathological evaluation. Intraoperatively, one (1.8%) patient had internal carotid artery injury which was successfully stented and had recovered fully without neurological deficit. There were no major postoperative complications reported. During a mean follow-up period of 18-month (range 12-48 months) postsurgery, five patients (9.1%) had residual or recurrence at the primary site. All five patients underwent re-surgery. One patient at rT3 passed away 6 months after re-surgery due to distant metastasis complicated with septicaemia. The 1-year local disease-free rate was 93% and the 1-year overall survival rate was 98%.

CONCLUSIONS

EETN is emerging treatment options for locally recurrent NPC, with relatively low morbidity and encouraging short-term outcome. Long-term outcome is yet to be determined with longer follow-up and bigger cohort study. However, a successful surgical outcome required a very experienced team and highly specialised equipment.

The anatomical and radiological evaluation of the Vidian canal on cone-beam computed tomography images

INTRODUCTION

The aim of this study is to explore the anatomy of the Vidian nerve to elucidate the appropriate surgical approach based on preoperative cone-beam computed tomography (CBCT) images.

MATERIALS AND METHODS

The Vidian canal and its surrounding structures were morphometrically evaluated retrospectively in CBCT images of 400 cases by the Planmeca Romexis program. The types of the Vidian canal were determined and seven parameters were measured from the images.

RESULTS

Three types of the Vidian canal according to the relationship with the sphenoid bone were found as follows: the Vidian canal totally protruded into the sphenoid sinus (19.75%), partially protruded into sphenoid sinus (44.37%) and embedded inside bony tissue of the body of sphenoid bone (35.87%). The position of the Vidian canal was medial (34.62%), on the same line (55.12%) and lateral (10.25%) to the medial plate of the pterygoid process. The distance between the Vidian canal and the vomerine crest, the mid-sagittal plane, the round foramen, the palatovaginal canal, and the superior wall of the sphenoid sinus, the length of the Vidian canal and the angle between the Vidian canal and the sagittal plane was found to be 16.69 ± 2.14, 13.80 ± 2.00, 8.88 ± 1.60, 5.83 ± 1.37, 23.98 ± 2.68, 13.29 ± 1.71 mm and 25.78° ± 3.68° in males, 14.62 ± 1.66, 11.43 ± 1.28, 8.51 ± 1.63, 5.78 ± 0.57, 22.37 ± 2.07, 12.91 ± 1.26 mm and 23.43° ± 3.07° in females, respectively.

CONCLUSIONS

Our results may assist with proper treatment for surgical procedures around the Vidian canal with a high success rate and minimal complications. Therefore, the results obtained in this study contribute to the literature.

Extended endonasal approach versus maxillary swing approach to the parapharyngeal space

BACKGROUND

The nasopharyngeal and parapharyngeal spaces are difficult for surgeons to access. Of the various external routes described, the maxillary swing has emerged as the gold standard because of its simplicity. However, its morbidity has led to the development of less invasive techniques. The purpose of our study was to compare the surgical anatomy of the maxillary swing with that of the endoscopic endonasal approach.

METHODS

Each procedure was performed on 10 anatomic specimens. The exposure and the limits obtained were evaluated. A CT scan analysis was performed.

RESULTS

The endoscopic endonasal approach extended the limits, offering wider exposure. The endoscopic endonasal approach made possible better visualization of deep structures and precise dissection of the parapharyngeal spaces. However, the maxillary swing provided better access to the oropharynx and could be completed 3 times faster.

CONCLUSION

The endoscopic endonasal approach provides excellent exposure, a wide dissection range, and precise definition of anatomic structures, making it an alternative of choice rather than the maxillary swing approach.

Volumetric Analysis of Endoscopic and Maxillary Swing Surgical Approaches for Nasopharyngectomy

Objectives/Hypothesis  The endoscopic endonasal approach (EEA) for nasopharyngectomy is an alternative to the maxillary swing approach (MSA) for selected recurrent nasopharyngeal carcinomas (NPC). We compare the access between these approaches. Methods  Three cadaver specimens were used to compare access volumes of the EEA and MSA. Exposure volumes were calculated using image guidance registration to cone beam computed tomography and tracking of accessible tissue with volumetric quantification. The area of exposure to the carotid artery was measured. Results  The MSA provided higher volumes for access volume compared with the EEA (66.6 vs 39.1 cm ³ , p  = 0.009). The working area was larger in the MSA (80.2 vs 56.9 cm ² , p  = 0.06). The exposure to the carotid artery was higher in the MSA (1.88 vs 1.62 cm ² , p  = 0.04). The MSA provided larger volume of exposure for tumors of the parapharyngeal space with exposure below the palate. Conclusions  This study suggests that the MSA for nasopharyngectomy provides a larger volume of exposure. However, much of the increased exposure relates to exposure of the parapharyngeal space below the palate. The EEA provides adequate access to superior anatomical structures.

Endoscopic Endonasal Craniofacial Surgery for Recurrent Skull Base Meningiomas Involving the Pterygopalatine Fossa, the Infratemporal Fossa, the Orbit, and the Paranasal Sinus

OBJECTIVE

Skull base meningiomas carry a nonnegligible risk of recurrence. In particular, those arising from the sphenoid wings or middle cranial fossa penetrate into extracranial regions, uncommonly showing massive expansion into the craniofacial regions on recurrence. The role of endoscopic endonasal surgery for those intractable lesions remains unclear.

METHODS

We performed endoscopic endonasal craniofacial surgery for 8 recurrent meningiomas invading into the pterygopalatine fossa, infratemporal fossa, nasopharynx, paranasal sinus, or orbit, comprising 2 meningothelial and 1 fibrous meningiomas (World Health Organization [WHO] grade I), 3 atypical and 1 clear cell meningiomas (grade II), and 1 anaplastic meningioma (grade III). All were large (15-80 cm³; median, 45 cm³) and highly vascularized.

RESULTS

All 8 tumors were sufficiently resected. Gross total resection of the craniofacial part of the lesions was achieved in 5 patients (62.5%). In 3 patients with WHO grade I meningiomas and 1 with grade II, tumors were successfully controlled as of the last follow-up. In 4 patients with WHO grade II or III meningiomas, craniofacial lesions were controlled, whereas original intracranial lesions were poorly controlled and became critical.

CONCLUSIONS

We consider the endoscopic endonasal approach as an acceptable, less-invasive alternative for recurrent craniofacial meningioma. Although all these cases were relatively large and highly vascularized, preoperative endovascular embolization of the feeding arteries contributes to significantly reducing vascularity of the tumors, and local control of the craniofacial lesions was successfully achieved in all cases. Endoscopic endonasal craniofacial surgery enabled sufficient mass reduction without disfiguring facial incisions.

Endoscopic Endonasal Resection of Recurrent Nasopharyngeal Mucoepidermoid Carcinoma

Nasopharyngeal mucoepidermoid carcinoma is a rare entity, for which surgical resection is the treatment of choice. The open technique is considered the standard approach, but this often results in significant morbidities such as trismus, dysphagia, and neurologic deficits. The advent of endoscopic endonasal techniques has made endoscopic resection a viable alternative to the open approach in terms of access, adequacy of resection, and lesser surgical morbidity. The authors describe a patient of recurrent nasopharyngeal mucoepidermoid carcinoma that was resected entirely endoscopically. The authors also present a literature review of this little-known disease and a comparison between the endoscopic and open approach.

Transnasal endoscopic partial maxillectomy: Operative nuances and proposal for a comprehensive classification system based on 1378 cases

BACKGROUND

Despite the development of functional endoscopic endonasal surgery, there are still areas of the maxillary sinus that remain technically difficult to access using a standard middle meatal antrostomy as well as deep-seated skull base lesions requiring expanded transmaxillary approaches.

METHODS

All patients who underwent transnasal endoscopic partial maxillectomy (TEPM) in a single institution from 2000 to 2014 were retrospectively reviewed. The TEPM was classified into 5 types according to the anatomic structures progressively removed and to the access provided.

RESULTS

The TEPM was performed in 1378 patients for the management of: inflammatory diseases in 513 cases (37%), benign sinonasal tumors in 425 cases (31%), skull base malignancies in 285 cases (21%), and as a corridor to address deep-seated skull base lesions in 155 cases (11%).

CONCLUSION

The TEPM is a stepwise approach offering increasing access that can be tailored to different maxillary, sinonasal, and skull base pathologies with minimal morbidity for patients. © 2016 Wiley Periodicals, Inc. Head Neck 39: 754-766, 2017.

Surgical treatment of salivary malignant tumors

Salivary gland malignant tumors (SGMT) are of key interest for head and neck surgeons since surgery with adjuvant radiotherapy is considered the treatment of choice in most of the cases. Some factors, namely rarity, high histologic heterogeneity, and possible occurrence in all the head and neck subsites, contribute to make this topic very controversial; some unclear aspects pertain surgical treatment. When dealing with major salivary gland malignant tumors (MaSGMT), the most debated issues remain the extent of surgery and management of facial nerve. In minor salivary gland malignant tumors (MiSGMT), conversely, surgical planning is influenced by the specific pattern of growth of the different neoplasms as well as the site of origin of the lesion. Finally, two additional issues, the treatment of the neck (therapeutic or elective) and reconstructive strategy after ablative surgery, are of pivotal importance in management of both MaSGMT and MiSGMT. In this review, we discuss the most relevant and controversial issues concerning surgery of SGMT.

Different Perspectives of Internal Carotid Artery in Transnasal Endoscopic Surgery

BACKGROUND

Several endoscopic landmarks for the internal carotid artery (ICA) have been identified, but they have always been proposed in a "static" perspective. The aim of this study was to investigate how the surgical corridor and optical distortion can influence the perception of carotid landmarks in transnasal endoscopic surgery.

METHODS

Computed tomography images of skulls in 20 subjects were analyzed. The petrous carotid angle (PCA) was calculated as the angle between the petrous carotid axis and the coronal plane connecting stylomastoid foramina. The angle of incidence (AI) on the anterior carotid genu of 3 different surgical corridors (contralateral nostril, ipsilateral nostril, and transmaxillary ipsilateral route) was evaluated. PCA, AI, and their differences were studied by Spearman's correlation test. Two cadaver heads were dissected, simulating the studied surgical corridors. The fish-eye effect was empirically quantified.

RESULTS

Mean PCA was 31° (range, 21-41°). PCA and AI are linked by an inverse proportion relationship. A transmaxillary approach always ensures the highest value of AI on the target. The cadaveric dissection qualitatively confirmed the radiologic data. The fish-eye effect can cause a compression of distance perception as high as 37%.

CONCLUSIONS

The surgical corridor and endoscope optic distortion can influence ICA visualization and the perception of its anatomic landmarks. In a 2-nostril, 4-handed approach, it is advisable to place the endoscope and instrument for dissection in the nostril that is ipsilateral to the lesion. Awareness of the different perspectives and related optical distortions is essential when working in proximity to the ICA.

A preliminary report on the role of endoscopic endonasal nasopharyngectomy in recurrent rT3 and rT4 nasopharyngeal carcinoma

Endoscopic endonasal nasopharyngectomy (EEN) has become increasingly used for recurrent nasopharyngeal carcinoma (rNPC) due to reduced functional and cosmetic morbidities compared to conventional external approach. Majority of the existing studies on EEN focused on patients with lower recurrent staging of rT1 and rT2. The aims of this study were to provide a preliminary report on the outcome of EEN performed in patients with advanced (rT3 and rT4) rNPC, and to determine the prognostic factors for patients' survival. All patients who underwent EEN for rNPC between January 2003 and December 2015 inclusive were analyzed. All surgeries were performed in University Malaya Medical Centre in Kuala Lumpur and Queen Elizabeth Hospital in Sabah, by a single surgeon. We reported the 2-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) and any related complications and significant prognostic factors. Fifteen patients with recurrent NPC (2 rT3 and 13 rT4 tumours) underwent EEN over the 13 years period. The mean age was 50.4 years (range 30-65) and the mean follow-up period was 28.7 months (range 9-81 weeks). The 2-year OS, DFS and DSS were 66.7 % (mean 19.4 months), 40 % (mean 15.7 months) and 73.3 % (mean 20.2 months), respectively. No severe operative complications were encountered. No independent prognostic factors for survival outcome were identified. This is the first preliminary report in English that exclusively looked at the use of EEN in advanced rT3 and rT4 NPCs, showing favourable patient outcome. However, further long-term follow-up of patients is required.

Spreading patterns, prognostic factors and treatment outcomes of nasopharyngeal papillary adenocarcinoma and salivary gland-type carcinomas

OBJECTIVES

In this study, we aim to analyse the different spreading patterns, prognostic factors and treatment outcomes of nasopharyngeal papillary adenocarcinoma (NPAC) and salivary gland-type carcinomas (NPCs).

DESIGN, SETTING AND PARTICIPANT

The current study report on a retrospective analysis of oncologic outcome of 76 pathologically confirmed consecutive cases of nasopharyngeal adenocarcinomas (NAC), including 31 NPAC, 33 adenoid cystic carcinomas (ACC) and 12 mucoepidermoid carcinomas (MEC).

MAIN OUTCOME MEASURE

Overall survival rates (OS) and disease-free survival rates (DFS).

RESULTS

In 12 patients with cranial nerve (CN) palsy, there were ACC (n = 9), NPAC (n = 2) and MEC (n = 1) (P = 0.016). CT-/MRI-detected CN involvements were found in 22 patients. Lymph node metastasis was observed in 25.8% of NPAC (n = 8), 12.1% of ACC (n = 4) and 8.3% of MEC (n = 1). Significant differences were observed in 5-year overall survival (OS) and disease-free survival (DFS) rates between patients with and without CT-/MRI-detected CN involvement (P = 0.002 and P = 0.002, respectively), and similar results were found between patients with and without lymph node metastasis (P = 0.002 and P = 0.018, respectively). In 37 patients with early-stage disease (stages I-II), significant differences were observed in 5-year OS and DFS rates between the surgical and non-surgical treated groups (P = 0.031 and P = 0.012, respectively). In 39 patients with advanced-stage disease (stages III-IV), significant or marginally differences were observed in DFS and OS between the chemoradiotherapy and non-chemoradiotherapy groups (P = 0.007 and P = 0.062, respectively).

CONCLUSIONS

ACC has a higher CN invasion than NPAC and MEC, and NPAC has the highest rate of lymphatic metastases. CT-/MRI-detected CN involvements and lymph node metastasis indicate a negative impact on the prognosis. The outcome of surgical patients in our series is encouraging in early-stage NPAC and NPCs, and chemoradiotherapy may be the optimal treatment for the advanced-stage patients.

Internal carotid artery injury in endoscopic endonasal surgery: A systematic review

OBJECTIVES/HYPOTHESIS

Internal carotid artery (ICA) injury during endoscopic endonasal surgery (EES) is a known and feared complication of paranasal sinus and skull base procedures. These ICA injuries can result in stroke, cranial nerve palsies, and death. This review examines the setting of injury along with the treatment approaches, and patient outcomes.

STUDY DESIGN

Systematic review using PubMed/MEDLINE and EMBASE.

METHODS

The databases were searched for articles reporting cases of ICA injury during EES. Variables analyzed included patient demographics, operative approach, preoperative diagnosis, setting of injury, repair method, imaging studies, patient outcomes, and follow-up.

RESULTS

Twenty-five articles with 50 cases were included in this review. The EES approach was used for skull base procedures in 34 cases and for inflammatory disease in 16 cases. The most commonly injured ICA segment was the cavernous (34 cases), followed by the ophthalmic (three cases). Injuries occurred more commonly on the left (1.3:1). Injury occurred in the setting of various steps during EES with instruments. Stereotactic image guidance was reported in two cases. Initial hemostasis was achieved with packing in 35 cases, endoscopic clip sacrifice in four cases, bipolar coagulation with the intent to seal defect in three cases, and bipolar coagulation with the intent to sacrifice the ICA in one case. Intraoperative or immediate postoperative angiography was reported in 27 cases.

CONCLUSIONS

The incidence of reported cases of ICA injury during EES remains low. Left-sided injuries to the cavernous segment of the ICA occurred more frequently than injuries on the right.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:582-590, 2016.

Salvage surgery for nasopharyngeal cancer

Nasopharyngeal carcinoma (NPC) is a special type of head and neck cancer with a widely variable geographical variation in incidence. The central location of the tumor inside the head coupled with the radiosensitivity of the tumor to radiation made radiation therapy the first choice in primary treatment of NPC. Advances in radiotherapy and chemotherapy have markedly improved the local control of NPC. Unfortunately, a small but significant number of patients still suffered from loco-regional failures that would be amenable to re-treatment. Traditional form of retreatment was to employ a second course of radiation. The efficacy of re-irradiation to treat local of regional recurrent NPC has been suboptimal. Moreover, the local tissue had already received a high dose of radiation and the second radiation could result in radiation toxicities to the local tissue, leading to significant complications.

Surgical salvage, on the other hand, could spare the patients from complications of re-treatment. Due to the difficult access of the nasopharynx, various surgical approaches had been devised for nasopharyngectomy. The maxillary swing approach had the largest published experience with over 300 cases from various centers. In the recent decade, the endoscopic approach with or without robotic assistance had gained popularity for resecting small, centrally located recurrences. This minimally invasive approach further reduced the morbidity for treating locally recurrent NPC.

Nodal recurrences had been a rare entity after the introduction of modern radiotherapy technique and concurrent chemotherapy. Treatment of nodal failure with second radiation has dismal results. Surgical removal of the lymph node harboring the recurrence should be in the form of a formal radical neck dissection. In cases of extensive nodal recurrence where microscopic disease may be present after a formal neck dissection, additional radiotherapy can be delivered with after-loading brachytherapy.

Surgical treatment played a definitive role in salvage of loco-regional failures of nasopharyngeal carcinoma.

Volumetric Analysis of Nasopharyngectomy via Endoscopic Endonasal, Maxillary Transposition, and Lateral Temporal-Subtemporal Approaches

OBJECTIVE

This project develops a computer model that allows volumetric analysis of the exposure afforded by an endonasal-endoscopic approach, maxillary transposition, and lateral temporal-subtemporal approaches during a nasopharyngectomy. The model will demonstrate idiosyncracies of these approaches, including sacrifice of normal tissues, ease of instrumentation, and gate of entry.

SUBJECTS AND METHODS

Computed tomographic scans of an anatomic specimen were used to create computer simulations of the endoscopic endonasal, maxillary transposition, and lateral temporal-subtemporal approaches for T1and T4 nasopharyngeal carcinoma; therefore, allowing assessment of their surgical corridor using Intuition, a software that allows a semiautomated computerized segmented volumetric analysis.

RESULTS

The smallest volumes of tissue mobilization or removal were observed during the endoscopic-endonasal nasopharyngectomy. The volumes of tissue mobilization for the maxillary transposition approach were higher than those of lateral temporal-subtemporal approaches.

CONCLUSIONS

This model adds to our understanding of select surgical corridors to the nasopharynx. It suggests that an endoscopic-endonasal approach requires less manipulation or resection of smaller volumes of normal tissue to expose a nasopharyngeal tumor than the lateral temporal-subtemporal and maxillary transposition approaches. It also, however, requires instrumentation through a smaller entry gate implying greater difficulty. Nonetheless, these factors should not be construed as superiority of one approach over the other. Factors that are important in the choosing of the surgical approach, such as surgeon's training and experience, invasion of neurovascular structures and method of reconstruction are not considered in this model.

Anatomy Relationship around Internal Carotid Artery in the Endoscopic Surgery of Nasopharynx: A Study Based on Computed Tomography Angiography

Objective Anatomic knowledge is needed to avoid injury to internal carotid artery (ICA) during the endoscopic surgery around nasopharynx and its surrounding space. Design We prospectively studied the computed tomography angiography (CTA) data of 28 patients with image processing software. Special attention was given to ICA and various landmarks around nasopharynx. Results The anatomic relationship between ICA and different landmarks around nasopharynx was clearly presented in three-dimension. The fossa of Rosenmuller is the nearest point of the nasopharyngeal cavity to ICA. The opening of the Vidian canal in the middle cranial fossa could be either above, below, or at the level of the horizontal segment of petrous ICA. The pharyngeal trunk of the ascending pharyngeal artery can also be clearly identified in most reconstructed CTA images. Multiple anatomic relationships were also quantified. Conclusions Reconstructed CTA can provide key anatomic information for a safe and accurate endoscopic dissection around nasopharynx.

The combined endonasal and transoral approach for the management of skull base and nasopharyngeal pathology: a case series

The posterior skull base and the nasopharynx have historically represented technically difficult regions to approach surgically given their central anatomical locations. Through continued improvements in endoscopic instrumentation and technology, the expanded endonasal approach (EEA) has introduced a new array of surgical options in the management of pathology involving these anatomically complex areas. Similarly, the transoral robotic surgical (TORS) approach was introduced as a minimally invasive surgical option to approach tongue base, nasopharyngeal, parapharyngeal, and laryngeal lesions. Although both the EEA and the TORS approach have been extensively described as viable surgical options in managing nasopharyngeal and centrally located head and neck pathology, both endonasal and transoral techniques have inherent limitations. Given these limitations, several institutions have published feasibility studies with the combined EEA and TORS approaches for a variety of skull base and nasopharyngeal pathologies. In this article, the authors present their clinical experience with the combined endonasal and transoral approach through a case series presentation, and discuss advantages and limitations of this approach for surgical management of the middle and posterior skull base and nasopharynx. In addition, a presentation is included of a unique, simultaneous endonasal and transoral dissection of the nasopharynx through an innovative intraoperative setup.

Endoscopic Endonasal Transpterygoid Transmaxillary Approach to the Infratemporal and Upper Parapharyngeal Tumors

Objectives

To describe the endoscopic transnasal approach to the infratemporal fossa (ITF) and upper parapharyngeal space (UPS) and to analyze the indications and outcomes of this surgical technique in the management of the tumors localized in this critical area.

Study Design

Case series with chart review.

Setting

Tertiary-care referral center.

Patients and Methods

Retrospective review of patients with benign and malignant tumors arising in or extending to the ITF and UPS, treated from 2002 to 2012 at a single institute. The tumors were surgically resected using an endoscopic endonasal transpterygoid transmaxillary approach.

Results

Thirty-seven consecutive patients with benign tumors (20 juvenile nasopharyngeal angiofibromas, 2 extracranial trigeminal Schwannomas, 2 meningiomas, 1 cavernous hemangioma) and nonmetastatic malignant tumors (2 adenoid-cystic carcinoma, 1 mucoepidermoid carcinoma, 1 squamous cell carcinoma, 1 adenocarcinoma, 1 recurrence of chondrosarcoma, and 6 recurrences of undifferentiated carcinoma of nasopharyngeal type) were treated with curative intent. A gross-total resection was achieved in 35 of 37 patients. Major complications were observed in 1 case (intraoperative internal carotid artery blowout). Postoperatively, 8 patients received some form of adjuvant treatment. Mean follow-up was 30 months for malignancies and 60 months for benign tumors. All patients are now alive without recurrences. Stable intracranial persistence of disease was reported in 2 cases (1 meningioma and 1 adenoid-cystic carcinoma).

Conclusion

The purely endoscopic endonasal technique may provide a minimally invasive and safe approach to radically resect selected tumors involving the ITF and UPS. Larger case series and longer follow-up are needed to validate the reproducibility and efficacy of this technique.