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Facial Translocation Approach to the Nasopharynx

Introduction The facial translocation approach (FTA) for access to the cranial base was first described in the late 1980s by Dr. Ivo P. Janecka and colleagues at the University of Pittsburgh. The FTA was one of a number of landmark approaches described in the early days of the evolving new discipline of skull base surgery. At that time—before intraoperative imaging and image-guided navigation were widely available—most…

Maxillary Swing/Transpalatal/Midface Degloving With Le Fort I Osteotomy Approach for Nasopharyngectomy

Introduction Nasopharyngeal carcinoma (NPC) is a squamous cell carcinoma of an undifferentiated type. This cancer is endemic among Chinese, having the highest incidence of 10 to 20 per 100,000 for men and 5 to 10 per 100,000 for women. It is sometimes called the “Cantonese Cancer” because of its prevalence as one of the most common cancers of the head and neck among Chinese. The most…

Robotic-Assisted Nasopharyngectomy

Introduction While radiotherapy with or without chemotherapy has been the mainstay of treatment for primary nasopharyngeal carcinoma (NPC), surgical resection of the recurrent cancer with the adjacent mucosal wall (nasopharyngectomy) has been established as an efficacious salvage treatment. Various open surgical approaches for nasopharyngectomy have been described in Chapter 43, Chapter 44 . With advancement in technology and endoscopic endonasal surgical techniques, it is now feasible…

Endoscopic Nasopharyngectomy

Introduction Certain ethnogeographic groups have been found to have an increased risk of developing nasopharyngeal carcinoma (NPC). Studies have shown that among the Chinese, there is a very high incidence of NPC affecting 10 to 20 per 100,000 for men and 5 to 10 per 100,000 for women, causing NPC to sometimes be called the “Cantonese cancer.” Most of these NPCs originate in the epithelial lining…

Pharyngectomy

Introduction A hollow viscus located immediately posterior to the larynx, the hypopharynx is related to the oral pharynx superiorly and the cervical esophagus inferiorly. It is divided into three anatomic sites: the pyriform sinuses (bilateral), the postcricoid mucosa, and the posterior pharyngeal wall. The postcricoid mucosa is the mucosa lying on the posterior aspect of the cricoid cartilage, which is also the anterior wall of the…

Transcervical Pharyngotomy

Introduction The transcervical approach to the oropharynx and hypopharynx provides excellent exposure for the removal of a variety of lesions. The lateral pharyngectomy approach was first described by Cheever in 1878 and was popularized later by Trotter in the UK and Orton in the United States, who added their own modifications. This technique has been used most frequently as an effective approach to early stage squamous…

Transoral Removal of Elongated Styloid Process

Introduction The association of an elongated styloid process with pharyngeal and cervical pain is known as Eagle syndrome and was first described in 1937. Eagle syndrome is characterized as a dull, aching pain localized to one or both sides of the throat with referred otalgia. Some pain may occur on swallowing or protrusion of the tongue or on rotating the head, and some patients complain of…

Surgery of the Soft Palate

Introduction The soft palate is a subsite of the oropharynx. Its axial plane defines the superior boundary of the oropharynx, incompletely separating it from the nasopharynx above. The soft palate comprises approximately one-third of the palate, with the more anteriorly positioned hard palate making up the remainder; the junction between the hard and soft palates also separates the oral cavity from the more posteriorly located oropharynx.…

Transoral Robotic Surgery for Neoplasms of the Base of Tongue

Introduction Carcinoma of the base of the tongue can be managed with either surgical or nonsurgical approaches. Historically, most surgical resections in this region have involved open approaches, such as suprahyoid pharyngotomy or lip-split mandibulotomy. Given the morbidity of these approaches, organ preservation protocols initially developed for cancer of the larynx were adapted to the oropharynx. However, primary chemoradiation is not without serious toxicity. Long-term treatment-related…

Transoral and Robotic Tonsil Surgery for Cancers of the Base of the Tongue and Pharynx

Introduction Almost 50,000 people develop oral and oropharyngeal cancers each year with almost 9000 deaths annually. When diagnosed and treated in its early stages, 5-year survival rates can exceed 83%. Oropharyngeal cancer is on the rise, and in particular, human papilloma virus (HPV)–related cancers have increased in the United States by 225% since 1998. Historically, open surgery of the oropharynx was fairly morbid and invasive and…

Transoral Laser Microsurgery of the Base of the Tongue

Introduction The base of the tongue (BOT) is the most anterior-superior portion of the oropharynx bounded anteriorly by the circumvallate papillae, laterally by the paired glosso-palatine sulci, and inferiorly by the vallecula. The BOT is formed from the medial fusion of elements from the first and second and is composed of both the endoderm and ectoderm. The branchial arch hypobranchial prominence, a specialized region of second…

Transoral Excision of Oropharyngeal Malignancy

Introduction The most favorable management of oropharyngeal cancer is still controversial. In the past, oropharyngeal cancers were treated with surgery followed by radiation. Surgical resection usually required mandibulectomy or mandibulotomy and removal of pharyngeal musculature, which resulted in significant morbidity. Because of the functional and cosmetic impairments and current development of organ preservation regimens, chemoradiation has become the treatment of choice in many patients with cancer…

Transoral Inferior Maxillectomy

Introduction The hard palate is the site of origin of benign and malignant tumors. The most common tumor of minor salivary gland origin in this site is pleomorphic adenoma, a benign tumor that appears as a smooth submucosal mass. Approximately 5% of cancers of the oral cavity involve the hard palate and maxillary alveolus. Squamous cell carcinoma accounts for approximately 90% of malignancies of the hard…

Operative Otolaryngology: Excision of Buccal Carcinoma

Introduction The buccal mucosa is an uncommon site for oral cavity cancer (SCC) and comprises 5% to 10% of all intraoral squamous cell carcinoma (IOSCC) in North America and Europe. However, it is more commonly seen among Taiwanese Chinese and in India, where betel nut chewing is prevalent in these communities. Among the published reports, buccal SCC was found to comprise between 23% and 37% of…

Excision of Cancer of the Floor of the Mouth

Introduction Cancer of the floor of the mouth accounts for approximately one-third of all cancers of the oral cavity, with squamous cell carcinoma accounting for more than 95% of cases. Affected patients tend to reflect many of the epidemiologic features that have come to define squamous cell carcinoma of the head and neck as a whole, including a male predilection, advanced age at the time of…

Total Glossectomy

Introduction Total glossectomy is used for advanced cancers of the tongue, mostly squamous cell, either as a primary surgical resection or as salvage following previous (chemo)radiation when partial glossectomy will not achieve adequate resection margins. A key clinical decision is whether a laryngectomy is required. This decision is based on whether a patient is likely to cope with some degree of aspiration and whether extension of…

Partial Glossectomy

Introduction Cancer of the tongue is most common in 60- to 70-year-old male drinkers and smokers but is also encountered in much younger and older individuals without a history of smoking or ethanol use. Most cancers of the tongue are squamous cell carcinomas, which arise on the lateral aspect of the tongue and exhibit a propensity for early spread to the lymph nodes of the neck.…

Cancer of the Lip

Introduction The lip is the most common site of origin for squamous cell carcinoma of the oral cavity. Unlike other cancers of the oral cavity, the etiology and clinical outcomes of squamous cell carcinoma more closely resemble squamous cell carcinoma of the skin. Cancer of the lips accounts for 0.6% of all malignancies diagnosed in the United States. The primary risk factor for cancer of the…

Closure of the Tracheoesophageal Fistula Site

Introduction Speech restoration is of great significance for the social and economic welfare of patients who undergo total laryngectomy. As outlined in Chapter 75 , Voice Restoration After Total Laryngectomy, speech restoration is most often accomplished with the use of the electrolarynx or by placement of a primary or secondary tracheoesophageal puncture (TEP), allowing for esophageal speech. More than 80% of patients with a TEP develop…

Voice Restoration After Total Laryngectomy

Introduction Although nonsurgical methods such as electrolarynx and esophageal speech are available for patients, tracheoesophageal puncture (TEP) is considered the best means of voice restoration after total laryngectomy (TL). A TEP allows a patient to channel air from the lungs through a puncture site in the posterior wall of the trachea, into the esophagus up through the pharynx, where the mucosa acts as a vibrating apparatus…