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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 cell cancer of the oropharynx and hypopharynx and for tumors of salivary gland origin of the base of the tongue. It has also been used for access to arteriovenous malformations, removal of a complex foreign body, treatment of severe pharyngeal stenosis, and excision of a lingual thyroid.
The suprahyoid pharyngotomy was first described by Vidal de Cassis in 1826, and modifications have been described by several surgeons down through the years. Fairbanks Barbosa, in 1974, included the description of this technique in his classic textbook. This technique is used in situations similar to the lateral pharyngotomy, including the management of benign and malignant tumors of the base of the tongue, hypopharynx, and posterior pharyngeal wall, and excision of lingual thyroid. This technique has been used in our department for many years in the management of T1/T2 squamous cell cancer. It has provided a safe and efficient approach to the oropharynx and provides an excellent cure rate, normal speech, good cosmesis, and swallowing without clinical evidence of aspiration. Similar reports from Moore and Calcaterra regarding the successful use of this technique in the management of T3 lesions of the base of the tongue and by Zeitels for limited lesions of the base of the tongue mirror our own experience.
Both the transhyoid and lateral pharyngotomy techniques offer a means of creating a corridor to the oropharynx and hypopharynx, which provides excellent exposure for the excision of a variety of lesions. It appears that over the years the lateral pharyngotomy approach has been more popular based upon the notion that it provides better exposure. In our own experience, the suprahyoid technique provides excellent exposure through a more direct route with less work involved. When more exposure is necessary, the suprahyoid approach may be extended to include a lateral pharyngotomy.
In the past several decades there has been an evolutionary change in the management of cancers of the oropharynx, largely driven by medical and radiation oncologists. They were inspired by the results of a VA trial for advanced cancer of the larynx, published in the New England Journal of Medicine in 1993, which revealed that chemoradiation had a cure rate similar to surgery/radiation. The most appealing aspect of this study was that those patients cured with chemoradiation retained their voice. This nonsurgical approach acquired a new audience in the form of a generally healthier, younger group of patients whose oropharyngeal cancer is caused by human papillomavirus (HPV). They were attracted to chemoradiation as a potential cure for their cancer that did not require external surgery with a tracheotomy, scarring and potential deformity, and decreased functionality. This, of course, resulted in a dramatically reduced market for the classical transcervical pharyngotomy.
More recently the introduction of robotic surgery using the daVinci surgical robot offers a very successful means of excising oropharyngeal cancer with acceptable swallowing results and involving lower doses of adjunctive radiation, if at all. This management scheme also includes neck dissections, since the majority of these patients will have cervical lymph node metastasis. This is an attractive management plan since it provides the patient with a high rate of curability and a low rate of disability in comparison with chemoradiation, which leaves a substantial number of patients with dysphagia and a permanent gastrostomy.
There are many patients in the United States and other countries who have cancer of the oropharynx and do not have access to chemoradiation or robotic surgery. These patients will find that the use of the established surgical techniques of transcervical pharyngotomy will offer them an opportunity for cure without downgrading their form or function.
Key Operative Learning
- 1.
The transcervical pharyngotomy approach remains a viable option for resection of selected tumors of the oropharynx and hypopharynx.
- 2.
The selection of the surgical approach should be properly tailored to the size, extent, and location of the patient’s tumor.
- 3.
A thorough examination of the head and neck, along with evaluation and palpation of the tumor under anesthesia, is essential for proper patient selection.
- 4.
Care must be taken to avoid injury to the hypoglossal nerves (suprahyoid pharyngotomy approach) and superior laryngeal nerve (lateral pharyngotomy approach) to limit postoperative morbidity.
- 5.
Aspiration in the immediate postoperative period is predictable and may adversely affect outcomes in the patient with severe chronic obstructive pulmonary disease (COPD).
- 6.
A pharyngocutaneous fistula that fails to close with conservative management may require a tissue flap for reconstruction.
Preoperative Period
History
- 1.
History of present illness
- a.
Primary symptoms
- 1)
Pain
- 2)
Dysphagia
- 3)
Odynophagia
- a)
May suggest invasion of deeper planes of the oropharynx
- a)
- 4)
Otalgia
- 5)
Weight loss
- 6)
Hemoptysis
- 7)
Mass in the neck
- 8)
Trismus
- 9)
Dysarthria (hot potato voice)
- a)
May suggest invasion of muscles of mastication or a bulky tumor
- a)
- 1)
- b.
Duration of symptoms
- c.
Previous assessment
- 1)
Biopsy
- a)
All outside pathology slides should be reviewed at your own institution, especially if human papillomavirus (HPV) testing has not been completed.
- a)
- 2)
Imaging—All prior imaging studies should be reviewed at your own institution.
- a)
CT
- b)
MRI
- c)
PET/CT
- a)
- 1)
- a.
- 2.
Past medical history
- a.
Comorbidities
- 1)
General medical history
- a)
Previous history of cancer of the head and neck
- a)
- 2)
Cardiovascular disease
- a)
Patients requiring long-term anticoagulation due to cardiac or thromboembolic history may be at increased risk for bleeding in the postoperative period.
- b)
Preoperative evaluation by a cardiologist is warranted in select patients with a known cardiac history.
- a)
- 3)
Pulmonary disease
- a)
Many patients with cancer of the head and neck have a significant smoking history and usually have concomitant COPD.
- b)
Temporary aspiration is a predictable postoperative occurrence. Patients who cannot tolerate this due to impaired pulmonary function may be considered for laryngotracheal separation or laryngectomy to prevent life-threatening aspiration.
- a)
- 1)
- b.
Social history
- 1)
Tobacco use
- a)
Most patients in the older age group have a significant history of heavy smoking. These patients may undergo withdrawal symptoms similar to delirium tremens.
- a)
- 2)
Alcohol abuse
- a)
Alcohol withdrawal is associated with increased perioperative morbidity in patients undergoing surgery of the head and neck, including increased risk of delirium tremens, aspiration, ventilator dependence, and death.
- b)
If heavy alcohol use is admitted or suspected preoperatively, consideration should be given to preoperative admission to the hospital or detoxification center to allow detoxification to take place prior to surgery.
- a)
- 3)
Information regarding sexual activities should be elicited as part of a thorough history in those patients with an HPV etiology, since this is thought to be a sexually transmitted disease.
- 1)
- c.
Medications
- 1)
Anticoagulants/Aspirin/NSAIDs
- 2)
Supplements that can increase the risk of bleeding
- 1)
- a.
Physical Examination
- 1.
Examination of the head and neck
- a.
Direct and indirect visualization of the oral cavity to assess for trismus, examination of the base of the tongue, larynx, and pharynx is essential. It is also important to evaluate the lateral and posterior extent and bulk of the mass as well as involvement of adjacent structures.
-
Indirect mirror laryngoscopy
-
Flexible or rigid fiberoptic pharyngolaryngoscopy
-
- b.
Direct laryngoscopy under anesthesia is the most important examination to evaluate tumor extent and infiltration.
- c.
Bimanual palpation of tumors at the base of the tongue is essential to most accurately assess the extent of the disease and differentiate the tumor from the lingual tonsils.
-
Palpation also assists in determining the mobility of the tumor and invasion of underlying and adjacent tissues.
-
- d.
Pay special attention to palpation for cervical lymphadenopathy.
- a.
Imaging
- 1.
CT scan
- a.
CT scan of the head and neck helps delineate the extent of the primary lesion and is especially helpful in evaluating bony anatomy, such as invasion of the cortex of the mandible.
- b.
Excellent in determining suspicious cervical lymphadenopathy
- c.
May also be used to screen the chest for metastatic cancer
- a.
- 2.
MRI
- a.
MRI is able to better define the extent of soft tissue invasion of the cancer into the deep musculature of the tongue or prevertebral tissues.
- b.
Drawbacks to MRI include increased cost, longer time of the examination, and potential patient intolerance due to claustrophobia.
- c.
The inability of the pharynx to elevate during deglutition suggests invasion of the prevertebral fascia in patients with cancer of the posterior pharyngeal wall.
- a.
- 3.
PET/CT
- a.
Valuable study to evaluate the primary cancer and to evaluate for the presence of metastatic cancer
- a.
- 4.
Barium esophagram
- a.
This study may be used in cases of cancer of the posterior pharyngeal wall in which invasion of the prevertebral fascia is suspected.
- b.
Limited laryngeal elevation during the bariumm esophagram may suggest invasion of the prevertebral fascia
- a.
Indications
- 1.
Suprahyoid pharyngotomy approach
- a.
Early stage cancer of the base of the tongue (T1/T2)
- 1)
Ideally, these cancers should be limited to the base of the tongue, posterior to the circumvallate papillae.
- 2)
May be combined with the lateral pharyngotomy approach for cancers involving the lateral pharyngeal wall or tonsil
- 3)
Usually combined with neck dissection
- 1)
- b.
Excision of cancer of the posterior wall of the oropharynx or hypopharynx
- c.
May be used without neck dissection for benign lesions or low-grade cancers of salivary gland origin
- d.
Useful for excision of a lingual thyroid
- a.
- 2.
Lateral pharyngotomy approach
- a.
Benign and malignant tumors arising from the lateral and posterior walls of the oropharynx or hypopharynx, postcricoid area, or base of the tongue (with involvement of the tonsil or lateral wall of the oropharynx)
- 1)
Depending on the extent and location of tumor, many of these lesions may also be amenable to endoscopic approaches, pending the availability of technology and equipment.
- 1)
- a.
Contraindications
- 1.
Suprahyoid pharyngotomy approach
- a.
Cancer of the vallecula that involves the lingual surface of the epiglottis
- 1)
Excision of the epiglottis may lead to considerable postoperative complications with delayed deglutition and chronic aspiration.
- 1)
- b.
Cancer of the base of the tongue that extensively involves the tonsil or lateral pharyngeal wall
- c.
Cancer involving the tongue anterior to the circumvallate papillae
- 1)
Cancers with this anterior extent are difficult to close primarily, may compromise the anterior surgical margin, and result in disability in swallowing.
- 1)
- d.
Patients with decreased pulmonary function who would not tolerate aspiration in the immediate postoperative period
- a.
- 2.
Lateral pharyngotomy approach
- a.
Patients with cancer that involves more than one-third of the pharyngeal circumference
- b.
Patients with cancer who would be better suited for suprahyoid or total laryngectomy due to comorbidities
- c.
Patients with decreased pulmonary function who would not tolerate aspiration in the immediate postoperative period
- a.
Preoperative Preparation
- 1.
Imaging studies and any studies from previous biopsies or surgical procedures done elsewhere should be obtained and reviewed during surgical planning.
- 2.
Patients who have not had a biopsy should undergo a direct laryngoscopy, biopsy of the tumor, and esophagoscopy.
- 3.
Surgery for those patients with nutritional depletion should be delayed to bring the patient into positive nitrogen balance.
- 4.
Patients should be seen by medical consultants and cleared for surgery.
- 5.
Patients should stop taking aspirin, nonsteroidal anti-inflammatories, other anticoagulants, and supplements at least 7 days preoperatively. If there is a history of bleeding with prior surgery or trauma, then a coagulation profile is obtained.
- 6.
Preoperatively, patients are counseled regarding the procedure, risks, and complications. The informed consent should be detailed and include the following risks: infection, bleeding, need for prolonged tracheostomy, dysphagia, aspiration, wound breakdown, and salivary fistula.
Operative Period
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