lateral pharyngotomy for selected cancer of the lateral oropharinx

LATERAL PHARYNGOTOMY FOR SELECTED CANCER OF THE LATERAL OROPHARINX: TECHNIQUE AND
FUNCTIONAL OUTCOMES
Laccourreye O¹, MD; Benito JJ², MD PhD; Menard M¹, MD; Garcia D ³, MD; Malinvaud D¹, MD PhD; Holsinger FCh *, MD.
1.Service ORL et ChCF. HEGP APHA. Université Paris Descartes Sorbonne. Paris. France 2. Servicio ORL y PCF. Hosp Universitario Sant Joan. Reus. Spain
3. Clinique d’Arcachon. Arcachon. France *Department HNS. University of Texas. MD Anderson. Houston. USA
INTRODUCTION
DISCUSSION
Lateral pharyngotomy (LP) first description is due to W. Trotter (1) in 1920, as a surgical approach designed to
resect “a large growth originating from the epilarynx” through the transection of the hypoglossal nerve,
lingual artery and mandible. Over time, this proceeding has been modified (2,3) to avoid injuring these
structures.
In a PubMed inquiring, we have found no series based on a large number of patients with a long term followup documenting the functional and oncologic results of this approach used to resect squamous cell carcinoma
(SCC) originated from the lateral oropharynx. This aimed us to present the current retrospective analysis.
Fig. 2
MATERIALS AND METHODS
Fig. 3
Fig. 4
91 patients with moderately-to-well differentiated untreated invasive SCC of the lateral oropharynx resected
with LP by 21 attending senior surgeons at the Université Paris Descartes Sorbonne Paris Cité (Paris, France).
Origin sites are described in fig 1. Median age was 56 years (27-73).
Variables
Patients
38 lateral tongue base
nb
%
Gender
6 tonsil
Male
81
89.0
Female
10
11.0
10 Posterior tonsillar pillar
Fig. 5
Charlson et al. comorbidity scale
0
No series based on a large number of patients with long term follow yet documented the functional outcome
when this surgical approach was elicited to manage SCC of the lateral wall of oropharynx.
Diaz-Molina et al. (2011) (6) reported a retrospective review of 155 patients surgically treated for SCC of the
lateral oropharynx, 71% with mandibulotomy, with slightly higher rates of mortality (3.2%), salivary fistula
(19%), pneumonia (15%), hemorrhage (8%), permanent tracheostomy and gastrostomys tubes (9% and 7%).
Extensive complications following mandibulotomy occur in one out of 4 to 5 patients (6,12,13) (dental
dysfunction, mandibular non-union, trismus and malocclusion). The combination of the LP and transoral
approaches (11 cases in our series) allowed for a wide exposure, similar to the one achieved by Cocek et al.
(10) when resecting the mandibular angle.
Our figures also compares favorably with the functional results achieved with chemoradiation therapy (CRT).
Nguyen et al. (2008) (7), in a series of 46 patients with T1-4, stage III-IV oropharyngeal SCC, find severe
aspiration requiring long-term gastrostomy in 44% of cases.
Our functional results using local or regional flaps is similar to that of Bozec et al. (11) with a radial forearm
free flap reconstruction.
The increasing in loco-regional complications noted in the patients who received postoperative RTP is
according to the data showed by the meta-analysis of Parsons (14) reviewing 51 North-American papers.
43
Fig. 6
47.2
1
20
21.9
2
12
13.1
3–5
9
9.8
6-9
5
5.4
13 Infratonsillar region
Fig. 1
24 glosso-tonsillar fold
Data not available (2)
Statistical analyses were performed
by using Statview (SAS Institute Inc.,
Berkeley, CA, 94704-1014). Fisher’s
exact test and the non-parametric
Mann-Whitney U test were utilized
for analysis of the variables under
investigation. Statistical significance
was set at the .05 level.
STAGE NB
I
Prior RTP
7.6%
Prior Partial Laryngectomy
9.8%
8
II
19
III
31
IV
33
Preop platin based induction CTP
91.2%
Ipsilateral neck dissection
94.5%
Postop RTP
49.4%
Lateral Pharyngectomy was performed under general anaesthesia.
Fig. 2: Neck dissection is first performed. The following structures are identified: lateral horn of the hyoid
bone (J), superior laryngeal nerve (F), hypoglossal nerve, external carotid artery (A), facial artery (B), lingual
artery (C), superior thyroid artery (M), digastric muscle (H) and mylohyoid muscle(I).
Fig. 3: Section of the tendon of the digastric muscle and retraction of its posterior belly. Stylohyoid and
mylohyoid muscles division from the hyoid bone.
Fig. 4: Facial artery ligation. Ascending pharyngeal artery (G) location. Inspection of the styloglossus muscle
(K) and its imbrication into the superior constrictor muscle (L) at the level of the tongue base.
Fig. 5: The most common entry point was the vallecula (76 cases).
Fig. 6: The complete exposure this approach permits. Pharyngotomy was performed higher at the level of the
tonsillar region in 11 cases, often in combination with a transoral approach(4). In the rest 4 cases the entry
was performed lower at the level of the piriform sinus (5).
Closure:
-Re-approximation by mobilization of the posterior pharyngeal wall from the prevertebral fascia (71 patients)
-Flap reconstruction (22 patients): pectoralis major flap (15 cases), sternocleidomastoid flap (5 cases), set-back
tongue-base flap (2 cases), dorsalis flap (1 case) and platysma flap (1 case).
Naso-gastric feeding tube (NFT) was placed in all patients. Tracheostomy was performed in 76.9% (70/91).
NFT was removed as soon as possible, once the tracheotomy had healed and the patients were able to swallow their
own saliva. Broad-spectrum antibiotics and a proton-pump inhibitor were indicated. Patients were sent home once
they could achieve normal oral alimentation.
All patients were followed up until death or until the 3rd postoperative year. All except 4 until the 5th year.
RESULTS
Mortality
No intra-operative death.
One death 16 days after surgery from a carotid artery rupture in a patient with salivary fistula
Morbidity
98.9% of patients uncomplicated medical postoperative course
None of the variables was significantly
73.6% of patients uncomplicated surgical postoperative course:
related to any complication
-4.3% (4 patients) oropharyngeal salivary fistula: 1/4 died
-6.5% (6 patients) swallowing impairment requiring PEG. 4/6 pneumonia from aspiration. Only 2 required PEG
between 6-12 months
-Among 44 patients with postoperative RTP: 13.6% (6 patients) related loco-regional complications, statistically
related with the total dosage (p=.025).
Recovery of swallowing 93.3% in the first
postoperative month
Median duration naso-gastric feeding tube: 11
days (3-30 days)
Tracheotomy 76.9% All of them temporary
Median duration: 5 days (1-17 days)
Hospitalization Median duration 16 days (7-33 days)
Significantly statistically correlated:
-development post-operative complication (p=.0003)
-duration tracheostomy tube (p<.0001)
-naso-gastric tube dependency (p=.0057)
CONCLUSIONS
From a functional point of view, the lateral pharyngotomy is a safe, reliable surgery with
few major complications and might be considered as a valuable alternative to
chemoradiation and/or mandibulotomy for selected tumors of the lateral oropharynx.
At a time when the concept of minimal invasive transoral surgery in patients with
oropharyngeal SCC is developing, this time-honoured approuch should remain within the
armamentarium of surgeons performing organ preservation oncological surgery.
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