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The Combined Endonasal and Transoral Approach for the Management of Skull Base and Nasopharyngeal Pathology: a Case Series

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The Combined Endonasal and Transoral Approach for the Management of Skull Base and Nasopharyngeal Pathology: a Case Series Neurosurg Focus 37 (4):E2, 2014 ©AANS, 2014 The combined endonasal and transoral approach for the management of skull base and nasopharyngeal pathology: a case series SATYAN B. SREENATH, B.S.,1 ROUNAK B. RAWAL, M.D.,1 AND ADAM M. ZANATION, M.D.1,2 1Department of Otolaryngology—Head and Neck Surgery, and 2Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina The posterior skull base and the nasopharynx have historically represented technically difficult regions to ap- proach surgically given their central anatomical locations. Through continued improvements in endoscopic instru- mentation 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, nasopharyn- geal, 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 nasopha- ryngeal 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. (http://thejns.org/doi/abs/10.3171/2014.7.FOCUS14353) KEY WORDS • combined endoscopic transoral approach • robotic • endonasal • skull base • nasopharynx HE posterior skull base and the nasopharynx have troduced a new array of surgical options in the manage- historically represented technically difficult re- ment of pathology involving this anatomically complex gions to approach surgically, given their central an- area. Neoplastic lesions of this area have been success- Tatomical locations. Traditional approaches to this region fully resected with favorable outcomes and adherence to include creation of an anterior transfacial corridor (Le oncological principles.1,7,8,32 However, the pure endonasal Fort I osteotomy, maxillary swing, and midface deglov- route can be inadequate for surgical management of pa- ing), lateral transcranial corridor (pre- and postauricular thology extending beyond the anatomical boundaries, infratemporal fossa and subtemporal approaches), and such as for extension below the level of the soft palate in inferior oral or cervical corridor (transcervical-transman- the oropharynx (Table 1). Given these limitations, several dibular or transpalatal approaches).2,6,15,18,21,30,37 Although institutions initially published studies on their clinical these approaches were previously frequently used, they and laboratory experience of combining both the EEA were also associated with high clinical morbidity and and nonrobotic transoral approach for a variety of patho- less than ideal cosmetic outcomes, which has greatly logical processes.10,12,14,16,17 decreased their use since the advent of the endoscopic, In our initial experience with this combined tech- minimally invasive era.6,18,23,27,32,35,36 nique, we successfully repaired oronasal fistulas and Through continued improvements in the Hopkins surgically managed chronic granulomatous disease, both rod-lens endoscope (Karl Storz) and endoscopic instru- of which required surgical access through the endonasal mentation, the expanded endonasal approach (EEA) in- and transoral corridors. By combining these windows, a larger operating corridor may be established to obtain Abbreviations used in this paper: CVJ = costovertebral junction; surgical margins during resection of neoplastic lesions, EEA = expanded endonasal approach; ICA = internal carotid artery; while minimizing displacement or dissection of normal TORS = transoral robotic surgery. tissue in the approach to the area of interest. Although Neurosurg Focus / Volume 37 / October 2014 1 Unauthenticated | Downloaded 10/09/21 05:12 PM UTC S. B. Sreenath, R. B. Rawal, and A. M. Zanation TABLE 1: Advantages and limitations of the EEA and TORS approaches to the nasopharynx and skull base Approach Advantages Limitations EEA improved cosmetic outcomes limited access below the soft palate direct visualization & minimal tissue displacement 2D endoscopic view angled endoscopic cameras & instrumentation limited lateral mobility & access TORS 3D imaging lack of bone-drilling equipment increased articulation with 3–4 robotic arms bulky robotic instrumentation ability to suture within the operative field steep learning curve this original, combined technique offered many advan- management of disease, which yielded 3 patients. All 3 tages to utilizing either surgical corridor separately, limi- patients exhibited distinct nasopharyngeal and skull base tations included significant reduction in simultaneous pathology. Data were collected regarding patient history, maneuverability given difficult intraoperative position- surgical indications, operative technique, and postopera- ing with reduced surgical manipulation and limited vi- tive outcomes. All surgical procedures were performed sion through the transoral route. These limitations were by the senior author (A.M.Z.). addressed with the introduction of the transoral robotic 38 surgery (TORS) approach. Case Reports Transoral robotic surgery using the da Vinci surgi- cal system (Intuitive Surgical, Inc.) has been extensively Case 1 described in the literature for the management of mid- dle cranial fossa skull base tumors, along with tongue History and Presentation. A 35-year-old woman with base, nasopharyngeal, parapharyngeal, and laryngeal le- a history of papillary thyroid carcinoma status post, fol- sions.4,9,13,19,22,24–26,34,38 Advantages of TORS include supe- rior 3D visualization, increased instrument access, pre- cise and tremor-free 3-handed surgery, and elimination of external incisions, while limitations include the lack of bone-drilling equipment, relatively bulky instrumen- tation, and a steep initial learning curve.22,24,25,40 TORS has been shown to be highly effective in obtaining a di- rect, illuminated surgical window into the nasopharynx, allowing for surgical management of nasopharyngeal carcinomas and performance of complete nasopharyn- gectomy. 25,33,34 However, without the capacity for bone resection via drilling instrumentation, the pure TORS ap- proach is limited to dissection of soft tissue and may be inadequate to manage involvement of the skull base at the basiocciput region superiorly or medial pterygoid later- ally (Table 1). Thus, the next logical step was to combine the EEA and the TORS approach for the greatest possible surgical window with the greatest degree of surgical ma- nipulation (Fig. 1). In this case series, we present our clinical experience with the combined endonasal and transoral approach and discuss its advantages, limitations, and possible future prospects. We also include presentation of a unique, si- multaneous endonasal and transoral dissection of the na- sopharynx through an innovative intraoperative setup of the endoscopic endonasal and robotic surgical equipment. Methods After Institutional Review Board approval, a retro- spective, consecutive review was performed to identify FIG. 1. Illustration of the anatomical corridor and boundaries in the patients who underwent the combined endoscopic en- EEA (blue triangle) and the TORS approach (yellow triangle) to the na- donasal and transoral robotic approaches for surgical sopharynx. 2 Neurosurg Focus / Volume 37 / October 2014 Unauthenticated | Downloaded 10/09/21 05:12 PM UTC Combined endonasal and transoral approach lowing total thyroidectomy with left neck dissection, pre- section portion of the procedure. With the robot positioned sented with a metastatic 1.5 cm × 2.5–cm retropharyngeal at the head of the bed, the articulating arms were fixed space lesion on routine surveillance MRI with contrast with a 30° endoscope, Maryland forceps, and monopolar administration. It was also noted on MRI that the internal electrocautery (Fig. 3). With the use of the angled endo- carotid artery (ICA) was inferior and lateral to the mass, scope, the surgical view through the robotic system was demonstrating the superomedial location of the mass in directly over the lateral pharyngeal recess and parapha- the parapharyngeal space, abutting the nasopharyngeal ryngeal space with minimal tissue and palatal retraction. region (Fig. 2). Given the extent and location of the tumor, The remainder of the excision of the skull base proceeded it was determined that the mass would be resected via the through the TORS approach, which was advantageous combined endonasal and transoral approach, as exposure in meticulously dissecting the lesion away from the ICA. of the superolateral portion of the mass would not be fea- Upon completion of the resection, the tonsillar and pharyn- sible through a purely transoral route. geal mucosa were reapproximated using vicryl sutures to Intraoperative Technique. Intraoperatively, the CT- ensure closure of the parapharyngeal
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