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Transoral Lateral Orophayngectomy / Radical Tonsillectomy For OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY TRANSORAL LATERAL OROPHARYNGECTOMY / RADICAL TONSILLECTOMY FOR CANCER OF THE TONSIL: ANATOMY, PRINCIPLES AND TECHNIQUES Johan Fagan & Wayne Koch In developed countries, early (T1/2) tonsil Surgical anatomy cancers are commonly resected by lateral oropharyngectomy (radical tonsillectomy) The oropharynx encompasses the base of employing transoral CO2 laser microsurge- tongue, tonsils, soft palate, and lateral and ry or transoral robotic surgery (TORS) posterior walls of the pharynx between the techniques. Yet most surgeons in the world levels of the hard palate and hyoid bone do not have access to CO2 laser or TORS. (Figures 1a, b). In such centers early tonsil cancers are often resected by simple tonsillectomy. However, dissecting along the tonsillar capsule and not including the pharyngeal constrictors as the deep margin often results in close or involved deep margins necessitating adju- vant (chemo)radiation. Because cancers of the tonsil are in a direct line-of-sight for the surgeon when using a simple tonsillectomy gag, there is little reason why the surgical principles that apply to lateral oropharyngectomy by trans- oral CO2 laser or TORS techniques should not be employed to lateral oropharyngec- tomy performed with headlight/diathermy, or microscope/diathermy, or loupes/head- Figure 1a: Oropharynx light/diathermy techniques to secure ade- quate resection margins. Regardless of the surgical tools being used, lateral oropharyngectomy requires a detail- ed understanding of the “inside-out” 3D anatomy of the oropharynx, and of the para- pharyngeal (PPS) and retropharyngeal spa- ces. Without such an understanding one is less likely to achieve adequate resection margins and more likely to encounter bleeding, nerve damage and injury to the internal carotid artery. This chapter details the surgical anatomy of the oropharynx, PPS and retropharyngeal Figure 1b: Oropharynx spaces, and discusses principles and techni- ques relating to transoral resection of tonsil Key anatomical structures relevant to lateral cancers regardless of the surgical tools oropharyngectomy are listed in Table 1 and being used. illustrated in Figure 2. 1 2 Ligaments Pterygomandibular raphe sillolingual sulci separate the tongue from and fasciae Buccopharyngeal fascia the tonsillar fossae. The valleculae separate Muscles Buccinator the BOT from the lingual surface of the Superior constrictor Middle constrictor epiglottis and are separated in the midline Medial pterygoid by the median glossoepiglottic fold (Figure Stylopharyngeus 3). Muscles of soft palate Nerves Lingual Epiglottis Glossopharyngeal (IX) Valleculae Arteries Internal carotid Median glosso- Dorsalis linguae epiglottic fold Ascending pharyngeal Tonsil Tonsillar and ascending palatine Tonsillolingual branches of facial artery sulcus Descending palatine Foramen caecum Spaces Prestyloid PPS Sulcus terminalis Poststyloid PPS Retropharyngeal space Table 1: Key anatomy for lateral oro- pharyngectomy Buccinator Pterygomandibular raphe Figure 3: Topography of BOT Palatoglossus Medial pterygoid fascia Soft palate Superior constrictor Buccopharyngeal fascia The soft palate has a complex muscular External carotid structure and innervation. It has key func- Styloglossus & Stylopharyngeus tions relating to speech and swallowing. Palatopharyngeus Resection and inadequate reconstruction of Internal carotid the palate results in loss of nasal separation Internal jugular vein which manifests clinically as nasal regurgi- tation of fluids and food, and hypernasal Figure 2: Key anatomical structures for speech which can be quite disabling. The lateral oropharyngectomy at level of tonsil; complex muscular anatomy of the soft yellow tissue is parapharyngeal fat palate and lateral pharyngeal wall is illu- (Adapted from Ento Key) strated in Figure 4. Muscles that contribute to the soft palate and lateral pharyngeal wall Base of tongue (BOT) are summarised in Table 2. This comprises the posterior 1/3 of the Lateral and posterior pharyngeal walls tongue behind the foramen caecum and sulcus terminalis (Figure 3). The mucosa is Lateral oropharyngectomy involves dissec- rough, thick and fixed to the underlying ting along the outer aspect of the pharyngeal muscle and contains lymphoid follicles constrictors. The oropharynx has several (lingual tonsil); this makes it difficult to layers i.e. mucosa, submucosa, muscle and identify the edges of a BOT tumour; hence buccopharyngeal fascia. The submucosa is frozen section is especially useful to assess represented by the pharyngobasilar fascia resection margins. Posterolaterally the ton- that lines the inner aspect of the constrictor 3 muscles. It thins as it extends inferiorly Levator veli palatini from its attachment to the skull base and Tensor veli palatini bridges the gaps between the skull base and Styloid the superior constrictor, the superior and Stylopharyngeus middle constrictors, and the middle and Pterygoid hamulus inferior constrictors (Figure 5). Posteriorly Palatopharyngeus it forms a median raphe to which the Salpingopharyngeus pharyngeal constrictors attach (Figure 5). Musculus uvulae Superior constrictor The buccopharyngeal fascia invests the pharyngeal constrictor muscles and is Figure 4: Posterior view of soft palate and continued forward from the superior pharynx with superior constrictor splayed constrictor over the buccinator (Figure 2). open It is loosely attached to the prevertebral layer by connective tissue, with the retro- pharyngeal space between them. Tensor veli palatini V3 Levator veli palatini X Soft palate Palatoglossus X The pterygomandibular raphé/ligament is Palatopharyngeus X a tendinous band of buccopharyngeal fas- Musculus uvulae X cia and is a key structure to identify initially Salpingopharyngeus X in lateral oropharyngectomy to gain access Lateral Superior constrictor X to the correct lateral dissection plane. It is pharyngeal wall Middle constrictor X Stylopharyngeus IX attached at one end to the hamulus of the medial pterygoid plate, and at the other end Table 2: Muscles of soft palate and to the posterior end of the mylohyoid line of oropharynx and cranial nerves which the mandible (Figures 6, 7). innervate them PBF Superior constrictor Stylopharyngeus Median raphe Middle constrictor Inferior constrictor Figure 5: Posterior view of pharynx illu- strates attachment of the superior con- strictor to pharyngobasilar fascia (PBF) above and the median raphe to which Figure 6: Note how buccinator and supe- pharyngeal constrictors attach; note close rior constrictor muscles attach to the pte- anatomical relationships of internal and rygomandibular raphe (yellow line) external carotid artery systems to pharynx 4 It is interposed between the buccinator mus- cle which is attached to its anterior edge, and the superior constrictor muscle which is attached to its posterior edge (Figures 2, 6). Medially it is covered only by buccal mucosa. Laterally it is separated from the MT ramus of the mandible and medial pterygoid muscle and fascia by adipose tissue (Figure LN 2). The pterygomandibular fold represents the surface marking of the pterygomandi- bular raphe (Figure 7). Figure 8: The lingual nerve (LN) courses lateral to the medial pterygoid muscle (MT) Pterygomandibular raphe (cut superiorly) Nerve to mylohyoid Submandibular ganglion Lingual nerve Hyoglossus Figure 7: Pterygomandibular fold repre- Figure 9: Lingual nerve emerging between sents the surface marking of pterygoman- lower attachment of raphe to the mandible dibular raphe and the mylohyoid muscle (adapted from Earthslab.com) The lingual nerve emerges anteriorly be- tween the medial pterygoid and the vertical Medially, it is covered by submucosa and ramus of the mandible (Figure 8). It is mucosa of the cheek. Laterally it is related therefore protected by the medial pterygoid to the ramus of the mandible, the masseter muscle during lateral oropharyngectomy. and medial pterygoid muscles, the buccal However, it is vulnerable to injury when fat pad and the buccopharyngeal fascia. dissecting inferiorly where it courses above the mylohyoid muscle (Figure 9). The superior and middle constrictor mus- cles form the lateral and posterior walls of The buccinator muscle is transected during the oropharynx (Figures 4, 5, 6, 9, 10), with lateral oropharyngectomy just anterior to lesser contributions from the salpingo- the pterygomandibular raphe. It is a thin, pharyngeus (Figure 4), stylopharyngeus quadrilateral muscle in the cheek, and origi- (Figures 4, 5, 6, 10) and palatopharyngeus nates from the outer surfaces of the alveolar (Figure 4) muscles. processes of the maxilla and mandible. Posteriorly it attaches along the length of The stylopharyngeus arises from the medial the pterygomandibular raphe (Figures 2, 6). side of the base of the styloid process, pass- es downward through the fat of the PPS 5 along the side of the pharynx, then between dissection. It has two heads: the larger deep the superior and middle constrictors, and head arises from just above the medial fans out beneath the mucosa (Figures 2, 5, surface of the lateral pterygoid plate; the 6, 10). The glossopharyngeal (IX) nerve in- smaller superficial head arises from the nervates the stylopharyngeus. It runs on the maxillary tuberosity and the pyramidal lateral side of the muscle and crosses over it process of the palatine bone (Figure 11). to reach the base of the tongue (Figure 10). The muscle passes inferolaterally to insert onto the inferomedial surface
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