Avoidance of Maxillary Swing for Nasopharyngectomy via Combined Open Lateral and Endoscopic Approach

Objectives: Protection of the internal carotid artery through a solely endoscopic approach for nasopharyngectomy has limitations in access and feasibility. We report three novel cases with one cadaver dissection where nasopharyngectomy was performed via a lateral open approach to the skull base, combined with an endoscopic approach. We highlight the benefits and technical considerations for this operative technique.

Study Design: Present study is a case series

Methods: Patients diagnosed with recurrent nasopharyngeal carcinoma (NPC) that underwent combined open and endoscopic nasopharyngectomy from 2016 to 2020 were analyzed retrospectively in a single institution. A cadaver dissection was also performed to highlight the critical anatomy.

Results: The open lateral approach consists of a preauricular incision extending from the temple to the neck. The superior and inferior facial nerves are kept within the parotid and mobilized to decrease traction on the nerves directly. The zygoma and mandibular ramus can be removed and replaced. Extending along the skull base, V3, and Eustachian tube are managed, and the carotid canal may be drilled to the level of the foramen lacerum. The remainder of the carotid is identified and protected from a transcervical approach after cutting the mandibular ligament. A pledget is placed over the carotid for protection. Then, tumor mucosal cuts are made via an endoscopic endonasal approach. These endoscopic cuts are carried to the open infratemporal fossa dissection. Management of the carotid up and through the carotid canal is achieved via the transcervical approach allowing for confident dissection endoscopically. Further drilling of the canal to foramen lacerum is achieved via either approach. Pterygoid plates are resected through the lateral approach. A free flap may be utilized for carotid or mucosal coverage. No carotid artery injury was reported. We present the details of workup, interoperative decision-making/approach, and follow-up in three patients with recurrent nasopharyngeal carcinoma.

Conclusion: The combined open lateral approach and endoscopic nasopharyngectomy technique without a maxillary swing is a useful technique in previously operated and irradiated patients with recurring nasopharyngeal cancer. It provides excellent control of major vessels, adequate access to the carotid canal, V3, and remainder of the skull base, and cervical and bony protection.

Fig. 1 Cadaveric dissection of the left preauricular approach revealing the carotid artery (*) and carotid canal (**).

Publikationsverlauf

Artikel online veröffentlicht:
12. Februar 2021