Introduction and Objectives: Endoscopic nasopharyngectomy (ENP) is a recently described surgical method that is
increasingly favored over open approaches due to comparable outcomes and reduced morbidity
for management of nasopharyngeal carcinoma (NPC). While the current literature has
focused on its role in the treatment of recurrent NPC, especially in regions where
NPC is endemic, its potential application extends to a wider range of pathologies.
The aim of this study is to characterize the application and outcomes of ENP at a
North American tertiary-care hospital over the past decade.
Methods: Retrospective review of all patients undergoing ENP for tumors in the nasopharynx
at a single tertiary-care center between 2013 and 2023. Patients with extensive tumor
centered elsewhere with extension to the nasopharynx were not included. All patients
who underwent this surgery were included. Relevant data were collected via chart review.
Results: A total of fifteen patients underwent ENP during this period, with a mean age of
61.4 years (range: 18–87). Mean follow-up was 112.3 months (SD: 96.1). Tumor types
included 7 (47%) recurrent nasopharyngeal carcinoma (NPC), 2 (13.2%) clear cell renal
carcinoma, 1 (6.7%) recurrent adenoid cystic carcinoma, 1 (6.7%) p16+ squamous cell
carcinoma, and 4 (26.4%) benign tumors (angiofibroma, angioleiomyoma, congenital choristoma,
and recurrent pleomorphic adenoma). For 33% of subjects, this was a primary surgery,
and 20% underwent simultaneous open transcervical exposure of the carotid artery.
No major intraoperative complications were encountered. Wound closure techniques included
a combination of nasoseptal flap (27%), other pedicled mucosal flap (20%), free mucosal
graft (60%), buccal fat rotational flap (47%), and temporoparietal flap (7%). Nine
patients had a history of prior nasopharyngeal radiation preoperatively and five received
adjuvant radiation; four of these were re-irradiation. Postoperative osteoradionecrosis
(ORN) developed in 5 (33%) patients. Of patients with ORN, 2 (40%) had reconstruction
with a pedicled mucosal flap and the remaining 3 with a rotational buccal fat flap
and free mucosal graft, all 3 of which underwent reirradiation. The single re-irradiated
patient who did not develop ORN had a temporoparietal flap with a vascularized buccal
fat pad flap. Long-term complications included eustachian tube dysfunction (47%),
dysphagia (33%), velopharyngeal insufficiency (7%), and patulous eustachian tube (7%).
There was no correlation of tumor type with complications. Tumor type of NPC was associated
with salvage surgery (p = 0.005). Four patients had tumor recurrence after ENP, with 1 recurrent adenoid
cystic carcinoma and the remaining recurrent NPC. 75% (N = 3) of recurrent tumors had positive margins on surgical pathology.
Conclusion: ENP is an increasingly utilized approach to tumors involving the nasopharynx. NPC
is the most common indication for ENP; however, other indications include a variety
of malignant and benign tumors. Common postoperative complications include dysphagia,
eustachian tube dysfunction, and ORN in patients receiving high doses of radiation.
The work-horse nasal septal flap is not always available as an option; thus, attention
to improved vascularized closure techniques is necessary.
