How To: Nasopharyngectomy without Maxillary Swing via a Combined Open Lateral and Endoscopic Approach

by Zachary Elliott, BS, Sean Parsel, DO, Brian Swendseid, MD, Kevin B. Xiao, MD, S. Hamad Sagheer, MD, Joseph M. Curry, MD, Mindy Rabinowitz, MD, Gurston Nyquist, MD, Marc R. Rosen, MD, James Evans, MD, Christopher J. Farrell, MD, and Adam J. Luginbuhl, MD •

INTRODUCTION

Nasopharyngectomy can be used as a salvage surgery to remove residual or recurrent nasopharyngeal carcinomas (rNPC) after radiotherapy and is associated with improved local control and increased overall survival compared to reirradiation alone (World J Otorhinolaryngol Head Neck Surg. 2015;1:34–43; Otolaryngol Clin North Am. 2011;44:1141–1154). The proximity of the nasopharynx to the skull base and critical anatomic structures, however, particularly the internal carotid artery (ICA), makes surgical resection of the nasopharynx challenging. To access these tumors, transfacial and transcervical corridors have been described, most notably through a maxillary or mandibular swing or endoscopic endonasal approach (Int Forum Allergy Rhinol. 2017;7:425–432).

The maxillary swing is a well-described approach that involves facial translocation through Le Fort I osteotomies and allows access to the nasopharynx and parapharyngeal space through the posterior wall of the maxillary sinus for en bloc resection. Although this approach results in better survival rates, there are risks of infraorbital nerve injury, facial numbness, trismus, palatal fistula, osteonecrosis, and difficulty accessing and protecting the ICA (World J Otorhinolaryngol Head Neck Surg. 2015;1:34–43).

Although a transcervical or transfacial approach affords maximal access to the nasopharynx, it has high postoperative morbidity. Endoscopic nasopharyngectomy provides minimally invasive access and is considered by many to be the preferred surgical treatment for rNPCs when feasible based on tumor anatomy and surgeon skill. Optical telescopes offer improved visualization of the nasopharynx compared to open approaches and allow for closer visualization of tumor margins. Using expanded endoscopic techniques, many tumors can be accessed using an endonasal approach with significantly reduced morbidity. Despite this access, identification of the parapharyngeal ICA remains challenging, as direct visualization is hindered by soft tissue and tumor. To mitigate these issues, we describe a method of combining a lateral transcervical approach, to provide proximal ICA control and early visualization without the morbidity of a maxillary swing, with the endonasal endoscopic approach, allowing two teams to work concurrently and more expeditiously with improved ICA management and sound oncologic control of the tumor laterally at the Eustachian tube and parapharyngeal space.

METHOD

A retrospective case series of patients with nasopharyngeal malignancies who underwent combined open lateral approach and endoscopic transnasal nasopharyngectomy was performed. Patients were included if they underwent a combined approach for resection of nasopharyngeal tumor and excluded if they underwent endoscopic resection without a simultaneous lateral approach. Data were collected on three males with rNPC and two females with adenoid cystic carcinoma. A cadaveric dissection was also performed to demonstrate the approach and identify relevant anatomy.