Complications including dysphagia following transoral non-robotic surgery for pharyngeal and laryngeal squamous cell carcinoma: A retrospective multicenter study

OBJECTIVE

Transoral surgery is a minimally invasive treatment but may cause severe dysphagia at a lower rate than chemoradiotherapy.

METHODS

We compared clinical information, surgical complications, and swallowing function in patients who underwent transoral nonrobotic surgery for laryngo-pharyngeal squamous cell carcinoma between 2015 and 2021 in a multicenter retrospective study.

RESULTS

Six hundred and forty patients were included. Postoperative bleeding was observed in 20 cases (3.1%), and the risk factor was advanced T category. Postoperative laryngeal edema was observed in 13 cases (2.0%), and the risk factors were prior radiotherapy, advanced T stage, and concurrent neck dissection in patients with resected HPC. Dysphagia requiring nutritional support was observed in 29 cases (4.5%) at 1 month postoperatively and in 19 cases (3.0%) at 1 year postoperatively, respectively. The risk factors for long-term dysphagia were prior radiotherapy and advanced T category. Short-term risk factors for dysphagia were prior radiotherapy, advanced T category, and concurrent neck dissection, while long-term risk factors for dysphagia were only prior radiotherapy and advanced T category.

CONCLUSION

Prior radiotherapy, advanced T stage, and concurrent neck dissection increased the incidence of postoperative laryngeal edema and short-term dysphagia, but concurrent neck dissection did not affect long-term dysphagia. Such features should be considered when considering the indication for transoral surgery and postoperative management.

MRI and frozen section evaluation of mylohyoid muscle in determining surgical approach for T2-T3 floor of the mouth cancer

PURPOSE

The choice of surgical approach for floor of the mouth (FOM) cancer, particularly for intermediate-stage tumors (cT2-cT3), remains controversial. This study aims to evaluate a method considering mylohyoid muscle (MM) invasion as a determinant for surgical approach selection, utilizing magnetic resonance imaging (MRI) preoperatively and frozen section (FS) analysis intraoperatively.

METHODS

This observational retrospective cohort study analyzed patients undergoing surgical resection of cT2 and cT3 FOM squamous cell carcinoma (SCC) between January 2013 and June 2023. MM infiltration assessed by preoperative MRI determined the surgical approach: clear infiltration led to compartmental surgery (CS), while doubtful or absent infiltration led to transoral surgery (TOS). Conversion from TOS to CS occurred intraoperatively based on macroscopic evidence or positive FS. Data collected included demographic, clinical, surgical, and pathological variables. Survival analysis was conducted using Kaplan-Meier method.

RESULTS

Among 44 patients included, majority had cT2 tumors (59.1%). MM resection was necessary in 22.7% of cases. Overall survival (OS) and progression-free survival (PFS) did not significantly differ between TOS and CS groups. Radiological depth of invasion (rDOI) < 10 mm is correlated with MM preservation in 89% of cases, while rDOI > 10 mm is correlated with MM resection only in 23.8% of cases. Pathological depth of invasion (pDOI) discrepancies were observed in the two groups: in CS group is shown a higher pDOI (> 10 mm) confirmation (90%). Surgical complications and functional outcomes differed between TOS and CS groups.

CONCLUSION

Considering MM invasion for surgical approach selection in cT2-cT3 FOM tumors appears oncologically safe, with better functional outcomes in muscle preservation. Preoperative MRI for MM assessment combined with intraoperative FS analysis provides reliable guidance for surgical decision-making.

Artificial intelligence-based diagnosis of the depth of laryngopharyngeal cancer

OBJECTIVE

Transoral surgery (TOS) is a widely used treatment for laryngopharyngeal cancer. There are some difficult cases of setting the extent of resection in TOS, particularly in setting the vertical margins. However, positive vertical margins require additional treatment. Further, excessive resection should be avoided as it increases the risk of bleeding as a postoperative complication and may lead to decreased quality of life, such as dysphagia. Considering these issues, determining the extent of resection in TOS is an important consideration. In this study, we investigated the possibility of accurately diagnosing the depth of laryngopharyngeal cancer using radiomics, an image analysis method based on artificial intelligence (AI).

METHODS

We included esophagogastroduodenoscopic images of 95 lesions that were pathologically diagnosed as squamous cell carcinoma (SCC) and treated with transoral surgery at our institution between August 2009 and April 2020. Of the 95 lesions, 54 were SCC in situ, and 41 were SCC. Radiomics analysis was performed on 95 upper gastrointestinal endoscopic NBI images of these lesions to evaluate their diagnostic performance for the presence of subepithelial invasion. The lesions in the endoscopic images were manually delineated, and the accuracy, sensitivity, specificity, and area under the curve (AUC) were evaluated from the features obtained using least absolute shrinkage and selection operator analysis. In addition, the results were compared with the depth predictions made by skilled endoscopists.

RESULTS

In the Radiomics study, the average cross-validation was 0.833. The mean AUC for cross-validation calculated from the receiver operating characteristic curve was 0.868. These results were equivalent to those of the diagnosis made by a skilled endoscopist.

CONCLUSION

The diagnosis of laryngopharyngeal cancer depth using radiomics analysis has potential clinical applications. We plan to use it in actual surgery in the future and prospectively study whether it can be used for diagnosis.

Outcomes of mini-invasive transoral surgery without neck dissection in supraglottic laryngeal cancer: Real world data from a tertiary cancer center

PURPOSE

The neck management in early-stage cN0 supraglottic cancer represents an argument of debate. The aim of our study is to evaluate the oncological and functional outcomes in patients with early-stage cN0 supraglottic carcinoma treated with a wait-and-see policy for the neck.

MATERIALS AND METHODS

Retrospective monocentric cohort study in a referral cancer care center. We collected a consecutive sample of patients from 2000 to 2020 with Squamous Cell Carcinoma of the supraglottis without clinical evidence of nodal metastases (cN0), surgically treated with Transoral Surgery (Laser or Robotic) without neck dissection. From 316 supraglottic cancer we finally selected 66 eligible participants that met all inclusion criteria.

RESULTS

Sixty-six patients (M 75.8 % vs F 24.2 %), median age 65.8 years (IQR 60.9, 70.5). The most common subsite was the epiglottis (62.1 %). Tumor stage distribution was as follows: 35 % cT1, 53 % cT2, 15.2 % cT3. Neither deaths nor major treatment-related complications were reported after surgery. The median follow-up was 62 months. For oncological outcomes, we evaluated 56 patients (10 excluded for adjuvant radiotherapy): 5-year overall survival rate 87 % (CI 95 %: 73.1-94), disease- specific survival rate 95.3 % (CI 95 %: 82-98.8) and neck recurrence-free survival rate 87 % (CI 95 %: 73.1-94). Six patients developed neck recurrence, with a median time of 13 months.

CONCLUSIONS

Supraglottic carcinoma has been historically associated to a considerable risk of occult metastasis. However, in early-stage cases data are still inconclusive. Our results suggest that in such patients a wait-and-see policy does not impact negatively on survival outcomes, while granting the reduced morbidity associated to a minimally invasive surgical approach.

Preservation of superior laryngeal nerve in transoral surgery: A technology to enhance the recovery of swallowing function after surgery of hypopharyngeal carcinoma

OBJECTIVES

We intended to preserve the internal branch of superior laryngeal nerve in transoral surgery of hypopharyngeal squamous cell carcinoma and observe swallowing function recovery.

METHODS

26 patients with hypopharyngeal squamous cell carcinoma underwent transoral surgery with the preservation of internal branch of superior laryngeal nerve. Sensation in the pharyngolaryngeal mucosa was tested by flexible laryngoscope and swallow function was evaluated by water swallow test and MD Anderson Dysphagia Inventory questionnaire after surgery.

RESULTS

Surgeries were successfully performed in all patients. The internal branch of superior laryngeal nerve were preserved in all patients. Testing of mucosa sensation revealed the presence of the cough reflex in most patients. The water swallow test showed that 12 cases (46.15%) on the 1st day, 23 cases (88.46%) on the 7th day and 25 cases (96.15%) on the 14th day after operation had normal swallowing function. The mean score of MD Anderson Dysphagia Inventory was 98 on the 14th day after operation. All patients achieved an oral soft diet at a median of 3 days (range, 2-6 days), full normal oral diet at a median of 5.5 days (range, 4-10 days) and removal of the nasogastric tube at a median of 6 days (range, 5-11 days). During the two-year follow-up, 3 patients recured, 1 patient died of lung metastasis.

CONCLUSIONS

Preserving of the internal branch of superior laryngeal nerve in transoral surgery is feasible, and it can help to achieve a satisfactory recovery of the swallowing function after surgery of hypopharyngeal squamous cell carcinoma.

Thunderbeat®: a new step forward in transoral surgery-systematic review of literature and our experience

INTRODUCTION

Minimally invasive surgery is today the main challenge of ENT surgeons who aim to achieve oncological radicality with less aesthetic and functional impact. This is the basis for the widespread transoral surgical techniques, as the Thunderbeat^®.

OBJECTIVE

To date, the use of Thunderbeat^® in transoral surgery is still little known and widespread. So, this study analyzes, with a systematic review, current literature about the transoral use of Thunderbeat^® and shows our case studies.

METHODS

The research was carried out on Pubmed, Scopus, Web of Science and Cochrane databases using specific keywords. Then, a retrospective study was carried out on 10 patients who underwent transoral surgery by Thunderbeat^® in our ENT Clinic. Both in our cases and in the systematic review the following parameters have been evaluated: treated anatomical site and subsite, histological diagnosis, type of surgery, duration of nasogastric tube and hospitalization, post-operative complications, tracheostomy, resection margin status.

RESULTS

The review included 3 articles that described transoral use of Thunderbeat^® for a total of 31 patients suffering from oropharyngeal, hypopharyngeal and/or laryngeal carcinoma. Nasogastric tube was removed after 21.5 days on average, temporary tracheostomy was performed in 6 patients. The main complications were: bleeding (12.90%) and pharyngocutaneous fistula (29.03%). Thunderbeat^® shaft was 35 cm long and 5 mm large. Our case studies included 5 males and 5 females, mean age 64.4 ± 10.28, with oropharyngeal or supraglottic carcinoma, parapharyngeal pleomorphic adenoma and cavernous hemangioma of the tongue base. Temporary tracheostomy was performed in 8 patients. Free resection margins were achieved in all cases (100%). No peri-operative complications occurred. Nasogastric tube was removed after 5.3 ± 2 days on average. All patients were discharged without tracheal tube and NGT after 18.2 ± 4.72 days on average.

CONCLUSION

This study demonstrated that Thunderbeat^® has several advantages over other transoral surgical approaches, such as CO2 laser and robotic surgery, in terms of best combination of oncological and functional success, less post-operative complications and costs. So, it could represent a step forward in transoral surgery.

Resection of an oropharyngeal venous malformation

BACKGROUND

Venous malformations (VMs) are congenital vascular lesions caused by enlarged and ectatic venous channels. Current methods of treatment for VMs involve a combination of sclerotherapy, laser therapy, and surgical resection. While sclerotherapy remains the most commonly used treatment for small VMs, surgery remains an important tool for isolated VMs or larger VMs with higher flow due to potential local and systemic side effects associated with the use of certain sclerosing agents.

METHODS/RESULTS

Here we present a case of a patient with a naso- and oropharyngeal venous malformation which was successfully resected with endoscopic-assisted transoral surgery.

CONCLUSIONS

This is a low-fingerprint technique to tumors of the oropharynx with excellent visualization and maneuverability in cases where TORS is not an option. This technique does not require palate splitting or excessive retraction, allows multiple surgeons to work simultaneously, and is associated with significantly lower morbidity than transcervical techniques.

LEVEL OF EVIDENCE

N/A.

A prospective evaluation of postoperative swallowing function and dysphagia following endoscopic laryngopharyngeal surgery

BACKGROUND

Endoscopic laryngopharyngeal surgery (ELPS) is a minimally invasive transoral surgery for superficial pharyngeal and laryngeal cancer, but dysphagia occasionally occurs post-treatment. We investigated dysphagia following ELPS and its risk factors.

METHODS

Of the 145 patients who underwent ELPS, 92 were evaluated in this study using the Hyodo score, Functional Outcome Swallowing Scale, Eating Assessment Tool-10 along with the total scores for the three items of the method of intake, time, and food preoperatively and on postoperative 1, 3, and 6 months. We examined the 6-month trends of these values. Furthermore, the fasting period post-surgery, the need for swallowing rehabilitation by a speech therapist, and postoperative pneumonia episodes were set as outcomes reflecting the short-term swallowing function. We determined the associations between these outcomes and patient background factors.

RESULTS

Postoperatively, the Hyodo score worsened at 1 month but recovered at 3 months. The Hyodo scores of all patients who underwent postcricoid ELPS did not worsen. The diameter of the resected specimen (DRS) was significantly associated with the need for swallowing rehabilitation and postoperative fasting time. A DRS ≥ 35 mm was considered the threshold for the need of swallowing rehabilitation, postoperative pneumonia, and prolonged postoperative fasting time.

CONCLUSION

ELPS exerts a temporal and limited impact on the swallowing function, which recovers within 3 months in every swallowing evaluation. This necessitates additional care during the treatment of patients with mucosal defects ≥ 35 mm, owing to the significant association between the DRS and short-term swallowing function.

Efficacy of endoscopy under general anesthesia for the detection of synchronous lesions in oro-hypopharyngeal cancer

Background/Aims

Image-enhanced endoscopy can detect superficial oro-hypopharyngeal squamous cell carcinoma; however, reliable endoscopy of the pharyngeal region is challenging. Endoscopy under general anesthesia during transoral surgery occasionally reveals multiple synchronous lesions that remained undetected on preoperative endoscopy. Therefore, we aimed to determine the lesion detection capability of endoscopy under general anesthesia for superficial oro-hypopharyngeal squamous cell carcinoma.

Methods

This retrospective study included 63 patients who underwent transoral surgery for superficial oropharyngeal squamous cell carcinoma between April 2005 and December 2020. The primary endpoint was to compare the lesion detection capabilities of preoperative endoscopy and endoscopy under general anesthesia. Other endpoints included the comparison of clinicopathological findings between lesions detected using preoperative endoscopy and those newly detected using endoscopy under general anesthesia.

Results

58 patients (85 lesions) were analyzed. The mean number of lesions per patient detected was 1.17 for preoperative endoscopy and 1.47 for endoscopy under general anesthesia. Endoscopy under general anesthesia helped detect more lesions than preoperative endoscopy did (p<0.001, paired t-test). The lesions that were newly detected on endoscopy under general anesthesia were small and characterized by few changes in color and surface ruggedness.

Conclusions

Endoscopy under general anesthesia for superficial squamous cell carcinoma is helpful for detecting multiple synchronous lesions.

Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

INTRODUCTION

Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars.

METHODS

Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021.

RESULTS

Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity.

CONCLUSTIONS

Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

CO2-TOLMS for laryngeal cancer in the elderly, pushing the boundaries of partial laryngectomy

INTRODUCTION

CO₂ transoral laser microsurgery (CO₂-TOLMS) has pushed the indications of partial surgery of the larynx regardless the age of the patient.

OBJECTIVE

To evaluate the complications and the oncologic and functional outcomes of CO₂-TOLMS in patients older and younger than 70 years.

METHODS

Retrospective analysis of 1244 consecutive laryngeal carcinomas treated with CO₂-TOLMS. Complications, length of hospitalization, functional and survival outcomes were evaluated.

RESULTS

The mean age was 64.2 ± 11.1 years (20-96). Four hundred and sixteen patients were older than 70 years and 104 older than 80 years. The main location was the glottis (912), followed by the supraglottis (332). There were no differences in pT classification between the age groups. No differences were observed in voice outcomes. A higher rate of signs of aspiration at the glottic location was observed for those older than 70 years (2.1 % vs 5 %, p = 0.027). The need for definitive gastrostomy in supraglottic tumours was higher in those older than 70 years (0 % vs 6.5 %, p: 0.001). In the glottis, no differences in tracheostomy or gastrostomy rates were observed. Five-year overall survival was lower in the older than 70 years. No differences in disease-specific survival were observed in early stages for both locations, but a lower survival was observed in stage III glottic cancer for the older than 70 years.

CONCLUSIONS

CO₂-TOLMS is a valid treatment for laryngeal carcinomas in the elderly, with a reduced number of complications and good functional and oncologic outcomes.

Evaluation of chronological changes in videofluorographic findings after transoral videolaryngoscopic surgery to reveal mechanism of dysphagia

OBJECTIVES

Transoral surgery preserves good swallowing function in most cases, however, postoperative dysphagia sometimes leads to fatal complication such as aspiration pneumonia. We investigated the chronological changes in swallowing function have not been revealed relationship with dysphagia. The primary aim of this study was to reveal the mechanism of dysphagia following transoral surgery by analyzing chronological videofluorography (VF) findings. Moreover, the secondary aim of this study was to evaluate the relationship between mechanism of dysphagia and risk factors of patients to clarify the risk for dysphagia lead to prevention of postoperative complications.

METHODS

22 patients who underwent transoral videolaryngoscopic surgery (TOVS) for either supraglottic or hypopharyngeal cancer were evaluated swallowing function. We performed VF during the preoperative, postoperative acute, and stable phases and investigated the chronological changes in the VF findings. The following parameters were evaluated by VF: horizontal distance of laryngeal movement, vertical distance of laryngeal elevation, laryngeal elevation delay time (LEDT), Bolus Residue Scale (BRS) scores, and Penetration Aspiration Scale (PAS) scores. Additionally, we evaluated risk factors for postoperative aspiration by investigating relationships between preoperative VF parameters, age of patients, history of radiation therapy, resection area, tumor (T) stage, postoperative Numeric Rating Scale (NRS), and PAS and BRS scores.

RESULTS

The median time at which oral feeding was resumed in this study was 9 (2-200) days. The patients who had postoperative acute PAS scores of 4 and above exhibited delays in resuming oral ingestion after surgery. TOVS did not impair laryngeal elevation and LEDT; however, the BRS and PAS scores temporarily worsened in the acute phase compared to the preoperative scores. These scores almost recovered to their preoperative states in the stable phase, and both the BRS and PAS scores worsened and recovered concurrently. Patients who exhibited poor vertical distance in laryngeal elevation as observed via preoperative VF or who had histories of radiation therapy had worse PAS scores in postoperative acute phase VF. Patients with broad resection areas had worse BRS scores in postoperative acute phase VF.

CONCLUSION

TOVS didn't impair the function of laryngeal elevation and elicitation of the swallowing reflex whereas pharyngeal bolus clearance, laryngeal penetration, and aspiration temporarily deteriorated concurrently but eventually almost recovered to their baseline values. Patients with histories of radiotherapy, poor laryngeal elevation, and broad resection areas are at the risk of postoperative dysphagia after TOVS. Patients with these risk factors need appropriate evaluation before resuming postoperative oral intake.

[Organ preservation in oropharyngeal cancers treatment: What arguments for radiotherapy?]

Management of oropharyngeal cancer depends on several factors. Immediate surgery or radiotherapy may be considered. If the patient is operable, the choice depends on the extent of the disease, the contributing factors, and the expected functional results. For HPV-positive cancers, studies show comparable efficacy between surgery and radiotherapy. For early-stage cancers, unimodal treatment should be preferred. For HPV-negative cancers, the results of retrospective and observational studies are in favor of surgery. These studies have some limitations. In observational and/or retrospective studies, reclassification biases and the applicability of propensity scores weaken the validity of studies showing differences in management. Tumor and patient comparability are others majors interpretation biases. It is precipitate to conclude that surgery is superior for HPV-negative oropharyngeal cancers. Toxicity, therefore, becomes a criterion of choice for treatment. Unimodal management by surgery allows limited toxicity for the early stages. Surgery has less impact on salivation. Radiotherapy is rather less deleterious for swallowing in the early stages. For the advanced stages of HPV-induced tumors, the non-superiority of surgery should lead to the choice of radiochemotherapy. For oropharyngeal cancers, the possible benefit of surgery in HPV-negative oropharyngeal cancers must be confirmed in randomized studies. For the early stages of oropharyngeal cancer with unimodal treatment, management could be decided by shared decision making.

Injection laryngoplasty during transoral laser microsurgery for early glottic cancer: a randomized controlled trial

BACKGROUND

Transoral laser microsurgery is widely used for treating T1/T2 glottic cancers. Hyaluronic acid (HA) is commonly used in vocal cord augmentation. We investigated the impact of intra-operative injection laryngoplasty on voice outcomes in early glottic cancer.

METHODS

Twenty patients were randomized to the treatment group receiving HA injection to the vocal cord contralateral to the lesion; or the control group, receiving no injection. Patients had a Voice Handicap Index-10 (VHI-10) questionnaire and a Maximum Phonation Time (MPT) measurement preoperatively and at 3, 12 and 24 months post-operatively. Mean change in VHI-10 and MPT, compared to baseline and between time points, were compared. Survival estimates were calculated.

RESULTS

Mean VHI-10 scores improved over time amongst all patients. There were no changes in mean VHI-10 from pre-operative values to 3, 12 or 24 months post-operatively. There were no significant differences when comparing various timepoints between groups. There were no significant changes in MPT amongst the groups, or the time-points compared. Two-year overall survival was 91.7%; disease free survival was 80.9%; no difference in recurrence free survival was seen between the groups.

CONCLUSION

Subjective voice scores improved over time in both groups; there were no improvements in VHI-10 or MPT scores in the injection group, over control, at any time points. We saw no significant impact for intra-operative HA injection laryngoplasty on subjective or objective voice outcomes following surgery for early glottic cancers.

Quantifying Tumor and Vasculature Deformations during Laryngoscopy

Retractors and scopes used in head and neck surgery to provide adequate surgical exposure also deform critical structures in the region. Surgeons typically use preoperative imaging to plan and guide their tumor resections, however the large tissue deformation resulting from placement of retractors and scopes reduces the utility of preoperative imaging as a reliable roadmap. We quantify the extent of tumor and vasculature deformation in patients with tumors of the larynx and pharynx undergoing diagnostic laryngoscopy. A mean tumor displacement of 1.02 cm was observed between the patients' pre- and intra-operative states. Mean vasculature displacement at key bifurcation points was 0.99 cm. Registration to the hyoid bone can reduce tumor displacement to 0.67 cm and improve carotid stem angle deviations but increase overall vasculature displacement. The large deformation results suggest limitations in reliance on preoperative imaging and that using specific landmarks intraoperatively or having more intraoperative information could help to compensate for these deviations and ultimately improve surgical success.

Complications of occipitocervical fixation: retrospective review of 128 patients with 5-year mean follow-up

PURPOSE

Occipitocervical fusion is necessary for many pathologies of the craniocervical junction. The anatomy of the region is unique, and fusion can cause significant morbidity. This retrospective review aims to investigate the complication rates and outcomes of occipitocervical fixation.

MATERIAL AND METHODS

This is a retrospective review of 128 patients with occipitocervical fixation operated between 1994 and 2020. The average follow-up is 63 months.

RESULTS

The indications of occipitocervical fixation were basilar invagination (53 patients; 41.4%), trauma (25 patients; 19.5%), tumor (23 patients; 18%), instability due to rheumatoid arthritis (13 patients; 10.2%), cervical deformity (7 patients; 5.5%) and os odontoideum (7 patients; 5.5%). There were six early postoperative (1st month) deaths. We observed complications in 67 patients (52%). Most common complication was implant-related (32%), followed by wound problems (23.4%), systemic and other complications (11.7%), neurologic complications (6.2%). Implants are removed in 31 patients (24%) for different reasons: deep wound infection (7), local pain and restriction of head movements (21), respiratory distress and swallowing problems (2), screw fracture and local pain (1).

CONCLUSIONS

Occipitocervical fixation has quite large number of complications and significantly restricts head movements. With the advent of our biomechanical concepts, indications should be limited, and shorter cervical fixations should be preferred.

LEVEL OF EVIDENCE

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Transoral thyroid surgery vestibular approach: is there an increased risk of surgical site infections?

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an upcoming surgical technique with the aim to optimize cosmetic outcome avoiding visible scars in the neck. However, the transoral access bears the risk of contamination and microbial allocation from the mouth into the thyroid region. Therefore, some authors recommend extended antibiotic therapy up to 7 days after surgery. Our aim was to evaluate infection rates and parameters before and after transoral surgery and to suggest a viable and safe routine in transoral surgery. Prospectively collected data of patients who were eligible for transoral surgery in Austria and Germany between June 2017 and July 2020 were retrospectively evaluated focussing on clinical and laboratory infection signs pre and postoperatively. White blood cell count (WBC) and C-reactive protein levels (CRP) were estimated before and after surgery. Patients` characteristics, surgical outcome and complications were also determined and compared to the current results reported in the literature. 113 transoral operations were performed in 108 patients. In 37 of 108 (36%) patients an additional retroauricular incision in the hairline and in two patients a submental skin incision was performed to extract thyroid specimen of more than 40 ml. Intravenous antibiotic prophylaxis and enoral mucosal disinfection were used in all patients before surgery. WBC and CRP levels were available in 75 patients. Median WBC was 5800/µl (range 3500–10,500/µl) before and significantly higher (median 8900/µl, range 4500–18,800 µl; p < 0.01) at day one after surgery. WBC returned to normal range (4500–11,500/µl) in all patients within the first 7 days postoperatively (median 5300/µl, range 3400–8700/µl). CRP levels were normal before (< 0.5 mg/dl) and slightly elevated within the first two days after surgery (Median 2.0 mg/dl, range 0.5–6.4 mg/dl, n.s.). In one patient oral antibiotic therapy was necessary due to transient erythema in the chin region which occurred 10 days after surgery and resolved completely without surgical intervention. Despite a transient increase in WBC transoral thyroid and parathyroid surgery via the vestibular approach does not seem to be associated with a significant number of wound infections in our patients. Intravenous antibiotic prophylaxis and enoral mucosal disinfection might be reasonable procedures to avoid microbial allocation from the mouth into the thyroid region. However, further investigations are required to finally estimate the need of antibiotics in transoral surgery.

The CO2 waveguide laser with flexible fiber in transoral resection of oral and oropharyngeal cancers: a retrospective cohort study on postoperative and quality of life outcomes

The aim of this study was to evaluate the CO₂ waveguide laser (WG CO₂ laser) with flexible fiber (Lumenis Ltd., Yokneam, Israel) in the treatment of oral and oropharyngeal cancers, specifically focusing on postoperative outcomes, pain, and quality of life (QoL). Eighty-one patients, 43 women and 38 men, with oral or oropharyngeal cancer who consecutively underwent transoral resection by WG CO₂ laser from August 2015 to April 2020 were retrospectively enrolled. Resections were performed in super pulsed mode with a power setting ranging between 3 and 10 W. Data about frozen sections, reconstruction, complication rate, length of hospital stay, tracheostomy rate and time to decannulation, nasogastric feeding tube rate and time to oral feeding, pain, and QoL were reviewed. Continuous variables were presented as mean and standard deviation. Concordance between intraoperative frozen section examination and definitive histology was calculated using Cohen's K test of agreement. The mean length of hospital stay was 13 days. The feeding tube rate was 81%; the tracheostomy rate was 35%; the feeding tube was left in place for 8 days on average, and the time to decannulation was 9 days. The only complication was a postoperative bleeding in 4 patients. The median postoperative pain score measured by the Numeric Pain Rating Scale on postoperative days 1, 3, and 5 was 0 and there was a constant decrease in painkiller use over the days. The overall mean composite QoL score was 77 ± 14, with excellent results in saliva, taste, pain, and speech domains. Frozen section evaluation had a specificity of 99% and a negative predictive value of 98%. WG CO₂ laser is a good and safe tool for transoral tailored resection of oral and oropharyngeal cancers. It ensures a good overall QoL and guarantees fast recovery and a very low postoperative pain.

Validation of the risk factors for primary control of early T-stage laryngeal, oropharyngeal, and hypopharyngeal squamous cell carcinoma by transoral surgery: a prospective observational study

BACKGROUND

We had previously identified the following risk factors for insufficient control of early T-stage head and neck cancer by transoral surgery (TOS): (1) tumor thickness > 7 mm on enhanced computed tomography (CT), and (2) poor differentiation in pathological examination. We subsequently used a different patient cohort to validate the usefulness of these factors in determining the need for adaptation of TOS.

STUDY SETTING

A prospective observational study METHODS: Patients who received TOS as a definitive treatment between April 1, 2016 and September 30, 2020 were included. Primary control rates (by single TOS and TOS alone) in relation to the above-mentioned risk factors were calculated. Overall (O), recurrence-free (RF), and disease-free (DF) survival (S) outcomes were evaluated. A combination analysis based on the number of risk factors was also performed.

RESULTS

Patients with tumor thickness > 7 mm had a 2.88-fold [95% confidence interval (CI) 1.01-8.51] higher risk of incomplete primary resection by single TOS, while patients who showed poor differentiation on pathological assessments had a 13.14-fold (95% CI 3.66-47.14) higher risk of insufficient primary control by TOS alone. The 3 year OS, RFS, and DFS rates were 99%, 83%, and 63%, respectively. Patients with both risk factors had a 93.00-fold (95% CI 4.99-1732.00) higher risk of incomplete primary control by TOS alone.

CONCLUSIONS

Among patients with early-stage laryngeal, oropharyngeal, and hypopharyngeal squamous cell carcinoma, primary control by TOS alone may not be achieved in patients with both risk factors, that is, tumor thickness > 7 mm as measured by enhanced CT and poor differentiation on pathological examination.

Buccal fat pad to improve velum competency after transoral lateral oropharyngectomy

This technical note documents an easily reproducible technique to improve velar competency after transoral lateral oropharyngectomy extending to the velum.

Transoral Excision of Parapharyngeal Space Tumors

Transoral excision of parapharyngeal space (PPS) tumors has increased in popularity along with the increased use of robotic and endoscopic surgical technology. Here, the authors highlight the indications, techniques, outcomes, and complications of transoral approaches to PPS tumors, with a special emphasis on salivary tumors of the PPS and the transoral robotic surgery approach.

Evaluation of synchronous multiple primary superficial laryngo-pharyngeal cancers that were treated by endoscopic laryngo-pharyngeal surgery

OBJECTIVE

ndoscopic laryngopharyngeal surgery (ELPS) is a useful surgery for superficial cancers of the head and neck region, but it has not yet been well evaluated for synchronous multiple primary cancers (multiple primaries). The purpose of this study was to clarify the safety and usefulness of ELPS for patients with multiple superficial primary cancers in the head and neck region.

METHODS

rom December 2009 to December 2016, 145patients with superficial head and neck cancers underwent ELPS. The patients were divided into two groups; a group consisting of patients with a single primary cancer (single primary) and another group consisting of patients with synchronous multiple primaries, and the incidences of postoperative complications and lymph node metastasis were retrospectively compared between the two groups.

RESULTS

f the 145 patients, 107 had a single primary cancer and 38 had multiple primaries. There was no significant difference in the age, sex, or rate of intraepithelial cancer between the two groups. Postoperative complications included dysphagia in 6 (5.6%) patients with a single primary and 2 (5.3%) patients with multiple primaries. One patient with multiple primaries required gastrostomy because of aspiration pneumonia. In addition, the following complications were also observed. Laryngeal paralysis occurred in 2 (1.9%) patients with a single primary, and 1 (2.6%) patient with multiple primaries; tracheostomy because of postoperative bleeding in 1 (0.9%) patient with a single primary; infection occurred in 2 (5.3%) patients with multiple primaries. Postoperative lymph node metastasis was found in 7 (6.5%) patients with a single primary and 6 (15.8%) patients with multiple primaries. Lymphatic invasion of the primary cancer was noted in 3 (2.8%) patients with a single primary and 5 (13.2%) patients with multiple primaries, being significantly higher in the latter group.

CONCLUSION

ELPS is also a safe surgery for patients with multiple primaries. However, the incidence of lymphatic invasion of the primary cancer was significantly higher in patients with multiple primaries.

A new transoral modality for the treatment of lingual thyroglossal duct cyst with suspension laryngoscopy by plasma coblation

INTRODUCTION

Lingual thyroglossal duct cysts (LTGDC) are a rare kind of thyroglossal duct cyst. However, Sistrunk surgery is not very suitable for this type of cyst. This study aimed to explore the efficacy of transoral excision of LTGDC by plasma coblation.

METHODS

The present study reviewed 11 patients, comprising seven males and four females, who had been diagnosed with LTGDC preoperatively by computed tomography (CT) and fibre-optic electronic laryngoscopy. Of those patients, two had recurrence after surgery of epiglottic cysts. All these patients underwent transoral excision by plasma coblation. Then, we collected preoperative data of the patients, observed the effect of surgery, and analysed factors relevant to LTGDC, including the estimated bleeding amount, postoperative hospitalisation, complications and recurrence rates.

RESULTS

The connection between LTGDC and hyoid was tapered on sagittal images of CT, which was vital evidence for the diagnosis of LTGDC. Surgery was performed successfully for all 11 patients, and all recovered without complication. There was no evidence of recurrence after surgery, during follow up for 3-43 months.

CONCLUSIONS

Transoral surgery for LTGDC can be performed successfully by plasma coblation, which is an effective and safe surgical treatment. Fibre-optic electronic laryngoscopy and CT are essential to the diagnosis of LTGDC in order to avoid missing detection and misdiagnosis.

Preclinical experience with a novel single-port platform for transoral surgery

BACKGROUND

We investigated a novel minimally invasive surgical platform for use in the oropharynx, hypopharynx, and larynx for single-port transoral surgery used in concert with standard transoral laryngeal and pharyngeal instrumentation.

METHODS

The preclinical investigational device by Fortimedix Surgical B.V. (Netherlands) features two channels for manually controlled flexible articulating surgical instruments. A third central channel accepts both rigid and flexible endoscopes. The system is coupled to a standard laryngoscope for transoral access. In three cadaver models, we evaluated the surgical capabilities using wristed grasping instruments, microlaryngeal scissors, monopolar cautery, and a laser fiber sheath. Procedures were performed within the oropharynx, supraglottis, glottis, subglottis, and hypopharynx.

RESULTS

Within the oropharynx, we found adequate strength, range of motion, and dexterity to perform lateral oropharyngectomy and tongue base resection. Within the larynx, visualization was achieved with a variety of instruments including a flexible, 0° and 30° rigid endoscope. The glottis, supraglottis, pyriform sinuses, post-cricoid space, and esophageal inlet were readily accessible. Visualization and manipulation of grasping, laser, and monopolar cautery instruments were also possible within the subglottis. Instrument reach and accuracy facilitated completion of a delicate micro-flap on the true vocal fold. Other procedures included vocal fold resection, cricopharyngeal myotomy, and resection of subglottic mucosa.

CONCLUSIONS

From this initial proof of concept experience with this novel platform, we found a wide range of procedures within the oropharynx, larynx, and hypopharynx to be feasible. Further work is needed to evaluate its applicability to the clinical setting. The ability of this platform to be used with conventional instrumentation may provide an opportunity for complex transoral surgery to be performed in a facile manner at greatly reduced cost.

3D 4K VITOM-assisted transoral removal of distal stone in the Wharton's duct

BACKGROUND

The aim of this study was to describe the potential advantages of the transoral 3D 4K exoscope-assisted removal of calculus of the Wharton's duct.

METHODS

A 24-year-old female with swelling in the left oral pelvis was diagnosed of sialolithiasis of distal Wharton's duct. A CT scan confirmed the lithiasic formation and a transoral removal in local anesthesia was planned through the 3D 4K exoscope (VITOM 3D, Karl Storz).

RESULTS

A high-quality magnification of the oral pelvis was obtained, with an easy identification of the entrance of the left submandibular gland's duct and the calculus. After blunt dissection the Wharton's duct was incised and the calculus removed. An angiocatheter (20G) was carefully inserted in the duct and removed after 3 days. No postoperative complications occurred. At 7 days post-operative follow-up the patient had developed a neo-ostium 5 mm from the papilla. The exoscope provided a better involvement in the surgery and more interactions of all operating room personnel, residents and students, that had access to the same field of view of the first surgeon with the perception of the depth of the surgical field with 3D technology.

CONCLUSIONS

The exoscope could represent a valid option for transoral removal of calculi, allowing for precise surgical dissection of the oral floor, thus reducing the risks for iatrogenic lesion of the lingual nerve. It showed also a high potential for training and educational purposes.

Preoperative predictors of dysphagia after transoral surgery

BACKGROUND

Transoral surgery (TOS) has been used to remove pharyngeal and laryngeal cancers with the objective of improving functional without worsening survival. However, there is a risk of postoperative dysphagia, which can severely impair quality of life. The aim of this study was to evaluate the preoperative predictive factors for postoperative dysphagia in patients undergoing TOS.

METHODS

One hundred and twenty patients who underwent TOS were evaluated in this study. The degree of dysphagia was evaluated using the Functional Outcome Swallowing Scale (FOSS) both preoperatively and 3 months postoperatively. Those whose FOSS stage was maintained postoperatively were classified into the FOSS-M group, while those with increased FOSS stage postopratively were classified into the FOSS-I group. The following parameters were assessed before surgery: age, weight, height, body mass index (BMI), forced expiratory volume in 1 s, and history of head and neck radiotherapy. Videofluoroscopy (VF) was performed preoperatively to evaluate swallowing function using the Penetration-Aspiration Scale (PAS).

RESULTS

The BMI of the FOSS-M group was significantly higher than that of the FOSS-I group. A history of radiotherapy was significantly more common in the FOSS-I group than in the FOSS-M group. Finally, preoperative PAS in the FOSS-M group was lower than that in the FOSS-I group.

CONCLUSION

This study suggested that patients with preoperative aspiration detected using VF might develop postoperative dysphagia severely. In addition, preoperative low BMI and a history of previous radiotherapy for head and neck cancer were associated with postoperative dysphagia. Objective examinations such as VF should be performed preoperatively.

Is the retropharyngeal lymph node the first echelon node for carcinoma tonsil? Prospective evaluation and literature review

PURPOSE

Tonsil cancer being predominantly treated by non-surgical means, there is a paucity of data on lymph nodal drainage pathways and histo-pathologically confirmed metastatic rates. This study assesses the retropharyngeal lymph node (RPLN) in N0 squamous cell carcinoma tonsil as a possible first echelon node and a site for occult metastasis.

METHODS

Prospective study involving treatment naïve N0 carcinoma tonsil treated by primary surgery and adjuvant treatment from June 2017 to March 2019. In-vivo lymph nodal drainage patterns were assessed by sentinel node mapping by preoperative SPECT-CT and intra-operative hand-held Gamma probe. All patients had a subsequent Level I-III/IV sampling neck dissection supplemented with RPLN dissection. Histological evaluation of sentinel nodes and RPLN involved step-serial sectioning and pan-cytokeratin immunohistochemistry. A comprehensive literature review was performed with keywords "retropharyngeal lymph node", "oropharynx", "tonsil", "squamous cell carcinoma" to determine the incidence of RPLN positivity in previously published series.

RESULTS

Sentinel node was successfully identified by SPECT-CT in all 17 patients (ipsilateral level 2a-13/17, 2b-1/17, 3-1/17; bilateral 2a-1/17; isolated contralateral retropharyngeal node-1/17). 8/17 had occult neck metastasis. In no patient was an ipsilateral RPLN identified as the sentinel node. Histological sampling did not indicate metastatic tumor in the RPLN in any patient (0/17). A systematic literature review further confirmed that RPLN metastasis in oropharyngeal cancer is noted only in the presence of pN + disease at other neck levels, and isolated RPLN metastasis is extremely rare (1.2%).

CONCLUSION

The ipsilateral RPLN is not identified either as the first echelon node or as a site of occult metastatic disease in N0 tonsil cancer.

CTRI REGISTRATION

CTRI/2019/06/019551.

[Application of rigid curved laryngoscope in the examination of hypopharynx and the treatment of early hypopharyngeal cancer]

Objective: To evaluate the efficacy of curved suspension laryngoscope assistant transoral surgery (CLATOS) in the examination of hypopharynx, and diagnosis and surgery of early hypopharyngeal carcinoma. Methods: Thirty-four patients who underwent detailed examination for lower part of hypopharynx and surgery for early hypopharyngeal carcinoma with CLATOS technique in the Second Affiliated Hospital of Harbin Medical University from January 2019 to January 2020 were analyzed retrospectively. The age ranged from 42 to 74 years old including 28 males and 6 females. Among them, 25 patients complaining of foreign body sensation in the pharynx for more than half a year with a poor exposure of the lower pharynx in the examination with flexible laryngoscope in the outpatient department were admitted to the hospital for the further examination with rigid curved laryngoscopy and 9 patients with stage T1-2 hypopharyngeal squamous cell carcinoma were operated with CLATOS technique. Preoperative, intraoperative and postoperative data were analized. Results: One case of squamous cell carcinoma in esophageal entrance (T1N0M0) and one case of carcinoma in pyriform sinus (T1N0M0) with cervical esophageal carcinoma (T1N0M0) were found in the 25 patients with foreign body sensation in the pharynx. En bloc resection of cancer was obtained in 9 patients with stage T1-2 hypopharyngeal carcinomas and 2 of them underwent tracheotomy. One patient with T1 retrocricoid carcinoma was found to have a carcinoma in situ at the lower part of posterior hypopharyngeal wall in the examination during follow-up, which was resected simultaneously. Postoperatively this patient developed a stenosis in the esophageal entrance, which was dilated twice until swallowing normally. Two patients of T2N0M0 and one of T2N1M0 underwent bilateral neck lymph node dissection just after the removal of primary tumors. During follow-up, none of the 9 patients showed tumor recurrence and complications such as dysphonia and dyspnea. Conclusion: CLATOS technique can provide a promising way in the examination of hypopharynx and the detection of early lesions of hypopharynx and esophageal entrance, and this technique has also the advantages such as full visual angle and easy operation for the resection of early hypopharyngeal carcinoma. The quality of life of patients can be improved while the tumor is removed en bloc with this technique.

Endoscopic transoral approach to accessory parotid gland

Objective; Neoplasm of accessory parotid glands are very rare, accounting for only 1% to 7.7% of all parotid gland tumors. External appproaches including parotidectomy or facelift incision are the recommended treatment, allowing a good control over the anterior facial nerve's branches and Stensen's duct, but they require a large flap elevation and leave an external scar.

METHODS

We report the case of a 76-year-old woman presented with a chief complaint of swelling in the right cheek. The patient underwent ultrasonography, FNAC and MRI which identified a subcutaneous mass over the anterior border of the masseter muscle.

RESULTS

An endoscopic-assisted transoral resection was performed, no postoperative complications were recorded. Final histology was consistent with pleomorphic adenoma.

CONCLUSION

In selected cases, the endoscope-assisted transoral approach allow accessory parotid mass excision with better cosmetic results if compared to the transcutaneous approach. Although not negligible, the risk of facial nerve injury is minimized under endoscopic magnification.

Comparative cost analysis between definitive radiotherapy and transoral surgery for oropharyngeal squamous cell carcinoma: A SEER-Medicare analysis

INTRODUCTION

Primary radiotherapy (RT) and transoral surgery (TOS) are effective local therapy treatments for oropharyngeal squamous cell carcinoma (OPSCC), but their cost profiles differ. We compared the one-year costs of these competing treatments using a large claims-based database.

METHODS

Eligible individuals were patients in the SEER-Medicare registry diagnosed with OPSCC between 2000 and 2011. Patients were categorized as receiving either primary RT +/- chemotherapy, or TOS +/- adjuvant RT or chemoradiotherapy (CRT), and all treatment costs from 1 month prior to diagnosis to 1 year after diagnosis were calculated. Univariable and multivariable linear regression models were used to determine predictors of payer expenditure. Patient-borne pharmacy costs were also analyzed.

RESULTS

The cohort included 3497 patients (73% RT, 27% TOS), of whom 73% were locally advanced. The mean total 13 month costs for RT alone, CRT, TOS alone, TOS + RT and TOS + CRT were $39,083, $63,537, $25,468, $36,592, and $99,919, respectively, for early-stage patients. For locally advanced individuals, the mean costs were $45,049, $68,099, $40,626, $53,729, and $71,397, respectively. On multivariable analysis, the adjusted increase in total costs versus RT alone were $21,844, -$5431, $7984, and $28,581 for CRT, TOS alone, TOS + RT, and TOS + CRT, respectively. The difference between CRT and TOS + RT became non-significant for TOS patients undergoing transoral surgery plus neck dissection. Cisplatin was associated with significant less cost than cetuximab and taxane-based chemotherapy.

CONCLUSION

In this population of elderly patients, transoral surgery was generally associated with less expensive treatment, with the addition of chemotherapy serving as the main driver of increased cost.

Novel induction therapy transoral surgery treatment paradigm with risk-adapted adjuvant therapy for squamous cell carcinoma of the head and neck - Mature clinical and functional outcomes

OBJECTIVE

Induction chemotherapy in head and neck squamous cell carcinoma (HNSCCA) has principally been studied prior to radiation therapy. We evaluated pre-operative induction therapy followed by surgery followed by risk-adapted adjuvant therapy. This report details the mature 5-year survival statistics, clinical and functional outcomes.

METHODS

An IRB-approved single institution prospective phase II clinical trial from October 2012 to November 2016 was conducted for patients with transorally-resectable American Joint Committee on Cancer 7th ed. stage III/IV HNSCCA. Patients were treated once weekly for six weeks with a multi-drug induction regimen of carboplatin, paclitaxel and daily lapatinib followed by transoral surgery and neck dissection. Patients were then stratified based on pathologic response to either observation or adjuvant therapy. Survival statistics and functional patient outcomes were analyzed. Specifically, peri-operative outcomes were analyzed and compared to a matched surgical cohort.

RESULTS

38/40 enrolled patients completed trial therapy. Median hospital stay was 3 days with 9/38 patients receiving a PEG (median 46 days). Median NPO status was 1 day, with a median return to a regular diet in 16 days. Mean patient weight was well preserved from pretreatment to 1 year after surgery (85.1 kg (95% CI 79.6-90.7) vs 83.1 kg (95% CI 77.7-88.6 kg) respectively). Of the 38 patients who completed trial therapy; DSS, PFS and OS were 100%, 97% and 97% respectively with median follow up of 4.9 years (3.33-7.25).

CONCLUSION

Transoral surgery was feasible following this novel induction regimen with excellent peri-operative, functional and longterm survival outcomes.

Comparative effectiveness trial of transoral head and neck surgery followed by adjuvant radio(chemo)therapy versus primary radiochemotherapy for oropharyngeal cancer (TopROC)

BACKGROUND

For loco-regionally advanced, but transorally resectable oropharyngeal cancer (OPSCC), the current standard of care includes surgical resection and risk-adapted adjuvant (chemo) radiotherapy, or definite chemoradiation with or without salvage surgery. While transoral surgery for OPSCC has increased over the last decade for example in the United States due to transoral robotic surgery, this treatment approach has a long history in Germany. In contrast to Anglo-Saxon countries, transoral surgical approaches have been used frequently in Germany to treat patients with oro-, hypopharyngeal and laryngeal cancer. Transoral laser microsurgery (TLM) has had a long tradition since its introduction in the early 70s. To date, the different therapeutic approaches to transorally resectable OPSCC have not been directly compared to each other in a randomized trial concerning disease control and survival. The goal of this study is to compare initial transoral surgery to definitive chemoradiation for resectable OPSCC, especially with regards to local and regional control.

METHODS

TopROC is a prospective, two-arm, open label, multicenter, randomized, and controlled comparative effectiveness study. Eligible patients are ≥18 years old with treatment-naïve, histologically proven OPSCC (T1, N2a-c, M0; T2, N1-2c, M0; T3, N0-2c, M0 UICC vers. 7) which are amenable to transoral resection. Two hundred eighty patients will be randomly assigned (1:1) to surgical treatment (arm A) or chemoradiation (arm B). Standard of care treatment will be performed according to daily routine practice. Arm A consists of transoral surgical resection with neck dissection followed by risk-adapted adjuvant therapy. Patients treated in arm B receive standard chemoradiation, residual tumor may be subject to salvage surgery. Follow-up visits for 3 years are planned. Primary endpoint is time to local or locoregional failure (LRF). Secondary endpoints include overall and disease free survival, toxicity, and patient reported outcomes. Approximately 20 centers will be involved in Germany. This trial is supported by the German Cancer Aid and accompanied by a scientific support program.

DISCUSSION

This study will shed light on an urgently-needed randomized comparison of the strategy of primary chemoradiation vs. primary surgical approach. As a comparative effectiveness trial, it is designed to provide data based on two established regimens in daily clinical routine.

TRIAL REGISTRATION

NCT03691441 Registered 1 October 2018 - Retrospectively registered.

A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311

PURPOSE

Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA.

PATIENTS AND METHODS

E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections.

RESULTS

120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients.

CONCLUSIONS

We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.

Surgical resection of oral cancer: en-bloc versus discontinuous approach

OBJECTIVES

In the past literature agreed on treating oral carcinomas, using an "en-bloc" resection (EBR) but recently minimally invasive transoral surgery has spread as the preferable treatment for selected cases. This latter technique, which is performed with a discontinuous resection (DR), allows for a satisfactory postoperative quality of life (QoL) maintaining good survival rates.

MATERIALS AND METHODS

In this study, we analyzed data about 147 surgically treated patients with oral cancer involving tongue and floor of the mouth. The sample was divided according to the surgical approach: EBR and DR group which were compared in terms of recurrence, overall survival, disease-free survival, and QoL.

RESULTS

In the DR group, survival analysis showed better results in term of survival, locoregional control, and postoperative anxiety, while the other QoL scores were similar in the two groups.

CONCLUSION

The more invasive approach does not correlate to a better outcome. In selected cases, DR is an oncologically safe technique; EBR is still a valid option to treat advanced oral cancers.

Endoscopic laryngopharyngeal surgery for hypopharyngeal lesions

OBJECTIVES

Transoral approaches for laryngeal/pharyngeal malignancies have been widely accepted as minimally invasive treatment options; however, hypopharyngeal lesions treated by transoral surgery have rarely been reported due to the difficulties in visualizing the hypopharynx. Since 2010, we have treated superficial hypopharyngeal lesions with endoscopic laryngopharyngeal surgery (ELPS), and herein report the outcomes of this transoral procedure.

MATERIALS AND METHODS

One hundred and eighteen patients with superficial hypopharyngeal lesions were treated by ELPS from February 2010 to February 2017, and the clinical courses of the patients were reviewed.

RESULTS

Four females and 114 males (average: 65.6 y-o) were included in this study. Some patients had multiple lesions and a total of 154 superficial hypopharyngeal lesions (dysplasia: 29, Tis: 52, T1: 44, T2: 20, T3: 9) were treated with ELPS. Ten patients had only dysplasia and no carcinoma. Five patients presented with nodal metastases and 11 patients had simultaneous oropharyngeal lesions. In all cases, the hypopharynx was well visualized with sufficient working space, and no cases required a change in surgical approach. All post-operative complications were safely managed. In regard to the oncological outcomes, of the 108 patients with malignant lesions, the 3-year and 5-year overall survival (OS) rate was 93.6% and 85.5%, respectively.

CONCLUSIONS

During ELPS, the hypopharynx was well visualized providing sufficient working space for the resection. The procedure was safe and feasible for superficial hypopharyngeal lesions and exhibited very good oncological outcomes. ELPS is thought to be a very effective surgical alternative for superficial hypopharyngeal lesions.

The anatomical basis and rational for the transoral approach during the surgical excision of the sublingual salivary gland for the management of plunging ranula

PURPOSE

The aim of this study was to illustrate and confirm that the complete intraoral excision of the sublingual gland alone, is anatomically the most rational approach, for the management of plunging ranula.

MATERIAL AND METHODS

We retrospectively reviewed clinical charts of diagnosed HIV-infected patients presenting with plunging ranula. The intraoral approach was used for the complete excision of the sublingual gland with evacuation of the pseudocystic content only. Neither extra oral approach, nor ranula dissection / drainage was performed. The surgical procedure was performed using local anesthesia. Pre- and postoperative MRI-scan investigations were recorded. Histological reports were documented to confirm the diagnosis of oral mucocele. Patients were clinically monitored.

RESULTS

We identified 90 adults presenting with oral mucocele, type ranula. Seventy (77%) of them were diagnosed with HIV infection. Plunging ranula was recorded in 35 (50%) patients from the latter group. The study enrolled 11 operated patients whose files contained useable data, including an acceptable follow-up period. The postoperative follow-up period ranged from three to 15 months. The clinical and postoperative MRI-scans of operated patients demonstrated satisfactory results. There were neither postoperative complications nor recurrence of ranula reported.

CONCLUSION

The location of the sublingual gland in the floor of the mouth coupled with the physio-pathogenesis of the plunging ranula, makes the transoral complete excision of the offending gland, with the intraoral evacuation of the pseudocyst, anatomically the most rational approach for plunging ranula management. There is no need for cervical approach, ranula dissection and/or postoperative placement of drainage.

Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): study protocol for a randomized phase II trial

Background

Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches.

Methods

This is a multicenter phase II study randomizing one hundred and forty patients with T1–2 N0–2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50–60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity.

Discussion

This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials.

Trial Registration

Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.

How we improve the transoral resection for oral and oropharyngeal cancer: the CO2 waveguide laser

PURPOSE

The main aim of this study was to evaluate the CO₂ waveguide laser (CO₂ WGL) with flexible fiber (Lumenis, Santa Clara, CA) in the treatment of oral and oropharyngeal cancers specifically focusing on the lateral thermal damage (LTD) induced by this instrument and therefore on the reliability of the analysis of frozen sections collected during margin mapping.

METHODS

A total of 48 patients with oral and oropharyngeal cancers from T1 to T4a were prospectively enrolled in the study. We collected data about LTD, pathologic tumor and node stage (pTNM), surgical intervention, kind of reconstruction (no flap, local vs free flap), need for tracheotomy and time of removal, postoperative complications (such as bleeding, mucosal dehiscence, and fistula), need for feeding tube and time of removal.

RESULTS

Mean LTD was 164.7 ± 92.4 μm. Comparing frozen section histology before and after formalin embedding we found 5 true positives, 170 true negatives, 4 false positives and 4 false negatives, with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 55.6%, 98%, 55.6%, 98%, and 96.1%, respectively.

CONCLUSION

CO₂ WGL is a very manageable tool, which allows a precise cut. However, its high costs, the inability to re-use the fibers and its low coagulation capability must be considered.

The effectiveness of transoral marsupialization for lingual thyroglossal duct cysts - Twelve successfully treated cases at a single institution

PURPOSE

Lingual thyroglossal duct cysts (L-TGDCs) are rare and sometimes lethal owing to their association with asphyxia. We aimed to analyze our single institutional experience with L-TGDCs.

METHODS

Twelve L-TGDC cases treated at our institution between January 2010 and December 2017 were investigated.

RESULTS

The male/female ratio was 6/6. The age at the diagnosis was 2 ± 1.4 months (7 days to 6 months), and 3 patients were diagnosed in the neonatal period. The patients presented with stridor (n = 12; 100%), growth retardation (n = 5; 42%), apnea (n = 3; 25%), and vomiting (n = 1; 8.3%). Lateral X-rays were obtained in 8 cases (66.7%); a lingual mass was suspected in 7 (87.5%). Transoral marsupialization of the cyst was performed under direct vision in all cases. All cases were nasally and orally intubated using a laryngoscope, bronchoscope, or airway scope. The mean operative time was 18 ± 2.9 min. The mean cyst size was 10.5 ± 1.8 mm. No recurrence was observed during the follow-up period (37.5 ± 18 months).

CONCLUSION

L-TGDC requires a precise diagnosis and rapid intervention because of the risk of asphyxia resulting in sudden death. Transoral marsupialization under direct vision is an effective and secure approach. L-TGDC should be considered when patients younger than six months of age present with respiratory distress.

TYPE OF STUDY

Retrospective Study.

LEVEL OF EVIDENCE

Level IV.

Elongated Clivus with Deficient Anterior Atlantal Arch and Congenital Posterior Atlantooccipital Dislocation: Pathoembryology and Management Nuances of a Rare Form of Proatlas Segmentation Anomaly

BACKGROUND

Proatlas segmentation anomalies represent a rare subset of congenital craniovertebral junction anomalies. In this condition, the structures originating from the proatlas, such as the clivus, occipital condyles, foramen magnum rim, and odontoid tip, may demonstrate congenital anomalies, usually without any spinal instability. Elongated clivus, as a result of nonsegmentation of the odontoid tip from the rest of the proatlas, has been reported before to cause ventral spinal cord compression. We report such a case with certain unreported other associations and explore the pathoembryology and management options of such complex anomalies.

CASE DESCRIPTION

An 8-year old girl presented with a 2-year history of progressive spastic quadriparesis. On neuroimaging, the anterior arch of the atlas was deficient, the odontoid process was foreshortened, and the clivus was elongated, encroaching into the spinal canal leading to ventral spinal cord compression. Additionally, there was rotatory posterior dislocation of the occipital condyles onto the posterior atlantal arch and vertebral artery anomaly. This patient underwent transoral decompression followed by occipitocervical fusion using rods and screws with satisfactory results.

CONCLUSIONS

Proatlas anomalies are rare, varied, and often subtle enough to go unrecognized. Knowledge of the embryology and its aberrations is necessary to understand these anomalies. Our case describes a rare form of bony anomalies pertaining to the fate of the proatlas with accompanying atlanto-occipital dislocation.

The interplay of IMRT and transoral surgery in HPV-mediated oropharyngeal cancer: Getting the balance right

Transoral surgery (TOS) and IMRT represent two primary local ablative treatment modalities for oropharyngeal cancer (OPC). The choice of one over the other represents an interplay between the chance of cure vs risk of late sequelae. HPV-mediated (HPV+) OPC patients generally have excellent outcomes, especially in TNM-8 stage I disease. Controversies exist over which treatment has a more favorable toxicity profile and equal efficacy in the management of this population. Non-randomized retrospective data show comparable oncological and functional outcomes between TOS-based vs IMRT-based treatment for this disease. Several de-intensification concepts have been explored in this subset in both primary surgery-based vs primary radiotherapy-based trials. However, no robust mature trial data are available to convincingly guide treatment selection. TOS is often presented as one of the de-intensification options although the majority of series also describe the use of adjuvant treatments which inevitably result in non-negligible toxicities. Patient selection and surgeons' training are paramount. Understanding tumor biology and the prognostic value of traditional 'adverse' features will further guide trial design for refinement of risk tailored approach. In conclusion, comparative data suggests TOS and IMRT are both effective treatment for TNM-8 stage I HPV+ OPC with similar oncological and functional outcomes. TOS as a single modality has potential advantages in mitigating radiation included toxicities. TOS should be avoided in the presence of clinically overt extranodal extension or when negative margins are unlikely to be achieved. TOS is also less ideal for cases with radiological features predicting a high risk of distant metastasis.

Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy

Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.

Preoperative predictors of difficult hypopharyngeal exposure by retractor for transoral robotic surgery

Introduction

Transoral endoscopic surgeries provide excellent oncologic outcomes while preserving speech and swallowing ability. However, feasibility has been a major concern about transoral surgery. Therefore, ensuring visualization of the surgical field and sufficient working space is required. The aim of this study was to evaluate the parameters in the preoperative assessment that affect hypopharyngeal exposure.

Methods

Before transoral surgery, parameters regarding the patient’s neck and face such as modified Mallampati index, thyroid–mental distance (TMD), and ability to fully open the mouth were evaluated. Cephalometry and cervical spine radiography were performed preoperatively to evaluate the size of the mandible bone, mouth opening, and cervical spine extension. Mandibular bone parameters such as intergonion distance, mental–gonion distance, articulare–gonion distance, and aperture angle were measured. According to hypopharyngeal exposure using FKWO retractor, patients were divided into difficult hypopharyngeal exposure group (DHE) and non-difficult hypopharyngeal exposure group (non-DHE). Parameters were enrolled to evaluate the relationship between these parameters and DHE status.

Results

This study included 51 patients, 37 in the non-DHE group and 14 in the DHE group. On radiographic evaluation, there was a significant difference in the degree of cervical lordosis between non-DHE and DHE patients. A significantly higher proportion of DHE patients had a history of radiotherapy compared with non-DHE patients.

Conclusion

Patients with limited cervical extension and a history of previous radiotherapy might have difficult hypopharyngeal exposure during transoral surgery. This is the first report to suggest a classification system for hypopharyngeal exposure during transoral surgery.

Ultrasound-Guided Transoral Videolaryngoscopic Surgery for Retropharyngeal Lymph Node Metastasis of Papillary Thyroid Cancer

Background

Endoscopic-assisted transoral surgery, including transoral robotic surgery for metastatic retropharyngeal lymph node (RPN) from well-differentiated thyroid cancer, has been reported to reduce the complications resulting from transcervical and transmandibular approaches. However, the narrow working space and difficulty identifying RPN are problematic. To solve these issues, several studies have used intraoperative ultrasound in endoscopic-assisted transoral surgery. However, the type of ultrasonography suitable for this purpose remains unclear.

Case Presentation

A 60-year-old female with thyroid papillary carcinoma (T4aN1bM0) initially underwent total thyroidectomy and paratracheal and selective neck dissections (D2a), with resectional management of recurrent laryngeal nerve, trachea, and esophagus. Three years later, she was diagnosed with left retropharyngeal and upper mediastinal lymph node metastases of papillary thyroid cancer. Transoral videolaryngoscopic surgery was performed with a combination of ultrasonography with a flexible laparoscopic transducer manipulated with forceps for identifying RPN intraoperatively. Due to the transducer's small size and thin, flexible cable, the transducer interrupted the procedure in spite of the narrowness of oral cavity. RPN was resected completely without adverse events.

Conclusion

We performed intraoperative ultrasound-guided endoscopic transoral surgery for metastatic RPN from papillary thyroid cancer and achieved complete resection as well as preservation of swallowing function.

Sialendoscope-assisted transoral removal of hilo-parenchymal sub-mandibular stones: surgical results and subjective scores

It has been suggested that a conservative trans-oral approach to proximal and hilo-parenchymal submandibular stones (HPSMS) is a valid alternative to the more frequently used sialadenectomy. The aim of this study was to evaluate the surgical, ultrasonographic and patients' subjective outcomes of results of the trans-oral removal of HPSMS. Between January 2003 and September 2015, sialendoscope-assisted trans-oral surgery was used to remove symptomatic, large (> 7 mm), fixed and palpable HPSMS from 479 patients under general anaesthesia. All patients were followed clinically and ultrasonographically to investigate symptom relief and recurrence of stones, and were telephonically interviewed to assess saliva-related subjective outcomes with a questionnaire. Stones were successfully removed from 472 patients (98.5%); the seven failures (1.5%) concerned pure parenchymal stones. One year after the procedure, 408 patients (85.1%) were symptom free, 59 (12.3%) had recurrent obstructive symptoms and 12 (2.6%) had recurrent infections. Of the 54 patients who developed a recurrent stone (11.2%), 52 underwent a second procedure: 29 interventional sialendoscopies, two sialendoscope-assisted intra-corporeal pneumatic lithotripsy, eight secondary transoral surgery to remove residual stones, six a cycle of extra-corporeal lithotripsy and seven submandibular sialadenectomy. Most patients (75.2%) reported mild surgery-related pain. The symptoms of 454 patients (94.8%) improved after adjunctive treatment and, at the end of follow-up, the affected gland was preserved in 98.5% of patients. A sialendoscope-assisted trans-oral removal of large HPSMS is a safe, effective, conservative surgical procedure, and functional preservation of the main duct and parenchyma of the obstructed gland allows sialendoscopic access through the natural ostium in case of recurrence. Combining a trans-oral approach with other minimally invasive, conservative procedures ensures symptomatic relief and salivary duct system clearance in the majority of patients.

[Transoral radiofrequency coblation surgery for the treatment of hypopharyngeal carcinoma]

Objective: To explore the feasibility and effectiveness of transoral surgery (TOS) for the treatment of hypopharyngeal carcinoma by means of the radiofrequency coblation(RFC). Methods: Twenty-two patients with hypopharyngeal carcinoma who were treated with TOS using RFC during the years of 2010-2016 were enrolled. Among these patients, 15 suffered from pyriform sinus carcinoma, 4 suffered from postcricoid carcinoma, and 3 suffered from posterior hypopharyngeal wall carcinoma. According to the AJCC 2002 guideline, the tumor stages were T1N0M0 for 3 patients, T2N0M0 for 9 patients, T1N1M0 for 1 patient, T1N2M0 for 1 patient, T2N1M0 for 4 patients, and T2N2M0 for 4 patients respectively. All patients with N+ underwent concurrent neck dissection; 2 patients underwent concurrent prophylactic tracheotomy; 17 underwent post-operative radiotherapy for 50-66 Gy. The follow-up time was 6-72 months with a median 35 months.Two patients were lost to follow-up. Results: All patients except 2 underwent the TOS successfully, while the two patients were treated with open approach surgery due to unsure safe margin. Most patients returned to oral feeding within one week. Among the 18 patients with complete follow up data, 3 had the local recurrence of the tumor (16.7%) and one died due to local recurrence, multiple primary esophageal carcinoma, and distant metastasis 4 years after surgery (5.6%). According to the Kaplan-Meier method, the 5-years local control rate and survival rate were 57.8% and 67.5% respectively. All patients had no disorders in speech, swallowing and respiration during the follow up. Conclusions: The RFC can be applied in TOS for the treatments of hypopharyngeal carcinoma with high cutting efficiency and better control of intraoperative hemorrhage, which is useful in lowering the operation difficulty. The oncologic results are comparable to the open surgery with satisfactory postoperative organ function preservation.

Should We De-escalate the Treatment for HPV-Positive Tumors?

De-escalation or de-intensification of therapy is discussed since many retrospective analyses of former trials demonstrated significantly better outcome for patients suffering from p16/HPV16-positive oropharyngeal squamous cell carcinoma of head and neck (OHNSCC). These observations are comprehensively addressed, but the reader has to keep in mind that none of the currently discussed data result from prospective controlled trials addressing the HPV-discrimination in the primary endpoint design. Identification of the true HPV16-related tumors is still challenging and in addition with different clinical reports and lack of data of prospective trials not mature for routine clinical decision making in 2016. Independent of the currently lacking evidence for HPV-dependent treatment de-escalation, there are some relevant arguments to address this question in ongoing and future trials.

Course of psychiatric comorbidity and utilization of mental health care after laryngeal cancer: a prospective cohort study

In a German multi-center prospective cohort study, we wanted to assess the course of psychiatric comorbidity, utilization of mental health care and psychosocial care needs in laryngeal cancer patients during the first year after partial laryngectomy (PRL). Structured interviews with patients were conducted before surgery, 1 week (1 w), 3 months (3 m) and 1 year (12 m) after PRL. Psychiatric comorbidity was assessed using the Structured Clinical Interview for DSM-IV (SCID). Psychosocial care needs and utilization of mental health care were evaluated with standardized face-to-face interviews. In 176 patients, psychiatric disorders were prevalent in 11 % (1 w), 15 % (3 m) and 14 % (12 m), respectively, of which 4 % (12 m) underwent psychiatric treatment or psychotherapy. Two percent had acute, 15 % emerging and 6 % chronic psychiatric comorbidity. Chronically mental ill patients were more frequently younger than 65 years (p = 0.026), female (p = 0.045) and experienced more often a need for psychological counseling (p ≤ 0.001). One year after surgery, 27 % of the comorbid psychiatric patients expressed a need for additional psychological counseling. Alcohol-related disorders were diagnosed in 3 % (1 w), 3 % (3 m) and 8 % (12 m), respectively. Only one of these patients received psychological treatment, while 14 % expressed a need for psychological counseling and 7 % for additional medical consultations. The non-treatment of alcohol-related disorders measured in our sample indicates a major problem since continued alcohol consumption in laryngeal cancer patients is associated with reduced global quality of life, increased functional impairments and reduced overall survival. Screening instruments integrated into acute care are necessary to detect harmful drinking behavior.

Computer tomography navigation for the transoral anterior release of a complex craniovertebral junction deformity: A report of two cases

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The surgical correction of the deformities of the craniovertebral junction (CVJ) remains a challenge due to its complex anatomy.

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A combined anterior-posterior approach is sometimes required, especially in patients with rigid CVJ deformities.

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Transoral anterior release assisted by CT navigation can be a safe and effective treatment option for rigid complex CVJ deformities.

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The identification of the patients’ anatomical features such as occipitoatlantal assimilation is crucial for accurate navigation.

Introduction

The surgical correction of deformities of the craniovertebral junction (CVJ) remains a challenge due to its complex anatomy. Despite the well-known usefulness of computed tomography (CT) navigation in posterior spinal surgery, it is applied far less frequently in anterior spinal surgery, mainly due to registration difficulties.

Presentation of the case

Case 1 was a 68-year-old female with rheumatoid arthritis, with a complaint of neck pain, motor weakness, and dysesthesia in the upper extremities. Case 2 was a 61-year-old male with Chiari malformation, with a complaint of neck pain and gait disturbance after a fall. Magnetic resonance imaging (MRI) showed severe atlantoaxial dislocation and multilevel cervical spinal cord compression in both patients. Continuous halo traction failed to reduce atlantoaxial dislocation, even under general anesthesia, and they were treated with combined anterior release and posterior decompression and fixation using CT navigation. Occipitocervical assimilation, which was present in both patients, enabled precise registration for navigation.

Discussion

The lack of anatomically characteristic landmarks on the vertebral surface makes obtaining accurate registration difficult in anterior CVJ surgery using CT navigation. The remaining mobility in the occipitocervical joint precludes the use of facial or cranial landmarks. However, occipitocervical assimilation, which is not uncommon in patients with CVJ deformities, enables accurate navigation during transoral surgery.

Conclusion

Transoral anterior release using CT navigation is an effective treatment option for rigid complex CVJ deformities. The accurate identification of the patients' anatomical features such as occipitoatlantal assimilation, is crucial for the conducting accurate preoperative CT-based navigation during transoral surgery.