Surgical Approaches to the Nasopharynx

👉The nasopharynx is a difficult area to access surgically due to:

• Its central location
• Its surrounding facial skeleton and skull base
• Presence of great vessels and lower cranial nerves

👉The ideal surgical approach to the nasopharynx should:

• Provide adequate exposure to the nasopharynx:
  • For tumor resection
• The great vessels:
  • Must be safely controlled
• Lower cranial nerves:
  • Should be spared

👉The surgical approach chosen is dependent on:

• Extent of primary tumor (size / T stage)
• Surgical expertise
• Facilities available

👉Classification of the surgical approaches to the nasopharynx:

• Anterior approach
• Inferior approach
• Lateral approach

👉Anterior approaches to the nasopharynx:

• Lateral rhinotomy
• Transnasal transmaxillary approach
• Midfacial degloving
• Lefort I osteotomy
• Maxillary swing approach

👉Lateral rhinotomy:

• This approach exposes the:
  • Nasal cavity and choana well
• It can be used alone or in combination with other surgical approaches:
  • To enhance exposure of the nasopharynx
• This approach is useful in resection of:
  • Anteriorly placed tumors

👉Transnasal transmaxillary approach:

• In this approach a lateral rhinotomy is combined with:
  • A medial / subtotal maxillectomy
• This approach exposes the:
  • Nasopharynx
  • Ipsilateral spheno-ethmoidal complex
  • Pterygopalatine fossa
  • Medial end of infratemporal fossa

👉Midfacial degloving approach:

• This is a bilateral transnasal, transmaxillary approach
• The advantage of this procedure is that it is performed:
  • Via sublabial incision:
    • Thereby avoiding facial scar
• In this approach the:
  • Infraorbital nerves on both sides:
    • Are safeguarded
  • Midface is degloved subperiosteally:
    • Up to the level of root of the nose
  • A bilateral medial maxillectomy is performed to improve exposure
  • The pterygopalatine fossa and the medial end of infratemporal fossa is ideally exposed

👉Lefort I osteotomy:

• In this approach through a sublabial incision:
  • A transverse maxillary osteotomy is performed through both maxillary sinuses:
    • Allowing the whole hard palate and both inferior maxillae to be down fractured
• Access to the central skull base and nasopharynx is ensured without any visible facial scars

👉Maxillary swing approach:

• This is one of the common approaches to the nasopharynx
• It exposes the nasopharynx and surrounding areas:
  • From the anterolateral aspect
• Through a Weber Ferguson incision:
  • The maxilla is separated from its bony attachments and swung laterally intact with the masseter muscle and cheek flap
• Access to the opposite side can be established by removing the posterior portion of nasal septum
• After tumor resection:
  • The maxilla is swung back and fixed to facial skeleton

👉Inferior approaches:

• Transpalatal approach:
  • The nasopharynx can be accessed by raising a palatal mucoperiosteal flap off the hard palate:
    • Separating the soft palate from its bony portion
  • The posterior edge of bony hard palate is removed as much as it is necessary:
    • To access the nasopharynx
  • Greater palatine neurovascular bundle:
    • Must be mobilized bilaterally to prevent flap necrosis

• Mandibular swing approach:
  • This is actually a combination of:
    • Transcervical, transmandibular, transpalatal approach:
      • Via Frazier incision
  • Soft tissues including parotid gland are elevated from the mandible
  • The mid portion of the ascending ramus of the mandible including the coronoid process:
    • Is cut and removed to facilitate exposure and to prevent post operative trismus
  • The lateral and medial pterygoid muscles are divided to enter the nasopharynx
  • Tracheostomy is a must to secure the airway
  • Dead space after tumor removal needs to be repaired

👉Lateral approach:

• This approach is via the infratemporal fossa:
  • This approach is limited by:
    • The facial nerve and carotid sheath
  • It is used when the tumor extends laterally to involve the parapharyngeal space

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