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

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SurgicalOncologist #HeadandNeckCancer

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