Vocal function after transoral videolaryngoscopic surgery (TOVS) for hypopharyngeal and supraglottic cancer

Abstract

Conclusion: The resection of the medial and lateral pyriform sinus was associated with post-operative voice impairment after TOVS. Scar contracture around the cricoarytenoid joint lead to arytenoid fixation toward lateral position, and this wound healing process caused insufficient glottis closure. Although oncological and functional outcomes of TOVS was satisfactory, surgeons should mention the risk of post-operative voice impairment in pre-operative counseling.

Objectives: Transoral surgery is a minimally invasive treatment option for hypopharyngeal and supraglottic cancer. Post-operative vocal function was satisfactory in most cases, but in some cases vocal cord was fixed and occasionally voice impairment persists.

Methods: Vocal function of 55 patients who underwent transoral videolaryngoscopic surgery (TOVS) for hypopharyngeal and supraglottic cancers was evaluated by the GRBAS perceptive scale, aerodynamic tests and acoustic analyses, and the Voice Handicap Index questionnaire. The risk factors for voice impairment were identified.

Results: Voice impairment (G score ≧2) was found in 16 cases (29.1%). Univariate analysis revealed that the resection of medial and lateral pyriform sinus (p?=?.0018) and neck dissection (p?=?.0421) were associated with post-operative voice impairment. Multivariate analysis revealed that the resection of medial and lateral pyriform sinus (p?=?.0021) was associated with post-operative voice impairment.     

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group

BackgroundCervical spondylodiscitis is a rare but severe complication of pharyngeal surgery.Material and methodsThis multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017.ObjectivesTo describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications.ResultsSeven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6 days. The interval between surgery and spondylodiscitis diagnosis ranged from 20 days to 4.5 months, for a mean 2.1 months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%).ConclusionThis French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.     

The temporalis muscle flap for reconstruction of soft palate and lateral oropharyngeal wall after transoral robotic surgery

Trans Oral robotic surgery (TORS) is a prominent surgical approach for the resection of oropharyngeal tumors without division of the lip and mandible. The current practice following TORS is to allow the defect to heal by secondary intention, but some defects following TORS are large and complex enough to benefit soft-tissue coverage. In the free flap era, regional flaps are often overlooked albeit they still represent a valid alternative. In terms of cost-effectiveness, the use of alternative pedicled flaps in TORS framework probably reduced the risks of postoperative complications, with consequent expenditure restraints and reducing treatment costs arising from operating room duration and double surgical team. In this report we described the successfully use of the pedicled temporalis muscle flap for the reconstruction of the soft palate and lateral pharyngeal wall following TORS. This versatile and reliable flap may be a valid option in TORS framework.     

Intraoperative imaging during minimally invasive transoral robotic surgery using near-infrared light

Purpose

The purpose of this study was to determine if the use of the FIREFLY imaging system could be an asset in transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC). The system uses indocyanine green dye (ICG), which fluoresces when illuminated by near-infrared light from the Da Vinci robot. The system may improve visualization of tumor margins, highlight important vascular structures, and help identify the location of tumors and unknown primary head and neck cancers.

How to optimize laryngeal and hypopharyngeal exposure in transoral robotic surgery

Objective

The aim of this study was to present the various strategies adopted in our center to improve and overcome problems with exposure of the operative field in 48 patients who underwent TORS for the treatment of laryngeal and hypopharyngeal cancer.

Methods

We present our operative and preoperative treatment protocols for patients undergoing TORS for laryngeal and hypopharyngeal cancer. In particular, we emphasize the role of preoperative exposure assessment and the usefulness of simple measures to overcome problems with exposure of the operative field.

Results

In 12 patients (25%), we experienced difficult laryngeal–hypopharyngeal exposure. However the correct positioning of the robotic arms, the proper use of the laryngeal and tongue blade and some simple maneuvers, such as the anterior traction of the tongue and the partial epiglottectomy, ensured the feasibility of TORS with negative margins in all patients.

Conclusion

In TORS, the exposure of larynx and hypopharynx can be difficult, but the adoption of certain methods may make it possible in most patients. An accurate preoperative evaluation under general anesthesia is the primary strategy for reducing the number of cases terminated intraoperatively. Currently, TORS is not feasible in all patients, but in our opinion, reductions in the size of robotic equipment and development of new devices will extend the application of TORS to a larger number of patients.