Tori, or torus in single use, are benign bony outgrowths within the oral cavity which are thought to arise from physical irritation. Tori tend to grow in distinct positions, along the hard palate and along the lingual cortex of the mandible. Tori palatinus grow typically as a single outgrowth along the midline of the hard palate and are of little consequence to the TORS surgeon. Tori mandibulares on the other hand are of substantial importance. As seen in Fig. 5.2, tori mandibulares grow from the medial, or lingual, surface of the anterior mandible in an uneven pattern. Unless extensive in size, they are rarely symptomatic and therefore generally are not elicited during the history portion of a patient evaluation. The physical examination can very often skip over this seemingly unimportant aspect of the oral cavity, particularly when an obvious exophytic pharyngeal tumor is distracting the surgeon’s attention. However, a gloved finger used to palpate the inner surface of the mandible can save the TORS surgeon significant stress by identifying this significant anatomic consideration.

Tori mandibulares fill the floor of mouth space with bony outgrowths. They will therefore block the oral tongue from being translocated to within the soft movable tissue of the floor of the mouth. Aside from trismus, it is this author’s opinion that tori mandibulares can have the most devastating effect on access and performance of TORS. The presence of tori is also significant as this entity can be readily excised. This author has referred patients for tori resection within the weeks leading up to TORS, or concurrent with TORS, with subsequent excellent exposure.

Similar to direct laryngoscopy, edentulous patients will provide improved TORS exposure as compared to exposure of dentate patients. With most retraction systems placing the inferior fulcrum point on the upper central incisors, it is these teeth that are the most concerning for excessive length restricting exposure. However in this author’s view, it is only in the most extreme cases of elongated dentition, or of dental prosthesis such as veneers, that produce a substantial effect on TORS exposure without additional confounding anatomical considerations. More commonly, large teeth will play a role in preventing successful TORS exposure when other factors are also suboptimal. The pressure placed on the upper central incisors should be discussed with patients, particularly with those patients who have placed previous investment in dental care.

Yet distinct from direct laryngoscopy, other teeth besides the upper central incisors have considerations during TORS. The TORS surgeon should take note of the presence and shape (sharp vs. dull) of the lower incisors. In all but the most accessible palatine tonsil tumor, some degree of tongue protrusion is required. By retracting the tongue out of the mouth to achieve the protrusion, the tongue will be compressed against the lower incisors which may result in ventral tongue laceration or contusion. The presence and position of the posteriormost molars will also impact the TORS approach, both maxillary and mandibular. As the robotic instruments approach through the lateral aspect of the oral cavity, patients with third molars (wisdom teeth) in place may offer restricted instrument movement or dental injury by the serrated neck of the instruments burring down the enamel of these teeth.

Catastrophic bleeding is the most serious intra- and postoperative complication of TORS. Special attention must be placed to understand the relationship between the laryngopharynx and the internal carotid arteries. Ideally, a distance of 2.5 cm should be between the pharyngeal mucosa and the carotid arterial wall [6]. While a medialized carotid is the general term of abnormally close relationship between the pharynx and the artery, the specific patterns of carotid aberrations include tortuosity, kinking, and coiling [5]. The overall incidence of medialized carotid arteries has been estimated between 10 % and 40%, making this anatomic anomaly quite common [4]. In the preoperative assessment, surgeons should pay close attentions to the posterior pharyngeal wall during flexible indirect laryngoscopy. At times, medialized carotid arteries may cause indentation of the posterior pharyngeal wall, as seen in Fig. 5.3, which can relay a strong pulsating motion to the pharynx. Radiologic evaluation will confirm this clinical finding and define the course of the common carotids as well as the internal and external branches. The TORS surgeon must be aware of this aberrant finding. Patients with medialized carotid arteries are unlikely to be acceptable candidates for TORS.