9
Palatal Resection and Reconstruction
Eric M. Genden
Palatal resection and reconstruction are most commonly performed for malignancy. Squamous cell carcinoma and minor salivary gland malignancies are the most common malignancies of the palate. Like most cancers involving the oral cavity, surgical resection is usually the treatment of choice. The use of postoperative radiotherapy is indicated in select cases (Table 9-1). Benign disease may be treated with aggressive surgical resection.
Diagnosis and staging of a palatal lesion requires a comprehensive workup, including a physical exam, radiological imaging, and tissue biopsy.
- Characterizing the histopathology of the tumor is important because it may predict the biological behavior of the tumor and impact therapy. For example, whereas squamous cell carcinoma directly invades adjacent tissue and bone, adenoid cyst carcinoma of the palate has a predilection for spreading via perineural channels. Although both neoplasms require meticulous margin assessment, the latter requires a sampling of adjacent nerves.
- Once a tumor of the palate has been identified, imaging using computed tomography (CT) or magnetic resonance imaging (MRI) is helpful in determining the extent of the lesion with regard to soft tissue involvement, bony invasion, and nerve involvement.
- Because hard palate lesions are commonly closely associated with the palatal bone, high-resolution CT scans represent the optimal method of imaging to assess the palatal bone for tumor invasion.
- MRI is useful for assessing the extent of soft tissue invasion. In malignancies such as adenoid cysts that have a propensity to spread via perineural pathways, MRI represents an effective tool to assess perineural invasion.
- Palatal resections are performed under general anesthesia. The patient should be intubated with a flexible nasotracheal tube to facilitate exposure of the oral cavity. Exposure to the lesion and operative area is paramount to ensure an adequate resection with margins that are free of tumor. Because most palatal surgeries are performed transorally, muscle paralysis is essential. This allows placement of an appropriate retractor.
- Gaining access to the palate requires appropriate retraction of the tongue, jaw, and soft tissue of the cheek. This can be accomplished using a Crowe-Davis or Dingman retractor. During placement and removal of the retractor, it is essential to secure the endotracheal tube to prevent unintentional extubation of the patient.
- Once the retractor is in place and access to the oral cavity has been accomplished, a throat pack should be placed to prevent the patient from swallowing blood during the course of the procedure.
- The planned resection should be delineated using a surgical marker. The margins around the tumor should be no less than 1 cm. The initial incisions can be made with either a knife or CO2
