History

• 1.
  

  History of present illness

  
  
  
  
  • a.
    

    Many patients will present initially with a mass in the neck; in these cases, questions regarding onset, location, duration, exacerbation, and any treatments may give insight into the underlying etiology of the mass (vascular, infectious, autoimmune, neoplastic).

    
    
  • b.
    

    The patient should be questioned regarding dysphagia, odynophagia, otalgia, weight loss, hemoptysis, hoarseness, dysgeusia, and dyspnea, because these are most likely to be seen in patients with underlying malignancy.

    
    
  • c.
    

    Current treatment with antibiotics or other medications.

  
  
  
  
• 2.
  

  Past medical history

  
  
  
  
  • a.
    

    Prior treatment: Any antibiotics or recent viral illnesses

    
    
  • b.
    

    Medical illness: History of other head and neck cancers (which can be seen in more than 36% of patients who smoke), history of lung cancer, history of cervical cancer, previous surgery in the oropharynx

    
    
    
    
    • 1)
      

      Any illnesses that would be contraindications for surgical intervention including significant cardiovascular, pulmonary, or other end-stage cancers

      
      
    • 2)
      

      Hypercoagulable disorders requiring chronic anticoagulation

      
      
    • 3)
      

      Coagulopathy including von Willebrand disease or other

      
      
    • 4)
      

      Stents requiring antiplatelet therapy

      
      
    • 5)
      

      Significant sleep apnea (to understand postoperative risk of flash pulmonary edema and/or need for tracheostomy)

      
      
    • 6)
      

      History of aspiration events

      
      
    • 7)
      

      History of autoimmune disorders or transplantation requiring long-term antirejection therapy

    
    
    
    
  • c.
    

    History of radiation to the head or neck area (including for Hodgkin, treatment of acne)

    
    
  • d.
    

    Surgery

    
    
    
    
    • 1)
      

      Previous tonsillectomy or sleep apnea surgery

      
      
    • 2)
      

      Any neck surgery

      
      
    • 3)
      

      Arm and leg surgery (in case the patient may require free flap reconstruction)

    
    
    
    
  • e.
    

    Family history

    
    
    
    
    • 1)
      

      History of head and neck cancers

      
      
    • 2)
      

      Autoimmune disorders

      
      
    • 3)
      

      Cervical cancer in significant other (Data from the Swedish Cancer Registry (1958–1996) showed that spouses of patients with cervical cancer had a significantly elevated risk of development of tongue or tonsil cancer.)

    
    
    
    
  • f.
    

    Medications

    
    
    
    
    • 1)
      

      Antiplatelet drugs or anticoagulant medications

      
      
    • 2)
      

      Immunosuppressive medications

      
      
    • 3)
      

      Herbal products (fish oil, valerian root)

    
    
    
    
  • g.
    

    Social History

    
    
    
    
    • 1)
      

      Alcohol

      
      
    • 2)
      

      Smoking tobacco

      
      
    • 3)
      

      Illicit or recreational drugs

      
      
    • 4)
      

      Support system at home

      
      
    • 5)
      

      Current occupation

    
    

  
  

Physical Examination

• 1.
  

  Overall appearance and breathing

  
  
  
  
  • a.
    

    Note quality of breathing—mouth breathing or stridor; signs of obstruction, drooling or dry mouth

    
    
  • b.
    

    Examine for cachexia, temporal wasting

    
    
  • c.
    

    Some patients will have a characteristic foul odor of the breath, particularly those with larger cancers.

  
  
  
  
• 2.
  

  Examination of the cranial nerves

  
  
  
  
  • a.
    

    In particular, lower cranial nerves (IX, X, XI, XII), because involvement indicates a significant disease process

  
  
  
  
• 3.
  

  Oral cavity/oropharynx

  
  
  
  
  • a.
    

    Examine lips, gums, teeth, floor of mouth, tongue, and visible oropharynx with two tongue blades.

    
    
  • b.
    

    Bimanual palpation of lips, floor of mouth, tongue, base of the tongue, cheeks, and hard palate

    
    
  • c.
    

    Mirror examination if patient tolerates; flexible endoscopy if not

  
  
  
  
• 4.
  

  Nasal cavity

  
  
  
  
  • a.
    

    Anterior rhinoscopy can be performed to evaluate for intranasal growths. Topical anesthetic and decongestant can also be applied at this time in preparation for nasal endoscopy.

  
  
  
  
• 5.
  

  Neck

  
  
  
  
  • a.
    

    Palpation of the lymph node basins of the neck from level Ia to level V

    
    
    
    
    • 1)
      

      Any lymph nodes need to be assessed for fixation, mobility in certain directions

    
    
    
    
  • b.
    

    Palpation of the thyroid gland

  
  

Imaging

• 
  

  Computed tomography (CT): CT with contrast should be done to better characterize the remaining neck for occult disease that is not felt on physical examination. It can also provide information regarding involvement of vessels or local structures. Special attention should be paid to the location of the carotid artery to ensure that it does not have a retropharyngeal course as this is a contraindication for radical tonsillectomy.

  
  
• 
  

  Magnetic resonance imaging (MRI): MRI is particularly useful for lesions of the base of the tongue or unknown primaries, because it can detect subtle changes in soft tissue.

  
  
• 
  

  Staging scans: Positron emission tomography (PET) CT can evaluate from the brain to the upper thighs for metastatic cancer. At the least, a chest CT should be performed to evaluate for metastatic cancer to the lungs.

Indications

• 1.
  

  Patients with primary T1, T2, T3, and select T4 lesions of the oropharynx with possible reconstruction

  
  
• 2.
  

  Patients with recurrent cancer of the oropharynx; to be performed in conjunction with a reconstructive surgeon

  
  
• 3.
  

  Metastatic cancer to the neck from an unknown primary as a part of the evaluation and treatment

Contraindications

• 1.
  

  Medical comorbidities with increased risk for general anesthesia: End-stage cardiac disease (Preoperative risk assessment by a cardiologist is necessary.)

  
  
• 2.
  

  End-stage cancer

  
  
• 3.
  

  Involvement of the carotid artery

  
  
• 4.
  

  Retropharyngeal carotid

  
  
• 5.
  

  Relative contraindication: Prevertebral fascia involvement

  
  
• 6.
  

  Relative contraindication: Pterygoid involvement (will require extensive reconstruction as part of planning)

Preoperative Preparation

Anesthesia

• 
  

  General anesthesia with full paralysis. Relaxation is of the utmost performance during transoral surgery because this aids in visualization, dissection, and in reducing the risk of the patient moving during surgery.

Positioning

• 
  

  Supine: The patient is positioned supine, without a shoulder bump. The eyes and teeth are protected. This allows for full range of motion by the surgeon. Additionally, if the surgical robot will be used, this allows maximization of the robotic camera and instrument mobility.

Perioperative Antibiotic Prophylaxis

• 
  

  First-generation cephalosporin and metronidazole: Due to the typical flora of the oral cavity, dual coverage with a cephalosporin and metronidazole are warranted.

  
  
• 
  

  Clindamycin: Can be used as an alternative in patients with penicillin allergy because it covers the majority of oral flora. The caveat with this medication is its association with Clostridium difficile as a complication.

Monitoring

• 
  

  Monitoring for continued neuromuscular paralysis

Instruments and Equipment to Have Available

For a nonrobotic procedure:

• 1.
  

  Loupe magnification and surgical headlight

  
  
• 2.
  

  Cautery unit (set at 15 to 20 W for COAG) with Bovie pedal and bipolar pedal—one pedal next to the assistant for suction cautery

  
  
• 3.
  

  Two Bovie pads (one for standard monopolar cautery and one for suction cautery)

  
  
• 4.
  

  Reusable bipolar cord

  
  
• 5.
  

  Crowe-Davis mouth gag

  
  
• 6.
  

  Extended tip Bovie

  
  
• 7.
  

  Extra-long DeBakey or Blue Burner forceps

  
  
• 8.
  

  Weder retractor or Minnesota retractor

  
  
• 9.
  

  Pediatric Yankauer suction

  
  
• 10.
  

  Tonsil sponges soaked with Afrin

  
  
• 11.
  

  Herd retractor

  
  
• 12.
  

  Fine dissector (Krile, Schnidt)

  
  
• 13.
  

  Surgical clip applier

  
  
• 14.
  

  Medications/pharmacologicals:

  
  
  
  
  • a.
    

    Methylene blue for marking margins on specimen

    
    
  • b.
    

    Topical phenylephrine for topical application transorally

    
    
  • c.
    

    Topical hemostatic agent

  
  
  
  
• 15.
  

  Optional: Can use a 30-degree endoscope to evaluate the base of the tongue if not well visualized transorally. Alternatively, this area may be visualized with a laryngeal mirror.

If using the surgical robot:

• 16.
  

  Intuitive Surgical high-magnification camera head (45-degree field of view [FOV])

  
  
• 17.
  

  Intuitive Surgical wide-angle camera head (60-degree FOV)

  
  
• 18.
  

  Ikegami high-definition 3D imaging system (da Vinci S only)

  
  
• 19.
  

  30-degree Intuitive Surgical endoscope

  
  
• 20.
  

  0-degree Intuitive Surgical endoscope

  
  
• 21.
  

  Three chairs that have a foot pedal for adjusting up and down, two at the bedside (for the nurse and the bedside surgical assistant) and one at the surgeon console

  
  
• 22.
  

  Three rectangular OR instrument carts and one small square OR instrument cart

  
  
  
  
  • a.
    

    Recommended 5-mm EndoWrist Instrumentation:

    
    
    
    
    • 1)
      

      Monopolar cautery

      
      
    • 2)
      

      Maryland forceps

    
    

  
  

Key Anatomic Landmarks

• 1.
  

  Laterally: Carotid artery, glossotonsillar sulcus

  
  
• 2.
  

  Posteriorly: Prevertebral fascia

  
  
• 3.
  

  Anteriorly: Base of the tongue

  
  
• 4.
  

  Medially: Uvula

Prerequisite Skills

• 1.
  

  Knowledge of inside-out anatomy

  
  
• 2.
  

  If using robot: Transoral robotic training

Operative Risks

• 1.
  

  Intraoperative hemorrhage from lingual artery, branches of facial artery, veins. Best prevented by preoperative or intraoperative transneck ligation of branches of the external carotid system, including superior laryngeal, facial, and lingual

  
  
  
  
  • a.
    

    The blood supply to the tonsil is the dorsal lingual branch (of the lingual artery), ascending palatine artery (of the facial artery), tonsillar branch (of the facial artery), ascending pharyngeal artery (of the external carotid artery), and the lesser palatine artery (of the descending palatine artery).

  
  
  
  
• 2.
  

  Fistula: Communication between the oropharynx and the neck. This can be prevented by leaving the submandibular gland intact, resecting only a portion of it, and/or rotating an anterior digastric flap to bolster this area. Staging surgery to allow for the region to granulate may also reduce this risk.

  
  
• 3.
  

  Injury to the carotid artery: Rare but possible if the surgeon dissects too far laterally. If the adipose tissue surrounding the carotid is not involved, this can be safely retracted laterally after identifying the pterygoids.

Surgical Technique: [include narrated videos online]

• 
  

  General anesthesia with paralysis is necessary when approaching from a transoral technique. This allows for maximal mouth opening and minimizes muscular contraction when using monopolar cautery. After induction, the patient is intubated orally with a reinforced tube, which is sutured into position in the nasolabial fold. The eyes are protected using a plastic shield or thick towels. The bed should be lowered completely and the patient should not be placed on a shoulder roll. Preoperative steroids are given for a total of three doses.