Oropharyngeal Reconstruction after Transoral Robotic Radical Tonsillectomy: When Reconstruction is Indicated?

Background: Transoral robotic surgery (TORS) has become an important treatment modality for oncologic resection of oropharyngeal cancers. While reconstruction of post-resection defects is not traditionally performed, scarring and contracture may lead to stenosis and velopharyngeal insufficiency (VPI). The nasoseptal flap (NSF) has been shown as a viable option for reconstruction of oropharyngeal defects after TORS. Additionally, the NSF may also expand the indication of TORS for patients with soft palate involvement. Here we review a series of patients who underwent TORS for oropharyngeal cancer and compare indications and outcomes between patients who received no reconstruction and those who underwent oropharyngeal reconstruction with NSF.

Methods: A retrospective chart review was performed for patients at our institution who underwent TORS for oropharyngeal cancer between 2015 and 2019.

Results: A total of n = 23 patients received TORS for radical tonsillectomy. Ten patients had no reconstruction (five males and five females), mean age: 63 years (range: 28–88 years); four patients had buccal fat flap (BFF) reconstruction of the tonsillar defect (three males and one female), mean age: 62 years (range: 47–74 years); and nine patients had reconstruction of the oropharyngeal defect with NSF (eight males and one female), mean: 65 years (range: 53–78 years). Patients who had NSF had larger oropharyngeal defects, partial soft palate resection, or exposure of the internal carotid artery (ICA). Patients who had no reconstruction or had BFF presented with smaller tumors limited to the tonsillar fossa and did not require major soft palate resection. All 14 patients with no reconstruction or BFF had some degree of palatal retraction, but none had stenosis or VPI postoperatively ([Fig. 1]). In the NSF group, the four last patients had extended dissection of the flap pedicle to PPF and internal maxillary artery (IMAX) to improve the flap reach. Only one patient out of nine developed mild VPI despite much larger defects resulting from the palatal resection ([Fig. 2]). None of the patients in the NSF group had palatal retraction or stenosis. The most common complication of the nasoseptal flap was nasal crusting. In addition to nasal crusting, one patient had partial necrosis of the NSF. There was no postoperative Eustachian tube dysfunction or serous otitis media in patients reconstructed with an NSF. The presence of the pedicle in the nasopharynx may function as a pharyngeal flap, occupying space in the area and preventing VPI in this patient population.

Conclusion: Soft palate involvement should not limit the resection achieved with TORS. Reconstruction with NSF has shown to prevent major complications associated with soft palate resection, such as severe VPI, palate retraction, or stenosis. It also offers excellent coverage when the parapharyngeal ICA is exposed. Pedicle dissection toward the PPF and IMAX offers a great improvement of the flap reach. Although all patients who had no reconstruction after TORS for tumors limited to the tonsillar fossa had some degree of palatal retraction, no clinical VPI was noticed in this group.