Transoral robotic assisted nasopharyngectomy via a lateral palatal flap approach.

INTRODUCTION Nasopharyngectomy has been established as a feasible curative treatment for salvaging recurrent nasopharyngeal carcinoma after radical radiotherapy. A large case series has also shown that the overall survival rate in nasopharyngectomy is comparable with reirradiation in small recurrent tumors. However, reirradiation has significant late complications from radiotherapy, and surgical salvage can avoid these complications. Open approach nasopharyngectomy usually requires osteotomies to the facial skeleton and a facial incision. To further decrease the morbidity of nasopharyngectomy, transnasal endoscopic approaches for resection of small recurrent tumors in the nasopharynx have been reported. Our unit has also reported our experience in nasopharyngectomy with a surgical robot. Nasopharyngeal carcinoma most commonly arises from the lateral aspect of the nasopharynx, in the fossa of Rosenmuller. The tumor frequently extends laterally into the parapharyngeal space. Endoscopic nasopharyngectomy with en bloc removal of the tumor in the parapharyngeal space is a challenging operation requiring a team skilled in the four-hands technique of endoscopic transnasal skull base surgery and removal of bones in the medial, posterior, and lateral wall of the maxillary antrum. Our previous description of robotic nasopharyngectomy employed a midline soft-palate split for exposure of the nasopharynx. Coupled with the versatile motion of the EndoWrist R instrument (Intuitive Surgical Inc., Sunnyvale, CA), this allowed en bloc resection of the lateral part of the nasopharynx. However, the lateral reach was still limited by the lateral soft palate. To refine the approach, we modified the approach to the nasopharynx with a lateral palatal flap approach instead of the midline soft-palate split. This lateral palatal flap approach has been devised in a cadaveric dissection. We have performed transoral robotic-assisted nasopharyngectomy of recurrent nasopharyngeal carcinoma via the lateral palate flap approach for a patient with recurrent nasopharyngeal carcinoma and now report our technique and result.