of life‐threatening hemorrhage, and the patient's prior definitive treatment with chemoradiation, open approach is favored over TORS. While TORS has been shown to be a safe and effective alternative to open resection of oropharyngeal malignancies in the salvage setting, this patient's anatomy is better suited for an open approach, which will allow dissection directly on the vessel, as well as proximal and distal control. Reirradiation, palliative chemotherapy, or hospice may be considered in poor operative candidates, in those with more advanced disease, or in patients who refuse surgery.
The patient's case was presented at the institutional Multidisciplinary Head and Neck Tumor Board, and open resection with right neck dissection and reconstruction via lip split and mandibulotomy approach, tracheostomy, and percutaneous endoscopic gastrostomy were undertaken. Sacrifice of the lingual nerve was necessary due to the location of the tumor, but the hypoglossal nerve was preserved. The specimen was removed en bloc, and the defect exposed the parapharyngeal carotid and radiated fat of the parapharyngeal space and the prevertebral fascia. Right neck dissection required resection of some branches of the external carotid artery, but all tumor was removed from the neck, and the internal jugular vein and the internal carotid artery were preserved.
Question: What is the best reconstructive option for this patient?
Answer: Due to the history of prior radiation therapy, the proximity to the carotid artery as well as the wide communication of the primary site resection and the neck, a vascularized flap reconstruction is required. Free tissue transfers have largely supplanted regional flaps for large oropharyngeal and oral cavity reconstruction in appropriate candidates, but because of this patient's comorbidities and poor recipient vessels, a regional flap reconstruction with the pectoralis major myocutaneous flap was performed (see Figure 10.3). A segment of skin with the flap is required for approximation with pharyngeal mucosa to ensure a water‐tight closure. Despite the favorability of free tissue transfer in oropharyngeal reconstruction, the pectoralis major myocutaneous flap remains a viable reconstructive alternative in patients who are not candidates for free flaps. A nonvascularized repair such as a skin graft or acellular dermal autograft would be inappropriate here given the large communication with the neck wound, poor tissue quality, the prior radiation, and the proximity to the internal carotid artery.
FIGURE 10.3 This intraoperative photo demonstrates an open approach to the oropharynx via lip split and paramedian mandibulotomy. The tumor has been excised and the defect reconstructed using a pectoralis major myocutaneous flap.
The patient failed a follow‐up modified barium swallow study and remained PEG‐dependent after surgery.
Final pathologic evaluation of the surgical specimens revealed a pT2N0M0 moderately differentiated SCC that was completely excised with >5 mm margins. Perineural invasion was present, but there was no lymphovascular invasion. Tumor immunohistochemical staining for p16 was negative. Reirradiation was discussed at tumor board, but observation was favored due to clear margins.
Key Points
Surgical salvage of oropharyngeal cancers in patients who have already received radiation therapy increases the risk of significant problems with swallowing and secretion management. Patients may end up being tracheostomy tube or gastrostomy tube dependent according to the exact location of the cancer and the nature of the prior treatment.
In the setting of operating on irradiated tissue in the pharynx, vascularized tissue in the form of a pedicled or free flap provides healthy tissue for closure.
Reirradiation of oropharyngeal cancer can predispose to soft tissue necrosis of the pharynx, carotid rupture and/or injury to the spinal cord. The additional benefit of improving the chance for cure through reirradiation must be balanced against the significant morbidity of another full course of radiation.
CASE 11
Daniel Pinheiro
History of Present Illness
A 73‐year‐old woman presents with a 2‐month history of right‐sided sore throat. She has mild dysphagia but eats a mostly unrestricted diet. She attributes her dysphagia to dry mouth because of prior radiation.
Past Medical History
Hypertension, hypercholesterolemia.
Past Surgical History
History of prior cervical spine surgery.
Social History
30 pack‐year smoking history.
She drinks alcohol on occasion with approximately one beer/week.
Question: What additional questions should you want to ask?
Any trismus? Patient denies.
Any otalgia? Patient denies.
Any neck masses? Patient denies.
Any prior head and neck cancer? She has a remote history of nasopharyngeal carcinoma for which she was treated with external beam radiotherapy to the nasopharynx and bilateral neck 24 years prior to presentation.
Physical Examination
Well‐developed female in no distress. Voice strong.
Skin: no suspicious lesions.
Well‐aerated middle ears without effusions.
Oral cavity: limited mouth opening to 2.5 cm. Teeth in good repair. No lesions seen or palpated.
Oropharynx exam: small asymmetry in right tonsil with an ulcerative area that measures approximately 1.5 cm; both tonsils are small. Right tonsillar lesion is firm, but the tonsil is mobile. There is no trismus and the soft palate moves symmetrically. No lesions are palpable in the base of tongue. Vallecula is clear on mirror indirect laryngoscopy. The nasopharynx was incompletely visualized.
Neck exam: normal salivary glands with no adenopathy. The patient does have radiation changes in the neck but no woody induration.
Cranial nerves II–XII intact.
Management
Question: Which of the following steps would be appropriate?
Flexible fiberoptic nasopharyngoscopy: yes/no. This is appropriate for full evaluation of nasopharynx (given prior history) and to examine the inferior extent of lesion in the right tonsil and rule out other lesions in larynx or hypopharynx.In this patient, exam showed no lesions in nasopharynx with a patent fossa of Rosenmuller bilaterally and radiation changes of the pharynx.
Tonsil biopsy in office: yes/no. This is appropriate since a visible lesion is apparent and is accessible for office biopsy.Pathology demonstrated invasive well‐differentiated SCC. Stains for p16 on immunohistochemistry were negative.
CT neck with contrast or MRI neck with contrast: yes/no. Kidney function may not permit administration of contrast, and, in general, MRI can be performed in patients with lower GFR who may not tolerate the contrast required for a CT.This patient was found to have normal kidney function with estimated GFR