Case Study from our Complex Cases Series
Steven B. Cannady, MD, Assistant Professor of Otorhinolaryngology – Head and Neck Surgery
Mr. G, a 55 year-old man, presented with progressive odynophagia and an enlarged lymph node of the left neck. An endoscopy identified a left superior left tonsil tumor with extension to the left soft palate to the midline.
The treatment options included chemoradiation upfront or TORS with microvascular free tissue transfer. The patient elected for a surgical approach, and underwent TORS, neck dissection (Figures 1 & 2) and tracheostomy, and a radial forearm free flap (Figure 3), which required reconstruction following surgery. The flap was used to rebuild a bi-layered soft palate with seamless integration into the tonsillar defect (Figure 4), preserving the patient's speech and swallowing. The patient's tracheostomy was decannulated and he was cleared to swallow in two weeks, eating solids within a month. He received low-dose postoperative radiation therapy with no effects to the reconstruction.
Patients with head and neck cancer face the dual challenge of surviving their cancer and facing functional changes in swallowing, speech, and sometimes appearance. Transoral Robotic Surgery (TORS) provides patients with oropharyngeal tumors a minimally invasive option to have their tumors surgically removed and enable de-escalation of postoperative treatments such as radiation or chemotherapy resulting in unparalleled success in both cancer and functional outcomes.
The success of TORS and the addition of complex reconstructive capabilities, using microvascular free tissue transfer to the pharynx with three-dimensional pharyngoplasty, has opened the door to offering this surgery to larger numbers of patients. This expansion in the indications for surgery includes tumors largely based in the soft palate, patients with retropharyngeal carotid anatomy, or larger tumors of the pharynx. Over the past four years, Penn Otorhinolaryngology has offered TORS with microvascular reconstruction to select patients whose cancer was too complex to be treated elsewhere, affording comparable functional outcomes to TORS for earlier tumors.
Images (Warning: Graphic content)