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Standard Tonsillectomy
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JasonC.Fleming andTrevorG.Hackman
33
33.1 Introduction
Tonsillectomy is one of the oldest described surgical operations.
The origins of the modern tonsillectomy are traceable back to
Galen (120–200AD), whose early writings included a description of the tonsil snare. During the medieval period, historical
reports indicate that the procedure fell into disrepute, with frequent complications of bleeding, infection, and most prominently, severe pain. In the era of modern medicine, reduction in
complications resulting from improvements in anaesthesia and
surgical technology, as well as the recognised benets of the procedure, have made tonsillectomy one of the most frequently performed surgical procedures worldwide, with over 500,000
procedures performed in children alone in the United States each
year [1]. National operative numbers of over 50,000 tonsillectomies performed in England in the early 2000s [2] have reportedly declined in recent years owing to stricter regional criteria for
referral and subsequent intervention. There is growing evidence
that this approach is having a negative impact on health, however, with rising admission rates for acute tonsillitis and tonsillitisrelated complications over a similar time period [3].
The palatine tonsils, together with the lingual tonsils and
adenoids, make up Waldeyer’s ring. This anatomically
related aggregate of lymphoid tissue functions as the mucosal immune organ of the upper respiratory tract, primarily
with respect to immune induction [4]. The location and surface conformation of the palatine tonsils predisposes them to
early and continuous exposure to inhaled or ingested environmental antigens. Early animal studies suggested that this
location made them an ideal site for generating IgA-mediated
J. C. Fleming (*)
Liverpool Head and Neck Centre, Liverpool University Hospitals
NHS Foundation Trust, Liverpool, UK
e-mail: Jason.eming@liverpool.ac.uk
T. G. Hackman
Department of Otolaryngology/Head and Neck Surgery, G108
Physicians, Chapel Hill, NC, USA
e-mail: trevor_hackman@med.unc.edu
mucosal immunity [5], although their full immunological
function is still not completely elucidated. The oropharyngeal complex, composed of the posterior third of the tongue,
the posterior pharyngeal wall, the soft palate, and the palatine tonsils, is a vital component of both the voluntary and
involuntary pharyngeal phases of swallowing. The palatine
tonsils themselves lie within fossae bounded anteriorly by
the palatoglossal arch and posteriorly by the palatopharyngeal arch; they are supported on the deep aspect by the superior constrictor muscle. All of these extracapsular muscular
and fascial structural relations to the tonsil should be preserved as much as possible during tonsillectomy in order to
minimise postoperative bleeding, pain, and loss of function.
33.2 Indications
The only two absolute indications for tonsillectomy are a
diagnostic procedure for malignancy or signicant obstructive sleep apnoea (OSA) in children. Unilateral pain and
ulceration are features more likely to represent squamous
cell carcinoma. Even without these features, studies have
demonstrated malignancy rates (most commonly secondary
to lymphoma) of over 2% in a signicantly asymmetrically
enlarged tonsil [6]. Associated constitutional symptoms, progressive growth, cervical lymphadenopathy, mucosal
changes, and abnormal palpation all increase the likely positive yield of diagnostic tonsillectomy.
OSA represents the most severe degree of sleep-related
breathing disorders, a disease continuum that ranges from
simple snoring at its most benign to signicant impairment of
ventilation. Objectively, hypopnoea represents a partial airway
obstruction resulting in over 50% reduction in ventilation,
causing a decrease in arterial saturation of at least 4%, whereas
apnoea is a complete cessation of respiration for more than
10seconds [7]. It is important to distinguish severely affected
patients, who are at elevated risk for long-term cardiovascular,
respiratory, endocrine, liver, and cognitive complications,
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_33
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J. C. Fleming and T. G. Hackman
from those who simply snore regularly (12% of 4–5-year olds)
[8]. At its most severe, untreated OSA can result in cor pulmonale and an increased risk of myocardial infarction [9, 10].
Tonsillectomy, often combined with adenoidectomy, is effective in treating over 80% of children with signicantly affected
sleep-related breathing obstruction [10].
Recurrent infections are the other common indication for
tonsillectomy. In the UK National Prospective Tonsillectomy
Audit (NPTA), recurrent acute tonsillitis was by far the most
commonly cited indication for surgery in all age groups (61%
under 5years, 82% between 5 and 16years, and 81% over 16)
[11]. Many of the current guidelines in use rationalising the
indications for tonsillectomy are derived from the study by
Paradise etal. of 187 children that both proposed minimum
criteria for intervention and supported appropriate nonsurgical
management [12]. This led to the publication of the Scottish
Intercollegiate Guidelines Network recommendations for consideration of tonsillectomy for recurrent acute sore throat [13]:
• Sore throats are due to tonsillitis.
• The episodes of sore throat are disabling and prevent nor-
mal functioning.
– ≥7 documented, signicant, treated sore throats in pre-
ceding year
– ≥5 episodes in each of the preceding 2years
– ≥3in each of the preceding 3years
Though these recommendations encompass both children
and adults, watchful waiting is especially recommended for
children with mild sore throats only. In the United States, in
addition to the indications already discussed, chronic tonsillitis or tonsilloliths and dysphagia secondary to signicant
adenotonsillar hypertrophy are also accepted indications to
proceed to surgery. Surgeons should continually audit their
own outcomes in addition to prescriptive guidelines to help
best inform practice.
33.3 Surgical Technique
A variety of techniques have been described and developed
over the past century for removing the palatine tonsils. More
recently, most large studies show that cold steel dissection,
bipolar or monopolar electrodissection, or a radiofrequency
coblation technique are the most prevalent surgical techniques. Whichever technique is used, the principles for tissue
handling promoted by William Halstead (1852–1922) remain
key, including gentle handling of tissue and meticulous haemostasis. It is beyond the scope of this text to describe every
different technique in detail, but even the largest studies recognise the importance of sound surgical technique to minimise postoperative complications.
A successful operative result begins with appropriate
preparation, anaesthesia, and positioning of the patient. As a
shared airway procedure, close cooperation with the anaesthesia team is essential for success. Any difcult airway concerns—more likely in patients with suspected
malignancy—should be discussed with the whole theatre
team prior to anaesthesia, with a primary and at least a secondary plan made in the event of any anticipated problems.
A headlight should be used with fully charged batteries and
adequate beam focusing ensured before the surgeon scrubs.
The gold-standard airway tube remains a south-facing oral
Ring-Adair-Elwyn (RAE) tube because of the risk of airway
soiling during a prolonged or difcult procedure, although
with appropriate training and case selection, the use of a
laryngeal mask airway (LMA; reinforced type) is appropriate. Intubation techniques will necessitate muscle paralysis
but offer unrestricted surgical access. The patient should be
positioned with his or her head close to the end of the table
for the surgeon’s comfort, and a shoulder roll positioned to
extend the neck. Head drapes are commonly utilised, allowing adequate exposure of both the nose and mouth, ensuring
that the eyes are taped and protected.
First, inspect the lips, teeth, and oral cavity. Make a note of
any preexisting trauma or loose teeth, most importantly so
that these can be checked after the procedure to ensure that
there is no aspiration risk and to provide appropriate postoperative care. A mouth gag is placed (e.g. Boyle-Davis, McIvor,
Dingman), expanded, and suspended in order to displace the
tongue anteriorly and improve oropharyngeal exposure
(Fig.33.1). Failure to adequately position the patient or gag
can make this a prolonged and unnecessarily tedious step for
the inexperienced. The tongue should be positioned in the
midline under the anaesthetic tube before the appropriately
sized gag is inserted, allowing for the natural curvature of the
tongue base and preventing blunt trauma to the posterior pharyngeal wall. The tube should sit in the groove of the gag with
the tooth guard against the upper incisor teeth. A damp swab
can be used in the edentulous patient as an alternative cushion
to minimise mucosal trauma. Mobilise the lip over this guard
to avoid compression- induced swelling. Any lateral tongue
displacement will hinder access to the lower tonsil pole on
one side and should be addressed at this stage; a nger
inserted to push the tongue base back under the tube is usually successful. The gag can then continue to be gently opened
to an appropriate (but not excessive) aperture and suspension,
then secured to an appropriate system (e.g. Drafn rods,
Mayo stand); the surgeon must remain aware that this
manoeuvre can result in inadvertent changes in position of the
tracheal tube. Whatever suspension method is used, always
ensure that the head is supported on the table and not left
suspended by the cervical spine, a position that could cause
injury over the course of the surgery.
The tonsillectomy technique now varies depending on the
technique used. Classic cold steel dissection will be
described, but variations will be addressed. In the UK, advice
from the NPTA warns of a proposed dose-response effect
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Fig. 33.1 View after correct
placement of Boyle-Davis gag
Fig. 33.2 Grasping the
palatine tonsil with Denis
Browne forceps and
medialising the tissue
323
Fig. 33.3 Scissor incision
lifting up mucosa with the
blade to identify the
peritonsillar plane
between power settings of energy devices and subsequent
tonsillectomy complications (haemorrhage). Monopolar use
remains popular in North America and Australia [14] and is
the method of choice in trans-oral robotic techniques. Bipolar
forceps should be used on the lowest effective setting.
Consideration of airway safety must be given to minimise
the risk of airway res when using diathermy in an oxygenenriched environment, reducing the Fi02 delivered to the
patient, guided by oxygenation monitoring.
Whatever the dissection method used, a basic requirement
is the medialisation of the palatine tonsil, utilising forceps
(Denis Browne) to grasp and manipulate the tonsil (Fig.33.2),
avoiding frequent repositioning. Scissors are used to make a
curvilinear incision anteriorly, minimising excessive mucosal loss and preserving the anterior tonsillar pillar. Lifting the
mucosa with an inserted scissor blade to make the mucosal
cuts ensures swift and accurate surgical plane identication
(Fig.33.3). Bipolar dissection methods also describe a ‘buzz
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J. C. Fleming and T. G. Hackman
and pull’ technique, producing haemostasis in the mucosa
before pulling it away from the required dissection plane.
Alternatively, the initial cuts can be performed with scissors
after marking the incision with the diathermy. The incisions
should be adequately extended, most importantly to dene a
plane adjacent to the uvula but separate from it, to avoid
trauma; excessive manipulation, suction, or heat transfer to
the delicate uvula will result in postoperative swelling that is
symptomatic and likely to delay eating and subsequent
discharge.
Time should be taken here to ensure exposure of the peritonsillar plane but after this step, dissection can proceed
quickly. The forceps can be repositioned with one limb in the
created peritonsillar pocket, retracting the tonsil medially. A
tonsil dissector (e.g. Gwynne Evans) is then used to scrape
peritonsillar fascia and vessels away from the tonsil capsule
in a medial to lateral direction, directly opposing the direction of the forceps and tonsil retraction, ensuring that dissection remains at all times on the tonsil itself (Fig.33.4). This
technique will minimise trauma to the adjacent pharyngeal
musculature. The dissection should proceed around the natu-
Fig. 33.4 Forceps are
repositioned in the newly
created plane and medialised,
followed by sharp dissection
on the tonsil surface, releasing
tissue off the tonsil surface
from medial to lateral
ral curvature of the tonsil, with care taken posteriorly to similarly preserve the posterior tonsillar arch (Fig.33.5). This
dissection can sometimes be facilitated with the use of a tonsil swab between the pillar and the dissector, whilst maintaining a sweeping motion to detach the tonsillar adhesions.
This cold steel dissection is completed when all that
remains is a tongue of tissue at the lower tonsillar pole,
which usually contains the tonsillar branches of the facial
vessels (Fig. 33.6). A curved forceps (Negus) is used to
clamp this tissue (Fig. 33.7), allowing completion of the
excision with scissors against the clamp, and a subsequent tie
using 2-0 Vicryl or silk and the knot pusher to ligate any
vessels in this remnant (Fig.33.8). Care should be taken to
avoid posterior pharyngeal wall trauma from deep knot
pusher protrusion, and the corner of the mouth should be
monitored to prevent a cheese-wire effect of a tensioning
suture.
An often cited disadvantage of the cold steel technique is
intraoperative blood loss. Whilst this is often mitigated by
the faster speed of the operation, the trauma to signicant
feeding vessels can in some cases reduce the view of the
Fig. 33.5 Dissection
continues to the posterior
pillar, remaining on the tonsil
and minimising damage to
underlying superior
constrictor muscle
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Fig. 33.6 The posterior pillar
is released off of tonsil,
preserving mucosa
Fig. 33.7 Curved Negus
forceps are applied around the
tongue of tissue remaining at
the lower pole, including
tonsil vessels
325
Fig. 33.8 After cutting and
excising tonsil specimen, a
knot is looped around the
forceps, utilising a Negus
knot pusher, and tightened
during slow release of the
forceps to secure the lower
pole
operative eld and require attention before completion of the
excision. In this case, careful identication of the causative
vessel with tonsil swab and suction can facilitate focused
bipolar haemostasis or, classically, ligation with a tie following straight forceps clamping. Further mucosal bleeding
after this tonsillectomy technique is also common, and the
tonsillar fossa should be packed with a tonsil swab prior to
proceeding to the contralateral side.
At completion of the dissection, all tonsil swabs should be
slowly removed, allowing direct treatment of any frankly
bleeding vessels by the surgeon’s preferred method
(Fig. 33.9). Meticulous haemostasis at this stage is impor-
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Fig. 33.9 Final view
following dissection, with an
undisturbed constrictor
muscle, non-traumatised
uvula, and complete removal
of tonsil tissue. The lower
pole tie is visible. Dissection
can proceed on the
contralateral tonsil
J. C. Fleming and T. G. Hackman
tant, and adequate time should be allowed for any bleeding
to present with the gag relaxed. This is a good opportunity to
suction the postnasal space for any clot, ensuring that suction
is not applied to the anterior nasal cavity, which could risk
septal trauma and troublesome epistaxis.
After this pause, the oropharynx should be inspected
again and any further haemorrhage controlled. If severe
refractory bleeding occurs and is not responding to direct
methods or electrocoagulation, an alternative technique is to
apply a haemostatic agent to the tonsillar fossa and use interrupted 2-0 Vicryl sutures to approximate the anterior and
posterior pillars. This necessitates preservation of this tissue
during the initial dissection technique, and this technique
should be used only to supplement but not replace appropriate direct haemostatic methods. Finally, the gag can be
removed, holding the anaesthetic tube in place during
removal. It is important at this stage to check blood loss and
ensure correct collection of swabs and instruments.
Radiofrequency dissection with coblation has gained
popularity recently, classically for intracapsular dissection
techniques in children with obstructive tonsillar tissue but
indications are expanding. In this technique, current is
applied through a eld of sodium chloride to create a plasma
eld to cause cell lysis; the result is signicantly lower temperatures during the dissection. It goes without saying that
surgeons using this or any other novel techniques should
have had appropriate training in accredited courses before
using them in clinical practice, and individual audit series
should be maintained.
33.4 Postoperative Care
Postoperative management after tonsillectomy is not well
standardised in the literature, but there are some generally
accepted practice patterns [15, 16]. Following procedure
completion, the patient is extubated in the operating room,
ideally with care by the anaesthesia team to avoid vigorous
Valsalva, retching, or emesis. If there has been signicant
bleeding, the stomach is decompressed with an orogastric
sump tube and the oropharyngeal airway is cleared of
residual clot. In cases of obstructive sleep apnoea (OSA) ,
a nasal trumpet may be placed to assist with post-procedure oxygenation. The patient is placed on humidifed oxygen and transported to the recovery room under
surveillance.
In the recovery area, the patient is observed for bleeding,
airway compromise, and tolerance of liquids by mouth. The
adult, non-OSA population is typically prepared for discharge home once the patient has displayed adequate oxygenation without supplemental support. The patient must
display the ability to hydrate with liquids prior to discharge.
A responsible adult must be present at the time of discharge,
who is willing to be with the patient for at least the rst 24h
postoperatively.
Inadequate pain control, poor oral hydration, inability to
maintain oxygen saturation above 92% without supplemental support, and preoperative OSA are indications to consider
prolonged recovery room surveillance or admission. Patients
with tonsillectomy for OSA are at increased risk for postobstructive pulmonary oedema in the rst 24h after surgery.
Chest radiography is recommended in the recovery room. In
the adult population, strong consideration should be given to
overnight observation, especially for patients with signicant distance of travel or those with severe sleep apnoea
(Apnoea–Hypopnoea Index [AHI] ≥30).
Disposition planning for the paediatric population is more
challenging, as adequate oral intake and pain control can be
difcult to achieve, especially in the toddler and adolescent
populations. A lower threshold for overnight observation is
recommended, to avoid return visits to the urgent care, emergency department, or hospital for dehydration. Tonsillectomy
for OSA in the toddler or adolescent is an absolute indication
for overnight observation.
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33.5 Complications
33.5.1 Bleeding
Though tonsillectomy has been a routine, widely performed
procedure for decades, it carries with it some signicant,
potentially life-threatening complications. First, regardless
of the technique used for the tonsillectomy procedure, there
is a real risk for signicant postoperative haemorrhage,
which can be fatal. Up to 4% of the population undergoing
tonsillectomy will experience bleeding within the rst
10days after surgery, in a bimodal distribution: within the
rst 24h and again 7–10days postoperatively [17]. Patients
are instructed to present immediately for any signs of bleeding. In the adult population, observation for 24h is advised
for patients with a well-documented history of a signicant
bleeding episode in which no source is seen on examination.
Minor bleeding may be controlled at the bedside in the
patient with a stable airway and minimal bleeding, but
patients with substantial bleeding or a large clot require
immediate intervention to protect the airway and control the
bleeding. Rapid sequence induction with intubation in the
operating room is recommended, with surgical personnel
ready for rigid intubation or tracheostomy if needed.
Postoperative bleeding is a rare and typically unpredictable occurrence after tonsillectomy, but multiple publications have surfaced evaluating risk factors for haemorrhage,
including adult age and male sex [18–21]. In children,
ADHD, recurrent tonsillitis, older age, elevated postoperative mean arterial blood pressure, and intraoperative blood
loss have been proposed as risk factors for haemorrhage. In
addition, the presence of a diagnosed coagulopathy such as
lupus anticoagulant disorder, platelet dysfunction, haemophilia, or von Willebrand’s disease signicantly raises the
risk of haemorrhage in spite of mitigating therapies such as
platelet transfusion, factor transfusions, or Amicar (aminocaproic acid) therapy. Anticoagulant medications such as warfarin, heparin or aspirin, signicantly raise the risk of
postoperative haemorrhage if not discontinued 5–7 days
prior to surgery.
After securing the airway, surgical management of bleeding involves removal of all clots and identication of the
bleeding site. If no bleeding is seen, the tonsil fossa should
be gently cleaned with a tonsil sponge/swab to uncover friable areas. Relief of mouth gag suspension may be necessary
at this time. Once the bleeding site is detected, various techniques are available for management. Most commonly, suction electrocautery or bipolar cautery is utilised to stop the
bleeding. In cases of refractory bleeding or exposed identiable arterial branches, consideration should be given to ‘gure eight’ suture ligation of the bleeding site. Once
haemostasis is obtained, the mouth gag is again released and
Valsalva is performed to assess for further bleeding. In the
event of signicant bleeding and extended oropharyngeal
surgery, in order to minimise retching and emesis, it is
imperative that the pharynx, oesophagus, and stomach are
decompressed with an orogastric tube prior to extubation.
33.5.2 Airway Complications
Airway complications also may also occur after tonsillectomy. The most common and signicant of these are aspiration pneumonia and post-obstructive pulmonary oedema.
Pre-emptive gastric emptying reduces the risk of postoperative aspiration pneumonia, but certain patients may still be at
risk for pulmonary complications. As mentioned, patients
with underlying obstructive breathing or lung disease may
experience respiratory difculty after surgery. In particular,
post-obstructive pulmonary (o)edema (POPE) affects
patients with longstanding OSA [22, 23]. In this patient population, normal lung physiology may undergo dramatic shifts
after surgery. The chronic obstruction creates a relative positive end-expiratory pressure (PEEP). The lungs are conditioned to function under this PEEP, and therefore, the
vascular system adjusts to the pressure dynamics with alterations to permeability. After the abrupt relief of obstruction,
the lungs may not be able to adjust the physiology of blood
ow. The sudden removal of the PEEP leads to interstitial
uid transudation and pulmonary oedema [1, 3]. In cases of
POPE, patients require continuous respiratory monitoring
and supportive care. Chest x-ray will conrm the diagnosis
of pulmonary oedema. Continuous pulse oximetry is
required, as well as frequent assessment of respiratory rate.
Humidied oxygen (typically via face mask) is recommended to maintain oxygen saturation above 94%. In cases
of increasing oxygen requirements (>40% FiO2 and/or
10L), increasing respiratory rate, or decreasing oxygen saturations, positive pressure via CPAP or BiPAP may be
required. Escalation of care to a step-down/high-dependency
unit is required. If the patient still does not respond, transfer
to an intensive care unit with repeat intubation and positive
pressure ventilation is required.
33.6 Pearls andPitfalls
Inadequate haemostasis: Failure to sufciently cauterise or
ligate vessels during tonsillectomy can lead to postoperative
haemorrhage. The most notorious locations for this haemorrhage are the superior pole and the inferior pole, as the visualisation of these areas is often obscured by palate or
tongue-base mucosal overhang. Often the facial artery provides the branch to the tonsil fossa in the inferior pole, and
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J. C. Fleming and T. G. Hackman
therefore, examination of this area with Valsalva, with the
mouth in a relaxed position, is imperative before completion
of the case. On a more basic level, care should be taken to
resect only the tonsillar tissue and to preserve the constrictor
muscles, to prevent exposure of larger external carotid system branches.
Velopharyngeal incompetence (VPI): Over-resection of
palate mucosa can result in decient palatal closure of the
nasopharynx, leading to hypernasal speech and reux of
food into the nasal cavity when swallowing. Preservation of
the uvula and tonsillar pillars during resection minimises the
risk of VPI.
Retropharyngeal carotid artery: Though an uncommon
nding, the retropharyngeal carotid artery should be suspected if pulsatile swelling is visible on the posterior pharyngeal wall during clinic and operating room evaluation prior
to commencement of surgery.
Local anaesthesia: Injection of local anaesthesia can signicantly improve postoperative swallowing and recovery, but
caution should be taken to avoid direct intra-arterial injection,
given the proximity of the external carotid system.
Paraesthesias: Tongue numbness or weakness and loss of
taste can be associated with prolonged pressure neuropraxia
of the tongue from retraction. This is an uncommon occurrence given the brevity of most tonsillectomies, but challenges of exposure in patients with limited mouth opening, a
large tongue, large mandibular tori, and limited neck extension may require more retractor force and longer procedural
time. In these situations, the risk of neuropraxia is higher, and
patients should be advised of the risks. The surgeon should be
mindful of periodically relieving the retractor, particularly if
venous congestion colour changes are noted on the tongue.
Postoperative steroids: Oral steroids given postoperatively may improve pain, nausea, reduce pharyngeal swelling, and improve oral intake, thereby reducing the risks of
dehydration, readmission, and need for opioid medication.
Clinicians should be aware, however, about the risk of bone
demineralisation, blood sugar disturbance, mood disorders,
and insomnia related to steroid use.
Obstructive sleep apnea: Patients with obstructive sleep
apnea who undergo tonsillectomy should be kept for observation, particularly if they live farther than 30min (UK) or
2h (USA) from a major medical centre.
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Transoral Resection forOropharyngeal
https://t.me/med1917
Neoplasms
MarioFernández, TerryM.Jones, andKatharineDavies
34
34.1 Introduction
The surgical management of oropharyngeal neoplasms was
classically based on open approaches including mandibulotomy, lateral or suprahyoid pharyngotomy for selected cases.
These approaches involve signicant morbidity in addition
to the one related to the tissue that is resected. Only small
and supercial lesions in the upper oropharynx could be
approached with conventional mouth gags and monopolar
scalpel under the naked eye. Direct transoral surgery has several limitations in achieving an adequate deep surgical margin for large resections, problems in reconstruction, and the
inaccessibility of certain areas like the base of the tongue or
the inferior aspect of the lateral oropharyngeal wall. The
morbidity of open approaches exacerbates the functional
impairment derived from the volume of tissue resected. If we
factor in the customary presence of a tracheostomy and/or
nasogastric or gastric feeding tubes in such procedures,
along with the aesthetic impact, it is not surprising that nonsurgical approaches to oropharyngeal lesions have been
explored. Radiation therapy with or without chemotherapy
has been used with satisfactory oncological results, but the
chemotherapy toxicity and the middle- and long-term morbidity of radiotherapy have had a deep impact on functional
results, quality of life, and overall survival rates [1].
M. Fernández (*)
Department of Otorhinolaryngology, Hospital Universitario
“Gregorio Marañón”, Universidad Complutense de Madrid,
Madrid, Spain
e-mail: mmarcos.fernandezf@salud.madrid.com
T. M. Jones
Department of Molecular and Clinical Cancer Medicine, Liverpool
Head and Neck Centre, University of Liverpool, Liverpool, UK
e-mail: T.M.Jones@liverpool.ac.uk
K. Davies
Liverpool Head & Neck Centre, Liverpool University Hospital
NHS Foundation Trust, Liverpool, UK
e-mail: KATHARINE.DAVIES@liverpoolft.nhs.uk
The arrival of new technologies has increased the interest
in transoral surgery (TOS) and its possibilities as a path to
improve functional outcomes in oropharyngeal surgery. The
avoidance of the morbidity derived from open surgical
approaches was a step forward in itself. The best functional
scenario was achieved for small, resectable tumours with no
indication for adjuvant radiotherapy [2]. For less favourable
lesions, a reduction in adjuvant treatment is being explored,
and it now seems that such a strategy can offer greater benet
for oropharyngeal tumours that are positive for human papillomavirus [3].
Transoral laser microsurgery (TOLM) was the rst one of
new technologies proposed to avoid open approaches. The
experience of its use for oral cavity neoplasms was soon
exported to the oropharynx. In 1973, Strong and colleagues
reported the rst series of cases that included oropharyngeal
lesions [4]. There is no doubt that TOLM has expanded indications for oropharyngeal transoral resections. There have
even been reports of good local control and functional outcomes in patients with locally advanced cancer [5, 6].
TOLM can reach any part of the oropharyngeal anatomy,
but the external location of the microscope limits the angle of
approach. And although laser is still the best energy for surgical resection of lesions where ne excisions are needed,
such as lesions on the vocal cords, the epiglottis, or any
supercial lesion in the aerodigestive cavity, more powerful
coagulation energies are required for the more challenging
expanded indications that require extensive local resections.
Since 2006, the replacement of the microscope by an
endoscope in transoral robotic surgery (TORS) offered a
higher quality of magnication and the possibility of better
angles of approach [7]. The addition of articulated instruments that can be easily manipulated by the operator using a
console with 3D vision opened the door for expanded indications in less approachable areas. The surgical space in the
pharynx is created using several mouth gags, but the FeyhKastembauer (FK) retractor, rst designed as a universal
retractor for ENT in 1995, was readapted for TORS in 2010.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_34
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M. Fernández et al.
Unaffordability of robotic equipment, doubts about its
efciency, and the lack of improvements related to cuttingcoagulating instruments to avoid bleeding complications
were reported. Transoral videoendoscopic surgery (TOVS),
described in 2014, used a rigid endoscope operated by the
assistant, and resection was done using electrocautery [8].
This was a more reachable proposal, but it shared the known
limitations related to cutting-coagulating instrumentation. In
2015, TransOral endoscopic UltraSonic Surgery (TOUSS)
was described, introducing a videoendoscope with a bendable tip attached to a scope holder arm; the resection was
done using an ultrasonic scalpel with improved coagulation
properties [9]. TOUSS is an attractive and affordable alternative that makes it possible to increase the safety of transoral
resections, but it must be combined with ne cutting energies
such as microelectrodes or a CO2 laser to avoid excessive
tissue damage to delicate mucosa.
Finally, the expanded indications of transoral surgery
require a deeper knowledge of transoral anatomy. Inside-out
anatomy of the oropharynx cannot be faced under the classic
outside-in anatomic references [10]. The knowledge of the
transoral anatomy of the oropharynx is the keystone for
safety in transoral resections and deep three-dimensional
location when working with two-dimensional endoscopic
equipment. However, the preservation of tactile input allows
the TOLM and TOUSS surgeons to take advantage of outside- in anatomy knowledge compared to TORS surgeons.
There are still doubts and concerns related to the extension of resections, involving the possibility of obtaining free
surgical margins in certain areas, the functional impact of
transoral resections based on their extent and the areas
involved, and the prospect of safely de-escalating adjuvant
treatment. The contribution of transoral surgery to the treatment of oropharyngeal neoplasms with improved function
and de-escalation of other therapies is still being explored
[11].
34.2 TOUSS Surgical Technique
34.2.1 General Aspects
The critical aspects of the technique are a correct exposure,
the knowledge of the transoral anatomy, and a correct use of
the ultrasonic scalpel. The ultrasonic scalpel permits a bloodless procedure with good visual control of the anatomy as the
resection progresses, but proper use of the instrument and a
knowledge of its particular characteristics are mandatory.
The mobile blade of the scissors has thermal protection that
should always be kept against the mucosa to better preserve
the quality of the specimen and facilitate the assessment of
the surgical margin by the pathologist. The left hand of the
surgeon is used for pushing the tissue from the external
aspect of the neck of the patient against the ultrasonic scalpel
inside the mouth. This manoeuvre is critical to improve the
tactile input from the tissue. It should be noted that tactile
input from the tissue is reduced in transoral surgery, compared with open surgery. This fact is especially important in
the assessment of the deep extension of the lesion during surgery, as well as localizing the important anatomic structures.
En bloc resections are not mandatory, but a proper orientation, inking, and labelling of every single piece of specimen
are mandatory for a safe piecemeal resection, particularly in
cases of locally advanced cancer.
Straight instruments can be used for transoral resection of
oropharyngeal neoplasms when the exposure is correct. As
mouth opening is not relevant in TOUSS, it is not considered
as an indication or contraindication for the transoral
approach. A wide internal surgical eld is achieved with the
mouth closed due to a maximum distance between the chin
and the hyoid bone, where the base of the tongue is compressed. These aspects become critical for approaching
lesions at the base of the tongue. The decision about covering
the defect with a ap is inuenced mainly by the presence of
cervicopharyngeal communication, the exposure of arterial
branches in the pharynx, or the necessity for lling the defect
with a functional intention. Care must be taken with uncovered surgical elds in salvage surgery: close follow-up is
mandatory to check that correct healing is occurring in the
pharynx. The transoral suture is a problem for all types of
surgery in such a narrow space. The implementation of articulated instruments signicantly simplies this task. It doesn’t
seem that there is no additional role for articulated laparoscopic instruments in TOUSS.
34.2.2 Operating Room Set-Up
The TOUSS procedure is inspired by laparoscopic surgery,
so the ergonomics of laparoscopy is basically the same as for
TOUSS. The surgeon is located at the head of the patient
(Fig. 34.1). The patient’s mouth should be placed a little
below the level of the surgeon’s elbows. The assistant can
help the surgeon from the left or the right side, using the
aspiration cannula to evacuate the smoke and blood from the
surgical eld. The endoscopy tower is in front of the table of
instruments, and an articulated arm takes the monitor close
to the position of the surgeon. Finally, the ultrasonic scalpel
generator is placed at the foot of the table.
34.2.3 Patient Position
To facilitate the creation of a wide surgical pharyngeal space,
a roll at the back of the patient should be avoided. Equally,
extension of the neck also interferes with a proper exposure,
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