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I. Mohammad et al.
7. The temporalis muscle is elevated from the
temporal squama.
8. Osteotomies of the zygomatic arch allow
inferior reection of the temporalis
muscle.
9. A fronto-temporal craniotomy is then fashioned, which includes the root of the zygomatic arch, the glenoid fossa and the oor of
the middle fossa lateral to the foramen spinosum and ovale, extending anteriorly to the
pterion (Fig.7.6c).
10. Using a microscope, further medial dissection elevates the dura to expose the arcuate
eminence, greater supercial petrosal nerve,
middle meningeal artery and mandibular
nerve (V3).
11. The middle meningeal artery is ligated and
divided.
12. The V3 can be retracted if it is not invaded by
the lesion.
13. Through this exposure, lesions around the
middle third of the Eustachian tube can be
resected.
14. Removal of more bone medial to the glenoid
fossa and antero-medially along the greater
wing of the sphenoid gives further access to
the anterior Eustachian tube and pterygopalatine fossa.
15. Selective removal of the pterygoid process
allows access to the anterior third and pharyngeal ostium of the ET and to the posterolateral aspect of the nasopharynx.
16. Further dissection along the pharyngobasilar
membrane exposes the entire nasopharyngeal
soft-tissue sleeve allowing circumferential
resection.
17. If the lesion extends to the cavernous and
petrous ICA, the ET is removed completely,
which gives access to the horizontal and vertical petrous segments of the ICA.
18. The oor of the cavernous sinus can be
accessed by unroong the horizontal segment of the ICA exposed.
19. Further exposure of the inferior and medial
border of the cavernous ICA is to be attained
by removal of the pterygoid root and the lateral walls of the sphenoid.
7.6.2 Advantages
This approach gives a wide exposure of the
infratemporal region, the petrous and cavernous
segments of the internal carotid and the cavernous sinus. It also provides good access for
reconstruction.
7.6.3 Disadvantages
The procedure requires craniotomy. The postoperative CSF leakage can be as high as 15–20%.
It does not give adequate exposure of the posterior petrous bone and otic capsule.
7.7 Facial Translocation
This approach (Fig.7.7) is suitable for extensive
tumours (T4) of the anterior and middle skull
base extending into the orbit, paranasal sinus
and posterior cranial fossa with intracranial
involvement. However, it is contraindicated in
tumours involving the bilateral optic chiasm and
ICA [24].
7.7.1 Procedure
1. The patient is supine with the head turned
30–40° to the opposite side and positioned in
an open head rest or Mayeld clamp.
2. The ipsilateral scalp, face, neck, lower abdomen and thigh are prepared and draped.
3. A modied Weber-Ferguson incision is made
in order to create a wide cheek ap pedicled
on the facial and inferior labial vessels.
4. The cheek ap includes the lateral third of
the upper lip, the entire cheek soft tissue
including the maxillary periosteum, lower
lid, facial nerve and parotid gland.
5. The incision starts from the philtrum of the
lip and is continued along the nasal
silhouette.
6. It then passes horizontally transecting the
medial canthus and follows the lower eyelid
7 Surgical Management ofNasopharyngeal Carcinoma
181
a
Fig. 7.7 Facial translocation. (a) A fronto-temporal scalp
ap reected to the midline, while the cheek ap along
with the transected masseter muscle reected inferiorly to
the level of hard palate. Upper lip is divided and extended
to the last molar. (b) Osteotomy sites passing through
b
frontozygomatic and temporozygomatic sutures, inferiorly at the level of hard palate and medially the orbit and
tip of the inferior orbital ssure to the lateral orbital wall
to create a orbito-maxillo-zygomatic free bone ap
dividing the conjunctiva and the lateral canthus. It then joins the preauricular incision.
7. The frontal branches of the facial nerve can
be transected and tagged for later reconstructive neurorrhaphy.
8. The soft tissues of the cheek are elevated
from the facial skeleton and in doing so the
infraorbital nerve is transected and the masseter muscle is divided just below the zygomatic arch.
9. A bicoronal incision is then made that meets
the lateral extension of the previous transfacial incision. This allows elevation of soft tissues from the temporal muscle and frontal
bone, thus creating a fronto-temporal scalp
ap.
10. The fronto-temporal scalp ap to the midline, while the cheek ap along with transected masseter muscle, is reected inferiorly
to the level of the hard palate.
11. This manoeuvre requires division of the
upper lip and extension of the lip incision
along the gingivolabial sulcus as far as the
last molar tooth.
12. An orbito-maxillo-zygomatic free bone ap
is created.
13. Osteotomies pass through the frontozygomatic and temporozygomatic sutures laterally; inferiorly through the maxilla at the
level of the nasal oor parallel to the hard
palate to reach the pterygopalatine fossa;
medially through the orbit in line with the
inferior part of the lacrimal fossa and the tip
of the inferior orbital ssure; and laterally
continue along the lateral orbital wall to join
the transected frontozygomatic suture.
14. The posterior wall of the maxilla is freed
from the pterygoid plates with a chisel.
15. A subperiosteal osteotomy of the coronoid
process and mandibular neck allows the temporal muscle and fascia to be mobilized from
the temporal fossa and reected inferiorly
along with the mandible.
16. This gives access to the nasopharynx, pterygoid process, anterior surface of the sphenoid as well as infratemporal fossa.
17. Further removal of the pterygoid processes
and muscles exposes the lateral wall of the
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I. Mohammad et al.
nasopharynx and foramen rotundum with the
maxillary nerve.
18. If even more access is required, it can be
achieved by removal of bone from any of the
exposed surfaces, and by doing this the entire
infratemporal, petroclival and cavernoclival
borders can be visualized.
19. Reconstruction follows the previously
described steps, starting with watertight sealing of the dura with bulky microvascular free
aps (e.g. rectus abdominis, latissimus
dorsi), which also eliminates the dead space
and provides a well-vascularized barrier
between the dura and the nasopharyngeal
mucosa.
20. The free bone aps are replaced and xed
with miniplates.
21. The cheek ap is realigned, and the medial
and lateral canthal ligaments are reattached
with stents being placed in the lacrimal duct.
22. Finally, the frontal branches of the facial
nerve are reanastomosed and the skin soft
tissue is closed in layers.
23. Nasal packings are introduced to prevent
obliteration of the nasal airway by encroachment of the reconstructive tissue in the operative defect.
24. Nasogastric feeding is necessary for a few
days, but oral alimentation can begin during
the rst week.
25. Any non-resorbable nasal packs are removed
on the eighth day.
26. Lacrimal stents are left in place for 3weeks.
7.7.2 Advantages
Facial translocation gives direct wide exposure of
the anterior and middle cranial base and good
access for reconstructions. This enables radical
resection of extensive tumours.
CSF leak. This also requires additional procedure
to drain the nasolacrimal duct. The dissection
also results in temporary or permanent palsy of
the frontal branches of the facial nerve. There is
high risk of post-operative osteonecrosis.
7.8 Endoscopic Endonasal Transpterygoid Nasopharyngectomy (EETN)
The primary treatment for untreated nasopharyngeal carcinoma (NPC) is radiotherapy for earlystage lesion and concurrent chemoradiation for
advanced tumour. The reported incidence of local
recurrence was approximately 8–58% [25–27].
Local recurrent NPC can be treated with salvage
re-irradiation or surgery [28]. Ridge recommended that resection of locally discrete recurrent NPC should be considered unless the patient
is not t for operation [29]. Surgery should be
considered for patients presenting with residual
or recurrent tumour after radiotherapy or chemoradiotherapy, and for patients with glandular or
mesenchymal differentiation tumours as initial
treatment, which are poorly responsive to radiotherapy [30]. Furthermore, high-dose reirradiation may result in severe complications
like osteoradionecrosis, brain necrosis, radiationinduced myelitis, hypopituitarism and trismus
[31, 32].
Endoscopic endonasal transpterygoid nasopharyngectomy (EETN) has emerged as a viable
treatment option for local recurrent NPC with
minimal invasiveness, avoiding morbidity from
external approaches and facial scar. A literature
review by Emanuelli etal. revealed that the endoscopic method attained a higher negative surgical
margin of 93.75% than external approach
(71.6%) [33].
7.7.3 Disadvantages
The major drawback of this procedure is that this
is a complex multistep surgical technique requiring craniotomy. Therefore, there is the risk of
7.8.1 Patient Selection
Patient selection is perhaps the most important
aspect of effectively treating patients with endoscopic endonasal transpterygoid nasopharyngectomy (EETN). Generally speaking, patients
7 Surgical Management ofNasopharyngeal Carcinoma
categorized as rT1, those categorized as rT2 with
minimal parapharyngeal extension and selected
patients categorized as rT3 (involvement of oor
of sphenoid sinus) can be treated with EETN
[34]. Exclusion criteria for patients can be based
on disease factors and patient factors. Disease
factors for exclusion include signicant parapharyngeal space extension, internal carotid artery
involvement, cavernous sinus with multiple cranial nerve involvement, brain parenchymal
involvement and presence of distant metastasis.
Patient factors include those patients who are
medically unt to tolerate surgery and undergo
general anaesthesia.
7.8.2 Surgical Technique
The surgery is done under general anaesthesia
with the patient lying in supine position. The
nasal cavities are decongested with Moffett’s
solution [30] for 15–30 min. The solution contains 1 mL adrenaline 1:1000, 2 mL of 10%
cocaine and 4 mL of 8.4% sodium bicarbonate
mixed together with 13mL of water for injection.
A topical decongestant of Moffett’s solution
could reduce nasal blood ow, optimizing surgical eld for surgery. Inltration of both middle
turbinates and nasal septum with a solution of
lidocaine 1% and epinephrine 1/100,000
enhances the haemostasis. Surgery proceeds via a
purely endoscopic endonasal approach using a 0°
and 30° rod lens endoscope. A fundamental
premise of the endonasal endoscopic approach is
that the two surgeons work concomitantly, using
a bimanual, three/four-handed technique via both
nostrils and nasal cavities. This facilitates
dynamic visualization as well as bimanual dissection, which is vital for depth perception, traction and countertraction and for maintenance of a
blood-free surgical eld [30].
183
Fig. 7.8 Creating HB nasoseptal ap
Fig. 7.9 Creating Caicedo ap
rendered ipsilateral to the transpterygoid dissection. Later, a Caicedo reverse ap is transposed
from the contralateral side to cover the HBF
donor defect [35, 36]. Clinical harvesting of these
septal aps presumes that the tumour does not
involve this area. If tumour involves the nasal
septum, other vascularized aps can be considered (Figs.7.8 and 7.9).
7.8.2.1 Nasoseptal Flap
Firstly, the Hadad-Bassagasteguy nasoseptal ap
(HBF) should be harvested from the contralateral
side of the tumour [30, 35]. It is critical to harvest
the HBF from the contralateral side because its
pedicle and proximal blood supply would be sur-
7.8.2.2 Sinonasal Corridor
Later, the surgery continues with enlarging the natural sinonasal corridor ipsilateral to the lesion by
removing the inferior half of the right middle turbinate and completing an uncinectomy, large midmeatal nasomaxillary window, and anterior and
184
I. Mohammad et al.
Fig. 7.10 Right medial maxillectomy performed as part
of the transpterygoid approach
posterior ethmoidectomies. Later, a medial maxillectomy is performed to expose the entire height of
the posterior wall of the maxillary sinus and allow
an extended dissection of the pterygopalatine fossa.
This medial maxillectomy is limited anteriorly by
the nasolacrimal duct, which acts like a fulcrum
point, preventing free movement of the scope laterally. Endoscopic Denker’s approach can be performed to further increase the lateral angle of
exposure and optimize instrument manoeuvrability
if needed [37]. Endoscopic Denker’s approach is a
procedure to remove the piriform aperture, as well
as the anterior maxillary wall, until the lateral wall
of the antrum is in direct and full view, particularly
the entire infratemporal fossa (Fig.7.10).
7.8.2.3 Posterior Septectomy
Additional lateral control is obtained by bringing
the instruments from the contralateral side of the
nose through a posterior septectomy. A generous
posterior bony septectomy allows a bimanual
technique traversing both sides of the nasal cavity. This extensive posterior septectomy allows
visualization of the entire posterior wall of the
maxillary sinus using a 0° endoscope that crosses
over the contralateral side of the nose.
7.8.2.4 Inferior Sphenoidectomy
The anterior face of the sphenoid sinus is often
opened early during the approach, enlarging the
Fig. 7.11 Drilling anterior wall and oor of the sphenoid
sinus
sphenoid ostium after completing the ethmoidectomies. As the superior part of the sphenoid crest
is removed, the oor of sella turcica and intersinus and intrasinus septations, as well as the
lateral walls of the sphenoid sinus, come into
direct view. The lateral walls of the sphenoid and
the medial pterygoid plates (lateral wall of the
posterior choana) form a vertical strut that intersects the oor of the sphenoid sinus. After complete removal of the vomer, the intersinus septum
and the sphenoid sinus oor, sphenoidectomy
should extend superiorly to be in plane with the
roof of the nose and laterally to be in plane with
the laminae papyracea bilaterally [38]. Complete
removal of the sphenoid sinus oor is performed
until the cavity is ush with the clivus (Fig.7.11).
7.8.2.5 Transpterygoid Dissection
Transpterygoid dissection starts with the identication of the vidian nerve proximal to the pterygopalatine ganglion, as it exits from the vidian
canal. The vidian nerve can be localized following the palatovaginal canal laterally or by drilling
its canal starting at the pterygoid wedge. The vidian nerve, within the pterygoid canal, courses
towards the second genu of the internal carotid
artery between the horizontal and vertical segments. For the most part, the vidian canal remains
inferior to the second genu of the ICA; therefore,
initial drilling in a 3 to 9 o’clock orientation helps
7 Surgical Management ofNasopharyngeal Carcinoma
185
to prevent injury to the ICA.In some cases, the
superior aspect of the canal is covered just with a
very thin bone or may even be dehiscent, thus
exposing the nerve in the oor of the sphenoid
sinus [38].
The maxillary division of the trigeminal nerve
passes through the foramen rotundum as it
courses from Meckel’s cave into the pterygopalatine fossa [39]. The maxillary nerve can also be
identied in its canal coursing the lateral wall of
the sphenoid sinus. The pharyngeal end of the
Eustachian tube or torus tubarius is just posterior
to the pterygoid process. Removal of the pterygoid process exposes the cartilaginous Eustachian
tube. The parapharyngeal segment of the ICA is
posterior to the Eustachian tube in most of the
cases.
All these landmarks are crucial to identify
during the transpterygoid approach before
tumour extirpation (Figs.7.12 and 7.13).
7.8.2.6 Tumour Extirpation
Tumour removal begins by marking out at least
1 cm margin if technically possible around the
tumour. The mucosal cuts are made with needlepoint electrocautery, which helps with haemostasis. The superior and posterior dissection occurs
by elevating the mucoperiosteum from the oor
of the sphenoid sinus and the clivus posteriorly.
The dissection proceeds inferiorly to the level of
the soft palate, and the prevertebral musculature
deep to the pharyngobasilar fascia and prevertebral fascia are encountered [40]. Electrocautery
or Kerrison rongeurs can be used and are effective at removing portions of the prevertebral muscle and fascia, as these structures are quite
resilient. The muscles are included in the en bloc
resection to get the better margin of clearance.
Laterally, the medial pterygoid plate and pterygoid process are exposed, above which lies the
sinus of Morgagni, through which passes the
Eustachian tube and tensor veli palatini muscle.
These structures can be excised along with the
levator palatini muscle to expose the parapharyngeal tissues [41]. The Eustachian tube cartilage
laterally is identied and included in the specimen. Following complete tumour removal, margin status is conrmed by sending circumferential
and deep margins for frozen section analysis
(Figs.7.14 and 7.15).
7.8.2.7 Nasopharyngeal
Reconstruction
Reconstruction with a vascularized pedicle ap
at the nasopharyngeal defect facilitates the healing of the defect, resists irradiation and protects
the ICA against exposure and blowout [30, 39].
The nasoseptal ap or HBF is rotated into the
nasopharyngeal defect. The edges of the ap are
allied well to cover the bare area, especially
exposed bony portion at the clivus. Absorbable
Fig. 7.12 Drilling pterygoid base and medial pterygoid
plate Fig. 7.13 Resecting of cartilage part of Eustachian tube
186
I. Mohammad et al.
Fig. 7.14 Resecting posteriorly at prevertebral muscle
Fig. 7.15 Final view of resection of right FOR of
nasopharynx
gelatin sponges are placed on the ap, and a
Foley catheter is used to support the nasoseptal
ap against the nasopharyngeal defect. In cases
where nasoseptal ap is unavailable, a lateral
nasal wall ap can be harvested for reconstruction. Other reconstructive options include healing
by secondary intention or use of regional aps
such as pedicled temporoparietal fascia ap
(Figs.7.16 and 7.17).
Following reconstruction, the nasal cavity is
thoroughly inspected for haemostasis followed
by careful suction of the nasopharyngeal
cavity.
Fig. 7.16 Placing of HB ap to the resected area
Fig. 7.17 Catheter tube with balloon to hold the ap at
place
7.9 Post-operative Care
andComplications
The patient is admitted to a standard ward unit
and is usually discharged from hospital within
2–3 days. After discharge from the ward, the
patients are generally seen every 1 to 2weeks to
undergo endoscopic examination. During these
clinic visits, decrusting is performed, paying
careful attention not to disrupt the nasoseptal ap
or any other aps that were laid on. Patients are
asked to liberally use sodium bicarbonate mixed
with mupirocin nasal rinse every 4 h. The re-
7 Surgical Management ofNasopharyngeal Carcinoma
187
epithelialization process at the operation site can
take up to 3 or more months, even with nasoseptal ap. Post-operative headache is a common
complaint following EETN due to exposed bone.
Covering exposed bone with pedicled nasoseptal
ap can reduce this incidence signicantly.
Serous otitis media is another common complication encountered in the post-operative
period. This can be managed by myringotomy
with tympanostomy tube insertion or amplication with hearing aids [40].
Post-operative epistaxis can occur secondary
to bleeders that are not secured during the surgery, especially when nasoseptal ap is not used,
and secondary to bleeding from posterior septal
artery. Other possible surgical sequelae include
xerophthalmia secondary to injury of the vidian
nerve, numbness in the V2 distribution, skull
base injury including cerebrospinal uid leak and
injury to the internal carotid artery in its parapharyngeal, petrous or clival portions.
7.10 Miscellaneous
Holistic approach is a must in managing patients
with nasopharyngeal carcinoma, which includes
the surveillance of disease and optimizing the
care, nutrition and pain management. Direct
visualization is the most sensitive method to
demonstrate recurrence of NPC, and about 27.8%
of deep-seated recurrent NPC was detected by
MRI [42]. However, post-radiation mucositis or
crust may limit endoscopic examination of the
mucosal surface. Narrowband imaging (NBI) and
Storz Professional Image Enhancement System
(SPIES) are able to provide image-enhanced
endoscopy to increase the diagnostic sensitivity
of primary or recurrent tumours. These systems
are able to recognize the supercial changes of
neoangiogenesis due to alterations of the vessel
architecture depending on the degree of dysplasia
[43]. A study reected that NBI offers a timely,
convenient and highly reliable assessment of
mucosal recurrent NPC, which accounts for
about 62.5% of the patients with early (T1) or
occult recurrent NPC that were detected with
positive ndings by NBI [44]. Image- enhanced
endoscopy also assists in the targeted biopsy of
the suspicious area and thus higher diagnosis
accuracy. Restaging of NPC can be performed by
using either magnetic resonance imaging (MRI),
combined positron emission tomography (PET)
and computed tomography (CT) or both as a
combination is more accurate than the use of
either technique individually [42].
In the early part of the disease, even with cranial
nerve involvement, nasopharyngeal tube feeding
will be sufcient. However, in extensive disease,
PEG or gastrostomy tube may be warranted. Hung
et al. have demonstrated that progesterone analogues such as megestrol acetate (MA) and
medroxyprogesterone (MPA) improve the quality
of life in terms of performance status, pain control
and plasma EBV DNA load in patients with locally
recurrent/metastatic NPC under palliative care.
Both MA and MPA are orally active synthetic analogues of natural steroid progesterone [45].
7.11 Conclusion
Selection of appropriate technique is necessary
according to the extension of the lesion.
Therefore, detailed studying of the pathology is
essential. The decision-making should always be
done in a multidisciplinary setting. Careful selection of the patient for surgical treatment is
extremely vital. The operation is best carried out
in centres which have established working teams
and regular exposure to such patients. Surgeons
need to give equal emphasis to the rehabilitation
of swallowing and hearing rehabilitation.
The advances in endoscopic equipment and
clarity are best utilized to make the above procedures an open endoscopic combined approach.
Endoscopic endonasal transpterygoid nasopharyngectomy (EETN) is a feasible approach for the
surgical treatment of selected primary and recurrent nasopharyngeal malignancy tumours. The
surgical technique requires trained and experienced team with specialized equipment. This
technique has relatively low morbidity with
promising preliminary outcomes and local control of the disease that is comparable to conventional techniques.
188
I. Mohammad et al.
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