Transoral robotic surgery for adult parapharyngeal lymphangioma:A case report

BACKGROUND Lymphangiomas are a group of benign swellings which are commonly seen in children.The most common sites of presentation is the head and neck region,less commonly seen in axilla,chest,liver,spleen,etc.The ideal modality of treatment has always been surgical excision irrespective of the site and age group.But with the advent of minimally invasive surgical techniques,it is now possible to perform excision of parapharyngeal space lesions with minimal morbidity and good clearance.CASE SUMMARY A 42-year-old male patient who presented with difficulty in swallowing and had undergone surgery twice outside,where Transcervical approach was attempted to remove the parapharyngeal mass,but failed.Magnetic resonance imaging scan demonstrated a 6 cm x 5 cm x 4 cm left parapharyngeal mass.He underwent transoral robotic surgery for the excision of the parapharyngeal lesion and had an uneventful post-operative recovery.CONCLUSION Lymphangiomas are hamartomatous swellings which are benign in nature.The symptoms of the patient with large parapharyngeal mass include dysphagia,dyspnoea and neck swelling.Clinicoradiological evaluation is of utmost importance to determine the adjacent vital structures and the approach to the tumor.With the advent of robotics in oncology,transoral robotic excision is one of the best approaches to perform such a surgery.

Spondylodiscitis, epidural abscess, and meningitis after transoral robotic surgical resection of a squamous cell carcinoma of the posterior pharyngeal wall

Transoral robotic surgery(TORS)is a minimally invasive technique for resection of tumors of the posterior pharyngeal wall.Rarely,post-TORS cervical spondylodiscitis has been reported in the literature,with high morbidity and mortality.A 64-year-old female with underlying cervical disk disease underwent TORS resection of a posterior pharyngeal wall carcinoma without reconstruction in April 2020.Roughly one month post-operatively,the patient presented with clinical and radiographic signs of spondylodiscitis,epidural abscess,and meningitis.The patient was treated with antibiotic therapy and anterior cervical discectomy and fusion.The patient recovered without neurologic deficit.A three-month post-treatment PET-CT scan showed no evidence of residual disease.Post-operative cervical spondylodiscitis and meningitis are rare complications of TORS resection for posterior pharyngeal wall carcinomas,but the risk is increased in patients with underlying cervical disk disease.In such patients,perioperative antibiotic treatment and/or reconstruction should be considered to prevent neurologic complications and death.

Transoral endoscopic excision of a giant parapharyngeal space tumour:A case report

Most of the parapharyngeal space tumours are benign.The primary treatment is complete resection of the tumour.Due to its location in the deep neck space,a pre-styloid tumour can be resected via the transoral approach.However,the surgical field is limited by the small oral cavity.With the use of rigid endoscopes,removing benign tumours through transoral approach in the parapharyngeal space is possible as they provide a broad and enlarged view of the confined space.Here,we report a case of a 64-year-old male with a giant pre-styloid parapharyngeal space tumour,who successfully underwent transoral endoscopic excision.Postoperatively,the patient had short hospital stay of total 3 days.His chewing and swallowing were not affected,and he resumed oral feeding prior to discharge.

Endoscopy-assisted transoral approach for parapharyngeal space tumors:Our experience and a systematic review of the literature

Background:Several approaches have been described for the excision of parapharyngeal space tumors(PPSTs).Advances in endoscopy gave a further stimulus to the use of the transoral route.Aims:We present our experience with the endoscopy-assisted transoral approach(EATA)in this regard and a review of the most recent literature about EATA for PPSTs excision.Materials and Methods:We retrospectively analyzed our experience and systematically reviewed the literature about the outcomes of this technique.Results:Seven PPSTs were completely excised,with three of them requiring a combined transcervical approach.Only one case of postoperative wound dehiscence was registered,and the mean length of stay was 3.9 days.Final histopathological examination confirmed the results obtained with preoperative fine-needle aspiration biopsy in all cases and no recurrences were apparent after a mean follow-up of 28.1 months.Discussion:Magnetic resonance imaging,the modified Mallampati score and the 8 Ts criteria are useful instruments for the choice of the most appropriate surgical approach.Conclusion:In light of our experience and following other published series in the literature,we believe that EATA may represent a safe and effective approach for the treatment of the majority of PPSTs.

Safe surgical zone during TORS radical tonsillectomy:An anatomical and radiological study

Objective:Parapharyngeal space contains intricate vascular anatomy(external and internal carotid arteries)that might be inadvertently injured during the dissection in this plane.None of the bony landmarks can be used during the transoral robotic surgery(TORS)radical tonsillectomy as these landmarks lie lateral to the internal carotid artery(ICA)and external carotid artery(ECA)in transoral approach.Our study aims to identify the safe surgical limits during the dissection of parapharyneal space in TORS radical tonsillectomy and to correlate the same with radiological study.Material and methods:Fifteen cadavers(30 head and neck regions)and 50 CT-Angiogram of neck(100 head and neck regions)were included in the anatomical and radiological study respectively.The vertical midpoint of anterior tonsillar pillar(palatoglossus muscle)was taken as the reference point and all the measurements were done at the level of reference point both for anatomical and radiological study.Distance between tonsillar fossa and ECA,distance between tonsillar fossa and ICA,relation between ECA and styloglossus and relation between ICA and stylopharyngeus at reference level were studied.Results:The mean distance of ECA from the tonsillar fossa at the reference point was 18.2 mm in the anatomical study and 16.2 mm in the radiological study.The mean distance of ICA from the tonsillar fossa was 23.4 mm and 23.3 mm in the anatomical study and radiological study.There was no significant difference between the anatomical and radiological findings for both the mean distance between ECA and ICA to the tonsillar fossa(p value was 0.45 and 0.30 respectively).ECA was located posterolateral to styloglossus in 24 cases(80.0%)and 79 cases(79.0%)in the anatomical and radiological study respectively.ICA was found posterolateral to stylopharyngeus in 21 cases(70.0%)and 69 cases(69.0%)in the anatomical and radiological study respectively.Conclusion:The muscular plane between styloglossus and stylopharyngeus can be used as an envelope to locate the ECA and ICA that lie medial to these critical vascular structures during TORS.We propose to divide the parapharyngeal space into two compartments(anterior and posterior)based on the surgical perspective of inside-out anatomy.The anterior compartment houses styloglossus muscle with ECA posterolateral to it and the posterior compartment has stylopharyngeus and ICA posterolateral to it.