Transoral approach to the upper cervical spine

Abstract

The transoral approach to pathology of the upper cervical spine is logical, but it is seldom used due to concerns about exposure and infection. The authors report on 16 consecutive patients requiring exposure from clivus through C3 for pathology, including spinal cord compression by rheumatoid pannus, craniovertebral anomalies, and tumor. Exposure was obtained using a Dingman mouth gag and soft palate retraction with silicone rubber sheeting. A horizontal "H" incision was made in the posterior pharyngeal wall creating three layers, closed separately, with attention to a watertight closure of the final mucosal layer. In no case was it necessary to divide the mandible, tongue, soft palate, or uvula. There were no deaths, wound breakdowns, infections, or persistent cerebrospinal fluid leakage. Patients with neurological indications improved postoperatively, and all tumors were grossly resected. Combined otolaryngology/neurosurgical exposure and treatment of pathology involving the upper cervical spine via the transoral approach is safe and effective. Functional results have been excellent, and no major complications were encountered.

Pediatric transoral surgery: indications, complications, and long-term outcome

“…Preoperative pharyngeal cultures, which are advocated by some authors, were not used. 23,30,35 At our institution, most patients have a fiberoptic nasotracheal intubation prior to surgery; 4 however, any patient with a significant risk of postoperative aspiration or ventilatory difficulty, either because of neurological deficits or palatal disruption, receives a prophylactic tracheostomy. Some authors advocate tracheostomy for all patients prior to transoral surgery, 11,39,44 whereas others use it more selectively.…”

Modified trans-oral approach with an inferiorly based flap

“…6 A similar technique using an H-shaped flap has also been used, but this flap further necessitates a complicated closure. 7 At our Institution, we used an inferiorly based flap in a subset of patients, which allows the surgeon to immediately define the maximum lateral exposure for safer access while avoiding vasculature. After its caudal retraction, the flap provides a clear operating field, allowing for a midline approach to the pathology.…”

Transnasal endoscopic approach to the pediatric craniovertebral junction and rostral cervical spine: case series and literature review

“…7,19,21,28,38 Rates of significant upper respiratory tract edema requiring intervention following transoral approaches have been reported in up to 5% of adults and 4% of children, but this rate may be artificially low due to a more cautious timetable for extubation. 6,9,13,20,26,27,36,39,40 Additionally, an endoscopic transnasal approach may allow for a more prompt return to a normal oral diet. 21,24 The incidence of new-onset dysphagia after a traditional transoral approach ranges from 0%-20% in adults and 0%-4% in the pediatric population, which is not unexpected given the dissection of the posterior pharyngeal tissues that is required.…”

“…21,24 The incidence of new-onset dysphagia after a traditional transoral approach ranges from 0%-20% in adults and 0%-4% in the pediatric population, which is not unexpected given the dissection of the posterior pharyngeal tissues that is required. 6,9,13,26,27,34,36,39,40 A final potential advantage of endoscopic transnasal approaches versus transoral approaches is greater access to the structures superior to the soft palate, facilitating a more direct trajectory to the rostral CVJ. This reduces the frequent need to split the palate, which may be required in up to 29% of adult patients undergoing transoral surgery.…”