The Laryngoscope, Bert W. O’Malley, Jr., MD; Gregory S. Weinstein, MD; Wendy Snyder, BS; Neil G. Hockstein, MD
Over the past 10 years, there have been increasing reports of the use of primary radiation or combined chemotherapy and radiation for tongue base neoplasms. The key factor driving this movement away from primary surgery was the reported morbidity of such surgical procedures.
Cervical incisions and dissections with mandibulotomy or pharyngotomy were typically required to remove base of tongue neoplasms even in the early stages. These approaches left the patient with various levels of significant speech and swallowing dysfunction as well as cosmetic deformity depending on the size and location of the tumor and extent of resection.
Nonetheless, combined chemotherapy and radiation is also associated with significant to severe speech and swallowing dysfunction along with varying degrees of chronic pain and xerostomia.
In addition, based on a retrospective analysis of a large number of patients in the National Cancer Data Base, survival may be better with surgery plus radiation when compared with either radiation alone or combined chemoradiation.
The introduction of endoscopic laser microsurgery for tongue base cancer has been reported by Steiner et al. Transoral CO2 laser pharyngeal surgery reintroduced primary surgery as a means of treating base of tongue cancer, but this technique is technically challenging, has a steep learning curve, and a limited operative field of view because it is performed through a laryngoscope. Furthermore, the transoral laser surgery requires cutting directly through the tumor to determine extent of resection.
It is possible that these limitations have contributed to the lack of widespread appeal of this approach. Nonetheless, the transoral approach did reveal that 92% of patients achieved swallowing without permanent gastrostomy tube.
These excellent swallowing function results led us to postulate that TORS for tongue base neoplasm should yield similar functional outcomes while overcoming some of the disadvantages of endoscopic laser surgery outlined above.
On the basis of our preclinical development and early patient experience, we believe that TORS for tongue base lesions has significant advantages over both classical open tongue base surgery and laser microsurgery.