Salvage Transoral Robotic Surgery: A Case of a Nearly Missed Carotid Injury

A 59-year-old male developed an asymptomatic, left-sided oropharyngeal lesion six months after chemoradiotherapy for a human papillomavirus-positive T2N2bM0 tonsillar cancer. In-office biopsy confirmed persistent disease. Preoperative imaging revealed a resectable recurrence without internal carotid artery (ICA) or retropharyngeal carotid abutment (see Figures 1 and 2). The patient was counseled about the increased risk of postoperative tracheostomy dependence, feeding tube dependence,¹ and postoperative hemorrhage.^2-4

Figure 1.

Preoperative CT scan images. Axial cuts demonstrating persistent cancer and relationship to the ICA. There is a very small recurrence with no direct tumor abutment to the carotid system and no retropharyngeal carotid. CT, computed tomography; ICA, internal carotid artery.

Figure 2.

Preoperative CT scan images. Axial cuts demonstrate the ICA position inferiorly at the level of the vallecula and submandibular gland. Note that there is no obvious retropharyngeal carotid. CT, computed tomography; ICA, internal carotid artery.

The patient underwent salvage transoral robotic surgery (TORS) using the incision shown in Figure 3. First, the pterygomandibular raphe was identified and careful blunt dissection was used to enter the parapharyngeal space just medial to the raphe. The superior constrictor was preserved as the lateral oncologic margin. Next, the incision was carried superiorly toward the muscularis uvulae and inferiorly toward the palatoglossus and intrinsic tongue base musculature. Finally, the posterior pharyngeal wall was incised, and dissection proceeded deep to the constrictor within the retropharyngeal space. Careful dissection and a high degree of suspicion for ICA medialization after radiation prevented near catastrophic ICA injury in the inferior retropharyngeal space (see Figure 4 and Supplemental Video). Finally, the mass was removed en bloc, oriented, and sent for frozen section analysis.

Figure 3.

Intraoperative image. The incision used during the procedure is shown in white. The approximate location of the pterygomandibular raphe is marked with the black, double arrowhead. The white arrrowhead is pointing to the tumor.

Figure 4.

Intraoperative image. The exposed retropharyngeal carotid artery, not appreciated on preoperative CT. The white arrow points to the internal carotid artery. CT indicates computed tomography.

Reconstructionwas undertaken to prevent carotid blowout.⁵ In this case, fascial edges were mobilized and sutured together primarily over the carotid.⁶ Given prolonged healing (up to 35 days) following salvage surgery,² a nasoseptal flap was used to cover the lateral oropharyngeal defect,⁷ and a fascia lata graft was used posteroinferiorly (see Supplemental Video). Tracheostomy (for airway protection in the event of hemorrhage) and nasogastric tube insertion were also performed.

The patient went to the intensive care unit for tracheostomy care and was transferred to a step-down unit on postoperative day (POD) #2. Intensive swallow therapy started on POD#2, but oral feeding was delayed until POD#4 after bolster removal. Repeat swallow evaluation revealed a mildly deconditioned swallow without aspiration, and the patient was discharged to a skilled nursing facility (SNF) on POD#7.

In clinic, final pathology revealed negative margins without perineural or lymphovascular invasion. The tracheostomy tube was removed on POD#18. The patient was discharged from the SNF to clinic on POD#23 but continued to have significant oropharyngeal phase dysfunction. The feeding tube was not removed until a final evaluation on POD#37.

Six months after salvage TORS, the cancer recurred. The patient then received stereotactic radiosurgery and cetuximab as part of a clinical trial. Fifteen months later, he developed radionecrosis of the pharynx, which required a total laryngopharyngectomy and microvascular free flap reconstruction. He is currently disease-free.

Salvage TORS for oropharyngeal cancer has been performed in single institution studies, albeit in limited fashion.^1,8 Currently, the 2-year disease-free survival following salvage TORS is 57.7% to 75.8%.^1,8 However, salvage TORS has been associated with higher risk of bleeding complications (10.8%-21.9%), higher rates of long-term tracheostomy dependence (0%-10%), and postoperative feeding tube dependency (10%-20%).^1,8,9 Salvage TORS is an advanced procedure and should only be performed by experienced TORS surgeons due to the technical challenges incurred following chemoradiation.¹ First, tissue fibrosis makes it difficult to recognize the natural anatomical dissection planes and landmarks amid dense scarring and/or bleeding.¹⁰ Secondly, salvage TORS presents challenges for healing by secondary intention.¹¹ Therefore, the surgeon should have a reconstructive plan to prevent the development of nonhealing wounds and decrease the risk of hemorrhage.^2,12 To date, no one has reported ICA exposure rates after salvage TORS. There is only one other case report of salvage TORS with a retropharyngeal carotid artery, and this was reconstructed with an anterolateral thigh microvascular free flap.¹³ We, along with others, advocate for salvage TORS reconstruction with either locoregional flaps or free tissue transfer.^14,15 Current practice may evolve with increasing salvage TORS experience.