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Combined Intraoral and Lateral Temporal Approach for Palatal Malignancies With Temporalis Muscle Reconstruction
J. Dale Browne, MD;
Bradford W. Holland, MD
Arch Otolaryngol Head Neck Surg. 2002;128:531-537.
ABSTRACT
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Objective To evaluate the use of a combined lateral temporal fossa and intraoral
approach to resect palatal carcinomas and the use of a temporalis myofascial
flap for reconstruction.
Design Retrospective chart review of a case series.
Setting Tertiary university referral hospital.
Patients Sixteen patients underwent a combined approach for resection of palatal
carcinoma; 5 of the 16 were edentulous. Six types of tumors were treated:
adenoid cystic carcinoma (3 patients), low-grade mucoepidermoid carcinoma
(5 patients), squamous cell carcinoma (3 patients), polymorphous low-grade
adenocarcinoma (2 patients), osteosarcoma (1 patient), ameloblastoma (1 patient),
and hyalinizing clear cell carcinoma (1 patient).
Main Outcome Measures The postoperative diet, velum competence, flap viability, complications,
and survival.
Results Fifteen (94%) of 16 patients were able to resume their preoperative
diets. No velopharyngeal insufficiency was encountered. All flaps survived
and none required repeated surgical intervention. Five patients developed
serous otitis media and 2 patients required flap revision secondary to posterior
choanal obstruction. One patient died of complications unrelated to the procedure.
Conclusions A combined intraoral and lateral temporal fossa approach allows for
(1) en bloc resection of palatal malignancies along with resection of involved
pterygoid muscles, (2) isolation and resection of descending palatine nerves
and the proximal second division of the trigeminal nerve, and (3) primary
reconstruction of the palatal defect by means of the temporalis muscle rotated
into the operative defect. This method is especially useful in treating patients
with perineural spread of palatal carcinoma, and in those who are edentulous.
INTRODUCTION
PALATAL CARCINOMA presents challenges to the head and neck surgeon in
terms of resection as well as defect reconstruction. Such tumors can grow
into the maxillary sinus, inferior orbital structures, and skin of the cheek,
as well as extend into skull base structures. Carcinomas of minor salivary
gland origin, as well as squamous cell carcinomas, have been shown to spread
perineurally along cranial nerves up to the skull base and through cranial
foramina.1-3 In
such instances of nerve involvement, the maxillary division of the trigeminal
nerve (cranial nerve division V2), including the greater and lesser
palatine nerves, is most frequently affected. Tumor can extend along the descending
palatine nerve into the pterygopalatine fossa (PPF) and ultimately through
the foramen rotundum.4-5 En bloc
resection of palatal malignancies with perineural spread ideally must use
an approach that allows for dissection of the descending palatine nerves into
the PPF and skull base.
There are numerous methods of resecting palatal malignancies. Facial
degloving approaches have been used extensively for access to these tumors.
More extensive tumors that grow into the maxillary sinus can require a subtotal
maxillectomy for en bloc removal. These are typically approached through facial-splitting
incisions such as the Weber-Furguson incision or modifications thereof. Approaches
to the PPF specifically include an extended Weber-Furguson incision6 and transcervical transmandibular dissection,7 both of which incur a significant morbidity encountered
with transfacial approaches. A previously described preauricular transzygomatic
infratemporal fossa (subtemporal) approach8-10
is useful in resecting the perineural growth extensions of the tumor; however,
this approach alone does not easily allow for en bloc resection of the primary
palatal tumor itself.
A variety of methods have been used to reconstruct the defect created
after removal of the hard and/or soft palate. Prosthetic obturators have been
used with success for defects that involve both the hard and soft palate.11-12 However, obtaining the proper fit
and seal with these prosthetics can be difficult for large defects in edentulous
patients, and many patients have transportation issues that limit access to
prosthedontic rehabilitation. Numerous surgical modalities for primary reconstruction
have been described. Regional flaps used to reconstruct the palate include
the temporalis myofascial flap,13-16
a nasal septal flap,17 an infrahyoid myocutaneous
flap,18 and a pectoralis major myocutaneous
flap.19 Vascularized free tissue transfer flaps
have also been used to reconstruct larger defects, especially those that involve
the orbit and/or facial skin.20-22
Ideally, primary reconstruction of the defect would obviate the need for a
prosthesis, have low or no donor site morbidity, and produce a functionally
and cosmetically pleasing result.
We report a procedure for resection of palatal malignancies that uses
a combined intraoral and lateral temporal fossa approach to remove the primary
tumor, resect tumor spreading perineurally to the skull base within the PPF,
and reconstruct the tissue defect with a temporalis muscle rotational flap.
The surgical technique is described herein, as well as the pathologic findings,
clinical history and course, and outcome of 16 patients treated at our institution
for palatal malignancy.
PATIENTS AND METHODS
PATIENTS
Patients selected for this retrospective review were those with palatal
or maxillary malignancy that did not involve the orbital floor or orbit. Preoperative
contrast-enhanced computed tomographic scanning and magnetic resonance imaging
were performed in each patient to evaluate perineural extension of the tumor
and possible involvement of the skull base. All patients were treated by one
of us (J.D.B.) at North Carolina Baptist Hospital, Winston-Salem, a tertiary
university hospital associated with the Wake Forest University School of Medicine's
Department of Otolaryngology–Head and Neck Surgery. Informed consent
was obtained in accordance with an approved human subjects protocol. A chart
review of these patients was performed in October 2000, and data were collected
regarding recurrence, length of follow-up, postoperative diet, velopharyngeal
insufficiency, survival, and complications.
SURGICAL TECHNIQUE
Illustrations that summarize the surgical technique are shown in Figure 1. The temporalis muscle and PPF–skull
base are approached through a curvilinear, pretragal incision that is extended
superiorly within the hairline. Electrocautery is used to elevate the skin
flap anteriorly to the zygomatic arch. The frontal branch of the facial nerve
is preserved by directly elevating it off the zygoma with the adjacent soft
tissue and periosteum. A miniplate is predrilled in the areas of the temporal
process of the zygoma and the posterior zygomatic process in preparation for
replacement at the end of the procedure. After removal of the arch, the temporalis
muscle is elevated off its superior insertion and elevation progresses inferiorly.
Electrocautery is used to perform this subperiosteal elevation of the temporalis
muscle off of the squamous temporal bone. The attachment of the muscle to
the coronoid process is preserved. The blood supply to the flap is the anterior
and posterior deep temporal arteries, which are branches of the maxillary
artery.13, 15 The vascular supply
on the undersurface of the flap is preserved. This results in exposure of
the greater wing of the sphenoid, orbital apex, and bone overlying the middle
fossa dura.
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Figure 1. An illustration of the overall
procedure. The squamous temporal bone has been drilled away and the pterygoid
plates released from the sphenoid bone (A). Areas where bone removal will
be continued to fully expose the maxillary division of the trigeminal nerve
and to remove tumor have been marked (B, hash-marked bone). The zygoma is
temporarily removed and the palate resected, while the temporalis muscle and
its vascular supply are preserved. The entire temporalis muscle can be rotated
into the defect, or only a portion of it (C). The flap is secured with sutures
and the zygoma replaced (D).
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Bone removal is continued to the root of the lateral pterygoid plate.
The pterygoid muscles are elevated from their anterior and lateral attachments,
and the pterygoid plates are drilled free and released from the sphenoid bone.
If necessary, a small craniectomy is performed at the base of the temporal
horn, posterior to the orbital apex, to allow full visualization of the maxillary
division of the trigeminal nerve to the level of the gasserian ganglion with
gentle extradural dissection. Resection of the involved division of the trigeminal
nerve (cranial nerve division V2in this instance) is then possible,
depending on the extent of tumor spread (Figure 1A).
The patient's mouth is opened and mucosal incisions are made along the
hard palate, alveolar ridge, gingivobuccal sulcus, and soft palate. Osteotomies
are made through the palate and into the maxillary sinus. Care is taken not
to disrupt the floor of the orbit. The deep attachments are released intraorally
and through the temporal approach. The entire tumor mass and hard palate are
then removed en bloc through the mouth (Figure
2B).
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Figure 2. Intraoperative view of patient
8 showing the mass on the left hard palate around the greater and lesser palatine
foramina (A). The tumor is removed through the mouth, leaving a 30% defect
of the left hard palate extending on to the soft palate (B).
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The temporalis muscle is then used to reconstruct the oral cavity. The
entire muscle or only the anterior portion is rotated into the infratemporal
region, depending on the size of the palatal defect (Figure 3A). Deep sutures are used to secure the flap, and resorbable
sutures are placed intraorally to oppose the flap and the remaining palatal
mucosa (Figure 3B). The temporal
incision is irrigated, and the zygoma is resecured into its original position
with miniplates. Any remaining posterior temporalis muscle is secured to the
lateral orbital rim to fill the temporal fossa. The temporalis fossa can be
recontoured with a porous polyethylene implant (Porex Surgical, Inc, College
Park, Ga) inserted at the time of resection if desired. The scalp incision
is closed. Suction drains are not used.
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Figure 3. Intraoperative view of patient
8 showing the temporalis fossa after the temporalis muscle (arrow) has been
rotated in to fill the tissue defect (A). The intraoral view after securing
the flap shows the excess amount of tissue used to allow for eventual contraction
(B).
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RESULTS
Sixteen patients were treated between August 1, 1994, and October 31,
2000. Four patients were women and 12 were men. Their ages ranged from 21
to 83 years, with an average age of 56 years. Three patients had adenoid cystic
carcinoma, 5 had low-grade mucoepidermoid carcinoma, 3 had squamous cell carcinoma,
2 had low-grade adenocarcinoma, and 1 patient each had osteosarcoma, hyalizing
clear cell carcinoma, and ameloblastoma. Table 1 summarizes the demographic and diagnostic information on
these 16 patients. The follow-up ranged from 9 months to 7 years, with a mean
follow-up of 31 months and a median of 24 months.
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Demographic and Diagnostic Information in 16 Patients With Palatal
Malignancies
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The amount of palate resected in this series varied from 25% to 100%,
but most had 30% to 50% removed. Patient 10 represents a special case in which
the entire palate was removed. This patient had a hyalinizing clear cell carcinoma
of the hard palate that did not respond to extensive radiation. He had bilateral
perineural extension of the tumor, and a total palatectomy was performed with
dissection up to the skull base on each side. To reconstruct this defect,
bilateral temporalis muscle flaps were rotated in to create an entire neopalate.
To facilitate healing, a split-thickness skin graft was placed over the temporalis
muscle. His postoperative diet differed from his preoperative diet in that
after surgery he subsisted on pureed foods. This patient had nasal obstruction
after surgery but no velopharyngeal insufficiency. Because nasal stenting
produced transient velopharyngeal insufficiency in this patient, he chose
to tolerate the nasal obstruction and alleviate nasal regurgitation. We believed
any procedure to open his nasal passage might produce velopharyngeal insufficiency,
and because the patient was not markedly concerned about his nasal obstruction,
he desired no further treatment.
All the flaps in this series survived, and none required postoperative
intervention to maintain flap viability. In the absence of radiation, no skin
grafting was necessary to cover the myofascial temporalis flap, as the entire
flap remucosalized within 3 to 4 weeks of surgery. Patients were typically
allowed to start oral intake of fluids on postoperative day 2. The flap did
experience volume reduction of approximately 50% with time; this needed to
be taken into account when we decided how much of the temporalis muscle to
rotate into the defect (Figure 4).
A typical postoperative result is shown in Figure 5. Three patients in this series had perineural extension
of tumor up into the PPF along the descending palatine nerves. These 3 all
had adenoid cystic carcinoma, and all 3 received postoperative radiation therapy.
Postoperative radiation did not appear to affect the degree of mucosalization
of the flap, nor the amount of flap volume reduction in this series.
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Figure 4. Patient 13. A sizable defect (A)
is reconstructed with the temporalis muscle, showing the amount needed to
overfill the defect (B). The flap subsequently undergoes mucosalization and
at 3 weeks postoperatively (C) is nearly completely covered with mucosa. Over
time, approximately 50% of the original volume is lost, as shown at a 6-month
follow-up (D).
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Figure 5. Postoperative view of patient
8 taken 8 months after the procedure. A porous polyethylene implant has been
used to recontour the temporalis fossa (A). The temporalis flap completely
mucosalizes, forms a tight seal between the nose and mouth, and incorporates
into a functioning soft palate preventing velopharyngeal insufficiency (B).
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The diet of each patient was examined before and after the surgical
procedure. Fifteen (94%) of the 16 were able to resume their preoperative
diets. Eleven of the 16 patients were able to eat a regular diet without limitation.
The other 5 were edentulous; of these, 2 ate the same diet they did before
surgery with the use of a denture plate, and 2 others tolerated a soft diet
and were candidates for denture plates but had no plans to obtain a denture
plate. No patient experienced velopharyngeal insufficiency while speaking
or nasal regurgitation with eating or drinking.
The complications of this procedure related to the flap bulk in the
nasopharnyx, which, if sufficiently large, can have obstructive effects. Five
patients developed serous otitis media in the ipsilateral ear requiring tympanostomy
tube insertion. However, 4 of these 5 had radiation therapy to the operative
site, which may have had some negative impact on the eustachian tube function
in these patients. Three patients experienced nasal obstruction because of
the temporalis flap obstructing the posterior choana. Patient 1 had mild obstruction,
which was successfully treated with a single carbon dioxide laser debulking
of the flap in the posterior choana. Patient 4 developed complete posterior
choanal stenosis and nasal obstruction, and this was treated with carbon dioxide
laser debulking of the temporalis flap and placement of a split-thickness
skin graft in the posterior nasal cavity and nasopharynx. The success of this
procedure could not be determined because the patient subsequently died of
osteoradionecrosis of the pons, which developed after she underwent radiation
therapy at another institution. This was the only death to date in this series.
COMMENT
Tumors with perineural extension and/or involvement of a large surface
area of palate may present a difficult problem in terms of access and availability
of tissue for reconstruction. Facial-splitting incisions such as the Weber-Furguson
incision allow for wide exposure, but visualization of the PPF can still be
limited, and cosmesis is not ideal. Facial degloving approaches have better
cosmesis but limited exposure. Our lateral approach most closely resembles
a previously described technique10 but differs
in the extent of lateral exposure, ours being limited
to cranial nerve division V2 in the PPF. A combined approach illustrated
in our series allows for excellent exposure of the deep perineural invasion
of these tumors, resection of involved pterygoid muscles, and en bloc resection
of the primary tumor bulk. Furthermore, it allows a double vantage point,
from which one can perform difficult deep dissections using one approach while
viewing from the other.
Many different methods have been proposed for reconstructing these defects,
which include a prosthetic obturator,11-12
temporalis myofascial flap,13-16
infrahyoid myocutaneous flap,18 and pectoralis
myocutaneous flap.19 Myocutaneous free flaps,
with or without an osseous component, have also been described to reconstruct
the palate.20 Davison et al21
proposed an algorithm for maxillectomy reconstruction that classifies defects
as superstructure defects, which may or may not involve the orbit, and infrastructure
defects. The patients described in our series all had large, subtotal infrastructure
defects, for which this algorithm recommends local flap reconstruction or
a prosthetic obturator. The use of obturators works for many patients, but
obtaining a proper fit and seal in an edentulous patient can be difficult,
as there are no teeth on which to anchor the prosthesis. Five of the 16 patients
in this series were edentulous. Furthermore, resection of such palatal tumors
often requires removal of so much hard palate that too little remains to stabilize
and support an obturator. Finally, because of exposure of proximal cranial
nerves, 4 of the 16 patients in our series had exposed dura that needed protective
covering. Although the algorithm recommends temporalis regional flaps for
reconstruction of superstructure defects, we have found them particularly
useful in reconstructing large infrastructure defects. These defects typically
do not need to have osseous reconstruction if they occur in an edentulous
patient, or are posterior enough not to incur stress during mastication. Thus,
a free flap can be avoided in these instances. Total maxillectomy or orbital
defects require more extensive reconstruction, and we have advocated the use
of rectus abdominis myofascial free flap reconstruction in this instance.22
Cancer of the maxilla can be a lethal disease, and its treatment often
leaves the patient with marked functional and cosmetic deficits. Use of the
temporalis myofascial rotational flap has allowed expeditious treatment and
rapid return of function, thereby maximizing the quality of life for the patient
and minimizing the functional and cosmetic deficits. We have had favorable
long-term results with the temporalis flap in this series. All but one of
the patients were able to resume their preoperative diets. Critics have claimed
that primary reconstruction hides local recurrences on postoperative surveillance
examination. We have not had any local recurrences (although follow-up is
limited on our most recent patients) and have used surveillance magnetic resonance
imaging to monitor these patients because it can distinguish between recurrent
tumor and temporalis flap tissue. Twelve of these patients have had implantation
of a synthetic porous polyethylene prosthesis into the temporal fossa. We
currently favor this technique should a patient desire recontouring of the
temporal defect for cosmesis.
The complications encountered in this series have been related to temporalis
flap bulk in the nasopharynx, causing posterior choanal stenosis and possibly
eustachian tube obstruction. These have been easily treated with tympanostomy
tube insertion in the ipsilateral ear and carbon dioxide laser debulking of
the flap obstructing the posterior choana (patients 1 and 4). A split-thickness
skin graft was used (patient 4) to prevent restenosis of the posterior choana
after the laser procedure. Unfortunately, the patient died, and so long-term
follow-up of this procedure was not possible. Reduction of temporalis flap
bulk in the anterior nasopharynx may reduce or alleviate the symptoms related
to excessive tissue in this area, but in general these problems have been
minor and easily corrected.
CONCLUSIONS
Palatal malignancies frequently spread perineurally along the descending
palate nerve and into the PPF. A combined intraoral and lateral temporal fossa
approach allows for excellent visualization and dissection of the perineural
spread of these tumors into the PPF and petrous apex for an en bloc resection
of the tumor mass. Such large lesions that require subtotal palatectomies
frequently do not provide sufficient support or seal for a prosthetic, nor
does a prosthetic provide adequate dural protection after an adjacent craniectomy
for resection of perineural spread into neural foramina. However, these defects
can be easily reconstructed with a temporalis muscle rotational flap and provide
velopharyngeal competence while allowing the patient to resume his or her
preoperative diet, in conjunction with a denture plate if needed. This combined
approach and this method of reconstruction should be considered an option
for treating palatal malignancies, especially those with perineural spread.
AUTHOR INFORMATION
Accepted for publication October 26, 2001.
This study was presented at the Fifth International Conference on Head
and Neck Cancer, San Francisco, Calif, August 2, 2000.
We thank Annemarie B. Johnson for her help with the anatomic illustrations.
Corresponding author and reprints: J. Dale Browne, MD, Department
of Otolaryngology–Head and Neck Surgery, Wake Forest University School
of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1034 (e-mail: jdbrowne{at}wfubmc.edu).
From the Department of Otolaryngology–Head and Neck Surgery,
Wake Forest University School of Medicine, North Carolina Baptist Hospital,
Winston-Salem.
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