Importance: With the adoption of transoral robotic surgery (TORS), the TORS approach to parapharyngeal space (PPS) tumors has been increasing in frequency as an alternative to the conventional transcervical or transparotid approaches. Its feasibility and overall safety have been documented in small case series and systematic reviews. However, follow-up duration was less than 2 years, thereby limiting the assessment of long-term outcomes like local recurrence rates.
Objectives: To assess intraoperative characteristics, histologic variables, complications, and recurrence rates in this 15-year series of patients who have undergone TORS approach to PPS tumor resection.
Design: Retrospective case series.
Setting: Tertiary referral center.
Participants: Consecutive patients with prestyloid PPS salivary gland pathology who underwent TORS approach for resection from May 1, 2007 to August 30, 2022 were included. Patients who underwent a combined transoral and external approach, such as transcutaneous and transparotid, and those with non-salivary PPS pathology, were excluded.
Main Outcomes and Measures: The primary outcome was local recurrence. Secondary outcomes included intraoperative events, such as tumor rupture and cut-to-close time; histologic factors; and complications, including postoperative intubation, major wound dehiscence, first bite syndrome, intraoral hemorrhage, cranial neuropathy, and length of stay.
Results: Of 87 patients who underwent TORS for PPS resection at our institution, 52 patients (mean age 56.5 [SD 13.0] years, 36 [69%] females) with prestyloid salivary pathology were included. Median tumor size based on pathology was 3.5 (range 1.2-8.0) cm. Pathologic diagnoses included pleomorphic adenoma (41/52, 79%), other benign salivary tumors (5/52, 10%), and salivary malignancy (6/49, 11%). Malignant pathology included carcinoma ex pleo (n=3), mucoepidermoid carcinoma (n=2), and myoepithelial carcinoma (n=1), and all were only discovered on final pathology after resection. The intraoperative tumor rupture rate was 23% (12/52), which included fragmentation of the specimen. Positive and close margins were found in 2 (4%) and 22 patients (42%), respectively. Median cut-to-close time was 1.49 (range 0.48-3.60) hours.
The local recurrence rate was 4% (2/52), one related to pleomorphic adenoma and the other to carcinoma ex pleo. There were 0 cases of first bite syndrome. The rate of postoperative intubation was 8% (4/52), which all occurred in the first few years of adopting this surgical technique. The rates of major wound dehiscence, intraoral hemorrhage, and cranial neuropathy were each 2% (1/52). Median resumption of liquid and pureed/soft diet was postoperative day 1.0 (range 0-16) and day 2.0 (range 0-16), respectively, and all patients resumed an oral diet after their first postoperative visit. Median length of stay was 2.0 (range 1-9) days. Median follow-up duration with office visits and/or imaging was 844 (range 3-5731) months.
Conclusions and Relevance: The transoral robotic approach to prestyloid PPS salivary tumors is safe and associated with very low long-term local recurrence risk, even with capsule rupture. There was 0% incidence of first bite syndrome and very low incidence of wound dehiscence, hemorrhage, cranial neuropathy, and prolonged NPO status in this case series, which is the largest to date of this surgical modality.