Open Transoral Approach

Abstract

Open transoral approaches are ideally suited for ventral midline pathologies at the craniovertebral junction. These approaches can also access paramedian and more lateral pathologies, particularly in the lateral clivus and the upper cervical spine. The transoral approach may be used in combination with posterior, lateral, and transnasal endoscopic approaches when a tumor requires staged surgery for complete resection.

The transoral approach and the extended transoral approaches (transmaxillary or transmandibular) were originally developed to treat pathologies such as rheumatoid arthritis and congenital basilar invagination, but are now more commonly used for tumors of the craniovertebral junction, particularly chordomas and chondrosarcomas. Other treatment options for these tumors include endoscopic approaches and nonsurgical management by proton or carbon ion therapies.

Patients for open transoral surgery should be assessed preoperatively by surgeon and anesthesiologist, and cases should be discussed in a multidisciplinary forum prior to operating. Postoperative management relies on experienced nurses and anesthetic staff to identify and avoid complications, which are rare but can be serious.

Complication rates for the open transoral approach are low, with minimal problems from CSF leaks which can usually be closed at the time of initial surgery. Infection rates for the standard transoral approach are less than 1% due to innate mucosal immunity. However, the technique should be performed in specialized centers with surgeons, theater nurses, and anesthetic staff who are experienced in the management of these unusual conditions, to maximize the chance of success.