TLM 2 - Oropharynx, tonsil

Considerations

• 2012: Transoral robotic surgery of the oropharynx: Clinical and anatomic considerations

• 2013: Anatomical landmarks for transoral robotic tongue base surgery: comparison between endoscopic, external and radiological perspectives

• 2013: Transoral anatomy of the tonsillar fossa and lateral pharyngeal wall: anatomic dissection with radiographic and clinical correlation

• 2016: Transoral Surgical Anatomy and Clinical Considerations of Lateral Oropharyngeal Wall, Parapharyngeal Space, and Tongue Base

• 2016: A description of the anatomy of the glossopharyngeal nerve as encountered in transoral surgery

Preparation

• • See TLM 1 - Setup for photos and instructions

  • Display photos on monitors for scrub tech to use as reference

  • Balance the microscope 

• Portable light source between microscope and bed

• 0 and 30 degree 4 mm endoscopes and camera

• Inspect the back table

  • FK retractor

  • Bovie

  • Suction Bovie

  • Bipolar

  • Topical 1:1000 Epinephrine

  • 3 suction tubings 

  • Marylands

  • Vessel clips 

  • Grasping forceps 

  • Pile of purple gloves 

  • Large red rubber tube 

• Inspect the Mayo stand

  • • No eye pads

  • Blue towels x 2 partially split in half soaked in water over face and neck

  • Hot water in HNS thermos, ice in cup

  • Thermasplint for upper tooth guard

Procedure

• • GETA, laser safe armored tube, tube to left lower lip vs corner of mouth 

• Positioning: Supine, turn head 90 degrees counter clockwise 

• Bimanual palpation

• Apply FK vs Crow-Davis 

• Bring in microscope vs surgical loupes 

• CO2 laser, 8-12 watts, continuous 

• Radical tonsillectomy with both anterior and posterior pillars -en bloc

  • Superior - lateral to uvula where pillars meet

    • dissect to just lateral of superior pharyngeal constrictor in plane between constrictor and parapharyngeal fat

    • dissect to level of styloglossus (may see medial pterygoid and mandible)

  • Medial - mucosa at posterior OP and to avoid taking too much constrictor deep to it

  • Superomedial - incise both pillars (palatoglossus/palatopharyngeus) to level of prevertebral fascia

  • Inferior - 1 cm of tongue base

  • Watch for bleeding from ascending/descending palatine / lingual artery vessels

• Orient the specimen and label

• Additional margins for frozen section analysis 

• Optional: Apply Floseal 

• Optional: Insert DHT 

• Perform neck dissection, as warranted 

Post-op

• • CPT codes

    • 42842 - Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure

  • Admit overnight 

    • Cool mist

    • Continuous pulse oximetry 

  • Dr. Fong (post-op radical tonsil) 

    • Observation x 24 hours 

    • Acetaminophen IV 1 gm q 6 hours scheduled while inpatient, then PO 4 grams / 24 hours at home 

    • Oxycodone solution PO 5-10 mg q 6 hours PRN pain  

    • Dexamethasone IV 10 mg q 8 hours x 3 doses 

    • Unasyn 1.5 gm q 6 hours x 4 doses

  • Diet 

    • CLD x 24 hours including ice chips 

    • ADAT FLD x 72 hours

    • ADAT pureed diet

    • Additional protein and vitamin supplements   

  • Home medications

    • Hycet PRN pain

    • Consider Oxycodone PRN BTP 

    • Colace 

    • +/- Zofran 

    • +/- Manuka honey

    • 2011: Honey in otorhinolaryngology: When, why and how?

  • Light activity

  • Follow-up

    • RTC 1-2 weeks

High-Yield

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