Table 6. Management of the Base of Tongue. IL: ipsilateral. BL:
bilateral. PE: panendoscopy. Ix: Investigation. Ex: examination. BOT:
base of tongue, TBM: tongue base mucosectomy, PT: palatine tonsillectomy
TOR: transoral Robotic Assisted Surgery. TLM: transoral laser
microsurgery, Dx: diagnosis, Tx: treatment
Novel Techniques
Several novel surgical techniques have been reported in the literature
to perform TBM. These include TORS, TLM as well as other endoscopic
cautery techniques. The majority of studies focus on outcomes following
TORS or TLM (table 7 location percentage is percentage of total
primaries found).
There were six studies15,37-41 where 331 patients
underwent TORS within the diagnostic workup and, 5 studies with 223
patients underwent TLM16,17,42-44, (Graboyes et al
used TLM but in two of 65 patients TORS was used for resection after
TLM44). The were two meta-analyses: Meccarellio et al45 and Farooq et al46. The primary
studies are all retrospective studies with significant heterogeneity.
There are no randomised controlled trials.
The meta analysis by Meccariello et al45 looked at the
use of TORS in HNSCCUP for 349 patients over 12 studies. They found an
overall detection rate of 64% in the base of tongue using a TORS
approach.
Farooq et al al46 looked at patients undergoing TBM
using either TORS or TLM in 556 patients over 21 studies. The pooled
rate of positive TBM was 64% in those that had negative clinical
examination and imaging (including PET). The detection rate went up to
78% in those patients who had also undergone an EUA and negative
tonsillectomy prior to TBM. They also reported a higher detection rate
for TLM (91%) versus TORS (74%) but this was based on very limited
evidence in 81 total patients.
The current evidence suggests that TBM should be undertaken in the
workup of HNSCCUP to increase the chances of primary site
identification. There is no evidence to suggest one technique is
superior to another. The detection rate is greater in patients who have
already undergone a negative tonsillectomy. This does mean further
general anaesthetic for those patients who go on to require TBM, or the
potential risk of increased complications (theoretical risk of
oropharyngeal stenosis) if the procedures are combined. The studies
where they are combined often use frozen sections as a surgical decision
node, an option not routinely used in the UK. Therefore, the decision on
a staged or a combined procedure would currently be based on surgeon
preference and on the individual case (ie suspicious scans, or HPV
positivity). Higher quality, prospective studies would be required to
look at the potential risks and efficacy in primary pickup of combining
these procedures in particular palatine tonsillectomy and TBM.