Transoral robotic surgery (TORS) provides a minimally invasive approach to address tumors in selected and challenging anatomical locations. Among the critical areas where TORS demonstrates its prowess is the oropharynx. Oropharyngeal tumors can invade parapharyngeal space (PPS) which contains vital structures such as the carotid artery, internal jugular vein, and cranial nerves IX-XII. A deeper understanding of the endoscopic anatomy of the parapharyngeal space could reduce the morbidity associated with tumor resection in this dense neurovascular area. This video-article provides a step-by-step cadaveric dissection of the lower PPS though a transoral robotic approach.

OBJECTIVE: A gap in knowledge exists concerning the functional outcomes and complications when comparing various surgical approaches for retropharyngeal lymph node (RPLN) metastases.
OBJECTIVE: To explore perioperative outcomes, functional outcomes, and complications associated in the treatment of RPLN metastases.
METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the PubMed and Scopus databases.
METHODS: We systematically searched 2 databases from inception to January 2023 for articles examining the treatment approaches and postoperative outcomes in the retropharyngeal space. We included English records about surgical approaches, complications, functional outcomes for patients >18 years old with retropharyngeal lymphadenopathy.
RESULTS: One-hundred ninety-nine articles were identified, of which 17 were included in the analysis. Three studies assessed RPLN dissection in the postradiation setting. We identified limited knowledge about functional outcomes and complications following surgery for retropharyngeal lymphadenopathy. Overall, acute postoperative dysphagia was documented in 35/170 patients (20.5%). However, the assessment of dysphagia was limited, and not described in the majority of studies. The overall rate of postoperative neuropathy and hematoma were 4.1% and 4.7%, respectively. No postoperative hematomas were documented in the transcervical approach.
CONCLUSIONS: Our findings underscore the need for further research on postoperative outcomes following RPLN dissection. We recommend further studies focusing on objective swallow assessments and long-term outcomes of either surgical approaches.

OBJECTIVE: The aim of this systematic review is to assess a relation between demographical, clinical and tumoral features and the need for a prophylactic tracheotomy during TORS procedure in patients affected by supraglottic laryngeal cancer.
METHODS: PRISMA 2020 guidelines were applied in this systematic literature review. A computerized search was performed using the Embase/Pubmed, Scopus and Cochrane database, for articles published from 2007 to December 2023. A statistical univariate analysis including selected papers with low or intermediate risk of bias was performed.
RESULTS: Through a study selection process 8 full texts were eligible for statistical univariate analysis. The most relevant factor related to a prophylactic tracheotomy was a contextual bilateral cervical nodes dissection, which increased the need for a tracheotomy of about 3 times. Other factors contribute with a minor impact, such as a patients age >60 years at the time of the diagnosis, a cervical lymph node metastasis and a false vocal fold involvement. Each ones increase by 20-70 % the need for a tracheotomy. However, this rate is decreased by about 60 % by the epiglottis involvement.
CONCLUSIONS: The prophylactic tracheotomy is considered a temporary protection strategy to achieve a valid recovery after TORS procedure. However, there are no guidelines regarding its routinely use. Only 25 % of patients undergone tracheotomy during TORS to treat supraglottic laryngeal cancer. These preliminary results may add more significant evidence regarding the use of tracheotomy during the TORS procedure, in order possibly to help the surgeon decide preoperatively whether to perform it or not.

OBJECTIVE: Pain following transoral robotic surgery (TORS) is a driver of adverse outcomes and can lead to readmission and treatment delays. A scoping review was conducted to characterize TORS-related pain and identify key management strategies utilized in the literature.
METHODS: OVID Medline, CINAHL, Cochrane, Pubmed, and Embase databases were queried.
METHODS: Two team members independently screened titles and abstracts and completed full-text reviews. Studies examining TORS for OPSCC with quantitative pain data were included. The study followed the PRISMA guidelines.
RESULTS: A total of 1467 studies were imported for screening and 25 studies were ultimately included. The average study sample size was 89 participants. 68% were conducted in a single-center academic setting. Pain was assessed on varying timelines up to 3 years using 13 different metrics. Pain peaks days-weeks postoperatively and returns to baseline thereafter. Postoperative pain is a significant cause of morbidity and limited data exist about optimal management.
CONCLUSIONS: Prospective studies are needed to characterize and address TORS-related pain.

BACKGROUND: Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP.
METHODS: An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates.
RESULTS: Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification.
CONCLUSIONS: This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.

BACKGROUND: Transoral Robotic Surgery (TORS) and radiotherapy are considered oncologically equivalent primary treatment options for early-stage HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). Quality of Life (QoL) and Patient Reported Outcome Measures (PROMs) are therefore imperative in supporting clinical decision-making and optimising patient-centred care. The aim of this article is to evaluate how these primary treatment modalities compare in terms of QoL.
METHODS: Systematic review and meta-analysis of studies comparing primary TORS and primary radiotherapy for OPSCC using validated QoL tools. Swallowing and global QoL were the primary endpoints with secondary endpoints including all other QoL domains. An inverse variance random-effects model was employed to calculate the weighted estimate of the treatment effects across trials.
RESULTS: A total of six studies collectively reporting on 555 patients were included (n = 236 TORS and n = 319 radiotherapy). Meta-analysis showed no significant difference for swallowing (mean difference = -0.24, p = 0.89) and global QoL (mean difference = 4.55, p = 0.14). For the remaining QoL domains (neck/shoulder impairment, neurotoxicity, voice, xerostomia, speech, and distress), the scarcity of data did not permit meta-analysis. However, the existing data showed no significant difference for any except for xerostomia where TORS appears favourable in the sole study reporting on this.
CONCLUSIONS: TORS and radiotherapy appear to be comparable primary treatment options for early stage OPSCC when it comes to QoL. However, a substantial proportion of patients in the TORS group received adjuvant (chemo)radiotherapy rendering it difficult to establish the \'true\' QoL outcomes following surgery alone. There are also minimal studies reporting QoL outcomes beyond swallowing and global QoL. Further research is therefore needed, including more randomised trials adequately powered to detect differences in QoL outcomes.

Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and opportunities for treatment, particularly regarding de-escalation strategies to reduce treatment morbidity without compromising oncological outcomes. This paper examines the role of Transoral Robotic Surgery (TORS) as a de-escalation strategy in managing HPV-related OPSCC. We conducted a comprehensive literature review from January 2010 to June 2023, focusing on studies exploring TORS outcomes in patients with HPV-positive OPSCC. These findings highlight TORS\'s potential to reduce the need for adjuvant therapy, thereby minimizing treatment-related side effects while maintaining high rates of oncological control. TORS offers advantages such as precise tumor resection and the ability to obtain accurate pathological staging, which can guide the tailoring of adjuvant treatments. Some clinical trials provide evidence supporting the use of TORS in specific patient populations. The MC1273 trial demonstrated promising outcomes with lower doses of adjuvant radiotherapy (RT) following TORS, showing high locoregional tumor control rates and favorable survival outcomes with minimal side effects. ECOG 3311 evaluated upfront TORS followed by histopathologically directed adjuvant therapy, revealing good oncological and functional outcomes, particularly in intermediate-risk patients. The SIRS trial emphasized the benefits of upfront surgery with neck dissection followed by de-escalated RT in patients with favorable survival and excellent functional outcomes. At the same time, the PATHOS trial examined the impact of risk-adapted adjuvant treatment on functional outcomes and survival. The ongoing ADEPT trial investigates reduced-dose adjuvant RT, and the DART-HPV study aims to compare standard adjuvant chemoradiotherapy (CRT) with a reduced dose of adjuvant RT in HPV-positive OPSCC patients. These trials collectively underscore the potential of TORS in facilitating treatment de-escalation while maintaining favorable oncological and functional outcomes in selected patients with HPV-related OPSCC. The aim of this scoping review is to discuss the challenges of risk stratification, the importance of HPV status determination, and the implications of smoking on treatment outcomes. It also explores the evolving criteria for adjuvant therapy following TORS, focusing on reducing radiation dosage and volume without compromising treatment efficacy. In conclusion, TORS emerges as a viable upfront treatment option for carefully selected patients with HPV-positive OPSCC, offering a pathway toward treatment de-escalation. However, selecting the optimal candidate for TORS-based de-escalation strategies is crucial to fully leverage the benefits of treatment de-intensification.

BACKGROUND: Patients presenting with head and neck squamous cell carcinoma of unknown primary (HNSCCUP) remain challenging clinical scenarios as large variation exists in practices used to locate the primary.
OBJECTIVE: The objective of this systematic review is to review of the literature and offer recommendations for oropharyngeal biopsies in HNSCCUP.
METHODS: Pubmed, Medline and Embase were searched to identify studies from inception to October 2021. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.
RESULTS: A total of 483 articles were included and screened, 41 studies met the inclusion criteria, including over 3400 patients from the original articles (122 of these patients were reported on in two sequential articles by a single author - table 1) and 4 large metaanalyses including 1852 patients. The primary site identification rate following random biopsies or deep tissue biopsies is less than 5% in most studies. The mean detection rate following ipsilateral tonsillectomy is 34%; two pooled analyses indicate that the mean detection rate following tongue base mucosectomy is 64%, with this figure rising when the tonsils are negative.
CONCLUSIONS: High level evidence is lacking, with heterogeneity in the reported studies. Published meta-analyses are based on retrospective data. There is little evidence supporting the practice of random/non-directed oropharyngeal biopsies. Available evidence supports palatine tonsillectomy and tongue base mucosectomy compared to deep tissue biopsies.

UNASSIGNED: Supraglottic squamous cell carcinoma (SCC) represents a major surgical challenge in organ-preserving treatment. Type I open partial horizontal laryngectomy (OPHL I) is considered the most popular. To date, minimally-invasive approaches such as laser microsurgery and transoral robotic surgery (TORS) have gained increasing relevance. The aim of this narrative review is to obtain a descriptive comparison of functional and oncological outcomes from studies on patients with supraglottic SCC treated with OPHL I and TORS, respectively.
UNASSIGNED: A computerised search was performed using the Pubmed database for articles published from 2000 to 2023. A comparative analysis on functional and oncological outcomes of patients treated by TORS and OPHL I was performed.
UNASSIGNED: The present narrative review shows a superiority of TORS compared to open surgery for supraglottic SCC in terms of functional outcomes, while maintaining comparable oncological outcomes.
UNASSIGNED: Although recently introduced in the treatment of laryngeal pathology, TORS has been shown to be a reliable technique not only for functional but also for oncological outcomes, ensuring good overall survival, disease-free survival, and disease control rates comparable to OPHL I.

OBJECTIVE: The modified frailty index (mFI-5) is a National Surgical Quality Improvement Program-derived 5-factor index that has been proven to reflect frailty and predict morbidity and mortality. We hypothesize that mFI-5 is a valid predictive measure in the transoral robotic surgery (TORS) population.
METHODS: Retrospective study utilizing the TriNetX US-collaborative health records network querying for TORS patients. Cohorts were stratified by mFI-5 score which uses five ICD-10 codes: nonindependent functional status, hypertension, obstructive respiratory disease, heart failure, and diabetes mellitus. Cohorts were matched by age using propensity score matching. Outcome measures included survival, infection, pneumonia, tracheostomy dependence, and percutaneous endoscopic gastrostomy dependence. Reported odds ratios were normalized to mFI-5 = 0.
RESULTS: A total of 9,081 patients were included in the final analysis. Greater mFI-5 scores predicted decreased survival and increased incidence of postoperative infection and pneumonia. Odds of 5-year mortality were 1.93 (p = 0.0003) for mFI-5 = 2 and 1.90 (p = 0.0002) for mFI-5 = 3. Odds of 2-year mortality were 1.25 (p = 0.0125) for mFI-5 = 1, 1.58 (p = 0.0002) for mFI-5 = 2, and 1.87 (p = 0.003) for mFI-5 = 3. Odds of postoperative infection were 1.51 (p = 0.02) for mFI-5 = 2 and 1.78 (p = 0.05) for mFI-5 = 3. Two-year odds of developing pneumonia were 1.69 (p = 0.0001) for mFI-5 = 2 and 2.84 (p < 0.0001) for mFI-5 = 3. Two-month odds of pneumonia were 1.50 (p = 0.0259) for mFI-5 = 2 and 2.55 (p = 0.0037) for mFI-5 = 3. mFI-5 = 4 or 5 had too few patients to analyze. Using polynomial regression to model age versus incident 5-year post-TORS death (R2 = 0.99), mFI-5 scores better predicted survival than age alone.
CONCLUSIONS: This study demonstrates that mFI-5 predicts mortality, pneumonia, and postoperative infection independently of age.
METHODS: 4 Laryngoscope, 2024.