Mandibulotomy Approach to Oropharyngeal Tumors
Ronald H. Spiro, MD, New York, New York
Frank P. Gerold, MD, New York, New York
Jatin P. Shah, MD, New York, New York
Roy 6. Sessions, MD, New York, New York
Elliot W. Strong, MD, New York, New York
The choice of therapy for patients with malignant
tumors that arise in the oropharynx remains contro-
versial. External radiotherapy has been preferred in
many centers because few oropharyngeal primary
cancers are accessible for peroral excision. Exposure
of the oropharynx through neck incisions is limited,
and composite resections including segments of the
mandible are disfiguring.
Reintroduction to the mandibulotomy for access
to upper aerodigestive tract tumors occurred more
than 25 years ago in our hospital. The first patient
had a small squamous cell carcinoma of the base of
the tongue. Our satisfaction with the mandibular
swing approach to the oropharynx has paralleled
our rapidly growing experience within the past few
years. Judging by the paucity of reports in the litera-
ture, we suspect that the versatility of this operation
has not been fully appreciated by others. We hope
this study will stimulate more interest in the surgi-
cal treatment of oropharyngeal carcinoma.
Material and Methods
From 1959 through 1984, we resected 191 neoplasms
through a median mandibulotomy approach with paralin-
gual extension (the mandibular swing procedure). Lateral
retraction of the divided mandible provided access to
tumors that involved the oral cavity in 63 patients, the
oropharynx in 120 patients and the pharynx or deep lobe
of the parotid gland in 8 patients. Most of these opera-
tions (58 percent) were performed during the last 4 years
of the study (Figure 1). This report concerns 120 patients
with oropharyngeal cancer, 68 of whom had lesions that
arose in the base of the tongue. The tonsils (22 patients),
soft palate (22 patients), and pharyngeal wall (8 patients)
were involved in the remaining patients. Gross tumor
extension to adjacent sites was evident in 23 patients, 13
of whom had primary lesions in the base of the tongue. A
total of 22 patients received previous therapy elsewhere
which included radiotherapy in 14 patients, surgery in 6,
and combinations of both in 2. Squamous cell carcinoma
From the Head and Neck Service, Department of Surgery, Memorial Sloan-
Kettering Cancer Center, New York, New York.
Requests for reprints should be addressed to Ronald H. Spiro, MD, 425
East 67th Street, New York, New York 10021.
Presented at the 31st Annual Meeting of the Society of Head and Neck
Surgeons, Dorado, Puerto Rico, May 5-8, 1985.
466
was the histologic diagnosis in 104 patients (87 percent),
whereas 10 patients had malignant minor salivary neo-
plasms. The remaining patients had anaplastic carci-
noma (two patients), lymphoma (two patients), angioma
(one patient), and a benign salivary neoplasm (one
patient).
The size of the primary lesion recorded in 114 patients
was 2 cm or less in 26 patients (22 percent), 2.1 to 4 cm in
60 patients (53 percent), and more than 4 cm in 28 pa-
tients (24 percent). Cervical lymph nodes were clinically
uninvolved (No) in 51 patients (42 percent) and clinically
positive (N+) in 69 patients (58 percent), including 7
patients who had undergone previous resection of meta-
static nodes. Clinical staging of the patients according to
the site of origin is described in Table I. Considering only
the 93 patients with previously untreated squamous cell
or salivary carcinoma, 29 patients (31 percent) had local-
ized disease (stages I and II), whereas 64 patients (69
percent) had more extensive tumors (stages III and IV).
Excision of the primary tumor was performed in each
patient after dividing the mandible in the midline using
previously described techniques [I]. The resection had to
be extended in 13 of the 68 patients (19 percent) with
tumors in the base of the tongue to include portions of the
oropharyngeal wall (6 patients), total laryngectomy (2
patients), partial laryngectomy (3 patients), part of the
hyoid bone (2 patients), partial maxillectomy (1 patient),
and a marginal mandibulectomy (1 patient).
Primary closure of the surgical defect was achieved in
99 patients. One patient treated early in the study had a
planned pharyngostoma and delayed closure. Flap recon-
struction was required in 20 patients (17 percent). The
tongue was utilized in 13 of the patients, a pectoralis
major myocutaneous flap in 4, the sternomastoid muscle
alone or with a dermis graft in 2, and the pharyngeal wall
in 1. Tongue flaps were most often used in patients with
tumors of the tonsils or palate, whereas use of the pectora-
lis major myocutaneous flap was limited to repair of mas-
sive defects in the base of the tongue. At least 38 patients
had dental splints applied postoperatively in order to
better stabilize the osteotomy.
Neck dissection had been previously performed in eight
patients. Conventional unmodified radical neck dissec-
tion was employed in 61 patients who were staged Nr on
admission. Of the remaining 51 patients who had no evi-
dence of cervical metastasis, all but 10 had elective neck
surgery, which consisted of conventional radical neck dis-
section in 17, modified radical neck dissection in 5, SU-
praomohyoid neck dissection in 11, and suprahyoid neck
The American Journal of Surgery
 Mandibulotomy for Oropharyngeal Tumors

TABLE I Clinical Presentation According to Site

30- Base of
Tongue Tonsils Palate Pharynx Total
(n = 66) (n = 23) (n = 23) (n = 8) (n = 120)

Previously 11 5 8 24
25- treated
Tumor
a OROPHARYNX = 120 PTS. status
Ti 12 3 3 1 19
20- T2 32 12 9 5 58
1 T3 11 3 3 2 19
Nodal
status
N, 20 6 11 3 40
N+ 35 12 4 5 65
Stage l

I 5 1 2 1 9
II 7 3 a 2 20
III 31 8 3 3 45
IV 10 5 2 2 19

’ Denotes patients with previously untreated squamous cell or

salivary carcinoma (n = 93).

most often pulmonary, occurred in six patients. The

median interval from surgery to discharge was 14
days when the course was uncomplicated and 17
‘64 ‘69 ‘74 ‘84 days when complications ensued.
Figure 1. The number of mandibular swing operations performed Specific comments about the adequacy of the sur-
at our hospital has increased dramatlcalty in recent years. Shad- gical margins were recorded in 111 of the pathology
ed areas indicate those patients whose primary lesions were in reports. Excision was considered adequate in 74
the oropharynx.
patients (67 percent), 15 patients had “close” mar-
gins, and 22 patients had positive margins (in situ
carcinoma only in 6). Local recurrence occurred in
dissection in 8. Histologic evidence of cervical node in-
21 percent of 83 patients who were eligible for at
volvement was confirmed in 37 percent of these patients.
Radiotherapy of limited dosage (five treatments of 400
least 2 years follow-up. Neck recurrence or distant
rads each) was given preoperatively to five patients who metastasis was observed in 14 and 10 percent of the
were treated early in the study. A total of 55 patients patients respectively. Excluding those who were lost
received planned postoperative radiotherapy of 5,000 to to follow-up and those who died from other causes
6,000 rads. This is currently the routine treatment for all disease free, 38 of 62 patients (61 percent) eligible
patients with stage III or IV disease or questionable resec- for at least 2 years of observation remained alive and
tion margins. well. Retrospective staging was possible in 47 of the
62 determinate patients who were previously un-
Results treated. The cure rate was 89 percent for those with
Complications occurred in a total of 47 patients stage I or II disease (8 of 9 patients), 78 percent for
(39 percent), most of which were minor. There were those with stage III disease (22 of 28 patients), and
no postoperative deaths. Delayed healing or sepsis 50 percent for those with stage IV disease (5 of 10
involving the mandibulotomy site was noted in 17 patients).
patients (14 percent). Osteomyelitis diagnosed by Functional results were satisfactory, with the
submental drainage, with or without radiographic exception of seven patients who had persistent
evidence, usually resolved over a period of weeks or swallowing problems after extensive resections
months with appropriate antibiotic therapy and lo- of the base of the tongue. One of these patients
cal wound care. Mandibulotomy wire removal required a laryngectomy 6 months postoperatively
(three patients) or surgical debridement (one pa- for uncontrollable aspiration, and three patients
tient) was occasionally required, but all patients required a permanent feeding tube.
eventually had solid bone union. Other wound prob-
Comments
lems occurred in 24 patients, including slough or
separation in 8 patients, hemorrhage in 5 patients, Most surgeons agree that resection should be re-
sepsis in 5 patients, orocutaneous fistula in 3 pa- served for those oropharyngeal lesions with well-
tients, transient chyle fistula in 2 patients, and tra- defined borders. When the margins of the primary
cheal injury in 1 patient. Systemic complications, tumor blend imperceptibly with the adjacent muco-

Volume150,October1985 467
Spiro et al
sa or when multifocal disease is present, radiothera-
py is usually preferable. Patient selection for a man-
dibulotomy approach requires accurate assessment
of proximity of tumor to the mandible. In some
patients who had painful lesions or trismus, exami-
nation under general anesthesia was necessary. Ide-
ally, there should be a rim of normal tissue between
the tumor and the mandible, but the line of excision
was occasionally carried to the alveolus or the ante-
rior border of the ramus when tumor that involved
the anterior tonsillar pillar approached the perios-
teum. Exposure usually improved as the operation
progressed, and adequate margins were usually
achieved even when the lesions encroached on the
hypopharynx or the nasopharynx.
Despite the fact that many of the tumors were
sizeable and portions of the supraglottic larynx,
pharyngeal wall, or maxilla were occasionally re-
sected, complex reconstruction was required in rela-
tively few patients. The importance of transverse
orientation of resections that involve the base of the
tongue deserves reemphasis [Z]. This technique fa-
cilitated primary tongue repair in most instances by
displacing the remaining mobile anterior segment
posteriorly. Providing that most of the contralateral
base of the tongue remained with an intact nerve
and blood supply, the functional result was usually
satisfactory. Tongue flaps proved useful in some
patients for repair of large tonsillar or palatal de-
fects. In a few instances, sizeable defects were par-
tially closed inferiorly, leaving a defect superiorly
which was temporarily packed with Xeroformm
gauze and allowed to heal by secondary intention.
Dental appliances facilitated rehabilitation in some
patients who required palatal resections.
Conventional radical neck dissection was per-
formed when cervical metastases were apparent,
and 80 percent of those with No disease had an
elective lymphadenectomy. In recent years, there
has been a growing preference for modified opera-
tions in the latter patients, which has most often
been a supraomohyoid neck dissection. Histologic
evidence of cervical metastasis was confirmed in 37
percent of those who had an elective neck dissec-
tion, almost all of whom received adjunctive postop-
erative radiotherapy.
Although complications occurred in more than a
third of our patients, most were minor and there
were no postoperative deaths. Sepsis and delayed
healing of the osteotomy occurred in 13 percent of
the patients despite prophylactic antibiotic therapy
and may have been influenced by surgical tech-
nique. Thermal damage to bone during transection,
incomplete soft tissue coverage of the osteotomy
site, and excessive mobility after wiring of the man-
dible segments must be minimized to encourage
primary healing. Mandibular splints were often ap-
plied postoperatively, but they are not essential if a
rigid osteotomy repair is achieved.
466
Although each surgeon differs somewhat in the
design of the osteotomy and the manner in which it
is wired for repair, we remain strongly committed to
our preference for a median rather than a lateral
mandibulotomy. We believe that stability is more
easily achieved after a midline osteotomy and the
vitality of existing dentition is better preserved.
Perhaps most important is the fact that healing of a
midline osteotomy site is not likely to be impeded by
previous or subsequent radiotherapy, as the mandi-
ble is transected anterior to the portals usually em-
ployed.
The follow-up period was brief in our most re-
cently treated patients, but our results in terms of
control at the primary site (79 percent) and disease-
free survival rate (61 percent) compare favorably
with those we and others have previously reported
using more conventional surgery or radiotherapy
alone [3-91. We believe that the liberal use of ad-
junctive postoperative radiotherapy has made the
difference, which is consistent with our recent re-
ports indicating that locoregional tumor control was
significantly enhanced when surgery was followed
by radiotherapy [10,11]. Most encouraging is the
fact that these gratifying results were achieved
while avoiding the deformity of more radical sur-
gery and the morbidity of the high dose radiothera-
py previously employed.
Summary
We have reviewed our experience with 120 select-
ed patients who had pharyngeal tumors resected
through a median mandibulotomy approach with
paralingual extension (mandibular swing). Clinical
findings, technique, and complications are dis-
cussed. Results were gratifying in terms of salvage,
patient appearance, and function. We believe that
this surgical approach, in combination with postop-
erative radiotherapy when appropriate, offers an
attractive alternative to high dose radiotherapy
alone in patients with oropharyngeal carcinoma.
References
1. Spiro RH, Gerold FP, Strong EW. Mandibular swing approach
for oral and oropharyngeal tumors. Head Neck Surg
1981;3:371-8.
2. Spiro RH. Surgery of the tongue. In: Nussbaum MH, ed.
Modern techniques in surgery: head and neck surgery. Mt.
Kisco, New York: Futura Publishing, 1984:1-20.
3. DeSanto LW, Whicker JH, Devine KD. Mandibular osteotomy
and lingual flaps: use in patients with cancer of the tonsil
and tongue base. Arch Otolaryngol 1975;101:652-5.
4. lldstad ST, Bigelow ME, Remensnyder JP. Squamous cell
carcinoma of the tongue. A comparison of the anterior two
thirds of the tongue with its base. Am J Surg
1983;146:456-61.
5. Parsons JT, Million RR, Cassisi NJ. Carcinoma of the base of
the tongue: results of radical irradiation with surgery re-
served for irradiation failure. Laryngoscope
1982;92:689-96.
6. Perez CA, Purdy JA, Breaux SR, Ogura JH, VonEssen S.
Carcinoma of the tonsillar fossa-a nonrandomized com-
The American Journal of Surgery

parison of preoperative radiation and surgery or irradiation
alone: long term results. Cancer 1982;50:2314-22.
7. Garrett PG, Beale FA, Cummings BJ, et al. Cancer of the
tonsil. Results of radical radiation therapy with surgery in
reserve. Am J Surg 1983;146:432-5.
8. Givens CD, Johns ME, Cantrell RW. Carcinoma of the tonsil:
analysis of 162 cases. Arch Otolaryngol 1981;107:730-4.
9. Talton BM, Elkon D, Kim J, Fitz-Hugh GS, Constable WC.
Volume 150, October 1995
Mandibulotomy for Oropharyngeal Tumors
Cancer of the posterior hypopharyngeal wall. Int J Radiat
Oncol Biol Phys 1981;7:597-9.
10. Vikram B, Strong EW, Shah JP, Spiro RH. Failure at the
primary site following multimodality treatment in advanced
head and neck cancer. Head Neck Surg 1984:6:724-g.
11. Vikram 9, Strong EW, Shah JP, Spiro RH. Failure in the neck
following multimodality treatment in advanced head and
neck cancer. Head Neck Surg 1984;6:730-3.
469