Dual-Acquisition Extracranial Computed Tomographic Angiography-Enhanced Neck Computed Tomography before Transoral...

Transoral laser microsurgery (TLM) is an alternative surgical technique for piecemeal endoscopic resection of mucosal-based aerodigestive tract tumors. Though uncommon, potentially catastrophic postoperative bleeding may occur with this technique secondary to vascular injury along invasive tumor inner margins. We describe our preliminary results using a preoperative dual-acquisition extracranial computed tomographic angiography (CTA)-enhanced neck computed tomographic (CT) imaging and postprocessing protocol developed to improve visualization of mucosal-based head and neck tumors and adjacent arterial branches with the objective of facilitating TLM surgery and reducing secondary bleeding complications. Twenty patients with known head and neck cancers anticipated for TLM resection were selected for a dual-acquisition CTA-CT scanning and postprocessing protocol. The mucosal-based pharyngeal tumors and peritumoral vessel enhancement were compared on matched CTA and enhanced neck CT axial images. Operative reports and clinical notes were retrospectively reviewed to identify patients in whom the TLM surgical approach was altered or changed to conventional open surgery as a result of presurgical CTA-CT findings. Enhancement of peritumoral vasculature was almost uniformly superior (19 of 20 patients) on extracranial CTA compared with enhanced neck CT images. In six candidates for TLM surgery (30%), CTA findings resulted in a change in surgical approach to improve intraoperative peritumoral vascular control. In this small pilot series, primary tumor-peritumoral vessel relationships delineated by the addition of extracranial CTA to preoperative enhanced neck CT frequently impacted the surgical approach and facilitated TLM planning.