Preoperative cephalometric analysis to predict transoral robotic surgery exposure

Transoral robotic surgery (TORS) is being increasingly used in the treatment of head and neck cancer and we wanted to determine the feasibility of predicting TORS access using cephalometric measurements obtained from preoperative imaging. 20 cephalometric measurements were obtained from imaging on 31 TORS base of tongue (BOT) resections and compared to adequacy of exposure. Three measurements were found to be significantly different between the restricted and adequate exposure groups. Distances from posterior pharyngeal wall (PPW) to hyoid, PPW to soft palate and epiglottis to vertical laryngeal angle were all statistically different between the two groups. Receiver operating characteristic (ROC) analysis revealed strong correlation to exposure for all three measurements with cut offs ≤30 mm between the PPW and the hyoid, ≤8.1 mm PPW and soft palate and ≥130° between the epiglottis and vertical plain of the larynx all representing restricted exposure. Duration of surgery for the restricted group, 85 min, was significantly longer than the adequate exposure group, 51 min (p = 0.026). Preoperative measurements of radiographic images of the oropharyngeal working space can predict restricted exposure for TORS resection of the BOT. These measures may be used in conjunction with other subjective assessment parameters to predict which patients could benefit from a staging endoscopy to determine adequate TORS exposure.