Definition & Overview
The radical resection of tonsils, tonsillar pillars, and/or retromolar trigone is a surgical procedure of removing lymph nodes and blood supply to these areas. In some cases, it also involves the removal of adjacent tissues and cells. It is performed to treat several diseases and conditions such as cancer and tumours.
The tonsils, tonsillar pillars, and retromolar trigone are adjacent structures found in the oral cavity and the oropharynx. The tonsils, which are sometimes referred to as palatine tonsils, are located in the rear part of the pharynx. Each is composed of soft tissues similar to those that make up the lymph nodes. Tonsils are considered to be part of the lymphatic system, helping the body fight off infections.
Tonsillar pillars or palatine arches, on the other hand, are composed of muscles adjacent to the tonsils. These structures are further classified into anterior and posterior pillars, which are made up of the palatoglossus muscle and the palate pharyngeal muscle, respectively. These structures provide support and anchor the tonsils in place. Meanwhile, the retromolar trigone is the space at the back of the third molar of the mandible or lower jaw. It extends to the maxillary tuberosity and serves as a connection point for the different parts of the oral cavity, the anterior tonsillar pillar, the floor of the mouth, and the soft palate.
Who Should Undergo and Expected Results
Patients diagnosed with tonsillar squamous cell carcinoma are suitable candidates for radical resection. Its risk factors include a long history of smoking and drinking alcohol, as well as human papillomavirus infection. This condition is characterised by the presence of recurring lesions at the back of the mouth, difficulty in swallowing, pain when chewing, pain in the ear and neck area, halitosis, and recurring tonsillitis. Cancer in the tonsils could also spread to the palatine arches or tonsillar pillars.
Those who are infected with human papillomavirus have a higher risk of developing tonsillar cancer. When warranted, people infected with this virus may be offered radical resection to halt the disease from progressing. One apparent symptom of this infection is the enlargement of cervical lymph nodes.
The procedure can also be recommended to those who have tumour growth in the tonsils, tonsillar pillars, or the retromolar trigone. These tumours do not need to be malignant but may cause significant distress and discomfort to the patient. Some tumour tissues may become so enlarged that it becomes painful to swallow or speak properly. In cases affecting the retromolar trigone, patients may find it hard to even open their mouths. If left unattended, tumours in this area of the oral cavity may also lead to the development of tumour in the salivary gland.
This procedure has a good success rate among patients with benign tumours of the tonsils, tonsillar pillars, or retromolar trigone. In most cases, patients who undergo this procedure at the early stages of cancer have high chances of treatment and survival. Better outcomes and prognosis are also expected if the cancer has not yet spread to the lymph nodes and adjacent blood vessels and nerves.
Patients are expected to rest for several weeks after surgery and adhere to soft food diet. Right after surgery, the patient will be likely placed under tube feeding to avoid disturbing the surgical site. Typically, those who had radical resection due to cancer are advised to undergo adjuvant chemotherapy and radiation therapy to make sure no cancer cells remain in the affected area. Close monitoring by the physician for several months is also expected.
How is the Procedure Performed?
There are several techniques that could be utilised to perform the radical resection of tonsils, tonsillar pillars, and retromolar trigone. Prior to making any incision, the patient is placed under general anaesthesia.
The transoral approach involves opening the patient’s mouth and putting in a mouth gag to allow the surgeon to access the surgical site. The surgeon then makes an incision in the superior constrictor muscle to access the tonsils and its adjacent parts. Using a scalpel, the surgeon then proceeds to remove the tumour cells including a margin of healthy cells surrounding it.
The use of laser microsurgery is also an option for this type of procedure. A mouth gag is also used in this technique to access the surgical site. An operating microscope is utilised to properly visualise the tonsils and its surrounding parts. Pulses from a carbon dioxide laser are then directed to the abnormal growth to kill tumour cells before removing the tumour piece by piece.
Another technique for this procedure is called transoral robotic surgery. After placing the mouth gag in the oral cavity, the surgeon will insert a robotic endoscope and specialised surgical tools. With the use of 3D images, the tumour or cancer cells are resected. Blood vessels that need to be cut during surgery are then clamped or sealed using either haemoclips or electrocautery devices.
In most cases when the transoral technique is used, the surgical site is left open for the tissues to slowly heal.
The procedure can also be performed via open surgery. In this method, the patient’s head is positioned in such a way that the surgeon will have an easy access to the floor of the mouth. An incision is then made in the middle of the lower lip and is directed to the curve around the chin pad. The surgeon will use specialised surgical tools to divide the mandibles. The underlying muscles are also divided. The surgeon then proceeds to remove any tumour cells. The mandibles are repaired using titanium plates. In most cases, surgical flaps are needed to repair the surgical wound. These flaps are harvested from the patient’s stomach, thigh, or buttocks.
Possible Risks and Complications
The radical resection of tonsils, tonsillar pillars, and/or retromolar trigone is associated with a number of risks and complications, including the following:
- Adverse reaction to anaesthesia
- Excessive bleeding (since the oral cavity and the oropharynx have numerous blood vessels)
- Pain, which is one common complaint among patients
- Dysphagia or difficulty in swallowing food
- Injury to the nerves, tongue, and adjacent parts
- Numbness or facial paralysis
- Poor wound healing
Failure of the mandibles to fuse properly resulting in disfigurement
Weatherspoon DJ, Chattopadhyay A, Boroumand S, Garcia I. Oral cavity and oropharyngeal cancer incidence trends and disparities in the United States: 2000-2010. Cancer Epidemiol. 2015 Aug. 39 (4):497-504.
Rich JT, Milov S, Lewis JS Jr, Thorstad WL, Adkins DR, Haughey BH. Transoral laser microsurgery (TLM) +/- adjuvant therapy for advanced stage oropharyngeal cancer: outcomes and prognostic factors. Laryngoscope. 2009 Sep. 119(9):1709-19.