Evolution of transoral surgery: three decades of change in patients, pathologies, and indications.

BACKGROUND: Transoral surgery may be used to approach pathologies at the craniocervical junction. However, the need for this approach has decreased over the past few decades.
OBJECTIVE: To assess the outcome and complications of transoral surgery and extended transoral approaches at a single UK center between 1980 and 2011.
METHODS: A retrospective review was performed of 495 ventral midline operations (between 1980 and 2004) and prospective review of 38 operations (2004-2011) in a total of 479 patients. Trends in surgery and factors associated with good or bad outcome were assessed over this 30-year period.
RESULTS: Of 533 operations, the most frequently performed surgeries were simple transoral surgery (321 operations), transoral surgery with splitting of the palate (107 operations), open-door maxillotomy (58 operations), and mandibulotomy (11 operations). Since the 1990s, there has been a steady decrease in the number of operations performed, mainly due to the decrease in the number of patients with rheumatoid arthritis presenting for surgery. The incidence of craniocervical junction tumors remained constant. The number of complications was significantly associated with the preoperative neurological status, and more complications were seen in myelopathic rheumatoid patients as well as a greater trend in congenital basilar invagination. The rates of pharyngeal infection (0.6%) and cerebrospinal fluid leak (0.3%) for standard transoral surgery were extremely low.
CONCLUSION: The number of transoral and associated operations has decreased over time. Transoral surgery is now mainly indicated for ventral midline tumors such as chordomas. Transnasal endoscopic techniques show promise, but a major advantage of standard transoral surgery is the low cerebrospinal fluid leak and infection rates.