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COMMON SURGICAL METHODS
Overview of surgical treatment
Surgical resection of the nasopharynx is inherently challenging due to its complex anatomy. In 1951, Wilson
made a significant breakthrough in addressing this complexity by introducing three surgical approaches for
[14]
nasopharyngeal resection: transnasal, transmaxillary, and transoral routes . Over time, technological
advancements have led to the development of additional techniques to manage NPC, including the
temporal fossa approach, inferior/transpalatal approach, maxillary swing approach, endoscopic
nasopharyngectomy, and robot-assisted resection. A landmark prospective randomized controlled study by
Liu et al. revealed that endoscopic nasopharyngectomy provides superior patient survival compared to re-
irradiation, with a 3-year overall survival rate of 85.8% vs. 68.0%. Additionally, this technique resulted in
fewer postoperative complications and significantly improved patients’ quality of life . Similarly, Teo et al.
[16]
[17]
found that nasopharyngeal resection is more effective than local re-irradiation in the treatment of NPC .
Surgery is preferred over re-irradiation in specific situations where it becomes the first-line treatment. This
includes cases where patients experience severe radiation-induced complications, such as
osteoradionecrosis, making additional radiation risky. Surgery is also favored for localized, resectable
recurrences (e.g., rT1-rT2) without distant metastasis, as it can achieve better local control. When patients
have reached the maximum safe radiation dose yet still experience recurrence, surgery can offer effective
management with fewer severe side effects. Additionally, in tumors located near critical structures or those
less responsive to radiation (e.g., nasopharyngeal adenocarcinoma), surgery allows for precise removal and
minimizes damage to surrounding tissues.

Surgical intervention remains instrumental in managing NPC. According to the guidelines set forth by the
National Comprehensive Cancer Network (NCCN), surgical resection is the preferred treatment for locally
recurrent NPC. The indications for surgery encompass a range of clinical scenarios: primary well-
differentiated squamous cell carcinoma (stages T1-T3, and selectively, T4), nasopharyngeal
adenocarcinoma, locally recurrent resectable NPC (rT1-rT3, and select rT4 cases), and recurrent neck
[5,9]
lymph nodes . Notably, Liu et al. suggested that for early-stage primary NPC (T1), minimally invasive
surgical resection alone can rival radiotherapy in terms of survival outcomes while inflicting fewer adverse
effects . However, these findings should be interpreted with caution due to the lack of a prospective
[10]
randomized control in the study. The applicability of surgical intervention in early undifferentiated
squamous cell carcinoma remains a subject of ongoing research. For patients suffering from skull base
osteonecrosis after nasopharyngeal radiotherapy, endoscopic debridement has been identified as an
[14]
efficacious management strategy . Table 1 summarizes the options for various surgical modalities.
Endoscopic nasopharyngectomy
Introduced in 2005, Endoscopic nasopharyngectomy has emerged as a primary technique for
nasopharyngeal cancer treatment [18-21] . This procedure focuses on the precise removal of tumors within the
nasopharynx, behind the nasal septum, and within the sphenoid sinus, using the accuracy afforded by nasal
endoscopy. Castelnuovo et al. outlined three specific resection techniques: Type 1 targets the posterior
nasopharyngeal wall; Type 2 expands upward to the sphenoid, and Type 3 adopts a trans-pterygoid strategy
focusing on the postero-lateral nasopharynx, necessitating the extraction of both the pterygoid plates and
the Eustachian tube, all executed while safeguarding the parapharyngeal-petrous-cavernous segments of the
[22]
internal carotid artery . These procedures can leave the exposed internal carotid artery in the neck
vulnerable, posing risks of severe complications such as rupture and bleeding. As a result, an intricate
mucosal repair of the nasopharynx is essential. Yet, for patients who have previously undergone radiation
therapy for recurrent NPC, effective repair can be challenging due to compromised mucosal regeneration
and heightened necrosis risk. In these cases, using a nasal septal mucosal flap, as highlighted by Chen et al.,