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Table 1. Decision-making for selecting surgical approach based on tumor characteristics
Surgical technique Indication Advantages Limitations
Endoscopic Early-stage NPC (T1-T2), localized Minimally invasive, better visualization, Limited for tumors near the internal
nasopharyngectomy and resectable recurrence fewer cosmetic concerns carotid artery
Maxillary swing Larger tumors with parapharyngeal Provides extensive exposure to the More invasive, potential
approach involvement nasopharynx and parapharyngeal space complications such as facial
numbness
TORS Small, localized recurrent tumors High precision, minimal invasiveness, Lacks tactile feedback, limited to
(rT1-rT2) enhanced recovery smaller tumors
Hard palate approach Small nasopharyngeal tumors; Improved cosmetic outcome, reduced Risk of oronasal fistulas, not suitable
avoids external incisions postoperative discomfort for complex or large tumors
Pterygopalatine fossa Tumors located within the No external incisions, direct access to the Not suitable for tumors outside the
approach pterygopalatine fossa target area pterygopalatine fossa
Infratemporal fossa Tumors in the ipsilateral Access to complex anatomical areas Limited exposure for contralateral
approach nasopharynx such as the skull base tumors, potential nerve damage

NPC: Nasopharyngeal carcinoma; TORS: transoral robotic surgery.

[23]
has proven advantageous, significantly enhancing the post-operative flap survival rates .

Endoscopic nasopharyngectomy is particularly suitable for patients with early-stage recurrent NPC (rT1-
rT2) and primary NPC (T1-T2) that are confined to the nasopharynx or parapharyngeal space without
invasion of critical structures such as the skull base or internal carotid artery. It is also recommended for
patients with nasopharyngeal adenocarcinoma who are not ideal candidates for radiotherapy due to
contraindications or preference for a less invasive approach [16,23,24] . In cases where radiation therapy has
failed or is associated with severe side effects, endoscopic resection offers an alternative with reduced
[14]
surgical trauma and better preservation of adjacent tissues . Some experts suggest that surgical excision
may be considered for tumors with lateral extension that does not exceed the foramen ovale or with
localized involvement of the pterygomaxillary fissure, provided that the upper boundary does not extend
into the anterior cranial fossa [25-27] .

Compared to traditional open surgical techniques, endoscopic nasopharyngectomy proffers an array of
advantages, including reduced invasiveness, no facial cosmetic concerns, a lower risk of damage to critical
vascular and neural structures, improved accuracy in identifying tumor margins, and better patient survival
outcomes [28-31] . Research by Liu et al. underscores that, for cases of locally recurrent NPC suitable for
resection, endoscopic procedures manifest superior survival outcomes and fewer post-operative
complications compared to intensified radiotherapy regimens . Nonetheless, the method has its
[16]
limitations. It might not be ideal for tumors that are close to or involve the internal carotid artery due to the
risk of flap necrosis. Liu et al. suggest that significant skull base involvement or proximity (< 0.5 cm) to the
internal carotid artery of the neck, coupled with non-resectable neck lymph nodes, is a contraindication for
[16]
endoscopic resection . While consensus on these contraindications is still lacking, advancements in
surgical techniques and instrumentation may expand the applicability of endoscopic resections in the
future.

Open surgery
Open surgery is indicated for patients with locally advanced or recurrent NPC where endoscopic
approaches are not feasible, such as when the tumor involves the carotid artery, the cavernous sinus, or
extensive soft tissue structures. It is particularly recommended for patients with rT3-rT4 tumors or when
there is significant involvement of the skull base that requires more extensive resection. Open surgery is also
suitable for cases where a clear surgical margin cannot be achieved with minimally invasive techniques,