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Pang et al. Mini-invasive Surg 2024;8:27 https://dx.doi.org/10.20517/2574-1225.2023.124 Page 5 of 11

providing direct access to the tumor and allowing for thorough excision. Compared to endoscopic surgeries,
open surgery offers enhanced visualization of the operative site, facilitating meticulous tumor excision. It is
particularly efficacious for tumors located near the carotid artery or those that invade a section of the artery.
However, it is paramount to recognize potential complications associated with open surgery, including
cosmetic challenges, facial numbness, trismus, formation of palatal fistulas, nasal obstructions, and eyelid
ectropion.

Maxillary swing approach
The maxillary swing approach is a leading open surgical procedure for the resection of NPC. This procedure
involves making an incision and performing osteotomies on the ipsilateral maxilla, which is then delicately
swung outwards, providing access to the tumor. A nasopharyngectomy is then executed under direct view,
allowing for en bloc tumor removal. The resection typically encompasses the medial pterygoid muscles, the
posterior portion of the nasal septum, and the entire posterior wall of the nasopharynx up to the medial
edge of the contralateral fossa of Rosenmüller. The extent of the excision is directed by intraoperative frozen
section findings, proceeding until all margins are devoid of tumor or when no further resection is viable.
Finally, the maxillary osteocutaneous unit is realigned and affixed with titanium miniplates and screws [32,33] .

The maxillary swing approach is ideal for patients with recurrent NPC that extends to the parapharyngeal
or retropharyngeal space, especially when the tumor invades structures such as the medial pterygoid
muscles or the posterior wall of the nasopharynx. This approach is indicated for cases where precise control
over tumor margins is needed due to its ability to provide extensive exposure of the nasopharyngeal region
and internal carotid artery. It is best suited for patients with rT3 or select rT4 tumors where other less
invasive techniques are not adequate.

This approach provides direct access to the nasopharynx and unrivaled exposure of the internal carotid
artery in the neck, making it particularly advantageous for tumors localized in the parapharyngeal space.
Documented postoperative complications are facial numbness (7.4%), ectropion (1.8%), epiphora (6.5%),
trismus (9.2%), palatal fistula (4.3%), and middle ear effusion (37.8%) . A study by Chan et al. involving
[32]
[34]
312 patients subjected to this procedure reported full macroscopic tumor resections in all instances . The
average postoperative hospital stay was 12 days, with a 74% five-year local tumor control rate. Notably,
tumor size and margin status emerged as pivotal influencers of postoperative survival rates.

Despite its invasive nature, this method is characterized by a minimal incision, reduced tissue trauma, lesser
postoperative pain, and shorter recovery times [35,36] . It is an excellent choice for complex NPC cases,
especially those with associated parapharyngeal and retropharyngeal lymph node metastases. The main
contraindications for this approach are tumor encroachments into the sphenoid sinus and comprehensive
encirclement of the internal carotid artery in the neck. Further findings by Chan et al. intimate that patients
undergoing maxillary swing nasopharyngeal cancer resection maintain a laudable postoperative quality of
[35]
life, with negligible alterations in the average Global Health System score . However, factors such as palatal
fistula and skull base osteonecrosis can notably impact the postoperative quality of life.

Hard palate approach
The hard palate approach is an operative technique used for resecting nasopharyngeal tumors. This
procedure provides access to the nasopharynx through an incision in the hard palate of the oral cavity,
[37]
facilitating excision of tumors localized in this area . Generally, this approach is designated for smaller
nasopharyngeal neoplasms and is less suitable for those involving complex anatomical areas, such as the
skull base. A salient advantage of the hard palate approach is its favorable cosmetic outcome; as it avoids
external incisions, offering improved aesthetic results for patients. Additionally, the technique minimizes