Introduction
Transoral robotic surgery has demonstrated favourable oncological and functional outcomes in selected base-of-tongue cancers.Reference Azalmad, Lambercy, Berezowska, Thierauf, Woodruff and Vander Poorten1–Reference Guarino, Chiari, Cordeschi, D’Alessio, Ingelido and Motta3 However, a substantial proportion of patients in the Indian subcontinent present with submucous fibrosis and associated trismus, rendering transoral access non-feasible. In addition, the high cost and limited availability of robotic platforms further restrict the widespread application of transoral robotic surgery in low- and middle-income settings.Reference Garg, Dwivedi, Sayed, Katna, Chauhan and Kazi4
As a result, chemoradiotherapy has become the standard treatment modality for many base-of-tongue tumours, largely because of the significant morbidity associated with traditional open surgical approaches involving mandibulotomy or segmental mandibulectomy.Reference Lee, Park, Byeon, Choi and Kim5 While effective, chemoradiotherapy carries its own acute and long-term toxicities, and may further exacerbate trismus and swallowing dysfunction in patients with submucous fibrosis.Reference Shiley, Hargunani, Skoner, Holland and Wax6, Reference Nguyen, Frank, Moltz, Vos, Smith and Nguyen7
In this article, we describe our transpharyngeal technique for resection of base-of-tongue cancer, incorporating flap reconstruction with hyoid suspension. This approach aims to provide adequate margin clearance while preserving function in patients for whom transoral techniques are not feasible.
Surgical technique
The surgical technique is described in a stepwise manner and is supported by intra-operative photographs. This approach is offered to patients with lateralised base-of-tongue tumours (T1–T3), with or without lateral pharyngeal wall involvement, particularly in the presence of severe trismus or submucous fibrosis precluding transoral access. Patients with carotid artery encasement, extensive prevertebral fascia involvement or radiological evidence of unresectability are excluded. Ethical approval for this study was obtained from the institutional ethics committee. The requirement for informed consent was waived because this was a retrospective technical study and no patient-identifiable information was included.
Step 1: Neck dissection
Bilateral selective neck dissection of levels I to IV is performed, with preservation of the internal jugular vein, spinal accessory nerve and sternocleidomastoid muscle (Figure 1). Neck dissection is undertaken as the initial step to allow early vascular control, facilitate exposure of the parapharyngeal space and enable en bloc planning of the transpharyngeal resection.
Selective neck dissection (levels I–IV).
Figure 1 Long description
A surgical view shows a neck dissection with tissue and muscle exposed.
Step 2: Parapharyngeal space exposure
This step serves as an intra-operative assessment of resectability without the need for mandibulotomy. The presence of a clear plane between the medial pterygoid muscle and the lateral pharyngeal wall confirms the feasibility of a mandibular-sparing approach. The mandible is elevated to release the stylomandibular ligament (Figure 2a), exposing the fibres of the medial pterygoid muscle. Dissection proceeds along this muscle to the mylohyoid ridge anteriorly and the posterior border of the medial pterygoid. This manoeuvre separates the pharyngeal wall from the pterygoid musculature, allowing access to the parapharyngeal space above the level of the styloid process.
Parapharyngeal space exposure and vascular control. (a) Separation of the lateral pharyngeal wall from the medial pterygoid muscle. (b) Identification of the posterior belly of digastric. (c) Ligating the lingual artery. (d) Lateralising the external carotid with its branches.
Figure 2 Long description
The image A shows a surgical field with instruments and sutures. The image B shows a surgical field with instruments and sutures. The image C shows a surgical field with instruments and sutures. The image D shows a surgical field with instruments and sutures.
Initial exposure of the parapharyngeal space involves division of the posterior belly of the digastric muscle and the stylohyoid muscle. Care is required during this step to avoid injury to the hypoglossal nerve, which lies immediately deep to these structures and is accompanied by parapharyngeal veins (Figure 2b).
The parapharyngeal space lies lateral to the pharyngeal wall and contains branches of the external carotid artery, the hypoglossal nerve and a plexus of parapharyngeal veins. All vessels traversing this space are ligated to permit complete mobilisation of the lateral pharyngeal wall. Dissection is continued until the lingual artery is identified at its origin from the external carotid artery inferior to the hypoglossal nerve (Figure 2c). The lingual artery along with the facial artery is ligated, and along with the trunk of the external carotid artery is lateralised to create a parapharyngeal plane separating the lateral pharyngeal wall from the carotid sheath contents (Figure 2d).
This plane is crossed by the styloglossus and stylopharyngeus muscles, which are divided only when there is superior involvement of the lateral pharyngeal wall. Preservation of the hypoglossal nerve is feasible in cases of limited base of tongue disease; however, for extensive or infiltrative tumours, sacrifice of the nerve may be required to achieve oncological clearance.
Step 3: Transpharyngeal exposure of the tumour
To expose the vallecular region, the hyoid bone is detached from the hyoglossus muscle and an inferior lateral pharyngotomy is performed. This provides direct access to the oropharyngeal cavity from the neck, allowing direct palpation of the tumour to guide resection planning. The pharyngotomy is extended laterally along the pharyngeal wall and inferiorly through the vallecula, providing adequate exposure of the base of the tongue tumour (Figure 3).
Trans-pharynx tumour assessment. (a) Lateral pharyngotomy. (b) Assessment of base-of-tongue tumour.
Figure 3 Long description
The image A shows a surgical procedure with instruments and tissue. The image is labeled (a). The image B shows a surgical procedure with instruments and tissue. The image is labeled (b).
Step 4: Excision of the tumour
A wide pharyngotomy provides sufficient exposure to allow careful palpation and excision of the tumour with clear margins under direct vision. This represents a key advantage over transoral robotic surgery. Continuous palpation of areas of induration during dissection facilitates accurate margin placement as the resection proceeds from superficial to deep musculature, ensuring adequate clearance throughout (Figure 4). The resection follows the principles of transoral partial glossectomy but is performed in a reverse orientation through the trans-pharynx opening. Care is taken to preserve the contralateral lingual artery in moderate to advanced cases to maintain vascular supply to the remaining tongue.
Trans-pharynx base-of-tongue resection. (a) Incision marking. (b) Tumour mobilisation in depth. (c) Tumour delivery. (d) Specimen with adequate margins.
Figure 4 Long description
The image A showing an incision marking. The image B showing a tumor mobilization in depth. The image C showing a tumor delivery. The image D showing a specimen with adequate margins.
Step 5: Defect and reconstruction
Post-operative images demonstrate preservation of the contralateral base of tongue and anterior tongue, as well as the extent of the surgical defect (Figure 5a,b). Extensive infiltrative tumours of the base of tongue may require resection of a substantial portion of the tongue, necessitating flap reconstruction. In such cases, a pectoralis major myocutaneous flap is our preferred reconstructive option. The skin paddle is sutured to the lateral pharyngeal wall, tongue and vallecular mucosa, while the muscle layer is secured to the surrounding external musculature as a second layer.
Defect and reconstruction. (a) Preservation of the anterior tongue. (b) Extent of the defect at the base of the tongue. (c) Reconstruction with pectoralis major myocutaneous flap and hyoid suspension, anterior view. (d) Reconstruction with pectoralis major myocutaneous flap and hyoid suspension, lateral view.
Figure 5 Long description
The image A showing a surgical procedure with a retractor and forceps. The image B showing a surgical procedure with a retractor. The image C showing a surgical procedure with a retractor. The image D showing a surgical procedure with forceps and a tube.
Hyoid suspension represents the critical modification in our technique. This manoeuvre elevates the laryngeal inlet in an anterosuperior direction, reducing laryngeal ptosis and minimising the risk of aspiration. Two drill holes are created in the mandibular symphysis to anchor the suspension sutures, providing stable osseous fixation and counteracting the downward traction exerted by the reconstructive flap. A thick nylon suture is passed around the body of the hyoid bone and through the mandibular drill holes (Figure 5c,d).
Smaller defects may be closed primarily by suturing the pharyngotomy in two layers. Additional reinforcement can be achieved by rotation of the sternocleidomastoid muscle, combined with hyoid suspension as described.
Results
This paper seeks to delineate the surgical procedure and provide preliminary data regarding its practicality and safety profile. A total of 15 previously untreated patients underwent transpharyngeal resection using this approach between 1 October 2024 and 15 August 2025. Twelve of the 15 patients presented with significant trismus.
Six patients had early-stage, lateralised base of tongue and lateral pharyngeal wall tumours, while nine patients had moderately advanced disease requiring more extensive resection. In all cases, preservation of the contralateral base of tongue and the majority of the anterior tongue was achieved.
Reconstruction was performed using a pectoralis major myocutaneous flap in 13 patients. In the remaining two cases, primary closure was reinforced with rotation of the sternocleidomastoid muscle. Hyoid suspension was performed routinely in all patients. Temporary tracheostomy and nasogastric feeding were employed in every case.
Adjuvant radiotherapy was administered to nine patients, with two of these receiving concurrent chemoradiotherapy based on adverse pathological features. Lymph node metastases were identified in 11 patients, with extracapsular spread present in one case with close resection margins.
No major peri-operative complications or salivary fistulae were encountered. Surgical margins were clear in 13 patients and close at the vallecula (4 and 3 mm) in 2 cases; both patients received adjuvant chemoradiotherapy.
Swallowing rehabilitation was initiated after seven days. Tracheostomy and feeding tubes were maintained for a minimum of 15 days in accordance with institutional protocol. The nasogastric tube was removed first, followed by decannulation after one week of successful oral intake without aspiration. In 10 patients, both tubes were removed within 30 days. In four patients, decannulation and tube removal occurred within two months following completion of adjuvant radiotherapy. One patient required long-term enteral feeding via jejunostomy.
These findings show initial feasibility and safety but do not demonstrate oncological superiority over non-surgical treatments. Swallowing outcomes were described without validated assessment tools, which limits this study.
Discussion
Chemoradiotherapy continues to be the standard treatment for most base-of-tongue tumours, despite its limitations.Reference Shiley, Hargunani, Skoner, Holland and Wax6–Reference Tseng, Chang, Chu, Tai, Wang and Shiao9 Swallowing difficulties are common in these patients, and the response rates for larger or more invasive lesions are often suboptimal. Complications from chemoradiotherapy increase significantly in patients with submucous fibrosis and trismus. Radiation can further restrict mouth opening, adding to patient discomfort and making follow-up examinations more challenging. In resource-limited settings, limited access to and affordability of scans make post-treatment surveillance even more difficult.Reference Watters, Cope, Keller, Padilla and Enciso8,10
Conventional open surgery is often avoided because of the morbidity of procedures like mandibulotomy or mandibulectomy.Reference Lee, Park, Byeon, Choi and Kim5 Transoral robotic surgery (transoral robotic surgery) offers a minimally invasive option with promising outcomes, but requires careful patient selection.Reference Azalmad, Lambercy, Berezowska, Thierauf, Woodruff and Vander Poorten1–Reference Guarino, Chiari, Cordeschi, D’Alessio, Ingelido and Motta3 Transoral robotic surgery is limited by cost, availability and restricted mouth opening in regions such as the Indian subcontinent, especially for patients with submucous fibrosis and trismus.Reference Garg, Dwivedi, Sayed, Katna, Chauhan and Kazi4 The transpharyngeal method for removing base-of-tongue tumours, once common, declined in use as a result of concerns about post-operative aspiration and the rise of chemoradiotherapy and transoral robotic surgery.Reference Cunningham, Myers and Johnson11 This feasibility study introduces a modified transpharyngeal approach with hyoid suspension to improve functional outcomes.
This approach offers several potential advantages. The generous pharyngotomy provides wide exposure, comparable to that achieved during transoral tongue resection, and facilitates accurate margin control through direct visualisation and bimanual palpation, as evident from results in this study. Ligation of the lingual artery and associated feeding vessels prior to tumour excision contributes to minimal intra-operative blood loss, as reflected by the absence of major peri-operative morbidity in this limited series. Use of the neck dissection incision avoids additional cosmetic morbidity.
The study demonstrates that this technique facilitates the treatment of early and moderate tumours while preserving function. Preservation of the hypoglossal nerve in patients with early-stage tumours notably contributes to improved swallowing function, as evidenced by the satisfactory recovery observed in all such patients within a few weeks. Moderately advanced tumours were judiciously selected in cases where preservation of the contralateral base of the tongue and anterior tongue was achievable. Existing literature supports the viability of surgical resection for these tumours.Reference Tseng, Chang, Chu, Tai, Wang and Shiao9, Reference Sinha, Pipkorn, Zenga and Haughey12, Reference Thurnheer, Buhl, Rajan and Morand13 Some authors have also illustrated that combining transoral robotic surgery with a trans-pharyngeal approach can be effective for the resection of moderately advanced or recurrent and/or residual tumours when transoral robotic surgery alone is insufficient.
Research has consistently found that removing part of the base of the tongue negatively affects swallowing, regardless of the reconstruction method used. Studies indicate that hyoid suspension to the mandible for reconstructing major glossectomy defects significantly improves function by moving the laryngeal inlet forward and upward.Reference Cristalli, Di Maio, Vallati, D’Amico, Vidiri and Mercante14 This adjustment creates a pronounced hump in the reconstructed flap at the base of the tongue, while pulling the inlet away from the food path helps lower aspiration risk. Additionally, evidence suggests that transpharyngeal resections without hyoid suspension result in poorer outcomes, with 8 out of 20 patients needing ongoing tube feeding because of various complications.Reference Sinha, Pipkorn, Zenga and Haughey12 Early results from this study show promising outcomes in terms of de-cannulation and discontinuation of feeding tubes.
Importantly, this technique provides a viable surgical option for patients with severe trismus in whom transoral approaches, including transoral robotic surgery, are not feasible. In addition, the procedure does not require specialised equipment or robotic infrastructure, making it cost-effective and reproducible in resource-constrained settings. Early functional outcomes suggest acceptable swallowing rehabilitation, although comprehensive long-term functional and oncological outcomes were not assessed.
This study has several limitations, such as a small sample size, being conducted at a single institution and lacking formal analysis of functional and oncological outcomes. To confirm this approach’s safety and potential benefits, larger studies using proper assessment tools and longer follow-up periods are necessary. Therefore, these findings should be viewed as preliminary, highlighting early safety and feasibility, and indicating the need for further validation.
• Trismus and cost availability are a hindrance for transoral robotic surgery for base-of-tongue tumours
• Concurrent chemoradiation has its own limitations
• The conventional trans-mandibular approach is too morbid
• Hyoid suspension elevates the laryngeal inlet and helps reduce aspiration
• Trans-pharynx resection combined with hyoid suspension enables oncological control with improved function and is a viable alternative to transoral robotic surgery in select patients
• The current study indicates feasibility and safety, but further evidence is needed
Conclusion
Transpharyngeal resection of base-of-tongue tumours combined with hyoid suspension represents a feasible and safe technique, offering an effective alternative for patients experiencing severe trismus as a result of submucous fibrosis.
Acknowledgements
We have used help of Chat GPT 5.1 and Microsoft Copilot for editing of the language. The authors take full responsibility for entire content of the article and final manuscript.
Competing interests
None declared
