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wilson's transpalatal approach

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Wilson's transpalatal approach surgical technique nasopharynx skull base

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I now have comprehensive information from the major ENT textbooks. Here is a detailed synthesis:

Wilson's Transpalatal Approach

Overview

The transpalatal approach (also called Wilson's transpalatal approach after the surgeon who popularized it) is an inferior approach to the nasopharynx and central skull base accessed via the oral cavity. It is most commonly used for salvage nasopharyngectomy in recurrent nasopharyngeal carcinoma (NPC) after radiotherapy failure. The nasopharynx sits at the center of the head, making access inherently difficult; the transpalatal route is one of the more direct inferior pathways.
Historical note: Auguste Nelaton (1807-73) of Paris first promoted a transpalatal approach to the nasopharynx in 1859, and the technique has been refined significantly since.

Indications

  • Primary use: Salvage nasopharyngectomy for local recurrence of NPC after radiotherapy (rT1/rT2 disease benefits most - rT3/rT4 show no survival advantage)
  • Access to retropharyngeal and central skull base lesions
  • Midline extradural lesions of the lower to middle clivus and upper cervical spine (C1-C3), sometimes in combination with endoscopic endonasal approach
  • Part of combined transpalatal/transmaxillary/transcervical approaches for select NPC lesions

Surgical Technique (Step-by-Step)

  1. Patient positioning: General anaesthesia with oral intubation using a reinforced endotracheal tube. The patient should be fit for a 5-hour operation.
  2. Mucoperiosteal flap elevation: A mucoperiosteal flap of the hard palate is raised from the bony hard palate, proceeding from anterior to posterior, exposing the attachment of the soft palate.
  3. Soft palate detachment: The soft palate is detached from the bony hard palate and retracted inferiorly to expose the nasopharynx.
  4. Bone removal (if needed): The posterior edge of the hard palate can be removed to increase the surgical exposure and allow direct visualization of the recurrent tumour.
  5. Tumour excision: The recurrent tumour is excised under direct vision.
  6. Closure: The palatal flap is re-sutured back to the anterior hard palate mucosa at the conclusion.
In robotic skull base surgery (TORS), the transpalatal approach requires elevation of a mucoperiosteal flap posterior to the molar teeth plus resection of a portion of the hard palate and vomer.

Advantages

  • Minimal bone removal required
  • No facial incision (no external scar)
  • Direct midline access to the nasopharynx
  • Best compromise of visualization and instrumentation for the nasopharynx, clivus, and anterior skull base (as demonstrated in TORS cadaveric studies by Ozer et al.)

Disadvantages / Limitations

  • Limited lateral access to the parapharyngeal space
  • Risk of palatal fistula (velopalatal insufficiency, speech, swallowing problems)
  • Cannot address tumours with internal carotid artery encasement, extensive skull base infiltration, or intracranial extension

Oncological Outcomes

Fee et al. reported a series of 37 NPC patients treated with this approach:
  • 5-year overall survival: 52%
  • 5-year local control: 67%
These results are comparable to a second course of radiotherapy but with lower morbidity.

Comparison with Other Nasopharyngectomy Approaches

ApproachClassificationAccessKey Feature
Transpalatal (Wilson's)InferiorCentral NPNo facial scar; limited lateral access
Transcervico-mandibulo-palatal (Morton)InferolateralNP + ipsilateral parapharyngeal spaceAdds lip-splitting mandibulotomy; more morbidity
Midfacial deglovingAnteriorNP (limited laterally)No scar; poor lateral exposure; worse oncological outcome
Maxillary swing (Wei)AnterolateralNP + bilateral parapharyngeal spaceWide exposure; facial scar; 5-yr local control 74%
Endoscopic endonasalAnteriorClivus/NPMinimal access; growing use for rT1
The transcervico-mandibulo-palatal approach (Morton, 1996) improves transpalatal access by adding a lip-splitting mandibulotomy and extending floor-of-mouth incision along the anterior pillar - but comes with higher morbidity (palatal defect, trismus, dysphagia, malunion in 6-8 of 11 patients in King's series).

Contraindications to Salvage Nasopharyngectomy (any approach)

  • Internal carotid artery encasement
  • Extensive skull base infiltration
  • Intracranial extension
  • Poor general condition / unfit for prolonged general anaesthesia
Sources: Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Ch. 8; Cummings Otolaryngology Head and Neck Surgery, Ch. 177 (Approach to the Clivus and Cavernous Sinus)
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