Other Current and Future Otolaryngology Uses
To date, TORS is most widely used in otolaryngology for select oropharyngeal cancers—largely management of throat and oropharynx cancers. But it’s also used for benign lesions, such as excising parapharyngeal space tumors to avoid neck incision, as well as in sleep surgery for base and tongue reduction for patients with sleep apnea.
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September 2021Dr. Weinstein also said that TORS has become a standard of care option for the management of patients in whom a squamous carcinoma is found in a head and neck node without an obvious primary noted on clinical or radiologic exam. For these patients, including robotics in the workup of the palatine and tongue base tonsillectomy has allowed for identification of the primary in about 90% of patients, compared to 50% when robotics is not included. “This has resulted in a marked reduction of the use of radiation with or without chemotherapy to the primary site and or neck,” he said.
Where TORS doesn’t offer significant improvement, Dr. Weinstein said, is for the management of laryngeal cancer. “In my opinion, TORS does not offer significant improvement over either surgical or nonsurgical treatment modalities, and so, at least for the technology in its present form, does not offer significant benefit,” he said.
Dr. Weinstein emphasized that, to date and for the foreseeable future, the main role of TORS is in the treatment of HPV-related oropharyngeal cancer, parapharyngeal space tumors, and sleep apnea. For him, a drawback of robotic surgery in its present technology is the paucity of indications for general otolaryngology as well as other otolaryngologic subspecialties outside head and neck cancer.
When looking further down the road, advancements in technology may offer even greater tools to surgeons working in difficult-to-reach areas of the head and neck. Dr. Holsinger is excited by the possibilities of expanding the current technologies in robotics: the single-port (SP) system with 6-mm instruments on double-wristed joints that allows for greater flexibility of movement, and high-definition vision that allows the surgeon to view the inside of the mouth unlike anything in the past. “Beyond the single-port and its mechanical advantages, I’m excited about how advances in computer vision and artificial intelligence can transform and augment the surgeon’s judgement in real time,” he said.
Also highlighting the benefits of the SP system now available, Andrés Bur, MD, director of robotics and minimally invasive head and neck surgery and an associate professor in the division of head and neck surgery within the department of otolaryngology–head and neck surgery at the University of Kansas Medical Center in Kansas City, noted that the instruments used to operate within the oropharynx are still fairly large, making it challenging to get all the instruments into the mouth despite the benefits of the single-port system. “Our hope is that as the technology improves, it will expand our ability to use the robot in different areas,” he said.
One area of expansion would be endoscopic skull base surgeries. “A robot with flexible arms like our current robot could potentially improve surgeries of the skull base by allowing surgeons to go through the nose to operate on tumors in the skull base,” he said.