PEDIATRIC TRANSORAL SURGERY - INDICATIONS, COMPLICATIONS, AND LONG-TERM OUTCOME

Knowledge of the role and hazards of transoral surgery has expanded ra pidly, but the application of this technique in children has been limi ted. To assess its usefulness, 27 pediatric patients who underwent tra nsoral surgery between 1985 and 1994 were studied. Transoral surgery w as performed for irreducible anterior neuraxial compression at the cra niovertebral junction caused by basilar impression, atlantoaxial sublu xation with pseudotumor, or chordoma. The patients ranged in age from 3 to 17 years. Symptomatic presentation varied widely, but 89% had sig nificant neurological deficits before surgery. No patient with normal strength deteriorated after surgery. Of the 16 patients with a preoper ative motor deficit, nine improved rapidly, three were unchanged, and four significantly worsened in the perioperative period. Those with mo bile atlantoaxial subluxation were most vulnerable to surgically relat ed neurological morbidity. Twenty-four patients were alive for long-te rm follow-up study (average 5.7 years, range 1-9.2 years). Of those wi th preoperative weakness, nine improved one Frankel grade, four remain ed the same, and one deteriorated from Frankel Grade D to C. Swallowin g and speech worsened in five patients; this occurred only after resec tion of lesions above the foramen magnum (p < 0.05) when rostral phary ngeal disruption resulted in velopharyngeal dysfunction. This study, u nlike previous reviews of pediatric transoral operations, leads the au thors to suggest that although transoral surgery can be effective, it also carries a significant risk of neurological injury in patients wit h symptomatic spinal cord compression and it is also associated with l ong-term swallowing and speech difficulties.