Daniel Brickman

Robotic Approaches to the Pharynx. Tonsil Cancer

Treatment of squamous cell carcinoma of the oropharynx is challenging because of its effects on speech and swallowing, which may affect quality of life. Transoral robotic surgery may be an effective alternative to open surgery. Robotic lateral oropharyngectomy is best suited for early stage oropharyngeal squamous cell carcinoma, with the goal of avoiding or reducing the use or dose of adjuvant therapies. Successful robotic lateral oropharyngectomy requires appropriate training, detailed preoperative planning, organized operating room setup to obtain exposure, an understanding of the pertinent surgical anatomy, and knowledge of the postoperative care of the oncologic patient.

Airway management after maxillectomy with free flap reconstruction.

Maxillectomy defects require complex 3‐dimensional reconstructions often best suited to microvascular free tissue transfer. Postoperative airway management during this procedure has little discussion in the literature and is often dictated by surgical dogma. The purpose of this article was to review our experience in order to evaluate the effect of airway management on perioperative outcomes in patients undergoing maxillectomy with free flap reconstruction.

The impact of prophylactic external carotid artery ligation on postoperative bleeding after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma

BACKGROUND Transoral robotic-assisted surgery (TORS) is increasingly utilized in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). Postoperative bleeding is a significant and potentially fatal complication of TORS. Prophylactic ligation of ipsilateral external carotid artery (ECA) branches is a recognized strategy to reduce postoperative bleeding risk. We examined the incidence and sequelae of postoperative oropharyngeal bleeding with and without routine ECA ligation. METHODS OPSCC patients treated with TORS between 2010 and 2015 with minimum 30days follow up were included. Clinicopathological data, operative details, and postoperative course were abstracted for analysis. Cases of postoperative bleeding were classified as Minor, Intermediate, Major, and Severe. The incidence and severity of bleeding was compared between patients treated with and without prophylactic ECA ligation. RESULTS Bleeding after TORS was documented in 13/201 (6.5%) patients. The majority of bleeding episodes were observed among anticoagulated or previously radiated patients. By surgeon preference, 52 patients had prophylactic ECA ligation during neck dissection while the remaining 149 patients did not. There was no significant difference in overall incidence of postoperative bleeding between patients with prophylactic ECA ligation (3/52, 5.8%) and patients without (10/149, 6.7%) [p=0.53]. However, severe bleeding complications (4, 2.0%) were only observed in patients without prophylactic ligation. CONCLUSION A small but meaningful risk of bleeding after TORS for OPSCC exists, particularly among anticoagulated or previously radiated patients. Prophylactic ECA ligation did not significantly impact the overall incidence of postoperative bleeding but may reduce the risk of severe (life-threatening) bleeding.

Predictors of extracapsular extension in HPV-associated oropharyngeal cancer treated surgically

OBJECTIVES Extracapsular extension (ECE) in cervical metastatic lymph nodes remains an indication for adding chemotherapy for patients with oropharyngeal squamous cell carcinoma (OPSCC). The aim of this study is to identify specific imaging characteristics on computed tomography (CT) scan that are predictive of ECE in order to better risk stratify patients preoperatively. MATERIALS AND METHODS A single cohort study was performed using a prospectively collected database of patients with HPV-related OPSCC who underwent transoral robotic surgery with cervical lymphadenectomy. CT scans were assessed for the presence of multiple imaging characteristics, including lymph node size, number of nodes positive, cystic appearance, and border irregularity. Univariable and multivariable analyses were performed to analyze each variables predictability of pathologic ECE. RESULTS 100 patients underwent TORS with cervical lymphadenectomy for OPSCC from 2010 to 2015. Ninety-one percent (21/23) of patients with 3 or more radiologically suspicious nodes were found to have pathologic ECE, which was a significantly greater proportion than patients with fewer suspicious nodes (p<0.001). CT scans with 3 or more radiologically suspicious nodes displayed a sensitivity and specificity of 55% and 94%, respectively with a positive predictive value (PPV) of 91% for ECE. Irregular borders and age were also correlated with ECE on multivariable analysis. CONCLUSION AND RELEVANCE The presence of 3 or more radiologically suspicious lymph nodes on CT scan has a 91% PPV for any histologic evidence of ECE. The absolute number of radiographically suspicious lymph node metastases may be a useful method for risk-stratifying patients for the presence of ECE.

A randomized controlled trial of corticosteroids for pain after transoral robotic surgery

To determine if an extended perioperative course of corticosteroids will improve pain control following transoral robotic surgery (TORS).

Is esophagoscopy necessary during panendoscopy

BACKGROUND Panendoscopy, or the evaluation of the upper aerodigestive tract with oral inspection, direct laryngoscopy, esophagoscopy, bronchoscopy, or some combination of these procedures, is a valuable tool in the evaluation of patients with head and neck squamous cell carcinoma (HNSCC). Despite the many advances made in imaging technology in recent years, these modalities cannot replace the surgeon’s ability to carefully inspect the mucosa of the upper aerodigestive tract to determine the true extent of a lesion and plan for possible surgical resection. Second primary malignancies are also a concern in HNSCC patients; historically, esophagoscopy during panendoscopy has been recommended to rule out esophageal carcinomas. However, this procedure can at times be difficult and also carries the potential for serious complications such as esophageal perforation. Thus, this article reviews the evidence for the utility of esophagoscopy in the diagnostic evaluation of the head and neck cancer patient.

Triological Society Best Practice: Is esophagoscopy necessary during panendoscopy?

BACKGROUND Panendoscopy, or the evaluation of the upper aerodigestive tract with oral inspection, direct laryngoscopy, esophagoscopy, bronchoscopy, or some combination of these procedures, is a valuable tool in the evaluation of patients with head and neck squamous cell carcinoma (HNSCC). Despite the many advances made in imaging technology in recent years, these modalities cannot replace the surgeon’s ability to carefully inspect the mucosa of the upper aerodigestive tract to determine the true extent of a lesion and plan for possible surgical resection. Second primary malignancies are also a concern in HNSCC patients; historically, esophagoscopy during panendoscopy has been recommended to rule out esophageal carcinomas. However, this procedure can at times be difficult and also carries the potential for serious complications such as esophageal perforation. Thus, this article reviews the evidence for the utility of esophagoscopy in the diagnostic evaluation of the head and neck cancer patient.

In response to “in reference to is esophagoscopy necessary during panendoscopy?”

We would like to thank Dr. Postma for his interest in our Triological Society Best Practice article, “Is Esophagoscopy Necessary During Panendoscopy,” and we also thank him for drawing attention to the important role that transnasal esophagoscopy (TNE) may play in the evaluation of patients with head and neck cancer. We absolutely agree with Dr. Postma that TNE is a safe, accurate, and costeffective procedure with great utility in a variety of otolaryngology patients, including head and neck cancer patients. In fact, at the corresponding author’s institution (Oregon Health and Science University, Portland, OR), in a recent review of all esophagoscopy procedures performed in the otolaryngology department over a 6-year period, nearly 250 out of 1,900 esophagoscopies were TNE procedures (unpublished data). We certainly support this procedure and its use. The primary rationale for not including TNE in this review was that the article focused on the narrow clinical question of performing esophagoscopy during a panendoscopy procedure. Panendoscopy, which typically is performed in an operating room on a patient under general anesthesia, is not a typical setting for TNE, which is primarily an office-based procedure. In an operative setting, either standard flexible esophagoscopy or rigid esophagoscopy typically is employed, due the somewhat easier visualization and ability to perform interventions, such as biopsies, with this larger instrumentation compared to a TNE. Due to length constraints with this type of article, we chose to focus exclusively on the role of inspection of the esophagus during the panendoscopy procedure. Dr. Postma’s excellent points on TNE would be best addressed in a review of an equally interesting question: Is panendoscopy necessary in the modern era? In some patients, the answer undoubtedly is yes; however, with the widespread use of TNE, high-definition distal chip laryngoscopes, and the ability to perform biopsies with a flexible scope, an office panendoscopy can be performed in selected patients. This would allow the head and neck surgeon to perform most of the critical tasks associated with panendoscopy in the clinic, avoiding a general anesthetic, operating room (OR) costs, and some potential complications. Furthermore, such an approach likely would decrease the time from initial consultation to the initiation of treatment. This approach recently has been described with good results and safety in nearly 250 patients with hypopharyngeal carcinoma; in this study, only 14% of patients had to go on to direct laryngoscopy in the OR due to inadequate biopsies during the office procedure. A review of such techniques, incorporating Dr. Postma’s excellent points on TNE, would make an excellent Triological Society Best Practice article on the utility of office-based procedures in the evaluation of head and neck cancer patients.

Median nerve injury associated with radial forearm free flap harvest

The radial forearm fasciocutaneous free flap has become a mainstay for head and neck reconstruction due to its versatility, soft tissue pliability, long vascular pedicle, low donor site morbidity, and potential for sensory reinnervation. Reported donor site morbidities include paresthesias, seromas, exposed tendon, and partial loss of skin graft coverage. Differences in wrist flexion, pinch strength, and sharp sensation in the anatomical snuffbox have been documented but are unrelated to subjective patient complaints. Major neural praxias of the median or ulnar nerve have not been reported. This report was approved by the institutional review board of our center.

Inner Ear Anomalies and Risk for Stapedectomy

Objective: 1) Quantify the anatomic relationships within the vestibule of temporal bones with known inner ear malformations that are relevant to stapes surgery complication rates. 2) Evaluate for pathologic evidence of stapes complications in temporal bones with structural inner ear malformations that have undergone stapes surgery. Method: Sensorineural hearing loss after primary stapes surgery is rare. Histologic examinations in these cases have identified hydrops formation, scala media atrophy, adhesion formation, and perilymph fistula. The study is a pathologic review of the National Temporal Bone Database for cases of inner ear malformations with and without otosclerosis. Results: The database contains 7,490 subjects with greater than 12,000 temporal bone specimens from 16 institutions. Database queries yielded 122 examples of structural inner ear malformations not related to chronic ear disease or malignancy. Of these, 10 had pathologic evidence of otosclerosis, and 6 of these had stapes surgery performed. Though retrospective and with malformations diagnosed postmortem, the clinical record of this group noted no operative complications. Only 1 of these 6 patients had documented worsening of hearing from the first to last clinical visit. Four of 6 patients had documented hearing improvement. Conclusion: The decision to perform stapes surgery in patients with known inner ear malformations has been dictated by surgical dogma in the past. This review may lend histopathological evidence to loosen those criteria, though more rigorous clinical testing is needed.