David H. Yeh

Transoral robotic surgery vs. radiotherapy for management of oropharyngeal squamous cell carcinoma – A systematic review of the literature

BACKGROUND Intensity-modulated radiation therapy (IMRT) with or without concurrent chemotherapy is widely utilized for the treatment of oropharyngeal squamous cell carcinoma (OPSCC). However, due to significant acute and late toxicities there has been increasing interest in minimally invasive surgical approaches, particularly transoral robotic surgery (TORS) in an attempt to preserve patient quality of life while maintaining oncologic outcomes. The aim of this study was to review the current literature in order to compare primary IMRT versus TORS in the management of OPSCC. METHODS A MEDLINE search was conducted to identify studies reporting on the outcomes of TORS or IMRT in the treatment of OPSCC. Reference lists were also reviewed for relevant articles. Oncologic, functional, and quality of life data is summarized and discussed. RESULTS One hundred-ninety papers were identified through the MEDLINE search. An additional 52 papers were retrieved by hand searching the reference lists. Ultimately, 44 papers were identified that discussed outcomes after IMRT or TORS for OPSCC. No outcomes from randomized trials were identified. CONCLUSION No randomized trials comparing TORS versus IMRT to each other were identified. Uncontrolled reports from the current literature suggest comparable oncologic outcomes with TORS compared to IMRT and functional outcomes may be superior. However, the median follow-up was relatively short and the TORS studies included patients with earlier stage OPSCC on average compared to IMRT studies. Prospective, randomized controlled trials and direct, well-matched comparisons are needed to further elucidate the role for TORS in the treatment of oropharyngeal squamous cell carcinoma.

The utility of routine polyp histopathology after endoscopic sinus surgery

Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner.

Evaluating organ preservation outcome as treatment endpoint for T1aN0 glottic cancer

Common endpoints in reporting the outcomes for early glottic cancer do not highlight the importance of organ preservation. We evaluated the treatment outcomes among patients with T1aN0 laryngeal cancer with laryngectomy‐free disease‐specific survival (LFS‐DSS), which is defined as time to total laryngectomy or time to death from cancer cause, against all other endpoints.

Surgeon‐estimated costs of common consumables in otolaryngology

The current fiscal climate demands increasing emphasis on curbing hospital expenses incurred from surgical procedures. Disposable instruments and consumables play a major role, but the end user (the surgeon) is often unaware of the cost of these materials. The objectives of our study were: 1) to assess knowledge of costs of disposable instruments and consumable products, and 2) to gauge interest in greater access to cost information and its potential to change practice.

Reconstruction after salvage laryngectomy

Both early and advanced stage laryngeal cancers are treated with organ-preserving strategies including radiation alone or concurrent chemoradiotherapy. While organ-preserving modalities have proven effective in eradicating cancer while also preserving laryngeal function, there remains a proportion of cases where residual or recurrent cancer prevails, or conversely, where radiotherapy renders a larynx dysfunctional. In these circumstances, salvage total laryngectomy is often the surgical treatment. The effects of radiotherapy to the neck, amplified by chemotherapy, can create an inhospitable surgical environment, making the salvage laryngectomy an operation fraught with the potential for major complications such as the dreaded pharyngocutaneous fistula. The introduction of vascularized tissue from outside the irradiated field decreases the risk of major wound complications. Free tissue transfer, with a variety of donor sites available, is commonly employed to reconstruct either a patch or a circumferential segment of the pharynx. When there is enough pharyngeal mucosa for primary closure, a vascularized onlay graft or a pharyngeal interposition graft can be used to reinforce the closure. This has been demonstrated to both reduce the severity of pharyngocutaneous fistula and decrease the risk of developing a pharyngocutaneous fistula compared to primary closure alone. Beyond mitigating the risk for perioperative complications, flap selection may have implications on the long-term outcomes after salvage total laryngectomy and these must be considered preoperatively. The purpose of this review is to examine the various options for reconstruction after salvage total laryngectomy and to examine some of their advantages and disadvantages in the short and long-term.

Boot Camps: Preparing for Residency

Simulation-based boot camps are growing in popularity and are effective in onboarding novice residents with new knowledge, skills, and behaviors. These intensive and immersive courses may be used to train residents and allied health professionals in specific procedures, teamwork, and management of rare clinical scenarios. A needs assessment of learners determines the course curriculum. Boot camps are designed to encourage active and hands-on participation with deliberate practice and immediate feedback. As surgical education shifts toward competency-based medical education, there may be an even greater role for simulation-based boot camps as a training and assessment tool.

Metastatic mammary carcinoma to the orbit masquerading as maxillary sinusitis.

Introduction We report on a case of isolated metastatic breast cancer to the medial rectus muscle. This entity is exceedingly rare. Case A 44-year-old female with a history of breast cancer presented with unilateral maxillary symptoms and was treated for sinusitis. Over time, she developed ocular pain, diplopia, blurred vision and eventually complete adduction deficit. Results T1-weighted magnetic resonance imaging revealed a medial rectus lesion. Biopsy via transnasal transorbital endoscopic approach revealed metastatic mammary carcinoma. Discussion Metastatic disease to the orbit should be considered in the differential diagnosis of refractory maxillary sinus pain in patients with a known underlying malignancy.

Predictors of plate extrusion in oromandibular free flap reconstruction

Plate extrusions after free tissue transfer for mandibular reconstruction can be problematic and generally require revision surgery. Our objective was to assess the predictors of plate extrusion and compare outcomes between fibular free flaps (FFF), lateral border scapular flaps (LBSF), and scapular tip free flaps (STFF).

Primary facial reanimation in head and neck cancer

Facial Paralysis (FP) profoundly impairs the life of individuals, both functionally and psychosocially. Surgical approaches to treat this condition are myriad, but the ultimate goal is to restore symmetry and movement. Ablative surgery for tumors of the head and neck region are amongst the most common etiologies causing FP and this group of patients represents unique challenges. Surgical defects may have multiple competing reconstructive requirements and addressing the FP must be considered in this context. Furthermore, extent of disease, patient age, duration of preceding paralysis, adjuvant treatment, as well as the various different type of facial nerve defects are factors that may influence the type of reconstructive technique selected to address the FP. The complexity of FP especially following head and neck ablation can lead to results that are inconsistent and humbling. FP defects can be broadly described as having the potential for facial muscle recovery versus irreversible paralysis. Literature that specifically focuses on primary facial reanimation procedures in the oncological setting is scarce. We present a comprehensive review of primary facial reanimation after ablative surgery including the descriptions of a wide array of surgical techniques such as reinnervation, dynamic muscle transposition, static suspension, and free tissue transfer. Understanding the advantages and limitations of the different options will enable the surgeon to offer treatment for the paralyzed face for most clinical scenarios.