Jason H. Kim

Transoral Excision of the Submandibular Gland

Submandibular gland excision is commonly performed for indications including neoplasm, chronic sialoadenitis, and sialolithiasis. Submandibular gland anatomy is complicated by the intimate association between its duct and the lingual nerve as well as the hypoglossal nerve that lies deep to the gland. Owing to this anatomic complexity, a wide cervical exposure has been advocated. However, this approach puts at risk the marginal mandibular nerve, which typically lies within the fascia of the submandibular gland. Further, the transcervical incision leaves the patient with an obvious cutaneous scar. We have successfully utilized transoral excision of the submandibular gland to manage chronic sialoadenitis, sialolithiasis, and benign salivary gland tumors.

Intraoperative Use of OCT in Endocrine Surgery

OBJECTIVE: Clinical trials have suggested suppression of EGFR pathway results in improved response to radiotherapy. AKT is a component of the phosphatidylinositol-3 kinase pathway that is downstream of the EGF receptor. Here we perform a preclinical assessment of the augmentation effect of AKT inhibitor on radiotherapy for head and neck squamous cell carcinoma. METHOD: Ex vivo ATP analysis on human tissue samples was performed to measure metabolic activity. Treatment groups were classified as control, AKT inhibitor, cetuximab and AKT i cetuximab. Nude mice with human SCC1-flank tumor xenografts were treated with combination treatments of 120 mg/kg AKT inhibitor, 10 mg/kg cetuximab, and 2 Gy radiation. Tumor size was assessed after each treatment using a pair of digital calipers. RESULTS: Ex vivo treatment with an AKT inhibitor alone significantly reduced ATP metabolic activity in human tissue specimens compared to control (64%, p 0.04). Combination treatment with cetuximab further enhanced this effect (29%, p 0.01). In vivo SCC1 flank tumor xenografts in Nude mice were significantly smaller following 2 weeks combination treatment with AKT i, cetuximab and radiation (15 mm) compared to control (102 mm, p 0.02) or radiation monotherapy (56 mm, p 0.05). CONCLUSION: Inhibition of the AKT pathway augments treatment with cetuximab on ex vivo human tissue and combination treatment with cetuximab and radiation in vivo.

Emerging applications for OCT in the head and neck

Objectives: To describe the current and promising new applications of Optical Coherence Tomography (OCT) as a helpful tool when imaging the different sites in the head and neck. We used the OCT Niris system, which is the first commercially available OCT device for applications outside the field of ophthalmology. Methods: OCT images were obtained of normal, benign, premalignant and malignant lesions in different areas of the head and neck. The OCT imaging system has a tissue penetration depth of approximately 1-2mm, a scanning range of 2mm and a spatial depth resolution of approximately 10-20μm. Imaging was performed using a flexible probe in two different settings, the outpatient clinic and the operating room. Results: High-resolution cross-sectional images from the larynx were obtained with the patient awake, without the need for general anesthesia, under direct visualization with a flexible fiberoptic endoscope. The OCT probe was inserted through the nasal cavity and placed in slight contact with the laryngeal tissue. In the ears, cholesteatoma was differentiated from inflamed middle ear mucosa by the different hyperintensity. In the neck, normal as well as different pathologies of the thyroid were identified. Conclusions: This system is non invasive and easy to incorporate into the operating room setting as well as the outpatient clinic. It requires minimal set-up and only one person is required to operate the system. OCT has the distinctive capability to obtain highresolution images, and the microanatomy of different sites can be observed. OCT technology has the potential to offer a quick, efficient and reliable imaging method to help the surgeon not only in the operating room but also in the clinical setting to guide surgical biopsies and aid in clinical decision making of different head and neck pathologies, especially those arising form the larynx.

Optical coherence tomography using the Niris system in otolaryngology

Objectives: To determine the feasibility and accuracy of the Niris Optical Coherence Tomography (OCT) system in imaging of the mucosal abnormalities of the head and neck. The Niris system is the first commercially available OCT device for applications outside ophthalmology. Methods: We obtained OCT images of benign, premalignant and malignant lesions throughout the head and neck, using the Niris OCT imaging system (Imalux, Cleveland, OH). This imaging system has a tissue penetration depth of approximately 1-2mm, a scanning range of 2mm and a spatial depth resolution of approximately 10-20μm. Imaging was performed in the outpatient setting and in the operating room using a flexible probe. Results: High-resolution cross-sectional images from the oral cavity, nasal cavity, ears and larynx showed distinct layers and structures such as mucosa layer, basal membrane and lamina propria, were clearly identified. In the pathology images disruption of the basal membrane was clearly shown. Device set-up took approximately 5 minutes and the image acquisition was rapid. The system can be operated by the person performing the exam. Conclusions: The Niris system is non invasive and easy to incorporate into the operating room and the clinic. It requires minimal set-up and requires only one person to operate. The unique ability of the OCT offers high-resolution images showing the microanatomy of different sites. OCT imaging with the Niris device potentially offers an efficient, quick and reliable imaging modality in guiding surgical biopsies, intra-operative decision making, and therapeutic options for different otolaryngologic pathologies and premalignant disease.

3D CT for Diagnosis of Facial/Mandibular Fractures

Objective To describe how the use of 3-D reformatted computer tomographic (CT) images increases the accuracy of diagnosis of facial and mandibular fractures and influences surgical planning. Methods Retrospective review of 20 patients with facial and/or mandibular fractures between 2005 and 2006, diagnosed with CT facial bones (axial and coronal images and 3-D renderings). The study was conducted at a university- affiliated institution. Standard CT facial bones protocol consisting of 1.5mm contiguous axial and coronal sections were performed on a 40-slice scanner (Philips Medical Systems, Cleveland, OH). 3-D reconstructions were then obtained. Scans were reviewed by the consulting surgeon. Pre-operative diagnoses were confirmed intraoperatively. Results Patient mean age was 31 years (17–46). Pre-operative diagnoses included: 18 mandible fractures, 8 zygomatico-maxillary/orbital floor, and 4 midface fractures. Mechanisms of injury included assault, motor-vehicle accidents, sports- and work-related injuries, and falls. Diagnosis and surgical planning was influenced in 1/3 of fractures after reviewing 3-D reformatted images. 3-D reformatting did not add any cost to the CT scans performed, did not expose patients to additional radiation, nor did it significantly increase the time to obtain the study. Conclusions 3-D CT reformatting is an inexpensive, easy-to-obtain diagnostic imaging modality that increases the accuracy of diagnosis and helps improve planning of surgical repair of facial and mandibular fractures.

P046: Aesthetic Superficial Parotidectomy: Technique and Outcomes

OBJECTIVES: A minimally invasive approach is indicated in solitary parathyroid adenoma when precisely localized with imaging. The aim of this report is to outline precise surgical indications and patient benefits of this procedure. METHODS: Retrospective study of 26 patients (67 years on average), with solitary parathyroid adenoma managed in a university hospital from 1997 to 2006. Every patient had a preoperative imaging study including neck ultrasonography and sestamibi scanning. Adenoma removal under local anesthesia was performed by the same surgeon. RESULTS: A minimally invasive approach under local anesthesia was performed for 26 patients with an operative time between 15 and 30 minutes. A second procedure under general anesthesia was performed for only one patient because of a posterior localization, behind the trachea. The mean postperative stay was 2,56 days. There was no recurrence of hyperparathyroidism. No intraoperative complications were noted. CONCLUSIONS: Minimally invasive approach can be performed when a parathyroid adenoma is precisely localized by neck ultrasonography and sestamibi scanning. In most cases, local anesthesia is the usual procedure. This technique appears to be cost–effective and efficient over the long term.

Clamshell Approach for Cervical Mediastinal Esophageal Reconstruction

Objectives: The thoracic inlet is a complex anatomic structure. Many vital structures ranging from vessels to organ systems traverse through here on their way from the chest into the neck. Access to reconstruct these areas can be quite difficult. The esophagus is a structure that stretches from the cervical region through the thoracic inlet into the mediastinum. Diseases or defects in the esophagus have traditionally been repaired by end-to-end anastomosis when a distal anastomosis is possible. Lesions where the distal esophagus is not accessible through a cervical approach often necessitate a total esophagectomy with a stomach pull-up. One approach, the clamshell approach, involves a median sternotomy and right thoracotomy with rotation of the anterior and lateral bony confinements of the thoracic inlet laterally. This provides access to the anterior mediastinum. Mobilization of the upper lung provides access to the posterior mediastinum. Methods: We present an interesting case of a gentleman with Boerhaave’s syndrome who had a diverting esophagostomy at the cervical thoracic level. The distal esophagus was allowed to retract into the chest. After he survived his initial insult, reconstruction was undertaken. Results: The distal esophagus could not be connected to the proximal esophagus. Using a clamshell approach, distal and proximal esophageal segments were isolated and a free jejeunal tissue transfer was undertaken. Anastomosis to the internal mammary vessels allowed reconstruction of the esophageal conduit. Conclusion: This poster will demonstrate the interesting complexity of the thoracic inlet with a photographic demonstration of the technical approach.

Sympathetic Chain Paragangliomas of the Parapharyngeal Space

Objectives: The parapharyngeal space is a complex anatomical feature of the head and neck that contains many important anatomic structures. Masses of the parapharyngeal space have an extensive differential diagnosis. Because of the vascular nature of some of the lesions that can occur in the parapharyngeal space, familiarity with a complete differential diagnosis, as well as radiologic investigation, is of paramount importance. Methods: We present a series of patients who had sympathetic schwannomas and presented with neck masses. Setting: Tertiary academic referral center at Oregon Health and Sciences University. Results: From 1998 to 2003, a series of 5 patients presented to the Otolaryngology Department with head and neck schwannomas of the sympathetic chain. The majority

Utility of bone scanning in the postoperative assessment of fibula-free tissue transfers

Abstract Objectives: The fibula osteocutaneous free flap has proven one of the most versatile and reliable flaps available for reconstruction of mandibular defects. Survival rates are exceedingly good with most centers reporting survival in >95% of cases. Viability of the bone is indirectly inferred by examination and visibility of the skin paddle. Occasionally, the skin paddle dies and the status of the bone is unknown. In these instances, one must ascertain the status of the bone in order to plan appropriately. We report on our experience with bone scanning in differentiating bone survival from bone death when the skin paddle has necrosed. Setting: Tertiary referral academic center Oregon Health & Science University. Methods: From 1998 to 2004, 130 fibula osteocutaneous free tissue transfers were undertaken. Results: In 7 of these, viability of the bone was questioned (5 skin paddle necrosis, 2 buried flap with no external monitor and a severe neck infection. Bone scanning was undertaken to help in operative planning. In 4 flaps, the bone paddle was felt to be alive on scan and confirmed intraoperatively. The skin paddle was debrided and replaced with a radial forearm free flap. Bone viability was confirmed at most recent follow-up. In 3 cases, the bone was confirmed to be nonviable by bone scan and confirmed by inspection intraoperatively. These cases were repaired with a second fibula free flap. Conclusion: Bone scanning is a useful investigation in cases where viability of the bone is in question. In flaps where the bone is buried or those in which the skin paddle has died, a positive bone scan will allow for planning of only soft tissue coverage, whereas a negative bone scan will imply a second bone flap.