Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome.

OBJECTIVES/HYPOTHESIS: To evaluate the efficacy of base of tongue (BOT) resection via transoral robotic surgery (TORS) in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: Case series METHODS: Between June 2010 and May 2012, BOT resection via TORS was performed on 27 patients with OSAHS. Patients were excluded from this analysis if other concomitant upper airway procedures such as uvulopalatopharyngoplasty were performed, or if postoperative polysomnograms were not available. RESULTS: Twelve patients who underwent BOT resection alone were included in this study. The median age for these 12 patients was 48.5 (range, 19-64) and included nine females and three males. The mean apnea-hypopnea index (AHI) was 43.9 ± 41.1 preoperatively and 17.6 ± 16.2 postoperatively. This difference in AHI was statistically significant (P = 0.007) and reflected an average AHI reduction of 56.2 ± 28.3%. Statistical significant reductions in daytime somnolence level, as measured by Epworth Sleepiness Scale (13.7 ± 5.2 preoperatively vs. 6.4 ± 4.5 postoperatively, P <0.001), and snoring intensity, as reported by a bed partner using a Visual Analogue Scale (8.6 ± 1.2 preoperatively vs. 4.2 ± 1.9 postoperatively, P <0.001), were achieved. There was no statistical significant difference between the preoperative and postoperative body mass index (34.5 ± 7.3 vs. 33.5 ± 6.7, P = 0.296) or minimum oxygen saturation (83.3 ± 5.5% vs. 84.0 ± 6.4%, P = 0.680). CONCLUSIONS: This is the first study looking at the use of TORS to address obstruction at the level of BOT only, not confounded by surgical alterations at other levels of upper airway. This preliminary result on the use of BOT resection via TORS for the treatment of patients with OSAHS is encouraging and warrants further investigations.

Single-incision transaxillary robotic thyroidectomy: challenges and limitations in a North American population.

OBJECTIVE: We reviewed our initial experience with robotic thy-roidectomy to identify challenges and limitations of this new surgical approach when applied to a North American population. STUDY DESIGN: Case series. SETTING: Academic institution. SUBJECTS/METHODS: Retrospective review of 18 consecutive robotic thyroid lobectomies performed from February 2010 to April 2012 involving 16 female patients. Two patients underwent robot-assisted completion thyroidectomy a few months following the initial thyroid surgery, one for cancer and the other for goiter. RESULTS: Median age was 47.5 years (range, 18-62 years), and median body mass index was 28.7 (range, 19.4-44.5). Median thyroid nodule size was 2.9 cm (range, 1.1-4.7 cm). All but 1 case (6%) was performed successfully via single axillary incision. There was no conversion to an open approach. Median operative time was 170 minutes (range, 95-220 minutes), and median blood loss was 12.5 mL (range, 5-75 mL). Complications occurred in 4 cases (22%) to include temporary vocal cord pareses (n = 3) and a postoperative hematoma that required exploration. Median hospital stay was 2 days (range, 1-3 days). CONCLUSION: Single-incision transaxillary robotic thyroidectomy can be technically challenging in North American patients with a larger body frame due to difficulty in optimal placement of all 4 robotic instruments via a single axillary incision. All 3 cases of temporary vocal cord paresis occurred early in our experience and may have been due to our relative inexperience with this new approach and associated instrumentation. Other limitations include less than optimal visualization of the recurrent laryngeal nerve in the contralateral lobe as well as poor access to the substernal region. LEVEL OF EVIDENCE: 4.

Cartilage grafts in dorsal nasal augmentation of traumatic saddle nose deformity: a long-term follow-up.

OBJECTIVES/HYPOTHESIS: To document the long-term advantages and disadvantages of cartilage grafts used to correct traumatic saddle nose deformity. Additionally, to demonstrate functional improvement and cosmetic satisfaction with the use of this graft. STUDY DESIGN: Retrospective chart review and prospective follow-up telephone survey of 20 patients after dorsal augmentation of saddle nose deformity secondary to trauma. METHODS: This is a single-surgeon, single-institution investigation within an academic tertiary care medical center. All patients presented for correction of saddle nose deformity after trauma, and cartilage grafts were used for augmentation of the dorsum. Minimum postoperative follow-up period of 1 year was required. A modified and expanded Nasal Obstructive Symptoms Evaluation survey, which included questions pertaining to the appearance of their nose, was used to assess both functional and cosmetic changes after surgery. RESULTS: Only 1 of the 20 patients was dissatisfied with the overall outcome. Three (15%) were extremely satisfied, 12 (60%) were very satisfied, three (15%) were somewhat satisfied, and one (5%) was indifferent. In terms of function, four (20%) experienced excellent relief in nasal obstruction, five (25%) moderate relief, four (20%) mild relief, and seven (35%) noted no difference. Regarding cosmesis, two (10%) noted excellent improvement, three (15%) moderate improvement, nine (45%) mild improvement, and five (25%) noted no significant change. One (5%) patient reported worsening due to tip edema. Mean follow-up time was 6.8 years. CONCLUSIONS: Autogenous cartilage grafts are useful in the correction of mild to moderate traumatic saddle nose deformity. The graft is readily available, preserves long-term structural stability, and achieves functional and cosmetic satisfaction in most patients.

Conservative management of iatrogenic esophageal perforation in head and neck cancer patients with esophageal stricture.

OBJECTIVE: Evaluate the efficacy of conservative management of iatrogenic esophageal perforation following dilatation of a stricture secondary to the treatment of head and neck cancer. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Retrospective chart review of 24 patients with esophageal perforation treated at the Detroit Medical Center from 1999 to 2008. Of these, eight head and neck cancer patients had esophageal stricture and underwent dilatation with subsequent esophageal perforation. RESULTS: Six patients were managed conservatively; two were managed surgically. All eight patients had radiation, six had chemotherapy, and five had surgery as part of their oncologic treatment. Stricture site was at the cricopharyngeus or neopharynx. Perforation size was estimated at 3 to 7 mm in conservative patients and approximately 10 mm in surgical patients. All patients survived to be discharged from the hospital and diet was tube feeds. CONCLUSION: In head and neck cancer patients with post-treatment esophageal stricture, iatrogenic cervical esophageal perforations can often be safely managed conservatively. The criteria are: prompt diagnosis within one hour, small perforation (3-7 mm), penetrating type of perforation with circumferential mucosal contact, proximal or cervical esophageal location, and stabilization and improvement of clinical signs and symptoms for 24 hours after initial ICU management.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome.

OBJECTIVE: First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors. METHODS: Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension. RESULTS: Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived. CONCLUSION: This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.

Tongue base schwannoma: report, review, and unique surgical approach.

Base of tongue schwannomas are exceedingly rare and therefore often are not immediately included in the differential diagnosis and treatment of oropharyngeal tumors. After a thorough review of the English literature, we found only 6 previously reported cases of tongue base schwannomas. We are contributing a report of a 37-year-old woman with progressive dysphagia, dysarthria, and large tongue base schwannoma. Diagnosis was confirmed by imaging studies and biopsy followed by surgical excision designed to preserve nerve function. A number of surgical approaches have been described for tongue base schwannomas. Each has its own degree of postoperative morbidity. The use of a unilateral transcervical incision with blunt dissection was simple and quickly accomplished with protection of nearby nerves. Histologic identification of Antoni A and B areas along with strong and diffuse staining with S-100 stain pathologically completed the diagnosis of schwannoma.

Cell carcinoma of the paranasal sinuses and skull base.

PURPOSE: To evaluate patients with squamous cell carcinoma of the paranasal sinus and skull base for factors that might predict clinical outcome. METHODS: A multi-institutional 13-year retrospective review of anterior skull base malignancies. RESULTS: Of 73 patients with anterior skull base malignancies, squamous cell carcinoma was the most prevalent-30 patients or 41%. Twenty-three patients underwent craniofacial surgery with or without adjuvant chemotherapy. Seven patients, deemed unresectable or not willing to have surgery, were treated with standard radiation protocols often with chemotherapy. The 3- and 5-year survival rates after surgery were 32% and 16%, respectively, compared to a 28% survival rate at 3 and 5 years for the nonsurgical group. Most tumors were in advanced stages accounting for a relatively poor survival in both groups. A Cox regression analysis demonstrated that age (P = .0172) was an independent determinant of poor outcome. Although 3- and 5-year survival of tumors free of sphenoid sinus, dura, retromaxillary, and ptyerygoid space, and orbit treated with surgery showed no significant difference to those patients with involvement, their median time of survival was increased for all anatomical regions. CONCLUSIONS: Squamous cell carcinoma of the sinus invading the skull base carries a very poor prognosis regardless of treatment modality. Surgery with adjunctive radiotherapy and/or chemotherapy offers a survival advantage over nonsurgical methods, but treatment should be individualized weighing prognostic factors, such as age, stage, and anatomical extension with morbidity of treatment.

Facial fracture repair in the traumatic brain injury patient.

PURPOSE: To review the surgical complications of patients who had facial fractures repairs in the setting of a traumatic brain injury (TBI). PATIENTS AND METHODS: A review of all individuals admitted with the diagnosis of TBI based on an evaluation by the neurotrauma service who also underwent facial fracture repair was performed. More than 600 charts were reviewed and 99 patients met study criteria. Univariate and mulitvariate logistic regression model analysis were performed comparing the complication rate in the immediate postoperative period to the patients' age, gender, mechanism of injury, zone of facial injury, preoperative Glasgow Coma score, presence of multisystem injury, mechanism of TBI and treatment, length of time from injury to surgical repair and length of surgical procedure. RESULTS: Of the 99 individuals studied, there was an 11% complication rate (8 minor, 3 major) in the immediate postoperative period. After univariate analysis, the length of time from injury to surgical repair, zone 1 facial injury and low Glasgow Coma score were all factors associated with increased complications. Multivariate logistic regression model analysis revealed that the odds of a patient sustaining a postoperative complication was 1.298 as the hour of procedure increased by 1 hour (95% CI, 1.065-1.582) and was 1.152 as the days of repair increased by 1 day (95% CI, 1.030-1.288). CONCLUSIONS: The overall complication rate of facial fracture repair in the TBI patient was 11%. A prolonged surgical procedure and delay in surgical repair were associated with higher complication rates as identified by multivariate logistical regression analysis.

Visual risks of facial fracture repair in the setting of traumatic optic neuropathy.

OBJECTIVE: To identify whether facial fracture repair in patients with traumatic optic neuropathy results in visual deterioration. DESIGN: A retrospective analysis was performed of all patients admitted from 1992 through 1997 with the diagnosis of facial fracture and traumatic optic neuropathy. Vision was recorded before and after fracture repair using logarithm of the minimum angle of resolution measurements. Visual outcome was compared with a nonsurgically treated group of patients with a similar diagnosis. SETTING: University trauma hospital. PATIENTS: A total of 700 medical charts were reviewed, and 54 patients met study criteria. All patients received megadose corticosteroid treatment and were divided into 3 groups: (1) facial fracture repair alone, (2) optic nerve decompression (OND) + facial fracture repair, or (3) nonsurgical treatment. RESULTS: For the 16 patients in the fracture repair alone group, 12 (75%) had improved vision and 4 (25%) had no change postoperatively. For the 10 patients in the OND + fracture repair group, 3 (30%) had improved vision, 5 (50%) had no change, and 2 (20%) had worsened vision postoperatively. For the 28 patients in the nonsurgical group, 18 (64%) had improved vision, 9 (32%) had no change, and 1 (4%) had worsened vision by discharge. Facial fracture repair alone and the nonsurgical groups both demonstrated significant visual improvement by discharge. The amount of improvement was not significantly different between all 3 groups (facial fracture repair, 0.38 +/- 0.40; OND + facial fracture repair; 0.32 +/- 1.38; and nonsurgical, 0.69 +/- 1.07). CONCLUSIONS: Facial fracture repair in the setting of traumatic optic neuropathy had no adverse effect on vision. Patients requiring OND + fracture repair had a significantly worse visual prognosis.

Acinic cell carcinoma of the parotid gland: a 15-year review limited to a single surgeon at a single institution.

The course of acinic cell carcinoma of the parotid gland following surgical and nonsurgical interventions is variable. The objective of this study was to report our experience in treating this disease and to evaluate the factors that might be involved in the treatment of the tumor and the prognosis of the patient. To limit the contributory variables that are usually found in most studies, we included only those patients (n = 11) who had been treated by a single surgeon at a single institution from 1988 through 2003. Hospital and office records were evaluated for demographic information, signs and symptoms, treatment modalities, pathology, and outcomes. Additional follow-up data were obtained through telephone interviews. For the most part, treatment included either superficial parotidectomy or total parotidectomy with facial nerve preservation; 1 patient with coexisting adenocarcinoma underwent a more radical procedure, and 4 patients underwent adjuvant radiation therapy. The most prevalent morphologic pattern of these tumors was microcystic. Follow-up ranged from 1 year and 3 months to 10 years and 9 months (mean: 4 yr and 11 mo). During that time, we found no recurrences of acinic cell carcinoma and no evidence of metastatic disease. Therefore, we conclude that acinic cell carcinoma can be successfully treated with a superficial or total parotidectomy with sparing of the facial nerve. Radiation therapy may provide adjunctive benefit.

Human papillomavirus (HPV) transcripts in malignant inverted papilloma are from integrated HPV DNA.

OBJECTIVES: The objectives of the study were to detect human papillomavirus (HPV) sequences in nasal inverted papilloma (IP) lesions and to determine whether HPV is involved in the progression of IP to sinonasal squamous cell carcinoma (SCC). STUDY DESIGN: A retrospective study was performed on 14 patients diagnosed with IP within the last 12 years. Three of these 14 patients developed SCC. METHODS: Eighteen formalin-fixed, paraffin-embedded tissue blocks were obtained for these 14 patients. After DNA extraction, polymerase chain reaction (PCR) was performed, followed by hybridization using HPV 6, 11, 16, 18, 31, 33, 35, 45, and 52 specific DNA probes, in an attempt to identify HPV type in each specimen. After RNA extraction, the integration status of the HPV genome was evaluated based on the relative abundance of E7 and E5 viral transcripts, assessed by quantitative real-time PCR. RESULTS: HPV sequences were detected in samples from 3 of the 14 patients with IP. Of the three patients with SCC, HPV sequences were detected in two patients, whereas one patient was negative for the oligoprobes tested. Of the 11 patients diagnosed only with IP, 1 patient was positive for HPV DNA (HPV type 11). This difference in HPV positivity between IP and SCC was not statistically significant (P = .09, Fisher's Exact test, two tailed). Viral transcripts were detected in both patients with SSC who were HPV positive. Because HPV early transcripts are polycistronic, loss of 3' transcript sequences (E5) and retention of 5' sequences (E7) indicates integration. One of the SSC containing HPV 18 sequences showed a E7/E5 ratio of 776:1. The other SSC showed E7 transcripts and an absence of E5 transcripts CONCLUSION: HPV transcripts were present in SCC positive for HPV, and the relative level of E7 to E5 transcripts indicates integration of the viral genome. These findings are suggestive of HPV having an active role in the lesion. More extensive studies are needed to determine the exact role of HPV in IP and progression to SCC.

Integration of human papillomavirus type 11 in recurrent respiratory papilloma-associated cancer.

OBJECTIVES/HYPOTHESIS: The main objective was to demonstrate that human papillomavirus (HPV) type 11 is an aggressive virus that plays a significant role in the development of laryngeal cancer in patients with a history of recurrent respiratory papillomatosis (RRP). We have done so by preliminary investigation into the molecular mechanism underlying the malignant transformation of RRP to invasive squamous cell carcinoma. STUDY DESIGN: An experimental, nonrandomized, retrospective study using tissue specimens from nine patients with a history of RRP that progressed to laryngeal or bronchogenic cancer was performed. METHODS: DNA and RNA were extracted from 20 formalin-fixed, paraffin-embedded specimens from six patients with a history of early onset RRP and laryngeal cancer and from three patients with early onset RRP and bronchogenic cancer. Polymerase chain reaction (PCR) was performed on DNA to determine the HPV type in each specimen. Reverse-transcriptase PCR specific for virus transcripts was performed on RNA to determine whether the viral genome was integrated into the host genome. RESULTS: HPV-11 but not HPV-6, 16, or 18 was found in all of the laryngeal and bronchogenic cancers in patients with a history of early onset RRP in this study. RNA, sufficiently intact for examination, was obtained from seven patients. Analysis of HPV 11 transcripts revealed integration of the viral genome in three of seven patients. CONCLUSIONS: HPV type 6 and 11 are considered "low-risk" viruses and are not associated with genital cancers, as are HPV types 16 and 18. However, our data suggests that HPV type 11 is an aggressive virus in laryngeal papilloma that should be monitored in patients with RRP.

Transoral versus extraoral reduction of mandible fractures: a comparison of complication rates and other factors.

OBJECTIVE: This retrospective study evaluates results and complications of the transoral and extraoral approaches for open reduction and internal fixation of mandibular body, angle, and ramus fractures. Our aim was to describe advantages and disadvantages of the techniques and to develop criteria for choosing between surgical approaches. STUDY DESIGN AND SETTING: A retrospective chart review was performed on patients with mandible fractures occurring between August 1999 and October 2001 at a level I trauma center. Only mandibular body, angle, and ramus fractures requiring open reduction were selected for this study. Cases were evaluated for cause, age, gender, dentition, site and extent of fractures, surgical approach, postoperative complications, operative time, and postoperative occlusion. RESULTS: Of the 227 patients with mandibular fractures, 78 had body, angle, or ramus fractures requiring open reduction. Of these, 36 were treated extraorally, and 42 were treated transorally. Criteria for selecting one procedure over another often involved training and surgeon experience and those factors normally considered important in defining the difficulty of treatment and prognosis of the patient. Seven of the 42 patients were converted from a transoral to an extraoral approach because of inadequate exposure. Similar complication rates occurred for the transoral and extraoral approaches, but because of the time required for converting from the transoral to extraoral approach, the average operative time was found to be increased in patients undergoing the transoral approach. CONCLUSION AND SIGNIFICANCE: Decisions regarding treatment approaches for open reduction of mandible fractures often relate to surgeon experience and training, modified by factors that can affect uncomplicated healing such as fracture locations and displacement, comminution of the fracture, infection, dentition, and atrophic changes of the mandible. In some cases, the choice is affected by availability of equipment and experience of operating room personnel. More difficult cases involving an edentulous, atrophic mandible or comminution should be considered for extraoral exposure.

Hypothesis: research in otolaryngology is essential for continued improvement in health care.

The present report, in the form of a research proposal, is based on the hypothesis that research in otolaryngology is essential for continued improvement in health care. Examples of advances in otolaryngology as a result of research are noted, but for continued success, otolaryngology must maintain and find better ways to train clinically directed researchers. Traditional methods of training such as hands-on experience, courses in the basic principles of research, protected time, and mentoring are discussed and evaluated. Barriers to success such as age, time, and debt are noted. Potential solutions are presented with an emphasis on integration of the research and clinical training. Success of faculty will continue to depend on laboratory and financial support, technical assistance, protected time, salary equivalent to other faculty, and accessibility of research funds. For research to gain support and enthusiasm and to keep it strong and productive, cost-effectiveness and value must be recognized.

A comparison of parietal and iliac crest bone grafts for orbital reconstruction.

PURPOSE: This study evaluated the results of cranial (membranous) versus iliac crest (endochondral) bone grafts as implants to correct post-traumatic globe malposition and/or diplopia. PATIENTS AND METHODS: Twenty-two patients underwent 25 orbital reconstructions with bone for enophthalmos, hypophthalmos, and diplopia after trauma to the orbit. Inclusion criteria consisted of at least 4 months postsurgical follow-up, pre- and postsurgical quantitative orbital measurements, photographic documentation, and complete medical records regarding inpatient and outpatient data. RESULTS: Nine cranial bone grafts and 16 iliac crest grafts were placed. Ages were similar in both groups. The average follow-up was 24 months for the cranial graft group (range, 4 to 54 months) and 18 months for the iliac crest graft group (range, 4 to 51 months). Preoperative enophthalmos averaged 4.11 and 5.06 mm in the cranial and iliac crest groups, respectively, and postoperatively the measurements were 1.78 and 1.37 mm, respectively. Changes in hypophthalmos generally reflected changes in the enophthalmos correction. In 10 patients diplopia was corrected by the procedure. There was a statistically significant change in the enophthalmos of patients when comparing pre- and postoperative status, but no statistically significant difference between the results of the cranial and iliac crest graft groups. CONCLUSION: There is no difference in the ability of cranial and iliac crest bone grafts to correct post-traumatic enophthalmos.

Trace Elements in Head and Neck Cancer Patients: Zinc Status and Immunologic Functions.

In this study we have assessed zinc status and zinc-dependent cell-mediated immune functions (interleukin-2 production by mononuclear cells, natural killer cell lytic activity, and interleukin-1ß production by mononuclear cells) in adult patients with squamous cell carcinoma of the upper aerodigestive tract at diagnosis and before any therapy was instituted. Inasmuch as significant interactions between zinc, copper, and iron exist, we also assayed the plasma copper level, serum iron level, and total iron-binding capacity in our patients. We recruited 30 cancer subjects and 21 control subjects. On the basis of cellular zinc criteria, we diagnosed a mild deficiency of zinc in 53% of cancer subjects. The plasma zinc level was not decreased in our subjects. A univariate analysis was applied by use of one-way analysis of variance comparing study variables among the three study groups (controls and zinc-deficient and zinc-sufficient cancer patients) and Tukey's multiple comparison test, and we showed that interleukin-2 production and natural killer lytic activity were decreased in zinc-deficient cancer patients. Interleukin-1ß production (ELISA assay) was increased in both zinc-deficient and zinc-sufficient groups. Plasma copper level was not different, but the iron utilization was decreased in both groups of cancer subjects. We conclude that zinc deficiency and zinc-dependent immunologic dysfunctions are present in more than half of the patients with head and neck cancer in the Detroit area.