Document 1403

February 18-21, 2012
Pacific Rim Otolaryngology–
Head and Neck Surgery
University of California
San Francisco
Presented by the Departments of
Otolaryngology-Head and Neck Surgery
University of California, San Francisco
and Tripler Army Medical Center
Honolulu, Hawaii
Waikiki Beach
Honolulu, Hawaii
Joseph C. Sniezek, MD, FACS, LTC, MC
Chief, Otolaryngology/Head and Neck
Tripler Army Medical Center
Honolulu, HI
David W. Eisele, MD, FACS
Professor and Chairman; Department
of Otolaryngology/Head and Neck Surgery
University of California, San Francisco
The Department of Otolaryngology – Head and Neck Surgery
University of California, San Francisco
Tripler Army Medical Center – Honolulu, Hawaii
Pacific Rim Otolaryngology –
Head and Neck Surgery
February 18- 21, 2012
Moana Surfrider
Honolulu, HI
Course Chairs
David W. Eisele, MD, FACS
University of California, San Francisco
Joseph C. Sniezek, MD, FACS, LTC, MC
Tripler Army Medical Center- Honolulu, HI
University of California, San Francisco
Tripler Army Medical Center
Acknowledgement of Commercial Support
This CME activity was supported in part by educational grants from the following:
ArthroCare ENT
ArthroCare ENT
Hemostatix Medical Technologies
Hitachi Aloka
KLS Martin
Olympus/Gyrus ACMI
Synthes CMF
University of California, San Francisco and
Tripler Army Medical Center
Pacific Rim Otolaryngology – Head and Neck Surgery Update
With improved understanding of pathophysiology and disease mechanisms and with technological
advancements, the approaches to head and neck surgical disorders and head and neck surgery
techniques continue to evolve at a rapid pace. The goal of this course is to provide an update in
contemporary head and neck surgery and to foster educational interaction between practitioners
from the Pacific Rim and beyond. A distinguished faculty will provide lectures and roundtable
discussions. Ample time for questions and interaction with the faculty is planned.
This course is intended for practicing otolaryngologist- head and neck surgeons, facial plastic
surgeons, oral and maxillofacial surgeons, dermatologic surgeons, and nurses.
Educational Objectives
Upon completion of this program, attendees should be able to discuss and, as appropriate, apply:
New management strategies for head and neck and cutaneous cancer;
Contemporary evaluation and management of head and neck trauma;
Current evaluation and management of dysphagia;
New approaches for obstructive sleep apnea and new tonsillectomy guidelines;
Contemporary avoidance and management of complications of mastoidectomy.
The University of California, San Francisco School of Medicine (UCSF) is accredited by the
Accreditation Council for Continuing Medical Education to provide continuing medical education for
UCSF designates this live activity for a maximum of 23 AMA PRA Category 1 Credits™ Each
physician should only claim only credit commensurate with the extent of his/her participation in the
This CME activity meets the requirements under California Assembly Bill 1195, continuing
education and cultural and linguistic competency.
For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA
Category 1 Credit™ issued by organizations accredited by the ACCME.
Physician Assistants:
AAPA accepts Category 1 Credit from AOACCME, Prescribed credit from AAFP, and AMA
Category 1 Credit™ from organizations accredited by the ACCME.
General Information
Sheet / CME Certificates
Each participant is required to sign-in and claim the number of credits in order to receive
a CME certificate. The sign-in sheet will be located at the UCSF Registration Desk.
Those that claim a total of 23 credit hours at the end of course on Tuesday, February
21st will receive their CME certificate on-site.
CME certificates will be mailed to participants that claim less than 23 credits
approximately 2-3 weeks post course.
Per ACCME guidelines, attendees must claim their credits in order to receive a CME
If you need to leave the course before it concludes you may claim your credits at any
time at the UCSF registration desk.
Your cooperation in completing and returning the course evaluation is an important part
of future course planning. The evaluation is the colored handout that you received when
you checked-in at the UCSF Registration Desk. Please turn in the evaluation at the
conclusion of the course.
The course will conclude at lunchtime each day with the exception of Monday 2/20/12.
Lunch is on own each day and a list of restaurants is available through the Moana
Surfrider concierge staff.
We urge caution with regard to your personal belongings. We are unable to replace
these in the event of loss. Please do not leave any personal belongings unattended in
the meeting room.
Industry exhibits will be available outside the General Session room during course
breakfasts and breaks.
Case Discussions
Each day of the course there will be an opportunity to discuss various cases along with
light refreshments.
The course reception will take place on Monday evening 2/20/12 from 7:00PM- 9:00PM
in the Lani Kai room and is open to the paid attendee and one adult guest. You will
receive tickets for you and your guest when you check-in at the UCSF Registration Desk.
Please note that the location is subject to change due to weather and we will make an
announcement if there is a location change.
Federal and State Law
Regarding Linguistic Access and Services for Limited English Proficient Persons
This document is intended to satisfy the requirements set forth in California Business and Professions
code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency
as part of their continuing medical education programs. This document and the attachments are
intended to provide physicians with an overview of federal and state laws regarding linguistic access
and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed
below also may govern the manner in which physicians and healthcare providers render services for
disabled, hearing impaired or other protected categories
Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August
11, 2000, and Department of Health and Human Services (“HHS”) Regulations
and LEP Guidance.
The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal
financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have
meaningful access to federally funded programs and services. Failure to provide LEP individuals with
access to federally funded programs and services may constitute national origin discrimination, which
may be remedied by federal agency enforcement action. Recipients may include physicians,
hospitals, universities and academic medical centers who receive grants, training, equipment, surplus
property and other assistance from the federal government.
HHS recently issued revised guidance documents for Recipients to ensure that they understand their
obligations to provide language assistance services to LEP persons. A copy of HHS’s summary
document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the
Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons –
Summary” is available at HHS’s website at: .
As noted above, Recipients generally must provide meaningful access to their programs and services
for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps”
may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in
designing an LEP program, should conduct an individualized assessment balancing four factors,
including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered
by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s
program; (iii) the nature and importance of the program, activity or service provided by the Recipient to
its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and
translation services.
Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five
recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii)
identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and
(v) monitoring and updating the LEP plan.
A Recipient’s LEP plan likely will include translating vital documents and providing either on-site
interpreters or telephone interpreter services, or using shared interpreting services with other
Recipients. Recipients may take other reasonable steps depending
on the emergent or non-emergent needs of the LEP individual, such as hiring bilingual
staff who are competent in the skills required for medical translation, hiring staff interpreters, or
contracting with outside public or private agencies that provide interpreter services. HHS’s guidance
provides detailed examples of the mix of services that a Recipient should consider and implement.
HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining
whether vital documents must be translated into other languages. Compliance with the safe harbor
will be strong evidence that the Recipient has satisfied its written translation obligations.
In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil
Rights for technical assistance in establishing a reasonable LEP plan.
California Law – Dymally-Alatorre Bilingual Services Act.
The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code
7290 et seq.) in order to ensure that California residents would appropriately receive services from
public agencies regardless of the person’s English language skills. California Government Code
section 7291 recites this legislative intent as follows:
“The Legislature hereby finds and declares that the effective
maintenance and development of a free and democratic society depends
on the right and ability of its citizens and residents to communicate
with their government and the right and ability of the government to
communicate with them.
The Legislature further finds and declares that substantial
numbers of persons who live, work and pay taxes in this state are
unable, either because they do not speak or write English at all, or
because their primary language is other than English, effectively to
communicate with their government. The Legislature further finds and
declares that state and local agency employees frequently are unable
to communicate with persons requiring their services because of this
language barrier. As a consequence, substantial numbers of persons
presently are being denied rights and benefits to which they would
otherwise be entitled.
It is the intention of the Legislature in enacting this chapter to
provide for effective communication between all levels of government
in this state and the people of this state who are precluded from
utilizing public services because of language barriers.”
The Act generally requires state and local public agencies to provide interpreter and written document
translation services in a manner that will ensure that LEP individuals have access to important
government services. Agencies may employ bilingual staff, and translate documents into additional
languages representing the clientele served by the agency. Public agencies also must conduct a
needs assessment survey every two years documenting the items listed in Government Code section
7299.4, and develop an implementation plan every year that documents compliance with the Act. You
may access a copy of this law at the following url:
Faculty List
David W. Eisele, MD, FACS
Professor and Chairman, Department of Otolaryngology – Head and Neck Surgery,
University of California, San Francisco
Joseph C. Sniezek, MD, FACS, LTC, MC
Chief, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI
Benjamin Cable, MD, MAJ, MC, USA
Chief, Pediatric Otolaryngology, Tripler Army Medical Center- Honolulu, HI
Steven W. Cheung, MD, FACS
Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
James Closmann, DDS
Chief, Oral/Maxillofacial Surgery and Residency Program Director, Tripler Army Medical Center- Honolulu, HI
Mark S. Courey, MD
Professor, Department of Otolaryngology-Head and Neck Surgery; Director, Division of Laryngology;
Director, UCSF Voice and Swallowing Center, University of California, San Francisco
John L. Dornhoffer, MD
Professor and Director, Division of Otology/Neurotology, University of Arkansas for Medical Sciences,
Little Rock, AR
Ivan H. El-Sayed, MD, FACS
Associate Professor; Co-Director, Center for Minimally Invasive Skull Base Surgery, Department of
Otolaryngology - Head and Neck Surgery, University of California, San Francisco
Andrew N. Goldberg, MD, MSCE
Professor; Director, Division of Rhinology and Sinus Surgery, Department of Otolaryngology- Head and Neck
Surgery, University of California, San Francisco
David Goldenberg, MD, FACS
Professor of Surgery and Oncology; Director of Head and Neck Surgery, Penn State Milton S. Hershey Medical
Center, Hershey, PA
David Y. Healy, Jr., MD, CDR, MC, USN
Chief, Otolaryngal Allergy, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI
Eric J. Kezirian, MD, MPH
Associate Professor, Department of Otolaryngology-Head and Neck Surgery; Director, Division of Sleep
Surgery, University of California, San Francisco
Christopher Klem, MD FACS, LTC, MC, USA
Chief, Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI
P. Daniel Knott, MD
Associate Professor and Director, Division of Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, University of California, San Francisco
Lawrence R. Lustig, MD
Professor and Director, Division of Otology, Neurotology, and Skull Base Surgery, University of California, San
Anna K. Meyer, MD, FAAP
Assistant Professor, Division of Pediatric Otolaryngology, University of California, San Francisco
Andrew H. Murr, MD, FACS
Professor and Vice Chair, Department of Otolaryngology – Head and Neck Surgery, University of California,
San Francisco School of Medicine; Chief of Service, San Francisco General Hospital;
Roger Boles, MD Endowed Chair in Otolaryngology Education
Steven D. Pletcher, MD
Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California,
San Francisco
Mitchell J. Ramsey, MD, LTC, MC, USA
Chief, Otology/Neurotology; Residency Program Director, Tripler Army Medical Center- Honolulu, HI
Scott B. Roofe, MD, LTC, MC, USA
Chief, Facial Plastic and Reconstructive Surgery, Tripler Army Medical Center, Honolulu, HI
William Ryan, MD
Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California,
San Francisco
Katherine C. Yung, MD
Assistant Professor, Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery,
University of California, San Francisco
The following faculty speakers, moderators and planning committee members have disclosed NO financial
interest/arrangement or affiliation with any commercial companies who have provided products or services
relating to their presentation(s) or commercial support for this continuing medical education activity:
David W. Eisele, MD, FACS
Joseph C. Sniezek, MD, FACS, LTC, MC
Benjamin Cable, MD, MAJ, MC, USA
Steven W. Cheung, MD, FACS
James Closmann, DDS
John L. Dornhoffer, MD
David Y. Healy, Jr., MD, CDR, MC, USN
Christopher Klem, MD, FACS, LTC, MC, USA
P. Daniel Knott, MD
Lawrence R. Lustig, MD
Anna K. Meyer, MD, FAAP
Andrew H. Murr, MD, FACS
Steven D. Pletcher, MD
Mitchell Ramsey, MD, LTC, MC, USA
Scott B. Roofe, MD, LTC, MC, USA
William Ryan, MD
Katherine C. Yung, MD
The following faculty speakers have disclosed a financial interest/arrangement or affiliation with a commercial
company who has provided products or services relating to their presentation(s) or commercial support for this
continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME
Updated Standards for Commercial Support:
Mark S. Courey, MD
Scientific Advisor
Lumenis, Inc.
Ivan H. El-Sayed, MD, FACS
Grant Resident Skull Base Approach Selection Course
Stryker Corporation
Andrew N. Goldberg, MD, MSCE
Scientific Advisory Baord Member- Sleep Division
Consultant & Stock Holder
Consultant & Stock Holder
Siesta Medical
David Goldenberg, MD, FACS
Speaker’s Bureau
Smith’s Medical
Eric J. Kezirian, MD, MPH
Medical Advisory Board
Medical Advisory Board
Apnex Medical
ReVENT Medical
Pavad Medical
Seven Dreamers
This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance,
independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when
unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced.
This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with
UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have
disclosed no relevant financial relationships.
Course Program
6:30 am
Registration and Continental Breakfast
Salivary Gland Stones
Dr. David W. Eisele
Transnasal Esophagoscopy
Dr. Joseph C. Sniezek
Endoscopic Management of
Early Laryngeal Cancer
Dr. Mark S. Courey
The Precarious Airway
Dr. David Goldenberg
Lip Cancer
Dr. Christopher Klem
AM Coffee Break
Recurrent Respiratory Papillomatosis –
Treatment Options
Dr. Katherine C. Yung
Tinnitus – Current Concepts
Dr. Steven W. Cheung
Endoscopic Dacryocystorhinostomy
Dr. Steven D. Pletcher
Meniere’s Disease 2012
Dr. Mitchell J. Ramsey
The Dizzy Patient:
Simple Diagnosis, Simpler Treatment
Dr. Lawrence R. Lustig
Case Discussions with Refreshments
6:30 am
Continental Breakfast
Pituitary Surgery Update
Dr. Ivan H. El-Sayed
Management of the TMJ Patient for the
Dr. James Closmann
Avoiding Complications in Sinus Surgery
Dr. Steven D. Pletcher
Cartilage Tympanoplasty
Dr. John L. Dornhoffer
Revision Thyroid Surgery
Dr. David Goldenberg
AM Coffee Break
Contemporary Comprehensive Treatment of
Facial Paralysis
Dr. P. Daniel Knott
Turbinate Surgery 2012
Dr. Scott B. Roofe
Advanced Head and Neck Skin Cancer
Dr. Ivan H. El-Sayed
Dr. Mark S. Courey
12:30 pm
Zenker’s Diverticulum and Cricopharyngeal
Spasm Management
Case Discussions with Refreshments
12:00 pm
Cochlear Implants 2012
Dr. Lawrence R. Lustig
Laryngeal Trauma
Dr. Andrew H. Murr
Head and Neck Sarcoma
Dr. William Ryan
Tympanostomy Update
Dr. Benjamin Cable
New Tonsillectomy Guidelines
Dr. Anna K. Meyer
PM Coffee Break
Endoscopic Treatment of Inverted Papilloma
Dr. Andrew N. Goldberg
Office Evaluation of Dysphagia
Dr. Katherine C. Yung
Pediatric Vascular Malformations Update
Dr. Anna K. Meyer
Functional Stimulation for
Obstructive Sleep Apnea
Dr. Eric J. Kezirian
Sublingual Immunotherapy
Dr. David Y. Healy, Jr.
Case Discussions with Refreshments
7:00 pm
6:30 am
Continental Breakfast
Oropharyngeal Cancer Epidemiology
Dr. William Ryan
Complications in Rhinoplasty
Dr. Scott B. Roofe
Paranasal Sinus Surgical Anatomy
Dr. David Y. Healy, Jr.
Base of Tongue Procedures for
Obstructive Sleep Apnea
Dr. Eric J. Kezirian
Serendipity in Otolaryngology
Dr. Andrew H. Murr
AM Coffee Break
What Causes Chronic Sinusitis?
Dr. Andrew N. Goldberg
Avoiding Complications in Mastoid Surgery
Dr. Steven W. Cheung
NCCN Head and Neck Cancer
Guidelines Update
Dr. David W. Eisele
Why Are We Using Robots?
Dr. Joseph C. Sniezek
Adjourn / Evaluations / Attendance Verification Records (AVR)
2013 Pacific Rim Otolaryngology – Head and Neck Surgery Update
Saturday, February 16 – Tuesday, February 19, 2013
Moana Surfrider
Group rates will be available at:
Moana Surfrider- starting at $245/night
Upcoming CME Courses
Primary Care Medicine: Update 2012
Sunday, April 1 – Friday, April 6, 2012
Wailea Beach Marriott and Spa – Wailea, Hawaii
33rd Annual Advances in Infectious Diseases: New Directions for Primary Care
Wednesday, April 25 – Friday, April 27, 2012
Hilton Financial District – San Francisco, California
Essentials of Women's Health: An Integrated Approach to Primary Care and Office Gynecology
Sunday, July 1 – Friday, July 6, 2012
Hapuna Beach Prince Hotel – Kohala Coast, Hawaii
Neurosurgery Update 2012 in the Wine Country
Thursday, August 2 – Saturday, August 4, 2012
Fairmont Sonoma Mission Inn, Sonoma, California
Pituitary Disorders: Advances in Diagnosis and Management
Saturday, October 27, 2012
Marriott Union Square – San Francisco, California
The Medical Management of HIV/AIDS
Thursday, December 6 – Saturday, December 8, 2012
Westin Market Street – San Francisco, California
19th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring
Friday, February 15 – Sunday, February 17, 2013
Disney's Boardwalk Inn Resort – Orlando, Florida
UCSF Otolaryngology Update: 2013
Thursday, November 7 – Saturday, November 9, 2013
Ritz-Carlton Hotel – San Francisco, California
20th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring
Friday, February 14 – Saturday, February 15, 2014
Grand Hyatt – San Francisco, California
2013 Pacific Rim Otolaryngology – Head and Neck Surgery Update
Saturday, February 16 – Tuesday, February 19, 2013
Moana Surfrider – Honolulu, Hawaii
All Courses Managed by:
UCSF Office of Continuing Medical Education
3333 California Street, Room 450, San Francisco, CA 94118
For attendee information call: 415-476-4251
For exhibitor information: 415-476-4253
Visit the web site at
Salivary Gland Stones
David W. Eisele, M. D., F.A.C.S.
Introduction - Sialolithiasis is a common cause of salivary gland duct obstruction.
Submandibular stones predominate. The exact etiology of salivary gland stones is
unknown. One theory is deposition of calcium salts around a nidus of desquamated
cells, microorganism, foreign body, or a mucous plug. Reduced fluid intake, smoking,
and certain medications may also contribute to their formation. Stones tend to grow
over time.
Symptoms: Episodic salivary gland pain and swelling, can be progressive or persistent
Sequelae: Can include recurrent painful gland swelling, episodes of acute bacterial
sialadenitis, abscess formation, chronic sialadenitis and gland atrophy, duct stricture
Evaluation: History, Physical Examination, Imaging Studies (CT Scan best)
Transoral removal
Therapeutic sialendoscopy – basket, laser lithotripsy
Combined endoscopic and external approaches
Extracorporeal lithotripsy
Suggested Readings:
Harrison JD. Causes, natural history, and incidence of salivary stones and
obstructions. Otolaryngol Clin North Am. Dec 2009; 42:927-947.
Huoh KC, Eisele DW. Etiologic factors in sialolithiasis. Otolaryngol Head Neck
Surg. 2011; 145:935-9.
Marchal F, Becker M, Dulguerov P, Lehmann W. Interventional sialendoscopy.
Laryngoscope 2000;110:318-320.
Marchal F. A combined endoscopic and external approach for extraction of
large stones with preservation of parotid and submandibular glands.
Laryngoscope 2007;117:373-377.
Marchal F, Dulguerov P. Sialolithiasis management: the state of the art. Arch
Otolaryngol Head Neck Surg. Sep 2003;129:951-956.
Trans-nasal Esophagoscopy
Joseph C. Sniezek, MD FACS
Pacific Rim Otolaryngology Updates
February, 2012
While rigid esophagoscopy is very commonly performed in the operating room by
Otolaryngologists, improvements in technology and techniques now allow flexible
esophagoscopy to be performed quickly and safely through a trans-nasal
approach in the clinic setting without sedation.
1. dysphagia
3. Globus sensation
4. Foreign bodies
5. Tracheoscopy
6. Biopsies of larynx/pharynx/esophagus
7. Tracheo-esophageal puncture
8. Panendoscopy for malignancy
1. 5 mm flexible esophagoscope utilized with sheath
2. topical anesthetic/afrin sprayed in nasal cavity, benzocaine spray to
oropharynx (occasionally nasal pledgets)
3. pt sits upright with visible video screen
4. pt flexes head and swallows as scope passes UES
5. air insufflation used to visualize esophagus
6. entire esophagus is visualized down to LES
7. suction/irrigation used as appropriate
Advantages over rigid esophagoscopy
1. same day procedure
2. avoidance of anesthesia/OR
3. magnification of esophagus with improved visualization
4. improved safety with decreased risk of perforation?
5. Coding same as esophagoscopy in OR
TNE is safe, tolerable, and reproducible. It offers a comparable, and in many
ways superior, examination to most rigid esophagoscopy procedures, with the
exception being in the immediate post-cricoid region. As Otolaryngologists
frequently perform esophagoscopy and are skilled endoscopists, clinic
esophagoscopy is a natural skill that can easily be added to their
Early Glottic Cancer: Endoscopic Management
Mark S. Courey, MD
Professor, Department of Otolaryngology/Head and Neck Surgery
Director, Division of Laryngology
The definition of early glottic cancer is variable, but is generally considered to include
neoplastic changes limited to the mucosa of the true vocal folds (carcinoma in-situ – CIS),
neoplastic changes invading through the mucosal basement membrane zone of one or both
vocal folds (T1) or extending to one additional sub-site in the supraglottis (T2). This clinical
classification is inadequate as it does not separate disease based on the bulk of the lesion,
degree of invasiveness, pattern of invasion, or the pattern of superficial involvement of the
disease. This has led to lumping of early glottic cancers into three relatively broad
categories and has not allowed us to accurately determine treatment outcome variables in
terms of voice results and efficacy of treatment options such as radiation therapy or surgery.
Historically, the treatment of early glottic cancer began with endoscopic transoral excision
with forceps, knives and scissors. As anesthetic techniques improved, open transcervical
approaches were developed. These techniques were relatively morbid in terms of voice,
swallowing and airway outcomes, and, therefore, as experience was gained with radiation
therapy, radiation become the preferred mode of treatment due to similar survival rates with
reduced morbidity.
During the late 1970’s and through the 1980’s the CO 2 laser was developed for laryngeal
diseases. Through the work of Robert Ossoff and others, it was established that for small
mid vocal fold lesions not extending to the vocal process or anterior commissure,
endoscopic resection with the CO 2 laser was equal in cure rates to radiation therapy. In
addition, the treatment could be accomplished in one or two outpatient operative
procedures and the cost was significantly less to the health care system than when
radiation therapy was used as the primary mode of therapy.
During the 1990’s Steiner and others extended the indications for the endoscopic
management of early laryngeal cancer and proved that many lesions could be treated
equally well or potentially with better outcomes in terms of morbidity and cure through
endoscopic excision over primary radiation therapy. Subsequent retrospective studies and
case series have shown that endoscopic management is indeed comparable to radiation
therapy in terms of overall disease control and that voice and swallowing outcomes are
dependent on the amount of tissue removed. If the disease is relatively superficial, then
endoscopic management may result in equal or better voice outcomes than primary
radiation therapy at a significant reduction in time and cost to the patient.
The goal for the next phase in treatment is to determine which lesions are best treated in
terms of voice outcome and success of primary therapy through which mode of therapy
(surgery vs. radiation). This will require improved methods of classification or
documentation of disease burden, patterns of invasion, and associated factors at the time of
presentation and treatment. Surgeons will need to learn to classify precisely the extent of
lesion and the extent of surgical resection to allow accurate comparisons. Pathologists will
need to identify appropriate patterns and markers that are associated with disease
outcomes. Finally, Radiation Oncologists will need to better standardize their methods of
David Goldenberg, MD, FACS
Professor of Surgery and Oncology; Director of Head and Neck Surgery, Penn State
Milton S. Hershey Medical Center, Hershey, PA
Abstract: the precarious Airway
A clinical situation involving the patient with a difficult airway can be broadly categorized
into (1) an acute or urgent problem or (2) an elective situation with a known or
suspected anatomical difficulty. Obviously, the 2 scenarios are handled differently. A
logical team approach can prevent a poor outcome in these often-stressful situations.
Securing the airway is the top priority in any critical or resuscitation algorithm. Thus,
ensuring an adequate airway is a basic skill all physicians should possess. The
otolaryngologist– head and neck surgeon (OHNS) has expertise in laryngoscopy,
bronchoscopy, and surgical approaches to the airway and is, therefore, uniquely
qualified to lead a team approach with the anesthesiologist in managing difficult airway
problems. This presentation discusses approaches to the patient with a precarious
airway. Problems are divided into either acute or elective situations. Algorithmic
approaches and specific techniques are reviewed.
Lip Cancer
Christopher Klem, MD, FACS, LTC, MC, USA
Carcinoma of the lip accounts for 25% of oral cavity cancer diagnosed annually in the
United States and is second in frequency only to tongue cancer. Of all cancer in the
head and neck, lip cancer has the most favorable prognosis. Five year survival rates
range from 85-90%. Sun exposure and tobacco use are the main risk factors for
development of carcinoma of the lip. Treatment is complete surgical excision. Adjuvant
radiation therapy can be used in patients with advanced or high-risk tumors.
Reconstruction of lip defects follows the reconstructive ladder from primary closure for
small defects to microvascular free-tissue transfer for total lip and cheek defects.
Recurrent Respiratory Papillomatosis- Treatment Options
Katherine C. Yung, MD
Recurrent respiratory papillomatosis (RRP) is a serious and potentially life
threatening disease that is caused by human papilloma virus (HPV). The exact
mode of transmission remains unclear, but juvenile onset RRP is thought to be
transmitted during gestation or during passage through the birth canal, while
adult onset may be reactivation of a latent infection or a newly acquired sexually
transmitted disease. Lesions most often occur at sites where ciliated and
squamous epithelium are juxtaposed, ie. at the glottis. Surgery remains the
mainstay of therapy, with the aim to eradicate visible lesions from the airway,
improve voice quality, control disease spread, and decrease the frequency of
surgery. There have been many adjuvant therapies proposed, but none have
shown clear benefit in studies. Surgery is typically performed using either a
microdebrider or a CO2 laser. The advantages of the microdebrider include a
shorter procedure time, decreased cost, and avoidance of risk for airway fire. The
CO2 laser affords greater precision, hemostasis, and is safer for sessile lesions.
The recent development of pattern generators for the CO2 laser allows the
surgeon to control the depth of incision or ablation, while decreasing operating
time by using a computer to generate lines up to 5mm in length and circles up to
4mm in diameter. The advent of channeled distal chip flexible endoscopes
enable physicians to now treat RRP in the office with laser fibers. Adjuvant
therapies that have been studied include 
-interferon, indole-3-carbinol,
acyclovir, ribavirin, mumps vaccine, cidofovir, among otheres. 
-interferon was
shown to have significant improvement in disease burden, with worsening of
disease after discontinuation. However, due to severe unfavorable side effects,
-interferon is not currently recommended as an adjuvant therapy. The evidence
for cidofovir efficacy is mixed, but the RRP taskforce recommends that it should
be offered as a treatment option in moderate-severe cases of RRP. Adjuvant
therapies for RRP currently under study are celecoxib and bevacizumab. Pilot
studies have been promising and we eagerly await the results of the clinical
trials. Lastly, the quadrivalent vaccine Gardisil could have a significant impact on
RRP. Although there is no therapeutic application for the vaccine at present,
there is a possibility that future incidence of RRP could dramatically decrease if
rates of HPV infection decline as a result of the vaccine.
10:30-11:00 18 February 2012 Tinnitus: Current Concepts
Steven W. Cheung
Subjective tinnitus, or head noises, affects 10-15% of the general population.
About 20% of tinnitus patients suffer from sleep disturbance, hearing trouble, and
depression. By far, hearing loss is the single most important predisposing factor
in tinnitus. While moderately troublesome tinnitus may be helped with hearing
aids, behavioral retraining, and/or mood altering medications, there is virtually no
effective medical or surgical therapy for catastrophic tinnitus.
Over the past two decades, cellular and brain imaging studies indicate
hyperactivity of the central auditory system plays an important role in the genesis
and persistence of tinnitus. That is, tinnitus can no longer be considered
primarily a problem of cochlear dysfunction. Chronic tinnitus appears to be
represented in brain networks.
Recent neuromodulatory approaches have focused on brain stimulation to
suppress tinnitus. Neuromodulation of auditory cortical function by repetitive
transcranial magnetic stimulation (rTMS) and direct electrical stimulation have
shown inconsistent results for suppressing tinnitus. Deep brain stimulation of the
basal ganglia has emerged as another candidate treatment modality to manage
troublesome tinnitus.
Learning Objectives
At the conclusion of this presentation, participants should be able to:
1. Describe current theories of tinnitus pathogenesis
2. Understand non-surgical therapies for tinnitus mitigation
3. Discuss emerging neuromodulation therapies for unremitting tinnitus
Endoscopic Dacryocystorhinostomy (DCR)
Steven D. Pletcher
Dacryocystorhinostomy – Opening of the nasolacrimal sac into the nasal
- Used to treat nasolacrimal duct obstruction
- Most patients present with epiphora, chronic dacryocystitis, and/or
Key Points:
1) Open and Endoscopic DCR have similar success rates (around 90%)
- Choice for procedure generally made by ophthalmologist
- Endoscopic approach frequently reserved for revision/challenging cases
2) Anatomy
- Superior and inferior punctum open to superior and inferior canaliculi
- Canaliculi come together to form common canaliculus prior to entering superior
aspect of the nasolacrimal sac
- DCR helpful for obstruction at or distal to the junction of the common
canaliculus and nasolacrimal sac
Surgical Technique:
1) Identification of the Nasolacrimal Sac
- Typically located at the anterior/superior attachment of the middle turbinate
- Can localize using lighted DCR probes
- Posterior aspect of nasolacrimal sac may extend into ethmoid cavity
2) Removal of the Medial Wall of the Nasolacrimal Sac
- Must first remove overlying lacrimal bone; typically done with drill
- Enter Sac with sickle knife after “tenting” with lacrimal probes
- Remove entire medial wall of Nasolacrimal Sac
3) Visualization of the internal common punctum
- Leaving bone and/or sac mucosa overlying the superior aspect of the
nasolacrimal sac is common reason for failure
- Visualization of both probes passing unobstructed through the same hole
(internal common punctum) into the sac ensures adequate superior tissue
- Probes should pass easily and remain parallel to the common canaliculus
- Stenting
- Mucosal Flap Preservation
- Mitomycin C
Clinical Pearls:
- Location of Nasion correlates with nasolacrimal sac location
- Be vigilant about neoplasms leading to nasolacrimal duct obstruction (send
biopsies of any abnormal appearing tissue)
- Use Adjunctive Techniques for altered anatomy/difficult cases (Image guidance,
light probes)
Ménière's Disease
Mitchell J. Ramsey, MD, LTC, MC, USA
This presentation we will review the pathologic features, diagnosis and
clinical management of Ménière's Disease. The basic pathologic feature is
endolymphatic hydrops or fluid buildup in the cochlear duct. Originally this process
was thought result from abnormal fluid mechanics resulting in either poor
absorption or overproduction. Distention of the membranes resulted in hydrops
and eventually increased pressure led to membrane rupture and paralysis of the
sensory epithelium and an episode of symptoms. Although the pathology remains
a mystery it is much more complex and likely related to disturbances in the
endolymphatic space resulting from multiple causes. The pathologic feature of
hydrops is likely a result rather than a cause of the disease. A clearer
understanding of the disease will enable us to provide improved management.
Ménière's disease is characterized by a constellation of four symptoms
consisting of episodic vertigo, tinnitus, fullness and fluctuating hearing loss. Other
variations of the disease can also occur and over the course of the disease the
symptoms and clinical feature may change often resulting in ‘burn out” in the later
phases. Diagnostic testing can provide some information that is suggestive of
Ménière's but there are no definitive diagnostic tests. The diagnosis is made by
history and includes the presence of two or more episodes of vertigo lasting 20
minutes or more, tinnitus, hearing loss, and a feeling of fullness in the ear.
Ménière’s disease must be differentiated from other causes of episodic vertigo.
The differential diagnosis of vertigo is large considering the multisystem nature of
our balance system. Since the diagnosis is made clinically attention to the history
is critical. A possible relationship between Migraine and Ménière’s has been
suggested in the past but the relationship if any remains unknown. Migraine is
emerging as a common condition causing dizziness that must be distinguished
from Ménière’s disease. Other peripheral causes of vertigo are generally more
easily distinguished from Ménière’s.
The management of Ménière's generally consists of conservative measures
including diet modification and medical management. The surgical management of
the disease is varied consisting of non-ablative and ablative measures. Surgery
has diminished in frequency and significance giving way to intratympanic
therapies. Intratympanic therapy is gaining popularity and evidence is increasing
to support its use. Two major drugs are used including steroids aimed at reducing
the inflammatory process and gentamycin (ototoxic) aimed at ablating the system.
The literature behind these two methods, indications, methods and results of
intratympanic therapy will be presented.
Abstract - Pacific Rim Otolaryngology
The Dizzy Patient: Simple Diagnosis, Simpler Treatment
Lawrence Lustig, MD
The treatment of the dizzy patient is often thought of as complex and
complicated. One reason for this misconception is due to the varied nature in
which patients present, and a common belief that little can be done to help these
patients. If fact, by distilling down the history and presentation of these patients,
the diagnosis can often be narrowed to one or two clinical entities. Response to
treatment subsequently confirms the diagnosis in a majority of cases.
The history is perhaps the most important aspect of the evaluation of the
patient with dizziness. A lengthy questionnaire, filled out prior to the visit, will
help the patient focus on the clinical problem and expedite the history taking in
the office. The 3 most important features to garner include: 1) Establishing that
the dizziness is in fact true vertigo; 2) The timing of the vertigo episodes
(seconds, hours, or days); and 3) Whether or not there is associated hearing loss
with each episode of vertigo. Ascertaining these 3 aspects of the vertigo spells
will go a long way towards a correct diagnosis in most cases, per the following
Episode Timing
+Hearing Loss
-Hearing Loss
Vestib neronitis
Note in the chart above how migraine can present with just about any form
of dizziness. In our experience, migraine-associated dizziness is often
underdiagnosed, because it doesn’t present in a uniform fashion, and often does
not appear in direct association with ‘classic’ migraine headaches. These
patients will often have other migraine ‘markers’, including photosensitivity,
sounds sensitivity, motion sensitivity, and disturbances in their visual fields.
Testing is an important part of the evaluation of the dizzy patient, and
most commonly includes audiometry and videonystagmography (VNG). A
majority of the tests in the VNG battery are used to assess centrally-mediated
balance. Rotatory chair testing is a useful tool for evaluating bilateral vestibular
dysfunction. Newer testing modalities, including vestibular evoked myogenic
potentials (VEMPs), allow us to test saccular and utricular function individually
using standard ABR recording equipment, and are also important for diagnosing
the unusual entity, superior semicircular canal dehiscence (as well as other
labyrinthine dehiscences).
Following the paradigm as outlined above will yield the correct diagnosis
in a majority of cases. Once the correct diagnosis is made, treatment is relatively
straightforward, depending upon the specific entity. In particular, treatment
strategies for migraine-associated dizziness will be discussed in detail, as this is
something that will be commonly seen by anyone who sees dizzy patients.
Pituitary Surgery Update
Ivan H. El-Sayed, MD, FACS
Pituitary surgery has come a long way since Caton and Paul performed the first
resection in 1873 via a transcranial approach. A variety of approaches have been
described over the years with a trend toward minimizing the approach and morbidity.
Modern surgery is often now performed through a transnasal approach with a
microscope, or more recently and endoscope. The endoscopic approach can address
lesions of the sella or be expanded superiorly to include supracellar lesions or inferiorly
to the clivus. Otolaryngologist can aid in the management of pituitary lesions by
working with their neurosurgical colleagues in an expanded endonasal approach (EEA).
This two surgeon, four handed surgery improves visualization, allows for fine dissection
working within the confines of the nasal cavity. This approach is useful to manage a
variety of lesions in the region of the sella with extension beyond, such a
macroadenomas, Rathke's cyst, clival chordoma's while minimizing the approach. This
talk will review the history, anatomy and update on surgical approaches and care of
patients with pituitary and adjacent lesions.
The vast majority of temporomandibular joint problems are nonsurgical, likely greater than 95%. Many
of these patients have had longstanding low to moderate pain and seek a “quick fix” to their problems
and suffering. With some simple understanding of the joint and the etiology of the pain some relief can
be attained. On the initial presentation an accurate history is mandatory. Particularly a history of
trauma, prior surgery to the joints, arthritis or other pathology should be noted. Imaging studies are
very helpful with your diagnosis. Namely, plain film xrays such as panoramic, Townes view and lateral
skull are helpful initially. Let their findings serve as a guide for other imaging studies as necessary (CT
scan/MRI) Don’t jump to ordering an MRI off the bat. The physical exam of the average TMJ pt will
reveal joint noises such as opening snap/pop, grinding, clicking, locking open or closed. Palpation of the
muscles of mastication may reveal pain on the pterygoids, massester, temporalis or buccinators. If you
find a mouth full of bad teeth it is important to rule out any odontogenic source first. Your exam
findings will guide your treatment. Should any gross hard or soft tissue pathology become noted on the
imaging studies (such as tumors, disk perforation, fractures, rheumatoid arthritis etc.) refer pt to a
practitioner that specializes in TMJ surgery. A differentiator to discern whether the problem is
intracapsular (ie disc problem) vs a myofascial problem is to have the pt move jaw laterally. If no lateral
movement then likely a disc/internal problem. If your exam findings reveal generalized tenderness of
the muscles of mastication without jaw locking, a history of headaches and possible bruxism,
nonsurgical management is generally successful. It would consist of stress reduction, soft diet, limitation
of stimulants such as caffeine/nicotine, Rx for muscle relaxants, NSAID’s, eliminate any parafunctional
habits, have a dentist fabricate an occlusal splint, warm/moist heat and possible use of low dose
tricyclics at night (elavil 10mg qHS). Many of these pts are taking SSRI’s, these drugs will cause bruxism.
A discussion with primary care provider to stop SSRI use may be in order depending on success of
treatment. For pts noted to have articular problems such as closed lock/restricted opening or a loud
opening pop and pain, that can be caused by anteriorly displaced disc, an arthrocentesis procedure can
provide relief. This can be done in the clinic under sedation. For the pts that continue to have pain after
an arthrocentesis and other conservative measures, a condylotomy or “IVRO” surgery can help to
“settle” or reposition the condyle in a more normal position for the pt therefore relieving pain. The pts
noted to have a history of problematic open lock can have a prominent eminence on the glenoid fossa
preventing smooth translation of the condyle. This can be alleviated by eminectomy such that the slope
of the eminence is less steep and allows the condyle to glide back into the fossa. Surgery should be
reserved as a last resort for most TMJ pts and intracapsular surgery in particular. Likewise, it is
important to assure the pts that their symptoms can be alleviated but it will take some time and a quick
fix isn’t likely. Frequently psychosocial issues will need to be managed with the aid of their primary care
J.J. Closmann Chief OMFS Tripler AMC Hawaii
Avoiding Complications in Endoscopic Sinus Surgery
Steven D. Pletcher
Case-based approach
Goal: Identify practices and techniques to minimize the risks of endoscopic sinus
Key Points:
1) Carefully study preoperative imaging
- Mental surgery on the CT scan
- Trace imaging of critical surrounding structures
2) Maintain visualization
- Adequate hemostasis
- Step-wise surgery
- Angled endoscopes as required
3) Caution with Middle Turbinate Resection
- Slope of skull base/Keros classification
- Fragile bone in Cribriform region
4) Caution with the Microdebrider/Shaver
- Mucosal sparing; may prevent synechiae when used correctly
- Rapidly removes tissue; can be disastrous with intracranial/intraorbital
- Most major complications today involve microdebrider use
Orbital complications
- Careful removal of the uncinate
- Identify medial orbital wall
- Palpation of the globe during surgery
CSF leak/intracranial complications
- Early recognition key
- Middle Turbinate Resection
- Sclerotic bone near skull base (revision surgery)
- Skull base variations
- Mis-identification of the sphenoid
- Preoperative treatment
- Intaoperative injections and vasoconstrictors
- Knowledge of the vascular anatomy of the nose
- Intraoperative control with directed packing and/or cautery
- Carotid anatomy
Techniques in Cartilage Tympanoplasty
John Dornhoffer MD, FACS
University of Arkansas for Medical Sciences
Little Rock, Arkansas, USA
Many graft materials are available for the reconstruction of tympanic
membrane (TM) defects, with temporalis fascia and perichondrium being the
most common. In certain situations, such as atelectatic TM, cholesteatoma, and
revision cases, results with the more traditional materials have not been as
gratifying. Cartilage, because of its more rigid quality, tends to resist resorption
and retraction in these more difficult cases. While the concept of TM
reconstruction with cartilage is not new, its routine acceptance as an alternative
graft material has been hampered by lack of understanding of the surgical
indications, techniques, and functional results of this material.
Our experience with over 3000 cartilage tympanoplasties will be discussed .
We have found the functional results with regard to hearing and graft-take to be
excellent compared to more traditional techniques. Both the perichondrium island
flap and the mosaic reconstruction, with cartilage harvested from the tragus and
concha, respectively, have been utilized and proven advantageous in TM
reconstruction. The palisade technique has proven useful when ossiculoplasty is
performed whereas the island flap is utilized in large perforations and atelectatic
ears. This presentation will provide instruction in surgical indications, both
cartilage techniques, outcome, and complication management.
David Goldenberg, MD, FACS
Professor of Surgery and Oncology; Director of Head and Neck Surgery, Penn State
Milton S. Hershey Medical Center, Hershey, PA
Abstract: Revision Thyroid surgery
There are circumstances when re-operation of the thyroid may be necessary,
including multinodular goiter with recurrent symptoms, residual or recurrent cancer, or
pathologic finding of invasive cancer after a hemithyroidectomy is accomplished. Reoperative surgery is usually technically more difficult because the inflammation and
scarring from the first operation can obscure tissue planes and make identification of
important structures, especially the RLN and parathyroid glands, more challenging.
Accordingly, there is up to a ten-fold increase in iatrogenic injuries and the risk of
complications appears to increase with the number of re-operations. This presentation
discusses a indications for and diagnostic and operative techniques used to perform
successful reoperative thyroid surgery.
Contemporary Treatment of Facial Paralysis
P. Daniel Knott, MD FACS
Director, Facial Plastic and Reconstructive Surgery
UCSF Medical Center
1. Facial paralysis is a complicated topic related with multiple disease states with
time-dependent diagnostic and treatment factors.
2. Patients with facial paralysis are often social pariahs, shunning face-to-face
3. Facial expressivity is a critical component of overall communication and lack of
expressivity tremendously affects listener’s attitudes and understanding.
4. Mechanism and degree of nerve injury is very important when considering
treatment, as directly related to expected time to recovery.
5. Ocular complications are the most important immediate issues, and there are
many ways to temporize: taping, ointments, tarsorraphy, moisture chamber, . .
6. Potential exacerbating factors that should be examined: Bell’s phenomenon,
corneal anesthesia, history of dry eye syndrome.
7. Lateral tarsal strip and upper lid weighting operation may rehabilitate ocular
manifestations, and are reversible. Platinum chain preferable to gold weight,
although gold weight acceptable in vast majority of patients. Usually performed in
clinic/procedure room setting.
8. Brow ptosis is less pressing need and may safely be observed. If leads to
asymmetry at rest or visual field disturbance, may be addressed with
contralateral frontalis botulinum toxin, endoscopic or open brow lift.
9. Upper third of the face may therefore be rehabilitated safely and effectively
without nerve or muscle grafts.
10. If nerve recovery is uncertain, EMG may be very useful for assessing
ongoing recovery.
11. Cranial nerve 12-7 or 5-7 grafts may be performed within the first 2 years of
nerve injury to maintain tone, and even some meaningful function.
12. These grafts may also serve as “baby-sitter” grafts until cross-facial grafting
may be performed.
13. Orthodromic temporalis tendon transfer offers immediate reanimation of the
lips without altering facial contour or requiring free tissue transfer.
14. Symmetry at rest is usually attainable, with gross symmetry during animation
is usually attainable.
15. Facial retraining and therapy are critical for ultimate success.
16. Anterolateral thigh free flap very useful for post-parotidectomy contour
rehabilitation, with motor nerves available for grafting and fascia lata available for
temporalis tendon transfer.
Turbinate Surgery 2012
LTC Scott Roofe, MD, FACS
Chief, Facial Plastic and Reconstructive Surgery
Tripler Army Medical Center, Hawaii
Turbinate surgery was first performed well over 100 years ago with nearly innumerable
modifications over the ensuing decades. Today, it is one of the most common
procedures performed by the rhinologic surgeon for the treatment of nasal congestion
and refractory allergic rhinitis. Recently there has been an explosion in technology and
tools available for sinonasal surgery and there are a variety of new techniques available
for turbinoplasty. These include radiofrequency ablation, laser turbinoplasty, and the
microdebrider. This presentation includes a discussion of the various techniques and
review of the literature on the most recent advances in turbinate surgery.
Advanced Head and Neck Skin Cancer
Ivan H. El-Sayed, MD, FACS
The AJCC identifies 82 nonmelanomatous skin cancers with a wide variability of
prognosis. In the United States, non melanoma skin cancer is the most frequent
cancer . The majority of non melanoma skin cancers present as early stage tumors
which are managed with local excision or Moh’s microsurgery. Of these tumors,
squamous cell cancer (SCC) and Basal cell cancer (BCC) comprise the majority of
tumors. SCC accounts for the majority of non melanoma deaths, and 20% of cutaneous
malignancy deaths over all. A rare tumor, Merkel cell carcinoma has a very aggressive
course due its tendancy to metastasize, and recognition of this entity is important.
Tumor staging of SCC and BCC is based on size, location, presence of high risk
features,extent of invasion, and nodal and distant spread. Occasionaly, due to a variety
of reasons such as neglect, immunosuppression, genetic conditions, tumors can grow
extensively and management of such lesions is difficult. In the head and neck, special
considerations are given to the tumor location, local invasion and risk of metastases.
Intracranial penetration of tumors the scalp present unique challenges requiring
multidisciplinary decision making, and data regarding outcomes is limited. This talk
presents an overview of management issues with advanced Head and Neck cutaneous
malignancies with focus on SCC and BCC with intracranial extension.
Management of Zenker’s Diverticulum and Cricopharyngeal Achalasia
Mark S. Courey, MD
Professor, UCSF Department of Otolaryngology/Head and Neck Surgery
Director, Division of Laryngology
Symptoms attributable to Zenker’s Diverticulum (ZD) and Cricopharyngeal achalasia
both result from failure of cricopharyngeal muscle (CP) relaxation during swallowing.
The CP is tonically contracted at rest presumably to prevent reflux of esophageal
contents into the pharynx. The CP normally relaxes – experiences a reduction in tone –
reflexively during swallowing. This has been demonstrated on electromygraphic
studies. In CP achalasia, the tone of the CP muscle is increased at rest and fails to
relax reflexively during swallowing. This has been shown to be associated with overall
pharyngeal dilation and a reduction in pharyngeal pressures. In ZD, the CP remains
prominent during swallowing and a pouch or pulsion diverticulum forms over the top of
and behind the muscle. The mucosa of the pharynx herniates through Killian’s triangle
(an area of natural dehiscence between the inferior constrictor and CP) to form a pouch.
This is does not involve the muscular layers of the esophagus and is not associated
with pharyngeal dilation.
It has been proposed by some that CP achalasia and ZD represent a continuum of
disease and that left untreated, CP achalasia will result in the development of ZD.
While this theory may be attractive, true association and/or causation have never been
shown in either animal models or through human study. In addition, it has been
demonstrated that in general, patients with CP Achalasia are more commonly found to
have additional swallowing deficits in terms of diffuse pharyngeal muscle weakness,
failure of hyolaryngeal elevation and reductions in tongue strength than patients with
ZD. These associated pharyngeal deficits complicate the surgical management of CP
achalasia and result in a reduced success rate of surgery in patients with CP achalasia
than patients with ZD.
While historically management of ZD was directed at suspending the pouch to allow
gravity drainage, contemporary management of both CP achalasia and ZD is primarily
directed at reducing the strength or tone of the CP muscle. This can be accomplished
through dilation, injection of Botox®, or surgically incising the muscle either in an open
or endoscopic manner. In recent years, due to reduced morbidity and reduced healing
times, endoscopic management has increased in popularity over traditional open
approaches for both CP achalasia and ZD. The successes of the surgical techniques
depend on the skills and experience of the surgeon as well as patient factors which
allow adequate exposure and the overall extent of the disease. No one technique has
been shown to be effective or applicable in all patients. Therefore, the successful
surgeon must appreciate the limiting factors and be familiar with multiple methods of
Cochlear Implants, 2012 - Lawrence Lustig, MD
There have now been over 150,000 cochlear implants placed worldwide.
When first introduced they were implanted in only those adults with the most
profound hearing loss. With advancing technology and improved performance,
they are now available to children and adults with severe hearing losses and
limited hearing aid benefit. This talk will focus on advances in the field of
cochlear implantation over the past several years, and include a discussion of
expanding indications, bilateral cochlear implants, electric-acoustic hybrid
stimulation and drug delivery.
One issue that repeatedly arises in patients deciding upon whether to
pursue a cochlear implant involves timing – that is, when is the best time to get
implanted and still take advantage of the latest technology? However, what
needs to be taken into consideration is that the success with cochlear implants is
inversely related to the length of time between the onset of deafness and when
the implant is placed. While having the optimal technology available is important,
it is equally, if not more important, to maximize the underlying ‘biology’, and the
longer one waits, the more changes will occur to the underlying neural structure
of the inner ear and acoustic pathways which may harm performance with the
A second issue that arises for many adults is whether to implant both ears.
What we now know from a number of studies, as well as recent results with
hybrid cochlear implants, is that patients can benefit from residual hearing, by
wearing a hearing aid on one ear and the implant on the other. This
arrangements allows the hearing aid to pick up the more natural acoustic low
frequencies, important for sound quality and ‘tembre’, while the implant side will
pick up the critical mid- to high-frequencies for speech understanding. Thus, in
this dual, or combined mode, patients will perform much better than with either
ear alone. However, when no residual or useful hearing is available, then
implanting both sides will allow the patient to perform much better in noisy
backgrounds and have the ability to localize sounds.
For many patients, there is good residual low frequency hearing but no
high frequency hearing, for example those with age-related hearing loss or
severe noise-induced hearing loss. These patients are not within traditional
cochlear implant candidacy range, yet they are extremely poor performers with
hearing aids. For these patients, “Hybrid” cochlear implants or “EAS” (electricacoustic stimulation) can be quite beneficial. This talk will discuss candidacy
criteria for Hybrid cochlear implants and recent results with this exciting
Lastly, as our results from cochlear implants shift from simply providing
speech understanding to much more complicated tasks including music
appreciation, technology is turning to drug delivery. It is anticipated that drug
delivery to the cochlear in association with the implant will improve cochlear
implant performance in the short-term, and ultimately over the long-term, replace
cochlear implant technology altogether.
Much of the trauma literature refers to Zones of the Neck shown above. The bottom line is in
general, zones I and III are studied preferentially rather than surgically explored and zone II
which contains the larynx is more accessible for exploration. Studies generally involved CT
angiograms in our practice.
Laryngeal trauma can be divided into intrinsic and extrinsic trauma.
Intrinsic Trauma
Vocal cord paralysis
Vocal cord granuloma
Subglottic stenosis
Anterior commissure webbing
Airway perforation
Laryngeal tears
Arytenoid dislocation
Laryngeal deconditioning
Extrinsic Injury
1. Penetrating trauma
2. Blunt Trauma
Indications for immediate laryngeal exploration:
1. Air blowing through wound
2. Active exanguination
Schaeffer Classification
Group 1: Minor endolaryngeal hematoma or laceration
Group 2: Severe soft tissue injury, single fracture
Group 3: Massive edema, exposed cartilage, displaced fracture, TVF paralysis
Group 4: Unstable larynx, comminuted fracture
Group 5: Laryngotracheal separation
Surgical Indications:
1. Goup III-V
2. Laceration of Anterior Commisure
3. Laceration of free edge of true vocal fold
4. Exposed cartilage
5. Comminuted or displaced fracture
6. TVF immobility
7. Arytenoid dislocation
8. Loss of cricoid integrity
Head and Neck Sarcoma
William R. Ryan, MD
Assistant Professor
Head and Neck Oncologic/Endocrine Surgery
Department of Otolaryngology-Head and Neck Surgery
UCSF Medical Center
Head and neck sarcoma is a rare and heterogeneous group of cancers.
Several subtypes exist with differing incidence, natural history, and prognosis.
The rare nature of head and neck sarcoma makes analysis challenging.
Osteosarcoma, malignant fibrous histiocytoma, and angiosarcoma are the most
common in adults.
Radiation is a risk factor for head and neck sarcoma.
Fine needle aspiration biopsy is sometimes insufficient for diagnosis.
Surgery with negative margins and possible post-operative radiation are the
current mainstays of therapy.
Negative margins are more difficult to achieve in the head and neck.
Post-operative radiation has a role with high grade and positive margins.
Chemotherapies may have a role preoperatively or postoperatively for
decreasing local recurrence.
Close follow up to detect local recurrence early is important.
Rhabdomyosarcoma is the most common in children. It can be treated in some
cases without surgery.
Multi-institutional cancer registries/studies may assist in further understanding.
Benjamin Cable M.D. Pacific Rim Otolaryngology Update
Tympanostomy Update
AAO OME Guideline Summary
1. Pneumotoscopy should be the primary method to diagnose OME (Sens
94% - Spec 80%)
2. Tympanometry should be used if the otoscopic diagnosis is uncertain
(Older than 4 months only)
3. Population based screening programs are not recommended for healthy
4. “At Risk” OME (any duration) patients should be treated more
aggressively than children not “At risk”
a. “At risk” Children
i. Permanent hearing loss independent of OME
ii. Suspected or diagnosed speech / language delay
iii. Autism spectrum disorder
iv. Syndromes which include cognitive, speech, or language
v. Visual impairment
vi. Cleft palate
vii. Developmental delay
b. Treatment recommended for OME “At risk” children
i. Hearing testing
ii. Speech and language evaluation
iii. Tubes vs. amplification
iv. Follow-up after intervention
5. Not “At Risk” OME – less than 3 months
a. Observe with behavioral modifications (i. e. Face child while
speaking / Preferential seating)
6. Not “At Risk” OME – more than 3 months or at any sign of significant
hearing loss/lang. delay
a. Hearing test
b. Language test if pure tone average > 20dB HLP
c. If hearing loss (in better hearing ear)
i. >40db – tubes
ii. 21-39dB – “individualized therapy”
iii. <20 db – repeat audio in 3-6 months
7. If tubes chosen
a. No adenoidectomy with first placement
b. Adenoidectomy with second set of tubes (i.e. no changes here)
New Pediatric Tonsillectomy and Sleep Study Guidelines 2011
Anna K. Meyer, MD, FAAP
Obama has highlighted tonsillectomy and questioned if too many are being performed.
Multidisciplinary taskforce developed evidence-based guidelines to improve quality of care and limit
unnecessary surgeries.
Goals of guidelines
o Clarify identification of appropriate candidates
o Improve operative and peri-operative care
o Improve communication with patient families
Summary of Guidelines
o Most children will outgrow frequent throat infections and surgery imparts only modestly better
outcomes when the strictest criteria are followed
o 7 or more episodes in 1 year, 5 per year for the past two years, 3 per year for the past 3 years
o An episode should include sore throat with at least one of the following: fever >38.3 C, tender
or >2 cm cervical lymphadenopathy, tonsillar exudate, positive GABHS culture
o Modifying factors may be considered in children who do not fulfill criteria (e.g. history of
peritonsillar abscess, antibiotic intolerance/allergy, PFAPA)
o Clinicians should ask caregivers of children about comorbidities associated with sleepdisordered breathing such as growth retardation, poor school performance, enuresis, and
behavioral problems. They should counsel families that these may improve after tonsillectomy.
o Families should be advised that SDB may persist after tonsillectomy, especially in those with
syndromes and obesity.
o Intra-operative steroids should be administered to reduce post-operative nausea and vomiting.
o Perioperative antibiotics are not recommended to be given routinely.
o Clinicians should actively discuss and educate about pain management with the families of
 Post-operative NSAIDS , other than toradol, do not confer an increased risk of postoperative hemorrhage.
 Codeine does not confer better pain relief than Tylenol and a substantial portion of the
population are either hyper- or hypometabolizers of codeine.
o Clinicians should assess their personal post-tonsillectomy hemorrhage rate annually.
o Clinicians should counsel families that children with abnormal polysomnography (PSG), tonsil
hypertrophy, and sleep-disordered breathing may benefit from tonsillectomy.
o Children with SDB and obesity, Down syndrome or other craniofacial syndromes,
neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses should undergo preoperative PSG.
o Children whose symptoms do not correlate with their exam should undergo pre-operative PSG.
o PSG results should be communicated by the physician to the anesthesiologist prior to induction.
o Children with severe OSA (AHI>10 and/or oxygen <80%) or who are under 3 years of age
should be admitted post-operatively.
o Laboratory-based PSG is preferred to unattended PSG with portable monitoring device.
Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to
Tonsillectomy in Children. Otolaryngol Head Neck Surg. 2011 Jul;145(1 Suppl):S1-15. Epub 2011 Jun 15.
Baugh RF, Archer SM, Mitchell RB, et al., Clinical Practice Guideline: Tonsillectomy in Children. Otolaryngol Head Neck Surg. 2011
Jan;144(1 Suppl):S1-30.
Management of Inverted Papilloma
Andrew N. Goldberg, MD, MSCE
Disclosures - Apnicure; Siesta Medical; Acclarent Sleep Division
Inverted Papilloma
Benign Nasal Epithelial Tumor
Described by Ward in 1854
Invasiveness described by Ringertz in 1938
Uncommon tumor ~ 0.6 cases / 100,000 population
Associated with HPV 11, 16, 18 in 30/38 cases Zhou 1997
Characterized by - Tendency to invade bone; Tendency to recur; SCCa
Be suspicious of any unilateral process in the sinuses!!
What needs to be done to treat this tumor?
Resection of tumor including the tumor base; Removal of bone, or burring base
Currently, no medical management strategies are available
Evolution of Surgical Approach
Transnasal approaches resulted in a high recurrence rate - up to 75% for “polypectomy”
Wide local excision was recommended Hyams AnnORL 1971
Radical surgery was gradually replaced by more tailored approaches; Lawson Laryn 1983
Medial Maxillectomy was recommended through 1990; Myers Laryn 1990
Surgical Management
Open approach advantages
Possibility for en block resection (not always realized!)
Access to areas not well instrumented endoscopically
Anterior Maxillary Sinus; Region of the nasolacrimal duct; Superior and lateral frontal sinus
How do you decide what resection to do?
What approach to use?
Tumor base access / Surgeon pref
Results of Open and Endoscopic Approaches
Endoscopic recurrence rate 12%; open 18%
Endoscopic Approaches
Improved precision for resection of involved areas
Realization that site of attachment may be small and other structures can be spared
Greatly improved visualization to determine site of attachment before resection is complete
Improved follow up in the office to detect and resect recurrences early
Targeted Approach to Base of Lesion
Site of attachment may be small
Inverted papilloma of the nose and paranasal sinuses can be resected with low incidence of
Endoscopic approaches allow for reduced morbidity
Endoscopic visualization of the attachment is superior to open techniques, in my opinion
Improved instrumentation and techniques will continue to evolve
Office Evaluation of Dysphagia
Katherine C. Yung, MD
Patients in an otolaryngology practice commonly present with the complaint of
difficulty swallowing. Dysphagia can affect a significant portion of the elderly,
those with neurologic insults, and also can be a result of neoplastic disease or
treatment. Dysphagia can be a result of deficits at any or all of the levels of
swallowing. When obtaining the patient history, the physician should ask
swallowing specific questions to investigate the etiology, the severity of the
dysphagia, and associated symptoms. During the physical examination, the
physician should perform a cranial nerve examination, paying special attention to
tongue function and strength, palate function, hyolaryngeal elevation, patterns of
pooling, tongue base movement, vocal fold mobility, and pharyngeal wall motion.
Further swallowing evaluation can be performed in the office by performing a
fiberoptic endoscopic evaluation of swallowing (FEES). If there is a question of
upper esophageal pathology, a modified barium swallow with esophagram
should be considered. Additional testing is considered based on the patient’s
complaint and the physical examination findings, but may include CT or MR
imaging, esophagoscopy, manometry, and pH probe study. Once the etiology of
the dysphagia is determined, treatment can be tailored. Surgical treatment is
typically considered for stenosis/stricture, diverticula, cricopharyngeal
hypertrophy, or vocal fold mobility impairment. Patients with oral cavity or
pharyngeal muscle weakness, or increased muscle tension are better suited for
swallowing exercises and/or modifications. Dysphagia has a significant impact on
a patient’s quality of life as well as overall health status. The diagnosis can be
complex and requires assimilation of a wide array of information. The evaluation
and treatment of dysphagia requires a multi-disciplinary team including the
physician and speech language pathologist to address diet modifications,
behavioral therapy, and surgery.
Pediatric Vascular Malformations Update
Anna K. Meyer, MD FAAP
Understand the natural history of infantile hemangiomas (IH)
Identify lesions that can masquerade as IH
Recognize high risk IH
Differentiate IH that requires treatment from that which does not
Understand how beta-blockers have changed our management of IH
Understant treatment options for IH
Natural history of IH:
• Most IH undergo a period of rapid growth is between 4-6 weeks of age and 80% of growth is done by 34 months. They may continue to proliferate over ~6-9 months. Those that are deep & segmental may
grow for longer. IH slowly involute over years.
• Several types of IH exist including those that are superficial, deep or mixed superficial/deep. Deep
hemangiomas are often mistaken for other entities, such as lymphatic malformations. IH may also be
focal (limited area) or segmental (large areas, distinct from dermatomes).
• Many skin lesions may masquerade as IH. These include nevus simplex (stork bite, angel kiss),
congenital hemangioma, tufted angioma, pyogenic granuloma, vascular malformations.
• Only IH are positive for Glut-1 on pathology staining.
Complicated IH:
• IH that are at risk for complications such as ulceration or disfigurement after involution are those on the
face, especially the lip/perioral, the eye/periorbital regions, the nose, and the ear. Those that are large
or segmental, have a beard distribution or are part of PHACE syndrome also have a higher rate of
complications, especially airway involvement.
• Propranolol has radically changed the management of IH and has rapidly become first line treatment for
complicated IH
• Uncomplicated IH does not require treatment and the risks of propranolol likely outweigh any benefit.
• Side effects of propranolol include bradycardia, hypotension, hypoglycemia, sleep disturbance, and
• Topical timolol has shown promising initial results.
• Other treatment options for the ~10% that do not respond to propranolol include topical treatments,
steroid injection, laser, and surgery.
• Practices should develop a protocol for treating patients with complicated IH and a multidisciplinary
approach is ideal.
Summary :
• Make the right diagnosis
• Be aware of high risk IH and possible complications
• Treat or refer complicated IH early but avoid treating uncomplicated IH.
Eric J. Kezirian, MD, MPH
Division of Sleep Surgery
UCSF Otolaryngology—Head and Neck Surgery
Pacific Rim OHNS Update 2012
Functional Stimulation for OSA
A number of novel (or not so novel) treatments offer indirect and direct stimulation of the
upper airway to treat obstructive sleep apnea. These include speech therapy exercises,
acupuncture, playing of the didgeridoo, and hypoglossal nerve stimulation. These
treatments are intriguing because they either offer less-invasive approaches or can be
used to treat populations that have generally responded poorly to available treatments.
Early results are encouraging, but additional research will evaluate more closely their
role in the treatment of obstructive sleep apnea.
Sublingual Immunotherapy
David Healy, M.D., FAAOA
Sublingual Immunotherapy (SLIT) is commonly used in Europe and other areas,
and is gaining traction in the United States as a viable alternative to traditional
subcutaneous immunotherapy (SCIT). SLIT involves placing antigen into the
sublingual space, typically on a daily basis from home, rather than receiving
weekly subcutaneous injections of antigen in a clinic setting. This at-home
regimen that does not involve injections is preferable to many potential
immunotherapy candidates, and can drastically change the structure of an
allergist’s clinical practice.
Many questions arise regarding this alternative to traditional subcutaneous
-Does it work?
-Is it safe?
-How does it compare to SCIT in controlled trials, and in the population at-large?
-Does the trans-mucosal delivery of antigen change the way the immune system
modulates its response in comparison to subcutaneous delivery?
-Are any sublingual products FDA-approved?
-How is it done, and what would comprise a therapeutic dose?
This presentation will review these issues, and present a common dosing
scheme for SLIT. It will highlight the ongoing scientific controversies regarding
this immunotherapy delivery mechanism, and update the audience on current
efforts for FDA-approval of sublingual antigen.
Oropharyngeal Cancer Epidemiology
William R. Ryan, MD
Assistant Professor
Head and Neck Oncologic/Endocrine Surgery
Department of Otolaryngology-Head and Neck Surgery
UCSF Medical Center
Oropharyngeal Carcinoma (OPC) is increasing in incidence in the context of
anoverall decrease in tobacco use in the U.S.
Risk factors for OPC include tobacco, alcohol, and human papilloma virus (HPV).
HPV-associated OPCs have a significantly better prognosis.
Tobacco/alchohol-related OPCs have worse prognosis, even when also
associated with HPV.
HPV+ OPC and tobacco/alcohol OPC have differing demographics.
Is HPV+ OPC a sexually transmitted form of cancer?
HPV and p16 status are closely correlated but not completely.
Epidermal Growth Factor (EGFR) protein expression may have significance.
Staging of OPC may need to be revised with attention to HPV status.
Screening and vaccination for HPV to could be important in decreasing the
impact of HPV+ OPC.
HPV+ OPCs maybe more appropriately treated with deintensified therapies (e.g.
lower dose radiation, less/different chemotherapy, and/or transoral robotic
Clinical trials are needed to help determine individualized therapies.
Multidisciplinary teams are important for diagnosis, treatment, and surveillance.
LTC Scott Roofe, MD, FACS
Chief, Facial Plastic and Reconstructive Surgery
Tripler Army Medical Center, Hawaii
Rhinoplasty is one of the most challenging operations performed by the
Otolaryngologist and Facial Plastic Surgeon, even in the most experienced hands. In
some reports, the rate of revision surgery approaches 15%. These revision surgeries
range from minor procedures to major reconstruction to improve cosmesis and function.
It is important that the rhinoplasty surgeon possesses an armentarium of techniques to
correct any deformities or irregularities following surgery. This presentation discusses a
variety of techniques and methods for nasal revision surgery which may be successfully
used to correct iatrogenic deformities.
Paranasal Sinus Anatomy
David Healy, M.D., FAAOA
A rigorous and detailed understanding of the paranasal sinuses and surrounding
structures is critical to safe and thorough sinus surgery. This presentation will
review paranasal sinus anatomy from the perspective of the sinus surgeon, with
a focus on landmarks and structures that help in specific endoscopic sinus
Elements of this presentation will include:
-The Maxillary Line
-The Anatomy of the Maxillary Antrostomy
-Ethmoid Sinus Anatomy and the Basal Lamella
-Frontal Approaches and the Modified Kuhn Classification of the Frontal Recess
-The Sphenoid Sinus and Anatomic Variations
-Anatomy of the Pterygopalatine Fossa
-Surgical Anatomy of the Sphenopalatine Artery and Ethmoid Arteries
-Paranasal Sinus Anatomic Variants
-Haller Cells and Onodi Cells
This presentation will highlight currently accepted paranasal sinus anatomy
nomenclature, and will endeavor to simplify the complex drainage pathways of
the frontal recess. It will serve as a thorough review of relevant sinus anatomy
for the sinus surgeon.
Eric J. Kezirian, MD, MPH
Division of Sleep Surgery
UCSF Otolaryngology—Head and Neck Surgery
Pacific Rim OHNS Update 2012
Base of Tongue Procedures for OSA
A large proportion of individuals with obstructive sleep apnea experience airway
obstruction in the base of tongue region, also known as the hypopharyngeal region. A
number of surgical procedures are available to treat base of tongue obstruction.
Because the evidence concerning these procedures are limited to case series studies, it
can be difficult to determine which procedures are “best”. This talk will review the most
common available procedures and highlight patient-specific factors associated with
outcomes. The objective will be to provide a synthesis of the available evidence in
order to assist with patient counseling and selection of procedures.
Serendipity in Otolaryngology/Head and Neck Surgery
Andrew H. Murr, MD
Serendipity is an unexpected finding. Many important discoveries have occurred
because physicians have been highly observant . One example of a recent discovery
that was serendipitous was the discovery that propranolol could be used to treat
hemangiomas in infants. A group of ICU doctors in France noted that hemangiomas
involuted quickly in patients who were receiving propranolol for other reasons. They
reported their findings in a letter to the editor in New England Journal of Medicine!
HHT or Weber Osler Rendu Syndrome is the bane of existence for otolaryngologists,
but it is even worse for the patients so afflicted. It is an autosomal dominant condition
whereby there is unstable vasculature. In some cases, there are pathological
connections between venules and arterioles. Several genes have been discovered that
cause HHT. HHT has been divided into 3 general types (I,II,III) with different
characteristics among them. Avastin is a humanized VEGF receptor blockade drug
used to treat different forms of cancer. It was serendipitously discovered to have
potential beneficial therapeutic effect on epistaxis and other symptoms of HHT.
Terrence Davidson at UCSD has had a special interest in this and has published on
different treatment formats to utilize Avastin either topically, intravenously, or via
mucosal injection to improve nasal bleeding symptoms in HHT.
GDC-0449 is a drug that was developed by a special unit of Genentech that works on
the so called Hedgehog pathway. Originally, the idea for the drug came out of an
outbreak of cyclopia in sheep in Northern California who had a diet heavy in California
Cornflowers. As information about the hedgehog pathway became known, the
Genentech group worked to create a drug that was active in parts of the pathway. The
drug seemed to have dramatic effect in patients with Gorlin’s Syndrome which as part of
its manifestation has multiple aggressive basal cell carcinomas occur. It is possible that
GDC-0449 may have therapeutic effects on routine basal cell carcinoma as well.
Sometimes, serendipity is not a positive factor. Bisphosphonate related necrosis of the
jaw appears to occur in patients who have been on oral bisphosphonates like Fosamax
and other related drugs. After their release on the market to treat osteoporosis, it was
discovered that jaw necrosis could occur. Treatment of osteonecrosis of the jaw is
difficult, but a team from University of Washington and Cleveland Clinic has shown that
vascularized bone grafts such as microvascular fibula transfers can effective reconstruct
after this problem has occurred.
What Causes Chronic Sinusitis?
Andrew N. Goldberg, MD, MSCE
Disclosures - Apnicure; Siesta Medical; Acclarent Sleep Division
Unsettling Questions in Sinusitis…
Why do so few people get chronic sinusitis?
Why can some patients pinpoint the date so well?
Why do some of my patients get better?
Why don’t ALL of my patients get better?
Theories on Sinusitis Etiology
Fungus; Super-antigen; Inflammatory; Biofilm
What causes chronic sinusitis? What role do microorganisms have? Are Biofilms important?
How should we Investigate? Type; Form; Quantitate; Connect to disease and environment
What is Microbial Ecology?
The study of micro-organisms and their relationship to each other
Role of the Microbiome - Immunologic and Colonization
The Microbiome in Chronic Sinusitis
Roediger AJR 2010
16S rRNA PhyloChip for standardized comparative bacterial community profiling
Sinusitis patients demonstrated smaller quantity, less evenness, less diversity
Working Hypotheses on CRS and the Microbiome
Sinus cavities possess a diverse bacterial community in healthy individuals
Native microbiome protects against outgrowth of pathogens – colonization resistance
Perturbation - outgrowth of opportunistic pathogens/immunomodulatory species
Induction of immune response/environmental changes by pathogen maintains low bacterial
community diversity and propagates chronicity
How does this relate to chronic sinusitis? What is the proposed pathophysiology?
Normal flora in sinus
Perturbation – viral illness, antibiotics, etc
Alteration of richness (#)/evenness/diversity
Usually – returns to “normal” post infection
Sometimes – continued imbalance of microbiome with altered homeostasis/inflammation
Revolutionary theory on etiology
Supported by studies of c. diff, malaria, asthma, infants
Moves beyond the Biofilm and other theories
Postulating a mechanism for etiology
A mechanism for chronicity
A mechanism for treatment – return to normalcy
Therapy related to reconstitution of normal flora through probiotics or custom mix
10:30-11:00 21 February 2012
Avoiding Complications in Mastoid Surgery Steven W. Cheung
Mastoid surgery for chronic ear disease and other indications can be
enormously satisfying for both the patient and surgeon. Yet the challenge to
eradicate or exteriorized disease without introducing deafness, dizziness, CSF
leak, and facial paralysis can sometimes be daunting. Safety in mastoid surgery
can be enhanced by adopting certain practice guidelines. The primary goal of
this presentation is to review relevant anatomy, surgical techniques, and
monitoring measures that are useful to avoid complications in mastoid surgery.
Learning Objectives
At the conclusion of this presentation, participants should be able to:
1. Recognize complications in mastoid surgery
2. Describe avoidance strategies
3. Discuss role of facial nerve monitoring in mastoid surgery
NCCN Head and Neck Cancers Guidelines Update
David W. Eisele, M. D., F.A.C.S.
Introduction - The NCCN Head and Neck Cancers Guidelines primarily address
appropriate treatments for upper aerodigestive tract cancers, salivary gland
cancers, and mucosal melanomas.
NCCN Guidelines- Developed by physicians at the 21 NCCN member cancer
Explicit review of evidence with expert medical
Category of evidence and consensus
designated for each recommendation
Available free of charge at
Updated at least annually and up to several times per year as new
evidence is available
Categories of evidence and consensus:
Category 1: based on high-level evidence, there is uniform NCCN
consensus that the intervention is appropriate
Category 2A: Based upon lower-level evidence, there is
uniform NCCN consensus that the intervention is appropriate
Category 2B: Based upon lower-level evidence, there is
NCCN consensus that the intervention is appropriate
Category 3: Based upon any level of evidence,
there is major NCCN disagreement that the intervention is appropriate
All recommendations are 2A unless otherwise noted
Multidisciplinary team approach and support modalities
For each subsite:
workup, clinical staging stratification, treatment options for primary and
neck, adjuvant treatment, follow-up
Follow-up recommendations
Principles of surgery: evaluation, assessment of resectability, primary tumor
resection, margins, management of cranial nerves, neck management,
recurrence management
Radiation therapy techniques
Principles of systemic therapy
Pfister DG, et al. National Comprehensive Cancer Network Clinical Practice
Guidelines in Oncology. Head and Neck Cancers. J Natl Compr Canc Netw. 2011;
Why are we using robots?
Joseph C. Sniezek, MD FACS
Pacific Rim Otolaryngology Updates
February, 2012
The use of the da Vinci surgical robot has permeated nearly all surgical
specialties and has emerged as a ubiquitous topic in both the lay and medical
literature. Recently, Otolaryngologists have begun to use the da Vinci robot in
two head and neck surgical procedures- transoral resection of oropharyngeal
malignancies and trans-axillary thyroidectomy.
Trans-oral Robotic Surgery
The use of the surgical robot to remove oropharyngeal malignancies through a
trans-oral route supports the trend toward minimally invasive and functionpreserving treatment of pharyngeal tumors. Early data supports the efficacy and
functional advantages of trans-oral robotic surgery for treating oropharyngeal
cancers in comparison with open surgical as well as non-surgical treatment
Robotic-assisted Thyroidectomy
The move toward minimizing the scar incurred during thyroidectomy has resulted
in the desire to perform thyroidectomy through remote access approaches and
completely avoid a neck incision. The da Vinci robot can be used to perform
thyroidectomy through a trans-axillary approach. Novel other approaches, such
as a facelift incision and approach, are also being explored.
Advantages of Robotic Surgery
1. Improved visibility
2. Tremor reduction
3. Improved range of motion
4. Remote-site access is possible (incisions may be located far away from
surgical target)
Disadvantages of Robotic Surgery
1. Cost of robot ($1.5 million)
2. Extensive training required
3. Learning curve with slower operating times
The da Vinci surgical robot has captured the attention and imagination of
surgeons as well as patients. While it offers some advantages to the surgeon
and patient, it is an expensive tool that requires extensive training and practice.
This lecture will discuss and define where this tool fits into the Otolaryngologist’s
armamentarium in 2012.
University of California
San Francisco