Faculty Bibliography

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Organ preservation surgery is a major focus in head and neck oncology. Current approaches are aimed toward improving quality of life and decreasing treatment-related morbidity. Transoral robotic surgery was developed to overcome the limitations of traditional surgical approaches. The most widely used robotic system is the da Vinci Surgical System. Although the da Vinci offers clear surgical advantages over traditional approaches, its rigid operative arms prevent complex maneuverability in three-dimensional space. The ideal surgical robot would configure to the anatomy of the patient and maneuver in narrow spaces. We present the first cadaveric trials of the use of a highly flexible robot able to traverse the nonlinear upper aerodigestive tract and gain physical and visual access to important anatomical landmarks without laryngeal suspension. STUDY DESIGN/METHODS:Feasibility. METHODS:Using human cadavers, we investigated the feasibility of visualizing the endolarynx transorally with a highly flexible robot without performing suspension of the larynx. Two fresh and four preserved human specimens were used. RESULTS:Unhampered visualization of the endolarynx was achieved in all specimens without performing laryngeal suspension. Standard mouth retractors facilitated the delivery of the robot into the endolarynx. CONCLUSIONS:The flexible robot technology mitigates laryngeal suspension and the limitations of current robotic surgery with rigid line-of-sight-directed instruments. Having demonstrated the feasibility of physical and visual access to the endolarynx, future work will study the feasibility of using the highly flexible robot in transoral robotic procedures with flexible instrumentation placed in the robot's available working ports.

BACKGROUND:Temporary remission of primary hyperparathyroidism (PHPT) following fine-needle aspiration (FNA)-induced hemorrhage of a parathyroid adenoma is extremely rare. The purpose of this report was to illustrate that parathyroid adenomas can masquerade as thyroid nodules and that these patients must be monitored closely following remission as their hyperparathyroidism may recur. PATIENT FINDINGS/METHODS:This report describes a patient who presented with a neck mass and was incidentally found to have PHPT. Ultrasound (US) evaluation revealed a lesion that was diagnosed as a thyroid nodule. After a nondiagnostic FNA, she developed a large neck hematoma and her PHPT went into remission. Soon thereafter, her hyperparathyroidism recurred, and she underwent parathyroidectomy and thyroid lobectomy, which confirmed a large parathyroid adenoma. SUMMARY/CONCLUSIONS:This report illustrates that remission of PHPT can occur because of FNA-induced hemorrhage leading to autoinfarction of a parathyroid adenoma. Following autoinfarction, the patient's parathyroid hormone and calcium levels must be monitored closely as the remission of PHPT may be temporary. Further, although US is a fast, inexpensive, often reliable modality for diagnosing neck masses, it does not always accurately identify parathyroid adenomas. CONCLUSION/CONCLUSIONS:Clinicians must be cognizant of the possibility that parathyroid adenomas can masquerade as thyroid nodules on US, especially as most patients with parathyroid adenomas are asymptomatic at presentation.

BACKGROUND:Currently described endoscopic techniques for subtotal resections of the maxilla include endoscopic medial maxillectomy and extended endoscopic medial maxillectomy; however, a complete resection of the maxilla is sometimes warranted. We describe a combined transoral and endoscopic technique for total and subtotal maxillectomy in an attempt to decrease the morbidity of traditional approaches. METHODS:Technical note, Feasibility, Human cadaveric dissection. RESULTS:Ten total and subtotal maxillectomies were performed in human specimens without the need of facial incisions or transfixion of the nasal septum. The pterygopalatine and infratemporal fossas were accessed and dissected in all cases. CONCLUSIONS:A combined transoral and endoscopic approach is feasible and can be used in selected patients when other minimally endoscopic techniques are not indicated. The benefits of no facial incisions and/or transfixion of the nasal septum, potential improvement in hemostasis, and visual magnification may help to decrease the morbidity of traditional open approaches.

BACKGROUND:This study reports the combined experience of the University of Miami and University of Pittsburgh with endoscopic endonasal resection of esthesioneuroblastoma (ENB). A retrospective case series review was performed in a tertiary care university hospital. METHODS:Twenty-three patients, 16 men and 7 women, were reviewed. Mean age was 56.6 years (15-79 years). Nineteen patients received primary endoscopic endonasal anterior skull base resection. Of these, the modified Kadish stage at presentation was A in 2 patients, B in 11 patients, C in 5 patients, and D in 1 patient. Three patients had revision surgeries for recurrent tumors. The main outcome measures were complete resection and margin assessment, short-term and long-term complications, and recurrence rate. RESULTS:Complete resection and negative intraoperative resection margins were achieved endoscopically in 17 of the primarily treated cases. The two other cases had one patient that required an additional craniotomy approach to complete the resection of a positive lateral dual margin, another patient had positive margins at the orbital apex. All patients tolerated the endoscopic procedure very well with no meningitis. There were four cerebral spinal fluid leaks. Mean follow-up period for the primarily treated cases was 45.2 months (11-152 months), all were disease free at the most recent available follow-up. CONCLUSION/CONCLUSIONS:In experienced hands and carefully selected patients, endoscopic resection of ENB respects the principles of oncologic surgery, providing an adequate exposure for margin assessment as well as reliable reconstruction of the anterior skull defect with a relatively low morbidity.