Faculty Bibliography

OBJECTIVE:Robotic head and neck surgery potentially reduces the morbidity associated with traditional open procedures. This study's goal was to employ a novel highly articulated robotic system (Flex Robotic System) for head and neck procedures, including a postauricular facelift approach thyroidectomy, submandibular gland (SMG) removal, and cervical lymphadenectomy. STUDY DESIGN/METHODS:It was hypothesized that the Medrobotics Flex Robotic System could be used for transcervical head and neck surgical procedures. METHODS:Three fresh upper body human cadavers were used. The Flex Robotic System was used to complete a thyroidectomy, neck dissection, and SMG removal on each cadaver. RESULTS:A postauricular incision and flap was manually raised. The robotic system was positioned on the right side of the cadaver's head. The system's manually controlled flexible instruments and highly shapeable, robot-assisted scope were used to perform a thyroid lobectomy. Neck dissection and SMG removal were also performed. CONCLUSIONS:Although a promising technology, the current robotic system (Intuitive Surgical Inc, Sunnyvale, California, USA) has limitations due to its rigid and large configuration, which decreases exposure and access. The new system's shapeable, computer-assisted scope seeks to reduce some of these difficulties and may be better adapted for transcervical approaches to the neck operations.

BACKGROUND:The purpose of this study was to characterize oncologic outcomes in early (T1-T2, N0) and intermediate (T1-T2, N1) oropharyngeal squamous cell carcinoma (SCC) after surgery. METHODS:Patients with oropharyngeal SCC treated with surgery were identified from 2 academic institutions. RESULTS:Of 188 patients, 143 met the inclusion criteria. Eighty-six (60%) had T1 to T2 N0 and 57 (40%) had T1 to T2 N1 disease. Sixty-five patients (45%) underwent a robotic-assisted resection, whereas the remaining had transoral (n = 60; 42%), mandible-splitting (n = 11; 8%), or transhyoid approaches (n = 7; 5%). Human papillomavirus (HPV) status was known for 97 patients (68%), and 54 (55%) were HPV positive. Three-year recurrence-free survival (RFS) was 82% (95% confidence interval [CI] = 0.75-0.89). Since 2008, HPV infection was protective of recurrence (log-rank p = .0334). A single node did not increase the risk of recurrence (p = .467) or chance of a second primary (p = .175). CONCLUSION:Complete surgical resection is effective therapy for early and intermediate oropharyngeal SCC. HPV-negative patients were at increased risk for locoregional recurrence or second primary disease. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1471, 2016.

Training and credentialing for robotic surgery in otolaryngology - head and neck surgery is currently not standardized, but rather relies heavily on industry guidance. This manuscript represents a comprehensive review of this increasingly important topic and outlines clear recommendations to better standardize the practice. The recommendations provided can be used as a reference by individuals and institutions alike, and are expected to evolve over time. © 2016 Wiley Periodicals, Inc. Head Neck 38: E151-E158.

BACKGROUND:Postoperative complications (POCs) can negatively impact survival after oncologic resection. POCs may also decrease the rate of adjuvant therapy completion. We evaluated the impact of complications on gastric cancer survival and analyzed the combined effect of complications and adjuvant therapy on survival. METHODS:We analyzed 824 patients from 7 institutions of the U.S. Gastric Cancer Collaborative who underwent curative resection for gastric adenocarcinoma between 2000 and 2012. POC were graded using the modified Clavien-Dindo system. Survival probabilities were estimated using the method of Kaplan and Meier and analyzed using multivariate Cox regression. RESULTS:Median follow-up was 35 months. The overall complication rate was 41 %. The 5-year overall survival (OS) and recurrence-free survival (RFS) of patients who experienced complications were 27 and 23 %, respectively, compared with 43 and 40 % in patients who did not have complications (p < 0.0001 for OS and RFS). On multivariate analysis, POC remained an independent predictor for decreased OS and RFS (HR 1.3, 95 % CI 1.1-1.6, p = 0.03 for OS; HR 1.3, 95 % CI 1.01-1.6, p = 0.03 for RFS). Patients who experienced POC were less likely to receive adjuvant therapy (OR 0.5, 95 % CI 0.3-0.7, p < 0.001). The interaction of complications and failure to receive adjuvant therapy significantly increased the hazard of death compared with patients who had neither complications nor adjuvant therapy (HR 2.3, 95 % CI 1.6-3.2, p < 0.001). CONCLUSIONS:Postoperative complications adversely affect long-term outcomes after gastrectomy for gastric cancer. Not receiving adjuvant therapy in the face of POC portends an especially poor prognosis following gastrectomy for gastric cancer.

The osteotemporoparietal fascia flap (OTPFF) has been used for bony defects, especially on the maxilla and orbital floor. However, there are limited reports about the reconstruction of the zygoma. We report the use of composite OTPFF for reconstruction of zygomaticomaxillary complex. The patient had undergone zygomaticomaxillary complex reconstruction with composite OTPFF because of the resection of recurrent postradiation tumor. Extratemporoparietal fascia was harvested and rotated to cover the medullary surface of the bone flap. Flap was successfully transferred with complete bone integration. There were no surgical complications and excellent cosmetic result. The patient is free of disease 12 months post surgery. The OTPFF seems to be a good option in zygomatic reconstruction, even in previously irradiated fields. Utilization of extratemporoparietal fascia to cover the medullary surface of the bone flap has potential to be an advantageous technique to minimize bone exposure and improve flap integration.

BACKGROUND:The purpose of this study was to evaluate the efficacy of postoperative intense pulsed light therapy on patients who undergo bilateral eyelid surgery. METHODS:Patients presenting over a 3-month period for bilateral eyelid surgery were asked to participate in an institutional review board-approved study. Intense pulsed light therapy was administered three times to the same randomly assigned side on postoperative days 1 to 2, 5 to 7, and 10 to 12. Sham light therapy was administered to the contralateral side. Patient surveys and physician ratings were obtained based on photographic evaluation of ecchymosis, edema, and erythema. Three physicians, including the senior author (A.E.W.), submitted ratings, and these ratings were assessed for interobserver reliability. RESULTS:Twenty-eight patients who underwent bilateral eyelid surgery followed by intense pulsed light therapy were enrolled. The mean age of the patients was 66 years (range, 44 to 81 years). Eighty-six percent of patients were female. The change in ratings between postoperative days 1 to 2 and 10 to 12, in the treatment and control groups, was statistically significant for severity of bruising by both patient and physician assessment and for color of bruising only by patient assessment. The interobserver reliability reached the greatest agreement in the ecchymosis category at each time point for the treatment group. CONCLUSION:In a series of patients who underwent eyelid surgery, intense pulsed light therapy decreased the degree of ecchymosis compared with sham treatment in postoperative eyelid surgery patients. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, II.

OBJECTIVE:To elucidate the progression of angioedema of the head and neck with routine management and to assess the utility of serial physical exams and fiberoptic laryngoscopy in its management. METHODS:This study was a prospective observational research. From 2013 to 2014, a prospective observational study was conducted at a tertiary referral center. Forty patient were approached, 7 refused, 33 (18-90 years old) were enrolled. Patients presented with angioedema involving the head and neck over a 12 month period were asked to participate in the study. Physical examination and fiberoptic laryngoscopy were performed at presentation and then repeated at least 1 h later. RESULTS: < 0.001). CONCLUSION/CONCLUSIONS:In stable patients with angioedema of any head and neck subsite, self-reported symptoms are associated with clinical stability or improvement as assessed by physical signs and fiberoptic laryngoscopy. Patients' symptoms may be an appropriate surrogate to monitor clinical status without the need for routine serial physical examinations or fiberoptic laryngoscopy, though further study is needed.

Submandibular gland ptosis is a common impediment to obtaining superior surgical aesthetic results in neck lift surgery. Techniques for suspending the submandibular gland have been proposed, but these procedures have the drawbacks of disturbing the floor of the mouth mucosa and periosteum. We present an approach of submandibular gland suspension for the treatment of gland ptosis by employing a platysma and hyoid bone fascia cradle. Our technique was performed on cadaveric models. The platysma muscle and hyoid bone cradle for submandibular gland ptosis was created on the left side of the neck in two cadavers. A submental incision with sharp dissection was performed to raise a supraplatysmal flap. A subplatysmal plane was developed until the submandibular gland was identified. Sutures were used to pexy the platysma to the hyoid bone periosteum and deep cervical fascia, tightening the overlying muscle and in turn elevating the submandibular gland. Submandibular gland ptosis must be corrected in order to achieve exemplary aesthetic results. Our approach of creating a cradle with the platysma and hyoid bone avoids the potential complications of previously described sling procedures, while still maintaining the integrity of the gland and surrounding tissues.