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February 2014
Panelists pinpointed recent advances in five areas of otolaryngology during the session “What’s the Latest and Greatest.”
Guided Therapeutics in Head and Neck Surgery
Jonathan Irish, MD, FACS, chief of surgical oncology at the University of Toronto’s Princess Margaret Cancer Center, thinks the wave of the future is a combination of several technologies into a surgical system that can provide real-time images and better surgical targeting.
This includes robotic knives and hands but also incorporates technology that allows near real-time “on-the-table” imaging through a procedure that allows surgical tool tracking and optical imaging technology for tumor targeting and contouring. This technology will be merged with “proximity alerts” to let surgeons know when a critical structure is being approached.
“The power is not any one technology, but it’s the merging of many, such that the sum becomes greater than its parts,” Dr. Irish said. At his center, researchers have developed an animal model using fluorescence imaging and long-lasting fluorophores to illuminate both primary tumors and the lymphatics, moving away from the tumor into what he describes as a “real-time” sentinel node biopsy.
“This is going to be transformative for us,” he added. This is where we will be five to 10 years from now.” A challenge, though, will be creating the infrastructure; combining these technologies involves greater manpower and operating rooms that can be more three-and-a-half times the size of a normal operating room.
Advances in Vertigo
Judith White, MD, PhD, head of otolaryngology at the Cleveland Clinic, said a big recent advancement in vertigo treatment was the creation of new diagnostic criteria for vestibular migraine in 2013 (see “ICHD-3 Diagnostic Criteria for Vestibular Migraine, right). The condition can complicate the management of many patients with Ménière’s disease, but it’s responsive to both behavioral and medical intervention, “so it’s worth knowing about,” Dr. White said.
There also have been recent changes to the reporting criteria for Ménière’s, which can fix a problem with classification. “The problem was if you institute a secondary treatment, you go to a Class F response, which is not what those guidelines were set up to imply,” Dr. White said.
Now, an “intent to treat” model is used: If treatment stays within the same “intent to treat” grouping, classification isn’t changed. If a different treatment is used, the classification bounces to Class F. This allows repetitive treatments without changing classification.
At the Cleveland Clinic, changes are underway that could serve as an example for how to apply guidelines of dizziness and vertigo. The institution’s “CarePath” system uses electronic medical records to prompt recommendations, reserves head CT scans for patients with focal neurological signs and symptoms in addition to dizziness and vertigo, encourages the use of Dix-Hallpike diagnostic testing and canalith repositioning, generates referrals for vestibular physical therapy, and emphasizes fall prevention.
Upper Airway Stimulation for Sleep Apnea
Ryan Soose, MD, assistant professor of otolaryngology at the University of Pittsburgh, reviewed the findings of the first clinical trial on upper airway stimulation for treating sleep apnea. The therapy, which uses an implanted pacemaker connected to the nerve that works the tongue, is intended to improve airflow by enlarging and stabilizing the upper airway.