Explore this issue: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.
The STAR trial (N Engl J Med. 2014;370:139-149) involved patients with moderate to severe sleep apnea who either couldn’t tolerate or didn’t adhere to use of continuous positive airway pressure (CPAP). Also, their BMI had to be 32 or lower.
The 126 patients enrolled saw a 68% reduction in apnea-hypopnea index from baseline to 12 months and a 70% drop in oxygen desaturation index over the same time frame. The study patients also reported significant improvements in daytime alertness and quality of life measures.
Patients who responded were randomized after 12 months to have the device kept on or turned off. Researchers found a relapse in those in whom the device was turned off but continued successful management in those who maintained use of the device.
“We have data that the vast majority of patients liked it, and that’s in stark contrast to the CPAP,” Dr. Soose said. “This is by no means a fix-all for every sleep apnea patient. This is a nice tool in the toolbox to have, a nice alternative to be able to provide for patients who are unable to achieve benefit with CPAP.”
Advances in Facial Nerve Paralysis
Kofi Boahene, MD, associate professor of facial plastic and reconstructive surgery and otolaryngology-head and neck surgery at The Johns Hopkins University School of Medicine in Baltimore, emphasized the importance of timeliness in procedures to treat facial nerve paralysis. “The longer you wait, the less your results will be,” he said.
He described a reliable method, called the subzygomatic triangle, to find the elusive masseteric nerve, a small but valuable nerve in facial nerve
paralysis cases. A triangle is formed by the zygomatic arch, the temporomandibular joint, and the frontal branch of the facial nerve, and it’s a valuable tool, Dr. Boahene said. This eliminates the need for extensive dissection. “Always the masseter nerve is there,” Dr. Boahene said. “Within 10 minutes, using this triangle, you can find the nerve.”
He also described a method of “supercharging” a facial nerve without risking the loss of partial recovery the patient may have already experienced. The method, called the “epineural window end-to-side anastomosis,” involves creating a window to make more nerve connections without cutting the main facial nerve.
Personalized Treatment of Sinusitis
Allergy and asthma have a role in differentiating types of sinusitis with polyps, he said. “There’s no new medical treatment for chronic sinusitis that has been written, but what is new is how you personalize treatment for sinusitis.”
Chronic rhinosinusitis (CRS) without polyps is fairly homogenous, but differentiation has to be made in CRS with polyps, he said. His center is looking at immunotherapy in patients who have asthmatic CRS with allergy. “In this group of patients, immunotherapy would be very helpful,” he said. “In fact, we’ve had several patients who have been steroid-dependent, [but] we’ve been able to get them off oral steroids with immunotherapy.”
For patients with aspirin triad, zileuton, a 5-LO enzyme inhibitor, can be helpful, because it blocks production of cysteinyl leukotriene, which drives inflammation in these patients. Before this treatment, though, a baseline liver function test (LFT) is needed. Approximately 4% of cases will develop elevated LFT, but in about half these patients, those levels eventually return to normal, Dr. Han added.
Additionally, leukotriene antagonists may be used in treating cystic fibrosis, he said.
“Understand that there are many different types of sinusitis,” he said, “and that medical treatment varies depending on what type of sinusitis you have.”