Innovative Doctors + Better Technology = Practice Changess

Head and neck surgical procedures are likely to be rapidly influenced by new developments created by the intersection of innovative practitioners and improving technology.

In a panel discussion at the Triological Society’s 111th annual meeting during the Combined Otolaryngology Spring Meeting, researchers explained how some of those technologies are already affecting how patients are being treated today and the likelihood that those treatments will be expanded in the near future.

However, David J. Terris, MD, Porubsky Professor and Chairman of the Department of Otolaryngology at the Medical College of Georgia in Augusta, moderator of the panel, said that the use of these new technologies comes with a major caveat.

We have to hold ourselves accountable to demonstrate an advantage with these technologies, he said. These technologies must allow us to do our procedures better or safer or faster or less expensive-or preferably some combination of these.

The panel reviewed advances and techniques in:

• Endoscopic skull base surgery.
• Sentinel node biopsy in head and neck cancer.
• Endoscopic thyroid and parathyroid surgery.
• Applying robotics to laryngeal surgery.

This article will discuss the first topic; the rest will be covered in upcoming articles in ENT Today.

Advances in Endoscopic Procedures

The discussion of endoscopic resection of head and neck tumors dominated much of the conference, and the panel also looked at how the procedures are being carried out.

We see the endoscope as just one more tool to complement traditional approaches, said Ricardo Carrau, MD, Professor of Otolaryngology-Head and Neck Surgery, Director of the Maxillofacial Trauma Service, and a member of the Minimally Invasive Endoneurosurgical Center at the University of Pittsburgh Medical Center.

The same oncologic and microsurgical principles still apply, regardless of the approach, Dr. Carrau said. Since the 1960s, we have been using a variety of transfacial and transcranial procedures to take out tumors that arise in the skull base or invade the skull base.

We have achieved oncological, functional, and cosmetic goals. The transfacial procedures include incisions, osteotomies, and ostectomies. The transcranial approach involves incisions, craniotomies, and craniectomies. Our oncologic goals are local control or palliation; our functional goals are to preserve the function of the brain, the ocular system, and the cranial nerves; the cosmetic goals are to reduce scarring and loss of bone.

Dr. Carrau said that clinicians who venture into endoscopic procedures to prevent scarring and other morbidities involved in traditional surgery should gain experience slowly in developing their surgical skills with a variety of instruments. We use a bimanual technique, with two nostrils and two surgeons and four hands, he said. I advise you to have a lot of experience with both oncological principles and endoscopic techniques-and I really mean a lot of experience, because we are dealing with cancer, and the life of the patient will be at stake.

Endoscopic Surgery for Olfactory Neuroblastoma

In a series of video clips, Dr. Carrau described one such procedure-an olfactory neuroblastoma. We first debride the tumor to give us more space and better visualization. Our next step is to identify surgical landmarks. You are going to need two major landmarks for this tumor. One is the skull base, and we obtain that by performing a wide sphenoidotomy. The other is the lamina papyracea, which is identified by creating a wide nasomaxillary window. The lamina papyracea is removed on both sides to gain vascular control of the skull base. We usually will put a clip on an artery supplying the tumor and cauterize it at the same time. Septal incisions are similar as in the open approach.