Presented by the Department ofOtolaryngology-Head and Neck SurgeryUniversity of California, San Francisco and Tripler Army Medical CenterHonolulu, Hawaii

Pacific Rim Otolaryngology–Head and Neck SurgeryUpdate

University of CaliforniaSan Francisco

COURSE CHAIRMENAndrew H. Murr, MD, FACSUniversity of California, San FranciscoWilliam R. Ryan, MD, FACSUniversity of California, San FranciscoBenjamin Cable, MD, LTC, MC, USATripler Army Medical Center, Honolulu, HI

GUEST SPEAKERSRobert Kern, MDNorthwestern University’s Feinberg School of MedicineMark Varvares, MDSt. Louis University, School of MedicineErich Sturgis, MD The University of Texas, MD Anderson Cancer Center

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American College of Surgeons Thyroid andParathyroid Ultrasound Skills-Oriented CourseSaturday and Sunday • February 14-15, 2015

MOANA SURFRIDER HOTEL • WAIKIKI BEACH • HONOLULU, HAWAII

Upcoming CME Courses

Primary Care Medicine: Update 2015 Sunday, April 5 – Friday, April 10, 2015

Wailea Beach Marriott and Spa – Wailea, Hawaii

36th Annual Advances in Infectious Diseases: New Directions for Primary Care Wednesday, April 22 – Friday, April 24, 2015

Hilton Financial District – San Francisco, California

Essentials of Women's Health: An Integrated Approach to Primary Care and Office Gynecology

Sunday, July 5 – Friday, July 10, 2015 Hapuna Beach Prince Hotel – Kohala Coast, Hawaii

Neurosurgery Update 2015

Thursday, August 6 – Saturday, August 8, 2015 Silverado Resort, Napa, California

27th Annual Medical Management of HIV/AIDS and Hepatitis

Thursday, December 3 – Saturday, December 5, 2015 Park Central Hotel – San Francisco, California

Pacific Rim Otolaryngology – Head and Neck Surgery Update

Saturday, February 13 – Tuesday, February 16, 2016 Moana Surfrider – Honolulu, Hawaii

All Courses Managed by:

UCSF Office of Continuing Medical Education 3333 California Street, Room 450, San Francisco, CA 94118

For attendee information call: 415-476-4251 For exhibitor information: 415-476-4253 Visit the web site at www.cme.ucsf.edu

The Department of Otolaryngology – Head and Neck Surgery University of California, San Francisco

and Tripler Army Medical Center – Honolulu, Hawaii

Pacific Rim Otolaryngology – Head and Neck Surgery

Update

February 14- 17, 2015 Moana Surfrider

Honolulu, HI

Course Chairs Andrew H Murr, MD, FACS

William R. Ryan, MD University of California, San Francisco

Benjamin B. Cable, MD, FACS, COL, MC, USA

Tripler Army Medical Center- Honolulu, HI

University of California, San Francisco Tripler Army Medical Center

Acknowledgement of Commercial Support

This CME activity was supported in part by educational grants from the following:

Acclarent/Ethicon Cook Medical, LLC

Exhibitors

Acclarent DePuy Synthes

Hitachi Aloka Medical Intersect ENT

Karl Storz KLS Martin

Mallinckrodt Pharmaceuticals Medtronic Surgical Technologies

Microline Surgical Olympus America ENT

Pentax Medical Smith & Nephew

Stryker Veracyte, Inc.

University of California, San Francisco and Tripler Army Medical Center present

Pacific Rim Otolaryngology – Head and Neck Surgery Update

With improved understanding of pathophysiology and disease mechanisms and with technological advancements, the approaches to head and neck surgical disorders and head and neck surgery techniques continue to evolve at a rapid pace. The goal of this course is to provide an update in contemporary head and neck surgery and to foster educational interaction between practitioners from the Pacific Rim and beyond. This course is intended for practicing otolaryngologist- head and neck surgeons, facial plastic surgeons, oral and maxillofacial surgeons, dermatologic surgeons, and nurses. Educational Objectives

Upon completion of this program, attendees should be able to:

Use a stair step approach to evaluating children with sinusitis; Apply enhanced design methods in developing an otolaryngology specific website; Incorporate molecular based approaches to the treatment of thyroid cancer; Understand new technology in salivary gland endoscopy that can be applied to salivary

duct disease including salivary duct stones ; Employ the use of botulinum toxin to non-cosmetic disease processes in otolaryngology

practice; Analyze rhinoplasty approaches which are designed to address form and function; Utilize enhanced strategies to manage difficult or argumentative patients.

Accreditation

The University of California, San Francisco School of Medicine (UCSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

UCSF designates this live activity for a maximum of 23.00 AMA PRA Category 1 Credits™ Physician should claim only the credit commensurate with the extent of their participation in the activity. This CME activity meets the requirements under California Assembly Bill 1195, continuing education and cultural and linguistic competency. Nurses: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 Credit™ issued by organizations accredited by the ACCME. Physician Assistants: AAPA accepts Category 1 Credit from AOACCME, Prescribed credit from AAFP, and AMA Category 1 Credit™ from organizations accredited by the ACCME.

General Information Attendance Verification/Sign-In Sheet / CME Certificates Please remember to sign-in on the sign-in sheet when you check in at the UCSF Registration Desk on your first day. You only need to sign-in once for the course, when you first check in. After the meeting, please visit this website http://www.ucsfcme.com/evaluation to complete the online Course Evaluation Part 2/ Electronic CME Certificate Claiming Upon completing the Electronic CME Certificate Claiming, your CME certificate will be automatically generated to print and/or email yourself a copy. Evaluation Your opinion is important to us – we do listen! We have a two part evaluation for this course.

The Course Evaluation Part 1/Speaker Evaluation is the bright yellow hand-out you received when you checked in. Please complete this during the meeting and turn it in to the registration staff at the end of the conference.

After the meeting, please visit this website http://www.ucsfcme.com/evaluation to complete the online Course Evaluation Part 2/ Electronic CME Certificate Claiming

We request you complete this evaluation within 30 days of the conference in order to receive your CME certificate through this format.

Lunch The course will conclude at lunchtime each day with the exception of Monday 2/16/15. Lunch is on own each day and a list of restaurants is available through the Moana Surfrider concierge staff.

Security We urge caution with regard to your personal belongings. We are unable to replace these in the event of loss. Please do not leave any personal belongings unattended in the meeting room.

Exhibits Industry exhibits will be available outside the General Session room during course breakfasts and breaks.

Case Discussions Each day of the course there will be an opportunity to discuss various cases along with light refreshments.

Reception The course reception will take place on Monday evening 2/16/15 from 7:00PM- 9:00PM on the Diamond Terrace and is open to the paid attendee and one adult guest. You will receive tickets for you and your guest when you check-in at the UCSF Registration Desk. Please note that the location is subject to change due to weather and we will make an announcement if there is a location change.

Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons

I. Purpose.

This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories

II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August

11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance.

The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government.

HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ .

As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services.

Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan.

A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other Recipients. Recipients may take other reasonable steps depending on the emergent or non-emergent needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services. HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations. In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan.

III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows:

“The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them. The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would otherwise be entitled. It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.”

The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm

Faculty List

COURSE CHAIRMEN

Andrew H. Murr, MD, FACS Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco School of Medicine; Chief of Service, San Francisco General Hospital; Roger Boles, MD Endowed Chair in Otolaryngology Education Benjamin Cable, MD, COL, MC, USA Chief, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI William R. Ryan, MD, FACS Assistant Professor, Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco

COURSE FACULTY

Macario Camacho, MD Staff, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI

Steven W. Cheung, MD, FACS Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Ivan H. El-Sayed, MD, FACS Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Jonathan R. George, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Joseph B. Golden, MD Staff, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI

Robert C. Kern, MD Chair, Department of Otolaryngology - Head and Neck Surgery; Professor in Otolaryngology - Head and Neck Surgery and Medicine-Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL

Christopher Klem, MD, FACS Physician, Queen’s Medical Center- Honolulu, HI

Philip D. Littlefield, MD Assistant Chief, Otolaryngology- Head and Neck Surgery, Walter Reed Army Medical Center, Washington, D.C.; Assistant Professor of Medicine- Uniformed Services, University of The Health Sciences, Bethesda, MD

Anna K. Meyer, MD, FAAP Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Steven D. Pletcher, MD Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Scott B. Roofe, MD, LTC, MC, USA Chief, Facial Plastic and Reconstructive Surgery Residency Program Director, Department of Otolaryngology Tripler Army Medical Center, HI

Rahul Seth, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

COURSE FACULTY (continued) Erich M. Sturgis, MD Professor, Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX

Aaron Tward, MD, PhD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Mark A. Varvares, MD Donald and Marlene Jerome Endowed Chair and Professor, Department of Otolaryngology, St. Louis University School of Medicine, St. Louis, MO

Steven J. Wang, MD, FACS Associate Professor, Division of Head and Neck and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco Eric D. Wirtz, MD Staff, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI

Katherine C. Yung, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Disclosures

The following faculty speakers, moderators and planning committee members have disclosed NO financial interest/arrangement or affiliation with any commercial companies who have provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity: Benjamin B. Cable, MD, COL, MC, USA Macario (Mac) Camacho, MD Jonathan R. George, MD Joseph B. (Blake) Golden, MD Robert C. Kern, MD Christopher Klem, MD, FACS Philip D. Littlefield, MD Anna K. Meyer, MD, FAAP Scott B. Roofe, MD, COL, MC, USA

Rahul Seth, MD Erich M. Sturgis, MD Mark A. Varvares, MD Aaron Tward, MD, PhD Steven J. Wang, MD, FACS Eric D. Wirtz, MD Katherine C. Yung, MD, FACS

The following faculty speakers have disclosed a financial interest/arrangement or affiliation with a commercial company who has provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME Updated Standards for Commercial Support: Andrew H. Murr, MD, FACS

Consultant/Minor Stockholder IntersectENT Honorarium Synthes

William Ryan, MD, FACS Consultant Medtronic Steven W. Cheung, MD, FACS

Stock Shareholder (excluding mutual funds) Decisive Health

Ivan El-Sayed, MD, FACS Consultant/Honorarium Stryker Steven D. Pletcher, MD, FACS Consultant BioInspire

Patent 61/624, 105; Sinus Diagnostics and Therapeutics Holder of Intellectual Property Rights

This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced. This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed no relevant financial relationships.

Course Program

SATURDAY, FEBRUARY 14, 2015 6:30 am Registration and Continental Breakfast 6:55 Welcome and Overview Drs. Cable, Ryan, Murr 7:00 Update on Drug-Eluting Stents in Sinus Surgery Dr. Andrew H. Murr 7:30 Tympanostomy Tubes - Still Relevant? Dr. Benjamin B. Cable 8:00 Sialoendoscopy and Salivary Duct Surgery Dr. William R. Ryan 8:30 Upper Lid Blepharoplasty and Ptosis Repair Dr. Scott B. Roofe 9:00 Oral Cavity Soft Tissue Reconstruction: The Basics Dr. Steven J. Wang 9:30 Break 10:00 Chronic Rhinosinusitis: Dr. Robert C. Kern

Current Therapy and Future Treatments 10:25 Evaluation and Management of Paragangliomas Dr. Eric D. Wirtz 10:50 Patient-centric Decision Making in Acoustic Tumors Dr. Steven W. Cheung 11:15 Early Glottic Cancer: Surgery or Radiation? Dr. Katherine C. Yung 11:40 Overview of Sleep Medicine and Surgery Dr. Macario Camacho 12:05pm Value-based Health Care in Otolaryngology: Dr. Christopher Klem Why It Is Important To You 12:30 Adjourn 5:00 Case Discussions 6:00pm Adjourn

SUNDAY, FEBRUARY 15, 2015 6:30 am Continental Breakfast

7:00 Parathyroidectomy Pearls Dr. William R. Ryan

7:30 Mastoid Obliteration - When and How? Dr. Philip D. Littlefield

8:00 Avoiding Complications In Endoscopic Sinus Surgery Dr. Steven D. Pletcher

8:30 Tinnitus Update Dr. Steven W. Cheung

9:00 Cancer Epidemics Affecting Otolaryngologists Dr. Erich M. Sturgis

9:30 Break

10:00 Leslie Bernstein Lecture – Dr. Mark A. Varvares Pharyngoesophageal Reconstruction

11:00 Sleep Disordered Breathing in Children: Dr. Anna K. Meyer What is Next After T&A?

11:25 Update In Juvenile Nasopharyngeal Angiofibroma Dr. Ivan H. El-Sayed

11:50 Molecular Diagnostics in Thyroid Surgery: Dr. Jonathan R. George Current Practice and Future Direction

12:15 Value-based Health Care in Otolaryngology: Part 2 Dr. Christopher Klem

12:40pm Adjourn

5:00pm Case Discussions

6:00 Adjourn

MONDAY, FEBRUARY 16, 2015

12:30pm New Techniques in OSA Surgery Dr. Macario Camacho

1:00 Evidence-based Guidelines for Chronic Sinusitis Dr. Steven D. Pletcher

1:30 Modern Management of Esthesioneuroblastoma Dr. Ivan H. El-Sayed

2:00 Beyond Aesthetics Dr. Scott B. Roofe

2:30 Clinical Implications of HPV-associated Dr. Erich M. Sturgis Oropharyngeal Cancer

3:00 Break

3:30 Management of Superior Semicircular Dr. Aaron Tward Canal Dehiscence

4:00 Chemotherapeutics in Head and Neck Cancer Dr. Eric D. Wirtz

4:30 Endoscopic Management of Laryngotracheal Stenosis Dr. Katherine C. Yung

5:00 Website Design and Search Engine Optimization Dr. Rahul Seth Basics for the Medical Provider

5:30 Oral Cavity and Oropharynx Carcinoma in the Dr. Steven J. Wang Nonsmoker/Nondrinker

6:00 Pediatric Sinusitis - The Stair-Step Approach Dr. Benjamin B. Cable Devices: What's Best for My Patient?

6:45 Adjourn

7:00pm Reception

TUESDAY, FEBRUARY 17, 2015

6:30 am Continental Breakfast

7:00 Advanced Thyroid Cancer: Interdisciplinary Dr. Jonathan R. George Management to Optimize Outcomes

7:30 Evaluation and Treatment of Nasal Obstruction Dr. Rahul Seth

8:00 Medical Decision Making in Head and Neck Cancer Dr. Mark A. Varvares

8:30 Transoral Robotic Surgery: Current and Future Utility Dr. Joseph B. Golden

9:00 Update on Cochlear Implantation Dr. Aaron Tward

9:30 Break

10:00 Role of In-office CT Imaging Dr. Robert C. Kern 10:30 Endoscopic Ear Surgery – Dr. Philip D. Littlefield

More Techniques and Applications

11:00 Salvage Surgery for Head and Neck Malignancy Dr. Joseph B. Golden 11:30 Tongue Tie: Dr. Anna K. Meyer

More Then You Ever Learned in Residency 12:00 Nasal Fractures: An Organized Approach Dr. Andrew H. Murr

12:30 pm Adjourn / Evaluations

Update on Bioabsorbable Steroid Eluting Stents Andrew H. Murr, MD

1. Bioabsorbable steroid eluting stents have been FDA approved for several years for immediate postoperative use.

a. Data showing utility is from a randomized, controlled, blinded prospective trial in the rhinology literature.

i. Murr AH, Smith TL, Hwang PH, Bhattacharyya N, Lanier BJ, Stambaugh JW, Mugglin AS. Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent. Int Forum Allergy Rhinol. 2011 Jan-Feb;1(1):23-32. doi:10.1002/alr.20020.Epub 2011 Feb 8. PubMed PMID: 22287304.

ii. Han JK, Marple BF, Smith TL, Murr AH, Lanier BJ, Stambaugh JW, Mugglin AS. Effect of steroid-releasing sinus implants on postoperative medical and surgical interventions: an efficacy meta-analysis. Int Forum Allergy Rhinol. 2012 Jul-Aug;2(4):271-9. doi: 10.1002/alr.21044. Epub 2012 May 1. PubMed PMID: 22550039.

2. Although not FDA approved, early data using a randomized, sham procedure controlled, blinded prospective study has been published investigating the efficacy of the steroid stent in use distant from surgery. Here is the reference:

a. Han JK, Forwith KD, Smith TL, Kern RC, Brown WJ, Miller SK, Ow RA, Poetker DM, Karanfilov B, Matheny KE, Stambaugh J, Gawlicka AK. RESOLVE: a randomized, controlled, blinded study of bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis. Int Forum Allergy Rhinol. 2014 Nov;4(11):861-70. doi: 10.1002/alr.21426. Epub 2014 Sep 29. PubMed PMID: 25266981.

 

 

Tympanostomy Tubes – Still Relevant? Dr. Benjamin Cable Ear infections remain one of the most frequent reasons for parents to seek health care for their children. Most estimates place the cost of this health care in the billions of dollars per year. Evidence-based medicine, despite being touted as the all-inclusive route to clear clinical decision-making, has only added to the questions regarding optimal care of children with ear disease. This discussion will review the current status of the debate, untangle the current guidelines, and offer practical suggestions for communicating with referring pediatricians and patients.

Sialoendoscopy and Salivary Duct Surgery – William R. Ryan, MD, FACS Introduction Sialoliths, Stenosis, Systemic Disease

Imaging (Xray, U/S, CT, MRI, Sialography)

Conservative Treatment

Diagnostic / Therapeutic Benefits

Examination/Workup

Conservative Management

Sialoendoscopy Set Up Equipment - Sialendoscope Sizes Forceps Baskets Guide Wires Dilators Introducer Dilators. Technique Diagnostic Sialendoscopy Therapeutic Sialendoscopy - Irrigation, Steroid Rinse - Dilation - Endoscopic Sialolithotomy - Transoral or Transfacial Sialodochotomy / Sialodochoplasty - Combined Approaches Sialadenectomy

Sialolith vs Non-Sialolith. Differences In Technique, Efficacy, Outcomes, and Expectations.

Location of Sialolith (Stenosis) Dictates Treatment / Expectations - Distal: Transoral or Sialendoscopy - Proximal: Sialendoscopy or Transoral or Transcervical / Transfacial Combined Approach - Parenchymal: Transcervical / Transfacial Combined Approach or Sialedenectomy Conclusions Algorithmic Approach Patient Selection / Establish Expectations Careful With Entry Into The Duct Parotid Higher Risk / More Challenging Than Submandibular Be Prepared For A Staged or Combination Approaches Ultrasound (Surgeon-Performed) Useful High Efficacy Rate If All Tools Used

Upper Eyelid Blepharoplasty and Ptosis Repair Scott Roofe, MD, FACS Objectives

1. Understand the pertinent anatomy of the upper lid in relation to aesthetic surgery and ptosis repair

2. Describe the etiology and physical examination findings associated with senile acquired ptosis

3. Provide an overview of surgical management of upper eyelid dermatochalasis and senile acquired ptosis

4. Discuss management of complications associated with ptosis repair Overview

Blepharoplasty has changed over the last two decades from simply excision of skin, fat, and muscle. In the past, resection of too much soft tissue has resulted in a variety of complications ranging from dry eye to an aged and almost cadaveric appearance. Today, facial plastic surgeons emphasize tissue preservation and conservation of volume in order to create a more youthful look.

In addition, upper lid ptosis is a frequently encountered entity in patients presenting for cosmetic blepharoplasty. There are a wide variety of etiologies which contribute to ptosis, but the most common in the patient population presenting for cosmetic surgery is senile acquired ptosis. Senile ptosis results from fatty replacement and dehiscence of the levator aponeurosis. This finding can often be subtle and is therefore often missed on examination. The surgeon should be adept at performing a thorough evaluation to detect ptosis and be familiar with its surgical management. An ophthalmologist or oculoplastic surgeon is often consulted to assist in treatment. References Weissman JD, Most SP. Upper lid blepharoplasty. Facial Plast Surg. 2013 Feb;29(1):16-21. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast Surg Clin North Am. 2005 Nov;13(4):487-92. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid surgery. Plast Reconstr Surg. 2014 Dec;134(6):1154-70. Massry GG. Nasal fat preservation in upper eyelid blepharoplasty. Ophthal Plast Reconstr Surg. 2011 Sep-Oct;27(5):352-5. Millay DJ, Larrabee WF Jr., Ptosis and blepharoplasty surgery. Arch Otolaryngol Head Neck Surg. 1989 Feb;115(2):198-201. Martin JJ Jr. Ptosis repair in aesthetic blepharoplasty. Clin Plast Surg. 2013 Jan;40(1):201-12.

Oral Cavity Soft Tissue Reconstruction: The Basics Steven J. Wang, MD Objectives

1. Understand the relevant physiology of speech and swallowing. 2. Know the key principles of oral cavity reconstruction to preserve speech and

swallowing function. 3. Be able to describe various reconstructive options for soft tissue reconstruction

after oral cavity surgery. Overview

The mainstay of treatment of oral cavity cancer is surgery. Attention to soft tissue reconstruction of the oral cavity is essential in achieving optimal functional outcomes. This lecture will discuss a practical approach to oral cavity reconstruction, with a particular focus on basic techniques that can be performed by an otolaryngologist-head and neck surgeon without microvascular training.

The functions of the oral cavity are (1) Mastication (chewing; (2) Deglutition (swallowing); (3) Oral competency (don’t drool); (3) Articulation (speech).

Reconstructive Ladder No reconstruction/secondary intention Always contracts, impacting speech/swallowing Not good option for large surface defect (floor of mouth) Consider for smaller defects of tongue Primary closure Fast wound healing Good for small defects of lip, tongue, buccal mucosa Skin grafts Good for superficial, small to medium soft tissue defects Don’t need to use bolster At best, partial take of skin graft is rule Always contracts, especially when used in sulci Floor of mouth/ventral tongue Buccal mucosa/gingival-buccal sulcus Local flaps Melolabial flap, Buccinator flap, Platysma flap Tongue flaps should be avoided Regional flaps Myocutaneous flaps: Infrahyoid myocutaneous flap, pectoralis flap Reliable, easy, anyone can do it Gets the job done—closes defect, avoids fistula For select patients, similar functional result as free flap

Free flaps: When do I have to use one? Total lower lip Extensive floor of mouth + hemi-tongue

Through-and-through buccal Anterior mandible Conclusions

We have applied the Reconstruction Ladder to a defect- based approach to oral cavity soft-tissue reconstruction. For oral tongue reconstruction, it is important to maintain mobility, restore volume, and minimize sensory deficits. For floor of mouth

defects, the key to an optimal reconstruction is to re-create a thin, pliable surface that does not tether the tongue. For buccal mucosa defects, the reconstruction should not be bulky and one must take steps to prevent scar contracture (especially with radiation treatment) which will lead to trismus. For lip defects, the reconstruction must maintain adequate oral opening (especially for dentures), maintain oral competence (motor/sensory function), and consider cosmesis. References Szeto C, Yoo J, Busato GM, Franklin J, Fung K, Nichols A. The buccinators flap: a review of current clinical applications. Current Opinion Otolaryngol Head Neck Surg 2011 Peng H, Wang SJ, Yang X, Guo H, Liu M. Infrahyoid Myocutaneous Flap for Medium-Sized Head and Neck Defects: Surgical Outcome and Technique Modification. Otolaryngol Head Neck Surg 2013;148:47-53.

Chronic Rhinosinusitis: Current Therapy and Future Treatments Robert C. Kern MD Objectives

1. Review the current therapy 2. Review the emerging treatments for CRS

Overview Current standard therapy for CRS consists of antibiotics and corticosteroids with surgery reserved for failures. The evidence supporting these practices will be reviewed as well as the expected outcomes. Advances at the basic science level coupled with new technological approaches suggest some innovative treatments for CRS. These include concepts of minimally invasive office procedures, local drug delivery devices and the use of newer biologic immunoglobulin therapies. The role of each will be discussed. Conclusions The management of CRS will evolve of the next decade to include a greater variety of treatments, more commonly delivered in an office setting.

Paraganglioma…Is it still a Surgical Disease? Eric D Wirtz, MD Objectives

1. Review the presentation, inheritance, histology, and workup of paragangliomas 2. Discuss the radiologic differentiation of a sympathetic chain versus a vagal

paraganglioma 3. Discuss the benefits of observation or radiation as compared to surgical

resection Overview Historically the treatment of paragangliomas has been surgical resection except for jugular paragangliomas of which radiation has been the preferred method for those with high morbidity inherent to resection. Surgical data have revealed the associated cranial neuropathies secondary to resection of vagal, sympathetic chain, and carotid body tumors. Given the morbidity associated with the resection and the slow growth rate inherent to paragangliomas, should we consider a watchful waiting strategy or possibly treatment with primary radiation to limit the morbidity associated with surgical treatment? References 1. Martin TPC, Irving RM, Maher ER. The genetics of paragangliomas: a review. Clin Otolaryngol. 2007;

32:7-11. 2. Sevilla MA, Hermsen MA, Weiss MM, et al. Chromosomal changes in sporadic and familial head and

neck paragangliomas. Otolaryngol Head Neck Surg. 2009;140: 724-729. 3. Wasserman PG, Savargaonkar P. Paragangliomas: classification, pathology, and differential diagnosis.

Otolaryngol Clin North Am. 2001;34(5) 845-62. 4. Old MO, Netterville JL. Head and Neck Paragangliomas. Head and Neck Cancer: Multimodality

Management. Springer Science+Vusinesss Media. 2011. 5. Manolidis S, Shohet J, Jackson G, et al. Malignant Glomus Tumors. Laryngoscope. 1999; 109:30-34. 6. Pellitteri PK, Rinaldo A, Myssiorek D. Paragangliomas of the head and neck. Oral Oncology. 2004: 40;

563-575. 7. Olsen WL, Dillon WP, Kelly WM, et al. MR imaging of paragangliomas. Am J Roentgenol. 1987;

148:201-204. 8. Telischi FF, Bustilloa A, Whiteman ML, et al. Octreotide scintigraphy for the detection of

paragangliomas. Otolaryngol Head Neck Surg. 2000; 122 (3):358-362. 9. Myssiorek D, Tronco G. 111Indium Pentetreotide Imaging in the Evaluation of Head and Neck Tumors.

Laryngoscope. 2005; 115:1707-1716. 10. Weed DT, Netterville JL, O’Malley BB. Paragangliomas of the Head and Neck. Head and neck cancer;

a multidisciplinary approach. Lippincott-Raven. 1999. 11. Walsh RM, Leen EJ, Gleeson MJ, et al. Malignant vagal paraganglioma. J Laryngol Otol. 1997;

111(1):83-88. 12. Phitayakorn R, Faquin W, Wei N, et al. Thyroid-Associated Paragangliomas. Thyroid. 2011; 21(7):725-

733. 13. Jin HR, Lee OJ, Ahn Y. Nasal cavity paraganglioma with malignant transformation: A case report. Auris

Nasus Larynx. 2008. 35(1);137-139. 14. Metzdorff MT, Seaman JC, Opperman DA, et al. Tracheal Paraganglioma: An Unusual Neoplasm of the

Upper Airway. Ann Thorac Surg. 2012. 93;1717-1719. 15. Langerman A, Athavale S, Rangarajan S, et al. Natural History of Cervical Paragangliomas. Arch

Otolaryngol Head Neck Surg. 2012; 138(4):341-345. 16. Lack EE, Cubilla AL, Woodruff JM, et al. Paragangliomas of the head and neck region: a clinical study

of 69 patients. Cancer. 1977; 39(2):397-409. 17. Netterville JL, Reilly MK, Robertson D, et al. Bilateral carotid body tumors: etiology and management of

physiologic changes resulting from bilateral excision. Triologic Thesis, 1993. 18. Hinerman RW, Amdur RJ, Morris CG, Kirwan J, Mendenhall WM. Definitive Radiotherapy in the

Management of Paragangliomas arising in the Head and Neck: A 35-Year Experience. Head & Neck. 2008; 30:1431-1438. 

Patient-Centric Decision Making in Acoustic Tumors Steven W. Cheung, MD, FACS

Objectives

1. Review treatment choices for acoustic tumors. 2. Understand tradeoffs among outcome expectations in complex decision making. 3. Consider implementation of a decision aid in shared decision making.

Overview

Acoustic tumors arise from either the superior or inferior vestibular nerve and accounts for about 10% of all newly diagnosed intracranial tumors.1 Asymmetric hearing loss, tinnitus, dysequilibrium, facial numbness, facial weakness, headache, and hydrocephalus are some presenting symptoms. Tumor size has been qualitatively classified by stages of enlargement2 to reflect the following typical growth pattern3: T1) origination and enlargement within the internal auditory canal (IAC), partially or fully filling the meatus, T2) excrescent extension beyond the medial limit of the IAC, T3) globular enlargement in the cerebellopontine angle cistern until tumor abuts the brainstem surface, and T4) displacement and compression of the brainstem with deformation of the fourth ventricle. Over the past decade, there has been greater acceptance of stereotactic radiosurgery, observation for smaller tumors, less-than-total tumor excision philosophy, and patient-centric decision making. Those changes have added new complexities to the management of acoustic tumors. At the core of decision making is time-intensive tradeoff analysis among the most salient expected clinical outcomes. With clinicians facing increasing pressure to drive greater patient flow through clinics, creating tools to foster more efficient encounters would be of benefit to patients and providers alike. A method to mechanize patient-driven explorations of treatment outcomes is use of a conjoint analysis-based health decision aid.4 While still under development, such a tool holds promise to enable shared decision making based on evidence-based medicine. Widespread implementation of an acoustic tumor decision aid would require validation studies.

Conclusions

The objectives of this presentation are to review tumor size classifications and their implications for treatment choices, to explain tradeoff analysis using conjoint techniques, and to conclude with clinical management heuristics and a candidate mechanized method to implement shared decision making.

References 1. Lunsford LD, Niranjan A, Flickinger JC, Maitz A, Kondziolka D. Radiosurgery of vestibular

schwannomas: summary of experience in 829 cases. J Neurosurg 2005;102:195-199. 2. Samii M, Matthies C. Management of 1000 vestibular schwannomas (acoustic neuromas): hearing

function in 1000 tumor resections. Neurosurgery 1997;40:248-260. 3. Jackler RK, Brackmann DE. Neurotology. Philadelphia: Mosby, 2005. 4. Cheung SW, Aranda D, Driscoll CL, Parsa AT. Mapping clinical outcomes expectations to treatment

decisions: an application to vestibular schwannoma management. Otol Neurotol 2010;31:284-293.

Early Glottic Cancer: Surgery or Radiation?

Katherine C. Yung, MD, FACS

Although early glottic cancer can have various definitions in the literature, for this talk, we will define it as T1a or T1b, disease of either one or both vocal folds, respectively. We can also include carcinoma in situ into this group, as the considerations for management are similar. The goals for treatment in early glottic cancer are 1) Cure 2) Organ preservation 3) Function/Quality of Life. The treatment modalities considered are typically definitive radiotherapy and endoscopic surgical resection. Historically, open partial laryngectomy was considered. However, given the greater morbidity of open surgery compared to endoscopic surgery, it is rarely performed presently. Cause specific survival rates are excellent for both radiation and endoscopic surgery in early glottic cancer. So how do we guide our patients? For many patients, a decision is made based on individual patient factors and preferences. We weigh expected voice outcomes, cost, treatment length, side effects, and possible future treatment options.

• Radiation o Avoids surgery and anesthesia o Can be done locally o Voice results more reliable? o Requires 5-7 weeks of

treatment o Cost o Lose treatment option for

recurrence or 2nd primary o Acute side effects o Delayed radiation effects

• Endoscopic Surgery o Outpatient procedure o Minimal/no dysphagia o Can be repeated o Good voice if resection is

superficial o Depth of invasion may only be

apparent intraop o Voice outcome is

unpredictable if muscle resected

o Requires specialized skill and equipment

• Recommend Radiation – Deeply invasive disease – Disease extending across anterior commissure – Field cancerization or diffuse dysplastic changes

• Recommend Surgery – Discrete superficial midfold lesion – Patients with low voice demand or concerns

Selected References:

1. Hartl DM et al. Evidence-based review of treatment options for patients with glottic cancer. Head Neck. 2011 Nov;33(11):1638-48.

2. Dinapoli N et al. Multidisciplinary approach in the treatment of T1 glottic cancer. The role of patient preference in a homogenous patient population. Strahlenther Onkol. 2010 Nov;186(11):607-13.

3. Vilaseca I et al. Voice quality after CO2 laser cordectomy--what can we really expect? Head Neck. 2008 Jan;30(1):43-9

Overview of Sleep Medicine and Surgery Macario Camacho, MD Objectives

1. To provide the learner with the pathophysiology of obstructive sleep apnea. 2. To provide the learner with information regarding sleep medicine and sleep

surgery. 3. The effectiveness of the surgical procedures will be presented based on the best

evidence to date. Overview

Obstructive sleep apnea is a highly prevalent disorder. The medical and surgical management of obstructive sleep apnea and sleep disordered breathing will be presented. Medical management currently consists of positive airway pressure therapy, mandibular advancement devices, positional therapy, myofunctional therapy, maxillary expansion (children), weight loss and several other techniques. Surgical treatment includes adenoidectomy, tonsillectomy, injection snoreplasty, radiofrequency of the soft palate, pillar implants, Cautery Assisted Palatal Stiffening Operation (CAPSO), uvulopalatopharyngoplasty (includes tonsillectomy), tongue suspension suturing techniques, lingual tonsillectomy partial glossectomy, genioglossus advancement, hyomandibular suspension thyrohyoid suspension, hyoid expansion, tracheostomy and maxillomandibular advancement have been described. Systematic reviews and meta-analyses of surgeries and select key articles will be discussed.

Conclusions Sleep medicine and sleep surgery for obstructive sleep apnea is a growing and changing field. References Anisha R. Kumar, Christian Guilleminault, Victor Certal, Doncai Li, Robson Capasso, Macario Camacho:

Nasopharyngeal airway stenting devices for obstructive sleep apnoea: A systematic review and meta-analysis. The Journal of Laryngology & Otology 12/2014;

Eric J. Kezirian, MD, MPH, Judy Maselli, MSPH, Eric Vittinghoff, PhD, Andrew N. Goldberg, MD, MSCE, and Andrew D. Auerbach, MD, MPH, San Francisco, CA. Obstructive sleep apnea surgery practice patterns in the United States: 2000 to 2006. Otolaryngology–Head and Neck Surgery (2010) 143, 441-447.

Macario Camacho, Victor Certal, Jose Abdullatif, Soroush Zaghi, Chad M Ruoff, Robson Capasso, Clete A Kushida: Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.. Sleep 10/2014;

Caldwell P, Hensley R, Machaalani R, Cheng A, Waters K. How effective is adenoidectomy alone for treatment of obstructive sleep apnoea in a child who presents with adenoid hypertrophy? Journal of Paediatrics and Child Health 47 (2011) 568–571

Brietzke SE , Mair EA . Injection snoreplasty: how to treat snoring without all the pain and expense . Otolaryngol Head Neck Surg 2001 ; 124 ( 5 ) : 503 – 10

Brietzke SE, et al. Injection snoreplasty: Investigation of alternative sclerotherapy agents. Otolaryngology Head and Neck Surgery. 2004. 130:47-57.

Powell NB, Riley RW, Troell RJ, Li K, Blumen MB, Guilleminault C. Radiofrequency volumetric tissue reduction of the palate in subjects with sleep-disordered breathing. Chest. 1998 May;113(5):1163-74.

Choi, J, et al. Efficacy of the Pillar Implant in the Treatment of Snoring and

Mild-to-Moderate Obstructive Sleep Apnea: A Meta-Analysis. The Laryngoscope. 2012.

Li HY, Chen NH, Wang CR, Shu YH, Wang PC. Use of 3-dimensional computed tomography scan to evaluate upper airway patency for patients undergoing sleep-disordered breathing surgery. Otolaryngol Head Neck Surg. 2003 Oct;129(4):336-42.

Fairburn SC, Waite PD, Vilos G, Harding SM, Bernreuter W, Cure J, Cherala S. Three-dimensional changes in upper airways of patients with obstructive sleep apnea following maxillomandibular advancement. J Oral Maxillofac Surg. 2007 Jan;65(1):6-12.

Nakata S, Noda A, Yanagi E, Suzuki K, Yamamoto H, Nakashima T. Tonsil size and body mass index are important factors for efficacy of simple tonsillectomy in obstructive sleep apnoea syndrome. Clin Otolaryngol. 2006 Feb;31(1):41-5.

B.T. Woodson and S.F. Conley, Prediction of uvulopalatopharyngoplasty response using cephalometric radiographs, Am J Otolaryngol 18 (1997), pp. 179–184

Farré R, Montserrat JM, Navajas D. Assessment of upper airway mechanics during sleep, Respir Physiol Neurobiol, 2008 Nov 30;163(1-3):74-81. Epub 2008 Jun 27.

Verin E, Tardif C, Buffet X, Marie JP, Lacoume Y, Andrieu-Guitrancourt J, Pasquis P. Comparison between anatomy and reistance of upper airway in normal subjects, snorers and OSAS patients. Respir Physiol. 2002 Jan;129(3):335-43.

Stuck BA, Neff W, Hörmann K, Verse T, Bran G, Baisch A, Düber C, Maurer JT. Anatomic changes after hyoid suspension for obstructive sleep apnea: an MRI study. Otolaryngol Head Neck Surg. 2005 Sep;133(3):397-402.

Hori Y, Shizuku H, Kondo A, Nakagawa H, Kalubi B, Takeda N. Endoscopic evaluation of dynamic narrowing of the phayrnx by the Bernouilli effect producing maneuver in patients with obstructive sleep apnea syndrome. Auris Nasus Larynx. 2006 Dec;33(4):429-32. Epub 2006 Aug 14.

Lowe AA, Fleetham JA, Adachi S, Ryan CF. Cephalometric and computed tomographic predictors of obstructive sleep apnea severity. Am J Orthod Dentofacial Orthop. 1995 Jun;107(6):589-95.

Tangugsorn V, Krogstad O, Espeland L, Lyberg T. Obstructive sleep apnoea: multiple comparisons of cephalometric variables of obese and non-obese patients. J Craniomaxillofac Surg. 2000 Aug;28(4):204-12.

Stuck BA, Maurer JT. Airway evaluation in obstructive sleep apnea. Sleep Med Rev. 2008 Dec;12(6):411-36. Epub 2007 Nov 28.

Vivat Tangugsorn,1 Olaf Krogstad,1 Lisen Espeland,1 Torstein Lyber. Obstructive sleep apnoea: multiple comparisons of cephalometric variables of obese and non-obese patients. Journal of Cranio-Maxillofacial Surgery (2000) 28, 204±212.

Friedman M, Ibrahim H, Joseph NJ. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope. 2004 Mar;114(3):454-9.

Macario Camacho, Muhammad Riaz, Robson Capasso, Chad M Ruoff, Christian Guilleminault, Clete A Kushida, Victor Certal: The Effect of Nasal Surgery on Continuous Positive Airway Pressure Device Use and Therapeutic Treatment Pressures: A Systematic Review and Meta-Analysis.. Sleep 10/2014;

Victor Certal, Macario Camacho, João C Winck, Robson Capasso, Inês Azevedo, Altamiro Costa‐Pereira: “Unattended sleep studies in Pediatric OSA: A systematic review and meta-analysis”. The Laryngoscope 03/2014;

Macario Camacho, Victor Certal, Scott E Brietzke, Jon-Erik C Holty, Christian Guilleminault, Robson Capasso: Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis.. The Laryngoscope 03/2014; 124(3):803-11.

Macario Camacho, Victor Certal, Robson Capasso: Comprehensive review of surgeries for obstructive sleep apnea syndrome.. Brazilian journal of otorhinolaryngology 12/2013; 79(6):780-788.

Victor Certal, Naoya Nishino, Macario Camacho, Robson Capasso: Reviewing the Systematic Reviews in OSA Surgery.. Otolaryngology Head and Neck Surgery 10/2013;

Jennifer C Hsia, Macario Camacho, Robson Capasso: Snoring exclusively during nasal breathing: a newly described respiratory pattern during sleep. Sleep And Breathing 05/2013;

Victor F Certal, Soroush Zaghi, Muhammad Riaz, Antonio S Vieira, Carlos T Pinheiro, Clete Kushida, Robson Capasso, Macario Camacho: Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. The Laryngoscope 11/2014;

Value-based healthcare in Otolaryngology: Why it matters to you (Parts 1 and 2) Christopher Klem, MD Objectives

1. Apply the basic principles of measuring the value of healthcare to improve the effectiveness of individual provider practice.

2. Understand current quality improvement initiatives and standardized quality measurements in Otolaryngology and the potential impact on individual practice.

Overview As healthcare costs in the United States continue at an unsustainable level, there is a move toward a value-based system to optimize outcomes per dollar spent. Otolaryngologists are playing a key role in defining how value will re-shape future practices. These lectures will discuss value-based healthcare and give examples of its current role in Otolaryngology. References 1. Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review, October 2013. 2. Porter ME. A strategy for healthcare reform – toward a value-based system. N Engl J Med. 2009;361:109-112. 3. Altman K. Improving health outcomes and value with care pathways: the Otolaryngologist’s role. Otolaryngol Head Neck Surg. 2014; 151(4): 527-529. 4. Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg 2014;219: 646-655.

Primary Hyperparathyroidism- Surgical Approach William Ryan, MD, FACS Assistant Professor Head and Neck Oncologic/Endocrine/Salivary Surgery Department of Otolaryngology-Head and Neck Surgery Objectives

1. Provide an overview of key issues/pitfalls with parathyroid surgery 2. Review key technical pearls during parathyroid surgery

Outline The Most Common Situation: Typical Hyperparathyroidism -> High Chance of Success However, There Are Many Pitfalls NIH Criteria Discussion Short Term Success and Long Term Success Criteria Differential Diagnosis and Other Pitfalls Preoperative Imaging: Tch-9m Sestamibi+/-SPECT, Ultrasound, MRI, 4D CT Parathyroid FNA Surgical Plan For Single Adenoma, Double Adenoma, Parathyroid Hyperplasia, Ectopic, and Parathyroid Carcinoma Supranumary Parathyroid Data Ectopic Parathyroid Locations/Statistics Technical Pearls During Parathyroid Surgery Timing of Intraoperative Parathyroid Hormone Algorithmic Operative Sequence “Minimally Invasive” Parathyroid Surgery Incision Length May Not Matter Outpatient Vs. Inpatient Surgery Indications Reexploration for Recurrent Hyperparathyroidism Recommendations Surveillance Guidlines

Mastoid Obliteration – When and How? Philip Littlefield, MD Objectives

1. To understand the indications and rationale for mastoid obliteration during cholesteatoma surgery.

2. To become familiar with a technique of mastoid obliteration that has worked well for the presenter.

Overview This presentation will go over the problems with canal-wall-up and canal-wall-down mastoidectomy techniques, and then introduce mastoid obliteration as one solution that maximizes the advantages of both techniques. The choice of obliteration material will be discussed, then a series of surgical videos will be used to demonstrate a typical case for the author. This will show how to do an endaural canal-wall-down mastoidectomy with meatoplasty and bone dust obliteration. Variations of this technique have been in common use in Europe for decades, as well as at several centers in the US, but it has not caught on with most otologists. The reasons for this will be discussed, and we will address the concern that obliteration can cover up cholesteatoma, leading to more serious disease. The presenter will also share some postoperative results. Conclusions Canal-wall-down mastoidectomy with autologous bone dust obliteration is a safe technique that maximizes surgical exposure, but also typically results in a small and easy to maintain mastoid cavity.

Avoiding Complications in Endoscopic Sinus Surgery Steven D. Pletcher, MD spletcher@ohns.ucsf.edu Objectives

1. Describe the most common serious complications which occur during endoscopic sinus surgery

2. Identify anatomy variations which contribute to surgical complications Overview In 1929, Harold Mosher identified surgery of the ethmoid sinuses as “one of the easiest ways to kill a patient.” Fortunately, the advent of the endoscope and other advances in surgical technique have dramatically improved the success rate of sinus surgery and diminished the frequency of complications. Serious complications, however, still occur during endoscopic procedures; this talk outlines several strategies for minimizing these risks.

1) Study the preoperative CT scan in multiple planes a. Pay particular attention to the relationship of the uncinated to the orbit

and the continuity (or lack thereof) of the medial orbital wall b. Note the position of the skull base in cribriform relative to the lateral

aspect of the anterior ethmoid roof (Keros Classification). Avoid aggressive medial dissection in this area

c. Follow the course of critical structures (carotid artery, optic nerve) to ensure that there is no dehiscent bone or involvement in the pathologic process

2) If you are resecting the middle turbinate, stay low to avoid the cribriform; the height of the ethmoid roof laterally is frequently not a safe level for turbinate resection

3) Identify the natural ostium of the sphenoid sinus prior to entry. a. The ostium sits relatively low, near the height of the orbital floor, in most

patients b. Mid-identification of the sphenoid face and puncture through the posterior

ethmoid roof with cleaning of “diseased” tissue beyond this lamella can lead to devastating complications

4) Appropriate hemostasis facilitates visualization and limits the risks of disorientation and damage to surrounding structures

Tinnitus Update Steven W. Cheung, MD, FACS

Objectives

1. Review tinnitus pathophysiology. 2. Understand rationales of experimental therapies. 3. Describe a treatment pathway for chronic tinnitus.

Overview

Tinnitus is the perception of internal sounds without corresponding external or physical stimuli. It is common, with estimates of 10-15% of the general population experiencing symptoms.1,2 Sixteen million Americans seek medical attention for tinnitus, and 2-3 million have severe symptoms that are debilitating.3 For those patients with tinnitus refractory to conventional acoustic and behavioral therapies, experimental approaches are considered. Investigational brain stimulation therapies targeting cortical4-6 and subcortical7-8 sites are at varying stages of clinical trial development. Brain regions of interest include: auditory cortex, associative cortex, limbic system, and deep brain nuclei. The rationales for those treatment targets will be discussed. The presentation will conclude with a conceptual framework to organize principles of various treatment modalities.

Conclusions

The objectives of this presentation are to review neural bases of chronic tinnitus and modulators that impact severity, to understand rationales of cortical and subcortical experimental brain stimulation approaches for bothersome tinnitus refractory to conventional acoustic and behavioral therapies, and to describe a treatment pathway for the management of chronic tinnitus.

References 1. Henry JA, Dennis KC, Schechter MA. General review of tinnitus: Prevalence, mechanisms, effects, and

management. J Speech Lang Hear Res. 2005;48(5):1204-1235. 2. Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US adults.

Am J Med. 2010;123(8):711-718. 3. Adams PF, Hendershot GE, Marano MA, Centers for Disease Control and Prevention/National Center

for Health Statistics. Current estimates from the national health interview survey, 1996. Vital Health Stat 10. 1999;(200)(200):1-203.

4. De Ridder D, Song JJ, Vanneste S. Frontal cortex TMS for tinnitus. Brain Stimul. 2013;6(3):355-362. 5. Frank E, Schecklmann M, Landgrebe M, et al. Treatment of chronic tinnitus with repeated sessions of

prefrontal transcranial direct current stimulation: Outcomes from an open-label pilot study. J Neurol. 2012;259(2):327-333.

6. Vanneste S, Plazier M, Van de Heyning P, De Ridder D. Repetitive transcranial magnetic stimulation frequency dependent tinnitus improvement by double cone coil prefrontal stimulation. J Neurol Neurosurg Psychiatry. 2011;82(10):1160-1164.

7. Cheung SW, Larson PS. Tinnitus modulation by deep brain stimulation in locus of caudate neurons (area LC). Neuroscience. 2010;169(4):1768-1778.

8. Larson PS, Cheung SW. Deep brain stimulation in area LC controllably triggers auditory phantom percepts. Neurosurgery. 2012;70(2):398-405.

Cancer Epidemics Affecting Otolaryngologists Erich M. Sturgis, MD, MPH Professor, Department of Head & Neck Surgery and Department of Epidemiology The University of Texas-M.D. Anderson Cancer Center Cancer Epidemics Affecting Otolaryngologists This presentation will feature an overview of the changing incidence of head & neck cancer in the U.S. with a specific attention to the increasing incidence of melanoma, papillary thyroid cancer, and oropharyngeal cancer. The demographic details of these increases will be presented both at a national level and within our institution. The controversy of cause of the rise in papillary thyroid cancer incidence will be discussed. The increasing incidence of oropharyngeal cancer as attributable to human papillomavirus (HPV) will be reviewed. The risk factors for HPV oral infection and HPV-associated oropharyngeal will be discussed. Review of current preventive vaccines will be reviewed.

Pharyngoesophageal Reconstruction Mark A Varvares MD, FACS Department of Otology and Laryngology, Harvard Medical School Department of Otolaryngology, Head and Neck Surgery, the Massachusetts Eye and Ear Infirmary Objectives

1. To understand the indications, advantages and disadvantages of the various options for reconstruction of the pharyngoesophagus.

2. To appreciate the role of vascularized tissue transfer for reconstruction of this anatomical site in the era of chemoradiotherapy.

Overview Pharyngoesophageal reconstruction as a component of treatment of malignancies of the larynx and hypopharynx remains an active and evolving area of interest amongst head and neck reconstructive surgeons. This talk will briefly review the history of pharyngoesophageal reconstruction, review the algorithm of options based on the defect, illustrate the different reconstructive approaches and discuss their outcomes. In addition, the role of vascularized tissue in prevention of complications following salvage surgery for cancer of the laryngopharynx and the preferences of surgeons for reconstruction of the pharyngoesophageal segment will be reviewed.

Sleep Disordered Breathing in Children: What is Next After T&A? Anna K. Meyer, MD, FAAP, FACS Objectives

1. Describe an appropriate work-up for persistent pediatric obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy.

2. Discuss treatment of different pathologies for persistent post-T&A pediatric OSA. Overview

• A significant proportion of children will have persistent obstructive sleep apnea following T&A.

• Some children will have minimal adenotonsillar tissue at initial evaluation and should be evaluated in a similar manner to those with persistent post-T&A pediatric OSA.

• High risk patients for persistent OSA are children who have Down syndrome or other craniofacial syndromes, neuromuscular disorders, mucopolysaccharidoses, or are obese/overweight.

• A post-surgical sleep study is recommended in these high risk patients and for patients with persistent symptoms

• Children with mild symptoms that are primarily nasal can be treated with a trial of nasal steroids prior to further work-up.

• Overweight/obese children should be enrolled in an comprehensive exercise and nutrition program

• Drug-induced sleep endoscopy (DISE) is an effective evaluation to identify sources of persistent pediatric OSA.

• Etiologies of persistent pediatric OSA are velar collapse, lateral pharyngeal wall collapse, inferior turbinate hypertrophy, tongue base collapse, lingual tonsillar hypertrophy, and sleep-associated laryngomalacia.

• Some procedures to treat persistent pediatric OSA may be easily performed at the time of DISE while others may require further planning and weighing of risks/benefits with parents.

• Some children may require CPAP and child life providers can aid in tolerance of this treatment.

Conclusions Persistent pediatric OSA after T&A is not uncommon and requires a thorough evaluation and treatment tailored to etiology(ies) that can include both medical and surgical intervention. References Ishman SL. Evidence-based practice: pediatric obstructive sleep apnea. Otolaryngol Clin North Am. 2012 Oct;45(5):1055-69. doi: 10.1016/j.otc.2012.06.009.

Chan DK, Liming BJ, Horn DL, Parikh SR. A new scoring system for upper airway pediatric sleep endoscopy.JAMA Otolaryngol Head Neck Surg. 2014 Jul;140(7):595-602.

Ulualp SO, Szmuk P. Drug-induced sleep endoscopy for upper airway evaluation in children with obstructive sleep apnea.Laryngoscope. 2013 Jan;123(1):292-7.

Title of Presentation: Molecular Diagnostics in Thyroid Cancer: Current Practices and Future Trends Jonathan R. George, MD, MPH Abstract: Advances in molecular testing of FNA samples have recently been shown to reduce unnecessary thyroid surgery. The purpose of this talk is to review current concepts in applying molecular diagnostic technology to fine needle aspiration cytopathology for thyroid neoplasms. The primary goal is to review the Bethesda classification for thyroid cytopathology and examine the role that gene expression classifiers (Afirma) and molecular alteration tests (Asuragen) play in facilitating preoperative decision-making for Bethesda III-V FNA cases. The genetic basis for thyroid cancer will be reviewed and the molecular underpinnings of this advanced diagnostic testing will be described in this framework. An assessment of the epidemiologic advantages of molecular diagnostic testing for Bethesda III-V cytopathology will be made. Recent clinical studies will be critically appraised. Finally, specific case scenarios will be reviewed to provide the practitioner with a basis for understanding the role that molecular diagnostics can play in the management of thyroid neoplasia.

Value-based healthcare in Otolaryngology: Why it matters to you (Parts 1 and 2) Christopher Klem, MD Objectives

1. Apply the basic principles of measuring the value of healthcare to improve the effectiveness of individual provider practice.

2. Understand current quality improvement initiatives and standardized quality measurements in Otolaryngology and the potential impact on individual practice.

Overview As healthcare costs in the United States continue at an unsustainable level, there is a move toward a value-based system to optimize outcomes per dollar spent. Otolaryngologists are playing a key role in defining how value will re-shape future practices. These lectures will discuss value-based healthcare and give examples of its current role in Otolaryngology. References 1. Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review, October 2013. 2. Porter ME. A strategy for healthcare reform – toward a value-based system. N Engl J Med. 2009;361:109-112. 3. Altman K. Improving health outcomes and value with care pathways: the Otolaryngologist’s role. Otolaryngol Head Neck Surg. 2014; 151(4): 527-529. 4. Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg 2014;219: 646-655.

New Techniques in OSA Surgery Macario Camacho, MD Objectives

1. To provide the learner information on new technologies for OSA surgical treatment.

2. Surgeries presented will include surgically assisted rapid maxillary expansion (SARME), transoral robotic surgeries (TORS) and hypoglossal nerve stimulators (HGNS).

Overview A historical perspective for SARME, TORS and HGNS will be presented, followed by additional information. Surgically assisted rapid maxillary expansion has been successfully used to treat adult obstructive sleep apnea, select articles will be presented. Transoral robotic surgeries have been used for treatment of cancers of the oropharynx and the application as treatment for OSA has recently been applied in the form of tongue base reduction. Results of preliminary studies will be presented. Hypoglossal nerve stimulators have been studied over the past decade, the effectiveness of the procedures will be presented. Conclusions Newer techniques to treat adult OSA are available. Technology has dramatically improved visualization for tongue base reduction (TORS). HGNS may be effective in select patients. References Victor F Certal, Soroush Zaghi, Muhammad Riaz, Antonio S Vieira, Carlos T Pinheiro,

Clete Kushida, Robson Capasso, Macario Camacho: Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. The Laryngoscope 11/2014.

Cistulli PA, Palmisano RG, Poole MD. Treatment of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep. 1998 Dec 15;21(8):831-5.

Friedman M, Hamilton C, Samuelson CG, Kelley K, Taylor D, Pearson-Chauhan K, Maley A, Taylor R, Venkatesan TK. Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck Surg. 2012 May;146(5):854-62. doi: 10.1177/0194599811434262. Epub 2012 Jan 13.

Evidence-based Guidelines for Chronic Sinusitis Steven D. Pletcher, MD spletcher@ohns.ucsf.edu Objectives

1. Identify the supportive literature for common medical and surgical treatments for chronic sinusitis

2. Describe flaws in the existing literature and how current studies can be applied to clinical practice

Overview Chronic sinusitis is a difficult disorder to treat. Both medical and surgical approaches are fraught with significant failure or recurrence rates. While the etiology of the disorder remains controversial, and multi-factorial, evidence-based treatment algorithms are difficult to apply. This talk reviews recent evidence-based reviews related to the treatment of chronic sinusitis. While ideal treatment for this disorder varies among specific patients, the following conclusions apply to the majority of CRS patients.

1) Steroids a. Topical steroid sprays beneficial, particularly for mild disease. Degree of

benefit is undefined b. Short term oral steroid treatment recommended in treatment of CRS with

polyps, Allergic Fungal Sinusitis, and as a perioperative treatment for these diseases

2) Antibiotics a. Limited benefit for antibiotic treatment (topical or systemic) for CRS b. If treating with oral antibiotics, 3 weeks or less is recommended c. Some data suggesting improvement with macrolide treatment

3) Endoscopic Sinus Surgery a. Lack large-scale randomized, controlled study b. Best data from non-randomized studies suggest patients who opt for

surgery following medical treatment benefit to a greater degree than those who continue with medical options alone

ALL OF THESE STUDIES HAVE FLAWS AND LITERATURE REVIEW IS ONLY ONE COMPONENT OF PROVIDING EVIDENCE-BASED TREATMENT

Beyond Aesthetics: Non-Cosmetic Uses of Botulinum Toxin A Scott Roofe, MD, FACS

Objectives 1. Compare the three subtypes of Botulinum Toxin A available in the US. 2. Discuss three applications for non-cosmetic applications of Botulinum Toxin A. 3. Describe the treatment for hemifacial spasm, facial paralysis and gustatory sweating using

neuromodulators.

Overview The use of neuromodulators for facial rejuvenation is widely recognized. However, the use

of botulinum toxin type A beyond cosmetic applications have expended significantly in the past several years. This presentation will compare the three subtypes of botulinum toxin currently available in the US and will focus primarily on three conditions encountered by the otolaryngologist: hemifacial spasm, facial paralysis, and gustatory sweating (Frey’s syndrome).

Hemifacial spasm is the involuntary irregular clonic or tonic movements of the facial musculature often treated with botulinum toxin. It occurs most frequently as a result of vascular compression of the facial nerve at the root exit zone. Disability associated with this disorder ranges from social embarrassment to interference with vision resulting from involuntary eye closure. Before any treatment is administered, a thorough evaluation must be performed.

In addition, botulinum toxin is used in the treatment of facial paralysis to enhance symmetry, both in the acute and chronic setting. Synkinesis occurring after recovery of facial nerve function may be treated in this manner. Selective injection of the contralateral facial musculature is effective in the treatment long standing facial paralysis resulting in hyperdynamic motion of the non-paralyzed side.

The social embarrassment and inconvenience of gustatory sweating has been well documented. Botulinum toxin has been shown to be a highly efficacious and minimal invasive treatment. The treatment strategies for effective management of Frey’s syndrome will be discussed.

References Persaud R, et al. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep. 2013 Feb;4(2):10.

Hartl DM, et al. Botulinum toxin A for quality of life improvement in post-parotidectomy gustatory sweating (Frey's syndrome). J Laryngol Otol. 2008 Oct;122(10):1100-4.

Ferraro G, et al. Botulinum toxin: 28 patients affected by Frey's syndrome treated with intradermal injections. Plast Reconstr Surg. 2005 Jan;115(1):344-5.

Frei K, et al. Botulinum toxin therapy of hemifacial spasm: comparing different therapeutic preparations. Eur J Neurol. 2006 Feb;13 Suppl 1:30-5.

Wabbels B, et al Double-blind, randomised, parallel group pilot study comparing two botulinum toxin type A products for the treatment of blepharospasm. J Neural Transm. 2011 Feb;118(2):233-9. Kim J. Contralateral botulinum toxin injection to improve facial asymmetry after acute facial paralysis. Otol Neurotol. 2013 Feb;34(2):319-24.

Lee JM, et al. Half-mirror biofeedback exercise in combination with three botulinum toxin A injections for long-lasting treatment of facial sequelae after facial paralysis.J Plast Reconstr Aesthet Surg. 2015 Jan;68(1):71-8. Salles AG, et al. Botulinum toxin injection in long-standing facial paralysis patients: improvement of facial symmetry observed up to 6 months. Aesthetic Plast Surg. 2009 Jul;33(4):582-90.

Mehta RP, Hadlock TA. Botulinum toxin and quality of life in patients with facial paralysis. Arch Facial Plast Surg. 2008 Mar-Apr;10(2):84-7

Clinical Implications of HPV-Associated Oropharyngeal Cancer Erich M. Sturgis, MD, MPH Professor, Department of Head & Neck Surgery and Department of Epidemiology The University of Texas-M.D. Anderson Cancer Center Clinical Implications of HPV-Associated Oropharyngeal Cancer This presentation will review the typical clinical presentation of human papillomavirus (HPV)-associated oropharyngeal cancer. The retrospective data suggesting a better prognosis for HPV-associated oropharyngeal cancer than HPV-negative cancer will be reviewed. The prospective clinical trials which have supported these findings will also be reviewed. Finally, future trials and potential areas for study will be discussed.

Management of Superior Semicirulcar Canal Dehiscence Aaron Tward, MD, PhD Assistant Professor UCSF Department of Otolaryngology – Head and Neck Surgery Otology, Neurotology, and Skull Base Surgery Objectives

1. Understand the pathogenesis of symptomatology of superior semicircular canal dehiscence

2. Understand selection criteria for surgical repair of superior semicircular canal dehiscence

3. Discuss selection of approach for repair of superior semicircular canal dehiscence

Overview Since the first description of superior semicircular canal dehiscence (SSCD) in 1998, our understanding of this condition has expanded substantially. Diagnosis of this frequently debilitating condition requires a careful history and physical examination, high resolution CT scan, audiogram, and is aided by c-VEMP or o-VEMP. Multiple surigical approaches for repair of SSCD may be used, including middle fossa and transmastoid approaches, with or without endoscopic assistance. We will discuss the underlying pathology of this condition, candidate selection for surgical repair, surgical techniques, and expected outcomes of repair of SSCD. References Carter et al. Laryngoscope 2014 124:1464-1468 Jung DH et al. Otol Neurotol. 36:126-132 Lookabaugh S et al. Otol. Neurotol. 2015 36:118-125 Merchant GR et al. Otol. Neurotol. 2015 36:172-177 Minor LB et al. Arch Otolaryngol Head and Neck Surg 1998 124:249-259 Niesten ME et al. Audiol Neurotol. 2015 20:62-71 Niesten ME et al. Audiol Neurotol 2014 19:97-105 Silverstein H et al. Am. J. Otolaryngol 2014 35:286-293’

Chemotherapy for Head and Neck Squamous Cell Carcinoma – Past, Present, and Future Eric D Wirtz, MD Objectives

1. Discuss the key studies supporting the use of chemotherapy as adjuvant treatment for head and neck squamous cell carcinoma

2. Weigh the evidence supporting and negating the use of induction chemotherapy 3. Present the up and coming chemotherapeutics and targeted therapy that may be

used in the adjuvant and primary treatment of head and neck squamous cell carcinoma

Overview Landmark studies have determined the standard of care by which we treat head and neck squamous cell cancer today. As we continue to attempt to improve the survival of our patients, studies continue to evaluate the benefits of induction chemotherapy and new-targeted therapies. In this lecture we will discuss the studies that have determined how we treat head and neck squamous cell cancer today as well as the studies that are currently determining how we will continue to treat head and neck squamous cell cancer in the future. References

Argiris, A., et al. "Long-Term Results of a Phase III Randomized Trial of Postoperative Radiotherapy with Or without Carboplatin in Patients with High-Risk Head and Neck Cancer." The Laryngoscope 118.3 (2008): 444-9. Print.

Belcher, R., et al. "Current Treatment of Head and Neck Squamous Cell Cancer." Journal of surgical oncology 110.5 (2014): 551-74. Print.

Bernier, J., et al. "Defining Risk Levels in Locally Advanced Head and Neck Cancers: A Comparative Analysis of Concurrent Postoperative Radiation Plus Chemotherapy Trials of the EORTC (#22931) and RTOG (# 9501)." Head & neck 27.10 (2005): 843-50. Print.

Bernier, J., et al. "Postoperative Irradiation with Or without Concomitant Chemotherapy for Locally Advanced Head and Neck Cancer." The New England journal of medicine 350.19 (2004): 1945-52. Print.

Bonner, J. A., et al. "Radiotherapy Plus Cetuximab for Squamous-Cell Carcinoma of the Head and Neck." The New England journal of medicine 354.6 (2006): 567-78. Print.

Cohen, E. E., et al. "Phase III Randomized Trial of Induction Chemotherapy in Patients with N2 Or N3 Locally Advanced Head and Neck Cancer." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32.25 (2014): 2735-43. Print.

Denaro, N., et al. "State-of-the-Art and Emerging Treatment Options in the Management of Head and Neck Cancer: News from 2013." Oncology 86.4 (2014): 212-29. Print.

Haddad, R., et al. "Induction Chemotherapy Followed by Concurrent Chemoradiotherapy (Sequential Chemoradiotherapy) Versus Concurrent Chemoradiotherapy Alone in Locally Advanced Head and Neck Cancer (PARADIGM): A Randomised Phase 3 Trial." The Lancet.Oncology 14.3 (2013): 257-64. Print.

Harari, P. M., et al. "Postoperative Chemoradiotherapy and Cetuximab for High-Risk Squamous Cell Carcinoma of the Head and Neck: Radiation Therapy Oncology Group RTOG-0234." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32.23 (2014): 2486-95. Print.

Hitt, R., et al. "A Randomized Phase III Trial Comparing Induction Chemotherapy Followed by Chemoradiotherapy Versus Chemoradiotherapy Alone as Treatment of Unresectable Head and Neck Cancer." Annals of Oncology : Official Journal of the European Society for Medical Oncology / ESMO 25.1 (2014): 216-25. Print.

Kiyota, N., M. Tahara, and M. Fujii. "Adjuvant Treatment for Post-Operative Head and Neck Squamous Cell Carcinoma." Japanese journal of clinical oncology 45.1 (2015): 2-6. Print.

Nguyen-Tan, P. F., et al. "Randomized Phase III Trial to Test Accelerated Versus Standard Fractionation in Combination with Concurrent Cisplatin for Head and Neck Carcinomas in the Radiation Therapy Oncology Group 0129 Trial: Long-Term Report of Efficacy and Toxicity." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32.34 (2014): 3858-66. Print.

Petrelli, F., et al. "Concomitant Platinum-Based Chemotherapy Or Cetuximab with Radiotherapy for Locally Advanced Head and Neck Cancer: A Systematic Review and Meta-Analysis of Published Studies." Oral oncology 50.11 (2014): 1041-8. Print.

Pignon, J. P., et al. "Chemotherapy Added to Locoregional Treatment for Head and Neck Squamous-Cell Carcinoma: Three Meta-Analyses of Updated Individual Data. MACH-NC Collaborative Group. Meta-Analysis of Chemotherapy on Head and Neck Cancer." Lancet 355.9208 (2000): 949-55. Print.

Pignon, J. P., et al. "Meta-Analysis of Chemotherapy in Head and Neck Cancer (MACH-NC): An Update on 93 Randomised Trials and 17,346 Patients." Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology 92.1 (2009): 4-14. Print.

Ye, A. Y., et al. "Toxicity and Outcomes in Combined Modality Treatment of Head and Neck Squamous Cell Carcinoma: Cisplatin Versus Cetuximab." Journal of cancer research and therapeutics 9.4 (2013): 607-12. Print.

Endoscopic Management of Laryngotracheal Stenosis

Katherine C. Yung, MD, FACS

Obstruction of the upper airway caused by laryngotracheal stenosis (LTS) often results in severe morbidity and even mortality. Treatment of LTS continues to present a challenge and a wide array of surgical techniques have been employed. Despite multiple endoscopic and/or open reconstructive procedures, patients often experience restenosis as a result of the abnormal wound-healing process that initially instigated the airway obstruction. The etiology of LTS is most commonly iatrogenic, mainly from prolonged intubation. Additional etiologies include autoimmune disorders, external trauma, and idiopathic LTS.

Endoscopic management is the preferred initial treatment method in most cases. The few exceptions include patients with external compression, cartilage collapse, or a long stenotic length. In these patients, the stenotic segment does not stay open after endoscopic treatment. Our typical procedure for LTS is microlaryngoscopy/subglottoscopy with CO2 laser radial incisions, dilation, plus or minus adjuvant therapies such as topical mitomycin or kenalog injection. Radial incisions are made to avoid circumferential disruption of the mucosal surface. If the patient fails the endoscopic management as described above, open airway surgery, formalized tracheostomy, t-tube placement, or stenting could be considered.

Posterior glottis stenosis (PGS) is approached differently than concentric subglottic or tracheal stenosis. It can often be mistaken for bilateral vocal fold paralysis. On close inspection, blunting or scarring of the interarytenoid region suggests PGS. When considering treatment options, one must consider the potential trade-offs amongst airway, voice, and swallowing. Options include posterior transverse cordotomy +/- medial arytenoidectomy, posterior microtrapdoor flap, and open resection and reconstruction.

Endoscopic management is the preferred initial treatment for LTS. Patients should be counseled that additional surgery may be necessary if the LTS recurs. Remember that it is not necessary to return the patient to a normal airway diameter --Flow ~ r4. Therefore, minimal increases in airway diameter can have dramatic clinical improvement.

Selected References:

1. Simpson GT, Strong MS, Healy GB, Shapshay SM, Vaughan CW. Predictive factors of success or failure in the endoscopic management of laryngeal and tracheal stenosis. Ann Otol Rhinol Laryngol. 1982 Jul-Aug;91(4 Pt 1):384-8.

2. Roediger FC, Orloff LA, Courey MS. Adult subglottic stenosis: management with laser incisions and mitomycin-C. Laryngoscope. 2008 Sep;118(9):1542-6.

Website Design and Search Engine Optimization Basics for the Medical Provider Rahul Seth, MD Objectives

1. Understand basic website terminology 2. Determine the components and approaches of basic website design 3. Appreciate the aesthetic and functional value in good website design

Overview The Internet is widely used as the primary means of researching any topic. Many individuals search for their physician online prior to meeting or consulting with them. Therefore, it is important for the physician to have an Internet presence for themselves, allowing the patient to easily find information about the physician rather than accessing this information at physician review sites. Basic website design and Internet vocabulary is essential knowledge to have to create and maintain a successful website. Additionally, basic websites can be easily designed and put together. Production of an aesthetically pleasing and functional website is well within the means of a physician without spending thousands of dollars to a website design company. Conclusions A strong Internet and website presence is important for any physician. This is achievable with basic knowledge and without formal training.

Oral Cavity and Oropharynx Carcinoma in the Nonsmoker/Nondrinker Steven J. Wang, MD Objectives

1. Understand the important changing demographics and new treatment trends in oral cavity and oropharynx carcinoma today

2. Describe the differences in etiology and prognosis for nonsmoker/nondrinker oral cavity carcinoma versus oropharynx carcinoma

Overview Today, we can observe several changing demographic trends among patients with oral cavity and oropharynx cancer in North America.

There has been a rapid increase in the incidence of oropharynx carcinoma over the past 30 years. The incidence of oropharynx carcinoma has now surpassed cervical cancer. HPV has been identified as a major cause of oropharyngeal cancer.

There is an increasing trend of never smokers developing oral cavity carcinoma, especially oral tongue cancers. In particular, there is an increasing incidence of young patients with oral tongue cancers, especially women under 40 often without tobacco history.

Treatment for oropharynx cancers includes surgery, radiation, and chemotherapy—often in combination. Primary radiation and concurrent chemoradiation has been the most common treatment strategy since 2000s. Primary surgery, with minimally invasive transoral approaches is increasingly common since 2010s.

Treatment for oral cavity is primarily surgery, if feasible, for all stages—with post-op adjuvant treatment (radiation with/without chemotherapy) based on surgical pathology. With modern reconstructive techniques, excellent functional and aesthetic outcomes can be achieved.

Conclusions ∙ Changing demographics with increased incidence among individuals with little or no smoking history ∙ Etiology of non-tobacco-related oral cavity cancers not known ∙ Never smokers with oral cavity and oral tongue SCC appear to have similar survival outcomes as smokers ∙ The initial treatment of oral cavity SCC, regardless of smoking status, should be with surgery ∙ HPV responsible for most oropharynx cancers today ∙ Very few oral HPV infections result in cancer, and only after a long latency period (> 15 years) ∙ Most HPV-positive oropharynx cancers have better prognosis and show better response to treatment ∙ HPV status has important clinical implications for the work-up of HNSCC ∙ Optimal treatment for HPV-positive oropharynx carcinoma balancing efficacy and toxicity remains to be determined References Patel SA, Magnuson JS, Holsinger FC et al. Robotic Surgery for Primary Head and Neck Squamous Cell Carcinoma of Unknown Site. JAMA Otolaryngol Head Neck Surg. 2013 Rodriguez-Bruno K, Ali MJ, Wang SJ. Role of pan-endoscopy of the upper aerodigestive tract for patients with oral cavity and oropharynx squamous cell carcinoma Head Neck 2011;33:949-53. Schantz SP, Yu GP. Head and neck cancer incidence trends in young Americans, 1973-1997, with a special analysis for tongue cancer. Arch Otolaryngol Head Neck Surg 2002;128:268-74. Llewellyn CD, Johnson NW, Warnakulasuriya KA. Risk factors for squamous cell carcinoma of the oral cavity in young people--a comprehensive literature review. Oral Oncol 2001;37:401-18. Koch WM, Lango M, Sewell D, Zahurak M, Sidransky D. Head and neck cancer in nonsmokers: a distinct clinical and molecular entity. Laryngoscope 1999;109:1544-51. Dahlstrom KR, Little JA, Zafereo ME, Lung M, Wei Q, Sturgis EM. Squamous cell carcinoma of the head and neck in never smoker-never drinkers: a descriptive epidemiologic study. Head Neck 2008;30:75-84. Wiseman SM, Swede H, Stoler DL, et al. Squamous cell carcinoma of the head and neck in nonsmokers and nondrinkers: an analysis of clinicopathologic characteristics and treatment outcomes. Ann Surg Oncol 2003;10:551-7. Harris SL, Kimple RJ, Hayes DN, Couch ME, Rosenman JG. Never-smokers, never-drinkers: unique clinical subgroup of young patients with head and neck squamous cell cancers. Head Neck 2010;32:499-503. Liang XH, Lewis J, Foote R, Smith D, Kademani D. Prevalence and significance of human papillomavirus in oral tongue cancer: the Mayo Clinic experience. J Oral Maxillofac Surg 2008;66:1875-80. Durr ML, Li D, Wang SJ. Oral cavity squamous cell carcinoma in never smokers: Analysis of clinicopathologic characteristics and survival. Am J Otolaryngol. 2013 Sep-Oct;34(5):388-93. Durr ML, van Zante A, Li D, Kezirian EJ, Wang SJ. Oral tongue squamous cell carcinoma in never-smokers: analysis of clinicopathologic characteristics and survival. Otolaryngol Head Neck Surg. 2013 Jul;149(1):89-96. Heaton CM, Durr ML, Tetsu O, van Zante A, Wang SJ. TP53 and CDKN2a mutations in never-smoker oral tongue squamous cell carcinoma. Laryngoscope 2014 Jan 15. doi: 10.1002/lary.24595

Pediatric Sinusitis – The Stair Step Approach Dr. Benjamin Cable

While pediatric sinus surgery may be performed safely and offer excellent outcomes, the vast majority of children with recurrent or chronic sinusitis can be treated medically. In the majority of these cases, otolaryngologists can play a key role in partnering with their primary care referring providers to tailor treatments for each patient. Currently guidelines will be discussed and practical, step-wise management strategies will be offered.

Evaluation and Treatment of Nasal Obstruction Rahul Seth, MD Objectives

1. Define nasal obstruction and its anatomic etiologies 2. Discuss surgical approaches to treat nasal obstruction 3. Describe the utility of the new nasal obstruction scales and their relevance to

patient treatment Overview The nasal valve is the narrowest portion of the human airway, and is formed by an opening between the nasal septum and side wall anatomy. Collapse of any of the structures making up the nasal valve can lead to nasal obstruction. Examples of structural causes include nasal septal deviation (cartilaginous or bony), bony inferior turbinate hypertrophy, concha bullosa formation (air in the middle turbinate), and narrow nasal aperture. The natural history of nasal obstruction is difficult to predict and may vary based on underlying etiology. The physical examination is key to determine the site of obstruction. Correction of nasal valve collapse generally requires surgical intervention, in particular the the augmentation of cartilage grafts to buttress and support the existing cartilage while enlarging the nasal valve (Fraser L, et al. An evidence-based approach to the management of the adult with nasal obstruction. Clin Otolaryngol 2009;34:151.) Particular surgical approaches and techniques help the patient to achieve successful relief in patients with significant nasal obstruction, forming the best practice ideal. Recent data emerging in the literature demonstrates the use of nasal obstruction scoring tools to help classify patients to determine those who may achieve surgical benefit (Lipan MJ, et al. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg 2013;15:358.) (Rhee JS, et al. A systematic review of patient-reported nasal obstruction score: defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg 214;16:219.). The new data and resources have resulted in a gap between best practice and current practice with regards to the identification of nasal obstruction patients who would benefit from surgical intervention. References Fraser L, et al. An evidence-based approach to the management of the adult with nasal obstruction. Clin Otolaryngol 2009;34:151. Lipan MJ, et al. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg 2013;15:358. Rhee JS, et al. A systematic review of patient-reported nasal obstruction score: defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg 214;16:219.

Medical Decision Making in Head and Neck Cancer Management Mark A Varvares, MD, FACS Department of Otology and Laryngology, Harvard Medical School Department of Otolaryngology, Head and Neck Surgery, the Massachusetts Eye and Ear Infirmary Objectives

1. To appreciate the role of the patient in the use of shared decision making in selection of options for treatment.

2. To understand the priorities of patients when choosing options for treatment of head and neck cancer.

Overview In spite of decades of clinical research in head and neck cancer, there are very few high impact studies based upon randomized prospective trials that allow the stratification of options for treatment that shows one modality offers superior survival over another. As a result, patients are left with what can be a confusing group of criteria such as survival, functional outcomes and quality of life upon which to determine the best options for treatment in their individual case. This talk will review the issues alluded to above and discuss the various priorities of patients in determining their course of treatment and the role of shared decision making in the process.

Transoral Robotic Surgery: Current and Future Utility MAJ J. Blake Golden, MD Objectives

1. Describe current uses for surgical robots in the head and neck 2. Recognize current FDA indications for use of the da Vinci robotic system. 3. Become familiarized with the ongoing evolution of robotic technology, equipment,

and techniques. Overview Over the past decade, robotic surgery has augmented the operative capabilities of the head and neck surgeon. Endo-wristed instruments, angled high-definition optics, and a variety of energy sources now allow once-difficult operations to be performed on a routine basis. In this lecture, we will discuss Intuitive’s da Vinci Robotic System, its FDA indications for use, and the ongoing developments that will continue to change the way Head and Neck surgeons approach pharyngeal disease. References

1. Byrd JK, Duvvuri U. Current trends in robotic surgery for otolaryngology. Curr Otorhinolaryngol Rep. 2013;1:153-157.

2. Cabot JC, Lee CR, Brunaud L, et al. Robotic and endoscopic transaxillary thyroidectomies may be cost prohibitive when compared to standard cervical thyroidectomy: a cost analysis. Surgery. 2012;152:1016-1024.

3. Davis KS, Byrd JK, Mehta V, et al. Occult Primary Head and Neck Squamous Cell Carcinoma: Utility of Discovering Primary Lesions. Otolaryngol Head Neck Surg. 2014;151:272-278.

4. Durmus K, Gokozan HN, Ozer E. Transoral robotic supraglottic laryngectomy: Surgical considerations. Head Neck. 2015;37:125-126.

5. Durmus K, Rangarajan SV, Old MO, Agrawal A, Teknos TN, Ozer E. Transoral robotic approach to carcinoma of unknown primary. Head Neck. 2014;36:848-852.

6. Lalich IJ, Olsen SM, Ekbom DC. Robotic microlaryngeal surgery: feasibility using a newly designed retractor and instrumentation. Laryngoscope. 2014;124:1624-1630.

7. Ozer E, Alvarez B, Kakarala K, Durmus K, Teknos TN, Carrau RL. Clinical outcomes of transoral robotic supraglottic laryngectomy. Head Neck. 2013;35:1158-1161.

8. Patel SA, Magnuson JS, Holsinger FC, et al. Robotic surgery for primary head and neck squamous cell carcinoma of unknown site. JAMA Otolaryngol Head Neck Surg. 2013;139:1203-1211.

9. Perrier ND. Why I have abandoned robot-assisted transaxillary thyroid surgery. Surgery. 2012;152:1025-1026.

Update on Cochlear Implantation Aaron Tward, MD, PhD Assistant Professor UCSF Department of Otolaryngology – Head and Neck Surgery Otology, Neurotology, and Skull Base Surgery Objectives

1. Identify expanding indications for cochlear implant candidacy 2. Understand factors involving selection of recently approved devices for cochlear

implant patients 3. Discuss indications and potential outcomes for auditory brainstem implants

Overview The past few years has seen rapid progress in the field of cochlear implantation with expanding indications, new and updated device and electrode designs, and additional options for patients with sensorineural hearing loss who are not candidates for cochlear implantation. Topics of discussion will include expanding candidacy criteria for cochlear implants including hearing preservation techniques and implants for single sided deafenss, implant and electrode selection and indications, and expected outcomes. We will also discuss the expanding indications for auditory brainstem implantation, as well as expected outcomes, particularly in patients who do not have Neurofibromatosis Type 2. References Behr et al. Otol. Neurotol. 2014 35:1844-1851 Colletti L et al. Audiol. Neurotol. 2014 19:386-394 Jurawtiz et al. Audiol. Neurotol. 2014 19:293-309 Mertens et al. Otol. Neurotol. 2015 36:51-60 Punte et al. Cochlear Implants Int 2011 12:Suppl 1:S26-29 Santa Maria PL et al. Otol. Neurotol. 2014 35:e256-259 Seyyedi M and Nadol J Otol. Neurotol. 2014 35:1545-51 Tward A. and Lee D. Sataloff’s Comprehensive Textbook of Otolaryngology in press Zhou L et al. Laryngoscopy 2014 epub doi: 10.1002/lary.24986

Role of In-Office CT Imaging Robert C. Kern MD Objectives

1. Review the current options for in-office CT imaging 2. Review the treatment impacts in terms of cost and outcome

Overview Historically, CT scans of the sinuses were expensive, associated with significant radiation exposure and relatively inaccessible. As a consequence, treatment algorithms typically recommended empiric oral antibiotics for the initial management of presumed CRS. The specificity of the history and physical exam including nasal endoscopy for the diagnosis of CRS is low. This has resulted in a massive overuse of antibiotics with CRS now accounting for 7% of all outpatient antibiotic prescriptions. The widespread availability of low radiation, office based CT scanning improves diagnostic accuracy, decreases antibiotic use, limits radiation exposure and improves patient satisfaction. Conclusions Office CT scanning has the potential improve outcomes in the CRS population.

Endoscopic Ear Surgery – More Techniques and Applications Philip Littlefield, MD Objectives

1. Introduce the concept of endoscopic ear surgery. 2. Explain the basic equipment and surgical setup. 3. To share some tricks and lessons learned.

Overview The presenter will review some of the material that he presented last year. This will include why endoscopic ear surgery is useful, when it is indicated, and how to perform it. This will include basic instrumentation, setup, and technique, followed by several case examples that will incorporate photos and video. This will include a discussion of surgical decision making and lessons learned over the last year of endoscopic ear cases. He will share some important tricks of technique, and will conclude by discussing the impact that endoscopic ear surgery has had on his surgical practice (mastoidectomies prevented), as well as its impact on resident education. Conclusions When used appropriately, endoscopic techniques can result in less invasive surgeries and improved overall outcomes.

Salvage Surgery for Head and Neck Malignancy MAJ J. Blake Golden, MD Objectives

1. Describe risk factors for recurrence of H&N squamous cell carcinoma 2. Understand indications for salvage surgery for recurrent disease 3. Recognize common complications after salvage surgery

Overview Head and neck squamous cell carcinoma remains a difficult disease to treat. Nonsurgical primary treatment for advanced-stage disease has gained ground over the last two decades. This has led to an increasing role for salvage surgery as treatment for recurrent disease, and in many cases represents the only curative option. This lecture will discuss recurrent H&N squamous cell carcinoma, preoperative evaluation, assessment of resectability, goals of treatment, and pitfalls of healing in the post-radiation setting. References 1. Basheeth N, O'Leary G, Sheahan P. Elective neck dissection for no neck during salvage total laryngectomy: findings, complications, and oncological outcome. JAMA Otolaryngol Head Neck Surg. 2013;139:790-796. 2. Chung EJ, Lee SH, Baek SH, Bae WJ, Chang YJ, Rho YS. Clinical outcome and prognostic factors after salvage surgery for isolated regional squamous cell carcinoma recurrences. Head Neck. 2014. 3. Hoang JK, Choudhury KR, Eastwood JD, et al. An exponential growth in incidence of thyroid cancer: trends and impact of CT imaging. AJNR Am J Neuroradiol. 2014;35:778-783. 4. Leon X, Quer M, Diez S, Orus C, Lopez-Pousa A, Burgues J. Second neoplasm in patients with head and neck cancer. Head Neck. 1999;21:204-210. 5. Mandapathil M, Roessler M, Werner JA, Silver CE, Rinaldo A, Ferlito A. Salvage surgery for head and neck squamous cell carcinoma. Eur Arch Otorhinolaryngol. 2014;271:1845-1850. 6. Matoscevic K, Graf N, Pezier TF, Huber GF. Success of salvage treatment: a critical appraisal of salvage rates for different subsites of HNSCC. Otolaryngol Head Neck Surg. 2014;151:454-461. 7. Nayan S, Ramakrishna J, Gupta MK. The Proportion of Malignancy in Incidental Thyroid Lesions on 18-FDG PET Study: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2014. 8. Prendes BL, Aubin-Pouliot A, Egbert N, Ryan WR. Elective lymphadenectomy during salvage for locally recurrent head and neck squamous cell carcinoma after radiation. Otolaryngol Head Neck Surg. 2014;151:462-467. 9. Rigby MH, Hayden RE. Total glossectomy without laryngectomy - a review of functional outcomes and reconstructive principles. Curr Opin Otolaryngol Head Neck Surg. 2014;22:414-418. 10. Roosli C, Studer G, Stoeckli SJ. Salvage treatment for recurrent oropharyngeal squamous cell carcinoma. Head Neck. 2010;32:989-996. 11. Sanderson RJ, Ironside JA. Squamous cell carcinomas of the head and neck. BMJ. 2002;325:822-827. 12. Sinha P, Hackman T, Nussenbaum B, Wu N, Lewis JS,Jr, Haughey BH. Transoral laser microsurgery for oral squamous cell carcinoma: oncologic outcomes and prognostic factors. Head Neck. 2014;36:340-351. 13. Sinha P, Hackman T, Nussenbaum B, Wu N, Lewis JS,Jr, Haughey BH. Transoral laser microsurgery for oral squamous cell carcinoma: oncologic outcomes and prognostic factors. Head Neck. 2014;36:340-351. 14. Strojan P, Corry J, Eisbruch A, et al. Recurrent and second primary squamous cell carcinoma of the head and neck: When and how to reirradiate. Head Neck. 2015;37:134-150. 15. Sturgis EM, Miller RH. Second primary malignancies in the head and neck cancer patient. Ann Otol Rhinol Laryngol. 1995;104:946-954. 16. Zafereo ME, Hanasono MM, Rosenthal DI, et al. The role of salvage surgery in patients with recurrent squamous cell carcinoma of the oropharynx. Cancer. 2009;115:5723-5733.

Tongue Tie: More Then You Ever Learned in Residency Anna K. Meyer, MD, FAAP, FACS Objectives

1. Identify appropriate evaluation and treatment of congenital anterior ankylglossia 2. Discuss the evolving diagnosis of posterior ankyloglossia and tight maxillary

frenulum and their effects on breastfeeding and other symptoms. Overview

• Anterior ankyloglossia has long been recognized as a cause of painful breastfeeding.

• Pediatrician awareness of or belief in pathologic anterior ankylglossia varies widely.

• Randomized trials of sham versus true frenotomy for ankyloglossia support that the procedure can improve breastfeeding.

• Educating local pediatricians about ankyloglossia is essential to limiting breastfeeding stress and early weaning.

• Posterior ankyloglossia and tight maxillary frenulum are recently identified possible pathologies in breastfeeding that have not been studied well.

• A small subset of providers are widely promoting surgical treatment of posterior ankyloglossia and tight maxillary frenulum.

• Self-diagnosis and layperson advice regarding posterior tongue tie and upper lip tie is rampant in social media.

• A large number of other infant problems are being attributed to oral ties, including colic, sleep apnea, gassiness, and migraine, without any supporting studies.

• The otolaryngologist will be facing increasing requests from patients and lactation consultants to treat posterior ankyloglossia and tight maxillary frenulum.

• Extensive research is needed to fully evaluate the pathologic nature of posterior ankyloglossia and tight maxillary frenulum, as well as the broader effects of anterior anyloglossia.

• A multidisciplinary approach to the mother-infant dyad, with consideration of a multitude of factors that impact breastfeeding, is more likely to benefit these patients.

Conclusions Ankyloglossia is rapidly evolving from a fairly clear-cut pathology leading to breastfeeding pain to a more broadly defined and implicated entity that is suggested as the cause of a whole host of infant problems. A dearth of evidence can substantiate these claims and further research, followed by outreach and education of pediatricians, lactation consultants, otolaryngologists and the lay public is essential to providing ethical and quality care to nursing mothers and their infants. References Buryk M1, Bloom D, Shope T. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Pediatrics. 2011 Aug;128(2):280-8.

O'Callahan C1, Macary S, Clemente S. Efficacy of neonatal release of ankyloglossia: a randomized trial. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):827-32.

An Organized Approach to Nasal Fractures Andrew H. Murr, MD

1. When evaluating nasal fractures, it is important to visualize the septum as untreated hematomas or abscessed can be devastating.

2. CT scans are the imaging study of choice if nasal fractures are to be imaged at all. With camera technology today, images of the injury can also be useful, more so if they can be added as part of the electronic medical record.

3. Early treatment can consist of closed reduction. This can be done in the clinic or the operating room depending on facilities available to you. A fairly high percentage of patients who have a closed reduction may seek further treatment, so follow-up appointments are a good idea.

4. Late treatment of fractures can be recommended using a graduated algorithm. a. If septal deflection is the main issue, septoplasty alone may be the best

recommendation b. If septal problems persist in addition to complaints about physical appearance

relating to dorsal deviation, a nasoseptal reconstruction or open rhinoplasty approach is reasonable.

i. Nasal obstruction is often a key issue for patients. If they are to have NSR, I prefer an open approach especially if I am planning on spreader grafts.

1. I find that spreader grafts are often a reasonable option to augment treatment of nasal obstruction after nasal trauma.

5. I think this is a good article for review: a. Ondik MP, Lipinski L, Dezfoli S, Fedok FG. The treatment of nasal fractures: a

changing paradigm. Arch Facial Plast Surg. 2009 Sep-Oct;11(5):296-302. doi: 10.1001/archfacial.2009.65. PubMed PMID: 19797090.

Pediatric Sinusitis: Case Based Review Benjamin Cable, M.D. Case 1: A 4-year-old child presents to your clinic with a history of copious nasal discharge for the previous 5 days. Initially clear, the mucous has become thick and green in the last 48 hours. His father reports noting intermittent fevers during the first 3 days (none measured) but has noted none in the last 48 hours. The father also reports a productive cough with nighttime waking for same. The child has complained a number of times about a sore throat. He has been treated for similar symptoms twice in the past 3 months with courses of amoxicillin. Rapid resolution of symptoms was noted on both occasions. The child has no significant medical history, has no known drug allergies, and is current for all recommended immunizations. On exam, you note thick nasal discharge from both nares as described, a unilateral serous effusion in the left ear, and halitosis. The remainder of your exam is WNL. Vital signs are WNL. How would you treat this child? A. Amoxicillin 45mg/kg/d for 7 days B. Amoxicillin 80-90mg/kg/d 14-21 days C. Amoxicillin/clavulanate 45mg/kg/d for 7 days D. Oseltamivir for 5 days E. Supportive care only

Viral URI – Answer E

Children experience an average of 6-8 viral infections a year with less than one in ten becoming a secondary bacterial infection. Hallmarks of viral upper respiratory tract infections include early onset of constitutional symptoms with resolution over the following 48 hours. Respiratory symptoms then follow and can last for an average of 5-7 days. (The overall average time for a viral URI in children is 6.6 – 8.9 days) Purulent nasal discharge has no predictive value for bacterial infections. Cough and odonyphagia are also common to both conditions. Physical exam factors are rarely able to distinguish bacterial from viral etiologies. Erythematous mucosal membranes and edematous nasal turbinates are common to both. Transillumination of the sinus cavities are of no value. Unilateral and reproducible pain with palpation over the maxillary (and sometimes frontal) sinus is not common but does suggest a bacterial cause. Examination of the remainder of the head and neck exam is important in the detection of other foci of infection but will also not discriminate sinonasal pathology causes. Current pediatric and otolaryngology literature recommends the diagnosis of acute sinusitis be based on duration and severity of symptoms. The 2013 APP Clinical Practice Guideline for the Management of Sinusitis makes the following recommendation: “The diagnosis of acute bacterial sinusitis is based on clinical criteria in children who present with upper respiratory symptoms that are either persistent, worsening, or severe. Acute bacterial sinusitis is an infection of the paranasal sinuses lasting less than 30 days that presents with either persistent, worsening, or severe symptoms. Patients are asymptomatic after recovery from episodes of acute bacterial sinusitis. Persistent symptoms are defined by nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement. Worsening symptoms are defined by similar symptoms to those listed above which recur after initial episodes of improvement are seen (usually around day 6 or 7). Severe symptoms include a temperature of at least 102.2°F (39oC) and purulent nasal discharge present concurrently for at least 3 to 4 consecutive days in a child who seems ill. Using this guidance, the presented child would not meet the criteria for a diagnosis of bacteria sinusitis and would not warrant antibiotic therapy. (Oseltamivir is not indicated after the first 48 hours of influenza symptoms) Supportive measures could include short-term use of decongestants (I use 1/2 strength (.025%) topical oxymetazoline for children having difficulty sleeping at night.) References:

1. American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013; 132:e262-e280

Case 2: A 5-year-old child presents to your office with a three-week history of post-nasal discharge, halitosis, and cough. Her mother reports the child has been somewhat more tired than normal but has otherwise been without complaint. She was treated for an episode of acute otitis media with amoxicillin 45mg/kg/d approximately 8 weeks ago, which symptomatically improved within 48 hours. With the exception of intermittent upper respiratory infections, she is without significant medical history or allergy. On exam, vital signs are normal. Mildly erythematous inferior turbinates are noted but no mucopurulence can be seen in the anterior nasal cavity. Oropharyngeal exam reveals cobblestoning of the posterior wall and a thin streak of thick nasal secretions running down from the nasopharynx. The child’s mother asks if she will need an “x-ray”? In regard to the query about x-ray films, you counsel: A. A sinus series will serve to confirm your clinical diagnosis of bacterial sinusitis B. A limited CT scan would be a better option and would provide a definitive

diagnosis C. Sinus films and CT evaluations will not change my diagnosis and at this point

would not be of benefit How would you treat this child? A. Amoxicillin 45mg/kg/d B. Amoxicillin 80-90mg/kg/d C. Amoxicillin/clavulanate 80-90mg/kg/d (amox) D. Trimethoprim-sulfamethoxazole 6-10mg/kg TMP/d

Acute Bacterial Sinusitis – Answers C,C This child clearly meets the criteria for acute bacterial sinusitis as described in the last question. Sinus imaging in this situation is not warranted due to the very high likelihood that either modality will show sinus pathology and that findings will not differentiate the underlying etiology. The AAP recommends that radiographic imaging not be performed in children unless the possibility of intracranial complication is being considered. Both the American College of Radiology and otolaryngology based Sinus and Allergy Health Partnership advise against plain films in the diagnosis and treatment of uncomplicated sinusitis. Although there has been some recent debate in the literature, it is generally agreed that antibiotic therapy offers significant advantage over placebo when treating pediatric sinusitis. One recent study showed antibiotics to both shorten time to cure and improve cure rates. Adult studies strongly agree with this conclusion. In the current AAP guideline, children with worsening or severe symptoms should be treated with antibiotics immediately. Children with persistent symptoms may either be observed for 72 hours or receive antibiotics. Antibiotic choices for sinusitis in children are evolving to reflect growing patterns of resistant organisms within the United States. Each of the most common respiratory pathogens is now capable of antibiotic resistance. S. pneumonia isolates make up approximately 30% of pediatric sinusitis specimens and are now reported to be 10-60% penicillin-resistant. H. influenza and M. catarrhalis represent 30% and 10% of cases respectively. H. influenza isolates are now 10-42% nonsusceptible to amoxicillin while nearly all M. catarrhalis isolates are non-susceptible. With these facts in mind, the AAP makes the following recommendations: Children >2 with uncomplicated mild to mod sinusitis amoxicillin 45-90mg/kg/d (no day care, no abx use for 4 weeks) Children <2, mod to severe sx, or recent abx use amoxicillin/clavulanate (80-90 mg/kg) Same children but with non-type I PCN allergy cefdinir cefuroxime cefpodoxime Same children with type I PCN allergy same as above (*** consider allergy consult prior to therapy) Children not improving on above therapy > 72 hr amoxicillin/clavulanate 80-90mg/kg/d or children not meeting above criteria ceftriaxone 50mg/kg/d x 1 dose (then orals if improved) cefdinir cefuroxime Second Failure or toxic appearing IV cefotaxime or ceftriaxone Consider ENT consult for Max sinus aspiration ***Optimal duration of therapy not concluded, one mentioned regimen is that the above abx be continued until the patient is symptom free for 7 days References:

1. American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013; 132:e262-e280

Case 3: A 4-year-old child presents to your clinic with a history of sinusitis persisting over the last 3 1/2 months despite an initial 14-day course of high dose amoxicillin and follow-up regimens of amoxicillin/clavulanate and cefuroxime for 3 and 4 weeks respectively. The patient’s mother reports mild improvement with symptoms while on the antibiotics but no resolution and almost immediate recurrence once antibiotics are completed. The child continues to have visible purulent nasal discharge, chronic cough, halitosis, and nasal obstruction. On close questioning, the mother denies any smoking in the home and reports that she has a history of moderate seasonal allergies which are treated with nasal steroids. The father has no history of allergies. The child attends a pre-school with 14 other children in her class. The child’s medical history is significant for mild reactive airway disease never requiring admission or emergent visits. There is no history of significant lower respiratory tract infections or witnessed sleep apnea. Your approach at this point could include:

A. In vitro allergy testing B. An allergy/immunology consult for formal allergy skin testing and immune

system evaluation C. An otolaryngology consult for endoscopic nasal evaluation and possible

adenoidectomy or sinus surgery D. CT scan of the sinuses E. In/outpatient IV antibiotic therapy

Chronic Sinusitis – Answer All of the above All of the possible answers are correct and each should be considered. Ordering of each particular evaluation should be tailored to the individual patient. Sinusitis in general and chronic sinusitis in particular is a mutifactorial disease. Dr. David Parsons, a prominent pediatric otolaryngologist and frequent author on the subject of sinusitis writes “…the primary cause of sinusitis is not bacteria. Rather, the primary causes of sinusitis are anything that leads to sinonasal edema.” This in turn leads to obstructed sinus cavities which can provide bacteria an extremely hospitable environment for growth.1

Factors which may influence edema or obstruction include allergies, adenoid hypertrophy, structural anomalies, GERD, and increased susceptibility to viral and bacterial pathogens from immune deficiencies: Allergic rhinitis has been reported to be present, at some time, in up to 40% of all children and has been associated with up to 80% of chronic sinusitis patients1,2. Testing should be considered in all children with sinusitis. Questions in the patient history should seek family history of allergy, seasonal symptoms, and frequently pruritic or watering eyes. Both serological and skin testing methods are available. Serologic testing is now widely available and has been found to have accuracy within 5-8% of intradermal skin testing (which continues to serve as a gold standard.)1 First line therapy for allergic rhinitis includes nasal steroid treatment. Continued symptoms can be managed with oral antihistamine therapy. Other medical alternatives include cromolyn sodium and hypertonic nasal saline. Refractory cases with positive testing should be evaluated for immunotherapy. Adenoid hypertrophy is a common anatomic obstruction in the pediatric population. Questions in the patient history should seek for chronic mouth breathing that may have predated the sinus symptoms. Adenoid pad size can be directly viewed with office endoscopy or with a soft tissue lateral film. Recent studies have shown relief of chronic sinusitis in 47-58% of cases after adenoidectomy.3

Structural Anomalies of the drainage pathways of the nasal sinuses can predispose patients to obstructive pathology. Examples include large agger nasi air cells and hypoplastic maxillary sinuses. Questions in the patient history and physical exam are not contributory. Coronal CT scans during periods of maximal treatment give detailed information in these areas. Current AAP Guidelines agree that CT scans are indicated when disease has been refractory to medical management. Treatment for structural anomalies is endoscopic sinus surgery. Meta-analysis of pediatric FESS reveals it to be a safe and effective treatment for chronic sinusitis with a positive outcome rate of 88% and a major complication rate of .6% (transfusion and meningitis).4 Often asymptomatic in children, GERD has been shown to occur, in one study, in 19 of 30 chronic sinusitis children tested by pH probe.5 In another study 25/28 children who were candidates for FESS avoided surgery with a regimen of behavioral modifications and proton pump inhibitor therapy.1 As with structural anomalies, history and exam are often noncontributory to the diagnosis of this disease. Empiric therapy with proton pump

inhibitors (with or without prokinetic medications) and behavioral modification is a reasonable approach. Diagnostic testing with pH probe analysis may also be considered. Immune deficiencies should always be considered in patients with significantly recurrent or chronic infections poorly responsive to medical therapy. One recent study in 79 adults with chronic sinusitis found immune system abnormalities in more than half of patients tested.6 Current testing should include immunoglobulin levels and T-cell responsiveness. History of lower respiratory tract infections should also trigger a sweat chloride analysis to rule out cystic fibrosis. With these facts in mind a reasonable approach to this patient may begin with allergy and immunology testing and medical therapy if indicated. If testing was negative or symptoms were unresponsive to allergy therapy, flexible endoscopy with subsequent CT scan would follow. If structural abnormalities and adenoid hypertrophy were absent, an empiric trial of medication for GERD or pH probe testing would be in order. (One additional modality that could be offered after a structurally normal CT scan would include maxillary sinus culture with directed IV antibiotic therapy. One published protocol using this approach (along with selective adenoidectomy) noted an 89% complete resolution rate in 70 patients with chronic sinusitis.)7 Summary – Evaluation of patients with chronic sinusitis Allergy Evaluation In Vitro Testing (mRAST) or skin testing Immunology Evaluation Immunoglobulin levels, pre/post vaccine titers, and sweat chloride testing Sinus Anatomy Evaluation Office endoscopy, CT Scan Reflux Evaluation Empiric trial of medication or 24 hour pH probe References:

1. Bothwell MR et al. Outcome of reflux therapy on pediatric chronic sinusitis. Otolaryngol Head Neck Surg. 121: 255-62, 1999

2. Join Task Force on Allergy, Asthma and Immunology. Diagnosis and management of rhinitis: Complete guidelines of joint task force on practice parameters in allergy, asthma, and immunology. Ann Allergy, Asthma, Immunol. 81, 1998

3. Vandernberg SJ, Heatley DG. Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. 123: 675-8, 1997

4. Hebert RL, Bent JP. Meta-analysis of outcomes of pediatric functional endoscopic sinus surgery. Laryngoscope. 108: 796-9, 1998

5. Phipps CD et al. Gastroesophageal reflux contributing to chronic sinus disease in children, a prospective analysis. Arch Otolaryngol Head Neck Surg. 126: 831-6, 2000

6. Chee L et al. Immune dysfunction in refractory sinusitis in a tertiary care setting. Laryngoscope. 111(2): 233-5. 2001

7. Don DM et al. Efficacy of a stepwise protocol that includes intravenous antibiotic therapy for the management of chronic sinusitis in children and adolescents. Arch Otolaryngol Head Neck Surg. 127: 1293-98, 2001.

Case 4 A 7 year old child presents to the emergency room with a chief complaint of right eye swelling. His father reports he has had a “severe cold” for the last 6 days manifested by a productive cough, fever to 101 degrees during the first 48 hours, general malaise, and coryza. On waking this morning, he was noted to have a “puffy” right eye that has not become any worse over the course of the last 6 hours. There is no history of trauma and the patient is otherwise healthy. The patient notes no visual changes in acuity or pain in the area of the eye. On exam, the patient is alert and cooperative. Edema of both right eye lids with mild erythema is noted. The eye is approximately 30% closed from the edema when compared with the normal eye. No proptosis is seen. Extraoccular movement, pupil, and acuity to near card testing are all WNL. Purulent nasal secretions are noted within both anterior nasal cavities. The remainder of the physical exam is WNL. Vital signs are WNL. How would you treat this child?

A. Supportive therapy and discharge B. Oral amoxicillin/clavulanate and discharge with follow-up in 24 hours C. IV Unasyn with admission and monitoring D. Surgical consultation for abscess drainage

Mild Preseptal Cellulitis – Answer B Given the close proximity and common vascular supply of the orbit to the sinus cavities, it is not surprising that the most common complications of sinusitis involve the orbit. The standard classification of orbital compliations is the Chandler classification: 1. Preseptal (aka periorbital) cellulitis – edema of the eye lids and periorbita caused

by vascular congestion of the ethmoid vascular system. Not an actual infection of the ocular structures. Tissue edema is limited by the orbital septum which is a fascial sheet attached to the orbital rim. This serves to separate the lids from the actual orbital contents (globe, fat, ocular muscles).

2. Subperiosteal abscess – a collection of purulent material just beneath the periosteum of the orbital wall. The source is often from a direct extension through the lateral wall of the ethmoid sinuses, known as the lamina papracea (paper thin layer).

3. Orbital abscess – a collection of purulent material within the cavity of the orbit, often from either direct extension or vascular migration of sinus infection.

4. Cavernous sinus thrombosis – extension of the sinus infection into the cavernous sinus.

With each increment of complication optic function is degraded. While little or no compromise in acuity or mobility is seen with preseptal cellulitis, significant compromise may be seen with any of the other three. The patient in this case best fits the description of preseptal cellulitis. Suspected complication be treated aggressively and include an otolaryngology referral. This report makes the recommendation that mild cases of preseptal cellulitis (lids < 50% closed) may be treated with outpatient oral antibiotic therapy and follow-up in 24-48 hours. This would be a reasonable approach to this patient. If any question remains, admission should be accomplished and IV therapy started with ceftriaxone 100mg/kg/d in 2 divided doses or ampicillin-sulbactam 200mg/kg/d in 4 divided doses. Otolaryngologists will often request a CT scan to rule out intra-orbital abscesses. One overriding idea that must be kept in mind at all times is preservation of visual function. Any evidence or even suspicion of ophthalmologic compromise should result in consultation with the ophthalmology service and often with the infectious disease service. Any evidence of neurologic compromise or meningeal symptoms should result in neurosurgical consultation. References:

1. American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013; 132:e262-e280

2. Richardson MA. Regional and Intracranial Complications of Sinusitis. In: Wetmore RF, Muntz HR, MgGill TJ, eds. Pediatric Otolaryngology Principals and Practice Pathways. New York, NY: Thieme; 2000: 487-495

Case 5 An 8-year-old child presents to the urgent care clinic with 6 hours of left eye pain and swelling. His mother reports a 10-day history of nasal congestion, intermittent headaches, and halitosis. She has noted subjective fevers in the last 48 hours that have been responsive to acetaminophen but that the swelling has markedly increased over the last 3-4 hours. The child is otherwise without significant medical history. On exam, the child is alert and oriented but in significant discomfort. The left eye is swollen shut and you are unable to manually open it to perform a full exam. When slightly open, the patient reports normal vision but mobility seems compromised. Exam of the nasal cavity shows moderate erythema but no obvious purulence. The remainder of the exam is WNL. Vital signs are WNL except for a temperature of 100.8 degrees. What is your initial treatment? A. Sinus plain film x-ray series B. CT Scan C. Repeat attempt at eye exam D. Start IV ampicillin/sulbactam

Subperiosteal Abscess - Answer D

In this case, questions about visual function alert the physician to localize the infectious process behind the orbital septum. Pain and additional edema add evidence to support this working diagnosis. Starting IV antibiotics immediately will allow initial treatment to begin as the remainder of the evaluation evolves. As with any possible orbital complication, globe function is of primary importance. Ophthalmology consultation in this case will help both to fully examine and follow the course of the child’s visual function. Otolaryngology consultation and a CT scan will serve to define localizing lesions.

In this case a large subperiosteal abscess was noted on the medial wall of the orbit. Assuming vision is fully intact, small abscesses may be treated with a trial of IV antibiotics and interval exams but larger lesions such as this and any lesion that does not show marked improvement in 24-48 hours requires surgical drainage. Approaches now include external and internal techniques. While an external approach involves a small incision between the medial canthus and the bridge of the nose, it tends to be a direct and expeditious route. Others prefer a strictly “internal” or endoscopic approach, which involves entering the ethmoid cavity and draining the abscess from its source. This technique avoids a facial scar but often requires a longer operative time.

References:

1. American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013; 132:e262-e280

2. Richardson MA. Regional and Intracranial Complications of Sinusitis. In: Wetmore RF, Muntz HR, MgGill TJ, eds. Pediatric Otolaryngology Principals and Practice Pathways. New York, NY: Thieme; 2000: 487-495

Pediatric Sinusitis Suggested Readings: 1. American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis

and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013; 132:e262-e280

A very well written review of the pathogenesis and common presentations of children with acute sinusitis. Algorithms are presented as part of the text and recommendations

2. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 123: 5-31, 2000

A nearly exhaustive examination of the current pathogens involved in sinusitis and their drug resistant characteristics. This information is then applied to the choice of specific antibiotics

3. Lusk, R. Pediatric chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck

Surg. Dec;14(6):393-6, 2006

A review of the approach to chronic sinusitis.

4. Cable BB, Mair EA. Pediatric functional endoscopic sinus surgery: frequently asked questions. Ann Otol Rhinol Laryngol. Sep;115(9):643-57, 2006

Summary of step-wise approach to recurrent and chronic sinusitis.

MOT15006: Pacific Rim Oto Update

2/10/2015University of California San Francisco

City, StateName

Registrant ListUCSF OCME Page 1 of 3

1 MD, PhD Saint Joseph, MOAnderson Blake

2 MD Hopkins, MNAnderson Todd

3 MD Atlanta, GAAthavale Sanjay

4 MD Bullhead City, AZBailey Richard

5 MD Rochester, MNBlum Daniel J.

6 MD Yarmouth, NS, CanadaBrodarec Ivan

7 MD Cupertino, CAButt Fidelia Y.

8 MD, COL, MC, U TAMC, HICable Benjamin B.

9 MD Gaithersburg, MDCamacho Macario

10 MD Calgary, AB, CanadaCampbell William N.

11 MD Lone Tree, COCarr Henry Patrick

12 MD Medford, ORChambers David

13 MD, FACS San Francisco, CACheung Steven W.

14 MD Honolulu, HICho John J.

15 MD Kailua, HIDierdorff Edwin P.

16 MD, FACS San Francisco, CAEl-Sayed Ivan

17 MD Hermiston, ORFlaiz Richard A

18 MD Newton, NJGaleos Warren

19 MD, MPH San Francisco, CAGeorge Jonathan R.

20 MD Forest Hills, NYGhirardo Silvio F

21 MD Tripler AMC, HIGolden Joseph B.

22 MD, PhD Manlius, NYGordon David C.

23 MD Augusta, GAGroves Michael William

24 MD Aiea, HIHadley Kevin S.

25 MD Tamuning, GUHahn Jason

26 MD Orlando, FLHan Wade W

27 MD Napa, CAHealey Kathleen

28 MD Paradise Valley, AZHeiland Kurt

29 NP Spokane, WAHerrbach-Neder Barbara

30 MD Draper, UTHill Justin

31 MSN Albuquerque, NMHolley Benjamin

32 MD Burlington, VTHubbell Richard N.

33 MD Turlock, CAHunt Walter L.

34 FRCSED, ENT Penrith, NSW, AustraliaHunter Michael

35 MD, FACS Steubenville, OHIsla Roger

36 DNP Pasadena, MDJacobs Lynne

37 MD Saskatoon, SK, CanadaJaggi Rick

38 MD Livermore, CAJansen Cornelius J.

City, StateName

Registrant ListUCSF OCME Page 2 of 3

39 MD Redlands, CAJeffries Sharen Knudsen

40 MD Cranbrook, BC, CanadaJewett Lawrence

41 MD Hyannis, MAJohnston Ross A.

42 MD Owatonna, MNJones Gregory C.

43 MD Walnut Creek, CAKahn Jonathan

44 MD Orlando, FLKanamori Glenn

45 MD Chicago, ILKern Robert C.

46 MD Modesto, CAKim Ji-Eon

47 MD Jamaica, NYKim Paul Joon

48 MD Walnut Creek, CAKleinberger Andrew

49 MD, FACS, LTC, Tripler AMC, HIKlem Christopher

50 NP Lima, OHKretzer Christy L

51 DO Edina, MNKuderer James

52 MD Edmonton, AB, CanadaKudryk William

53 MD Fremont, CAKung Brian

54 MD Moscow, RussiaLarin Roman

55 MD Waconia, MNLarsen John W

56 MD East Lansing, MILebeda Mark David

57 MD Honolulu, HILee Seung

58 MD Tripler AMC, HILittlefield Philip D.

59 MD Greenfield, WILong Christopher M.

60 MD Reno, NVLough Jeremy

61 MDCM, FRCSC Vancouver, BC, CanadaLudemann Jeffrey

62 MD Winchester, KYMakdessian Ara

63 MD Spokane Valley, WAMalone David

64 MD Vancouver, BC, CanadaMaloney Amanda

65 MD Bemidji, MNMarion Mitchell S.

66 MD Panorama City, CAMayeno John

67 MD Yellow Knife, NT, CanadaMcArthur Peter D.

68 DO Tulsa, OKMcClain Wade

69 MD Burien, WAMcClean Patrick

70 MD Coeur D'Alene, IDMcCormick Chad

71 DO Honolulu, HIMcLaughlin Timothy J.

72 MD Spokane, WAMcVey Kevin Kenneth

73 MD Santa Barbara, CAMester Andrew

74 MD, FAAP San Francisco, CAMeyer Anna K.

75 MD, FACS Seattle, WAMoore David W.

76 MD Escondido, CAMorelock Michael

77 MD Aiea, HIMurakami Wilson T.

78 MD, FACS San Francisco, CAMurr Andrew H.

79 MD Bismarck, NDNelson Jeffrey

80 MD Honolulu, HINewbill Daniel C.

City, StateName

Registrant ListUCSF OCME Page 3 of 3

81 MD Mandan, NDOliveira Filho Edgar Kramer

82 MD, FACS San Francisco, CAPletcher Steven D.

83 MD San Francisco, CARafii Amir A.

84 MD Santa Clara, CARezaee Ali

85 MD Aarau, SwitzerlandRohner Dennis

86 MD, COL, MC, U Tripler AMC, HIRoofe Scott B.

87 DO Rocherster Hills, MIRoos Jason D.

88 MD, FACS San Francisco, CARyan William R.

89 MD Vancouver, BC, CanadaSamad Imran

90 MD Yakima, WASchefter Robert P

91 DO Royal Oak, MISchleimer David P

92 MD Marshfield, WISchreiber Nathan

93 MD San Francisco, CASeth Rahul

94 MD Saint Paul, MNShafiei Majid

95 MD Louisville, KYShotts Steven D.

96 MD Arlington, VASpagnoli Scott

97 MD Anderlues, BelgiumSpinato Linda

98 MD Ann Arbor, MIStanley Jeffrey

99 MD Bakersfield, CAStone David M

100 MD, MPH Houston, TXSturgis Erich M.

101 MD Las Vegas, NVTolan Timothy Matthew

102 MD Kaneohe, HITsai Paulus D.

103 MD Changhua, TaiwanTseng Pao-Yu

104 MD Whitefish, MTTubbs Kyle J.

105 MBBS Pago Pago, AS, American SamoaTuioletai Malaela

106 MD Loma Linda, CAUmeda Alvin

107 MD Campbell, BC, CanadaVan Rooy Charles

108 MD West St Paul, MB, CanadaViallet Norbert R. J.

109 Melbourne, VIC, AustraliaVinayagamoorthy Aravinthan

110 MD, FACS San Francisco, CAWang Steven J.

111 MD Boulder, COWarren James Douglas

112 MD Hopkinton, MAWilson Yushan Lisa

113 MD Tripler AMC, HIWirtz Eric D.

114 MD San Francisco, CAYung Katherine C.

115 MD Austin, TXZapata Syboney

115Total Number of Attendees for MOT15006:

University of CaliforniaSan Francisco