Download Course Syllabus - Continuing Medical Education

Presented by the Departments of
Otolaryngology-Head and Neck Surgery
University of California, San Francisco
and Tripler Army Medical Center
Honolulu, Hawaii
University of California
San Francisco
Pacific Rim Otolaryngology–
Head and Neck Surgery
Update
SATURDAY - TUESDAY • PRESIDENTS’ DAY WEEKEND
February 15-18, 2014
CONCURRENT COURSE! AMERICAN COLLEGE OF SURGEONS THYROID AND
PARATHYROID ULTRASOUND SKILLS-ORIENTED COURSE FEB 15-16, 2014
MOANA SURFRIDER
HOTEL
Waikiki Beach
Honolulu, Hawaii
COURSE CHAIRMEN
Andrew H. Murr, MD, FACS
University of California, San Francisco
Benjamin Cable, MD, MAJ, MC, USA
Tripler Army Medical Center, Honolulu, HI
William R. Ryan, MD
University of California, San Francisco
Upcoming CME Courses
Primary Care Medicine: Update 2014
Sunday, April 6 – Friday, April 11, 2014
Wailea Beach Marriott and Spa – Wailea, Hawaii
35th Annual Advances in Infectious Diseases: New Directions for Primary Care
Wednesday, April 23 – Friday, April 25, 2014
Hilton Financial District – San Francisco, California
Essentials of Women's Health:
An Integrated Approach to Primary Care and Office Gynecology
Sunday, July 6 – Friday, July 11, 2014
Hapuna Beach Prince Hotel – Kohala Coast, Hawaii
Neurosurgery Update 2014
Thursday, August 7 – Saturday, August 9, 2014
Silverado Resort, Napa, California
Pituitary Disorders: Advances in Diagnosis and Management
Saturday, October 25, 2014
Marriott Union Square – San Francisco, California
26th Annual Medical Management of HIV/AIDS and Hepatitis
Thursday, December 11 – Saturday, December 13, 2014
Westin Market Street – San Francisco, California
Pacific Rim Otolaryngology – Head and Neck Surgery Update
Saturday, February 14 – Tuesday, February 17, 2015
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 15- 18, 2014
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, LTC, 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
ArthroCare ENT
Karl Storz
Exhibitors
ArthroCare ENT
Atos Medical
DePuy Synthes CMF
Entellus
Hemostatix Medical Technologies
Hitachi Aloka
KLS Martin
Medtronic ENT
Microline Surgical
NeilMed
Olympus America
Pentax Medical
Stryker ENT
University of California, San Francisco and
present
Tripler Army Medical Center
Pacific Rim Otolaryngology – Head and Neck Surgery Update
With continued advancements in knowledge, technique, and technology, the management of
disorders in otolaryngology-head and neck surgery evolves at a rapid pace. The goal of this course
is to provide an update in contemporary otolaryngology - 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 discuss and, as appropriate, apply:
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New management strategies for migraine related dizziness and understand advancements
in BAHA technology;
An understanding of the success rates and techniques for closure of nasoseptal
perforations;
Current options for management of reconstruction of facial cutaneous defects;
Strategies for developing an airway response team and the pros and cons of utilizing
percutaneous tracheotomy techniques in your practice;
Assessment of factors and trends in the operationalization of the Affordable Care Act;
Concepts of human biome research as it applies to the pathophysiology of sinus disease;
Current concepts in the diagnosis and management of vocal cord paralysis;
Management of upper aerodigestive tract related disease of the neck and the management
of neck metastasis related to thyroid cancer.
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 22.75 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 to complete the online course evaluation:
http://www.ucsfcme.com/evaluation
Upon completing the online evaluation, your CME certificate will be automatically
generated and emailed to you.
Evaluation
Your opinion is important to us – we do listen! We have two evaluations for this meeting.
The 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.
The overall conference evaluation is online at: http://www.ucsfcme.com/evaluation
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 2/17/14.
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 2/17/14 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, LTC, 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
Jennifer M. Bager, MD, MAJ, MC, USA
Staff, Otolaryngology – Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI
Nikolas H. Blevins, MD
Larry and Sharon Malcolmson Professor; Chief, Division of Otology/ Neurotology; Medical Director,
Stanford Cochlear Implant Center, Department of Otolaryngology - Head and Neck Surgery,
Stanford University School of Medicine, Stanford, CA
Dylan K. Chan, MD, PhD
Assistant Professor, Division of Pediatric Otolaryngology,
Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco
Jolie L. Chang, MD
Assistant Professor, Department of Otolaryngology - Head and Neck Surgery,
University of California, San Francisco
Mark S. Courey, MD
Professor, Department of Otolaryngology – Head and Neck Surgery; Director, Division of Laryngology;
Director, Voice and Swallowing Center, University of California San Francisco
Michael A. Fritz, MD
Staff Surgeon, Facial Plastic and Reconstructive Surgery, Cleveland Clinic Head and Neck Institute,
Cleveland, OH
Andrew N. Goldberg, MD, MSCE, FACS
Professor, Department of Otolaryngology – Head and Neck Surgery; Director, Division of Rhinology and
Sinus Surgery; Director, Outcomes Research; Director, Center for Clinical Research in Otolaryngology,
University of California, San Francisco
Laura A. Kirk, MSPAS, PA-C
Physician Assistant, Department of Otolaryngology – Head and Neck Surgery,
University of California San Francisco
Christopher Klem, MD, FACS, LTC, MC, USA
Chief, Head and Neck Surgery, Tripler Army Medical Center- Honolulu, HI
P. Daniel Knott, MD, FACS
Associate Professor and Director, Division of Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology – Head and Neck Surgery, University of California, San Francisco
Dennis H. Kraus, MD
Director, Center for Head & Neck Oncology, New York Head & Neck Institute,
North Shore-LIJ Cancer Institute, New York, NY
COURSE FACULTY (continued)
Philip D. Littlefield, MD
Chief, Otology and Neurotology; Assistant Residency Program Director, Department of Otolaryngology,
Tripler Army Medical Center, HI
Lawrence R. Lustig, MD, FACS
Professor and Francis A. Sooy, MD Endowed Chair, Department of Otolaryngology – Head and Neck
Surgery; Director, Division of Otology, Neurotology, and Skull Base Surgery, University of California, San
Francisco
Scott B. Roofe, MD, COL, MC, USA
Chief, Facial Plastic and Reconstructive Surgery; Residency Program Director, Department of
Otolaryngology, Tripler Army Medical Center, HI
Marika D. Russell, MD, FACS
Assistant Professor, Department of Otolaryngology – Head and Neck Surgery,
University of California, San Francisco
Matthew S. Russell, MD, FACS
Assistant Professor, Department of Otolaryngology – Head and Neck Surgery,
University of California, San Francisco
Joseph C. Sniezek, MD, FACS, COL, USA
Consultant to the Surgeon General of the Army for Otolaryngology, Tripler Army Medical Center;
Associate Clinical Professor, University of Hawaii John A. Burns School of Medicine, Honolulu, HI
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, LTC, MC, USA
Jennifer M. Bager, MD, LTC, MC, USA
Dylan K. Chan, MD, PhD
Jolie L. Chang, MD
Mark S. Courey, MD
Michael A. Fritz, MD
Laura A. Kirk, MSPAS, PA-C
Christopher Klem, MD, FACS, LTC, MC, USA
Dennis H. Kraus, MD
Philip D. Littlefield, MD
Lawrence R. Lustig, MD, FACS
Scott B. Roofe, MD, COL, MC, USA
Marika D. Russell, MD, FACS
Matthew S. Russell, MD, FACS
Joseph C. Sniezek, MD, FACS, COL, MC
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
Consultant
IntersectENT
Allakos
William Ryan, MD, FACS
Consultant
Honorarium
Medtronic
Health Care Research and Analytics
Nikolas H. Blevins, MD
Scientific Advisory Board
Consultant
Sonitus Medical
Aria Innovations, Inc.
Andrew N. Goldberg, MD, MSCE, FACS
Stock Holder/OSA Device
Patent application #61/624,105
Apnicure; Siesta Medical
Sinusitis Diagnostics and Treatment
P. Daniel Knott, MD, FACS
Advisory Board- Basal Cell Cancer
Genentech, Corporation
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 15, 2014
6:30 am
Registration and Continental Breakfast
6:55
Welcome and Announcements
A. Murr; B. Cable; W. Ryan
7:00
Standardizing Your Endoscopic Exam: The DIP Score
Andrew H. Murr
7:30
Pediatric Aerodigestive Tract Foreign
Body Management Pearls
Benjamin B. Cable
Parotidectomy – Balancing Treatment Needs with
Functional and Cosmetic Outcomes
William R. Ryan
8:30
Malpractice in Otolaryngology
Joseph C. Sniezek
9:00
Updates in Management for Acute and
Chronic Vocal Fold Paralysis
Mark S. Courey
8:00
9:30
Break
10:00
Cochlear Implantation - Indications, Techniques, and
Future Directions
Nikolas H. Blevins
10:30
Update on Adult Obstructive Sleep Apnea
Jennifer M. Bager
11:00
Treatment of the Crooked Nose
P. Daniel Knott
11:30
Percutaneous Tracheostomy
Marika D. Russell
12:00
New Care Pathways for Penetrating Neck Trauma
Christopher Klem
12:30pm
Adjourn
5:00pm
Case Discussions
6:00pm
Adjourn
SUNDAY, FEBRUARY 16, 2014
6:30 am
Continental Breakfast
6:55
Announcements
William R. Ryan
7:00
Oropharyngeal Carcinoma –
A Comparison of Treatment Side Effects
William R. Ryan
7:30
Migraine Dizziness: Evaluation and Treatment
Philip D. Littlefield
8:00
Complications of Acute Sinusitis
Matthew S. Russell
8:30
Laryngeal Microsurgery for Benign Disease
Mark S. Courey
9:00
Sialoendosopy and Minimally- invasive Techniques for
Benign Salivary Disorders
Jolie L. Chang
9:30
Break
10:00
Leslie Bernstein Lecture – Innovations in Microvascular
Facial Reconstruction: Pushing the Boundaries
Michael A. Fritz
11:00
Chronic Ear Surgery: Staying Out of Trouble
Lawrence R. Lustig
11:30
Pediatric Sleep Endoscopy and Surgical
Management of Recalcitrant Pediatric Sleep Apnea
Dylan K. Chan
12:00
Update of Facial Laser Resurfacing Techniques
Scott B. Roofe
12:30 pm
Adjourn
5:00
Case Discussions
6:00
Adjourn
MONDAY, FEBRUARY 17, 2014
12:25pm
Announcements
Benjamin B. Cable
12:30
Head and Neck Manifestations of Autoimmune Disease
Jennifer M. Bager
1:00
Bone Conduction Hearing Aids –
I'm Not Your Grandma's BAHA!
Lawrence R. Lustig
1:30
The Difficult Airway Team
Matthew S. Russell
2:00
Update on Neuromodulators and Fillers for 2014
P. Daniel Knott
2:30
Current Evidence for Radiosurgery in VS Treatment
Nikolas H. Blevins
3:00
Break
3:30
Management of the Neck – An Overview
Dennis H. Kraus
4:00
Integrating Ultrasound into Clinical Practice
Christopher Klem
4:30
Surgical Repair of Septal Perforations
Scott B. Roofe
5:00
Do Our Sinuses Crave Certain Bacteria for Health?
Andrew N. Goldberg
5:30
Management of Sudden Sensorineural Hearing Loss
Jolie L. Chang
6:00
Panel Discussion – Otology Panel
Implantable Hearing Devices: What's Best for My Patient?
Moderator:
Lawrence R. Lustig
Panelists: Lawrence R. Lustig, Nikolas H. Blevins, Philip D. Littlefield, and Dylan K. Chan
6:45
Adjourn
7:00 pm
Reception
TUESDAY, FEBRUARY 18, 2014
6:30 am
Continental Breakfast
6:55
Announcements
Andrew H. Murr
7:00
Diagnostic Workup for Congenital Sensorineural
Hearing Loss
Dylan K. Chan
Complications in Functional Endoscopic Sinus Surgery –
Avoidance and Management
Andrew N. Goldberg
8:00
Managing Lymph Node Disease in Thyroid Cancer
Joseph C. Sniezek
8:30
Thyroglobulin as a Tumor Marker in Well-differentiated
Thyroid Cancer
Dennis H. Kraus
9:00
Ultrasound-guided FNA
Marika D. Russell
9:30
Break
10:00
Reconstruction of Facial Cutaneous Defects
Michael Fritz
10:30
Endoscopic Ear Surgery:
Minimally-invasive Surgery that Matters
Philip D. Littlefield
Incorporating an Advanced Health Practitioner into an
Otolaryngology-HNS Practice
Laura A. Kirk
Load Sharing Mandible Reconstruction:
The Champy Technique
Andrew H. Murr
12:00
Affordable Care Act - Progress Report Since Initiation
Benjamin B. Cable
12:30 pm
Adjourn / Evaluations
7:30
11:00
11:30
STANDARDIZING YOUR ENDOSCOPIC EXAM: THE DIP SCORE
Andrew H. Murr, MD, FACS
KEY: Each category is scored from 0 – 10. 30 points in total is allowed for each nasal
cavity.
Discharge: 0 = absent discharge; 5 = thick mucus; 10 = purulent discharge
Inflammation: 0 = no inflammation; 5 = moderate inflammation; 10 = severe inflammation
Polyp: 0 = normal mucosa; 5 = marked edema but NO POLYPS; 10 = polyps filling the nasal
cavity
Tip on polyp scoring: [6,7,8,9,10 are scores indicating polyps which is similar to a 1 – 5 scale
for polyps at the top end of the polyp scale]
DIP SCORE
Pediatric Aerodigestive Tract Foreign Body Management Pearls
Benjamin Cable, M.D.
Objectives
1. Participants will be able to describe specific techniques and airway
management instruments that facilitate spontaneous anesthesia
techniques for use in foreign body removal.
2. Participants will be able to contrast multiple approaches and
instrument pairings to optimize foreign body removal.
Overview
This presentation will focus on specific steps that can be taken to facilitate
optimal safety and efficiency in the surgical removal of aerodigestive tract foreign
bodies during all three phases of treatment, planning, anesthesia induction, and
instrumentation.
Parotidectomy – Balancing Treatment Needs with Functional and Cosmetic
Outcomes
William R. Ryan, MD, FACS
Objectives
1. Update on studies analyzing management of parotid tumors with
regard to incision placement, degree of margin, facial nerve
management, great auricular nerve management, and management of
lymph nodes
2. Update on studies analyzing management of parotid tumors with
regard to reconstructing facial contour defect, reducing the risks of and
treating sialocele, seroma, and gustatory sweating.
Overview
Parotidectomy surgery though a fairly routine procedure in the field of
otolaryngology-head and neck surgery, has some varying points of management
with regard to treating specific tumor types and addressing issues of function and
appearance. Over 30 minutes, I plan to cover a spectrum of these critical points
and present evidence when it exists to justify decision-making to optimize results.
Photo representations will be presented as much as possible.
Malpractice in Otolaryngology
Joseph C. Sniezek, MD
Background:
-The cumulative career probability of a surgeon facing a malpractice claim is nearly
100% by age 50
-33% of claims against Otolaryngologists that go to trial result in a financial payment,
which is strikingly similar to high risk specialties such as Ob/GYN (34%) and General
Surgery (33%)
-When an Otolaryngologist loses a law suit, the average financial award is $1,782, 514
-If a case involving an Otolaryngologist settles, the average settlement is $1,149,451
-The trend in malpractice trial outcomes for Otolaryngologists seems to be improving,
with over 60% of trial verdicts favoring the Otolaryngologist
Otolaryngology malpractice conclusions:
-Use of an ENT defense expert results in higher chance of verdict favoring the physician
-While careful and thorough informed consent is critical, it is unlikely to result in a lost
lawsuit if that is the only allegation
General Otolaryngology/Pediatric malpractice conclusions:
-Otolaryngologists are perceived by medical AND legal community as the airway
experts
-Otolaryngologists most often held liable for failing to establish an airway in a chaotic
setting (like post-tonsillectomy hemorrhage) along with the anesthesiologist.
Head & Neck malpractice conclusions:
-use (or absence) of facial nerve monitoring not medicolegally significant
-most H&N suits involved a complication resulting during a procedure deemed
unnecessary
Otology malpractice conclusions:
-most suits involved gross negligence.
-NIM use not recognized as “standard of care” and can’t be only allegation
Updates in Management for Acute and Chronic Unilateral Vocal Fold Paralysis
Mark S. Courey, MD
Paramount in the management of unilateral vocal fold paralysis is the ability to distinguish
immobility due to neurologic injury from immobility due to joint injury. In spite of the long
recognized differences between these different etiologies inaccuracy in diagnosis still occurs
and treatment results are comprised. Patient history around the time of onset of immobility is
strongly related to the etiology of the immobility(1). Paralysis is specifically defined as a loss of
function due to neurological injury. After injury to the vagus or specifically the recurrent
laryngeal nerve branch, vocal fold usually regain or maintain some amount of residual
neurologic activity. The old theories of a simple 2 nerve innervation pattern for laryngeal
function are currently under investigation(2). Paralysis of the vocal fold is rarely flaccid or
electrically silent. Therefore, the value of laryngeal EMG is limited in evaluating and
managing patients with vocal fold paralysis.
In the case of an acute of to the RLN or vagus, re-anastomosis/repair of the injured nerve
should be attempted immediately(3). Recovery of neurologic input will occur over 6 to 18
months and is dependent on the length of the injured nerve. While the neurologic input is
recovering, the vocal fold can be medialized through injection laryngoplasty with a temporary
agent. Even if the patient does not recover appropriate vocal fold abduction and adduction,
they will often end up with less vocal deficit than patients who were strictly observed. Injection
laryngoplasty with temporary agents, those known to be reabsorbed, has been shown to result
in less long-term vocal disability than in patients managed with observation alone(4,5). During
the acute phase of paralysis, injection with longer lasting agents containing calcium
hydroxylapatite is not recommended as this may lead to inflammation and permanent stiffness
of the vocal fold(6).
In chronic vocal fold paralysis, the voice can be improved either through reinnervation
procedures with the transfer of a branch of the ansa hypoglossal nerve or through static
framework surgery designed to reposition the vocal fold in the midline. How using a nonnative nerve to reinnervate the vocal fold results in a better voice than relying on spontaneous
reinnervation or residual innervation(7) is unknown, yet multiple case series show a benefit in
terms of voice in patients undergoing this procedure(8,9). With regard to results from
framework surgery, multiple studies show vocal improvement that is maintained. The degree
of the improvement in voice is probably related to the quality and type of surgery that is
performed. Finally injection laryngoplasty can provide long-term vocal improvement, however,
probably not to the same degree as seen in patients undergoing framework surgery. A
substance for injection that results in reliable sustained medialization and is non-inflammatory
has not yet been developed.
References
1.
2.
3.
4.
Cohen SM, Garrett CG, Netterville JL, Courey MS, Laryngoscopy in bilateral vocal fold immobility: can you
make a diagnosis? Ann Otol Rhinol Laryngol. 2006 Jun;115(6):439-43.
Kupfer RA, Old MO, Oh SS, Feldman EL, Hogikyan ND, Spontaneous laryngeal reinnervation following
chronic recurrent laryngeal nerve injury. Laryngoscope. 2013 Sep;123(9):2216-27. doi:
10.1002/lary.24049. Epub 2013 Jul 1.
O'Neill JP, Fenton JE. The recurrent laryngeal nerve in thyroid surgery.
Surgeon. 2008 Dec;6(6):373-7.
Yung KC, Likhterov I, Courey MS, Effect of temporary vocal fold injection medialization on the rate of
permanent medialization laryngoplasty in unilateral vocal fold paralysis patients. Laryngoscope. 2011
Oct;121(10):2191-4. doi: 10.1002/lary.21965. Epub 2011 Sep 6.
5.
Prendes BL, Yung KC, Likhterov I, Schneider SL, Al-Jurf SA, Courey MS, Long-term effects of injection
laryngoplasty with a temporary agent on voice quality and vocal fold position. Laryngoscope. 2012
Oct;122(10):2227-33. doi: 10.1002/lary.23473. Epub 2012 Aug 2.
6. Cohen JC, Reisacher W, Malone M, Sulica L, Severe systemic reaction from calcium hydroxylapatite
vocal fold filler. Laryngoscope. 2013 Sep;123(9):2237-9. doi: 10.1002/lary.23762. Epub 2013 Jul 2.
7. Crumley RL, Laryngeal synkinesis revisited.Ann Otol Rhinol Laryngol. 2000 Apr;109(4):365-71.
8. Wang W, Chen D, Chen S, Li D, Li M, Xia S, Zheng H, Laryngeal reinnervation using ansa cervicalis for
thyroid surgery-related unilateral vocal fold paralysis: a long-term outcome analysis of 237 cases. PLoS
One. 2011 Apr 29;6(4):e19128. doi: 10.1371/journal.pone.001912.
9. Paniello RC, West SE, Lee P, Laryngeal reinnervation with the hypoglossal nerve. I. Physiology,
histochemistry, electromyography, and retrograde labeling in a canine model.Ann Otol Rhinol Laryngol.
2001 Jun;110(6):532-42.
10. Young VN, Zullo TG, Rosen CA, Analysis of laryngeal framework surgery: 10-year follow-up to a national
survey. Laryngoscope. 2010 Aug;120(8):1602-8. doi: 10.1002/lary.21004.
Cochlear Implantation – Indications, Techniques, and Future Directions
Nikolas Blevins MD
Objectives
1. To be able to identify pediatric and adult candidates for cochlear implantation
2. To become familiar with current technology and approaches that are making
cochlear implantation more effective
Overview
Although cochlear implantation has now been FDA approved for 3 decades, it continues
to be a rapidly evolving field. One challenge is now to reach patients who may benefit
from this intervention in a timely manner, and present to them realistic expectations of
what can be expected. Indications for implantation have changed over the years as
patients with increasingly greater hearing have been found to benefit. We are currently
considering patients with near-normal low-frequency hearing for implantation with
“hybrid” devices that preserve remaining acoustic hearing while supplementing absent
frequencies with electrical stimulation. Similarly, children with hearing loss have clearly
been shown to have greater benefit with early identification, educational intervention,
and implantation. We will cover these trends to facilitate patient identification and
counseling, and identify trends that are expected to change hearing prosthesis use in the
future.
References
Nicholas JG. Geers AE. Will they catch up? The role of age at cochlear implantation in the
spoken language development of children with severe to profound hearing loss. Journal of
Speech Language & Hearing Research. 50(4):1048-62, 2007 Aug.
Schrijver I. Gardner P. Hereditary sensorineural hearing loss: advances in molecular genetics and
mutation analysis. Expert Review of Molecular Diagnostics. 6(3):375-86, 2006 May.
Arndt S. Aschendorff A. Laszig R. Beck R. Schild C. Kroeger S. Ihorst G. Wesarg T. Comparison
of pseudobinaural hearing to real binaural hearing rehabilitation after cochlear implantation in
patients with unilateral deafness and tinnitus. Otology & Neurotology. 32(1):39-47, 2011 Jan.
Miyamoto RT, Hay-McCutcheon MJ, Ilyer Kirk K, Houston DM, Bergeron-Dana T. Language skills
of profoundly deaf children who received cochlear implants under 12 months of age: a preliminary
study. Acta Oto-Laryngologica, 2008; 128: 373-377.
Leigh J. Dettman S. Dowell R. Briggs R. Communication development in children who receive a
cochlear implant by 12 months of age. Otology & Neurotology. 34(3):443-50, 2013 Apr.
Woodson EA. Reiss LA. Turner CW. Gfeller K. Gantz BJ. The Hybrid cochlear implant: a review.
Otology & Neurotology. 31(8):1300-9, 2010 Oct.
Treatment of the Crooked Nose
Knott, Daniel, MD FACS
Objectives
1. To gain understanding of the forces that resist straightening
2. To learn new techniques to straighten both bony and cartilaginous
deviation
Overview
Considered much more difficult than purely aesthetic surgery of the nose,
treatment of the crooked nose requires accurate pre-operative diagnosis,
innovative and strict intra-operative technique. Complete treatment commonly
involves aggressive surgical maneuvers to entirely release the bony and
cartilaginous deviations. Careful analysis of pre-operative photos will permit
surgical planning. Surgery often starts with straightening of the septum. Once
straightened, attention turns to management of the bony deviations. After
complete bony release has been realized, careful suturing and soft tissue
technique, as well as cartilaginous grafting will allow realization of aesthetically
pleasing results.
References
1. Cerkes, Nazim. The Crooked Nose: Principles of Treatment, Aesthetic
Surgery Journal 2011 31: 241
2. Parker Porter, Jennifer and Toriumi D. Surgical Techniques for
Management of the Crooked Nose, Aesthetic Plastic Surgery, 2002
3. Ronald P. Gruber, M.D., Farzad Nahai, M.D., Michael A. Bogdan, M.D.,
and Gary D. Friedman, M.D., Changing the Convexity and Concavity of
Nasal Cartilages and Cartilage Grafts with Horizontal Mattress Sutures:
Part II. Clinical Results. Plast. Reconstr. Surg. 115: 595, 2005.
4. Ronald P. Gruber, MD, Edward Chang, MD, Edward Buchanan, MD,
Suture Techniques in Rhinoplasty, Clin Plastic Surg 37 (2010) 231–243.
5. Bahman Guyuron, M.D., and Ramin A. Behmand, M.D., Caudal Nasal
Deviation, Techniques in Cosmetic Surgery, Plastic and Reconstructive
Surgery, June 2003.
6. Christopher Roxbury, BS; Masaru Ishii, MD, PhD; Andres Godoy, MD; Ira
Papel, MD; Patrick J. Byrne, MD; Kofi D. O. Boahene, MD; Lisa E. Ishii,
MD, MHS, Impact of Crooked Nose Rhinoplasty on Observer Perceptions
Of Attractiveness, Laryngoscope, 122:773–778, 2012
7. Scott B. Roofe, Craig S. Murakami. Treatment of the Posttraumatic and
Postrhinoplasty Crooked Nose, Facial Plastic Surgery Clinics of North
America,14, 279-289, 2006.
8. Fanous, Nabil. Unilateral osteotomies for external bony deviation of the
nose. Plastic and Reconstructive Surgery, 115-123, 1997.
9. Kim D, Toriumi D. Management of post-traumatic nasal deformities: the
crooked nose and the saddle nose. Facial Plastic Surgery Clinics of North
America, 12 (2004)111-121.
10. Stepnick D, and Guyuron B. Surgical treatment of the crooked nose.
Clinics in Plastic Surgery 37 (2010) 313-325.
Percutaneous Tracheotomy: what you should know
Marika Russell, MD, FACS
Objectives
1. Review technique for performing percutaneous tracheotomy
2. Review outcomes associated with percutaneous tracheotomy
3. Discuss timing of tracheotomy
4. Discuss patient safety and quality related to tracheotomy
Overview
This lecture describes indications and patient selection for percutaneous dilational
tracheotomy (PDT). The technique is reviewed, including set-up, equipment and
personnel required for the procedure. Outcomes, including complication rates, are
discussed. PDT appears to be a safe alternative to traditional open surgical
tracheotomy, with similar perioperative complication rates. There may be an increased
risk of long-term tracheal stenosis, with unclear clinical significance. There is no clear
benefit to performing early tracheotomy early (<1week) in critically ill patients.
Systematizing post-tracheotomy care is essential to facilitating safe and coordinated
care of tracheotomy patients.
References
1. Kost K. Endoscopic percutaneous dilational tracheotomy: a prospective
evaluation of 500 consecutive cases. Laryngoscope 115:October 2005
Supplement:1-30.
2. Higgins KM, Punthakee X. Meta-analysis comparison of open versus
percutaneous tracheostomy. Laryngoscope 2007;117:447-54
3. Oliver ER, Gist A, Gillespie MB. Percutaneous versus surgical tracheotomy: an
updated meta-analysis. Laryngoscope 2007;117:1570-5.
4. Koitschev A, Simon C, Blumenstock G, Mach H, Graumuller S. Suprastomal
tracheal stenosis after dilational and surgical tracheostomy in critically ill patients.
Anesthes 2006;61:832-7.
5. Norwood S, Vallina VL, Short K et al. Incidence of tracheal stenosis and other
late complications after percutaneous tracheostomy. Ann Surg 232:233-41.
6. Christenson TE, Artz GJ, Goldhammer JE et al. Tracheal stenosis after
placement of percutaneous dilational tracheotomy. Laryngoscope 2008;118:2227.
7. Weissbrod PA, Merati AL. Is percutaneous dilational tracheotomy equivalent to
traditional open surgical tracheotomy with regard to perioperative and
postoperative complications? Laryngoscope 2012;122:1423-4.
8. Tong CCL, Kleinberger AJ, Paolino J, Altman KW. Tracheotomy timing and
outcomes in the critically ill. Otolaryngol Head Neck Surg 2012;147:44-51
9. Wang F, Wu Y, Bo L et al. The timing of tracheotomy in critically ill patients
undergoing mechanical ventilation: a systematic review and meta-analysis of
randomized controlled trials. Chest 2011;140:1456-65.
10. Young D, Harrison DA, Cuthbertson BH et al. Effect of early vs late tracheostomy
placement on survival in patients receiving mechanical ventilation. JAMA
2013;309:2121-9.
New Care Pathways for Penetrating Neck Trauma
Christopher Klem, MD, FACS
With the experience of the US Military during over a decade of war in Iraq and
Afghanistan, the management of penetrating neck trauma has evolved. CT angiography
has become standard in most trauma centers as the initial study of choice for
asymptomatic penetrating neck trauma. Traditional mandatory angiography for Zone 1
and 3 injuries may not be necessary.
References
1. Feldt BA, Salinas NL, Rasmussen TE, Brennan J. The joint facial and invasive neck
trauma (J-FAINT) project, Iraq and Afghanistan 2003-2011. Otolaryngol Head Neck
Surg. 2013;148(3):403-8.
2. Brennan J, Lopez M, Gibbons MD, Hayes D, Faulkner J, Dorlac WC, Barton C.
Penetrating neck trauma in Operation Iraqi Freedom. Otolaryngol Head Neck Surg.
2011;144(2):180-5.
Oropharyngeal Carcinoma –A Comparison of Treatment Side Effects
William R. Ryan, MD, FACS
Objectives
1. Update on studies addressing the spectrum of side effects from
surgery/reconstruction, radiation, cisplatin, and cetuximab for the treatment of
oropharynx carcinoma
2. Update on studies comparing surgery vs radiation for early stage and
surgery/post-operative radiation vs chemoradiation for advanced stage
carcinoma.
Overview
Oropharynx carcinoma can be treated in two main ways for early stage cases
(surgery vs radiation) and advanced stage cases (surgery/postoperative radiation vs
chemoradiation). Studies appear to show general equivalence in local control,
recurrence, and survival rates between these two modes of therapy. Over 30 minutes, I
plan to cover the potential and degree of side effects and complications from each
therapy group and then compare the groups. I hope the audience will be better
equipped to answer patients’ questions about treatment decisions and expectations.
Evidence-Based Migraine Dizziness: Making an Impact and Making Sense
Philip Littlefield, MD
Objectives
1. Review the evidence available for common migraine treatments - and
for dizzy symptoms in particular.
2. Provide a treatment strategy based on this evidence.
3. Discuss the role of the otolaryngologist in treating migraine-associated
dizziness.
Overview
Otolaryngologists see a lot of migraine-associated dizziness, as well as
conflicting information on what to do about it. This lecture will discuss why this is
so, and then review the evidence available for various migraine treatments. We
will compare this evidence to current practice patterns, and then consider a
treatment strategy that attempts to marry the scientific rigor of the evidencebased approach to logic, personal experiences, patient feedback, and common
sense. The goal this approach is to have a positive impact on each patient
without undue risk, and not to waste anybody’s money or time.
References
1.
2.
3.
4.
5.
6.
7.
Cherchi M, Hain TC. Migraine-associated vertigo. Otolaryngol Clin North
Am. 2011;44(2):367-75.
Cha YH. Migraine-associated vertigo: diagnosis and treatment. Semin
Neurol. 2010; 30(2):167-74.
Finocchi C, Sivori G. Food as trigger and aggravating factor of migraine.
Neurological Sci. 2012; 33 Suppl 1:S77-80.
Hoffmann J, Recober A. Migraine and triggers: post hoc ergo propter hoc?
Curr Pain Headache Rep. 2013; 17(10):370.
Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers
in a clinic-based population. Headache. 2010; 50(8):1366-70.
Fasunla AJ, Ibekwe TS, Nwaorgu OG. Migraine-associated vertigo: a
review of the pathophysiology and differential diagnosis. Int J Neurosci.
2012; 122(3):107-13.
The Cochrane Library (Headache and Migraine).
Complications of Acute Sinusitis
Matthew Russell, MD, FACS
Objectives
1. Understand the manifestations and treatment of orbital complications
of acute sinusitis
2. Understand the manifestations and treatment of intracranial
complications of acute sinusitis
Overview
Acute Bacterial Rhinosinustis (ABRS) is a common infectious process.
Uncommonly, complications of ABRS can occur when bacterial pathogens
spread from the paranasal sinuses to adjacent structures through direct
extension or thrombophlebitis.
Orbital complications are classically described by the Chandler classification.
Pre-septal cellulitis, orbital cellulitis, subperiosteal orbital abscess, orbital
abscess and cavernous sinus thrombosis each have distinct presentations and
management algorithms, which will be discussed.
Intracranial spread of infection can present as epidural, subdural or cerebral
abscesses. The high morbidity and mortality of these infections requires prompt
recognition and management, often in collaboration with our neurosurgical
colleagues.
References
1.
2.
3.
4.
5.
Rosenfeld et al. “Clinical Practice Guideline: Adult Sinusitis”. OHNS (2007), 137, S1-S31
Rubin et al. “Drainage of subperiosteal orbital abscesses complicating pediatric ethmoiditis” Int J Ped Oto
(2013) 77, 796.
Donahue et al. “Preseptal and orbital cellulitis in childhood”. Ophthalmology 1998; 105: 1902-6
Manning, et al. “Endoscopic Drainage of subperiosteal orbital abscess”. Op Tech OHNS (2002) 13; 1: 73-76
Glickstein et al. “Intracranial Complications of pediatric sinusitis”. OHNS (2006) 134; 733
Laryngeal Microsurgery for Benign Disease
Mark S. Courey, MD
It is well established that many types of benign vocal fold lesions respond well
behavioral interventions designed to help the patient produce voice with efficient
muscular use patterns(1). Therefore, before surgery is undertaken for disease
presumed to be benign, all patients should undergo evaluation and management by a
Speech-Language Pathologist with special training in voice disorders(2).
If surgery is undertaken, then careful microdissection has been shown to produce
more reliable vocal outcomes than surgery done under low magnification or with
stripping type instrumentations(3). Micordissection techniques vary among surgeons,
but successful techniques share the common gold of removing only the diseased
tissue and preserving the non-involved tissue to promote healing.
Lasers have long been used in the management of benign laryngeal disease(4).
These are safe, regardless of wavelength, as long as the surgeon limits the amount of
thermal injury to the uninvolved tissue. There are no smart lasers. Rather, there are
only smart surgeons who understand the laser tissue interactions and can use them to
their patients’ advantage. All laser used rely on the absorption of laser light which is
converted to eat and destroys tissue(5,6). By using the laser appropriately the
surgeon limits the destruction to only the involved tissue.
Specific techniques with cold instruments and laser will be demonstrated.
1.
2.
3.
4.
5.
6.
Garrett CG, Francis DO, Is surgery necessary for all vocal fold polyps? Laryngoscope. 2013 Jun 4. doi:
10.1002/lary.24112. [Epub ahead of print]
Gartner-Schmidt JL, Roth DF, Zullo TG, Rosen CA, Quantifying component parts of indirect and direct
voice therapy related to different voice disorders. J Voice. 2013 Mar;27(2):210-6. doi:
10.1016/j.jvoice.2012.11.007. Epub 2013 Jan 22.
Courey MS, Gardner GM, Stone RE, Ossoff RH. Endoscopic vocal fold microflap: a three-year
experience. Ann Otol Rhinol Laryngol. 1995 Apr;104(4 Pt 1):267-73.
Benninger MS, Laser surgery for nodules and other benign laryngeal lesions. Curr Opin Otolaryngol Head
Neck Surg. 2009 Dec;17(6):440-4. doi: 10.1097/MOO.0b013e3283317cae.
Altshuler GB, Anderson RR, Manstein D, Zenzie HH, Smirnov MZ, Extended theory of selective
photothermolysis. Lasers Surg Med. 2001;29(5):416-32.
Reinisch L, Garrett CG, Courey M. A simplified laser treatment planning system: Proof of concept.Lasers
Surg Med. 2013 Dec;45(10):679-85. doi: 10.1002/lsm.22204. Epub 2013 Nov 19.
Sialendoscopy and Minimally-Invasive Techniques for Benign Salivary
Disorders
Jolie Chang, MD
Objectives
1. Define clinical indications for sialendoscopy.
2. Describe minimally invasive approaches to obstructive salivary gland
disorders including endoscopy-directed basket retrieval, laser
lithotripsy, and combined approaches.
3. Understand the limitations, risks, and complications associated with
sialendoscopic approaches.
4. Discuss current outcomes and future directions for obstructive salivary
disease management.
Overview
Sialendoscopy has emerged as a minimally invasive diagnostic and therapeutic
modality for management of obstructive salivary gland disorders. Diagnostic
sialendoscopy provides a means for systematic visualization of the
submandibular and parotid ducts to localize and identify pathology. Therapeutic
sialendoscopy allows for the ability to administer therapy including: stenosis
dilation, basket or endoscopic forceps insertion for retrieval of salivary stones,
and laser lithotripsy application. The techniques and applications for
sialendoscopy will be discussed and demonstrated with videos. Benefits,
expected outcomes, limitations and risks of minimally invasive procedures will
also be reviewed.
Innovations in Microvascular Facial Reconstruction: Pushing the Boundaries
Michael A. Fritz MD
Objectives:
1) Describe recent advances in microvascular free tissue transfer and how these
have changed the reconstructive mindset with regard to management of both
ablative head and neck cancer defects and complications related to adjunctive
treatment.
2) Identify new techniques in microvascular free tissue transfer which have
improved functional and aesthetic patient outcomes.
Overview:
This lecture will highlight advances in microvascular reconstruction which have altered
the reconstructive mindset in general and have lead to expanded indications for and
increased utilization of free tissue tranfer. Accumulated knowledge and facility with
technique has lead to increased flap reliability and abbreviated operative times, while
changes in flap harvest sites and common use of minimal access approaches for
vascular access have decreased overall sugical morbidity. As a result, free flaps are
being applied more aggressively and hospital stays in a significant subset of patients
have become dramatically shortened. With the overall patient “cost” of these
techniques minimized, he reconstructive ladder has been altered - free tissue transfer,
previously regarded as a last resort in reconstruction, is now the primary choice in most
major head and neck repairs. This change has lead to lower complication rates (e.g.
fistulas, infections) and improved functional and aesthetic outcomes.
New techniques which have lead to dramatic improvement in functional and aesthetic
outcomes include several novel applications of the anterolateral thigh fascia lata flap.
These include include secondary contour deformities, smaller complex defects (eg nasal
lining and eyelid reconstruction) and early intervention for moderate osteoradionecrosis.
These applications including harvest and reconstructive technique and patient outcomes
will be reviewed in detail.
Chronic Ear Surgery: Staying Out of Trouble
Lawrence R. Lustig, MD
Objectives
1. Understand the anatomical landmarks in the ear that allow safe Otologic surgery
2. Understand what factors lead to chronic mastoid cavity drainage
Overview
Ear surgery can be challenging due to many factors, including complex
anatomy, variably anatomical landmarks, and post-operative challenges with healing.
However by employing some simple strategies, even an infrequent ear surgeon can
avoid the most serious pitfalls. This talk will highlight my Top 10 methods for staying out
of trouble during ear surgery, providing details one each. These include: 1) Know when
to operate, and more importantly, when NOT to operate; 2) Always be prepared going
into the OR with scans, audiograms and other tests available to you; 3) Have a clear
understanding of the surgical approach before you start, but also be flexible and willing
to change course if you encounter something unexpected; 4) Adequate exposure is the
key to any surgery, especially ear surgery; 5) The facial nerve is the most critical
structure in the ear, and you should be very familiar with its course through the temporal
bone, and how it can change in response to disease or exposure; 6) Intraoperative
ossicular trauma is a common cause of hearing loss, and there are a number of methods
to avoid trauma during ear surgery that will be highlighted; 7) Despite manufacturer
assurances, all ossicular prostheses have the potential to extrude, and thus I
recommend that one should always use a cartilage graft between the prosthesis and the
tympanic membrane if they would otherwise be in direct contact; 8) Staging surgery for
cholesteatoma is important to prevent recurrent disease, though there are newer
strategies using imaging that will also be discussed; 9) When performing a modified
radical mastoidectomy, there are a number of technical maneuvers that will contribute to
a healthy and self-cleaning ear that will be described; and 10) Practice makes perfect!
You should strive to attend at least one temporal bone dissection course every other
year to keep up your skills and anatomical knowledge. During this talk I will be
providing details on all these points to help you avoid complications during Otologic
surgery.
References
A review of facial nerve anatomy. Myckatyn TM, Mackinnon SE. Semin Plast Surg. 2004 Feb;18(1):5-12 .
Toward safer practice in otology: a report on 15 years of clinical negligence claims. Mathew R,
Asimacopoulos E, Valentine P. Laryngoscope. 2011 Oct;121(10):2214-9.
Modified radical mastoidectomy: a relook at the surgical pitfalls. Prasanna Kumar S, Ravikumar A, Somu L.
Indian J Otolaryngol Head Neck Surg. 2013 Dec;65(Suppl 3):548-52.
Method and reproducibility of a standardized ossiculoplasty technique. Gluth MB, Moore PC, Dornhoffer JL.
Otol Neurotol. 2012 Sep;33(7):1207-12
Ear canal cholesteatoma: meta-analysis of clinical characteristics with update on classification, staging and
treatment. Dubach P, Mantokoudis G, Caversaccio M. Curr Opin Otolaryngol Head Neck Surg. 2010
Oct;18(5):369-76.
Staging primary middle ear cholesteatoma with non-echoplanar (half-Fourier-acquisition single-shot turbospin-echo) diffusion-weighted magnetic resonance imaging helps plan surgery in 22 patients: our
experience. Majithia A, Lingam RK, Nash R, Khemani S, Kalan A, Singh A. Clin Otolaryngol. 2012
Aug;37(4):325-30
Pediatric Sleep Endoscopy and Surgical Management of Recalcitrant
Pediatric Sleep Apnea
Dylan K. Chan, MD, PhD
Objectives
1. To understand the indications, technique, and interpretation of
pediatric sleep endoscopy
2. To understand the options for surgical management of obstructive
sleep apnea in children who have failed adenotonsillectomy as primary
management.
Overview
Obstructive sleep apnea (OSA) is one of the most commonly seen disorders in
children by otolaryngologists. Adenotonsillectomy is the standard of care for firstline treatment of OSA in children, and has a very high rate of success. However,
many subpopulations of children are at high risk for failure, and many children
overall have persistent sleep apnea even after adenotonsillectomy. In this talk, I
will describe the role of anesthesia-induced upper-airway endoscopy, or “sleep
endoscopy” in the evaluation and management of children with sleep-disordered
breathing and obstructive sleep apnea. This technique is a means of identifying
site and degree of upper-airway obstruction under general anesthesia. I will then
describe the surgical options, including lingual tonsillectomy and
supraglottoplasty, for treatment of persistent obstructive sleep apnea after
adenotonsillectomy.
References
Ulualp SO, Szmuk P (2013). Drug-induced sleep endoscopy for upper airway
evaluation in children with obstructive sleep apnea. Laryngoscope 123:292-297
Chan DK, Truong MT, Koltai PJ (2012). Supraglottoplasty for occult
laryngomalacia to improve obstructive sleep apnea syndrome. Arch Otolaryngol
Head Neck Surg 138:50-54.
Llin AC, Koltai PJ (2009). Persistent pediatric obstructive sleep apnea and
lingual tonsillectomy. Otolaryngol Head Neck Surg 141:81-85.
Updates in Laser Resurfacing
Scott B. Roofe, MD
Colonel, US Army
Chief, Facial Plastic and Reconstructive Surgery
Program Director, Otolaryngology Residency
Tripler Army Medical Center, Hawaii
Over the last decade, there has been an explosion in laser and light technology that has
revolutionized management of the aging face. These advances have resulted in decreased
recovery time and have expanded the treatment options for treatment of aging skin beyond
traditional surgery. In addition, the range of options that can be safely used in ethnic skin has
expanded.
This presentation will include a description of the following modalities and their
applications. Management and prevention of common side effects and complications will also
be discussed.
Fractional resurfacing: Fully ablative carbon dioxide laser therapy was long considered the gold
standard for facial resurfacing. However, the advent of fractional resurfacing has largely
replaced this modality due to its decreased down time and fewer number of long term side
effects with comparable results. A number of fractional lasers are available utilizing CO2 and
Erbium:YAG modalities. A broad spectrum of patients can be treated in this manner, including
those who were previously “off limits’ for laser therapy, such as Fitzpatrick IV-V skin types.
Broadband (BBL) and intense pulsed light (IPL) therapies: Visible light therapies include BBL
and and IPL. Like fractional resurfacing lasers, a variety of new devices have been developed to
specifically improve the visible signs of aging and photodamage in a less invasive manner.
These devices can also be used to treat hypertrichosis, vascular and pigmented skin lesions,
and acne.
Radiofrequency (RF), infrared (IR), and ultrasound (US) devices: Like light therapy, nonablative procedures for facial rejuvenation such as RF, IF, and US have become increasingly
popular. Monopolar and bipolar-coupled radiofrequency utilizes electromagnetic radiation to
improve skin laxity and diminish rhytids. Like IR, thermal energy from radiofrequency devices is
used to heat the dermis and induce collagen generation and remodeling which in turn improves
skin laxity and appearance. Similarly, microfocused ultrasound recently was introduced as an
energy modality for transcutaneous heat delivery that reaches the deeper subdermal connective
tissue. The goal is to produce a deeper wound healing response at multiple levels with collagen
remodeling and a potentially more durable clinical response.
Bone Conducting Hearing Aids – I’m Not Your Grandma’s BAHA!
Lawrence R. Lustig, MD
Objectives
1. Understand the indications and outcomes for bone conduction hearing aids
2. Become familiar with the variety of bone conduction hearing aids available in
today’s market
Overview
There was a time when patients with single sided deafness or conductive hearing
losses not amenable to surgical treatment had very few options. While conventional
hearing aids can benefit those with conductive losses, those with chronic draining ears
or with absence of an external auditory canal are unable to benefit from this proven
technology. Similarly patients with single sided deafness for years had as their sole
rehabilitative option the CROS hearing aid.
Beginning in the 1990s, however, the field was transformed by modifying
osseointegrated implants, previously used for dental implants, to accept sound
processors when placed on the skull. Using trusted surgical methodologies, the Bone
Anchored Hearing Aid, or BAHA™, significantly transformed the auditory rehabilitation
field. The BAHA enabled patients with chronic draining ears or those without an ear
canal or ability to use a conventional hearing aid to hear.
A subsequent indication for BAHAs became patients with single sided deafness,
providing improved performance on hearing in noise tests over the CROS aid, with
improved patient satisfaction. However the BAHA was not without its own limitations:.
For many the presence of the osseointegrated implant was unsightly, and complications
surrounding skin reactions from the implant-cutaneous junction could be quite
problematic, despite the auditory benefits.
Over the last decade, however, the field has grown and transformed itself. The
BAHA™, now owned by Cochlear Corp., is no longer the only osseointegrated implant in
the marketplace. A similar technology is now available from Oticon, which also uses an
osseointegrated percutaneous post. The past decade has also seen the emergence of
several transcutaneous implants, that transmit the sound through the skin to an implant
without a post. These include the Sophono Alpha1, the Cochlear BAHA Attract, and the
Med-El BoneBridge. The advantages of these newer technologies include improved
cosmetics and reduced complications, though sometimes at the cost of lower gain.
Lastly, the SoundBite from Sontius Corp, is a dental appliance that also transmits sound
via bone conduction, but through the teeth. This talk will focus on these newer
technologies, and compare with conventional implantable bone conduction hearing
devices.
References
1. Amplification options for patients with mixed hearing loss. Zwartenkot JW, Snik AF, Mylanus EA, Mulder JJ. Otol
Neurotol. 2014 Feb;35(2):221-6
2.
Comparison between a new implantable transcutaneous bone conductor and percutaneous bone-conduction
hearing implant. Hol MK, Nelissen RC, Agterberg MJ, Cremers CW, Snik AF. Otol Neurotol. 2013 Aug;34(6):1071-5
3.
Introducing the Sophono Alpha 1 abutment free bone conduction hearing system. Mulla O, Agada F, Reilly PG. Clin
Otolaryngol. 2012 Apr;37(2):168-9
4.
Baha-Mediated Rehabilitation of Patients with Unilateral Deafness: Selection Criteria. Saroul N, Akkari M, Pavier Y,
Gilain L, Mom T. Audiol Neurootol. 2013 Dec 21;19(2):85-90.
5.
The SoundBite hearing system: patient-assessed safety and benefit study. Gurgel RK, Shelton C. Laryngoscope.
2013 Nov;123(11):2807-12
6.
A new bone conduction implant: surgical technique and results. Manrique M, Sanhueza I, Manrique R, de Abajo J.
Otol Neurotol. 2014 Feb;35(2):216-20
7.
Transcutaneous bone-conduction hearing device: audiological and surgical aspects in a first series of patients with
mixed hearing loss. Barbara M, Perotti M, Gioia B, Volpini L, Monini S. Acta Otolaryngol. 2013 Oct;133(10):1058-64
The Difficult Airway Team
Matthew Russell, MD, FACS
Objectives
1. Review the difficult airway algorithm
2. Discuss a team-based approach to difficult airway management
Overview
The A-B-C’s of emergency medical care are engrained in the mind of
every physician. Airway – maintenance of a patent respiratory tract for gas
delivery. Breathing – ventilation with alveolar gas exchange. Circulation – cardiac
output for tissue oxygenation. These are the fundamentals of initial resuscitation.
As Otolaryngologists, we may rarely find ourselves responding to cardiopulmonary arrest, yet, we are frequently the call of last resort when a patent
airway cannot be established.
Through active engagement in a multidisciplinary difficult airway team,
response to critical airway scenarios can be streamlined with improved safety
and outcomes. Furthermore, as the team builds rapport, critical airway events
(low-probability, high-risk airway event) can be reduced through pre-emptive
planning.
References
1.
2.
3.
4.
Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98: 1269-77
Long et al. “Management of Difficult Airways using a hospital-wide “Alpha Team” approach”. Am J Med
Qual. 2010; 25 (4):297
DART: A two year review. Difficult Airway Response Team. 7th Annual Maryland Patient Safety
Conference. 2011
Gooi et al. “Operative Room Airway Management for Advanced Oropharyngeal Angioedema” AAO-HNS
Annual Meeting 2013.
Fillers and Neurotoxins, 2014
Daniel Knott, MD FACS
Objectives
1. To understand the newer fillers on the marketplace.
2. To understand the characteristics of the newer neuromodulators
Overview
The filler and neuromodulator marketplace is undergoing continual
evolution. Given the size of the marketplace and the potential profitability of a
successful filler/neuromodulator, companies are constantly introducing new
products and altering their current formulations. These products offer
considerable profit potential for otolaryngologists as well as high levels of patient
satisfaction. A firm and current understanding of the offerings is therefore critical
to stay abreast of the technology and to offer the patients the most advanced
treatment options.
Current Evidence for Radiosurgery in VS Treatment
Nikolas Blevins MD
Objectives
1. To evaluate the current evidence for radiosurgery treatment outcomes in
vestibular schwannoma surgery
2. To appreciate the potential risks and benefits of radiosurgery when
counseling patients with VS when compared to watchful waiting or
microsurgical resection
Overview
Stereotactic radiosurgery (STR) has become an increasingly common treatment
modality for patients presenting with vestibular schwannomas. The risks, benefits and
expectations of this approach are significantly different from those of other treatment
options, including watchful waiting and microsurgical resection. Clinicians counseling
patients with these options should be familiar with the current state of knowledge
regarding the expectations in outcomes from this relatively new treatment modality. This
talk with discuss the basics of STR and different delivery systems involved. We will
consider issues such as patient selection, tumor growth control, hearing preservation,
facial nerve outcomes, and the risk of malignant transformation. The literature on this
subject is inconclusive in many respects, and the limits of our ability to extrapolate from
existing studies will be examined.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Andrews, D.W., et al., Stereotactic radiosurgery and fractionated stereotactic radiotherapy for
the treatment of acoustic schwannomas: comparative observations of 125 patients treated at one
institution. International Journal of Radiation Oncology, Biology, Physics, 2001. 50(5): p. 126578.
Battista, R.A. and R.J. Wiet, Stereotactic radiosurgery for acoustic neuromas: a survey of the
American Neurotology Society. American Journal of Otology, 2000. 21(3): p. 371-81.
Bloch, D.C., et al., The fate of the tumor remnant after less-than-complete acoustic neuroma
resection. Otolaryngology - Head & Neck Surgery, 2004. 130(1): p. 104-12.
Chang, S.D., et al., Staged stereotactic irradiation for acoustic neuroma. Neurosurgery, 2005.
56(6): p. 1254-63.
Harsh, G.R., et al., Proton beam stereotactic radiosurgery of vestibular schwannomas.
International Journal of Radiation Oncology, Biology, Physics, 2002. 54(1): p. 35-44.
Ito, K., et al., Risk factors for neurological complications after acoustic neurinoma radiosurgery:
refinement from further experiences. International Journal of Radiation Oncology, Biology,
Physics, 2000. 48(1): p. 75-80.
Iwai, Y., et al., Radiosurgery for acoustic neuromas: results of low-dose treatment. Neurosurgery,
2003. 53(2): p. 282-87; discussion 287-8.
Kida, Y., et al., Radiosurgery for bilateral neurinomas associated with neurofibromatosis type 2.
Surgical Neurology, 2000. 53(4): p. 383-89; discussion 389-90.
Kondziolka, D., et al., Long-term outcomes after radiosurgery for acoustic neuromas. New
England Journal of Medicine, 1998. 339(20): p. 1426-33.
Kondziolka, D., L.D. Lunsford, and J.C. Flickinger, Gamma knife radiosurgery for vestibular
schwannomas. Neurosurgery Clinics of North America, 2000. 11(4): p. 651-8.
Lunsford, L.D., D.B. Kamerer, and J.C. Flickinger, Stereotactic radiosurgery for acoustic
neuromas. Archives of Otolaryngology -- Head & Neck Surgery, 1990. 116(8): p. 907-9.
Lunsford, L.D., et al., Radiosurgery of vestibular schwannomas: summary of experience in 829
cases. Journal of Neurosurgery, 2005. 102: p. 195-9.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Miller, R.C., et al., Decrease in cranial nerve complications after radiosurgery for acoustic
neuromas: a prospective study of dose and volume. International Journal of Radiation Oncology,
Biology, Physics, 1999. 43(2): p. 305-11.
Petit, J.H., et al., Reduced-dose radiosurgery for vestibular schwannomas. Neurosurgery, 2001.
49(6): p. 1299-306; discussion 1306-7.
Poen, J.C., et al., Fractionated stereotactic radiosurgery and preservation of hearing in patients
with vestibular schwannoma: a preliminary report. Neurosurgery, 1999. 45(6): p. 1299-305;
discussion 1305-7.
Pollock, B.E., et al., Vestibular schwannoma management. Part II. Failed radiosurgery and the
role of delayed microsurgery. Journal of Neurosurgery, 1998. 89(6): p. 949-55.
Prasad, D., M. Steiner, and L. Steiner, Gamma surgery for vestibular schwannoma. Journal of
Neurosurgery, 2000. 92(5): p. 745-59.
Rowe, J.G., et al., Clinical experience with gamma knife stereotactic radiosurgery in the
management of vestibular schwannomas secondary to type 2 neurofibromatosis. Journal of
Neurology, Neurosurgery & Psychiatry, 2003. 74(9): p. 1288-93.
Schulder, M., et al., Microsurgical removal of a vestibular schwannoma after stereotactic
radiosurgery: surgical and pathologic findings. American Journal of Otology, 1999. 20(3): p.
364-7; discussion 368.
Slattery, W.H., 3rd and D.E. Brackmann, Results of surgery following stereotactic irradiation for
acoustic neuromas. American Journal of Otology, 1995. 16(3): p. 315-9; discussion 319-21.
Unger, F., et al., Radiosurgery of vestibular schwannomas: a minimally invasive alternative to
microsurgery. Acta Neurochirurgica, 1999. 141(12): p. 1281-5; discussion 1285-6.
Unger, F., et al., Cranial nerve preservation after radiosurgery of vestibular schwannomas. Acta
Neurochirurgica Supplement, 2002. 84: p. 77-83.
Unger, F., et al., Radiosurgery of residual and recurrent vestibular schwannomas. Acta
Neurochirurgica, 2002. 144(7): p. 671-6; discussion 676-7.
Wackym, P.A., et al., Gamma knife radiosurgery for acoustic neuromas performed by a
neurotologist: early experiences and outcomes. Otology & Neurotology, 2004. 25(5): p. 752-61.
Werner-Wasik, M., et al., Immediate side effects of stereotactic radiotherapy and radiosurgery.
International Journal of Radiation Oncology, Biology, Physics, 1999. 43(2): p. 299-304.
Management of the Neck
Dennis H. Kraus, MD
Objectives
1. Describe the diagnostic and therapeutic interventions of patients with
metastatic lesions to the neck with an unknown primary.
2. To describe the management of the clinically negative and positive neck in
patients with a known primary in the upper aerodigestive tract.
Overview
This presentation will focus on the management of the neck in squamous carcinoma of
the upper aerodigestive tract. Specifically, the presenter will focus on the evaluation and
treatment of patients with metastatic carcinoma to the neck with an unknown primary.
The diagnostic and radiographic evaluation including endoscopic assessment of the
patient will be detailed. Treatment strategies will be reviewed. In addition, the presenter
will focus on the management of the clinically negative and positive neck in patients with
a known primary in the upper aerodigestive tract. Assessment and treatment of the neck
will be detailed. Moreover, the presenter will focus on salvage treatment for recurrent
carcinoma in the neck.
References
Gil Z, Carlson DL, Boyle JO, Kraus DH, Shah JP, Shaha AR, Singh B, Wong RJ, Patel
SG. Lymph Node Density is a Significant Predictor of Outcomes in Patients
with Oral Cancer. Cancer. 2009 Dec; 115(24):5700-10.
Givi B, Linkov G, Ganly I, Patel SG, Wong RJ, Singh B, Boyle JO, Shaha AR, Shah JP,
Kraus DH. Selective Neck Dissection in Node-Positive Squamous Cell
Carcinoma of the Head and Neck. Otolaryngol Head Neck Surg. 2012
Oct;147(4):707-15. Epub 2012 Apr 18.
Ferris RL, Kraus DH. Sentinel Lymph Node Biopsy Versus Selective Neck
Dissection for Detection of Metastatic Oral Squamous Cell Carcinoma. Clin
Exp Metastasis. 2012 Oct;29(7):693-8.
Integrating Ultrasound into Clinical Practice
Christopher Klem, MD, FACS
Clinical ultrasound has become increasingly popular among many clinicians, including
Otolaryngologists. Ultrasound provides immediate, real-time, easily interpretable data to
the provider and allows more expeditious care for patients than conventional
radiographic modalities.
Barriers to clinical ultrasound incorporation include time, cost, specialized training, and
acceptance by fellow providers.
References
1. Bumpous JM, Randolph GW. The expanding utility of office-based ultrasound for
the head and neck surgeon. Otolaryngol Clin North Am. 2010;43(6):1203-1208.
2. Smith RB. Ultrasound-guided procedures for the office. Otolaryngol Clin North
Am. 2010;43(6):1241-54.
3. Nagarkatti S, Mekel M, Sofferman R, Parangi S. Overcoming obstacles to setting up
office-based ultrasound for evaluation of thyroid and parathyroid disorders.
Laryngoscope. 2011;121:1-7.
4. Practical Head and Neck Ultrasound – Ahuja, Evans.
5. Head and Neck Ultrasonography - Orloff
Management of Septal Perforations
Scott B. Roofe, MD
Colonel, US Army
Chief, Facial Plastic and Reconstructive Surgery
Program Director, Otolaryngology Residency
Tripler Army Medical Center, Hawaii
Nasal septal perforations are often challenging to repair, but successful management
can be potentially very rewarding for the patient. These perforations may be secondary to a
number of causes such as trauma, inflammatory and neoplastic disease, nasal sprays, illicit
drugs, and prior nasal surgery. Therefore the patient should be thoroughly evaluated to
determine the etiology. Many septal perforations are asymptomatic and may be incidental
findings on examination, but a significant number develop symptoms such as nasal obstruction,
bleeding, crusting, and whistling.
Conservative management, consisting of emollients, irrigation, and humidification, is
often all that is necessary. A septal button may also be considered for those who decline
surgery and are still symptomatic, or in those who have co-morbidities that preclude surgical
repair.
Many surgical techniques and approaches have been described to repair symptomatic
perforations. These may range from simple elevation and primary closure to more complex
approaches with interpositional grafting and rotational flaps.
This presentation will discuss the etiology, evaluation, and management of patients with
nasal septal perforations. Surgical techniques will be described to address perforations of
various sizes and offer predictive factors for successful repair.
Do the Sinuses Crave Certain Bacteria for Health?
Andrew N. Goldberg, MD, MSCE, FACS
Objectives
1. Describe the role of the microbiome in human health
2. Describe the theory of microbial ecology with reference to the sinuses
3. Describe how changes in microbial ecology may cause chronic inflammation
‐
Theories on the Etiology of Chronic Sinusitis
o Hypersensitivity to Fungus(1, 2)
o Staphylococcus Superantigens(3)
o Osteitis (4, 5)
o Biofilms (6-8)
o Host Genetics/Supertasters (9)
o Disease of the Mucosal Barrier (10, 11)
o Innate Immunity (12)
‐
Microbial Ecology
o Study of microorganisms and their relationship to each other and their
environment
o Microbiome is the community of microbes in a given ecological niche
‐
Role of the Microbiome
o Importance emphasized by evolutionary co-dependence
 Oligosaccharides in breast milk indigestible by humans, selects for
intestinal probiotic bifidobacterium species(13)
o Colonization Resistance
 C. Difficile colitis treatment with fecal transplant(14)
o Immune System Education/Modulation
 Gut-associated lymphoid tissue interacts with microbial communities to
modulate the immune system(15)
 Inflammatory Bowel Disease modulated by alterations in gut
microbiome(16)
 Hygiene Hypothesis
 Asthma rates increased after C-section(17)
 Childhood outdoor dog exposure associated with decrease
atopy(18)
 Early antibiotic exposure(17)
The Sinus Microbiome
o Are there microbes in the sinuses of healthy patients?
 YES – no difference between total bacterial count in CRS and control
patients(19)
Differences between microbial communities in the CRS and healthy patients
o Loss of microbial diversity in healthy patients(20)
o Pathogen dominated communities in CRS patients(20)
 C. Tuberculostearicum, Staph, Strep, Pseudomonas, Enterobacter
‐
‐
‐
Do changes in the microbiome drive mucosal inflammation or does mucosal
inflammation result in an altered microbiome?(20)
o Murine model of the Sinus Microbiome
o Pathogen (C.Tuberculostearicum) inoculation led to inflammatory changes after
depletion of the native microbiome through antibiotic treatment
o Co-instillation of a probiotic (L. Sakei) and pathogen following antibiotic treatment
resulted in normal appearing mucosa
‐
Working Hypothesis for Chronic Sinusitis
o Healthy sinus cavities possess a divers microbial community
o Native microbiome protective through colonization resistance and immune
modulation
o Perturbation of community provides opportunity for outgrowth and
overabundance of pathogenic species
o Induction of immune response and micro-environmental changes result in new
homeostasis, propagating poor microbial diversity and chronicity of disease
‐
Moving from Microbial Community Characterization to Microbial Community Function
o How are these communities interacting with the epithelial barrier and what is
there impact on local immune response?
o How does the sinus microbiome change with treatment – antibiotics, steroids,
surgery?
o How can we manipulate the sinus microbiome?
References
1.
Ponikau JU, Sherris DA, Kern EB, Homburger HA, Frigas E, Gaffey TA, et al. The diagnosis and incidence
of allergic fungal sinusitis. Mayo Clinic proceedings Mayo Clinic. 1999 Sep;74(9):877-84. PubMed PMID: 10488788.
Epub 1999/09/17. eng.
2.
Shin SH, Ponikau JU, Sherris DA, Congdon D, Frigas E, Homburger HA, et al. Chronic rhinosinusitis: an
enhanced immune response to ubiquitous airborne fungi. The Journal of allergy and clinical immunology. 2004
Dec;114(6):1369-75. PubMed PMID: 15577837. Epub 2004/12/04. eng.
3.
Bachert C, Zhang N, Patou J, van Zele T, Gevaert P. Role of staphylococcal superantigens in upper airway
disease. Current opinion in allergy and clinical immunology. 2008 Feb;8(1):34-8. PubMed PMID: 18188015. Epub
2008/01/12. eng.
4.
Kennedy DW, Senior BA, Gannon FH, Montone KT, Hwang P, Lanza DC. Histology and histomorphometry
of ethmoid bone in chronic rhinosinusitis. The Laryngoscope. 1998 Apr;108(4 Pt 1):502-7. PubMed PMID: 9546260.
Epub 1998/04/18. eng.
5.
Lee JT, Kennedy DW, Palmer JN, Feldman M, Chiu AG. The incidence of concurrent osteitis in patients with
chronic rhinosinusitis: a clinicopathological study. American journal of rhinology. 2006 May-Jun;20(3):278-82.
PubMed PMID: 16871929. Epub 2006/07/29. eng.
6.
Cryer J, Schipor I, Perloff JR, Palmer JN. Evidence of bacterial biofilms in human chronic sinusitis. ORL;
journal for oto-rhino-laryngology and its related specialties. 2004;66(3):155-8. PubMed PMID: 15316237. Epub
2004/08/19. eng.
7.
Palmer J. Bacterial biofilms in chronic rhinosinusitis. The Annals of otology, rhinology & laryngology
Supplement. 2006 Sep;196:35-9. PubMed PMID: 17040016. Epub 2006/10/17. eng.
8.
Foreman A, Jervis-Bardy J, Wormald PJ. Do biofilms contribute to the initiation and recalcitrance of chronic
rhinosinusitis? The Laryngoscope. 2011 May;121(5):1085-91. PubMed PMID: 21520128. Epub 2011/04/27. eng.
9.
Lee RJ, Cohen NA. The emerging role of the bitter taste receptor T2R38 in upper respiratory infection and
chronic rhinosinusitis. American journal of rhinology & allergy. 2013 Jul;27(4):283-6. PubMed PMID: 23883809. Epub
2013/07/26. eng.
10.
Kern RC, Conley DB, Walsh W, Chandra R, Kato A, Tripathi-Peters A, et al. Perspectives on the etiology of
chronic rhinosinusitis: an immune barrier hypothesis. American journal of rhinology. 2008 Nov-Dec;22(6):549-59.
PubMed PMID: 18786300. Pubmed Central PMCID: PMC2802263. Epub 2008/09/13. eng.
11.
Den Beste KA, Hoddeson EK, Parkos CA, Nusrat A, Wise SK. Epithelial permeability alterations in an in
vitro air-liquid interface model of allergic fungal rhinosinusitis. International forum of allergy & rhinology. 2013
Jan;3(1):19-25. PubMed PMID: 22927233. Pubmed Central PMCID: PMC3511593. Epub 2012/08/29. eng.
12.
Lane AP. The role of innate immunity in the pathogenesis of chronic rhinosinusitis. Current allergy and
asthma reports. 2009 May;9(3):205-12. PubMed PMID: 19348720. Epub 2009/04/08. eng.
13.
Zivkovic AM, German JB, Lebrilla CB, Mills DA. Human milk glycobiome and its impact on the infant
gastrointestinal microbiota. Proceedings of the National Academy of Sciences of the United States of America. 2011
Mar 15;108 Suppl 1:4653-8. PubMed PMID: 20679197. Pubmed Central PMCID: PMC3063602. Epub 2010/08/04.
eng.
14.
van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, et al. Duodenal infusion of
donor feces for recurrent Clostridium difficile. The New England journal of medicine. 2013 Jan 31;368(5):407-15.
PubMed PMID: 23323867. Epub 2013/01/18. eng.
15.
Penders J, Stobberingh EE, van den Brandt PA, Thijs C. The role of the intestinal microbiota in the
development of atopic disorders. Allergy. 2007 Nov;62(11):1223-36. PubMed PMID: 17711557. Epub 2007/08/23.
eng.
16.
Blumberg R, Powrie F. Microbiota, disease, and back to health: a metastable journey. Science translational
medicine. 2012 Jun 6;4(137):137rv7. PubMed PMID: 22674557. Epub 2012/06/08. eng.
17.
Couzin-Frankel J. Bacteria and asthma: untangling the links. Science (New York, NY). 2010 Nov
26;330(6008):1168-9. PubMed PMID: 21109643. Epub 2010/11/27. eng.
18.
Havstad S, Wegienka G, Zoratti EM, Lynch SV, Boushey HA, Nicholas C, et al. Effect of prenatal indoor pet
exposure on the trajectory of total IgE levels in early childhood. The Journal of allergy and clinical immunology. 2011
Oct;128(4):880-5 e4. PubMed PMID: 21820714. Pubmed Central PMCID: PMC3185205. Epub 2011/08/09. eng.
19.
Roediger FC, Slusher NA, Allgaier S, Cox MJ, Pletcher SD, Goldberg AN, et al. Nucleic acid extraction
efficiency and bacterial recovery from maxillary sinus mucosal samples obtained by brushing or biopsy. American
journal of rhinology & allergy. 2010 Jul-Aug;24(4):263-5. PubMed PMID: 20819463. Epub 2010/09/08. eng.
20.
Abreu NA, Nagalingam NA, Song Y, Roediger FC, Pletcher SD, Goldberg AN, et al. Sinus microbiome
diversity depletion and Corynebacterium tuberculostearicum enrichment mediates rhinosinusitis. Science translational
medicine. 2012 Sep 12;4(151):151ra24. PubMed PMID: 22972842. Epub 2012/09/14. eng.
21.
Nagalingam NA, Cope EK, Lynch SV. Probiotic strategies for treatment of respiratory diseases. Trends in
microbiology. 2013 Sep;21(9):485-92. PubMed PMID: 23707554. Epub 2013/05/28. eng.
Management of Sudden Sensorineural Hearing Loss
Jolie Chang, MD
Objectives
1. Review the definition of sudden sensorineural hearing loss
2. Discuss the initial steps for diagnosis, timing of treatment, and typical
corticosteroid dosing.
3. Understand the role of intratympanic steroid therapy.
4. Describe the indications for further diagnostic testing.
Overview
Expeditious recognition and management of sudden sensorineural hearing loss
can lead to improved outcomes and patient quality of life. The etiology of SSNHL
is still not completely understood and most cases is idiopathic. Additionally, a
variety of diagnostic testing and proposed therapies have been described. In this
presentation evidence-based recommendations for clinical assessment and
approaches to management will be discussed.
Diagnostic Workup for Congenital Sensorineural Hearing Loss
Dylan K. Chan, MD, PhD
Objectives
1. To understand the reasons and options for diagnostic workup of
congenital sensorineural hearing loss
2. To understand the rationale behind a paradigm for diagnostic workup
of congenital sensorineural hearing loss that takes into account cost,
side effects, and management options as well as likelihood of
diagnostic success
Overview
1 in 500 infants born in the United States are identified through Newborn Hearing
Screening as having congenital sensorineural hearing loss (SNHL). Identification
of these infants and rapid throughput through audiology and otolaryngology is
critical for intervention to occur before the target of 6 months of age, which is
associated with significantly improved speech and language outcomes.
Identification of the etiology of hearing loss is important for patient/family
knowledge, exclusion of other syndromic causes, genetic/family counseling,
prognosis, and potentially management decision-making. A sequential, rational
diagnostic workup paradigm is presented, starting with history and physical to
identify potential syndromic associations and working those up appropriately. In
cases of non-syndromic congenital SNHL, three core diagnostic modalities –
genetic testing, imaging, and congenital CMV testing - should be considered.
Though audiogram profile and symmetry are important, it is also important to
take into account 1) cost; 2) side effects, in particular the morbidity and risk
associated with CT radiation exposure and/or general anesthesia; and 3) effect
on management, including cochlear implantation and, potentially, antiviral
therapy.
References
Chan DK, Schrijver I, Chang KW (2011) Diagnostic yield in the workup of congenital
sensorineural hearing loss is dependent on patient ethnicity. Otol Neurotol 32:81-87.
Misono S, Sie KC, Weiss NS, Huang ML, Boeckh M, Norton SJ, Yueh B (2011).
Congenital cytomegalovirus infection in pediatric hearing loss. Arch Otolaryngol Head
Neck Surg 47-53.
Miglioretti DL et al., (2013) The use of computed tomography in pediatrics and the
associated radiation exposure and estimated cancer risk. JAMA Pediatr 167:700-717.
Preciado DA et al. (2005) Improved diagnostic effectiveness with a sequential diagnostic
paradigm in idiopathic pediatric sensorineural hearing loss. Otol Neurotol 26:610-615.
Complications in Functional Endoscopic Sinus Surgery –
Avoidance and Management
Andrew N. Goldberg, MD, MSCE, FACS
Objectives
1. Describe factors that contribute to complications during endoscopic sinus
surgery
2. Describe pre-operative and intraoperative methods for avoidance of
complications during endoscopic sinus surgery
3. Describe methods for management of intraorbital and intracranial
complications during endoscopic sinus surgery
•
Reasons for Injury
– Loss of orientation / loss of landmarks
– Excessive bleeding
– Orientation of Landmarks
•
Avoidance of Complications - Begin pre-operatively!
– Coronal CT with 1-3mm cuts, bone windows, no contrast
– Review bony anatomy
– Have an operative plan (may adjust intra-op)
– Understand your comfort zone / limitations
– Study Your Scan
– Have scan up on light box during the case
– Restudy scan while vasoconstriction is working
– Refer to scan intra-operatively
•
CT review
– Name / date / type of scan / right and left
– Skull Base from anterior to posterior
– Medial orbital wall from anterior to posterior
• NLD, uncinate, ant ethmoid
– Height of posterior ethmoid
– Sphenoid sinus – dehiscence, Onodi, optic/carotid
– Review pathology and plan
•
Common Intraoperative Complications
– Excessive Bleeding
– Violation of lamina paprycea / orbit
– Violation of nasolacrimal duct
– Violation of Fovea/Cribriform/CSF Leak
–
•
Excessive Bleeding
– Control pre-operatively!
• Control inflamed tissue in the nose
• Antibiotics and oral steroids prior to surgery
• Antibiotic and prednisone begin 10 days pre-op and
continue 10 days post-op
• Typical prednisone dose for chronic sinusitis
• 40 mg qd x 5
• 30 mg qd x 5
• 20 mg qd x 5
• 10 mg qd x 5
•
Control of Hemorrhage Intraoperatively (prophylactic)
– Use oxymetazoline and/or epinephrine 1:1000 topically
– be sure to label 1:1000 epi (color with fluoroscein)
– Injection of middle turbinate root / middle turbinate
–
Greater palatine foramen block
•
Control of Hemorrhage Intraoperatively (avoidance)
– Mucosal bleeding
• Placement of cotton pledgets under endoscopic vision
• Gentle handling of mucosa
• Careful instrument manipulation
– Sphenopalatine Artery
• Posterior end of middle turbinate at lateral nasal wall
• Carterize free edge of middle turbinate if resected
– Violation of anterior ethmoid artery
• Examine CT scan to determine location of artery
• On coronal scan, the plane of posterior globe
• Observe for low hanging ethmoid artery
• Relationship to frontal recess
•
Violation of lamina papyracea / orbit
– Examine CT and determine the integrity of the orbital wall
• Position of uncinate (atelectasis)
• Integrity of the lamina
• Height of ethmoid
• Presence of Onodi cell
Intraoperatively
– Identify lamina early – clean it well!
– Use antrostomy for orientation
– May put pressure on the orbit to observe herniation of orbital fat or
movement of periorbita
–
•
•
Violation of nasolacrimal duct
– Examine CT to determine the configuration of the uncinate
• Position with reference to orbit (atelectasis)
• Points of attachment
•
Intraoperatively
– Palpate mobile attachment of uncinate
– Nasolacrimal duct - hard bone
– Use backbiter to remove uncinate, not to make antrostomy
•
•
Violation of skull base
Examine CT scan and depth and slope of skull base
– Cribriform is lower than the fovea and thin anteriorly at the root of the
middle turbinate
– Fovea is strongest laterally / superiorly
– Note height of the ethmoid above the maxillary sinus
Intraoperatively
– Use 0 degree scope as much as possible for ethmoid
– Feel behind bony fragments before biting
– Only bite what is clear behind
•
•
Repair CSF leaks intraoperatively
– Must recognize violation of skull base
– CSF fluid must be differentiated from irrigation
– CSF can appear as black swirl in pool of blood
– Neurosurgery consult / lumbar drain
– Consider possibility of intracranial injury
– Repair during same anesthetic unless intracranial injury is suspected
•
Conclusions
– There is a relationship between experience and complication rate and
type
– Integration of cadaver dissection, structured courses, and experienced
proctors during early surgical experience can improve complication profile
– Coronal CT scans are critical to orientation and safety
– Bleeding in conjunction with loss of orientation are principal reasons for
intraoperative complications
– The vast majority of complications can be treated with minimal morbidity if
recognized early and addressed
Managing Lymph Node Disease in Thyroid Cancer
Joseph C. Sniezek, MD FACS
Background:
30-80% of patients with well-differentiated thyroid cancer (WDTC) have microscopic or
macroscopic metastasis to the cervical lymph nodes. The challenge of managing lymph
node disease in thyroid cancer is to balance the benefit of surgical removal with the
risks of intervention. When managing cervical LN mets, it is important to remember that
the biology of thyroid cancer is much different than that of other common malignancies
in the head and neck, as is the staging system. It is also incumbent on the surgeon to
remember that the staging, survival, and management of patients with WDTC depends
greatly on their age (< or > 45 years of age).
ATA Guidelines:
The 2009 revised ATA guidelines provide a rational approach to managing the central
and lateral neck for WDTC that can be tailored accordingly by the treatment team.
-
Preop thyroid and neck US should be done for all pts with WDTC (rec #21)
US-guided FNA of cervical LN’s > 8 mm should be performed (rec #21)
Routine preop use of MRI, CT, PET not recommended (rec #22)
Central Compartment Neck Dissection (CND)
-Total thyroidectomy without CND appropriate for T1 or T2 PTC’s (rec #27c)
-Therapeutic central compartment dissection- removes nodes present clinically or seen
on US (rec #27a)
-Prophylactic central compartment dissection- surgical removal of nodes when no
clinically suspicious nodes are seen ( T3 or T4 primary tumors, > 45 years old) (#27b)
-CND is a COMPREHENSIVE removal of prelaryngeal, pretracheal, and at least one
paratracheal node basin
-berry picking is not recommended
-if a pathologic lateral neck node is present, a CND should accompany the neck
dissection (80% likelihood of central compartment mets)
-after diagnostic lobectomy finding WDTC, elective reoperation in ipsilateral central neck
not indicated
Lateral Neck Dissection: should only be done for known lateral disease and should
always include levels IIa, III, IV, and Vb
Thyroglobulin as a Tumor Marker in Well-Differentiated Thyroid Cancer
Dennis H. Kraus, MD
Objectives
1. To review the current risk stratification for patients with well-differentiated
thyroid cancer and detail patients who would be best served by adjuvant
therapy.
2. To detail the use of thyroglobulin as a serum tumor marker for recurrent
papillary carcinoma of the thyroid.
Overview
The author will detail the use of thyroglobulin as a tumor marker in well-differentiated
thyroid cancer. Even in a low-risk population, there is approximately a 10% risk of
recurrence. Utilization of thyroglobulin as a means for detecting early recurrence of
cancer will be detailed. Management of the at-risk nodal basin will be discussed with
review of guidelines for elective and therapeutic node dissection. Moreover, a review of
indications for radioactive iodine will be detailed. The presenter will focus on the optimal
treatment of well-differentiated papillary thyroid cancer with a focus on avoiding
unnecessary treatment.
References
Kim AJ, Liu JC, Gainly I, Kraus DH. Minimally invasive video-assisted thyroidectomy
2.0: Expanded indications in a tertiary care cancer center. Head and Neck
Surgery. Nov 2011.
Cohen EG, Tuttle M, Kraus DH: Postoperative Management of Differentiated Thyroid
Cancer In Disorders of the Thyroid, The Otolaryngologic Clinics of North America
Philadelphia: W.B. Saunders Co, February, 2003: 129-157.
Ultrasound-Guided FNA: When, How and Why
Marika Russell, MD, FACS
Objectives
1. Review background and indications for ultrasound guided fine needle
aspiration biopsy (USG-FNA)
2. Describe technique of USG-FNA
3. Discuss diagnostic outcomes related to USG-FNA
Overview
Surgeon-performed ultrasound is becoming increasingly common. USG-FNA is a safe
and simple diagnostic tool that can be easily performed by surgeons. Indications for
USG-FNA will be reviewed and the technique will be described. Surgeon-performed
USG-FNA is safe and effective in the hands of surgeons. No clear benefit for on-site
cytopathology has been demonstrated. Performance of this technique is a rewarding
experience that benefits patients and surgeons alike.
References
1. Smith RB. Ultrasound-guided procedures for the office.. Otolaryngol Clin N Am
2010;43:1241-54.
2. Koike E, Yamashita H, Noguchi S et al. Effect of combining ultrashonography
and ultrasound-guided fine needle aspiration biopsy findings for the diagnosis of
thyroid nodules. Eur J Surg 2001;167:656-61.
3. Bohacek L, Milas M, Mitchell K et al. Diagnostic accuracy of surgeon-performed
ultrasound guided fine needle aspiration of thyroid nodules. Ann Surg Oncol
2012;19:45-51.
4. Kangelaris GT, Kim TB, Orloff LA. Role of ultrasound in thyroid disorders.
Otolaryngol Clin N Am 2010;43:1209-27.
5. Giacomini CP, Jeffrey RB, Shin LK. Ultrasonographic evaluation of malignant
and normal cervical lymph nodes. Semin Ultrasound CT MR 2013;34:236-47.
6. Langer JE, Baloch ZW, McGrath C et al. Thyroid nodule fine-needle aspiration.
Semin Ultrasound CT MR. 2012;33:158-65.
7. Robitschek J, Straub M, Wirtz E, et al. Diagnostic efficacy of surgeon-performed
ultrasound-guided fine needle aspiration: a randomized controlled trial.
Otolaryngol Head Neck Surg 2010;142:306-9.
8. Bhatki AM, Brewer B, Robinson-Smith et al. Adequacy of surgeon-performed
ultrasound-guided thyroid fine needle aspiration biopsy. Otolaryngol Head Neck
Surg 2008;139:27-31.
Reconstruction of Facial Cutaneous Defects
Michael A. Fritz MD
Objectives:
1) Outline a general approach and mindset which can be applied to facial defect
repair
2) Describe several reconstructive methods for each facial subsite which can be
applied to defects ranging from small to moderately large.
This lecture will cover repair of facial cutaneous and composite defect reconstruction
using locoregional techniques. It will highlight a general approach to decision making
and underscore a flexible plan reconstructive plan suited to both defect and patient
factors. Techniques of nasal, auricular, lip and eyelid reconstruction will be covered
from small to moderately large defect repair.
Endoscopic Ear Surgery: Minimally Invasive Surgery that Matters
Philip Littlefield, MD
Objectives
1. Introduce the concept of endoscopic ear surgery.
2. Show its benefits and limitations.
3. Explain the equipment requirements and operating room setup.
4. Describe common techniques/tricks.
5. Explain how/when to incorporate it into your practice.
Overview
Endoscopic ear surgery has been around for nearly 20 years, but is only practiced by a
minority of otologists despite some fervent advocates. The presenter believes that this
will change soon, and will show the advantages to incorporating modern endoscopes
into otologic surgery. This practical presentation will go over the equipment
requirements, patient and operating room setup, and basic endoscopic techniques. We
will discuss what cases to start with, and then go over specific pathologies that are well
treated via the endoscope. We will conclude by addressing common questions and
concerns for the unfamiliar.
References
1.
2.
3.
4.
5.
6.
Tarabichi M. Endoscopic management of limited attic cholesteatoma. Laryngoscope. 2004;
114(7):1157-62.
Tarabichi M. Endoscopic management of cholesteatoma: long-term results. Otolaryngol Head Neck
Surg. 2000; 122(6):874-81.
Tarabichi M. Transcanal endoscopic management of cholesteatoma. Otol Neurotol. 2010;
31(4):580-8.
Marchioni D, Mattioli F, Alicandri-Ciufelli M, Presutti L. Transcanal endoscopic approach to the
sinus tympani: a clinical report. Otol Neurotol. 2009; 30(6):758-65.
Pothier DD. Introducing endoscopic ear surgery into practice. Otolaryngol Clin North Am. 2013;
46(2):245-55.
Badr-El-Dine M, James AL, Panetti G, Marchioni D, Presutti L, Nogueira JF. Instrumentation and
technologies in endoscopic ear surgery. Otolaryngol Clin North Am. 2013; 46(2):211-25.
Incorporating AHPs into Your OHNS Practice
Laura Kirk, MSPAS, PA-C
To address the rising demand for patient care, increase in insured population, continued decline
in physician workforce, and altered reimbursement plans of modern healthcare, the addition of
an Advanced Health Practitioner to an Otolaryngology-Head and Neck Surgery practice is an
excellent consideration. AHPs have been shown in many studies to provide safe, affordable,
and quality access to care. Patient acceptance of and satisfaction with seeing an AHP has also
been repeatedly demonstrated. In this session we will examine what AHPs are, their specific
roles within otolaryngology, how to hire and incorporate an AHP, and the benefits expected from
embracing a team approach to healthcare.
Load Sharing Mandible Reconstruction: The Champy Technique
Andrew H. Murr, MD, FACS
1. The Champy Technique is a mono-cortical mini-plate technique that utilizes compressive
forces to their greatest advantage and counteracts tensile forces to repair mandible
fractures using minimal hardware.
2. The Champy Technique is a load sharing technique which means that the repair is NOT
absolutely rigid.
3. The Champy Technique can be used with supplemental intermaxillary fixation or without
supplemental intermaxillary fixation.
4. The Champy Technique is particularly compatible with trans-oral approaches using intra-oral
incisions and trans-buccal trocars.
5. The Champy Technique is NOT USEFUL in the following circumstances:
a. Bone loss or in a comminuted fracture
b. When a tooth is removed in the line of the fracture (in general)
c. When a fracture is thought to have osteomyelitis
d. For mandible fractures in edentulous mandibles with a large degree of alveolar bone
absorption
6. The Champy Technique is particularly useful for relatively non-displaced, non-comminuted
angle fractures and has the lowest reported complication rate (~3%) for angle fractures.
7. Anterior to the mental foramen, because a higher degree of torsional force is present in the
mandible, 2 mono-cortical miniplates are required. Two plates may also be used at the
angle placed along Champy’s lines of osteosynthesis. The diagram below shows Champy’s
Lines:
Affordable Care Act – Progress Report Since Initiation
Benjamin Cable, M.D.
Objectives
1. Participants will be able to describe the three core strategies utilized by the
ACA to broaden health care insurance coverage rates in the United States.
2. Participants will be able use their knowledge of the three core strategies of
the ACA to objectively evaluate news and data presented by government
agencies and press.
3. Participants will be able to describe the ACAs approach to managing health
costs.
Overview
This presentation will begin with a brief review of the mechanisms within the ACA
designed to broaden health care coverage rates in the United States and to control
health care cost inflation over time. Using the three core strategies, a structure will be
offered to interpret the wide range of news stories and data analyses being offered since
the advent of the ACA. Finally, a brief review ACAs cost containment strategy will be
offered.
Courses to Consider:
Coursera.org
Health Policy and the Affordable Care Act. Professor Ezekiel Emanuel
University of Pennsylvania
Edx.org
Innovating in Health Care. Professor Regina Herzlinger
Harvard University
United States Health Policy. Professor John McDonough
Harvard University
University of California San Francisco
1/23/2014
MOT14006: Pacific Rim Oto Update
Registrant List
UCSF OCME
Name
1Allen
2Beitia
3Bitgood
4Blum
5Boesen
6Boyd
7Brant
8Bravo
9Briscoe, Jr.
Burk
10
Butt
11
Cain
12
Campbell
13
Carr
14
Carter
15
Chambers
16
Chang
17
Chesnick
18
Doo
19
Duff
20
Dumper
21
Ekbom
22
Francis
23
Goland
24
Golden
25
Hakim
26
Healey
27
Heichel
28
Hetland
29
Hong
30
Huang
31
Hubbell
32
Hunt
33
Hunter
34
Jaggi
35
Jimenez
36
Johnson
37
Johnson
38
City, State
Arthur
Carlos A.
Mark J.
Daniel
Torben
James H.
Kristin
Roberto
Michael
Ronald
Fidelia Y.
Ryan A
William N.
Henry Patrick
Clifford
David
Edward T.
Steven R.
Gene W.
Nathaniel K.
Jaymi
Dale
Aren
Jay
Joseph B.
Ishrat
Kathleen
David J.
Andrew
Steven S.
Jimmy
Michael
Walter L.
Michael
Rick
Alfredo
Dennis Lee
Shayla Anne Frisb
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
PA-C
MD
MD
MD
MD
MD
MD
MD
MD
MD
FRCSED, ENT
MD
Md.
Murray, KY
Panamá, Panama
Stockton, CA
Rochester, MN
Lyngby, Denmark
St. Louis, MO
Johnstown, PA
Panama, Panama
The Woodlands, TX
Rockledge, FL
Cupertino, CA
Cranbrook, BC, Canada
Calgary, AB, Canada
Lone Tree, CO
Edmonton, AB, Canada
Medford, OR
Tripler AMC, HI
Blue Bell, PA
Honolulu, HI
Tripler AMC, HI
Nanaimo, BC, Canada
Rochester, MN
Ripon, CA
Long Beach, CA
Tripler AMC, HI
Glendale, AZ
Napa, CA
Marquette, MI
Bismarck, ND
Tripler AMC, HI
Los Angeles, CA
Spokane, WA
Turlock, CA
Penrith, NSW, Australia
Saskatoon, SK, Canada
Houston, TX
Stockton, CA
Stockton, CA
Page 1 of 3
Registrant List
UCSF OCME
Name
Kanamori
39
Kron
40
Kudryk
41
Lait
42
Larsen
43
Levin
44
Lewis
45
Leyton
46
Liu
47
Malone
48
Maloney
49
Mann
50
McArthur
51
McLaughlin
52
McTigue
53
Mcvey
54
Miller
55
Moore
56
Morelock
57
Mushtaq
58
Neff
59
Newbill
60
O'Donnell
61
Oxley
62
Payton
63
Pelausa
64
Pio
65
Porter
66
Proctor
67
Reschak
68
Robin
69
Roller
70
Ruhl
71
Sakamoto
72
Samad
73
Schoenberg
74
Seibert
75
Shotts
76
Smith
77
Song
78
Spagnoli
79
Spangsberg
80
City, State
Glenn
Thomas
William
Marci
John W.
David J.
William B.
Bryan D.
Alfred J.
David
Amanda
David B.
Peter D.
Timothy J.
Stephen T.
Kevin Kenneth
Jonathan
David W.
Michael
Ednan
Brian A.
Daniel C.
Patrick
Kevin S.
Harry Howard
Edilberto O.
Felipe Federico
Glen
Todd B.
Steve
Jeffrey M.
Carrie
Douglas
Michio
Imran
Erik D.
Jared R.
Steven D.
Wendy
Sungjin A.
Scott
Carin
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
DO
MD
MD, FACS
MD
MD
MD
MD
Jr
MD
MD
PA-C
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
Orlando, FL
Willowbrook, IL
Edmonton, AB, Canada
Greenville, NC
Waconia, MN
Shell Beach, CA
Oakland, CA
Bellevue, WA
Honolulu, HI
Spokane Valley, WA
Vancouver, BC, Canada
Connelly Springs, NC
Yellow Knife, NT, Canada
Honolulu, HI
South Bend, IN
Spokane, WA
Grants Pass, OR
Seattle, WA
Escondido, CA
Mclean, VA
Rochester, MN
Honolulu, HI
Honolulu, HI
Morgantown, WV
Salida, CO
Suffolk, VA
Naga City, Philippines
Pleasant Grove, UT
Auburn Hills, MI
Clarkston, MI
Tripler AMC, HI
Spokane, WA
Tripler AMC, HI
Ichihara City, Japan
Vancouver, BC, Canada
Portland, OR
Tripler AMC, HI
Louisville, KY
South San Francisco, CA
Tripler AMC, HI
Arlington, VA
Skovlunde, Denmark
Page 2 of 3
Registrant List
UCSF OCME
Name
Steven
81
Strom
82
Tolisano
83
Tran
84
Warren
85
Wong
86
Yabe
87
Yammine
88
Yim
89
Yung
90
City, State
Ryan R.
C. Gordon
Anthony M.
Daniel D.
James Douglas
Louis Wing Wah
Takao
Nadine
Donald W. S.
Richard
MD
MD
MD
MD
MD, MSC
MD
Corvallis, OR
Hayward, CA
Tripler AMC, HI
Tripler AMC, HI
Boulder, CO
Lafayette, CA
Tokyo, Japan
Chatham, ON, Canada
Kailua, HI
White Plains, NY
Total Number of Attendees for MOT14006: 90
Page 3 of 3
University of California
San Francisco