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"Greg Klitz" <[email protected]>
Thu, Feb 14, 2013 10:15 am
[email protected]
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Department of Otolaryngology - Head & Neck Surgery
Winter 2013
Inside this Edition
Nasal Sinus Center at Loyola
Spring CME Program Offered
Grand Rounds: Laryngeal Trauma
Service Opportunity
Annual Resident Research Competition Winners
With Gratitude
Heartfelt Gift from Former Colleague
At The Podium
Poster Presentations
In Print
Meet the Docs
From the Chairman
Dear Colleagues:
The New Year has arrived and we are thankful for a very good 2012 in the Department of Otolaryngology-Head & Neck Surgery.
Our clinical programs have again been successful, with head and neck cancer surgery, otology/neurotology, and rhinology/skull
base surgery leading the way. Our facial plastic, allergy, general otolaryngology, and laryngology divisions are increasingly
productive and our pediatric otolaryngology practice continues to grow. This year, U.S. News and World Reports ranked our
program 35th in the country.
We will have three new hires in July 2013. Dr. Matt Kircher is finishing an ear/skull base fellowship at Michigan Ear Institute and
will be joining our section, headed by Dr. John Leonetti. Dr. James Jaber is completing a head and neck cancer fellowship at the
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will be joining our section, headed by Dr. John Leonetti. Dr. James Jaber is completing a head and neck cancer fellowship at the
University of Pittsburgh and will join Drs. Kim, Borrowdale and Bier-Laning in our department. Dr. Jaber is also a PhD researcher
and will be setting up a laboratory at the VA Hines Hospital. Dr. Amy Pittman is completing a head and neck microvascular
reconstructive fellowship at Oregon University Health Center and will also be joining us in July.
I have been blessed with a great group of doctors who continue to work hard for our patients and our department. We are looking forward to an equally
successful 2013.
We have many challenges coming in health care, and we as Otolaryngologists, need to be ready. An area of present difficulty is the jockeying for position
and control amongst health care providers. Audiologists are lobbying for primary care of hearing disorders; oral surgeons for control of oral cavity
disorders; and nurse practitioners for primary care of the head and neck. Please look at our Academy website under Advocacy for more information. We
need your volunteer and financial help to thwart these threats.
Finally, my sincere wishes for a joyous New Year!
Sincerely,
James A. Stankiewicz, MD
Professor and Chair
Department of Otolaryngology-Head & Neck Surgery
Nasal Sinus Center at Loyola
Nasal and sinus problems can run from the common, to the chronic, to life altering. For anything more than an ordinary case of rhinitis, it is good to know
that a place exists where expert care is available. For nearly thirty years, Loyola University Health System has provided comprehensive rhinology services
in the Chicagoland area.
Loyola was the first academic center in the Midwest to establish a Nasal Sinus Center (1985), founded by James A. Stankiewicz, MD, FACS, professor
and current chair of the Department of Otolaryngology-Head and Neck Surgery.
Today, Loyola's Nasal Sinus Center offers a complete range of medical and surgical treatments for all nasal and sinus disorders. Loyola boasts an
accomplished team of board-certified physicians who skillfully manage every dimension of rhinologic and skull base disease such as:
Allergic and non-allergic rhinitis
Chronic rhinosinusitus (with/without nasal polyps)
Sinus and revision sinus surgery (endoscopic, balloon sinuplasty, external procedures)
Nasal deformity or obstruction (due to deviated septum or enlarged turbinates)
Skull base tumors (both benign and malignant)
Cerebrospinal fluid leaks (without incisions or lumbar drains)
Orbital proptosis (due to Graves' disease)
Chronic tearing (due to tear duct obstruction or infection)
Cutting-edge medical therapies (topical steroids, antibiotics, antifungals, surfactants)
In-office procedures (polypectomy, injections for pain and polyps, turbinate reduction, etc.)
Second opinions
Always pioneering, Loyola was also the first otolaryngology program in the Midwest to offer endoscopic sinus surgery for the treatment of chronic sinusitis
and nasal polyps, which Dr. Stankiewicz has been performing and teaching since the mid-1980's. In that time, Dr. Stankiewicz has performed thousands
of nasal and sinus procedures and is recognized throughout the United States and internationally for this expertise.
A majority of surgeries performed by the team (60-70%) are revision endoscopic sinus surgeries, with a reported 90% improvement in outcomes. “We
treat the most straight forward and most difficult surgical problems and specialize in patients who have failed previous surgery,” says Dr. Stankiewicz.
Such outcomes are one of the many reasons patients seek help at Loyola. An example is the 56 year-old male patient who presented with Churg-Strauss
Syndrome, a rare case of eosinophilic vasculitis. However, this case presented more like Wegener's granulomatosis. There was a loss of anatomy and
scarring from the disease process. Upon exam, Dr. Stankiewicz found a total septal perforation and scar obstruction of the ethmoid, sphenoid and frontal
sinuses. The inferior and middle turbinates were completely absent. A subsequent CAT scan revealed eight or more cystic mucoceles in the frontal,
ethmoid and sphenoid sinuses. Using computerized guidance via a GPS probe to help confirm anatomy, Dr. Stankiewicz found and opened a total of ten
mucoceles. While close observation and ongoing medical therapy are required, the patient reports no recurrent infection or headache.
Dr. Stankiewicz specializes in the treatment of chronic rhinosinusitis and its complications, particularly endoscopic sinus and revision surgery; balloon
sinuplasty; medical and surgical treatment of rhinologic disease; treatment of nasal and paranasal sinus disease; and skull base surgeries such as CSF
leak closure, tumor and orbital surgery.
Co-director of the Nasal Sinus Center is Kevin Welch, MD, assistant professor. In addition to the medical and surgical treatment of chronic rhinosinusitis,
endoscopic sinus surgery and revisions, Dr. Welch also specializes in the treatment of skull base tumors, sleep apnea, and cerebrospinal fluid leaks. He
uses techniques so advanced that he is able to detect and treat CSF leaks that have been undiscovered for years, such as the case of the 54-year old
female with a three-year history of spontaneous CSF rhinorrhea of both the sinuses and ear. Dr. Welch detected a sinus encephalocele and was able to
repair it entirely endoscopically, avoiding a craniotomy and lumbar drain while preserving sinus structures. “Endoscopic repair is definitely the way to go,”
says Dr. Welch. “It has supplanted the traditional ‘open' repair of CSF leaks. There isn't a CSF leak that can't be repaired endoscopically.” Dr. Welch is
often invited to speak about this and other rhinology and skull base topics.
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Loyola physicians employ the latest technology including MRI and CT image guidance, fusion, high-speed drills and other cutting-edge instrumentation.
They are also known for their pioneering use of the Coblator®, ultrasonic aspirator and plasma knife for the removal of skull base tumors.
Monica Patadia, MD, assistant professor, is the third and newest member of the rhinology team. She also specializes in endoscopic sinus surgery and
revision sinus surgery. Dr. Patadia also completed a fellowship in Facial Plastic surgery and has a great interest in nasal obstruction and rhinoplasty
surgery, including the repair of functional and cosmetic nasal deformities and other facial cosmetic procedures.
One of Dr. Patadia's patients, a 64 year-old female with a history of severe obstructive sleep apnea and nasal congestion, was unable to tolerate CPAP
machine. An exam revealed a large right-sided maxillary mass. Dr. Patadia performed an in-office biopsy, revealing an inverted papilloma. The patient
underwent an endoscopic medial maxillectomy for removal of the tumor. Now more than one-year out from surgery, she reports breathing nicely through
her nose and her most recently sleep study shows that her sleep apnea is cured. There has been no recurrence of the tumor.
Dr. Patadia is also director of the otolaryngology allergy program, which provides skin and blood testing for inhalant allergies including seasonal and yearround allergens. Patients with severe allergies are evaluated for allergy shots. "We have several medications, each with different mechanisms of action,
that we can offer patients to optimize their allergic symptoms,” states Dr. Patadia. “We can dramatically improve a patient's quality of life."
All three members of the Nasal Sinus Center team are also members of the American Rhinologic Society; Dr. Stankiewicz is a former president and Dr.
Welch is a committee chairman and ARS Summer Sinus program director. Each physician actively publishes in numerous recognized journals, including
the prestigious International Forum of Allergy & Rhinology.
The combined experience of this team, its clinical expertise, academic achievements, excellent patient care results and patient satisfaction make Loyola
among the busiest and most well known programs in the Midwest.
To consult with a member of the Nasal Sinus Center team, please call Nurse Triage at (708) 216-3664. Patients may call Central Appointment Scheduling
at (708) 216-8563.
Spring CME Program Offered
Common Yet Challenging ENT Problems” is the title of Loyola’s Spring CME program, scheduled for Saturday
March 16.
Ten experts will provide detailed information on the causes and treatment of several ear, sinonasal and upper
aerodigestive tract diseases. General practitioners, internists, pediatricians, allergists, otolaryngologists, nurses,
audiologists and anyone interested in learning how to better diagnose and treat ENT diseases are invited to
attend.
This seminar will take place at the Stritch School of Medicine in Maywood. To register, contact Loyola’s
Continuing Medical Education department at (708) 216-3236.
Grand Rounds: Laryngeal Trauma
Originally presented by Ryan Burgette, MD (PGY-5)
Laryngeal trauma is relatively rare in occurrence, accounting for only 1% of all traumas. Its incidence is about 1 in every 30,000 emergency room visits.
These patients often suffer multiple injuries and the airway can frequently be overlooked due to intubation in the field or the use of cervical collars. Despite
its rarity, the initial management of these patients is critical, as airway preservation can mean the difference between life and death.
Anatomy and Mechanism of Injury
The larynx is a framework of cartilages within the neck. The likely reason for the rarity of injuries to this structure is due to its location. The larynx is
protected from anterior blows by the inferior projection of the mandible; posteriorly it is protected by the spine, inferiorly by the sternum, and laterally by the
sternocleidomastoid muscles. The pediatric larynx is even more protected due to its higher position at the level of C4 versus C7 in the adult. The increased
elasticity of the pediatric cartilaginous framework allows for more tolerance to trauma and results in fewer fractures, but the lack of fibrous support causes
an increase in soft tissue injury. Although the lack of fractures is advantageous, the narrower cross-section at the level of the cricoid and the glottis, gives
these injuries greater potential for disaster.
Blunt injury is the most common cause of laryngeal trauma, although there are several
mechanisms of injury including penetrating trauma, iatrogenic injury, inhalational injury, and
caustic ingestion. The most common cause of blunt injury is motor vehicle accidents (MVA)
though the incidence of this is decreasing with increased patient education and mandatory seat
belt laws. Other causes of blunt trauma include clothesline injury, which can cause devastating
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belt laws. Other causes of blunt trauma include clothesline injury, which can cause devastating
cricotracheal separation and strangulation.
Strangulation is a low velocity injury and can occur from assault or attempted suicide.
Strangulation accounts for 10% of the violent deaths in the United States. Patients present with
hoarseness or abrasions but progress to delayed edema 12-24 hours after injury. The evaluating
physician should consider the magnitude of force when dealing with these patients.
In contrast to trauma due to MVA, penetrating trauma has been increasing with the rise in
personal assaults. This is important to know because up to 60% of patients with penetrating
trauma to the larynx will have injury elsewhere, be it esophageal or neurovascular. Bullet injury
causes damage via two mechanisms: direct contact and shock wave injury. The size of the shock
wave is directly related to square of the bullet velocity, which is why high-velocity muzzles cause
more extensive damage. Knife wounds are cleaner and cause less peripheral injury, but can
cause injury to deeper structures well away from the entrance wound.
Diagnosis
Often times you will be unable to obtain a history from these patients, but your history should start with the mechanism of injury. In any patient with any
neck injury, the physician should have a high degree of suspicion. Signs and symptoms vary with the degree of injury, but any dysphonia or hoarseness
should be considered a severe laryngeal injury until proven otherwise. Significant injuries may present with voice change, pain, dysphagia, odynophagia, or
hemoptysis. Severe injuries create airway compromise with stridor, dyspnea, and aphonia. As with all trauma patients, it is vitally important to remember
your A-B-C’s. Securing the airway is obviously the first step in management, particularly with these patients. After securing the airway, it is most important
to rule out cervical injury or at least stabilize the cervical spine. An inspection of the neck will reveal any vascular injuries with the presence of hematomas,
bleeding wounds, or audible bruits. Listening to the character of the stridor can help identify the location of the obstruction. Inspiratory stridor typically
indicates a supraglottic obstruction, which may be edema, hematoma, foreign body, or cartilaginous fracture. Expiratory stridor may indicate a tracheal
injury, and a combined stridor could be obstruction at the level of the glottis. Subcutaneous emphysema is associated with loss of the integrity of the upper
aerodigestive tract. This can vary widely from minimal to massive pneumomediastinum.
After a physical examination is performed and the airway deemed stable, the examiner should perform a flexible laryngoscopy. Care must be taken not to
cause any additional trauma or inadvertent laryngospam. Any decreased or lack of vocal cord range of motion, hematoma, exposed cartilage or mucosal
lacerations will require surgical intervention.
The use of CT scan in diagnosis is somewhat controversial. CT allows for evaluation of the larynx in a non-invasive manner, avoiding unnecessary
operative explorations. Although the consensus is not unanimous, it is generally agreed that two groups of patients do not benefit from CT: patients with
minimal symptoms and minimal findings and patients with obvious fractures who are en route to the operating room. Some authors state that if the airway
is secured, a CT scan will help with operative planning.
Treatment
Patients with minimal symptoms and minimal findings on endoscopy can be observed with medical management including bed rest, humidified oxygen,
and an anti-reflux regimen to prevent any further mucosal injury. Racemic epinephrine and steroids can be used as well although these have not been
proven to be beneficial.
Indications for open laryngeal repair are many: mucosal lacerations, exposed cartilage, displaced or comminuted cartilage fractures, avulsed or dislocated
arytenoids, or any cricoid fractures. Open repair is done through a horizontal incision done at the level of the cricothryoid. This incision can be extended to
an apron flap, if the lateral neck needs to be explored. Non-displaced fractures can simply be closed with non-absorbable sutures of the outer
perichondrium, or plated. If there is mucosal damage or exposed cartilage that needs to be assessed and repaired, the larynx will need to be opened. It is
recommended that this be done through a midline thyrotomy. Some surgeons use a vertical fracture, 2-3 mm off midline, but most state that the vocal cord
can still remain attached to the anterior commissure, and entry here would result in vocal cord transection. This complication is not worth the convenience
of using the fracture, thus the use of a midline thyrotomy.
This midline thyrotomy offers exposure of the entire endolarynx, allowing the physician to inspect the arytenoids and reduce a dislocation if needed.
Exposed cartilage is the primary factor for the formation of granulation tissue and fibrosis and must be dealt with appropriately. This is done with the
meticulous closure of the mucosal laceration with either 5-0 or 6-0 absorbable stitches in a buried fashion. Immediate intervention rarely requires the use of
grafts with primary repair, but mucous membrane or split-thickness skin graft can be used to cover exposed areas that cannot be closed primarily.
However, this results in a higher likelihood of scar formation versus primary closure.
The cartilaginous fractures can either be plated with absorbable plates or mini-plates, or wired for
fixation. Both methods have proven equally effective with no method clearly superior. In either
case, the priority is the lack of penetration of the laryngeal mucosa with either wire or screw.
Post-operative care is similar to medical management with humidified oxygen, head of bed
elevation, and an anti-reflux regimen. Patients with tracheostomy are decannulated as soon as
possible to prevent further irritation. They are followed regularly and should have routine
endoscopy to assess for any granulation tissue.
Once the airway is established, these patients typically do well. The most commonly assessed
outcomes are voice and airway and only those patients with the most severe injuries have been
found to have a significant degree of hoarseness, or are left with a permanent tracheostomy. The
most common complication is granulation tissue requiring re-excision in the operative room,
however a meticulous mucosal repair could prevent it. Another complication often seen is
stenosis at any level of the glottis, with subglottic stenosis being the most difficult to treat.
Summary
In summary, laryngeal trauma is a rare occurrence that requires prompt and adequate airway
assessment, which may be the difference between life and death. Caution should be exercised in
the management of patients with any airway distress or obvious injury, resulting in an awake tracheostomy in the operating room. These injuries should
then be explored via a midline thyrotomy, with meticulous closure of all mucosal injuries, and open reduction of the framework with mini-plates or wires.
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then be explored via a midline thyrotomy, with meticulous closure of all mucosal injuries, and open reduction of the framework with mini-plates or wires.
These patients need frequent follow-ups to assess for granulation or subglottic stenosis, which can be an aggravating and difficult complication to treat.
Service Opportunity
Once again, Loyola’s Department of Otolaryngology-Head & Neck Surgery will be leading a medical mission to Santiago, Dominican Republic.
Over the nine-day stay, Loyola physicians will treat an average of 400 patients and perform more than 130 surgeries. Audiologists will conduct more than
fifty audiograms and approximately fifteen children are fitted with hearing aids, allowing them to hear for the very first time.
The mission is scheduled for February 7-15. Donations and volunteers are always welcome. Please contact Janet Lancsak at (708) 216-9637 for
information.
Annual Resident Research Competition Winners
Residents (PGY2- PGY5) presented their latest research at Loyola’s 22nd Annual Peter J. Girgis Resident Research Competition on January 15.
This year’s winners are:
1st place
James Martin, MD
“Using Data Mining to Predict Outcomes in Oropharyngeal Carcinoma”
2nd place
Muhamad Amine, MD
“Effects of Gonadal Steroids and Electrical Stimulation on Cell Survival Following an Intracranial Facial Nerve Crush Injury”
3rd place
Nadieska Caballero, MD
“Auditory Thresholds Following Chronic Exposure to High-Dose Vicodin in a Rodent Model”
Honorable Mention
Jeffrey Hotaling, MD “Correlation of Critical Care Scores with ICU Tracheostomy Data” Winners receive $500, $300 and $200 respectively.
This year’s judges were Gerry F. Funk, MD, professor, Holden Cancer Center, Head & Neck Oncology, Department of Otolaryngology-Head & Neck
Surgery, University of Iowa Hospitals and Clinics; John Brockenbrough, MD, assistant clinical professor of Surgery, University of Illinois; and Charles
Bouchard, MA, MD, John P. Mulcahy Professor of Ophthalmology, Chairperson of the Department of Ophthalmology, Loyola University Health System.
With Gratitude
In 2010, Loyola’s ENT department created the Otolaryngology Resident Education Fund, in order to continue providing residents with travel to academic
meetings, books, loupes and other necessities.
We would like to gratefully acknowledge the following persons for their leadership gifts to this fund:
(In alphabetical order)
James Chow, MD
Raymond Konior, MD
Resident education requires the efforts and support of many people. If you would like to help, please contact Dr. Stankiewicz directly at (708) 216-8526.
Heartfelt Gift from Former Colleague
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Dr. and Mrs. Richard Buckingham donated an expansive collection of slides, books and cameras to Loyola’s Department
of Otolaryngology-Head & Neck Surgery. Dr. Buckingham recently retired from Edward Hines, Jr. VA Hospital where he
taught many Loyola residents over his long and illustrious career.
“It is with great honor and respect that we accept this most generous donation of Dr. Buckingham’s life’s work as a world
renown otologist,” says James A. Stankiewicz, MD, professor and chairman. “It represents a virtual history of American
otology in the 20th Century. It is a treasure we will put to good use.”
The collection was thoughtfully curated by Dr. Ron Stefani, Dr. Buckingham’s associate at Hines.
At The Podium
John P. Leonetti, MD recently presented "Non-Neoplastic Destructive Lesions of the Temporal Bone" at the Triological Society Combined Sections Meeting
in Scottsdale, Arizona.
Poster Presentations
Loochtan MJ, Leonetti JP, Katsantonis N, Marzo SJ, Anderson D, Prabhu V. Clinical and Operative Differences Between Lateral Skull Base Meningiomas.
Poster presentation at the 23rd Annual North American Skull Base Society Meeting. February 2013.
In Print
James A. Stankiewicz, MD, professor and chairman, was recently quoted in Women’s World magazine. The article on home remedies for post-nasal drip
appears in the January 14 issue. Woman's World is one of the largest women's magazines, with a circulation of 1.3 million.
Meet the Docs
Dr. Brubaker is the division director for general otolaryngology for Loyola’s Department of Otolaryngology-Head and Neck
Surgery.
He earned his medical degree from Rush Medical College of Rush University in Chicago. After completing an internship in
general surgery at Jewish Hospital in St. Louis, Missouri, he went on to complete a residency in otolaryngology at
Washington University Medical Center, also in St. Louis.
Dr. Brubaker is a diplomat of the American Board of Otolaryngology a member of the Alpha Omega Alpha Medical Honor
Society, the American Medical Association and a fellow of the American College of Surgeons.
Both adult and pediatric patients may see Dr. Brubaker at the Loyola Center for Health in Burr Ridge, Loyola Center for
Health at Wheaton, as well as the Loyola Outpatient Center in Maywood.
In addition to general otolaryngology, Dr. Brubaker has a special interest in sinus surgery, thyroid surgery, salivary gland
disorders and sleep apnea.
To make a referral to Dr. Brubaker, please call the Nurse Triage line at (708) 216-3664. Patients may call Central
Appointment Scheduling at (708) 216-8563.
Rockne Brubaker, MD
Assistant Professor
Feedback
We're always happy to receive your comments and suggestions Feedback
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