The SARS‐CoV‐2 virus, which causes coronavirus disease 2019 (COVID‐19), has rapidly swept across the world since its identification in December 2019. Otolaryngologists are at unique risk due to the ...close contact with mucus membranes of the upper respiratory tract and have been among the most affected healthcare workers in Wuhan, China. We present information on COVID‐19 management relevant to otolaryngologists on the frontlines of this pandemic and provide preliminary guidance based on practices implemented in China and other countries and practical strategies deployed at Stanford University. Laryngoscope, 130:2537–2543, 2020
Transoral endoscopic head and neck surgery is a new approach for the treatment of oropharyngeal tumors. Using either a robotic system and/or laser, surgeons gain access through the mouth via ...minimally invasive technique and thus have improved visualization of the tumors of the oropharynx, without disfiguring incisions. This transoral route of access minimizes long-term speech and swallowing dysfunction. Surgeons view this approach as a considerable technologic advance, analogous to the evolution in radiation therapy from conventional two- and three-dimensional conformal techniques to intensity-modulated techniques. Although the use of radiation with or without chemotherapy to treat oropharyngeal cancer (OPC) is supported by evidence from prospective clinical trials, there are no prospective data supporting the use of this new surgical approach for OPC. Here, we review the fundamentals of transoral endoscopic head and neck surgery, with robotics and laser technology, and discuss ongoing clinical trials for patients with OPC.
Objectives/Hypothesis
To describe the application of a novel flexible robotic surgical system to transoral endoscopic head and neck surgery of the tonsillar fossa and lateral oropharyngeal wall.
...Study Design
Preclinical anatomic study using three human cadavers.
Methods
Transoral resection of the lateral oropharyngeal wall with mucosal and muscular resection of the tonsillar fossa.
Results
This single‐port flexible robotic system could be used to successfully perform transoral resection of this region. The optimal angle to dock the patient‐side cart was at a 90‐degree angle to the operating room table. The placement of the remote center of the robotic instrument arm was evaluated in three positions. When the cannula tip was placed at 10 to 15 cm, all instruments could be deployed past the first and second joggle joint settings, without collision or restriction of arm movement. Using this position and docking location, all four arms were deployed inside the oral cavity without collision or restriction of movement in all three cadavers. The Da Vinci SP (Intuitive Surgical, Inc., Sunnyvale, CA) provided sufficient access, reach, and visualization in order to complete a transoral lateral oropharyngectomy.
Conclusion
The first preclinical feasibility study of a novel, flexible, single‐arm robotic surgical system is presented for its use in transoral endoscopic head and neck surgery.
Level of Evidence
N/A. Laryngoscope, 126:864–869, 2016
Objectives To document the 10‐year results of transoral mandibular preservation surgery for patients with T1‐2 squamous cell carcinoma (SCC) arising from the lateral oropharynx. Methods This was a ...retrospective 30‐year review using STROBE guidelines at an academic, tertiary referral center. A total of 294 patients with T1‐2 SCC of the lateral oropharynx were reviewed. Only 19% of patients were never‐smokers, suggesting a predominantly HPV‐negative population. All patients had transoral mandibular preservation surgery. Follow‐up therapy included neck dissection (76.5%), induction chemotherapy (57.8%), and postoperative radiation therapy (31.6%) Local control, survival, and functional endpoints, as well as the consequences of local recurrence, were analyzed. Results The 10‐year local disease control was 88.3%. Local recurrence was salvaged in 50% of cases, resulting in an overall 94.5% local control rate. The overall 10‐year survival was 50%. Mortality was related to metachronous second primary cancer (MSPC) (29.2%), medical comorbidities (25.7%), uncontrolled local recurrence (10%), and complications following transoral resection (4.2%). In multivariate analysis, the development of an MSPC significantly increased ( p < 0.005) the risk of death. Overall, 95.2% of patients achieved mandibular preservation. However, gastrostomy and tracheostomy dependence occurred in 1% and 0.3% of cases, respectively. Conclusions For a patient population with a significant percentage of tobacco‐associated oropharyngeal cancer (OPC), transoral surgery was associated with long‐term minimal postoperative complications and a high rate of local control. MSPC was the main cause of death during the first 10 postoperative years. Such long‐term figures support transoral surgery as an effective first‐line treatment for early‐stage predominantly tobacco‐related OPC. Level of Evidence 4 Laryngoscope , 2024
Background
Round trip signal latency, or time delay, is an unavoidable constraint that currently stands as a major barrier to safe and efficient remote telesurgery. While there have been significant ...technological advancements aimed at reducing the time delay, studies evaluating methods of mitigating the negative effects of time delay are needed. Herein, we explored instrument motion scaling as a method to improve performance in time-delayed robotic surgery.
Methods
This was a robotic surgery user study using the da Vinci Research Kit system. A ring transfer task was performed under normal circumstances (no added time delay), and with 250 ms, 500 ms, and 750 ms delay. Robotic instrument motion scaling was modulated across a range of values (− 0.15, − 0.1, 0, + 0.1, + 0.15), with negative values indicating less instrument displacement for a given amount of operator movement. The primary outcomes were task completion time and total errors. Three-dimensional instrument movement was compared against different motion scales using dynamic time warping to demonstrate the effects of scaling.
Results
Performance declined with increasing time delay. Statistically significant increases in task time and number of errors were seen at 500 ms and 750 ms delay (
p
< 0.05). Total errors were positively correlated with task time on linear regression (
R
= 0.79,
p
< 0.001). Under 750 ms delay, negative instrument motion scaling improved error rates. Negative motion scaling trended toward improving task times toward those seen in non-delayed scenarios. Improvements in instrument path motion were seen with the implementation of negative motion scaling.
Conclusions
Under time-delayed conditions, negative robotic instrument motion scaling yielded fewer surgical errors with slight improvement in task time. Motion scaling is a promising method of improving the safety and efficiency of time-delayed robotic surgery and warrants further investigation.
Objectives/Hypothesis
Based on current guidelines, surgical and nonsurgical therapies are viable frontline treatment for patients with locoregional oropharyngeal carcinoma (OPC). We sought to compare ...financial parameters between chemoradiation and transoral robotic surgery (TORS) in this patient population.
Study Design
Case‐control study.
Methods
In this study we identified patients with selected American Joint Committee on Cancer 7th Edition stage II to IVa OPC treated with TORS between January 2013 and December 2014. Fifteen patients who underwent TORS were stage matched with 15 patients treated with chemoradiation. Total charges and cost data for each patient were analyzed at 4‐month and 1‐year time points; functional and oncologic outcomes were assessed.
Results
There were no significant differences in functional and oncologic outcomes. Patients undergoing TORS had a longer inpatient hospital stay, and most required a nasogastric tube for an average of 3.5 days. There were no local or regional recurrences. Across all time points, the TORS group had lower charges and costs compared to the chemoradiation group, with 14% lower costs at 1 year. In the chemoradiation group, nearly two‐thirds of costs came from radiation therapy and pharmacy expenses. Chemotherapy accounted for most pharmacy costs. The costs of operating the surgical robot accounted for a about half of surgical costs.
Conclusions
Selected patients with stage II to IVa oropharyngeal carcinoma treated with TORS may incur lower costs than those treated nonsurgically. With rising healthcare spending, the financial impact of treatment might be considered for those patients eligible for treatment regimens with comparable functional and oncologic outcomes.
Level of Evidence
3b
Laryngoscope, 129:1604–1609, 2019
Objective
To determine if multispectral narrow‐band imaging (mNBI) can be used for automated, quantitative detection of oropharyngeal carcinoma (OPC).
Study Design
Prospective cohort study.
Methods
...Multispectral narrow‐band imaging and white light endoscopy (WLE) were used to examine the lymphoepithelial tissues of the oropharynx in a preliminary cohort of 30 patients (20 with biopsy‐proven OPC, 10 healthy). Low‐level image features from five patients were then extracted to train naïve Bayesian classifiers for healthy and malignant tissue.
Results
Tumors were classified by color features with 65.9% accuracy, 66.8% sensitivity, and 64.9% specificity under mNBI. In contrast, tumors were classified with 52.3% accuracy (P = 0.0108), 44.8% sensitivity (P = 0.0793), and 59.9% specificity (P = 0.312) under WLE. Receiver operating characteristic analysis yielded areas under the curve (AUC) of 72.3% and 54.6% for classification under mNBI and WLE, respectively (P = 0.00168). For classification by both color and texture features, AUC under mNBI increased (80.1%, P = 0.00230) but did not improve under WLE (below 55% for both models, P = 0.180). Cross‐validation with five folds yielded an AUC above 80% for both mNBI models and below 55% for both WLE models (P = 0.0000410 and 0.000116).
Conclusion
Compared to WLE, mNBI significantly enhanced the performance of a naïve Bayesian classifier trained on low‐level image features of oropharyngeal mucosa. These findings suggest that automated clinical detection of OPC might be used to enhance surgical vision, improve early diagnosis, and allow for high‐throughput screening.
Level of Evidence
NA. Laryngoscope, 2514–2520, 2018
Summarize functional outcomes after transoral robotic surgery (TORS) ± adjuvant therapy for oropharyngeal cancer (OPC). A systematic review was conducted. The MEDLINE database was searched (MeSH ...terms: TORS, pharyngeal neoplasms, oropharyngeal neoplasms). Peer-reviewed human subject papers published through December 2013 were included. Exclusion criteria were as follows: (1) case report design (
n
< 10), (2) review article, or (3) technical, animal, or cadaver studies. Functional outcomes extracted included feeding tube dependence, swallow examination findings, speech ratings, velopharyngeal insufficiency, pneumonia, and oral intake measures. Twelve papers comprising 441 patients with OPC treated with TORS ± adjuvant therapy were included. Feeding tube rates were the most commonly reported functional outcome. Excluding prophylactic placement, 18–39 % of patients required gastrostomy placement, typically during adjuvant therapy. Chronic gastrostomy dependence ranged from 0 to 7 % (mean follow-up 11–26 months), regardless of disease stage. Composite MD Anderson Dysphagia Inventory (MDADI) scores ranged from 65.2 to 78 (89 patients, 3 series, mean follow-up 12–13 months). Videofluoroscopic swallowing studies were not systematically reported. Incidence of postoperative pneumonia was 0–7 %. Predictors of swallowing function included baseline function, T-stage, N-stage, tongue base primary tumors, and adjuvant chemoradiation. Rates of transient hypernasality were 4–9 %. A single study suggested dose-dependent effects of adjuvant therapy (none, radiation alone, chemoradiation) on diet scores at 6 and 12 months. Crude end points of functional recovery after TORS ± adjuvant therapy suggest promising swallowing outcomes, depending on the functional measure reported.
Objectives/Hypothesis:
Our objective was to determine the safety, feasibility, and the adequacy of surgical margins for transoral robotic surgery (TORS), by reviewing the early results from ...independent institutional review board‐approved clinical trials in three separate institutions.
Study Design:
Pooled Data from Independent Prospective Clinical Trials.
Methods:
One hundred ninety‐two patients were initially screened, but inadequate exposure did not permit TORS in 13 (6.7%). For two additional patients, TORS was begun but intraoperatively converted to an open procedure. Thus, the intent‐to‐treat population was 177 patients (average age, 59 years; 81% male), predominantly comprised of tumors arising in the oropharynx (139, 78%) and larynx (26, 15%). TORS was performed for 161 (91%) patients with malignant disease: 153 (95%) with squamous cell carcinoma (T1 50, 32.7%, T2 74, 48.4%, T3 21, 13.7%, T4 8, 5.2%), six patients (3.72%) with salivary gland tumors, and two patients with carcinoma in situ. The average follow‐up was 345 days.
Results:
There was no intraoperative mortality or death in the immediate postoperative period. Average estimated blood loss was 83 mL; no patient required transfusion. The rate of positive margins was 4.3%. Twenty‐nine patients (16%) experienced 34 serious adverse events that required hospitalization or intervention (grade 3) or were considered life threatening (grade 4, 2.3%). Tracheostomy was performed in 12.4% of all patients (22/177), but only 2.3% had a tracheostomy at last follow‐up. For all patients undergoing TORS without previous therapy, the percutaneous endoscopic gastrostomy dependency rate was 5.0%. The average hospital stay was 4.2 days.
Conclusions:
Based on this multicenter study, TORS appears to be safe, feasible, and as such play an important role in the multidisciplinary management of head and neck cancer.
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