New Consensus Statement on Balloon Dilation of the Eustachian Tube

The American Academy of Otolaryngology–Head and Neck Surgery recently published a set of clinical statements on the indications for and appropriate use of balloon dilation of the Eustachian tube (BDET) for adult patients (aged 18 years and older) with obstructive Eustachian tube dysfunction (OETD). Published June 4, 2019 in Otolaryngology-Head and Neck Surgery, “Clinical Consensus Statements: Balloon Dilation of the Eustachian Tube” was compiled by a panel of experts in response to the increasing rates of use of this technology for treatment of OETD by otolaryngologists and the need for some guidance given evidence gaps regarding its use.

“Balloon dilation of the Eustachian tube holds promise for the management of OETD, but because it is new territory for most clinicians an official statement was deemed necessary to reduce variations in care and prevent misapplication of this technology,” said Edward D. McCoul, MD, MPH, associate professor and director of rhinology and sinus surgery in the department of otorhinolaryngology at the Ochsner Clinic in New Orleans and a coauthor of the statement. “This statement calls attention to the current state of the literature as interpreted by experts in the field.”

The consensus statement offers 28 specific points of guidance categorized into the areas of patient criteria, perioperative considerations, and outcomes. Dr. McCoul highlighted a number of key areas he thought may be new to otolaryngologists and therefore particularly useful.

Patient criteria: Accurate diagnosis of OETD prior to considering BDET is critical given the variable and nonspecific symptoms that patients may present with. Along with a careful history, the panel emphasized the need to identify any underlying extrinsic causes of OETC such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux for which targeted treatment could also improve OETC. If any of these comorbid conditions are found, the panel recommends treating them prior to offering BDET.

The panel also emphasized the need for nasal endoscopy prior to consideration of BDET. “Nasal endoscopy and tympanometry are important to include when evaluating a patient for the presence of OETD,” said Dr. McCoul, underscoring the need to rule out other causes of ear fullness, including patulous Eustachian tube dysfunction.

Perioperative considerations: The panel underscored that tympanostomy tube placement is not a mandatory prerequisite for performing BDET. In addition, the panel stated that BDET should be considered an alternative to tympanostomy tube placement for treating OETD.

Outcomes: To determine outcomes, the panel noted the most reliable outcome measure is a standardized questionnaire (the Eustachian Tube Dysfunction Questionnaire-7) to record patient-reported symptoms using.
The statement also discusses and highlights clinical areas for which no consensus could be reached. Dr. McCoul highlighted a few: the extent of optimal medical therapy prior to offering BDT remains unclear, and additional objective outcome measures are still needed.

Overall, the consensus statement offers clinicians a guide to what experts currently agree on regarding the role and implementation of BDET for OETD. The authors hope that application of the statements will reduce variation in how BDET is currently used for OETD and increase the quality of care.

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Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Human papillomavirus-positive (HPV+) head and neck squamous cell carcinomas (SCC) are increasing in incidence worldwide. The palatine tonsils are the most commonly involved anatomical subsite, followed by the base of tongue and then the soft palate. Secondary primary malignancy (SPM) is a well-established phenomenon among patients with head and neck SCC and can present in up to 36% of patients within 20 years of their original diagnosis. Furthermore, synchronous tumors are defined as those that occur simultaneously with the index cancer; these tumors are present in approximately 4% of cases.

SPM is thought to arise secondary to field cancerization, a biological process by which prolonged exposure to carcinogens leads to independent malignant transformation at multiple sites. The prevalence of synchronous bilateral HPV+ SCC of the tonsil (SBTC) is largely unknown, and there is much controversy regarding routinely removing the contralateral tonsil. Fear of increased pain, bleeding, circumferential scarring, and functional impairment have all been cited as reasons to avoid contralateral tonsillectomy in these scenarios. Proponents of contralateral tonsillectomy, however, raise concerns over the potentially fatal consequences of missing occult contralateral disease. Another advantage is the resulting symmetric appearance of the palatal arches, which allows for improved oncologic surveillance and easier detection of tumor recurrence.

Given the important prognostic and therapeutic implications of identifying a SBTC, should the contralateral tonsil routinely be removed in cases of HPV+ squamous cell carcinoma of the tonsil (TSCC)?

Best Practice

The contralateral tonsil should routinely be removed in cases of suspected or known unilateral HPV+ TSCC. Furthermore, preoperative clinical exam findings and imaging studies including PET-CT should not be used to exclude the possibility of SBTC. Although there are reports of significant complications resulting from bilateral radical surgery, performing a routine contralateral tonsillectomy does not appear to increase rates of morbidity or complications, and the resulting symmetric palatal arch could potentially improve oncologic surveillance and detection of recurrence.

Furthermore, identifying a contralateral TSCC can dramatically alter treatment and prognosis. The patient may need further surgery and/or radiation therapy to the contralateral oropharynx and neck, which otherwise would not be indicated in unilateral disease. Although the true incidence of SBTC remains unknown, the oncologic outcome of missing the second primary and delaying treatment can be devastating and even fatal. Future prospective studies should be performed to identify any clinical disparities or differences in tumor characteristics that could improve preoperative identification of SBTC patients (Laryngoscope. 2019;129:1257–1258).

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Is Core Needle Biopsy Effective for Assessment of Head and Neck Lesions?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Ultrasonography in combination with fine needle aspiration (FNA) has served as the primary line of investigation for head and neck lesions. In the 10% to 15% of cases for which FNAs yield nondiagnostic material, the next option is often excisional biopsy under general anesthesia. In patients who are poor surgical candidates, core needle biopsy (CNB) with a larger gauge needle under ultrasound guidance has emerged as a simple, minimally invasive, and accurate method for the diagnosis of head and neck lesions, especially when conservative treatment is likely. CNB has been shown to yield a higher sensitivity and specificity compared to FNA in head and neck lesions, including malignant lymphoma. Surveys show physicians are reluctant to incorporate this diagnostic method into practice due to concerns regarding bleeding, infection, nerve injury, and tumor cell seeding. This article reviews the evidence for the safety of CNB in the diagnosis of head and neck lesions, with an emphasis on the risk of tumor cell seeding and bleeding.

Best Practice

Based on current studies, ultrasound guided CNB is a minimally invasive and accurate diagnostic option for the assessment of head and neck lesions, including lymphoma. In comparison to FNA, CNB has achieved a higher accuracy in providing specific diagnoses, detecting malignancy, and identifying true neoplasms. CNB should be the procedure of choice in patients with multiple nondiagnostic FNAs prior to excisional biopsy. These studies have shown that CNB has enhanced accuracy and equivalent safety compared to FNA and lower rates of complications as compared to excisional biopsy (Laryngoscope. 2018;129:2669–2670)

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Mild Obstructive Sleep Apnea in Children: What Is the Best Management Option?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope. May 2019

Background

Pediatric obstructive sleep apnea (OSA) is characterized by upper airway obstruction, poor sleep, and daytime sequelae such as hyperactivity. Although controversy exists regarding the ideal evaluation for children with sleep-disordered breathing, the severity of OSA is currently determined by full-night polysomnogram (PSG). Mild OSA is defined by an apnea-hypopnea index (AHI) > 1 and <5. The majority (approximately 85%) of healthy school-aged children evaluated by otolaryngologists for tonsil hypertrophy and obstructive symptoms have either primary snoring or nonsevere OSA.

The treatment of mild OSA in children is controversial. There is a lack of data on the natural history of mild sleep apnea. Furthermore, a poor correlation exists between quality of life (QOL) scores and OSA severity; mild OSA in children may have a significant impact on their general health and well-being. High-quality studies comparing observation, medical management, and surgery for mild pediatric OSA are just beginning to emerge. Many of these studies use varied measures to assess outcomes. Thus, it may be difficult for providers treating children with mild OSA to counsel parents on the optimal treatment for their child.

Best Practice

Multiple therapeutic options may be effective for treating mild pediatric OSA including observation, management with anti-inflammatory medications, and surgery (Table 1). Validated instruments that assess symptom burden and the impact of OSA on QOL may be useful in determining which treatment option is most appropriate for the child. Shared decision making between caregiver, child (when appropriate), and physician may be useful in developing a management strategy for mild OSA. Data on the sequelae of mild OSA in children, including the impact of obstruction on cardiovascular parameters and neurocognition, are lacking. Future research is needed to compare long-term outcomes for the different treatment options for mild OSA in children (Laryngoscope. 2018;128:2671–2672).

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Do Preoperative Corticosteroids Benefit Patients with Chronic Rhinosinusitis with Nasal Polyposis?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Optimizing the surgical field in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) increases the chances for a safe and efficient surgery. Preoperative medical management, anesthetic choice, patient positioning, and topical vasoconstrictors are methods currently used to mitigate cumbersome bleeding during surgery. Decreased bleeding improves the quality of the optical cavity, thereby enhancing visualization of nearby critical structures.
Pretreatment with corticosteroids is a common practice with the theory that decreased preoperative mucosal inflammation and edema results in less blood loss and better surgical visualization. Several randomized trials have addressed the efficacy of CRSwNP pretreatment with corticosteroids with respect to bleeding loss and surgical field quality.

Best Practice

Preoperative treatment of patients with CRSwNP undergoing endoscopic sinus surgery with corticosteroids is indicated and beneficial. Pretreatment with corticosteroids shortens operative time, likely decreases bleeding, and improves the quality of the surgical field allowing for safe and efficient surgery. There are known risks of administration of systemic corticosteroids, and clinicians must take these into account when evaluating an individual patient. Additionally, future studies are needed to determine the optimal dose and duration of treatment (Laryngoscope. 2019;129:773–774).

Table 1. Summary of Management of Pediatric Obstructive Sleep Apnea

(click for larger image) Table 1. Summary of Management of Pediatric
Obstructive Sleep Apnea

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Professional Voice Care May Reduce Vocal Disorders in Children

The vocal training and regular examinations by otolaryngologists that children who sing in choirs receive may pay off beyond voice training to benefit their overall vocal health, according to data from a recently published study that showed voice disorders were less common in a cohort of children singing in a choir compared to children who did not (JAMA Otolaryngol Head Neck Surg [published online ahead of print March 14, 2019]. doi: 10.1001/jamaoto.2019.0066).

“These findings suggest that there is a negative association between singing in a children’s choir and the presence of voice disorders,” said lead author of the study, Pedro Clarós, MD, PhD, who is with the Clarós Otorhinolaryngology Clinic in Barcelona, Spain.

The prospective cohort study was conducted to more fully examine whether an association exists between the development of vocal disorders and children who sing in a choir. According to the study authors, examination of this association in prepubescent children is lacking. To fill that gap, investigators enrolled 1,495 children (aged 8 to 14 years) from four local schools in Barcelona, Spain between October 2016 and April 2018. Of the children enrolled, 752 sang in a children’s choir and 743 children did not. Children in the choirs sang for a mean time of 7.5 hours per week for 2.5 years.

All children underwent videolaryngoscopy followed by videostroboscopy to assess the effect of singing or not singing in a choir on voice disorders (primary outcome). The study also looked at voice symptom complaints using surveys and the GRBAS (grade, roughness, breathiness, asthenia, strain) scale measurements (secondary outcomes).

The study found 12 voice disorders that were more common among the children who did not sing compared to those who did (32.4% vs 15.6%), with both functional voice disorders and organic voice disorders occurring more frequently in the non-singing children than the singing children (20.2% vs. 9.4% and 12.2% and 6.1%, respectively). Voice complaints or dysphonia were also higher in the children who did not sing in choirs compared to those who did (28.9% vs 21.0%) as reported by both the children and their parents, teachers, and choir directors. Muscle tension dysphonia (MTD) accounted for the largest difference between the two groups overall (17.2% vs. 8.4%) followed by psychogenic dysphonia (3.0% vs. 1.1%) and vocal fold nodules (7.9% vs. 4.0%).

These findings suggest that professional voice care that includes speech therapists and frequent otorhinolaryngologic examinations may be an important intervention to prevent or reduce voice disorders in children who sing in choirs, according to Dr. Clarós.

He also underscored that similar interventions to promote good voice care are important for all children, including non-singing children, particularly given the influence of good voice care over the long term on both the personal and professional lives of people. “The importance of voice care is particularly salient in children because they do not control their behavior or voice as well as adults and therefore are more vulnerable to possible voice trauma,” he said. “We believe it is crucial to introduce the same solicitude for voice in non-singing children.”

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UAS Successful Treatment for OSA When Compared with TORS

How do transoral robotic surgery (TORS) and upper airway stimulation (UAS) compare for treating tongue base obstruction contributing to obstructive sleep apnea (OSA)?

Bottom line: UAS is successful in treating OSA, showing improved outcomes, length of stay, and readmission compared to TORS.

Background: TORS tongue base reduction utilizes robotic instrumentation to perform a lingual tonsillectomy combined with midline glossectomy and supraglottoplasty. With UAS, the hypoglossal nerve is selectively stimulated to induce muscle tone in the upper airway, relieving obstruction and reducing apnea and hypopnea burden; there is also evidence that it improves obstruction at the velum through coupling of the palatoglossus muscle.

Study design: Retrospective review of 100 patients (24 TORS, 76 UAS) from the senior authors’ surgical database who were treated between January 2011 and July 2017.

Setting: Thomas Jefferson University, Philadelphia.

Synopsis: Thirty-seven TORS and 94 UAS were performed. In the TORS cohort, 16 underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 35.70 and 80.50, respectively. In the UAS cohort, 14 patients underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 36.64 and 80.27, respectively. The mean postoperative AHI and O2 desaturation nadir in the TORS cohort were 20.05 and 84.10, respectively. The surgical success rate, patients who reached an AHI less than 15, and patients who reached and AHI less than 5 were 54.17%, 50.00%, and 20.83%, respectively. The mean postoperative AHI and O2 desaturation nadir of the UAS cohort were 7.20 and 88.77, respectively. Surgical success rate, patients who reached an AHI less than 15, and patients who reached an AHI less than 5 were 86.84, 89.47, and 59.21, respectively. TORS cohort patients had a mean length of hospital stay of 1.33 days; four patients had a 30-day unplanned readmission for dehydration and pain control. All UAS cohort patients underwent ambulatory surgery, and no patients were readmitted to the hospital. There were no major complications in either group. Limitations included a less-direct comparison between UAS and TORS due to the multilevel nature of UAS.

Citation: Huntley C, Topf MC, Christopher V, et al. Comparing upper airway stimulation to transoral robotic base of tongue resection for treatment of obstructive sleep apnea. Laryngoscope. 2019;129:1010–1013.

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Tranexamic Acid Could Decrease Operative Time, Intraoperative Blood Loss in ESS

How effective is systemic tranexamic acid compared to a control in blood loss, operative time, and surgical field and incidence of postoperative emesis and thromboembolism in endoscopic sinus surgery (ESS)?

Bottom line: The systemic administration of tranexamic acid could decrease operative time and intraoperative blood loss, increasing the satisfaction of surgeons. It did not provoke intraoperative hemodynamic instability, postoperative emetic events, or coagulation profile abnormality.

Background: Because the nose and paranasal sinuses are highly vascularized, surgery there may cause significant bleeding, making identification of important anatomic landmarks and structures difficult, increasing intraoperative complication risks and prolonging operating time. Tranexamic acid can decrease intraoperative bleeding. Although it is usually well tolerated, nausea and vomiting are known common side effects, and hypotension has been observed during rapid intravenous administration.

Study design: Literature review of seven studies comprising 562 participants, comparing perioperative tranexamic acid administration (treatment group) with a placebo (control group).

Setting: PubMed, SCOPUS, Embase, the Web of Science, Google Scholar, and the Cochrane database; search results are from their inception to July 2018.

Synopsis: Outcomes of interest were intraoperative morbidities, including surgical time, operative bleeding, and hypotension; postoperative morbidities such as nausea and vomiting; and coagulation profiles. Operative time, intraoperative blood loss, and the surgical field score were statistically lower in the treatment group than in the control group. Surgeon satisfaction was statistically higher in the treatment group than in the control group. There was no significant difference between the groups in intraoperative blood pressure. The incidence of postoperative nausea and vomiting and thrombotic accident showed no significant differences between the groups. Platelet count, prothrombin time, and partial thromboplastin time showed no significant differences between the groups. In sensitivity analyses that evaluated the differences in the pooled estimates by repeating the meta-analyses with a different study omitted each time, all results were consistent with the outcomes previously found. Limitations included a lack of consideration of external factors such as polyps versus no polyps, revision versus primary, and usage of other hemostatic agents because the analysis was performed based on the statistical measurements of the figures.

Citation: Kim DH, Kim S, Kang H, Jin HJ, Hwang SH. Efficacy of tranexamic acid on operative bleeding in endoscopic sinus surgery: a meta-analysis and systematic review. Laryngoscope. 2019;129:800–807.

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Is Hearing Preserved Following Radiotherapy for Vestibular Schwannoma?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

A common question by patients with newly diagnosed vestibular schwannomas (VS) is, “Which treatment will best preserve my hearing?” Currently, management of this benign tumor arising from the eighth cranial nerve sheath includes three broad options: observation with serial imaging, microsurgery, and radiotherapy. There are no high-quality, prospective controlled trials comparing outcomes among these three treatment modalities. Therefore, treatment recommendations are largely based on data from single-institution case series. As outcomes of tumor control and facial nerve preservation have improved with modern surgical and radiotherapy techniques, the possibility of hearing preservation (HP) often plays a significant role for patients and physicians making treatment decisions.

The heterogeneity of data poses a major challenge to providing accurate estimates of hearing preservation rates with radiotherapy for VS. Indications for treatment and inclusion criteria vary widely by institution. Radiation may be delivered in a single dose or as many as 30. The radiation source may be cobalt (e.g., GammaKnife surgery [GKS]) or a linear accelerator (e.g., CyberKnife). The methods for reproducing localization differ between techniques as well. Moreover, hearing outcomes are not standardized. For example, some publications simply report the patient’s subjective ability to use the telephone at the first post-treatment visit, whereas other studies utilize audiograms to provide an objective measure of hearing in the treated ear. Traditionally, serviceable hearing has been defined as pure-tone audiometry (PTA) < 50 db with speech discrimination scores (SDS) > 50%, corresponding to American Academy of Otolaryngology–Head and Neck Surgery class A or B, or Garner-Robertson (GR) grade 1 or 2. These differences result in widely varied rates of hearing preservation (between 10% and 90%) after radiotherapy for VS.

Best Practice

The level of evidence of reviewed articles is low. Given that the field involves rapidly developing technology, this is not surprising. Moreover, synthesis of data from case series is vitally important, as controlled studies comparing radiotherapy against microsurgery or conservative management would logistically be very challenging. Evidence from modern, highly conformal, low-dose radiation techniques demonstrate that long-term hearing preservation rates are poor; an approximately 80% hearing preservation rate at two years posttreatment falls to approximately 23% at 10 years. Although radiation therapy provides patients with satisfactory short-term hearing preservation, this treatment modality does not reliably preserve hearing in the long term. It is important when assessing publications in this field to thoroughly scrutinize the methodology, systems of hearing classification, and time to follow-up to provide patients with the most accurate estimations of hearing preservation (Laryngoscope. 2019;129:775–776).

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Virtual Surgical Planning and Custom Implants Can Help Treat Complex Facial Trauma

Advanced technology such as virtual surgical planning (VSP) and 3D-printed implants are helping otolaryngologists treat patients with complex facial trauma with more accuracy for improved outcomes.

Oral and maxillofacial surgeons use computer-generated modeling to plan for complex reconstructive procedures and order custom implants from manufacturers for patients who have facial bone loss due to trauma, cancer, or congenital deformities, said Shaun C. Desai, MD, associate residency program director and assistant professor of otolaryngology–head and neck surgery at Johns Hopkins School of Medicine in Baltimore. “We use the 3D technology for more complex cases, such as patients with complex loss of the maxilla or mandible or the skull. For a more complex defect, you can create a shape using the technology, and use it as a guide to make the bone cuts,” said Dr. Desai. “You can be more precise as you take a straight, long bone like the fibula and cut it into the shape of a jawbone. Even now, we often eyeball this technique, and there is asymmetry as a result. It takes a lot of time and surgical expertise. This technology gives you a more precise cut. You basically create a plan for where you will make the cuts into bone before you begin the surgery.”

Scan-Guided Surgery and Custom Implants

First, computed tomography (CT) scans are taken of the damaged facial areas. The surgeon analyzes these images using software designed for virtual surgical planning, said Dr. Desai. The data may also be sent to an engineer at a manufacturer to 3D print customized implants.

“If a patient has a facial fracture, such as a cheekbone that has collapsed, if you don’t fix it quickly, it can heal like that,” said Dr. Desai. The patient may require multiple revision surgeries as a result. To avoid this outcome, “we can use CT scanning to mirror the bad, damaged side of their face to the good side, and repair those maxillofacial injuries.”

VSP is useful for collaboration with an oral surgeon to perform reconstructive surgery on the maxilla, where both specialists use 3D software technology to guide the dental procedure and 3D printing of customized dental implants, said Dr. Desai.

With his patient’s CT scan data on his computer screen, J. David Kriet, MD, director of facial plastic and reconstructive surgery at the University of Kansas Medical Center in Kansas City, can examine a malpositioned cheekbone and orbit (such as a zygomaticomaxillary complex fracture) and then measure the patient’s “good side.”

“We can take the right half of the CT in virtual space and flip it over to map out a mirror image. That becomes our plan,” he said. “We can create an orbital implant using the mirrored image. We could either take an implant off the shelf or work with an engineer at a manufacturer to design a custom, patient-specific implant. By doing this, there are a number of advantages. We can do planning and create the implant before we get to the operating room. The time saved often offsets the more expensive implant. The less time we have a patient under anesthesia, the better,” he said.

Dr. Kriet has been using these technologies to plan for many oral and maxillofacial reconstructive surgeries for seven years. While 3D printing and VSP using CT scans are not yet the standard of care, these tools improve accuracy in more complex surgical cases, and they lower the risk of long-term discomfort or deformity for patients, he said.

Improved Outcomes

Image Courtesy of J. David Kriet, mD

Working model of frontal reconstruction.
Image Courtesy of J. David Kriet, mD

Do these technological advances really improve patient outcomes? In a 2016 retrospective review of 92 patients who underwent osteocutaneous free flap reconstruction of the mandible at a single cancer center from 2002 to 2013, researchers compared outcomes for 43 patients whose surgery was based on prefabricated models to those for 49 patients who had preoperative CT-guided surgical plans (Plast Reconstr Surg. 2016;137:619–623). The authors concluded that VSP refined mandible reconstruction with osteocutaneous free flaps through patient-specific cutting guides, improved reconstruction accuracy, and decreased operating time.

Christopher F. Viozzi, MD, DDS, an oral and maxillofacial surgeon at the Mayo Clinic in Rochester, Minn., uses these technologies to plan for many different procedures, including surgical reconstruction for patients who have had cancer, benign tumors that destroyed bone and soft tissue, or congenital deformities.

“In my own practice, I use [VSP] to plan for craniofacial surgery, including skeletal and soft tissue deformities. We try to normalize the bone and tissue as much as we can,” said Dr. Viozzi. “We use 3D models for virtual surgical planning all the time and for all sorts of operations, not just post-traumatic surgery. This technology is actually used more often for facial reconstruction than for post-traumatic corrections. To clarify, there are specific patients who come into the clinic with severe facial traumas and acute injuries. We will use computer-generated data to plan for their surgery.”

CT scans are used to help surgeons understand how their patient’s anatomy may vary from that of a normal patient, said Dr. Viozzi. He and his surgical team take precise measurements of the patient’s face or jaw and examine the patient’s unique facial symmetry. “We use this technology to see how an injured side of the face looks compared to the other, uninjured, side to help us plan for the surgery. The data can be used to create a model through 3D printing. There is a use for this in planning for acute, early treatment of a trauma patient as well, and we use the CT data for surgical navigation. We can use this data to pinpoint where certain things are located on or within the bony structures of a patient’s face,” said Dr. Viozzi.

Efficiency and Accuracy

VSP could reduce overall treatment time for patients with facial trauma or deformities because it improves the accuracy and quality of reconstructive surgery, not because it makes the surgery faster, said Dr. Viozzi. “Surgery has nothing to do with speed. We want to be efficient, careful, thoughtful, and accurate. We want to go into surgery with an accurate, well-thought-out plan. We want to do the procedure once, and get the patient to the end of the surgery as close to the surgical plan as we can,” said Dr. Viozzi.

Post-traumatic surgery patients often undergo multiple revision surgeries if the first surgery was performed incorrectly or if other factors prevented prompt treatment, and their bones have healed in incorrect positions, he added. “So, 3D technology can help us virtually plan the surgery, and 3D modeling can help us plan for revision surgery too.”

In a 2017 study of 10 patients who required orthognathic surgery, researchers found that VSP using CT and surface scanning of the upper and lower dental arch to generate 3D models of their skulls, as well as computer-aided design of fabricated surgical splints, improved surgical accuracy and facilitated planning (J Craniomaxillofac Surg. 2017;45:1962–1970).

To treat a patient with cancer in the mandible, Dr. Viozzi may work with a multidisciplinary team to virtually plan what portions of the jaw need to be removed along with the tumor and how to reconstruct the defect with a portion of the patient’s fibula, and to work with a prosthodontist to pinpoint where dental implants will be placed. “This approach takes a patient from an 18-to-24-month, multistep process to one surgery. It will make that surgery and time in the operating room longer for us, but it makes the surgery process more efficient for the patient,” he said.

Customized implants or plates based on CT scan data can be made in about one to three weeks, said Dr. Desai. Costs seem to be going down, and he believes they reduce operating time and improve aesthetic results. “These implants look more symmetrical. Outcomes, in terms of cosmesis, are improved. This may be subjective, but I get better results from it,” said Dr. Desai. “There is definitely a role for this technology, and people are still learning to use it. They are finding more indications for it.” He predicts that these technologies will become more widely available, cheaper, and available on a quicker turnaround.

Oral and maxillofacial reconstructive surgery can positively impact a patient’s quality of life, because facial defects or asymmetry are visible to others every day, said Dr. Viozzi. “Virtual surgical planning fits in perfectly with the concept of patient-specific and personalized medicine. It’s a perfect example of that, and for providing service to the patient with the lowest overall cost, morbidity, and complication possible.” 


Susan Bernstein is a freelance medical writer based in Georgia.

VSP and Custom Implants: Any Cons?

Custom implants secured.

Custom implants secured.
Image courtesy of J. David Kriet, MD

Are there any potential pitfalls for VSP or 3D-printed implant customization that head and neck surgeons should know about? In a retrospective analysis of 54 virtually planned craniofacial surgeries performed from July 2012 to October 2016 at the University of Montreal Teaching Hospitals, researchers analyzed surgical errors. The study included 46 orthognathic surgeries and eight free bone transfers (Plast Reconstr Surg Glob Open. 2018;6:e1443).

While 85% of the orthognathic virtual surgical plans were completely adhered to by surgeons, 11% of the VSPs were partially adhered to and 4% of the VSPs were abandoned, they found. Reasons for partially or totally abandoning the plan included poor communication between surgeon and engineer, poor appreciation for condyle placement on preoperative scans, soft-tissue impedance to bony movement, rapid tumor progression, and poor preoperative assessment of anatomy.

The study’s authors concluded that while VSP is a useful tool for craniofacial surgery, improving outcomes and decreasing operative time, surgeons must be aware of potential pitfalls. They called for more surgical training and experience with these technologies.

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