ne of the most recent advances in minimallyinvasive surgery is salivary endoscopy. Using

endoscopic techniques to remove calculi or stonesthat cause recurrent infections in the salivary andparotid ducts allows surgeons to avoid making exter-nal incisions or removing the entire gland. As endo-scopic tools improve, the procedure is being appliedto the pediatric population.

According to Max M. April, MD, the new tech-niques represent a tremendous advance. “Stones arethe most common reason for performing a sialen-doscopy. Some can be taken through the mouth butwhen a stone is too large or it’s stuck more proxi-mal in the duct, in the past the only option was tomake an incision in the neck and remove thegland,” he said. “Now we can go through the ductwith a very small endoscope, and if the stone is nottoo big we can take it out.”

When patients have recurrent swelling of theparotid or the submandibular gland, a computerizedaxial tomography (CAT) scan is used to identify thesource of the problem. If the stone is causing theswelling, a CAT scan can help to locate it within theduct. With the patient under anesthesia, the surgeoninserts a small scope into the duct via the mouth.Once the stone has been found and examined withthe scope, a tiny basket is introduced into the ductand used to remove the stone. “Probably 90% ormore of these cases are due to stones,” Dr. April said,“and the other 10% result from narrowing of theduct, a stricture, or mucous plugging of the duct.Some patients have Sjögren’s syndrome and those arealso patients that would benefit from endoscopy.”

Dr. April mostly treats young patients. “An olderperson who has recurrent attacks of stone-related

problems might be willing to have the whole glandremoved, but you would not want to create a scar ona child’s neck or remove the gland if you don’t haveto,” he said. Patients benefit from reduced hospitalstays, speedy recovery times, and improved quality oflife. Dr. April collaborates with otorhinolaryngolo-gists at NewYork-Presbyterian Hospital/WeillCornell Medical Center who treat these conditions inadults. “We’re working with Dr. Ashutosh Kackerand Dr. David I. Kutler [in] performing these proce-dures. Children’s ducts are smaller, so maneuveringthe scope and the basket is more difficult. Experiencewith adults helps to improve our technique, so wecan take even better care of our younger patients.”

In addition to common cases of stones in thesee Salivary, page 3

INSIDE SPRING 2008Medical Education

2 Hospital’s first otolaryngology CME

course receives high marks.

Voice Disorders

3 New technologies arechanging how clinicians

are able to diagnose and treatvocal fold paralysis.

ndoscopic procedures conducted through thenatural openings of the mouth and throat are

increasingly being used to treat head and neckcancers. New techniques, such as endoscopic lasersurgery (ELS), allow surgeons to avoid performingtracheotomies and other invasive surgeries. Becausemany patients undergoing endoscopic procedures are70 years of age or older, and because younger patientsmay frequently have concurrent viral infections, the

shortened recovery times and reduced hospital staysare seen as extremely beneficial.

According to Salvatore M. Caruana, MD, heal-ing is faster with the endoscopic approach becausehealthy tissue is not damaged. “There is less injuryto the resident blood vessels and muscles and, moreimportantly, to the nerves in the area. We usuallydo not need to do a tracheotomy with this kind of

see Head/Neck, page 2

Head and Neck Cancer: ELS Improves OutcomesE

Salivary Gland Endoscopy Techniques RefinedO

Affiliated with Columbia University College of Physicians and Surgeons and Weill Cornell Medical College

NEWYORK-PRESBYTERIANEAR, NOSE, &THROAT

Sialendoscopy performed with forceps to extract stonein submandibular duct.

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SAVE THE DATEOtolaryngology Update in NYCOctober 16-17, 2008New York CityFor more information, visit:www.ENTColumbia.org/cme

For more information on Ear, Nose, & Throat services, visitwww.nyp.org/ent

RESOURCES FORPROFESSIONALS• Webcasts • CME Activities • Medical Presentations • Specialty Briefings • Newsletters

Visit nyp.org/pro

ore than 120 physicians from across thecountry packed New York City’s W

Hotel for the first “Otolaryngology Update inNYC” continuing medical education course,hosted by the Weill Cornell Medical CollegeDepartment of Otorhinolaryngology this pastOctober. “The course was a terrific success,”said Michael G. Stewart, MD, MPH.

The course format consisted of brief talksand panel discussions of intriguing casescovering the entire ear, nose, and throatspectrum, including allergy, voice, otology,rhinology, and pediatric otolaryngology.

“Speakers reviewed the management ofcommon problems, such as hearing loss andallergic rhinitis,” said Dr. Stewart, “as well ascutting-edge developments such as biofilms,transnasal skull base surgery, sentinel node

biopsy, sleep apnea surgery, new techniquesfor partial tonsillectomy, and transnasalesophagoscopy, plus new diagnoses like supe-rior semicircular canal dehiscence syndrome.”

A total of 31 faculty members participatedin presentations, including 16 from WeillCornell Medical College, 5 from ColumbiaUniversity College of Physicians andSurgeons, and 10 from other institutions.

Speakers also addressed economic andregulatory issues affecting ENT practition-ers. Surgical topics included recent develop-ments in plastic and reconstructive surgeryas well as head and neck surgery techniquesand challenges.

“Attendees came from far and wide, includ-ing Washington state, Florida, Oklahoma,Alabama, and Texas, and they gave the venue

and the course excellent ratings,” added Dr.Stewart. Building on this success, the 2008course will be hosted by Columbia UniversityCollege of Physicians and Surgeons’Department of Otolaryngology–Head andNeck Surgery. It will take place at the NewYork Athletic Club on Central Park South inNew York City, October 16-17, 2008.

“It takes about a year to plan a coursethis big, so Columbia and Weill Cornellwill alternate hosting and organizing,” Dr.Stewart explained. The “OtolaryngologyUpdate in NYC” course will continue as anannual event; Weill Cornell’s Departmentof Otorhinolaryngology will host thecourse again in 2009.

2 www.nyp.org/ent

NEWYORK-PRESBYTERIAN EAR, NOSE, & THROAT

Contributing faculty for this article:Michael G. Stewart, MD, MPH

surgery, which is often necessary for openhead and neck cancer resection,” he said.“The return to complete swallowing func-tion is faster than with open surgery.”

Recent improvements in technology,such as a carbon dioxide (CO2) laser thatcan fit through an endoscopic tube, arewhat make the procedures possible. Dr.Caruana noted that it is important to findan endoscope of the right size. “We havespecial sets of endoscopes which extend oropen to give us room to work,” he said. “Wepass down whatever instruments we needand actually remove the tumor—instru-ments for grasping the tumor through thescope, for cauterizing bleeding vessels, andfor placing clips across bleeding vessels. Weuse the CO2 laser to do all of the cutting.Removal of the tumor is actually done with

the CO2 laser viewed through an operatingmicroscope as we’re working.”

However, many tumors are too big topass through the endoscopic tube. In suchcases, the surgeon uses the laser to cut thetumor into smaller pieces and then removesthem individually. Questions have beenraised about this practice, but Dr. Caruanaemphasizes the safety of the procedure.

“There’s been plenty of experience with

this over the years, mostly work done inGermany that has become popular here andelsewhere. It doesn’t spread the tumor bycutting through it with the laser,” said Dr.Caruana. “That was a big concern in the past,and people are still concerned about it on atheoretical level, but if you look at the data,it’s been shown that the local control ratesare equal to or better than [those with] tra-ditional open surgery. Just as with the con-ventional procedure, it’s actually an excisionof the tumor along with a margin of normaltissue, an oncologically sound thing to do.”Research by Wolfgang Steiner, MD, at theUniversity of Göttingen in Germany, andothers has spearheaded efforts to refine endo-scopic laser surgery techniques (Eur ArchOtorhinolaryngol 2007;264[6]:577-585).

Although the size of a tumor does notgenerally cause problems, its location

might. Patient anatomy can be an issue.“Tumors are very often at the bottom of thetongue, or down by the voice box, so accessis a major issue, and it sometimes limitswhether we can do these operations,” Dr.Caruana explained. “Sometimes people havea tumor that’s a very good candidate for thissurgery, but the shape of the mouth—suchas a very high tongue, very large teeth, or anunderbite—will limit our ability to get an

endoscope in to actually see the tumor. Ifwe cannot visualize the tumor, an endo-scopic approach cannot be done.”

Patients with early- and middle-stagetumors are generally the best candidates forthis surgery because they affect a relativelysmall area and are easier to remove com-pletely. With later-stage cancers, a com-bined approach may be the best option.“We might take the primary tumor out ofthe throat using an endoscopic techniqueand then need an external approach toclean out the regional lymph nodes,” Dr.Caruana said. “Sometimes we stage theseprocedures—we take the primary tumorout first and get final permanent sectionson it, which are generally more accuratethan the frozen sections that we get in theoperating room. When we go to do theneck dissection, if any of the margins havecome back positive, we can go back andremove the remaining cancerous tissuewhile doing the second procedure.”

Dr. Caruana suggests that the next tech-nologic advance in head and neck cancerresection will be the introduction of robot-ic instruments. “Robotic surgery will makeit much easier to perform these opera-tions,” he said. “Right now they’re verylabor-intensive.”

Ultimately, he approaches patients on acase-by-case basis: “We don’t think endoscopyis the answer to every case of head and neckcancer, and we’re committed to finding thebest course of care for our patients.”

Contributing faculty for this article:Salvatore M. Caruana, MD

continued from Head/Neck, page 1

“We might take the primary tumor out of the throat using anendoscopic technique and then use an external approach toclean out the regional lymph nodes.”

—Salvatore M. Caruana, MD

High Marks for Hospital’s First Otolaryngology CME CourseM

salivary and parotid ducts, Dr. April treatsthe occasional case of recurrent parotitis inchildren. According to Dr. April, endo-scopic techniques have revolutionizedtreatment. “In the past my only option wasto take all of the parotid gland out, whichis a very difficult operation,” he said. “Notonly do you have all the difficulties associ-ated with a parotidectomy with potentialfacial nerve injury, but it is even harderbecause all the surrounding tissue has beenchronically infected. Now we will be ableto do sialendoscopy and hopefully dilatethe stricture that is precipitating the recur-rent infections.”

As new tools become available in theUnited States, Dr. April will be able to treatmore cases endoscopically, particularly caseswhere a stone is too large or firmlyentrenched, making it difficult to remove.“The FDA has to approve techniques andinstrumentation that are already used inEurope,” he said. “That includes the laser,and newer extraction devices to remove the

stones. Currently, we only have the baskets.We are eagerly awaiting the FDA approvalfor those techniques to be available. It willprobably be months rather than years, or atleast that’s what we’re hoping.”

In the meantime, Dr. April is workingon spreading the word about new endoscop-ic procedures to other pediatric otorhino-laryngologists. Since recurrent parotitis isuncommon in children, many ear, nose, andthroat physicians (ENTs) have never hadreasons to explore options for treatment andthey may not be sure how to proceed. “This

is an unusual clinical entity, and I still onlysee 1 or 2 patients a year who have it,” he said.“ENTs who are not familiar with recurrentparotitis of childhood may just tell parents togive children antibiotics if they don’t want togo through with the parotidectomy, andinfections recur once or twice a year. We needto increase awareness of recurrent parotitis ofchildhood and of the options for treating itwith sialendoscopy. Hopefully we’ll see morepatients that we can help with this problem.”

3

NEWYORK-PRESBYTERIAN EAR, NOSE, & THROAT

continued from Salivary, page 1

lthough the diagnosis of vocal foldparalysis has been around for decades, as

many as 20% of cases have no known cause.It is often difficult to determine a prognosiseven when the reason for the paralysis isknown. For idiopathic vocal fold paralysis,the task becomes even trickier. New tech-nologies are rapidly changing how cliniciansare able to diagnose and treat this condition.

At NewYork-Presbyterian Hospital/WeillCornell Medical Center, Lucian Sulica, MD,and colleagues are increasingly using laryn-geal electromyography (EMG). “BridgetCarey, MD, from the Department ofNeurology, has joined our group and ishelping with the interpretation of laryngealEMG, which really adds a depth of expertiseto our investigations that we didn’t havebefore. It is helping us uncover causes for idio-pathic vocal fold paralysis,” said Dr. Sulica.

By measuring the electrical activity in themuscles of the vocal fold, laryngeal EMG helpsdetermine a patient’s chance of recovery, whichaffects the course of treatment. However,Dr. Sulica noted that it’s not enough to knowthat there is electrical activity in the muscle;in some cases, the process of reinnervation cancause further disruptions to the vocal fold andinhibit its function (Curr Opin OtolaryngolHead Neck Surg 2007;15[3]:159-162).

“The many small muscles that move thevocal folds have to be very finely controlled.Most vocal folds get some nerve functionback after paralysis, but reinnervation can goto the wrong muscles, or it can provide inad-equate force,” he said. “It can actually evenset up a situation where synkinesis mayoccur. We’re trying to determine predictivefactors and mechanisms of spontaneousrecovery, and we’re watching to see how longthat recovery takes. We have many ways totreat this problem and we’re good at it, but

we need to understand how to deploy them.”The data from EMG also make it easier to

stratify cases and choose among treatmentoptions, noted Jonathan Aviv, MD. “It doesnot necessarily precisely guide you, but if youknow a vocal cord is not going to come backon its own you’re more apt to perform a pro-cedure, injecting a substance into the curvedvocal cord to straighten it out,” he said. “Onthe other hand, if there is electrical activity,you might still perform the procedure but

Advanced Technology Sheds New Light on Familiar Diagnoses A

NewYork-Presbyterian Ear, Nose, & Throat Editorial BoardLanny Garth Close, MDDirector of Service, Department of

Otolaryngology/Head and Neck SurgeryNewYork-Presbyterian Hospital/Columbia

University Medical CenterChairman and Howard W. Smith

Professor of OtolaryngologyColumbia University College of

Physicians and SurgeonsE-mail: lgc6@columbia.edu

Michael G. Stewart, MD, MPHOtorhinolaryngologist-in-ChiefNewYork-Presbyterian Hospital/Weill

Cornell Medical CenterChairman, Department of OtorhinolaryngologyProfessor of Otorhinolaryngology and

Public HealthWeill Cornell Medical College E-mail: mgs2002@med.cornell.edu

Related Links: www.ENTColumbia.org • www.CornellENT.org

Contributing faculty for this article:Max M. April, MD

Figure 2. One week after an injection of calciumhydroxylapatite paste to the right vocal fold, thevocal fold remains paralyzed but has good closureand both aspiration and hoarseness have resolved.

Figure 1. The right vocal fold of a 39-year-oldfemale patient is paralyzed and hypotonic, caus-ing the patient to aspirate liquids and have a pro-foundly hoarse voice.

Figure 1 Figure 2

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see Voice, page 4

inject a substance that you know will dissolvein 30 to 60 days or 60 to 90 days—some-thing less permanent than what you woulduse if you knew the cord was not going tocome back on its own.”

Dr. Aviv and colleagues at NewYork-Presbyterian Hospital/Columbia UniversityMedical Center have also been using RadiesseFN, a purified bone protein composed of cal-cium hydroxylapatite. “It is a fairly recentdevelopment. The injection itself can oftenbe performed in an office setting, which isalso relatively new,” said Dr. Aviv.

Dr. Aviv’s passion for cutting-edge tech-nology is finding another outlet in improvedtools for endoscopy, most notably a tiny dig-ital camera. “We have begun to use a distalchip scope for the larynx and the esophagus,”he said. “It’s only 3 mm in diameter and thecamera is at the tip, so the image is unbe-lievable. A single-use disposable EndoSheathfits over it so that you can reprocess the scopevery quickly without risk of cross-contami-nating a patient,” he said. Dr. Aviv cited itsapplication not only in the ear, nose andthroat, but also in gastroenterology, urology,and obstetrics/gynecology. “We’re probablythe first to use it in the larynx and fortransnasal esophagoscopy,” he added.

Previous instruments included a camerain the eyepiece of the scope and a fiber-optic cable. Here the camera is actually atthe tip of the scope, and it sends a digitalsignal. “Now you can see as well as you canwith a rigid-end scope,” Dr. Aviv said.“This is going to change the way we prac-tice because we’re going to be able to do

things with much less topical anesthesiaand much less discomfort to the patient.We’re going to be able to see things wehadn’t seen before—lesions, tumors, andcancer—in a much safer way. The implica-tions are groundbreaking.”

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NewYork-Presbyterian Hospital525 East 68th StreetNew York, NY 10065

Important news from the Ear, Nose, and Throat Centers of NewYork-Presbyterian Hospital—current research projects, clinical trials, and advances in the diagnosis, treatment, and rehabilitation of ear, nose, and throat disorders.

continued from Voice, page 3Contributing FacultyThe following is a list of the doctors quoted in this issue of the NewYork-PresbyterianHospital Ear, Nose, & Throat Newsletter. For more information on their work, pleasecontact them at the e-mail addresses listed.

Contributing faculty for this article:Jonathan Aviv, MD, and Lucian Sulica, MD

Weill Cornell Medical College

Max M. April, MDProfessor of Clinical Otorhinolaryngology Professor of Clinical Otorhinolaryngology

in Pediatrics E-mail: mma2005@med.cornell.edu

Michael G. Stewart, MD, MPH Otorhinolaryngologist-in-Chief Chairman, Department of Otorhinolaryngology Professor of Otorhinolaryngology and

Public HealthE-mail: mgs2002@med.cornell.edu

Lucian Sulica, MD Director, Voice Disorders/Laryngology Associate Professor of Otorhinolaryngology E-mail: lus2005@med.cornell.edu

Columbia University College of Physicians and Surgeons

Jonathan Aviv, MDDirector, Division of Laryngology Medical Director, Voice and

Swallowing Center Professor of Otolaryngology/

Head and Neck Surgery E-mail: jea10@columbia.edu

Salvatore M. Caruana, MD Director

Division of Head and Neck CancerAssistant Professor of Otolaryngology/

Head and Neck Surgery E-mail: sc2876@columbia.edu

NEWYORK-PRESBYTERIAN EAR, NOSE, & THROAT

Affiliated with Columbia University College of Physicians and Surgeons and Weill Cornell Medical College

NEWYORK-PRESBYTERIANEAR, NOSE, &THROAT

NewYork-Presbyterian Hospital