University of Maryland Otorhinolaryngologists Increasingly Providing Minimally Invasive Head & Neck Surgery
The University of Maryland Medical Center treats the highest volumes of head and neck cancer of any center in Maryland because of the solid reputation of its multidisciplinary team. Its oncologists specializing in this area have deep expertise, and UMMC has a robust radiotherapy armamentarium for treating head and neck cancer that includes proton therapy. Now, UMMC's otorhinolaryngologists are improving surgical care for head and neck tumors by increasingly employing minimally invasive approaches that result in less morbidity, easier recoveries and better cosmesis for patients.
All of UMMC's head and neck surgeons employ minimally invasive surgical approaches for appropriate candidates. Rodney Taylor, MD, and Jeffrey Wolf, MD, senior members of the head and neck cancer team, have welcomed two very talented additions who contribute even greater depth to UMMC's highly specialized, minimally invasive surgery offerings: Kyle Hatten, MD, and Andrea Hebert, MD, both assistant professors of Otorhinolaryngology at the University of Maryland School of Medicine. After completing a fellowship at the Hospital of the University of Pennsylvania in head and neck cancer and vascular reconstruction, Dr. Hatten specializes in transoral robotic surgery. The University of Maryland–trained Dr. Hebert completed a fellowship in rhinology and anterior skull base surgery at the University of Pittsburgh Medical Center, one of the best programs in the world at which to study endoscopic skull base surgery. Together, the two of them are able to treat a full spectrum of head and neck pathologies in a minimally invasive fashion for the right surgical candidates.
Transoral Robotic Surgery for Treating Tumors While Preserving Quality of Life
Just as robotic surgery has revolutionized many surgical subspecialties, it has also permitted less invasive treatment of hard-to-access tumors at the pharynx and larynx. At UMMC, Dr. Hatten regularly performs transoral robotic surgery (TORS) to treat patients with HPV-related oropharyngeal cancers as well as carcinoma of unknown primary.
"We're in need of better ways to treat oropharyngeal cancer, the fastest growing area in head and neck cancer," says Dr. Hatten, who notes that although this cancer is highly curable, standard treatments can significantly compromise quality of life. Open surgical approaches often involve mandibulotomies, resulting in significant postoperative swallowing dysfunction and prolonged recovery. An alternative to surgery for HPV-related cancers is high-dose chemoradiation; however, this treatment strategy frequently leads to long-term swallowing impairment requiring feeding tubes after treatment.
TORS represents an attractive alternative to the standard treatments of open surgery or high-dose chemoradiation. The surgical robot permits the surgeon to perform operative procedures with seven degrees of freedom in confined spaces to extend the reach of surgery through the mouth. In addition, TORS has the potential to make the rest of cancer treatment easier for patients by reducing or eliminating the need for radiation or chemotherapy. "Our team's ability to treat oropharyngeal cancer through transoral robotic surgery and, if necessary, proton therapy has dramatically reduced treatment side effects," says Dr. Hatten. "We're treating patients effectively while leaving them with improved abilities to swallow, eat and talk."
Endoscopic Skull Base Surgery to Avoid Morbidity and Disfigurement
Prior to the development of the endoscopic endonasal approach (EEA) – which has greatly evolved over the past two decades because of improved intraoperative imaging, angled endoscopes that permit the surgeon to see around corners and hemostatic instrumentation – surgical procedures for conditions at the skull base were necessarily extensive and involved open craniotomy. These cases required retraction of the brain to facilitate the procedure, potentially causing neurologic sequelae. For the right patient, EEA can circumvent these issues.
"In addition, you can avoid external incisions and scars in some instances," says Dr. Hebert, who stresses that in select patients, anterior craniofacial resections can be performed without making an incision on the face. Likewise, clival chordomas can possibly be treated through the nose rather than through a palatal split, or other fairly morbid approach, that could adversely affect speaking and swallowing abilities.
At UMMC, an endoscopic endonasal approach may be used to treat rhinologic conditions such as sinonasal tumors, CSF leaks and encephaloceles as well as neurologic conditions such as pituitary adenomas and other tumors located at the skull base including meningiomas, chordomas, craniopharyngiomas and chondrosarcomas.
However, Dr. Hebert says, "It's less about the pathology and more about the location, where the tumor is in relation to particular arteries and nerves, that will dictate the surgical approach." Endoscopic skull base surgery evolved as endoscopic sinus surgery opened up new possibilities. "We have a better understanding of the anatomy [than we did 20 years ago] and what tumors are accessible via the endoscopic approach," she says. Other UMMC otorhinolaryngologists are starting to use endoscopy to treat middle ear pathologies.
A minimally invasive skull base procedure takes two surgeons – four hands – working simultaneously. One of these surgeons performs "dynamic endoscopy" to compensate for the lack of a 3D view. Dr. Hebert works closely with several UMMC neurosurgeons to facilitate the removal of skull base CNS tumors. Graeme Woodworth, MD, Professor of Neurosurgery at the University of Maryland School of Medicine and director of UMMC's Brain Tumor Treatment and Research Center, also has fellowship training in endoscopic approaches and performs many of these tandem operations. For sinonasal tumors, Dr. Hebert often performs EEA procedures with another UMMC otorhinolaryngologist.
Even surgical reconstruction can be easier for patients with EEA compared to an open approach. Because EEA relies heavily on vascular flaps inside the nose, a patient can be spared a free tissue transfer that adds time and morbidity to anterior skull base operations.
Cancer of Unknown Primary: Improved Ways to Manage Patients
UMMC white paper by Kyle Hatten, MD
Geltzeiler M, Nakassa ACI, Turner M, Setty P, Zenonos G, Hebert A, Wang E, Fernandez-Miranda J, Snyderman C, Gardner P. Evaluation of intranasal flap perfusion by intraoperative indocyanine green fluorescence angiography. Oper Neurosurg (Hagerstown). 2018 Dec 1;15(6):672-676. doi: 10.1093/ons/opy002.