New Opportunities in ENT

We recently asked several forward-thinking ENT surgeons for insights on innovations that improve outcomes and enhance patient care. Removing the thyroid from inside the lower lip, maneuvering instruments along pre-planned virtual pathways during sinus surgery and freezing nerves to solve chronic sniffling were among the buzz-worthy developments that have them excited about their specialty’s future.

This “scarless” laparoscopic procedure lets surgeons remove the thyroid via a vestibular approach instead of open surgery. Jonathon Russell, MD, director of endoscopic and robotic thyroid and parathyroid surgery, and assistant professor of otolaryngology, at Johns Hopkins Medicine in Baltimore, Md., is one of the surgery’s pioneers. He says surgeons make a 1.5-cm incision in the gingival sulcus and 2 stab incisions at the oral commissure. They then tunnel down through the incisions, dissect around the thyroid and remove the gland through the central incision.

“It’s a great approach, because it doesn’t require any additional instrumentation, and it doesn’t take too much extra time over the traditional surgery” — about 15 additional minutes, says Dr. Russell. “And patients can still go home same-day. In every way, it’s the same surgery except for no scarring.”

Transoral thyroidectomy, however, can be a somewhat radical adjustment in terms of technique for surgeons. “It’s a different skill set for most thyroid surgeons who are accustomed to using open instrumentation,” says Dr. Russell. “It lends itself well to surgeons who have laparoscopic skills.”

The learning curve is short — about 10 cases — but high-volume thyroid surgeons are often booked 2 months in advance, so it’s difficult for them to take on these cases to master this technique. That’s been the biggest hurdle to widespread adoption, according to Dr. Russell, who champions making the technique more widely available. “It’s better for patients,” says Dr. Russell.

“Certainly, we’ve seen very happy patients [who have the procedure done].”

Traditionally, correcting valve collapse involved rhinoplasty. With this option, the surgeon simply makes a stab incision, passes an instrument into the correct area and deploys the implant. “It creates a scar or an inflammatory reaction, with the goal of stiffening that area to prevent collapse,” says R. Peter Manes, MD, FACS, an associate professor of otolaryngology at Yale School of Medicine in New Haven, Conn.

The procedure is said to lead to quicker recoveries and shorter surgical times than the traditional surgery for this condition, during which grafts must be harvested and additional incisions made.

Patients with perpetually runny noses often run out of patience when looking for a cure. “We don’t have a lot of good treatment options for them,” says Dr. Manes. “We can give them nasal sprays, which sometimes work and sometimes don’t.”

Enter cryotherapy, something of an older technology that’s been modified for use in the nose. Surgeons apply cryotherapy to the posterior nasal nerves, which often provide the stimulus that causes constant nasal drip, and freeze them. Dr. Manes says the procedure can be done “fairly quickly” in an OR or even an office setting with minimal instrumentation. He also says the procedure is “very well tolerated,” with the main complaint from patients being that they get something of an ice cream headache.

New surgical techniques are emerging for the growing problem of sleep apnea. Robson Capasso, MD, chief of sleep surgery at Stanford Health Care in Redwood City, Calif., says hypoglossal nerve stimulation (HGNS) involves implanting and activating a pacemaker-like device in the patient. Unlike soft tissue and skeletal surgery treatments, both of which cannot be reversed, the implant can easily be removed.

The risks of HGNS, says Dr. Capasso, are small. It leaves 3 scars — one below the right side of the jaw, one in the chest and one on the right side of the ribcage. Most patients feel a mild degree of discomfort in the tongue. And like any implant, it carries a small risk of infection. But recoveries are much less lengthy and painful with the implant compared with the other surgical techniques, says Dr. Capasso.

This procedure, which equalizes air pressure for patients who suffer from the common condition of eustachian tube dysfunction, uses technology similar to that used for balloon dilation of the sinuses. “You place this balloon in the eustachian tube under visualization, and you inflate that area,” says Dr. Manes. “You’re creating a better opening to allow equalization of pressure.” He says some surgeons have been performing this procedure for a while, but adoption is growing as more literature about it emerges.