Soundings

Fall 2016

from the Pennsylvania Academy of Otolaryngology - Head and Neck Surgery

Published in the interest of our members and their patients PRESIDENT’S MESSAGE

President Jeffrey P. Simons, MD Department of Otolaryngology Children’s Hospital of Pittsburgh of UPMC University of Pittsburgh School of Medicine Faculty Pavilion 7th Floor 4401 Penn Avenue Pittsburgh, PA 15224

Jeffrey P. Simons, MD, FACS, FAAP

President-Elect Ahmed M.S. Soliman, MD Temple Otorhinology Associates Kresge West Building 3440 N Broad St Fl 1 Philadelphia, PA 19140-5104 Secretary-Treasurer Johnathan D. McGinn, MD Division of Otolaryngology – Head & Neck Surgery Penn State College of Medicine-Hershey 500 University Drive, MC H091 Hershey, PA 17033-2360 Administrative Office 777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 717-558-7750 ext. 1519 717-558-7841 (fax) Visit our website at www.otopa.org Soundings accepts classified advertisements, however, there is no guarantee that they will be published. All submissions are subject to review. The advertisement should be of interest/pertain to otolaryngologists, their practice, and health care in Pennsylvania. Submissions that are self-promotional or commercial in nature will not be accepted. Publication of advertising does not imply endorsement of the products advertised or the statements contained in such advertising by Soundings or the PAO-HNS. The opinions expressed in this newsletter do not necessarily reflect the opinion of PAO-HNS.

INSIDE ENT Manifestations of Down Syndrome 2 Advances in Orbital Fracture Repair

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Contemporary Management of the Neck in Human Papillomavirus-Associated Orapharyngeal Cancer

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The Importance of Ultrasound Otolaryngology 12 Annual 40 Under 40 Awards

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Legislative Update

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It is hard to believe that the summer is over, kids are back in school, and the fall and winter holidays are almost upon us! The Pennsylvania Academy of OtolaryngologyHead and Neck Surgery (PAO-HNS) has certainly had a busy past several months. We had a very successful Annual Scientific Meeting this past June, which was held at the Omni Bedford Springs Resort in Bedford, PA. Our program coordinator, Amanda Hu, MD, and the planning committee led an outstanding program that included sessions on HPV, otology, and practice management. There were also many excellent research abstracts presented by otolaryngology residents in the state, as well as an exciting resident bowl competition (the “Conchal Bowl”). Most importantly to many of us, the meeting was a great opportunity to learn, network, and socialize in a beautiful, collegial setting. I also want to congratulate Dr. Hu for being a recipient of one of the Pennsylvania Medical Society’s (PAMED’s) Physician 40 Under 40 awards this year (see separate article in this issue of Soundings). We have continued to work on updating and expanding the PAO-HNS website. We recently launched a new “Find an Otolaryngologist” function for patients. We also have added a “Job Board” on the website for otolaryngology practices in the state to advertise job openings for physicians. We are also planning to add a

“Calendar of Events” which would offer Pennsylvania otolaryngology programs the opportunity to list upcoming meetings and courses. In addition, we are working to enhance the patient information section of the website. After many years with the same format, we also recently decided to redesign our newsletter, Soundings. The new version, which is more colorful and appealing, will be debuted in the spring of 2017. We have opportunities for advertising both in our newsletter and on our website. Over the past year, the PAO-HNS has been working more closely with the Pennsylvania Medical Society (PAMED) to address practice management and political issues of interest to otolaryngologists in the state. Participating in PAMED’s Specialty Leadership Cabinet (SLC) has helped us to improve our communication with other state specialty societies and PAMED in general. The leadership of PAMED has also agreed to offer joint membership to the PAO-HNS and PAMED for all interested resident members free of charge during the time they are residents, which provides a great way for otolaryngology residents to get involved with organized medicine at the state level. The PAO-HNS is fortunate to work with an excellent government relations firm, Milliron and Goodman, LLC, which helps support us in Harrisburg. Some of our legislative priorities include preventing taxes on medical procedures, truth in advertising for doctors, tobacco and E-cigarette use, smoking cessation, medical liability reform, and noise exposure for children. Perhaps the most important function of our lobbying firm is to help increase awareness of our specialty to state senators and representatives. As continued on page 15

ENT Manifestations of Down Syndrome Nicole L. Aaronson, MD and Jeffrey P. Simons, MD Down syndrome (DS) is the most common type of chromosomal abnormality in liveborn infants and occurs in 1 of every 800 births.[1] While the hallmarks of DS include mild-to-moderate mental retardation, heart defects, and a characteristic facies, there are also multiple otolaryngologic manifestations. Indeed, 50% of DS patients regularly see an ENT for care.[2] Awareness of the otologic, rhinologic, and sleep abnormalities seen in these patients is essential to providing them with optimal care and helping them to maximize their potential. Hearing loss occurs in up to 70% of DS patients and further exacerbates language delay. The American Academy of Pediatrics Committee on Genetics and the Down Syndrome Medical Interest Group Guidelines recommend that initial hearing evaluation at birth should be followed by testing every six months up to age 3 with subsequent testing annually. Auditory brainstem response (ABR) and otoacoustic emissions (OAE) testing are the recommended modalities for evaluation; ear-specific results by behavioral audiometry are difficult to achieve in children younger than 3½ years old. DS patients have structural ear abnormalities and high rates of conductive hearing loss. Up to 75% have stenotic canals, compared to 15% of general population. Stenosis increases cerumen impaction and impedes diagnosis of middle ear disease.[3] Eustachian tube abnormalities also predispose patients to middle ear dysfunction. The Eustachian tubes in patients with DS are more cylindrical in shape with smaller width, decreased cartilage cell density, and abnormal insertion. Decreased tensor veli palatini function secondary to generalized hypotonia induces Eustachian tube collapse with obstruction of air flow through the middle ear space.[4] DS patients have three times higher incidence of chronic ear disease and secondary hearing loss compared to other children with developmental delays. Cholesteatoma and ossicular chain erosion are also more common in children with DS.[5]

to increase rates of normal hearing in DS patients.[6] Furthermore, the use of boneanchored hearing aids has demonstrated improvements in emotional functioning, physical health, learning, and vitality.[7] Concomitant or isolated sensorineural hearing loss is reported in 4-9% of DS patients.[8] Radiographic evidence shows hypoplastic cochlea, narrow cochlear nerve canals, hypoplastic semicircular canals, and enlarged endolymphatic sacs.[9] Wellmanaged middle ear disease assists in the recognition of the sensorineural hearing loss and better guides attempts at amplification. Obstructive sleep apnea (OSA) is present in 63% of DS patients. Midface and maxillary hypoplasia, a small upper airway with relatively large and medially positioned tonsils, large adenoids relative to nasopharynx, glossoptosis, and soft palate elongation all contribute to the high incidence of OSA in this population. Furthermore, OSA contributes to the high rates of pulmonary hypertension among DS patients, which is higher than the rate that would be predicted by cardiac anomalies alone.[10] The American Academy of Pediatrics recommends sleep studies for all

Aggressive management with PE tubes insertion and replacement has been shown

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DS patients by age 4 to identify those patient who have not previously presented sleeprelated concerns.[11] First line treatment for DS patients with OSA is tonsillectomy and adenoidectomy. However, the procedure has lower efficacy for children with DS than their nonsyndromic counterparts. Studies have demonstrated that up to 55% of DS children require CPAP or BiPAP and 18% require nocturnal oxygen post-operatively.[12] Furthermore, there is an increased frequency of complications including velopharyngeal insufficiency.[13] A post-op sleep study is required to assess for residual apnea and necessity of further intervention. Flexible endoscopy, sleep video fluoroscopy, cine CT, and cine sleep MRI can better define the level of residual obstruction.[14] Revision adenoidectomy, partial palatal excision, palatal advancement, radiofrequency tongue base ablation, maxillary expansion, genioglossus advancement, and mandibular advancement can all be considered to target the obstruction identified. Tracheotomy can be considered in cases of severe OSA and oxygen desaturation where other medical and surgical options are not possible.[15]

Children with DS also have an increased incidence of rhinologic abnormalities. Midface hypoplasia with a contracted nasopharynx results in nasal obstruction, leading to rhinorrhea and sinusitis. DS patients have reduced T and B lymphocyte function and defective neutrophil chemotaxis, producing an increased incidence of upper respiratory tract infections.[16] Radiologic studies show hypoplasia and even total nonpneumatization in the frontal, maxillary, and sphenoid sinuses. Symptoms typically improve with age as the involved structures grow larger. Medical therapy include appropriate antibiotics, nasal steroids, antihistamines, and decongestants. Nasal saline is helpful in the context of frequent nasal crusting. If maximum medical intervention is unsuccessful, CT is indicated to evaluate for chronic sinus mucosal disease and blockage of the osteomeatal complex. Surgery may be beneficial for cases of enlarged adenoids, deviated nasal septum, enlarged nasal turbinates, and medicallyrefractory disease.[17] When DS patients require surgery, other comorbidities must be evaluated. Over half of DS patients have congenital heart anomalies, most commonly atrioventricular septal defects. Polycythemia, hypertension, pulmonary hypertension, and thyroid function abnormalities are common and must be assessed preoperatively.[18] Cervical spine abnormalities include atlantoaxial instability, abnormal congenital fusion of the vertebral bodies, and degenerative changes in the C2–3 and C3–4 cervical interspaces. Instability is often asymptomatic. Nevertheless, hyperextension of the neck is avoided to prevent spinal cord compression and neurologic compromise.[19] DS patients also tend to have narrower subglottic diameters than non-syndromic patients. To avoid injury to the laryngeal or subglottic airway, an endotracheal tube two sizes smaller than would be expected for the child’s age should be initially used for safety. This sizing should be confirmed by checking for an audible air leak at an inspiratory pressure between 10-30 cm H2O.[20] Many of the manifestations of DS involve the head and neck and, therefore, are best managed by an otolaryngologist. Structural midface, airway, and ear abnormalities place DS patients at high risk for hearing

loss, chronic otologic disease, sinusitis, and obstructive sleep apnea. Without intervention, many of these conditions can exacerbate behavior problems and act as further barriers to communication. Effective assessment and treatment of these various otolaryngologic manifestations of DS prevents morbidity, improves quality of life, and allows children with DS to achieve their maximal potential. References 1. Down syndrome. NIH US National Library of Medicine. 16 August 2016. https://ghr.nlm.nih.gov/condition/ down-syndrome#statistics. Accessed 20 August 2016. 2. Hans PS, Belloso A, Sheehan PZ. Parental Satisfaction with health services provided to children with Down Syndrome in north-west England: an ENT perspective. J Laryngol Otol. 2006; 121: 382-386. 3. S Satwant, KN Subramanian, N Prepageran, et al. Otological disorders in Down’s Syndrome. J Laryngol Otol. 2008; 122(12): 1318-1324. 4. Yamaguchi N1, Sando I, Hashida Y, et al. Histologic study of eustachian tube cartilage with and without congenital anomalies: a preliminary study. Ann Otol Rhinol Laryngol. 1990; 99(12): 984-7. 5. Bacciu A, Pasanisi E, Vincenti V, et al. Surgical treatment of middle ear cholesteotoma in children with Down syndrome. Otol Nerotol. 2005; 26: 1007-1010. 6. Shott SR, Joseph A, Heithaus D. Hearing loss in children with Down syndrome. Int J Pediatr Otorhinolaryngol. 2001; 61: 199-205. 7. McDremott A, Williams J, Kuo M, et al. The role of bone anchored hearing aids in children with Down syndrome. Int J Ped Otorhinolaryngol. 2008; 72: 751-757. 8. S Blaser, A Feigenbaum, P Shannon. Inner Ear Dysplasia is Common in Children with Down Syndrome (Trisomy 21). Laryngoscope. 2006; 116: 2113-2119. 9. Hess C, Rosanowski F, Eysholdt U, Schuster M. Hearing impairment in children and adolescents with Down syndrome. HNO. 2006; 54(3): 227-32.

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10. SR Shott, “Down Syndrome: Common Otolaryngologic Manifestations” American Journal of Medical Genetics 142C, 2006: 131-140. 11. Shott S, Amin R, Chini B, Heubi C, Hotze S, Akers R. Obstructive sleep apnea: should all children with Down syndrome be tested? Arch Otolaryngol Head Neck Surg. 2006; 132: 432-436. 12. MM Shete, RM Stocks, ME Sebelik, et al. Effects of Adeno-Tonsillectomy on Polysomnography Patterns in Down Syndrome Children with Obstructive Sleep Apnea: A Comparative Study with Children without Down Syndrome. Int J Ped Otorhinolaryngol. 2012; 74: 241-244. 13. Goldstein N, Armfield D, Kingsley L, et al. Postoperative complications after tonsillectomy and adenoidectomy in children with Down syndrome. Arch Otolaryngol Head Neck Surg. 1998; 124: 171-176. 14. Shott S, Donnelly L. Cine magnetic resonance imaging: Evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with Down syndrome. Laryngoscope. 2004; 114: 1724-1729. 15. Mitchell R, Call E, Kelly J. Diagnosis and therapy for airway obstruction in children with Down syndrome. Arch Otolaryngol Head Neck Surg. 2003; 129: 642-645.’ 16. Nespoli L, Burgio GR, Ugazio AG, Maccario R. Immunological feature of Down’s syndrome: a review. J Intellect Disabil Res. 1993; 37: 543-551. 17. BA Woodworth, K Meetze, RJ Schlosser. Chronic Rhinosinusitis in Congenital Craniofacial Malformations. Int J Ped Otorhinolaryngol. 2006; 70(2): 247-52. 18. FL Luce, D Sarandria, G Pozzobon, et al. Pediatric Otorhinolaryngology Manifestations of Endocrinologic Pathologies. Int J Ped Otorhinolaryngol. 2009; 73S: S49-S55. 19. Miller J, Bapusten B, Lampard R. Changes at the base of skull and cervical spine in Down syndrome. Can Assoc Radiol J. 1986; 37: 85-89. 20. Shott SR. Down Syndrome: analysis of airway size and guide for appropriate intubation. Laryngoscope. 2000; 110: 585-592.

Advances in Orbital Fracture Repair Tom Shokri, MD and Jessyka G. Lighthall, MD

Introduction Orbital fractures are a common outcome of trauma sustained to the midface. The complex anatomy and proximity to vital structures present a reconstructive challenge to the facial surgeon. Further complicating matters, the approach to management of these fractures is a source of continued controversy including when to repair, surgical approach, and material used for reconstruction. Recent advances in computer-aided technology including the use of three-dimensional printing, implementation of planning software, intraoperative navigational imaging, and the use of novel implants and minimally invasive procedures has allowed for progression in prospective management modalities. However, these innovations have also stimulated further deliberation with respect to the optimal approach and surgical correction of these complex injuries. Once the decision has been made to surgically treat an orbital floor fracture, a primary goal of reconstruction is to reduce orbital soft tissue and to reapproximate the orbital volume to a normal size. Improper reconstruction of orbital dimensions can result in enophthalmos, periocular muscle dysmotility, and diplopia. The implementation of computer-assisted therapy may improve both functional and aesthetic outcomes of reconstruction. Computerassisted reconstruction may be performed in several phases including preoperative planning, intraoperative navigation or imaging to confirm appropriate reduction, and post-therapeutic analysis of repair.

Intraoperative Imaging and Navigation While preoperative planning using imaging modalities is a crucial measure in surgical preparation, intraoperative imaging provides real-time assessment of progression with the added ability to perform intraoperative revisions correcting potential inadequate reduction of soft tissue contents or malposition of implants and resultant

malreduction. While helping to decrease the need for secondary corrective procedures, there are disadvantages, including increased costs, operative times, and radiation exposure, which must be considered. CT scanners can be divided into two types, including traditional fan beam CT and cone beam CT, or digital volume tomography. Fan beam CT generates a fan-shaped beam using a collimator and allows for evaluation of images in two dimensions with possible three dimensional volume reconstructions. In contrast, cone beam CT emits a concentrated x-ray beam that generates three dimensional volumetric images that can be reconstructed into two dimensional cross-sections in any plane. While the traditional modality provides better image resolution, digital volume tomography allows for decreased radiation which limits its soft tissue resolution, but maintains bone resolution for intraoperative evaluation. Both modalities have been shown to be particularly helpful in orbital fractures involving the junction of the orbital floor and medial wall or complete separation of the floor, where standard approaches may provide difficult exposure and may result in misplacement of reconstructive implants requiring repeat surgery.1 A study by Shaye et al. reviewed 38 facial reconstructive procedures that implemented intraoperative CT after fracture reduction using parameters including: fracture complexity, procedure type, scan time, and subsequent revision rate. Notably, the average total scan time was approximately 14.5 minutes and did not show major variability based on the complexity of the procedure. Immediate intraoperative revisions were required in 24% of patients (nine total, eight of which were defined as complex), which would otherwise have gone unnoticed or only noticed in postoperative imaging studies and require delayed revision. The authors therefore concluded that intraoperative imaging to confirm adequate reduction and fixation is an expeditious and reliable adjunct in reconstructive surgery and may be particularly useful in confirming

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optimal results in complex cases that would otherwise require secondary procedures.2 Furthermore, a review of the literature by Van Hout et al. found that intraoperative imaging resulted in intraoperative revisions of orbital and orbito-zygomatic fractures in 22% of patients.3 A review of 46 reconstructive procedures with intraoperative imaging by Stuck et al. showed a 26% revision rate with revised cases consisting of five malpositioned implants, two retained bone fragments requiring removal, and five malreductions.4 Overall, recent data show a 20-25% rate for intraoperative correction when imaging is utilized as an adjunct prior to leaving the operating suite, indicating that routine use, particularly in complex reconstructions, is beneficial. As obtaining routine post-postoperative imaging in most cases is not standard, one criticism of these studies is that it is unknown how many of these cases that underwent revision may have resulted in a negative functional or aesthetic outcome if left undisturbed. Intraoperative imaging modalities may be particularly useful to less experienced surgeons as they allow for confirmation of appropriate reduction while other, more experienced, surgeons may use it more sparingly. Intraoperative navigation has been heavily implemented in endoscopic sinus surgery. However, this same modality can be used to confirm implant placement and successful fracture reduction. Although it does not provide you with definitive real time feedback in comparison to intraoperative imaging, there is no radiation exposure allowing it to be repeated as often as necessary. Additionally, intraoperative navigation allows for an accuracy of within 1-2mm. The reconstruction of the orbit is performed using the virtually mirrored bony orbit of the unaffected side to guide reconstruction intraoperatively. Cai et al evaluated 58 patients, with orbital trauma undergoing orbital reconstruction, in a prospective matched controlled trial. Half these patients were reconstructed with the Kolibri navigation system (BrainLab,

Munich, Germany; n=28) while the control group (n=29) was reconstructed without the aid of a navigation system. The navigation group displayed a statistically significant decrease (3.24 mm) in variation of implant placement between the preoperative plan and actual reconstruction. Postoperative follow-up at one, three, and 12 months also showed significantly less ophthalmologic complications in the group with navigation including diplopia, infraorabital hypoesthesia, ophthalmoplegia, and enophthalmos.5 Andrews et al. published a retrospective study evaluating eight patients with traumatic orbital injury with use of intraoperative navigation to assist with repair. They analyzed implant placement, fracture type, and surgical outcomes, concluding that intraoperative navigation aids in safe identification of poorly visualized areas including the posterior most limits of the fracture and allows reconstruction of orbital contour to within 1mm of normal without postoperative complications.6 Many of these studies are, however, limited in that the information presented is qualitative and anecdotal in nature with small sample sizes.

Implant Contouring Template contouring can be greatly facilitated by the fabrication of three dimensional (3-D) rapid prototype models using preoperative CT datasets and 3-D printing. Titanium mesh can then be shaped onto the model replicating the mirrored normal orbital contour. Park et al. used this technique on 104 patients and demonstrated accurate volume reconstructions with an average of <1.5 ml discrepancy from the planned volume and minimal complication rates.7 Preformed implants can also be purchased by commercial manufacturers. These implants have a standardized orbital contour that is largely based on a composite of several hundred normal CT datasets. Metzger et al. evaluated the use of pre-bent titanium mesh implants in cadaveric orbits. They found that these provided accurate contours to within 1mm for both medial and orbital floor repair.8 Additionally, patient specific implants are constructed to fit the individual patientâ&#x20AC;&#x2122;s anatomy using the preoperative CT dataset and mirroring the contralateral unaffected side as detailed above. This technique is still relatively

new and has not been widely adopted but has shown promising results with regard to precision of premorbid orbital contour reconstruction. Gander et al. implemented CT imaging to create a virtual implant using the mirrored contralateral unaffected orbit as a template in 21 patients. They reported an efficient preoperative planning time ranging from 30-36 minutes with implant manufacturing taking approximately 4-6 days. They verified positioning by using three indentations placed on the implant as a means of assessing correct positioning using intraoperative navigation as well as for use as measuring points during placement, improving overall accuracy. The authors reported correction of enophthalmos and resolution of diplopia with no need for reoperation to reposition implants or correct ocular bulb displacement.9 Patient specific implants are also used more frequently in complex multi-wall fractures or in secondary revision cases for persistent enophthalmos or diplopia. Multiple different implant materials exist, which may be customized based on the contralateral, uninvolved orbital volume of the patient. Although larger custom implants may be difficult to place via standard orbital approaches, a multi-piece implant may be fashioned if necessary for ease of placement. The literature supporting patient specific implant techniques suggests improved outcomes but is limited to small poorly designed or retrospective studies. As advanced implants may significantly increase the cost of treatment without clear evidence to show a decrease in operative times, fewer returns to the OR, or improved outcomes, they are not yet widely implemented for orbital fracture management.

Endoscopic-assisted Approaches Although endoscopic-assisted approaches are thought of as minimally invasive, in reality they are not much different from traditional open approaches in regards to orbital reconstruction. Additionally, there is a learning curve to the use of endoscopes with initially prolonged operating room times, and in transantral approaches implant placement may be non-anatomic.10 Good candidates for these approaches are patient with medial floor or trap door fractures or patients without an adequate posterior bony

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ledge for implant maintenance. In transantral approaches, a window is made at the anterior face of the maxilla and the herniated soft tissue along the orbital floor or medial wall is visualized. Herniated soft tissue is typically reduced in retrograde fashion and the stable bony ledges are visualized. An implant may be placed intraorbitally through the maxillary sinus and will overlap in the stable bony ledges. Alternatively, a piece of titanium mesh may be contoured then rolled and placed through the maxillary window into the sinus. It is then unfurled on the sinus-side of the orbital floor after reduction of contents and secured to the walls of the maxillary sinus to support the floor as a non-anatomic implant. These approaches are particularly useful when an orbital fracture occurs in conjunction with midface fractures in which a sublabial approach is already being used. Additionally, transantral/transnasal approaches may also be combined with eyelid approaches as necessary to improve visualize and provide confirmation of soft tissue reduction and implant placement if intraoperative imaging is not available.

Conclusion Orbital fractures involve complex soft tissue and bony reconstruction. Although there has been considerable progress in the diagnosis, perioperative care, and technologically advanced approaches, an insufficiency in the level of evidence still exists preventing the development of a general guideline or algorithmic approach to reconstruction. Controversy still exists regarding the optimal management of orbital fractures including when to operate, approach to the repair, and ideal implant. There is increasing availability of intraoperative imaging techniques, popular interest in minimally-invasive procedures, surgical advances in repair techniques and approaches, and continued improvement in custom implant contouring. High quality research is necessary to identify which advanced techniques will improve patient outcomes and decrease complications or need for revision surgery. Surgeons treating maxillofacial trauma patients should be aware of these advances and use them in appropriately selected patients with complex orbital trauma or need for secondary revisions. continued on page 6

Advances in Orbital Fracture continued from page 5

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References 1. Schramm A, Suarez-Cunqueiro MM, Rucker M, et al. Computer-assisted therapy in orbital and mid-facial reconstructions. Int J Med Robot. 2009;5(2):111-124. 2. Shaye DA, Tollefson TT, Strong EB. Use of intra-operative computed tomography for maxillofacial reconstructive surgery. JAMA facial plastic surgery. 2015;17(2):113-119. 3. Van Hout WM, Van Cann EM, Muradin MS, Frank MH, Koole R. Intra-operative imaging for the repair of zygomaticomaxillary complex fractures: a comprehensive review of

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the literature. J Craniomaxillofac Surg. 2014;42(8):1918-1923. Stuck BA, Hulse R, Barth TJ. Intraoperative cone beam computed tomography in the management of facial fractures. Int J Oral Maxillofac Surg. 2012;41(10):1171-1175. Cai EZ, Koh YP, Hing EC, et al. Computer-assisted navigational surgery improves outcomes in orbital reconstructive surgery. J Craniofac Surg. 2012;23(5):1567-1573. Andrews BT, Surek CC, Tanna N, Bradley JP. Utilization of computed tomography image-guided navigation in orbit fracture repair. The Laryngoscope. 2013;123(6):1389-1393. Park SW, Choi JW, Koh KS, Oh TS. Mirror-Imaged Rapid Prototype Skull Model and Pre-Molded Synthetic

Scaffold to Achieve Optimal Orbital Cavity Reconstruction. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2015;73(8):1540-1553. 8. Metzger MC, Schon R, Weyer N, et al. Anatomical 3-dimensional pre-bent titanium implant for orbital floor fractures. Ophthalmology. 2006;113(10):1863-1868. 9. Gander T, Essig H, Metzler P, et al. Patient specific implants (PSI) in reconstruction of orbital floor and wall fractures. J Craniomaxillofac Surg. 2015;43(1):126-130. 10. Mohadjer Y, Hartstein ME. Endoscopic orbital fracture repair. Otolaryngol Clin North Am. 2006;39(5):1049-1057, viii.

Contemporary Management of the Neck in Human Papillomavirus-Associated Oropharyngeal Cancer Patrick T Tassone, MD; Joseph M Curry, MD; and David M. Cognetti, MD

Introduction Human Papillomavirus in Oropharyngeal Cancer Head and neck squamous cell carcinoma (HNSCC) as a whole represents the sixth most common type of cancer, with approximately 60,000 new cases diagnosed in the United States each year.1 Recently, the incidence of oropharyngeal squamous cell carcinoma has increased, and is now the third most common subsite for head and neck cancer.2,3 This increase is attributed to infection with the human papillomavirus (HPV). HPV has long been implicated as a causative agent in cervical cancer, but its presence in head and neck cancer was only first reported in the 1980s.4 This was further refined to oropharyngeal subsites, most commonly tonsil and tongue base5,6 HPV-positive patients were noted to be younger, have less tobacco exposure, and have better survival than their HPV-negative counterparts.7 HPV-positive oropharyngeal tumors are more sensitive to radiation and chemotherapy than HPV-negative tumors,8,9

leading to an estimated 30% absolute improvement in five-year survival.2,9 While radiation and chemotherapy are effective in the treatment of HPV-associated oropharyngeal tumors, many clinicians have concerns about long term sequelae of radiation and chemoradiation treatments for this largely young, healthy population of HPV-positive oropharyngeal cancer patients.3,10-12 These concerns, along with increasingly sophisticated transoral techniques for resection of primary tumors, including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS), have led to controversy regarding the optimal treatment of patients with oropharyngeal cancer, especially those with HPV-associated disease. Accordingly, surgical management strategies for neck disease are evolving simultaneously; the focus of this review is the neck. Historically, regional metastasis to cervical lymph nodes has been held as the most powerful prognostic factor in HNSCC, reducing survival by half.13 Increasing

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cervical nodal metastases also reduces disease-free survival in HPV-associated oropharyngeal cancer.14 There is an overall lack of prospective, randomized, controlled trials regarding the best management of the neck in HPVpositive disease. Clinical practice, therefore, is based primarily on retrospective series, expert opinion, and personal experience. This paper reviews and describes the relevant published series and opinions found in the literature to describe how and why different clinicians are managing the neck in HPVpositive patients.

Presentation of the Neck in HPV-Positive Patients Many oropharyngeal primary tumors grow without initially causing symptoms; thus, as many as 70% of patients with oropharyngeal primary tumors present with neck adenopathy,15 and patients with HPV-positive neck disease can have characteristics unique to HPV-positive disease. First, HPV-positive

nodes are often cystic, with a small rim of tumor tissue around a fluid-filled cystic node.16 HPV-positive nodes are also larger than HPV-negative nodes, and this increased size may upstage patients from N1 to N2a disease.17 Nodes are also often highly avid on positron emission tomography (PET).18

Elective Neck Dissection Nodes at Risk Selective neck dissection is generally used in clinically negative necks for any nodal level that has at least a 15 to 20% risk of occult metastasis.19 According to the NCCN guidelines for oropharyngeal cancer, surgical management of the clinically negative neck should address at least levels 2-4.20 In the case of an oropharyngeal primary tumor with no nodal disease evident on exam or imaging, lymph nodes in levels 2, 3, and 4 are considered to be at highest risk, while levels 1 and 5 harbor occult disease in less than 10 percent of cases.21-24 (Nguyen 2014). Likewise, sentinel lymph node studies have identified sentinel draining lymph nodes primarily in level 2 and occasionally in level 3 for oropharyngeal subsites; sentinel lymph nodes have not been identified in levels 1, 4, or 5.25 While early tonsil primary tumors tend to metastasize only to the ipsilateral neck, bilateral metastasis is much more likely from base of tongue, posterior pharyngeal wall, and soft palate primary tumors.18,22 Bilateral neck dissection is often performed for primaries at these subsites, especially for tumors approaching or crossing the midline.26-28 Risk of contralateral metastasis from tonsil primary also increases with advanced primary tumor stage and ipsilateral neck node positivity, leading some authors to advocate for dissection of the contralateral neck in tonsil tumors with T3 or T4 primary tumors, or positive ipsilateral nodes.29 Others cite the efficacy of ipsilateral-only neck treatment among tonsil primaries, even with positive ipsilateral nodes.30 The available data typically do not stratify by HPV status, but are primarily used to guide treatment for oropharyngeal cancer, regardless of HPV status. No studies to date have suggested that HPV-positive tumors metastasize to different regional lymph nodes than HPV-negative tumors.

Retropharyngeal Lymph Nodes Retropharyngeal lymph nodes (RPLN) may be positive at presentation in up to 20% of oropharyngeal squamous cell carcinoma patients.31 Positive RPLNs have been associated more commonly with tonsil and posterior pharyngeal wall subsites within the oropharynx.31,32 While RPLNs are more likely to be positive with advanced T or N stage, up to 10% of otherwise N0 necks may have positive RPLNs.14,32 In a study of 165 HPV-positive oropharyngeal patients, 9.7% had PET-positive RPLNs.33 Primary tumor location among RPLN-positive patients was most commonly base of tongue (63%) followed by tonsil (37%). All patients with positive RPLN had at least N2b disease in the lateral neck. Patients with positive RPLNs received full dose radiation to the entire retropharynx, and over 2-year followup all patients in this study had disease-free survival of 75%; RPLN positivity did not have a significant impact on survival. The presence of positive retropharyngeal lymph nodes may, for some clinicians, preclude surgical management of the neck, as retropharyngeal dissection can worsen post-operative swallowing function.34 In some cases, however, the retropharynx can be addressed surgically, often in conjunction with open, trans-cervical resection of oropharyngeal primary tumors.28 Level 2b There is disagreement in the literature regarding the management of level 2b in the elective setting for oropharyngeal carcinoma. Limited series suggest that sparing level 2b may improve post-operative shoulder function, owing to less dissection of the spinal accessory nerve (SAN).35 While limited data are available for HPV-positive disease specifically, published series in oropharyngeal cancer suggest that level 2b harbors occult positive disease in less than five percent of cases.36,37 Thus, many clinicians spare level 2b in early T-stage, clinically N0 necks. However, in a series of 81 N0 necks in oropharyngeal carcinoma, level 2b positivity was significantly associated (p<0.001) with the presence of level 2a metastasis.37 In this series, 29% of patients with occult disease in 2a also had occult disease in 2b, leading some to continue to advocate for the removal of 2b

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lymph nodes at the time of initial elective neck dissection. Selective Neck Dissection In the elective setting, some surgeons routinely perform modified radical neck dissection, but many prefer selective neck dissection. In addition, one series of observation in the elective neck has been published.38 Among 49 surgically-treated N0 oropharyngeal cancer patients, 32 underwent elective neck dissection and 17 were observed in the neck without either surgery or radiation. The neck failure rate among the observed patients was 24%. In this series, observed patients who failed in the neck went on to neck dissection, and had similar (76% vs. 82%, p=0.996) five-year overall survival as those who had elective neck dissection initially. While the authors of the study propose that no patients were harmed by observing the neck and using salvage neck dissection if necessary, others may respond that a neck failure rate of 24% justifies elective neck dissection.

Therapeutic Neck Dissection Nodes at Risk Nodal levels at highest risk in the context of neck disease are levels 2, 3, and 4.37,39 Level 2b is positive in 16% of therapeutic neck dissections,37 and is commonly removed with level 2a. Level 1b and level 5 are reported to be involved in 7.5% and 2.6% of cases, respectively, but this series includes only T1 and T2 stage tumors.39 Sparing the submandibular gland in a level 1b dissection has not adversely impacted disease-free or overall survival in a series of 253 oropharyngeal cancer patients.40 In general, therapeutic neck dissection includes at least levels 2, 3 and 4, and many surgeons routinely perform modified radical neck dissection in this setting.29,41 Without prospective randomized data to compare selective to modified radical neck dissection in this setting, practices are largely based on retrospective data that point to low rates of neck recurrence with excellent disease-free and overall survival after appropriatelydirected selective neck dissection.42 continued on page 8

Contemporary Management continued from page 7 Timing of Neck Dissection in Definitive Surgical Management Many patients with HPV-associated oropharyngeal cancer present with advanced disease, and the appropriate treatment of the primary tumor heavily influences the treatment of the neck. If the primary is to be treated surgically, the neck is likely to be addressed surgically. With open procedures, the neck is typically managed simultaneously. With transoral approaches to the primary, the surgeon must decide the best timing of neck dissection relative to primary resection: this can be done simultaneously with, prior to, or following primary resection. Different institutions have applied each strategy. Advantages of simultaneous primary resection and neck dissection include the ability to manage vessels intraorally and externally in order to minimize risk of hemorrhage. When the primary tumor is surgically resected, there is a small but significant risk of post-operative bleeding. Ligation of appropriate branches of the external carotid artery at the time of upfront neck dissection has not been shown to significantly reduce bleeding, but the practice is routinely carried out at many centers without morbidity.43,44 Upfront Neck Dissection in Non-Surgical Treatment of the Primary Upfront neck dissection prior to definitive chemoradiation has achieved excellent oncologic results in oropharyngeal cancer in general,45 and in HPV-associated disease specifically.46 In addition, upfront neck dissection combined with surgical treatment of the primary has spared adjuvant treatment at some centers. In a series of 49 oropharyngeal cancer patients treated surgically, upfront neck dissection spared chemotherapy for 80% of stage III patients while maintaining over 80% five-year survival.47 In a series of 31 surgically treated oropharyngeal cancer patients, 30% of N2 patient were spared chemotherapy, and 86% of N1 patients were spared chemotherapy.48 In particular, very advanced neck disease has a worse response to chemoradiation, even in HPV-associated tumors.49 Treatment of

the N3 neck often involves a combination of surgery, radiation, and chemotherapy. While HPV-positive tumors are more sensitive to chemoradiation in general, there are no studies to support the inclusion or exclusion of treatment modalities in the N3 neck. Planned Post-Treatment Neck Dissection As many as 20% of HNSCC patients will have persistent disease in the neck following definitive treatment with chemoradiation, and five-year survival for persistent disease is as low as 10%.50,51 For that reason, many advocate for planned neck dissection: a neck dissection six to eight weeks following radiation or chemoradiation, regardless of response to treatment.52 The benefit of planned neck dissection among patients with complete response to radiation or chemoradiation, however, is unclear. Complete response to treatment is predicted by PET-CT obtained 8-12 weeks after treatment.53 In HPV-associated disease, post-treatment PET-CT has a negative predictive value of over 90%.54 Large series of oropharyngeal cancer patients who respond completely to chemoradiation have regional recurrence rates below 3%.55,56 In a series of 38 HPV-positive oropharyngeal cancer patients of whom half received planned neck dissection, planned neck dissection did not provide survival benefit among HPV+ patients.57 Salvage Neck Dissection Among patients treated for HPV-associated oropharyngeal cancer, as many as 20% may have recurrent or persistent disease.58 In patients with resectable disease, many surgeons perform modified radical neck dissection, while some perform selective neck dissection or even super selective neck dissection,59-61 based on the high negative predictive value of PET-CT in this setting.62 Even in a salvage setting, HPV-positive patients have improved overall survival compared to HPV-negative.63,64

Pathologic Markers in HPV-Associated Cancer Extracapsular extension (ECE) has long been recognized as a marker of poor prognosis in head and neck cancer.65 Recent studies, however, question the independent

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importance of ECE in HPV-associated oropharyngeal cancer. Several series published by Lewis, Sinha, and Haughey grade ECE from minimal to complete replacement of the lymph node with invasion of adjacent structures. These studies suggest that while extensive ECE that replaces the lymph node entirely may worsen prognosis, there is no worse prognosis among patients with less extensive ECE.66-69 This has been corroborated by other investigators as well.70,71 When HPV-positive patients with ECE are spared chemotherapy, diseasespecific survival is not affected.69 Traditional N staging may not effectively predict disease behavior among HPVpositive patients. The number of positive lymph nodes, especially greater than five positive lymph nodes, may worsen prognosis.65,66

Unknown Primary Compared to HPV-negative oropharyngeal tumors, HPV-positive tumors much more commonly present as unknown primary squamous cell carcinoma (UPSCC).72 In fact, UPSCC is increasing in frequency, with as many as 90% of UPSCC being HPV-positive.73 Search for a primary lesion, including biopsies, tonsillectomy, and lingual tonsillectomy or tongue base mucosectomy, may perhaps be improved by the addition of TORS.73,74 This strategy often uses tonsillectomy with tongue base biopsies first, followed by tongue base mucosectomy if no primary is found initially. Motz et al. reported a 60% primary tumor detection rate among HPV-positive UPSCC using tonsillectomy and tongue base mucosectomy.73 In the setting of UPSCC, as in the case of an easily identified primary, HPV-positivity increases survival over HPVnegative patients.75,76

Smoking and HPV Significant smoking exposure, especially greater than 10 pack-years, is known to attenuate the favorable prognosis of HPVpositive disease.2,10 It remains vital to obtain a careful history for all HNSCC patients; patients with HPV-positive disease but significant tobacco exposure may not be appropriate for de-escalation of therapy. Ongoing studies and forthcoming results

should be considered in the context of patients’ tobacco exposure in order to define the relationship between HPV and tobacco.

Conclusion and Future Directions HPV-associated oropharyngeal cancer represents a unique subset of head and neck cancer. HPV-positive disease affects young non-smokers, has a unique presentation in the neck, and carries an overall excellent prognosis. De-escalation trials have begun in HPV-positive oropharyngeal cancer, in an attempt to reduce morbidity of treatment while maintaining excellent survival.11,77 Ongoing randomized prospective trials should provide data critical to the decision making for treatment of HPV-positive patients to maximize cure and minimize morbidity. References 1. DeSantis CE, Lin CC, Mariotto AB, Siegel RL, Stein KD, Kramer JL, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014 Jul-Aug;64(4):252-71. 2. Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tan PF, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010 Jul 1;363(1):24-35. 3. Deschler DG, Richmon JD, Khariwala SS, Ferris RL, Wang MB. The “New” Head and Neck Cancer Patient-Young, Nonsmoker, Nondrinker, and HPV Positive: Evaluation. Otolaryngol Head Neck Surg. 2014 Sep;151(3):375-80. 4. Loning T, Ikenberg H, Becker J, Gissmann L, Hoepfer I, zur Hausen H. Analysis of oral papillomas, leukoplakias, and invasive carcinomas for human papillomavirus type related DNA. J Invest Dermatol. 1985 May;84(5):417-20. 5. Snijders PJ, Cromme FV, van den Brule AJ, Schrijnemakers HF, Snow GB, Meijer CJ, et al. Prevalence and expression of human papillomavirus in tonsillar carcinomas, indicating a possible viral etiology. Int J Cancer. 1992 Jul 30;51(6):845-50. 6. Paz IB, Cook N, Odom-Maryon T, Xie Y, Wilczynski SP. Human papillomavirus (HPV) in head and

neck cancer. An association of HPV 16 with squamous cell carcinoma of Waldeyer’s tonsillar ring. Cancer. 1997 Feb 1;79(3):595-604. 7. McKaig RG, Baric RS, Olshan AF. Human papillomavirus and head and neck cancer: epidemiology and molecular biology. Head Neck. 1998 May;20(3):250-65. 8. Lindel K, Beer KT, Laissue J, Greiner RH, Aebersold DM. Human papillomavirus positive squamous cell carcinoma of the oropharynx: a radiosensitive subgroup of head and neck carcinoma. Cancer. 2001 Aug 15;92(4):805-13. 9. Fakhry C, Westra WH, Li S, Cmelak A, Ridge JA, Pinto H, et al. Improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst. 2008 Feb 20;100(4):261-9. 10. Kumar B, Cipolla MJ, Old MO, Brown NV, Kang SY, Dziegielewski PT, et al. Surgical management of oropharyngeal squamous cell carcinoma: Survival and functional outcomes. Head Neck. 2015 Dec 23. 11. Vokes EE, Agrawal N, Seiwert TY. HPV-Associated Head and Neck Cancer. J Natl Cancer Inst. 2015 Dec 9;107(12):djv344. 12. Cognetti DM, Luginbuhl AJ, Nguyen AL, Curry JM. Early adoption of transoral robotic surgical program: preliminary outcomes. Otolaryngol Head Neck Surg. 2012 Sep;147(3):482-8. 13. Shimizu K, Inoue H, Saitoh M, Ohtsuki N, Ishida H, Makino K, et al. Distribution and impact of lymph node metastases in oropharyngeal cancer. Acta Otolaryngol. 2006 Aug;126(8):872-7. 14. Dirix P, Nuyts S, Bussels B, Hermans R, Van den Bogaert W. Prognostic influence of retropharyngeal lymph node metastasis in squamous cell carcinoma of the oropharynx. Int J Radiat Oncol Biol Phys. 2006 Jul 1;65(3):739-44. 15. Lin DT, Cohen SM, Coppit GL, Burkey BB. Squamous cell carcinoma of the oropharynx and hypopharynx. Otolaryngol Clin North Am. 2005 Feb;38(1):59,74, viii.

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16. Goldenberg D, Begum S, Westra WH, Khan Z, Sciubba J, Pai SI, et al. Cystic lymph node metastasis in patients with head and neck cancer: An HPVassociated phenomenon. Head Neck. 2008 Jul;30(7):898-903. 17. Joo YH, Cho KJ, Park JO, Nam IC, Kim CS, Kim MS. High-risk human papillomavirus and lymph node size in patients with single node metastasis of oral and oropharyngeal cancer. Acta Otolaryngol. 2014 Apr;134(4):395-400. 18. Clark J, Jeffery CC, Zhang H, Cooper T, O’Connell DA, Harris J, et al. Correlation of PET-CT nodal SUVmax with p16 positivity in oropharyngeal squamous cell carcinoma. J Otolaryngol Head Neck Surg. 2015 Sep 15;44(1):37. 19. Pitman KT. Rationale for elective neck dissection. Am J Otolaryngol. 2000 Jan-Feb;21(1):31-7. 20. Pfister DG, Spencer S, Brizel DM, Burtness B, Busse PM, Caudell JJ, et al. Head and neck cancers, Version 2.2014. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2014 Oct;12(10):1454-87. 21. Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1972 Jun;29(6):1446-9. 22. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg. 1990 Oct;160(4):405-9. 23. Lim YC, Koo BS, Lee JS, Lim JY, Choi EC. Distributions of cervical lymph node metastases in oropharyngeal carcinoma: therapeutic implications for the N0 neck. Laryngoscope. 2006 Jul;116(7):1148-52. 24. Nguyen A, Luginbuhl A, Cognetti D, Van Abel K, Bar-Ad V, Intenzo C, et al. Effectiveness of PET/CT in the preoperative evaluation of neck disease. Laryngoscope. 2014 Jan;124(1):159-64. 25. Werner JA, Dunne AA, Ramaswamy A, Folz BJ, Brandt D, Kulkens C, et al. Number and location of radiolabeled, intraoperatively identified sentinel nodes in 48 head and neck cancer patients with clinically staged N0 and N1 neck. Eur Arch Otorhinolaryngol. 2002 Feb;259(2):91-6. continued on page 10

Contemporary Management continued from page 9 26. Olzowy B, Tsalemchuk Y, Schotten KJ, Reichel O, Harreus U. Frequency of bilateral cervical metastases in oropharyngeal squamous cell carcinoma: a retrospective analysis of 352 cases after bilateral neck dissection. Head Neck. 2011 Feb;33(2):239-43. 27. Byers RM, Wolf PF, Ballantyne AJ. Rationale for elective modified neck dissection. Head Neck Surg. 1988 Jan-Feb;10(3):160-7. 28. Spiro JD, Spiro RH, Shah JP, Sessions RB, Strong EW. Critical assessment of supraomohyoid neck dissection. Am J Surg. 1988 Oct;156(4):286-9. 29. Lim YC, Lee SY, Lim JY, Shin HA, Lee JS, Koo BS, et al. Management of contralateral N0 neck in tonsillar squamous cell carcinoma. Laryngoscope. 2005 Sep;115(9):1672-5. 30. Koo TR, Wu HG. Long-term results of ipsilateral radiotherapy for tonsil cancer. Radiat Oncol J. 2013 Jun;31(2):66-71. 31. Tauzin M, Rabalais A, Hagan JL, Wood CG, Ferris RL, Walvekar RR. PET-CT staging of the neck in cancers of the oropharynx: patterns of regional and retropharyngeal nodal metastasis. World J Surg Oncol. 2010 Aug 16;8:70,7819-8-70. 32. Gross ND, Ellingson TW, Wax MK, Cohen JI, Andersen PE. Impact of retropharyngeal lymph node metastasis in head and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 2004 Feb;130(2):169-73. 33. Baxter M, Chan JY, Mydlarz WK, Labruzzo SV, Kiess A, Ha PK, et al. Retropharyngeal lymph node involvement in human papillomavirusassociated oropharyngeal squamous cell carcinoma. Laryngoscope. 2015 Jul 30. 34. Bussels B, Hermans R, Reijnders A, Dirix P, Nuyts S, Van den Bogaert W. Retropharyngeal nodes in squamous cell carcinoma of oropharynx: incidence, localization, and implications for target volume. Int J Radiat Oncol Biol Phys. 2006 Jul 1;65(3):733-8. 35. Celik B, Coskun H, Kumas FF, Irdesel J, Zarifoglu M, Erisen L, et al. Accessory nerve function after level 2b-preserving

selective neck dissection. Head Neck. 2009 Nov;31(11):1496-501. 36. Lee SY, Lim YC, Song MH, Lee JS, Koo BS, Choi EC. Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma. Oral Oncol. 2006 Nov;42(10):1017-21. 37. Gross BC, Olsen SM, Lewis JE, Kasperbauer JL, Moore EJ, Olsen KD, et al. Level IIB lymph node metastasis in oropharyngeal squamous cell carcinoma. Laryngoscope. 2013 Nov;123(11):2700-5. 38. Boscke R, Cakir BD, Hoffmann AS, Wiegand S, Quetz J, Meyer JE. Outcome after elective neck dissection and observation for the treatment of the clinically node-negative neck (cN0) in squamous cell carcinoma of the oropharynx. Eur Arch Otorhinolaryngol. 2014 Mar;271(3):567-74. 39. Sanguineti G, Pai S, Agbahiwe H, Ricchetti F, Westra W, Sormani MP, et al. HPV-related oropharyngeal carcinoma with Overt Level II and/ or III metastases at presentation: The risk of subclinical disease in ipsilateral levels IB, IV and V. Acta Oncol. 2014 May;53(5):662-8. 40. Howard BE, Hinni ML, Nagel TH, Chang YH, Cheng MR, Hayden RE. Submandibular gland preservation during concurrent neck dissection and transoral surgery for oropharyngeal squamous cell carcinoma. Otolaryngol Head Neck Surg. 2014 Apr;150(4):587-93. 41. Paximadis PA, Christensen ME, Dyson G, Kamdar DP, Sukari A, Lin HS, et al. Up-front neck dissection followed by concurrent chemoradiation in patients with regionally advanced head and neck cancer. Head Neck. 2012 Dec;34(12):1798-803. 42. Schmitz S, Machiels JP, Weynand B, Gregoire V, Hamoir M. Results of selective neck dissection in the primary management of head and neck squamous cell carcinoma. Eur Arch Otorhinolaryngol. 2009 Mar;266(3):437-43. 43. Mandal R, Duvvuri U, Ferris RL, Kaffenberger TM, Choby GW, Kim S. Analysis of post-transoral roboticassisted surgery hemorrhage: Frequency,

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outcomes, and prevention. Head Neck. 2015 Apr 27. 44. Melong JC, Rigby MH, Bullock M, Hart RD, Trites J, Taylor SM. Transoral laser microsurgery for the treatment of oropharyngeal cancer: the Dalhousie University experience. J Otolaryngol Head Neck Surg. 2015 Sep 30;44(1):39. 45. Cupino A, Axelrod R, Anne PR, Sidhu K, Lavarino J, Kung B, et al. Neck dissection followed by chemoradiotherapy for stage IV (N+) oropharynx cancer. Otolaryngol Head Neck Surg. 2007 Sep;137(3):416-21. 46. Richards BL, Spiro JD. Controlling advanced neck disease: efficacy of neck dissection and radiotherapy. Laryngoscope. 2000 Jul;110(7):1124-7. 47. Walvekar RR, Li RJ, Gooding WE, Gibson MK, Heron D, Johnson JT, et al. Role of surgery in limited (T1-2, N0-1) cancers of the oropharynx. Laryngoscope. 2008 Dec;118(12):2129-34. 48. Weinstein GS, Quon H, Oâ&#x20AC;&#x2122;Malley BW,Jr, Kim GG, Cohen MA. Selective neck dissection and deintensified postoperative radiation and chemotherapy for oropharyngeal cancer: a subset analysis of the University of Pennsylvania transoral robotic surgery trial. Laryngoscope. 2010 Sep;120(9):1749-55. 49. Hasegawa M, Maeda H, Deng Z, Kiyuna A, Ganaha A, Yamashita Y, et al. Prediction of concurrent chemoradiotherapy outcome in advanced oropharyngeal cancer. Int J Oncol. 2014 Sep;45(3):1017-26. 50. Denis F, Garaud P, Bardet E, Alfonsi M, Sire C, Germain T, et al. Final results of the 94-01 French Head and Neck Oncology and Radiotherapy Group randomized trial comparing radiotherapy alone with concomitant radiochemotherapy in advanced-stage oropharynx carcinoma. J Clin Oncol. 2004 Jan 1;22(1):69-76. 51. Mendenhall WM, Villaret DB, Amdur RJ, Hinerman RW, Mancuso AA. Planned neck dissection after definitive radiotherapy for squamous cell carcinoma of the head and neck. Head Neck. 2002 Nov;24(11):1012-8. 52. Frank DK, Hu KS, Culliney BE, Persky MS, Nussbaum M, Schantz SP, et al. Planned neck

dissection after concomitant radiochemotherapy for advanced head and neck cancer. Laryngoscope. 2005 Jun;115(6):1015-20. 53. Lango MN, Myers JN, Garden AS. Controversies in surgical management of the node-positive neck after chemoradiation. Semin Radiat Oncol. 2009 Jan;19(1):24-8. 54. Koshkareva Y, Branstetter BF,4th, Gaughan JP, Ferris RL. Predictive accuracy of first post-treatment PET/CT in HPV-related oropharyngeal squamous cell carcinoma. Laryngoscope. 2014 Aug;124(8):1843-7. 55. Corry J, Peters L, Fisher R, Macann A, Jackson M, McClure B, et al. N2-N3 neck nodal control without planned neck dissection for clinical/ radiologic complete responders-results of Trans Tasman Radiation Oncology Group Study 98.02. Head Neck. 2008 Jun;30(6):737-42. 56. Goenka A, Morris LG, Rao SS, Wolden SL, Wong RJ, Kraus DH, et al. Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer. Int J Cancer. 2013 Sep 1;133(5):1214-21. 57. Maquieira R, Haerle SK, Huber GF, Soltermann A, Haile SR, Stoeckli SJ, et al. No benefit for regional control and survival by planned neck dissection in primary irradiated oropharyngeal cancer irrespective of p16 expression. Eur Arch Otorhinolaryngol. 2015 Jun 10. 58. Guo T, Qualliotine JR, Ha PK, Califano JA, Kim Y, Saunders JR, et al. Surgical salvage improves overall survival for patients with HPV-positive and HPVnegative recurrent locoregional and distant metastatic oropharyngeal cancer. Cancer. 2015 Jun 15;121(12):1977-84. 59. Lango MN, Andrews GA, Ahmad S, Feigenberg S, Tuluc M, Gaughan J, et al. Postradiotherapy neck dissection for head and neck squamous cell carcinoma: pattern of pathologic residual carcinoma and prognosis. Head Neck. 2009 Mar;31(3):328-37. 60. Goguen LA, Chapuy CI, Sher DJ, Israel DA, Blinder RA, Norris CM, et al. Utilizing computed tomography as a road map for designing selective and superselective neck dissection after

chemoradiotherapy. Otolaryngol Head Neck Surg. 2010 Sep;143(3):367-74. 61. Suarez C, Rodrigo JP, Robbins KT, Paleri V, Silver CE, Rinaldo A, et al. Superselective neck dissection: rationale, indications, and results. Eur Arch Otorhinolaryngol. 2013 Nov;270(11):2815-21. 62. Yeung AR, Liauw SL, Amdur RJ, Mancuso AA, Hinerman RW, Morris CG, et al. Lymph node-positive head and neck cancer treated with definitive radiotherapy: can treatment response determine the extent of neck dissection? Cancer. 2008 Mar 1;112(5):1076-82. 63. Joseph AW, Guo T, Hur K, Xie Y, Yin L, Califano JA, et al. Disease-free survival after salvage therapy for recurrent oropharyngeal squamous cell carcinoma. Head Neck. 2015 Nov 11. 64. Fakhry C, Zhang Q, Nguyen-Tan PF, Rosenthal D, El-Naggar A, Garden AS, et al. Human papillomavirus and overall survival after progression of oropharyngeal squamous cell carcinoma. J Clin Oncol. 2014 Oct 20;32(30):3365-73. 65. Johnson JT, Barnes EL, Myers EN, Schramm VL,Jr, Borochovitz D, Sigler BA. The extracapsular spread of tumors in cervical node metastasis. Arch Otolaryngol. 1981 Dec;107(12):725-9. 66. Lewis JS,Jr, Carpenter DH, Thorstad WL, Zhang Q, Haughey BH. Extracapsular extension is a poor predictor of disease recurrence in surgically treated oropharyngeal squamous cell carcinoma. Mod Pathol. 2011 Nov;24(11):1413-20. 67. Sinha P, Lewis JS,Jr, Piccirillo JF, Kallogjeri D, Haughey BH. Extracapsular spread and adjuvant therapy in human papillomavirusrelated, p16-positive oropharyngeal carcinoma. Cancer. 2012 Jul 15;118(14):3519-30. 68. Haughey BH, Sinha P. Prognostic factors and survival unique to surgically treated p16+ oropharyngeal cancer. Laryngoscope. 2012 Sep;122 Suppl 2:S13-33. 69. Sinha P, Kallogjeri D, Gay H, Thorstad WL, Lewis JS,Jr, Chernock R, et al. High metastatic node number, not extracapsular spread or N-classification is a node-related prognosticator in transorally-resected, neck-dissected

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p16-positive oropharynx cancer. Oral Oncol. 2015 May;51(5):514-20. 70. Maxwell JH, Ferris RL, Gooding W, Cunningham D, Mehta V, Kim S, et al. Extracapsular spread in head and neck carcinoma: impact of site and human papillomavirus status. Cancer. 2013 Sep 15;119(18):3302-8. 71. Klozar J, Koslabova E, Kratochvil V, Salakova M, Tachezy R. Nodal status is not a prognostic factor in patients with HPV-positive oral/ oropharyngeal tumors. J Surg Oncol. 2013 May;107(6):625-33. 72. Zengel P, Assmann G, Mollenhauer M, Jung A, Sotlar K, Kirchner T, et al. Cancer of unknown primary originating from oropharyngeal carcinomas are strongly correlated to HPV positivity. Virchows Arch. 2012 Sep;461(3):283-90. 73. Motz K, Qualliotine JR, Rettig E, Richmon JD, Eisele DW, Fakhry C. Changes in Unknown Primary Squamous Cell Carcinoma of the Head and Neck at Initial Presentation in the Era of Human Papillomavirus. JAMA Otolaryngol Head Neck Surg. 2016 Jan 14:1-7. 74. Durmus K, Rangarajan SV, Old MO, Agrawal A, Teknos TN, Ozer E. Transoral robotic approach to carcinoma of unknown primary. Head Neck. 2014 Jun;36(6):848-52. 75. Vent J, Haidle B, Wedemeyer I, Huebbers C, Siefer O, Semrau R, et al. P16 Expression in Carcinoma of Unknown Primary: Diagnostic Indicator and Prognostic Marker. Head Neck. 2013 Nov;35(11):1521-6. 76. Jensen DH, Hedback N, Specht L, Hogdall E, Andersen E, Therkildsen MH, et al. Human papillomavirus in head and neck squamous cell carcinoma of unknown primary is a common event and a strong predictor of survival. PLoS One. 2014 Nov 4;9(11):e110456. 77. Masterson L, Moualed D, Masood A, Dwivedi RC, Benson R, Sterling JC, et al. De-escalation treatment protocols for human papillomavirusassociated oropharyngeal squamous cell carcinoma. Cochrane Database Syst Rev. 2014 Feb 15;2:CD010271.

The Importance of Ultrasound in Otolaryngology: Applications, Future Developments, Resident Education, and Accreditation Christopher E. Fundakowski, MD The concept of ultrasound dates back to 1794 when Lazaro Spallanzani proposed a novel mechanism of spatial orientation used by bats—echolocation. It took approximately 120 years before one of the first ultrasound transducers was developed, a hydrophone to identify icebergs, three years after the Titanic sank in 1912. Over the course of that century, several key breakthroughs occurred which allowed for the development of ultrasound technology as we see it today. A series of experiments by Swiss physicist, Jean Colladon, utilized two boats on Lake Geneva 10 miles apart from one another, and compared the speed of sound of ignited gunpowder to that of a bell struck underwater. He observed that sound traveled approximately four times faster in water than in air, proposing a speed of 1435 meters/ second (an impressive observation for the early 1800’s, only off by 49 meters/second to the accepted speed of sound in water known today at 1484 meters/second). The second key discovery was the piezoelectric effect by the Curie brothers in 1880. This effect notes that when electric stimulation is applied to specific materials (such as quartz), it will cause mechanical distortion and vibration, which will subsequently produce energy in the form of sound waves. Clinical applications lagged by approximately 60 years, until Dussik (an Austrian psychiatrist) first utilized ultrasound for the detection of brain tumors in 1942.1 For comparison, computed tomography (CT) was developed in the 1960’s, with magnetic resonance imaging (MRI) first developed in the 1970’s.2,3 Today ultrasound has extremely wide clinical utility with various applications in nearly all facets of medicine. The field of surgery as a whole was a comparatively early adopter of ultrasound. Today, many otolaryngologist-head and neck surgeons consider it to be an indispensible tool. Ultrasound has become essential in the workup and subsequent management

of both thyroid and parathyroid disorders.4 Ultrasound may also be utilized as the initial imaging modality for neck mass evaluation in both adults and children.5-7 Other investigations regarding the utility of ultrasonography for pediatric laryngeal nodule evaluation have also been described to avoid anesthesia.8 In addition, salivary glands are readily imaged with ultrasound, with neoplastic, inflammatory, and infectious disorders all able to be characterized.9 In these various head and neck subsites, ultrasound also serves a critical role in terms of image guidance for both fine needle aspiration and core biopsy procedures. Ultrasound possesses inherent advantages which have led to its increasingly widespread use and broadening applicability within otolaryngology despite the availability of advanced imaging technologies such as CT, MRI, sestamibi, and PET. Lack of ionizing radiation, relative portability, decreased comparative cost, lack of intravenous contrast, lack of confined space for which to incite claustrophobia, and instantaneous image acquisition are some of the benefits. The availability and applicability of ultrasound is being taken to new limits by technological advancements in telehealth. Investigators in Europe have utilized various portable devices which are operated over an internet connection to obtain ultrasonographic images at distances up to 7,000km between the patient and sonographer.10 Our group (Fundakowski, et al, unpublished data) has also performed feasibility studies here in the United States for thyroid ultrasound utilizing a robotic arm controlled over a wi-fi connection at a distance of approximately 1,200km. Rapidly occurring refinements in both hardware and software may soon permit for the placement of tele-operated ultrasound probes in locations remote from a trained sonographer outside of an experimental setting. Some 12

specific applications of this technology will range from local (where a sonographer may no longer need to be present at bedside during image acquisition in either an outpatient or hospital setting), regional (where a sonographer may control/read ultrasounds from numerous sites in an area), to remote (where a tele-operated device may be placed in a medically underserved region without ultrasound support or trained sonographers in order to provide this diagnostic service). A comparative disadvantage of ultrasound lies in the inherent variability of image acquisition which may occur secondary to various sonographer technique and probe positioning, as well as the inability of a probe to capture the entire cross-section of the neck in a single image as in the case of a CT or MRI scan. While for a comprehensive neck or thyroid ultrasound, “standard” images are expected to be obtained at predetermined regions/levels/views, the provider who interprets the ultrasound is only able to comment on regions which are covered by the sonographer (and in many situations this is two different individuals). This drawback has potential consequences when examining lateral neck, posterior neck, and even some thyroids, as the probe may require multiple passes to adequately survey this area. Any pathology which may fall in a “watershed” area between probe passes may not be imaged, and consequently not reported by the radiologist. When reviewing adult thyroid/central compartment and lateral neck ultrasound the provider must view several separate cineloops, (in children the additional topography/width is able to be obtained in a single pass given smaller diameter/anatomy) compared to the comprehensive axial/sagittal views of either CT or MRI. Opportunity exists to further refine ultrasound rendering software which merges passes together. Unfortunately, when compared to the photostitching which occurs

on a panoramic setting on many consumer cameras (relatively flat surface with infinite depth of field), the neck is a convex structure and as a result the ultrasound has variable beam overlap which increases as beam depth increases. Thus, software must be programed to consequently eliminate this overlap without losing any of the detail critical for diagnosis and clinical decision-making. Modifications to both hardware and software to improve and standardize images are currently underway. Technological advances have dramatically decreased the size of ultrasound systems, and have resulted in increased portability. Ultrasound transducers are now able to be wireless as well. Of additional interest is a new wireless ultrasound transducer likely pending FDA clearance at the end of 2016 which communicates directly with either smartphone or tablet. As a result of this technology, providers will be able to go from room to room in clinic with ease, transition from outpatient to inpatient consults, and perform head/neck ultrasounds where the only additional equipment is the transducer as most individuals already carry a smartphone. The implications of this degree of portability are dramatic in terms of clinical productivity, rapid patient assessment in various settings, community health screenings, and educational opportunity for properly trained residents in both outpatient and inpatient settings.

that examines all aspects of the practice (physician training, exam protocols, machine maintenance/calibration, and case study evaluation). As a result, all physicians performing ultrasound in the practice are covered under the accreditation. Fees associated with the accreditation are based on such factors as number of ultrasound machines, number of different specialties performing ultrasound, and number of sites where ultrasounds are performed. Implications of accreditation may be of increasing importance for otolaryngologists performing office ultrasounds in situations where third party payers require accreditation in ultrasound as a condition for reimbursement. AIUM has 2 different sets of accreditation training guidelines for physicians who evaluate/interpret: (1) ultrasound examinations of the head/neck versus (2) ultrasound examinations of the thyroid/ parathyroid. Minor differences exist between the two sets of guidelines with regards to background training, maintenance of skills/case number, and continuing medical education.

Given the many advantages of ultrasound technology and the broad applicability to otolaryngology, several avenues have been developed to provide additional structured training and subsequent certification and/ or accreditation. A collaboration by a joint task force of the American Academy of Otolaryngology â&#x20AC;&#x201C; Head & Neck Surgery (AAO-HNS) and the American Institute of Ultrasound in Medicine (AIUM) has resulted in an accreditation program for otolaryngology practices aimed to signify that high quality ultrasonography is being performed by trained providers.

For head/neck ultrasound accreditation training, involvement in 150 head/neck ultrasounds during residency along with structured didactics in ultrasonography (if residency was completed within the last 36 months). If residency was completed greater than 36 months prior, involvement with 150 head/neck ultrasounds over a 36 month period, in addition to the American College of Surgeons (ACS) head and neck ultrasound course, and passing of both the pre/post ACS examination is required. Ten ultrasound cases are required for be submitted for review from at least three of the six major categories (salivary gland, lymph nodes, congenital, endocrine, infection/trauma, miscellaneous mass lesions), two of which must be FNA. AIUM recommends 50 head/neck ultrasounds annually for maintenance of competence, along with 12 AMA category 1 credits in head/neck ultrasound every three years.

This joint task force has established guidelines for training/experience, continuing medical education, and for performance of ultrasound examinations in an otolaryngology practice. Compared to certification, ultrasound practice accreditation is a peer review process

For thyroid/parathyroid accreditation training, involvement with at least 100 thyroid/parathyroid ultrasounds during training along with structured didactics in thyroid/parathyroid ultrasound. If training was completed over 36 months ago, then involvement with 100 thyroid/parathyroid

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ultrasounds is required over the last 36 months, along with 15 AMA category 1 credits in thyroid/parathyroid ultrasound. Four abnormal ultrasound cases are required to be submitted, one of which with FNA. Maintenance of competence is considered to be at 100 ultrasound exams and 30 FNAâ&#x20AC;&#x2122;s annually, with 15 AMA category 1 credits every three years. Alternatively, successful completion of the endocrine certification in neck ultrasound (ECNU) program by the American Association of Clinical Endocrinologists (AACE) will be accepted as proof of sufficient training in thyroid/ parathyroid ultrasound. ECNU certification requires a certification examination, and validation of competency with case submission, with fees ranging between $1,050-$1,550 depending on level of training, and AACE membership status. Ultrasound will continue to play an increasing role in the otolaryngology practice and it will be of great importance to maintain that otolaryngologists possess excellent knowledge of the relevant anatomy, appropriate training, and proficiency to utilize this technology for clinical decision-making and various procedures for patient care. It is important to note that all of the above mentioned certifications and accreditations are currently voluntary, and that just as prior to the existence of these guidelines, many otolaryngologists who already integrate ultrasound routinely into their practice will be able to continue to provide high quality care without formal certification and/or accreditation. The development of recommendations for standardized ultrasound training will hopefully not only benefit currently practicing otolaryngologists who are interested implementing and/or further refining the role of this technology in their practice, but also current and future residents in the form of more structured educational sessions, practice on phantom models, and hands-on opportunity during the course of their training so that they are able to transition seamlessly to independent clinical practice. References 1. Dussik KT. The ultrasonic field as a medical tool. American journal of physical medicine 1954; 33:5-20. continued on page 14

The Importance of Ultrasound continued from page 13 2. Oldendorf WH. Isolated flying spot detection of radiodensity discontinuities-displaying the internal structural pattern of a complex object. IRE transactions on bio-medical electronics 1961; BME-8:68-72. 3. Damadian R. Tumor detection by nuclear magnetic resonance. Science 1971; 171:1151-1153. 4. Sung JY. Parathyroid ultrasonography: the evolving role of the radiologist. Ultrasonography 2015; 34:268-274. 5. Cvorovic L, Milutinovic Z, Strbac M, Markovski S. What is important for ultrasound evaluation of occult metastatic lymph nodes in laryngeal cancer: size, shape, vascularity or cytological findings? ORL; journal for oto-rhino-laryngology and its related specialties 2007; 69:172-175. 6. Roper B, Nuse N, Busch R, Zimmermann FB, Nahrig J, Molls M. Tissue characterization of locoregionally advanced head-and-neck squamous cell carcinoma (HNSCC) using quantified ultrasonography: a prospective phase II study on prognostic relevance. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology 2007; 85:48-57. 7. Stern JS, Ginat DT, Nicholas JL, Ryan ME. Imaging of pediatric head and neck masses. Otolaryngologic clinics of North America 2015; 48:225-246. 8. Ongkasuwan J, Devore D, Hollas S, Jones J, Tran B. Laryngeal ultrasound and pediatric vocal fold nodules. The Laryngoscope 2016. 9. Zajkowski P, Ochal-Choinska A. Standards for the assessment of salivary glands - an update. Journal of ultrasonography 2016; 16:175-190. 10. Arbeille P, Zuj K, Saccomandi Aet al. Teleoperated Echograph and Probe Transducer for Remote Ultrasound Investigation on Isolated Patients (Study of 100 Cases). Telemedicine journal and e-health : the official journal of the American Telemedicine Association 2016; 22:599-607.

PAO-HNS Member Recognized by Pennsylvania Medical Societyâ&#x20AC;&#x2122;s

Annual 40 Under 40 Awards

Amanda Hu, MD, has been selected as a recipient of this yearâ&#x20AC;&#x2122;s 40 under 40 awards, presented by the Pennsylvania Medical Society. This annual awards program recognizes those physicians who have demonstrated a significant amount of success early in their medical career. Dr. Hu is a practicing Otolaryngologist with Philadelphia Ear, Nose & Throat Associates. She is an emerging leader at PAO-HNS, as well as the AAO-HNS, where she sits on several committees. Additionally, she serves on the board of directors for both the Ear, Nose & Throat Journal and the Journal of Voice.

The PAO-HNS would like to congratulate Dr. Hu for this recognition and thank her for her continued dedication to our organization.

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President’s Message

L E G I S L AT I V E U P D AT E

continued from page 1

Milliron Goodman The 2015-16 legislative session has been difficult for medicine, due to reasons such as political infighting, financial responsibilities, and a transition of knowledge within the halls of Pennsylvania Government. Nonetheless, the PAO-HNS has and continues to deliver positive results for your patients and profession. Undoubtedly, the engagement of PAO-HNS in state government has ensured quality results for patients. Specific issues that PAO-HNS has delivered for its membership include the following: 1. Scope of practice – The PAO-HNS is the first line of defense for patients to receive quality care. It is your Academy that has ironed out details to ensure patients are not being exposed to medical treatments and diagnosis from individuals that do not have medical education and training. Even though the legislation that we amended to ensure quality care is passed into law, the fight continues. The Academy is dependent upon you as a constituent to make sure your local Representatives and Senators know the importance of their legislative decisions, and that they have you expertise to rely on when making votes on issues. Audiologists and SLPs will undoubtedly come back for a scope expansion soon. When they do, it will be much more realistic to expect help from legislators who know you rather than rushing in at the last minute. We will be in Harrisburg every day to help make sure your message is delivered to the right ears. However, we will need your support “back home” to make sure patients are only exposed to quality healthcare. 2. We expect regulations promulgated from the State Board of Audiology and SLPs. While we are hopeful that language in the regulations will be palatable, we certainly are prepared for variables. These regulations are a result of the scope expansion for Audiology and SLPs signed into law a few years back. Regulations have the power of law, and they are critically important. 3. Back in April, the Academy worked with the House of Representatives to recognize World Voice Day in Pennsylvania. This recognition is important for patients and your profession. We work in concert with the American Academy to bring this important Resolution to the floor of the Pennsylvania General Assembly. 4. The Pennsylvania Academy continues to engage in the E-Cigarette issue. There are currently two bills in the Pennsylvania legislature that put regulation on this growing industry. The first was taxation, which is now law. The second is age; this issue is still being considered. The Academy focuses advocacy on issues that protect patients. E-Cigarettes is certainly one of those issues and will continue to become a greater focus for the Academy moving forward. 5. The PAO-HNS lobbyists at Milliron Goodman continue to work in concert with PAMED on some key issues, including Truth in Advertising, Opioids, Balanced Billing, Medical Marijuana, and CRNP independent practice. Obviously these are complex issues and you’ve read plenty about them from PAMED; however, it is important for you to know that we are all in this together. A few months back, Milliron Goodman sent out an analysis on the transition of Pennsylvania state government, which included statistics of transition. Since 2010, there has been nearly a 60% turnover in the House and Senate. There is a tremendous opportunity to provide new Representatives and Senators with critical knowledge for the issues that impact your patients and profession. Building relationships with key legislators during this time of transition will prove to be invaluable for PAO-HNS. I challenge you right now to ask yourself if you know who your Representative and Senator are. If so great, reinforce that relationship. If not, why not? They certainly have a tremendous impact on your patients and profession. Do you really want to let that power go unchecked? Please do not hesitate to contact us at Milliron and Goodman Government Relations if we can be of further assistance or you have questions, (717) 232-5322.

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otolaryngologists, we can all help with this task by working together, identifying important legislative and advocacy issues, and talking with state legislators and community groups. Our next Annual Scientific Meeting will be held at the Hotel Hershey in Hershey, PA on June 16-17, 2017. Our program coordinator, David Cognetti, MD has already started working to develop another tremendous program. I look forward to seeing you all in Hershey next June. The PAO-HNS has continued to strive to support all otolaryngologists in the state by addressing educational, legislative, advocacy, and practice management issues. I encourage you all to get involved with our vibrant state society. There are many ways to contribute, from serving on a committee, to coming to our annual meeting, to educating state legislators in your area on issues important to otolaryngologists and our patients, to informing other otolaryngologists about the value of joining the PAO-HNS. If you have an interest in playing a more active role, please do not hesitate to contact me. It has been an honor to serve as your President for the past 15 months. I wish you all a happy, healthy holiday season.

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