Robotic Surgery of the ThroatA New Tool for an Old Problem

Nate Joos, MD, ENT

www.SpringfieldClinic.comwww.SpringfieldClinic.com

The Scope of Ear, Nose, and Throat...

• Otolaryngology includes the care and treatment of a variety of diseases:– Ear: Hearing loss, infections, eardrum repair– Nose: Rhinoplasty, sinus surgery, cancers of the nose and

sinuses– Throat: Voice surgery, cancers of the lips, mouth, throat,

voice box, thyroid and parathyroid surgery– Skin lesions of the head and neck (basal cell, squamous cell,

and melanoma cancers)– Sleep medicine and surgery (Also robotic)– Allergy and immunotherapy– Facial trauma repair and facial reconstruction

Of All of Those...

• Head and neck cancer is the scariest!– Many of these lesions are diagnosed after they

have been around for some time due to their sometimes subtle and confusing symptoms

– Difficult to diagnose due to their ‘hidden’ location, making discovery by your PCP a rare event

Where is it happening?

• In 2006, there were approximately 31000 cancers of the oral cavity and the throat diagnosed– Another 9000 were diagnosed in the voice box, or

larynx

• That incidence rises 10 fold across the globe, considering the different uses of oral tobacco products and carcinogens

• Most patients are older than 45, largely between the ages of 60-80

Speaking of Risk Factors...

• We all know that smoking is bad for you, but often the lungs dominate the attention on that fact– Head and neck carcinomas are dominated by the

abuse of tobacco and alcoholic products• 2ppd smokers have been shown to have a 20 fold

increased risk of occurrence when compared to nonsmokers

• Heavy alcohol use has been associated with a 3-4 fold increase

• But TOGETHER, they raise that risk up to 100 fold!

Human Pappilloma Virus

• Certain HPV subtypes have also been implicated in the formation of tonsil/tongue/and throat– The same types that have been shown to cause

cervical cancer in women

– The Gardasil vaccine prevents this association, one motivating factor in the decision to provide it to young people in the United States

Symptoms of H/N Cancer

• Chronic pain: if you have a mouth sore, or sore throat that has been present for more than 4 consecutive weeks, with or without antibiotic use, have it checked out!

• Ear pain: The glossopharyngeal nerve is often responsible for the pain associated with these lesion. It also delivers sensation to the middle ear, and can get cross-wired!– The ear is usually normal on examination in these cases

• Trouble swallowing or painful swallow: The base of the tongue in the throat is key in initiating a swallow– A mass can alter the function of this muscle– Or can directly impeded the passage of food based solely on

the extra mass at this narrow location

More Symptoms...

• Difficulty breathing!

– See in either smaller cancers located on the vocal cords

• Leading to their often earlier diagnoses

– Or at locations right above them (tongue, rim of the voice box)

– Stridor is a term for noisy air turbulence through the voice box, or larynx, and is a serious concern!

• Difficulty opening the mouth fully, or trismus

– Can be caused by tumor invasion into the small muscles responsible for jaw motion, or directly into the jaw joint (TMJ)

More symptoms...

• Cancer has an extremely high metabolic rate, leading to:– Unexplainable weight loss

– Fever

– Night sweats

– Fatigue

• Any unexplainable blood in the mouth or throat should be investigated!

If you have any of these...

• Schedule a visit with your PCP! There can be a number of different diagnoses overlapping in these symptoms, so don’t build anxiety over it, just go get it checked out!

• If your PCP is concerned, they’ll likely refer you to an ENT specialist for a workup.

How are these lesions diagnosed?

• Your ENT provider will perform a complete physical examination and history

• Often times, you may receive a flexible laryngoscopic exam in the office as well

• A CT scan with contrast provides detailed anatomic information regarding the size and extent of the issue

How are these lesions diagnosed?

• A sample of the lesion must be obtained to conform the tissue diagnosis– This is usually done through a short outpatient

procedure known as a direct laryngoscopy

– If the presenting problem was a firm neck mass (which is the case 20% of the time), a specimen may be obtained initially through a fine needle aspiration

• Squamous cell carcinoma accounts for the vast majority of these problematic lesions

How is it Treated?

• There are many treatment modalities available in cases of head and neck cancer.

• Generally, a team of physicians made up of surgeons, medical oncologist, and radiation oncologist accompanied by dietitians and speech therapists will tailor a therapy specific to each patient.

• These decisions are made based upon the tumor size, location, extent of involvement, and patient function with regards to speech and swallow

• And of course.... STOP SMOKING!

Surgical Non-surgical

TransoralEndoscopic

Primary Cancer Site Treatment

What are the Pros and Cons of Each?

Open Surgery

• Pro:– Able to address any sized lesion

– Able to clearly see the margins of resection

– Able to simultaneously address any neck disease in appropriate patients

• Cons:– Very invasive

– High complication rates

– Longest hospital stay

– Pain control more difficult

Chemotherapy and Radiation

• Pros:– No incisions involved

– Able to cure with similar rates to surgery in appropriate patients

– Able to keep all of the voice box in laryngeal tumors

• Cons:– Decreased saliva flow

– Pain of the mucous membranes

– Skin changes

– Can have compromised swallow function and laryngeal function in some cases

Minimally Invasive Surgery

• Pros:– Able to remove lesions without external incisions– Similar cure rates to open surgery in appropriate patients– Short hospital stay– Lower complication rates

• Cons:– Not able to handle tumors larger than about 3-4cm– May still need radiation therapy in some cases, so patient

selection is important!– Can still have compromised laryngeal function in some

cases

What is da Vinci TORS?• Transoral Robotic

Surgery (TORS) provides an alternative treatment option to open surgery, transoral laser surgery, chemoradiation and radiotherapy.

• While TORS is cleared for resections of T1 and T2 lesions as well as benign tissue in otolaryngological procedures, TORS is most commonly used to treat oropharyngeal and laryngeal cancer.

Robotic System Overview

da Vinci® Surgical System U.S. Installed Base 1999 – 2011

199920002001200220032004

Alaska

2005

Hawaii

20062007

20082009

Puerto Rico

20102011

Common TORS ProceduresTORS is ideally suited for the treatment of oropharyngeal and laryngeal cancers and specifically treats:

Tonsillar cancerTumor Location: tonsil, superoposterior tongue, soft palate, lateral and posterior walls of oropharynx

Base of tongue cancer Tumor Location: inferoposterior tongue (base), lateral and posterior walls of oropharynx, superior to epiglottis

Supraglottic cancer Tumor Location: anatomy superior to glottis (vocal cords), including epiglottis, lateral and posterior walls of superior larynx

Oropharynx

Larynx

Common da Vinci TORS ProceduresRadical Tonsillectomy

Perform a meticulous, tissue-sparing dissection at unique angles utilizing the da Vinci EndoWrist Instrumentation

Tongue Base Resection

The superior visualization and increased dexterity provided by the da Vinci System facilitates dissection in the proper tissue planes for cancer that extends deeply into the tongue base

Supraglottic Partial Laryngectomy

The fully articulating EndoWrist instruments allow surgeons to mobilize the ventricular mucosa and meticulously separate the false cord from the attachments of the arytenoid cartilage

•Chemoradiation

•da Vinci

• Surgery

Why da Vinci TORS?

Value for the Patient:

– Low blood loss1,2,3,4

– No visible scarring or disfigurement2

– No tracheotomy2

– Minimization or elimination of need for chemoradiation therapy2,3

– Low rate of complications1

– Short length of stay1,4

– Fast recovery, return to normal speech and swallowing1

– Excellent cancer control1

1 Weinstein GS,O’Malley Jr BS, Desai SC, Quon H; Transoral robotic surgery: does the ends justify the means? Current Opinion in Otolaryngology & Head and Neck Surgery,17:126–131, 2009 2 O’Malley Jr. B, Weinstein GS, Snyder W, Hockstein, NG; Transoral Robotic Surgery (TORS) for Base Tongue Neoplasms, Laryngoscope 116: August 2006. 3 Weinstein GS, O’Malley Jr. BW, Synder W, Sherman E, Quon H; Transoral Robotic Surgery, Radical Tonsillectomy; Arch Otolaryngol. Head Neck Surg/Vol. 133 (No. 12), Dec 2007.4 Boudreaux BA, Rosenthal EL, Magnuson SJ, Newman RJ,, Desmond RA, Clemons L, Carroll WR; Robot-Assisted Surgery for Upper Aerodigestive Tract Neoplasms; Arch Otolaryngol Head Neck Surg/Vol 135 (No. 4), Apr 2009

da Vinci TORS Adoption

• FDA cleared in December 2009: Resection of Benign and Cancerous (T1 & T2) Lesions

da Vinci Transoral Surgery Outcomes

Data from: Dean NR, Rosenthal EL, Carroll WR, Kostrzewa JP, Jones VL, Desmond RA, Clemons L, Magnuson JS. Robotic-assisted surgery for primary or recurrent oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2010;136(4):380-384.

Measure Robotic-Assisted for primary neoplasm (N=15)

Robotic-assisted salvage (N=7)

Open salvage(N=14)

P value*

Median Length of Stay (days)

1.5 5.0 8.2 .14

Gastrostomy tube dependent @ 6 mos

0% 0% 43% .06

Tracheotomy tube dependent @ 6 mos

0% 0% 7% .48

Negative margins 100%* 100% 86% NS

Complications 0% 0% 4/14 NS* Stated P values compare the Robotic-assisted salvage group to the Open salvage group.

“Transoral Robotic Surgery (TORS) not only offers our patients comparable or better oncologic outcomes for oropharyngeal and supraglottic cancer, it does so without  decreasing quality of life in terms of speech and swallowing.  This technology has changed the game entirely. Finally we have  an FDA cleared technique that can be performed by well trained clinicians and offer them excellent outcomes for their patients.” Gregory Weinstein, MD

Other Robotic Uses in ENT

• Thyroid Surgery:– Portions of the thyroid gland may be removed through

the axilla, eliminating any scar on the neck

– Possible due to the visibility provided by the robotic system

• Sleep surgery– Chronic snoring and sleep apnea may be addressed in

appropriate patients with the robot

– Allows visibility to the base of the tongue to allow a reduction in tissue size at this narrow location

– Come hear more about this topic next month at MMC!

Thank You!Questions?

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