DCR and Nasolacrimal System (Cadaver) Prithwijit Roychowdhury, BS1; C. Scott Brown, MD2; Matthew D. Ellison, MD2 1University of Massachusetts Medical School 2 Department of Otolaryngology, Duke University
Nasolacrimal duct obstruction (NDO) is the most common disorder of the lacrimal system that affects patients of every age and results in excessive tearing (epiphora) and if untreated, painful infection (dacryocystitis). When NDO symptoms progress and can no longer be managed with conservative measures, endoscopic dacryocystorhinostomy (DCR) is indicated.
In this case, DCR exploration of the nasolacrimal anatomy is performed on a cadaver. The typical presentation of NDO is epiphora but the presence of painful swelling of the medial canthus and mucoid or purulent discharge may indicate the presence of dacryocystitis. The approach presented here involves the creation of a mucosal flap and subsequent use of the DCR drill to expose the nasolacrimal duct anatomy.
The application of minimally-invasive approaches in otologic surgery, including the management of middle ear tumors like glomus tympanicum tumors, represents a promising advancement in the field, potentially improving surgical outcomes and patient recovery. In this article, a patient with pulsatile tinnitus is found to have a glomus tympanicum tumor of the right ear. Calhoun Cunningham III, MD performs a transcanal resection of the mass using the KTP laser.
Partial laryngectomy, with its roots tracing back to the early 19th century, has evolved over time as an alternative operative approach for a select group of patients with glottic and supraglottic malignancies. The goal was to preserve speech and swallowing without committing to a permanent tracheostomy. In this video, in the context of a cadaver dissection course held at Duke University, the techniques for partial laryngectomy are demonstrated. The initial segment of this video focuses on explaining the two types of laryngeal surgeries: supraglottic laryngectomy and supracricoid laryngectomy with cricohyodopexy, or cricohyodoepiglottopexy (CHEP). Although these surgeries aim to preserve the functionality of the larynx, performing them may impact voice, swallowing, and airway protection.
Temporal Bone Dissection (Cadaver) Cameron M. A. Crasto1; C. Scott Brown, MD2 1University of Toledo College of Medicine 2University of Miami Miller School of Medicine
Temporal bone dissections are a critical learning tool for otologic/neurotologic surgery. The “Temporal Bone Dissection Manual” from the House Institute has long served as a ‘gold standard’ for the stepwise demonstration of this process. In this video, a progressive step-by-step dissection of the temporal bone is performed. Key anatomical structures and landmarks and outlined, and their physiological importance in the context of different otologic pathologies is explained. The procedure begins with the identification of soft tissue landmarks and surface anatomy before delving into cortical mastoidectomy and facial nerve identification. The mastoid tip region is discussed, before moving on to describe the tegmen and endolymphatic sac. A facial recess dissection is performed and middle ear anatomy is explained. A labyrinthectomy and exposure of the internal auditory canal conclude the dissection. In addition to going over the anatomy of the temporal bone dissection, a discussion of how to execute these procedures safely and efficiently is conducted.
By having a thorough understanding of the anatomy of the temporal bone, medical students, residents, and fellows are better able to understand the reasoning behind different otologic procedures and how they can be used to treat patients. This demonstration was created to inform and teach residents and medical students about temporal bone anatomy.
Vocal fold injection (VFI) is a treatment modality applicable to various laryngeal diseases and is successfully used as an alternative to laryngeal framework surgery. The indications for in-office VFI include vocal fold paralysis, paresis, atrophy, and scarring along with their sequelae. This video is a detailed demonstration of office-based VFI in a patient with unilateral vocal fold paralysis (UVFP), which is the most common neurologic disorder affecting the larynx.
Mastoidectomy David M. Kaylie, MD, MS1; Adam A. Karkoutli2; C. Scott Brown, MD1 1Duke University Medical Center 2Louisiana State University Health Sciences Center – New Orleans
Mastoidectomy involves the removal of bone and air cells contained within the mastoid portion of the temporal bone. Common indications for this procedure include acute mastoiditis, chronic mastoiditis, cholesteatoma, and the presence of tympanic retraction pockets. Mastoidectomy may also be performed as part of other otologic procedures (e.g. cochlear implantation, lateral skull base tumors, labyrinthectomy, etc.) in order to gain access to the middle ear cavity, petrous apex, and cerebellopontine angle.
The procedure involves dissecting within the confines of the mastoid cavity, which include the tegmen superiorly, the sigmoid sinus posteriorly, the bony ear canal anteriorly, and the labyrinth medially. Mastoidectomy is traditionally classified as: simple (cortical/Schwartze), radical, and modified radical/Bondy’s mastoidectomy. The procedure can also be classified based on the preservation of the posterior canal wall: canal wall up (CWU) or canal wall down (CWD).
Cochlear Implant C. Scott Brown, MD; Calhoun D. Cunningham III, MD Duke University Medical Center
For patients who present with bilateral severe-to-profound sensorineural hearing loss who have little-to-no benefit from conventional hearing aids, cochlear implants can restore hearing by directly stimulating the cochlear nerve.
This video demonstrates the placement of a cochlear implant. A standard mastoidectomy and facial recess approach is performed to visualize the round window niche and membrane. The round window membrane is opened, and the cochlear implant electrode is carefully inserted into the scala tympani. After several weeks, the patient returns for implant activation with a dedicated team of audiologists.
Hypoglossal Nerve Stimulator Russel Kahmke, MD1; Adam Honeybrook, MBBS1; Clayton Wyland2; C. Scott Brown, MD1 1 Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center 2 Lake Erie College of Osteopathic Medicine
Obstructive sleep apnea (OSA) is a common condition with several effective treatment strategies centered around relieving airway obstruction. The gold standard for OSA treatment remains continuous positive airway pressure (CPAP), but other options exist.
A recent therapy developed within the past decade utilizes hypoglossal nerve stimulation (HGNS) through a surgically implanted device. As the patient inspires, the device sends an electrical impulse similar to a cardiac pacemaker. The impulse activates targeted branches of the hypoglossal nerve, leading to stimulation of muscles that protrude the tongue and open the airway posteriorly. This mechanism has been shown to reduce airway obstruction by activating these muscles during inspiration.
Along with detailing the chronological order of events, this case outlines various complex anatomical structures that are identified in order to safely and effectively implant the hypoglossal nerve stimulator.
Anterior Skull Base Resection of Esthesioneuroblastoma (Endoscopic)
David W. Jang, MD¹; Ali R. Zomorodi, MD¹; Feras Ackall, MD¹; Josef Madrigal, BS²; C. Scott Brown, MD¹ ¹Duke University Medical Center ²David Geffen School of Medicine at the University of California, Los Angeles
First described by Berger in 1924, esthesioneuroblastoma (ENB) remains a rare sinonasal tumor believed to originate from specialized sensory olfactory cells. To date, the literature includes 1,000 recorded cases of ENB. Patients with ENB often present with non-specific symptoms, most often chronic nasal obstruction or epistaxis. Careful examination may reveal a pink or brown polyploid mass in the nasal cavity. Overall, ENB may demonstrate various growth patterns ranging from slow, indolent progression to aggressive invasion with widespread metastasis.
Current literature indicates that ENB should be treated with a combination of surgical resection and postoperative radiation therapy with or without chemotherapy. However, significant controversy remains regarding the appropriate surgical approach. This video demonstrates a transnasal endoscopic approach, which has gained significant popularity over the previous two decades compared to classic “open” approaches. Although this approach demonstrates improved perioperative outcomes while still achieving oncologic margins, further work is required to evaluate long-term survival.
Otosclerosis can lead to progressive conductive hearing loss, significantly affecting quality of life. For patients who choose surgery, the tympanic membrane is elevated, and the middle ear space is explored. If the surgeon confirms that the stapes is fixed in the oval window, either a stapedotomy or stapedectomy can be performed.
In the stapedotomy, the surgeon removes the stapes superstructure, creates a fenestration in the footplate, and places a prosthesis from the incus through the fenestration into the vestibule. In this instance, the patient was able to regain nearly all of the hearing that had been lost as a result of stapes fixation.
