Surgery will remain mainstay of treatment in management of Head & Neck Cancer but surgeon’s role will change

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SAARC ENT Conference Proceedings

Surgery will remain mainstay of treatment in
management of Head & Neck Cancer but
surgeon’s role will change

Those most responsive to changing spectrum
will survive - Dr. Jatin Shah

KARACHI: Dr. Jatin Shah a world renowned Head and Neck Surgeon from New York delivered Prof. Javed Alam Khan Memorial lecture during the recently held 8th SAARC ENT Conference at Karachi. The topic of his presentation was the evolving role of the surgeon in multidisciplinary treatment of Head and Neck Cancer. Surgery, he said, has bright history in the management o diseases of head and neck. The role of surgeon has been changing as it does not remain the only modality for treatment. Changes have taken place and we have to be part of this change if we have to survive. Cancer treatment modalities now include surgery, radiotherapy, chemotherapy, targeted therapy and gene therapy.
Speaking about the treatment goals, he mentioned quality of life and longevity of life. If there is not quality of life, it is just prolongation of misery for the patient. Almost 50% of cases will require surgery, 20% will need radiotherapy and the remaining 30% will require combination of chemotherapy and radiotherapy. Management should aim at preservation of functions and organs. In advanced disease all the three treatment modalities may be needed or at least two will have to be used. There is a changing trend in epidemiology and etiology of oropharyngeal cancer. Open surgery is going down but chemotherapy and radiotherapy is on the rise with good preservation of larynx. Salvage operation is going up. Endoscopic surgery, minimally invasive surgery and robotic surgery are going up while salvage surgery has emerged as a specialty in itself. He also talked about complication of concurrent radiotherapy and chemotherapy in detail. Surgeons have a role in salvage surgery for persistent diseases, recurrences, palliation, rehabilitation; surgery for complications as an adjunct therapy. Surgery will remain but the role of surgeons will change. Surgery has definitive treatment in thyroid cancer, parotid cancer, oral cancer, nasal cavity paranasal sinuses and very advanced cancer. Salvage surgery may be considered for previous surgery. It offers good quality of life, improvement of survival and alleviation of symptoms. He then talked about post operative wound complications after salvage surgery besides discussing post operative measures in salvage surgery. One has to be careful to avoid hypotension and use antibiotics. Surgery will also be needed for strictures, contractures. While managing a cancer patient, the surgeon, radiotherapist, and medical oncologist all have to make a commitment for life to their patients. Surgery, Dr. Jatin Shah said will remain main stay of treatment in the management of head and neck cancer but the surgeons role will change. The surgeons should have a working knowledge in radiation, medical oncology, genetics, molecular biology and basic sciences to be a leader of the team. Future for surgery is exciting, challenging and will require practice of evidence based medicine to ensure value based care. He concluded his presentation by stating that only those who are most responsive to changing spectrum will survive and not the intelligent and strong one.
Earlier Prof. Umer Farooq read the citation for late Prof.Javed Alam Khan and paid him rich tributes for his contribution to promote the discipline of ENT, Head and Neck Surgery in Pakistan.

Prof. Hiranandani Memorial lecture

Dr. Ravi Ramalingam from KK Hospital and Clinics Chennai India delivered Prof.Hiranandani memorial lecture and the topic of his presentation was Tips and Tricks of Stapes Surgery. To begin with he disclosed that he and their team at KKR ENT Hospital and Clinics have performed 298 cochlear implants during the Year 2013. We do lot of work and my father has done over fifteen thousand stapes surgery and many amongst the participants may be interested to know how to do this operation. Government of India, he said, provides free cochlear implants for children. We do stapes in local anaesthesia and this is the way we do and it works. He also showed the patient position during the surgery which provides support to surgeon’s hands. First one must clean the air canal. For canal infiltration use five gauze needles. He then showed how they do canal incisions and curettage. He also discussed the required exposure and how much bone should be removed. He then demonstrated removal of supra structures of stapes, making the fenestra. Large fenestra does not work in thick foot plate. There should be space between the piston and fenestra. He then showed repair of tympanic membrane and tear during stapes surgery. In case of congenital ossicular chain malformations, do not proceed for the operation. It is extremely important that one should know when not to go for surgery and learn when to say No. He also showed the over hanging facial nerve. One might see some complications in persistent stapedil artery. He then showed a video of malleous to footplate assembly.
Earlier Dr. Arun Agarwal from India read the citation for late Prof. Hiranandani who contributed a great deal to this discipline. He was the recipient of numerous awards from the government of India and various organizations in recognition of his services.
The next day Dr.Shahid Qureshi from UK talked about Day Case Parathyroid surgery. He pointed out that the patient must be first cleared by endocrinologist. He gave details of 170 patients they had managed and the operation time was sixty minutes. They were all Day Cases and discharged in the afternoon. Most of the patients were female. None of the patients were converted from local to general anaesthesia. Normal calcemia was achieved in 93.7% of cases. His conclusions were that open MIP is a safe and well tolerated procedure.
Dr. M.K. Teneja from India made a presentation on minimum access mastroidectomy. He stated that we do canaloplasty and meatoplasty which can be performed in small towns as well. We do loud speech testing and facial nerve can be assessed. We practice save blood supply techniques during surgery. He then showed the canal incision. I give antibiotics for ten days and polish the cavity carefully, he added. Dr.Bimal Kuma Sinha from Nepal gave details of their project ENT Hospital at Door Step. He discussed in detail this programme which is being run and managed by Impact Nepal for the last many years. In our department, he said we conduct regular workshops on Temporal Bone Dissection and FESS surgery. Talking about prevalence of hearing impaired he said it was about 4% in South Asia, 9% in Bangladesh, 16.6% in Nepal. In Nepal about four million patients require ear surgery. Impact India stated organizing Mobile Ear Camps and their whole set up is built in a Train which goes to various parts of India to do ear surgery and so far they have performed four thousand operations and examined three lac patients. The train is named as LifeLine Express. Impact has also helped Bangladesh and they have established Life Boat Moving Hospital. Giving details of the work done by Impact Nepal, he said that we started this programme in 1988 and so far we have organized fifty one camps and examined over one lac patients under this programme. Under international Nepal Fellowship, twelve camps were organized where four thousand operations were performed and over forty thousand patients have been examined so far. In 1993, Impact Nepal Tent Operation Theatre was introduced. Local support is always required for such a programme to be successful. Local healthcare personnel are involved to do post operative care and they can refer these patient to us if need be. In the absence of good laboratory facilities, one has to rely on clinical examination and good history. The team consists of one resident, four to six nurses, audiometerician, driver, manager and this is included in the Residents training programme. At eighty camps, sixty thousand patients were screened and four thousand surgeries were performed. Follow up was done in 53 ear camps. In 80% of the cases ear was dry and graft was taken and these patients had good hearing. Through this project poor patients are benefitted. Our results are comparable and it also provides excellent training opportunities to resident young doctors, he remarked.
In the afternoon in the instructional session, Dr.Taneja described canaloplasty in Ear Surgery. This he said is performed when medical treatment has failed and the hearing loss is more than 20 DB. This was followed by an excellent presentation by neuro physician Nadir Ali Syed on fixing Beningn Paroxymal Positional Vertigo (BPPV) in five minutes. This, he said, is a vestibular disorder and it causes spells of vertigo. One in four persons, he said, will suffer from it in their life time but it is easy to treat. He then demonstrated this maneuvering technique and pointed out that if the patient does not move their head, it goes away in few seconds. About 85-95% of patients require just one treatment and it has very few side effects. This technique he further stated is safe, easy to do. No medications are required for this treatment. It is not a popular treatment because no company can promote it and sell it. While exercising this technique, you must tell the patient that this treatment might induce vertigo and they have to be careful but assure them that this will go away soon.
During the discussion Dr.Nadir Ali Syed said that one has to do this technique on both sides with a ninety degree turn. It can also occur post ENT general surgery. The procedure will work the same day, if it remains, call the patient after two three days and repeat the procedure, he added.
According to another report Dr. Muhammad Abdullah from Bangladesh delivered Professor Alauddin Memorial Lecture and highlighted the National strategy on prevention of deafness in Bangladesh. Early detection of hearing impairment and proper management, he said, could prevent permanent hearing disability. Therefore, for prevention and proper management strengthening of services at the primary, secondary and tertiary level is required. Hearing impairment and deafness is an illness that afflicts large numbers of people from all walks of life. Its diagnosis, treatment and prevention are one of the major health challenges in our society. The national strategic plan for prevention of deafness has been developed in Bangladesh. It is expected that implementation of this programme will help to eliminate deafness and hearing impairment in Bangladesh to a great extent. Cochlear implant program in Bangladesh he stated is totally free for the poor candidates with the help of ministry of welfare.
Dr. Jatin Shah from USA delivered a state of the art lecture on risk based treatment of cancer of the thyroid gland. Thyroid cancer incidence and morbidity, he said, is going to be a major problem in all over the world. In USA eight thousand new cases were reported every year but now seven fold increase has been reported and majority of patients are female. Prognosis in Thyroid cancer is very small. The role of radioactive iodine treatment in all patients has not been shown to be beneficial. We have to be careful because it involves lot of money. Apply risk group stratification in selecting appropriate surgical treatment. In low risk patients treatment increase morbidity without improvement in survival. All thyroid operations done for proven or suspected cancer should be extra capsular, he added.
Dr. K.K Handa from, India talked about use of laser in ENT surgery which he stated is very effective in our practice. Standard carbon dioxide laser is used by us in 90% cases and it has lot of advantages. There are different machines available but one should prefer good laser machine with scanner if you want to have good result. Laser, he stated is a good and versatile tool, has better healing and better homeostasis but should be used by expert hands, indications should be proper and safety issues must be considered.
Dr. Muaaz Tarabichi from UAE discussed the management of endoscopic management of cholesteatoma and presented his personal experience of twenty years. Endoscopic technique allows minimally invasive removal of cholesteatoma with results that compare well to traditional post auricular tympanomastoidectomy. The advantages and limitations of the microscope have defined transmastoid access as the surgical intervention of choice for the treatment of cholesteatoma. The wide-angle view provided by the endoscope enables transcanal access to the tympanic cavity and its otherwise difficult-to reach extensions. The attic, sinus tympani, facial recess, and hypo tympanum are the primary sites of disease and surgical failure to cure. Transcanal operative endoscopy is the primary approach to the management of cholesteatoma, he added.
Dr. Zillur Rehman from Bangladesh talked about the endoscopic assisted neck surgery which he stated is relatively a new technique, it is video assisted, and less dissection and no special instrument are required. Selection of patents is very important for this procedure. It has good cosmetic outcome, excellent visualization, better meaningful view, most distal and difficult sites can be revealed. Talking about difficulties, he said, that flap raising, retraction of the slap, going in to difficult areas and identification of the sutures besides long-term follow up and more skill and experienced hands are required. He presented his personal experience of six months duration having twenty four patients operated under general anesthesia with excellent result. All the patients are coming for follow up regularly. It is new addition in the modern devices in the field of Head & Neck surgery. It is safe and feasible procedure but experienced surgeons can do it, he stated.
Dr. Jamil Haider discussed the management of Tongue Carcinoma. It is the most difficult procedure and it is rising in most of the countries. Every year 405,000 new cases are being reported and 50% of them are oral cancer. Early lesions survival rate is 70 to 75%. Complete clinical examination is required including mobility and palpation to access tumor thickness. Incisional biopsy is required to establish histopathology. Early lesions T1 and T2 disease require treatment surgery or radiotherapy, its treatment is expensive and prolongs treatment by six to eight weeks. In advance disease T3 and T4 lesions adjuvant and chemotherapy is required. Occult neck metastasis is the main independent predictor of overall survival. It has its pitfalls and it is essential to maintain adequate margins through the depth of dissection, it has unclear histology, sever dysplasia and failure to accurately mark the specimen.
Dr. Philip W Rouadi from Lebanon discussed the rational of prescribing in Allergic Rhinitis & ENT. Infections. Nasal conjunction is the most difficult to treat and it is alarmingly rising. According to WHO over 400 million people are affected but we think the incidence is much higher. In 2020 half of the World Population will be affected by allergic rhinitis. This disease affects the daily activities of the persons. Patient’s education is most important in the management of allergic rhinitis besides avoidance of environmental triggers, indoor outdoor allergens. Newer oral antihistamines and intranasal steroids are superior to placebos, he added. Prof. Nasir Ahmad from USA presented a short history of management of Head & Neck Cancer.