S C I E N T I F I C P R O G R A M A B S T R A C T S

62nd ANNUAL MEETINGFairmont Jasper Park Lodge, JASPER

OVERALL LEARNING OBJECTIVES

This meeting offers our delegates the unique opportunity to learn from experts and share their own professional experience in various areas of otolaryngology-head & neck surgery. Participants are also encouraged and challenged to expand their knowledge and ideas beyond the boundaries of health care.

The overall objective of this meeting is to provide community and academic otolaryngologists with relevant and up-to-date information in all otolaryngology sub-specialty areas.

Upon completion of this CME activity, the otolaryngologist should be able to acquire the current approach to formulating differential diagnoses, diagnostic, therapeutic and preventive management of common otolaryngological conditions in the fields of pediatric, laryngology, head and neck cancer, rhinology and facial plastics.

Participants will be cognizant of the latest research undertaken across Canadian universities.

Participants will identify common post-operative complications and learn technical aspects to avoid or minimize such complications.

SUNDAY, JUNE 1, 2008 - MORNING Mary Schaffer Ballroom (ABC)

CPD Credits – 3.5 hoursPOLIQUIN MEDTRONIC RESIDENT COMPETITION Chair: Dr. Emad Massoud, HALIFAX

LEARNING OBJECTIVES:- Participants will be exposed to the array of current clinical and basis science research taking place in the various

otolaryngology head and neck surgery training programs in Canada- Participants will have the opportunity to discuss with the presenters the study plan, research methodology, data

analysis and clinical applicability of their research projects.

09:00-09:15 Introduction and Outline of the Competition – MASSOUD, E., (Awards Chair), HALIFAX, NS

09:15-09:30 The Effect of Lingual and Hypoglossal Nerve Reconstruction on Swallowing Function in Head and Neck Surgery: A Prospective Functional Outcomes Study (University of Alberta) – O'CONNELL D., Rieger J., Harris J.R., and Seikaly H., EDMONTON, AB

OBJECTIVES: To examine the effect on swallowing function of reanastomosis of lingual and hypoglossal nerves divided and reconstructed during head and neck cancer surgery. METHODS: 65 patients underwent resection and free tissue reconstruction of oropharyngeal squamous cell carcinoma between April 1999 and July 2006. Post-operative lingual and hypoglossal nerve status was recorded. All patients were scheduled to undergo videofluoroscopic swallowing assessments pre- and 12 months post-operatively. The pharyngeal residue score, aspiration score, and bolus oral transit time was recorded on all patients completing the assessments. RESULTS: Patients who underwent reanastomosis of their lingual and hypoglossal nerves had decreased pharyngeal residue scores and decreased bolus oral transit times compared to patients who had these cranial nerves sacrificed at 12 months post-surgery. CONCLUSION: Reconstruction of lingual and hypoglossal nerves divided or sacrificed during head and neck cancer surgery preserves the efficiency of the oral phase of swallowing. This improves overall post-operative swallowing function and likely enhances patient quality of life.

09:30-09:45 Informed Consent in Rhinoplasty: A Prospective Randomized Study of Risk Recall in Patients Who are Given Written Disclosure of Risks versus Traditional Oral Discussion Group (Dalhousie University) – HONG, P., Makdessian, A.S., Ellis, D.A.F., Taylor, S.M., HALIFAX, NS

OBJECTIVE: To determine the effectiveness of providing written information to rhinoplasty patients in enhancing patient understanding and retention. DESIGN: A multicenter prospective randomized study in university-affiliated ambulatory surgical centers: 100 consecutive patients seen for rhinoplasty consultation were randomly assigned to (1) those receiving traditional oral dialogue of the surgical risks or (2) those receiving oral discussion and written pamphlet about the risks of the procedure. Ten to 14 days after the consultation, each patient was contacted for the assessment of risk recall. RESULTS: Overall risk recall was higher in the group that received written information (2.3 vs 1.3 of 5 risks; P<0.008). As well, in the group that received a pamphlet, patients with university and post-graduate levels of education had better rate of recall (P<0.05). Female patients in both groups reported higher risk recall (P<0.01). CONCLUSION: Patient risk recall of rhinoplasty is improved with the addition of written information during the informed consent process. The use of supplemental educational materials, in turn, may enhance patient understanding and post operative satisfaction.

09:45-10:00 Quantitative Proteomics of Nasal Mucus in Chronic Sinusitis with Nasal Polyposis (McGill University) –AL BADAAI, Y., DiFalco, M., Tewfik, M.A., Desrosiers, M., Samaha, M., MONTREAL, QC

OBJECTIVE: To investigate qualitative and quantitative difference in protein content of nasal mucus in patients with chronic hypertrophic sinusitis with nasal polyposis as compared to control subjects. METHODS: Prospective case control study. Nasal mucus from patients and control subjects collected, de-salted, re-solubilized and digested using proteolytic enzymes. Peptides were tagged and subjected to 2-dimensional liquid chromatography-mass spectrometry differential expression analysis. RESULTS: Preliminary analysis of 8 samples (4 patients and 4 controls) identified differences in a total of 35 proteins, many of which were related to innate and acquired immunity. A detailed analysis and characterization of the protein isolates from a total of 20 samples (10 patients and 10 controls) will be presented. CONCLUSION: This is the first proteomics study of nasal mucus in chronic sinusitis with polyposis. The interesting findings suggest that innate and acquired immunity is likely to play a role in the progression of the disease. Continuation of this work likely to lead to targeted therapies and biomarkers for chronic sinusitis.

10:00-10:15 A Blinded, Randomized Clinical Study of Preoperative Flexible Fiberoptic Nasopharyngoscopy Alone versus Flexible Fiberoptic Nasopharngoscopy with Mutiview Videofluoroscopy in Determining Pharyngoplasy Type (University of Ottawa) – CONLIN, A., MacCormick, J., Vaccani, J.P., Husein, M., OTTAWA, ON

Velopharyngeal insufficiency (VPI) is a condition characterized by speech hypernasality which is commonly corrected with pharyngoplasty. Literature regarding pre-operative evaluation of VPI emphasizes two investigations: flexible fibreoptic nasendoscopy (FFN) and multiview videofluoroscopy (MVF). Both investigations evaluate velopharyngeal closure and allow the clinician to analyze the nature of the insufficiency; however, the later investigation involves exposure to ionizing radiation. We hypothesize that surgical decision making will not differ, whether the otolaryngologist reviews both FFN and MVF, or FFN alone. This blinded, randomized, clinical trial of pediatric subjects with a diagnosis of VPI compares type of pharyngoplasty planned by an otolaryngologist who has reviewed both FFN and MVF to pharyngoplasty planned by an otolaryngologist who has reviewed FFN, only. Secondary outcome measures include standardized criteria for height of flap, wall movement, and closure pattern. Clinical implications are discussed.     

10:15-10:30 Steel Scalpel vs Electrocautery – A Comparison of Cosmetic and Patient Satisfaction Outcomes of Different Incision Methods (University of Alberta ) - CHAU, J., Cote, D., Harris, J., Allen, H.,RN, Seikaly, H., EDMONTON, AB

OBJECTIVE: To determine which method of skin incision has the superior cosmetic and patient satisfaction outcomes. METHODS: Consenting patients undergoing major head and neck operative resection with bilateral neck dissection that met the inclusion criteria were prospectively enrolled. Each side of the neck was randomly assigned at the time of surgery into one of the following two groups: 1. Scalpel incision; 2. Electrocautery incision. Cosmetic and patient satisfaction outcomes were collected prospectively with patients and outcome assessors blinded to treatment group assignment. Validated self report questionnaires and objective functional measures were utilized. RESULTS: 20 patients met the criteria for inclusion. Analysis revealed no significant differences between groups in terms of cosmetic and satisfaction outcomes. CONCLUSION: Steel scalpel or electrocautery may be used to incise the skin of patients undergoing major head and neck surgery with no difference in cosmetic or patient satisfaction outcome.

10:30-10:45 COFFEE BREAK

10:45-11:00 Development of a New Visual Analogue Scale for the Assessment of Area Scars (University of Western Ontario) - MICOMONACO, D., Fung, K., Mount, G., Doyle, P.C., LONDON, ON

OBJECTIVE: Clinical scar assessment lacks a standardized methodology and consensus on the most appropriate tools for evaluation. This study empirically evaluated whether area scars could be validly assessed by naive observers, as well as

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developing a novel multidimensional visual analogue scale (VAS) for the assessment of area scars. METHODS: Digital photographs of area scars (radial forearm free flap donor site) obtained using a standardized method were evaluated by naïve adults using a paired comparison (PC) paradigm. Observers evaluated scars for 4 dimensions (pigmentation, vascularity, observer comfort, acceptability). Photographs also were assessed for overall severity using a newly developed VAS. Fifty observers generated >10,000 observations. RESULTS: PC data demonstrated observers were able to assess the series of scars with high reliability for all dimensions. Observers demonstrated consistency levels of >95%. For the new VAS, statistical analyses indicated high correlations for ratings of pigmentation, observer comfort, acceptability (r>0.95, p<0.01) and vascularity (r>.70, p<0.05). These data validated use of the VAS in the second experiment. CONCLUSIONS: Comprehensive VAS analysis shows high reliability in mirroring results from the more elaborate PC method for multiple dimensions. Our data support this novel multidimensional VAS method as a valid, reliable, simple, and time-efficient instrument for clinical and research use in reconstructive surgery.

11:00-11:15 Polymorphisms in the TNF Alpha-Induced Protein 3 Gene are Associated with Chronic Rhinosinusitis (Université de Montréal) – CORMIER, C., Bossé , Y., Mfuna , L., Kilty, S., Hudson , T.J., Desrosiers, M., MONTREAL, QC

OBJECTIVE: Possible polymorphisms in genes encoding the TNF alpha-induced proteins 3 (TNFAIP3) and 6 (TNFAIP6) have been suggested by a pooling-based genomewide association scan with more than 550,000 single nucleotide polymorphism (SNPs) in a case-control population with refractory chronic rhinosinusitis (CRS). Review of the literature suggests additional polymorphisms in the gene encoding the inflammatory cytokine TNF-A. We wished to investigate the role of polymorphisms within these three genes in CRS. METHODS: DNA extracted from a population of 206 patients with severe CRS and 200 postal-code matched controls was used. An informative set of 36 SNPs in the TNF, TNFAIP3 and TNFAIP6 genes were selected from the HapMap dataset and genotyped. RESULTS: Two SNPS in the TNFAIP3 gene were significantly associated with CRS (p=0.02-0.04, odds ratio (OR=1.70-1.95). CONCLUSIONS: Theses results support the role of genetic variants in TNFAIP3, but not TNFAIP6, in CRS susceptibility. Previous associations with TNF polymorphisms were not replicated in this study.

11:15-11:30 Do We Measure Up? Is an Objective Measuring Device Necessary for the Accurate Assessment of Oral Cavity Lesions? (Dalhousie University) – BARTLETT, C., Taylor, M., Trites, J., Nasser, J., Hart, R., HALIFAX, NS

OBJECTIVES: The T-stage of oral cavity squamous cell cancer lesions has a significant impact on patient treatment and overall outcome. Oral cavity lesions are often assessed by visual approximation alone. The focus of this study was to determine if the introduction of a measurement tool (a ruler) changes the T-stage of oral cavity lesions. MATERIALS / METHODS: Various pieces of felt that represented oral cavity lesions were placed on the tongues of cadaver specimens. Several pieces of felt of different shapes were used to represent each T stage in the oral cavity tumor staging system (AJCC). The study participants were four head and neck surgeons, four residents and four medical students. All subjects were asked visually inspect the oral cavity of the cadaver and approximate, to the nearest 0.5-centimeter, the size of the lesion. Once they recorded their answers they were asked to use a ruler and measure the same lesions (felt) positioned in the cadaver oral cavity. RESULTS / CONCLUSIONS: In staging of oral cavity cancer the use of a ruler is necessary to increase the accuracy of tumor staging. There was a significant difference in the staging of tumours based on the use of an objective measuring device.

11:30-11:45 Prospective, Double-Blind Randomized Trial Evaluating Patient Satisfaction, Bleeding and Wound Healing Using Polyurethane Foam (Nasopore ®) as a Middle Meatal Spacer in Functional Endoscopic Sinus Surgery (FESS) (University of British Columbia) – SHOMAN, N., Flamer, D., Gheriani, H., Javer, A., VANCOUVER, BC

OBJECTIVE: To compare NasoPore ® and the traditional non-resorbable Polyvinyl Alcohol Merocel® as a middle meatal spacer in FESS. DESIGN: A prospective, double-blind randomized trial of 30 consecutive adults with chronic sinusitis undergoing bilateral FESS. METHODS: Preoperatively, all patients were randomized and blinded to receive NasoPore® on one side and Merocel® in a glove finger on the other. Patients were evaluated one week postoperatively, at which time they completed a questionnaire assessing various symptoms, and then had both spacers removed. The primary surgeon then objectively assessed the nasal cavities with respect to bleeding status. A second clinician (blinded) objectively assessed the healing status at four and twelve weeks postoperatively. MAIN OUTCOME MEASURES: Patient satisfaction, bleeding and wound healing. RESULTS: 24 patients have thus far been enrolled, 11 females and 13 males. Objective bleeding scores at one week postoperatively between the NasoPore® and Merocel® groups showed no significant difference (average 1.05 and 1.03 respectively). Mucosal healing at 4 weeks also showed no statistical significance between the NasoPore® (average Grade 1.00) and Merocel® (average Grade 1.06) groups. Mucosal assessment at 12 weeks and questionnaire

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analysis remain pending. CONCLUSIONS: Preliminary results show no statistical difference between NasoPore® and Merocel® with regards to postoperative bleeding and early mucosal healing.

11:45-12:00 Laser v. Drill Stapedotomy. A Randomized Double Blind Study Comparing Two Common Techniques (University of Alberta) – SZUKEK, J., Admais, J., Diamond, C., Liu, R. , EDMONTON, AB

INTRODUCTION: Laser and microdrill stapedotomy are proven effective methods in the treatment of otosclerosis, a common cause of hearing loss in the adult population. This is the first randomised prospective study comparing outcomes between these two techniques. DESIGN: Randomized Double Blind Study. METHODS: Patients were randomly assigned to laser or drill technique. Audiograms and quality of life questionnaires were administered prior to surgery and at 6 weeks and 3 months post-operatively. Statistical analysis was used to compare outcomes between the two groups. RESULTS: 40 patients were included in the study. 4 were excluded intraoperatively due to either a dehiscent facial nerve or mobile stapes. Audiogram results did not differ significantly between the laser and drill groups, but the laser group had significantly lower incidence of post-operative dizziness. However, the overall cost analysis favored the drill technique. CONCLUSIONS: Outcomes analysis shows a difference in both the techniques and overall costs.

12:00-13:30 LUNCH sponsored by MEDTRONIC OF CANADA

SUNDAY, JUNE 1, 2008 - AFTERNOON Mary Schaffer Ballroom (ABC)

CPD Credits – 2.5 hours13:30-13:45 The Reliability of the Reflux Finding Score Among General Otolaryngologists (University of British

Columbia) – McNEIL, D., Morrison, M., Zhang, H., Lee, P.K., VANCOUVER, BC

BACKGROUND: The reflux finding sore (RFS) is a validated clinical severity scale for findings of laryngopharyngeal reflux on fiberoptic laryngoscopy. To our knowledge there have been no studies to determine whether severity of patient symptoms influence the RFS, nor has the reliability of the RFS been tested for general otolaryngologists. OBJECTIVES: 1. To determine whether the reflux finding score for laryngopharygeal reflux is influenced by symptoms of reflux. 2. To determine the interrater and intrarater reliability for general otolaryngologists in diagnosing laryngopharygeal reflux using the reflux finding score. METHODS: Thirty general otolaryngologists were selected to participate. Participants were asked to complete an internet survey consisting of flexible endoscopic videos of larynges with varying physical findings of reflux and grade the severity of reflux using the RFS. The videos were randomly shown with and without accompanying patient symptoms. RESULTS AND CONCLUSIONS: Preliminary data suggests that the patient symptoms influence whether a larynx is more likely to achieve a high or low RFS. Our results may lead otolaryngologists to rely more on patient symptoms than on endoscopic findings when diagnosing laryngopharyngeal reflux.

13:45-14:00 Microvascular Changes in Oral Mucositis (University of Western Ontario) – HAMILTON, S., Yoo, J., Badhwar, A., Hammond A, Read N, Venketesan V., LONDON, ON

Oral mucositis is one of the most significant toxicities for patients undergoing chemotherapy or radiotherapy for head and neck tumours. Despite the current belief that inflammatory mediators play a pivotal role in the development of mucositis, there remains a lack of effective treatment for this debilitating side effect. The microcirculatory changes which accompany this process have not previously been examined. Orthogonal Polarized Spectral (OPS) imaging is a novel method of evaluating microvascular circulation in real-time. This technology utilizes a non-invasive, hand-held microscope that polarizes and filters light in order to obtain images of the microcirculation. Quantification of inflammatory markers such as red blood cell velocity, aggregation and white blood cell extravasation is then possible. A prospective, cohort observational study was performed using OPS imaging to examine the sublingual microvascular changes in twenty patients undergoing radiotherapy or chemoradiotherapy for head and neck tumours. Longitudinal examination of patients undergoing treatment demonstrates that, despite a high level of objective and subjective mucositis, microcirculatory inflammatory changes were not present. This is the first time that the microcirculatory effects of oral mucositis have been directly observed. These findings contradict the currently proposed mechanism of mucosal damage, and may therefore have an important role in the development of therapeutic interventions.

14:00-14:15 Reconstruction of Parotidectomy Defects Using Free Tissue Transfer Flaps (University of Alberta) - CÔTÉ, D., Seikaly, H., Guillemaud, J., Harris, J., EDMONTON, AB

OBJECTIVE: To utilize objective three-dimensional surface laser scanning and subjective questionnaire data to evaluate post-parotidectomy reconstruction with free tissue transfer flaps. METHODS: A series of patients at the University of Alberta Hospital who required parotidectomy underwent simultaneous reconstruction of the resulting contour deformity employing radial forearm or anterolateral thigh fascial free flap. These patients were matched to a series of patients who

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underwent parotidectomy without contour reconstruction. Both series of patients underwent volumetric analysis using three-dimensional surface laser scanner at the Craniofacial Osseointegration and Maxillofacial Prosthetic Rehabilitation Unit to objectively evaluate volumetric asymmetry. Patients also completed a comprehensive survey to assess post-operative function, complications, and perceptions of cosmetic outcome. RESULTS: Preliminary analysis of the volumetric data suggests a significant objective benefit in symmetry among patients who underwent free flap reconstruction. Additionally, reconstructed patients tended to have better functional and subjective cosmetic outcomes. CONCLUSIONS: Parotidectomy patients who underwent free tissue transfer flap reconstruction tended to have better contour and functional outcomes. Objective volumetric analysis using laser surface reconstruction has a strong correlation with patients’ own subjective perceptions of post-operative cosmesis.

14:15-14:30 Functional Outcomes in BAHA: Comparing Unilateral and Bilateral Conductive Hearing Loss, Single Sided Deafness and Unilateral Mixed Hearing Loss (University of Alberta) – DUMPER, J., Hodgetts, B., Bradner, N., Liu, R., EDMONTON, AB

OBJECTIVE: To compare functional auditory outcomes of patients with bone anchored hearing aids(BAHA), in 4 subgroups (unilateral conductive(UC), and mixed(UM) hearing loss, bilateral conductive(BC) hearing loss and single sided deafness(SSD)), both with and without the BAHA. STUDY DESIGN: Cross-sectional Cohort Study. SETTING: Tertiary Medical Centre. METHODS: 60 adult patients (15/group) received a BAHA between June 1996 and June 2007, they were recalled to undergo a pre and post intervention audiometric evaluation (with and without the BAHA). Quality of life questionnaires, the speech and spatial qualities questionnaire and abbreviated profile of hearing aid benefit, were used to measure subjective benefit. Objective benefit was measured with the hearing in noise test (HINT). RESULTS: Subjective testing showed a significant (P<0.05) benefit for all 4 subgroups when comparing aided to unaided. Objective testing showed a significant (P<0.05) benefit in both BC and UC subgroups, but failed to show a benefit in UM or SSD subgroups. CONCLUSION: BAHA should be encouraged in patients with bilateral and unilateral conductive hearing loss. Patients with SSD and UM hearing loss may get limited benefit.

14:30-14:45 COFFEE BREAK

14:450-15:00 Auditory Testing in Mice: A Comparison of Three Methods (University of Manitoba) – QUDDUSI, T., Blakley, B., WINNIPEG, MB

BACKGROUND: Although auditory brainstem response (ABR) is the most commonly used method to assess hearing in basic research electrocochleography (ECoG) is reportedly more sensitive. To address the differences in sensitivity and reliability of ABR and ECoG (soft and needle electrodes) this study was undertaken. METHODS: Seventeen mice were studied. ABR and ECoG tests with soft and needle electrodes were interpreted in a blinded manner. Kappa statistics were calculated for different types of test, examiners, and repetition of the same test on the same mice at various time intervals. RESULTS SUMMARY: ABR test was more sensitive and repeatable than either the ECoG with soft or needle electrodes. Of the two types of ECoG testing the needle electrode was more sensitive and repeatable. CONCLUSION: Murine testing illustrates and probably exaggerates the difficulties in obtaining reliable objective auditory measurements. We believe that these results should be kept in mind when testing hearing in humans in certain situations.

15:00-15:15 Measurement of Impact Stress on the Human Cadaveric Larynx - A Novel Technique (McGill University) - YOUNG, J., Daniel, S., Black, M.A., Rind, G., Mongeau, L., MONTREAL, QC

OBJECTIVE: To investigate a non-invasive method for measuring the stresses associated with impact between the vibratory surfaces of the vocal folds. These impact stresses may be responsible for the formation of nodules, polyps and cysts. METHODS: High-speed images of the human cadaveric larynx will be studied using Digital Image Correlation (DIC), a method used to measure strain fields by tracking random speckle pattern deformations. Impact stresses may be estimated from the resulting data through the use of a Hertzian impact model. Prior to human testing, pig larynges will be studied in order to perfect speckling and dye choices. RESULTS: Two dyes have been found to speckle successfully. Preliminary results of a fresh human larynx using DIC has shown promising results for impact stress measurements. CONCLUSIONS: The proposed method is a promising tool for measuring impact stresses. Human trials are warranted. These findings may have clinical application for laryngeal pathology..

15:15-15:30 Octreotide (Sandostatin): Radioprotective Agent For Rats Salivary Glands Receiving Gamma-Knife Radiation (Sherbrooke University) – BELZILE, M., St-Amant, M., Dorion, D., SHERBROOKE, QC

OBJECTIVE: Radiation therapy for head and neck cancer has deleterious side effects. Xerostomia affects quality of life in patients treated for SCCHN. Octreotide (sandostatin), a drug used specifically in acromegaly and other digestive pathologies, can have a radioprotective effect on salivary glands. METHODS: This is a prospective randomized controlled study on animals. We collected saliva bilaterally for 40 minutes from the parotids of 20 anesthetized rats pre-radiation and at 72h et 1

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month post-radiation. The rats were randomly injected 30 minutes before radiation with either saline or octreotide and given 30 Gy of radiation on the left parotid by gamma-knife. RESULTS: The difference between irradiated and non-irradiated gland at 1 month is significantly more important in the saline group than in the octreotide group considering the initial difference (p=0,036). CONCLUSION: Our results suggest that octreotide has protected the left parotid from the negative effect of gamma-knife radiation at 1 month.

15:30-15:45 Testing Biomechanical Strength of Grafts Sealed with Adjuncts in an Ex Vivo Model of CSF Leaks (University of Toronto) – DE ALMEIDA, J., Morris, A., Whyne, C., James, A., Witterick, I., TORONTO, ON

OBJECTIVES: Repair of CSF leaks with grafts can be augmented with various adjuncts to improve approximation such as tissue adhesives, sutures, and U-Clips. Here we test each of these adjuncts in an ex vivo model of CSF leak repairs. METHODS: A novel pressure testing system was designed to evaluate the burst pressures of graft-substrate interfaces. Porcine pericranium grafts were harvested and were used to repair a 0.5cm defect in a tissue substrate. These grafts were sealed in place with serum (control), Tisseel, suture, U-clips, and combined suture and Tisseel. Tisseel samples were tested both as 'underlay' and 'overlay' repairs. Specimens were subject to burst pressure testing and pressure-time graphs were recorded. RESULTS: Mean burst pressures for grafts sealed in place with Tisseel were significantly better than all other adjuncts (14.96 psi (Tisseel) vs. 3.96 (control) vs. 4.16 (U-clip) vs. 6.22 (Suture); p< 0.05). U-clips and sutures did not increase burst strength over controls and sutures did not have a synergistic effect with Tisseel (12.09 psi). Grafts tested with Tisseel were stronger when tested as 'underlay' than as 'overlay' ( 14.96 vs. 2.95 psi). Three patterns of graft failure were observed based on unique pressure-time graphs. CONCLUSIONS: Burst pressure testing yields valuable information about the strength of repairs for simulated defects. Three mechanisms of graft failure are hypothesized based on unique pressure-time curves.

MONDAY, JUNE 2, 2008 - MORNING Mary Schaffer Ballroom (ABC)

CPD Credits – 1.0 hoursSATELLITE SYMPOSIUM 07:00-08:00 Principles of Tympanoplasty Surgical Techniques

CHAIR: Westerberg, B., VANCOUVER, BCPANEL: Bance, M., HALIFAX, Rappaport, J., MONTREAL, Chen, J., TORONTO

LEARNING OBJECTIVES:At the conclusion of the workshop, the attendee should:1. Have have an understanding of different surgical approaches to repair TM perforations;2. Know which patient-related factors are important to recognize when deciding on a surgical tympanoplasty approach;3. Be able to appropriately counsel patients regarding the likely success rates of tympanoplasty surgery based on patient-related factors.

OBJECTIVE: to review appropriate approaches to maximize successful surgery for repair of tympanic membrane (TM) perforations. PARTICIPANTS: this workshop is designed to meet the requirements of Otolaryngologists who perform tympanoplasty surgery as part of a general otolaryngology practice, and of otolaryngologists in-training. WORKSHOP OUTLINE: The panel will be presented clinical examples of TM perforations. They will be asked to describe their typical surgical approach to each perforation, what factors they considered in deciding on that approach, and what success rate for closure of the perforation is expected. Informal discussion between the panel members and the audience will be paramount.

This symposium is supported by ALCON CANADA through a non-restricted educational grant.

MONDAY, JUNE 2, 2008Mary Schaffer Ballroom (ABC) - MORNING

CPD Credits – 4.0 hoursOPENING SESSION Chair – Dr. R. Rae, President

08:00-08:10 Welcome and Presidential Address – R. Rae, SAINT JOHN, NB08:10-08:15 Introduction of First Guest of Honour Dr. Joseph Wong, Toronto, ON – R. Rae, Saint John, NB08:15-08:35 Guest of Honour Presentation – J. Wong, TORONTO, ON08:35-08:40 Introduction of Second Guest Speaker Dr. Derald Oldring, Edmonton, AB – TBA

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08:40-08:50 Guest of Honour Presentation – D. Oldring, EDMONTON, AB08:50-09:00 Awards Presentations: Residents Competition – E. Massoud, HALIFAX, NS, C. Muir, MEDTRONIC /

Educational Excellence – E. Massoud, HALIFAX, NS, R. Rae, SAINT JOHN, NB / COHNS Fund Fellowships – K. Kost, MONTREAL, QC, J. Harris, EDMONTON

09:00-09:05 Introduction of the Inspirational Speaker, Senator R. Dallaire, OTTAWA, ON – H. Seikaly, EDMONTON, AB

09:05-10:00 Inspirational Guest Speaker Address – R. Dallaire, OTTAWA, ON10:00-10:30 COFFEE BREAK10:30-10:35 Introduction of Guest Speaker Dr. Warren Bell, Canadian Assoc. of Physicians for the Environment,

SALMON ARM, BC – A. Tan, KINGSTON, ON10:35-11:15 The Environment ‘R’ Us – How We Humans (including members of the CSOHNS) are Interacting With

the Ecosystem and It With Us – W. Bell, SALMON ARM11:15-11:20 Introduction of Guest Speaker Dr. John Chaplin, AUCKLAND, NZ – H. Seikaly, EMONTON, AB11:20-12:00 Cutaneous Malignancy of the Head & Neck in the Southern Pacific Region – J. Chaplin, AUCKLAND,

NZ12:00-13:30 LUNCH & VISIT TO EXHIBITORS

MONDAY, JUNE 2, 2008 - AFTERNOONMary Schaffer Ballroom (AB)

CPD Credits – 2.5 hoursPAPER SESSION: GENERAL OTOLARYNGOLOGYModerator: Dr. M. Black, Montreal, QC

13:30-13:37 Botulinum Toxin Injection for Spasmodic Dysphonia – T. Alandejani, A. Lamothe, J. Lemire, E. Lalonde., OTTAWA, ON

LEARNING OBJECTIVES:1. To review, evaluate and compare the effects and side effects of botulinum toxin injection for the treatment of spasmodic dysphonia in the literature and in a local hospital in a Canadian city (Ottawa).2. To review and evaluate the technique, doses, effectiveness and side effects of botulinum toxin used in The Ottawa hospital, Voice clinic.

OBJECTIVE: To review our experience with botulinum toxin injection for the treatment of patients with spasmodic dysphonia. STUDY DESIGN: Retrospective chart review. METHODS: Between January 2001 and December 2006, 26 patients were treated in The Ottawa Hospital, voice clinic. All patients had adductor spasmodic dysphonia. Botox was injected into unilateral thyroaryetenoid muscle under EMG guidance, in an alternating fashion. The dose was adjusted by titrating its efficacy and side effects.Patients were seen at 2,6 and 10 weeks post 1st injection by SLP. At each visit patients reported their benefits and side effects and a VHI (voice handicap index) was filled prior to injection and 2 weeks after injection.(peak effect). Patients reported their benefit as: very good, satisfied (not fully recovered, but returned back for reinjection for better voice quality) or unsatisfied. RESULTS: 77% of patients had a very good result , 15.4% had a satisfied result and 7.6% had an unsatisfied result. Side effects included 2 patients who had mild dysphagia to liquids. CONCLUSION: The method and technique we use appears to be safe and effective in the treatment of adductor spasmodicdysphonia and corresponds with results in the literature.

13:37-13:44 Acoustic Analysis of Normal Saudi Adults – F. Alzhrani, K. Almalki, A. Hagr, RIYADH, KSA

LEARING OBJECTIVES:1. To review the normative data of acoustic analysis in normal Saudi adults.

OBJECTIVES: Our main objective is establishing normative data of acoustic analysis in normal Saudi adults. This normative database is important in order to confirm diagnosis, determine severity of dysphonia and follow patient after treatment. METHODS: Institutional ethics committee approval and individual informed consent from study participants were obtained. We are performing acoustic analysis to a random sample of 50 male and 50 female normal Saudi adults who have no vocal symptoms by using the Multidimentional Voice Program (MDVP) software installed to the Computerized Speech Lab (CSL). RESULT: The normative data will be analyzed using SPSS software. Multiple linear regression will be used to identify statistically significant associations between the acoustic voice variables and the independent variables of sex and age P < 0.05 will be considered statistically significant. CONCLUSION: The results will permit us to explore the normative data of acoustic analysis in normal Saudi adults.13:44-13:51 Nasal Patency Assessment in Sleep Apnea – W. Qian, J. Chen, J. Haight, Y. Ma, TORONTO, ON

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OBJECTIVES: Nasal patency was measured on patients with obstructive sleep apnea (OSA) and normals to find out the relationship between nasal congestion and OSA. METHODS: 79 patients with OSA (male: 76; mean aged: 42.8+/-10.3 years old; Apnea Hypopnea Index (AHI)>10) and 41 normal subjects (male: 33, mean aged: 37.9+/-10.9; AHI <10) undertaken measurements of nasal respiratory resistance and nasal volume at 7 am right after polysomnograpgy. Average nasal respiratory resistance was measured by anterior rhinomanometry and the sum of bilateral nasal cavity volumes, 2 to 5 cm from the front nostril, was measured by acoustic rhinometry (AR). RESULTS: The nasal resistances were 2.02+/-1.43 Pa∙m-3∙s-1 in patients with OSA and 0.64+/-0.57 in normals. The sum of bilateral nasal volumes were 4.90+/-2.75 ml in patients with OSA and 6.44+/-1.65 in normals. There were significant differences between two groups both in the nasal ressistance measurements (p<0.001) and the nasal volume measurements (p<0.001). CONCLUSIONS: Nasal resistance measurement by anterio rhinomanometry and measurement of nasal volume by acoustic rhinometry are non-invasive and easy performing techniques in nasal patency assessment. OSA patients had more congestednasal airways during sleep compared to the non-apneas.

13:51-14:00 DISCUSSION

14:00-14:07 Do We Know How to Clean? A Survey Comparing Flexible Nasopharyngoscope Decontamination Procedures Across Canada – M. Brake, L. Savoury, B. Lee, ST. JOHN’S, NL

LEARNING OBJECTIVES:1. To elucidate the patterns of cleaning of nasopharyngoscopes in Canada2. To determine whether there is a need for a recommended minimum cleaning standard, particularly in office space settings3. To see if there is a wide variation between hospital and private practices of nasopharyngosope cleaning.

BACKGROUND: Nasopharyngoscopes are essential tools for any otolaryngology practice. Due to their frequent usage, it is important to ensure that clean equipment is accessible and obtainable. To date, there are no official guidelines provided by the Canadian Otolaryngological Society for minimal cleaning procedures. OBJECTIVE: To compare the different flexible nasopharyngoscope cleaning practices across Canada. METHOD: An online questionnaire regarding nasopharyngoscope cleaning procedures was distributed to all Otolaryngologists registered with the Canadian Society of Otoarlyngology. The survey was anonymous. Compulsory demographics were limited to province and practice-type. Maintenance, operations, ventilation and in-house standards were also addressed in the survey. RESULTS: There was a participation rate of 35% of the 505 Canadian Otolaryngologists contacted. Automated sterilization of nasopharyngoscopes is employed by 15.5% of participants, of which 73% of this usage is in hospital settings. Over 62% of participants use a multi-step decontaminating soak for cleaning. Over 27% of participants are unsure as to whether their procedures adhere to infectious disease and industry standards. CONCLUSION: Various procedures are employed throughout Canada, due to lack of standardization. Survey responses indicate that Canadian Otolaryngologists would appreciate a national standard for the cleaning of flexible nasopharyngoscopes, particularly for non-hospital practices.

14:07-14:14 Sinus Irrigation Bottles: A Potential Source of Infection? – E. Chang, K. Wong, H. Shoman, A. Javer, VANCOUVER, BC

INTRODUCTION: Normal saline irrigation is an important component of the treatment of sinusitis. Sinus irrigation bottles are commonly utilized to perform this task. It is not uncommon for the irrigation solution to backflow out of the nasal cavity into the tubing of the irrigation bottle itself, potentially contaminating it. OBJECTIVE: To determine if organisms responsible for sinusitis can be cultured from the tubing and the sinus irrigation bottles. METHOD: A prospective study was performed. Fifteen patients were given sinus irrigation bottles for a period of four weeks for the treatment of their sinusitis. All patients had endoscopically guided swabs taken directly from the middle meatus on the first visit prior to the initiation of the sinus bottle use. The bottles were then returned and cultured. Microbiology data was collected. RESULTS: All fifteen irrigation bottle tubing had positive cultures. There was a significant correlation between initial nasal cavity cultures and those from the sinus bottle tubing. CONCLUSIONS: Sinus irrigation bottles are potential source of sinus re-infection. We recommend that patients change their irrigation bottles on a biweekly basis and clean them after each use. A sinus irrigation bottle without tubing and one that is not prone to nasal backwash may be an alternative option.

14:14-14:23 DISCUSSION

14:23-14:30 Percutaneous vs Open tracheostomy: Separating Myth from Reality – K. Kost, MONTREAL, QC

OBJECTIVES: Several 'dictums' pertaining to traditional open surgical tracheostomy (ST) and percutaneous tracheostomy(PCT) have been handed down in the literature from paper to paper and are simply accepted as fact. For example, it has beensaid that ST: 1. Done in the OR is the safest way to perform tracheostomy. 2. Is safer in patients with anatomicallyunfavorable necks. 3. Allows for placement of 'stay sutures', which facilitate recannulation. Of PCT, it has been said that: 1.There is a learning curve. 2. It is contraindicated in obese patients. 3. Bronchoscopy is optional. 3. There is a higher incidence

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of stenosis. 4. It ‘should be relegated to the wastepile of other failed techniques’. METHODS: An exhaustive review of the published literature as well as the author’s published experience. Results:The‘dictums’ are addressed and answered one by one based solely on the available literature. Some of the answers are indeedunexpected and surprising. CONCLUSIONS: A critical and exhaustive review of the available literature allows for an evidence-based evaluation of long-held assumptions pertaining to both ST and PCT. It is time to separate myth from reality.

14:30-14:37 Endoscopic Stapling versus External Transcervical Approach for Treatment of Zenker's diverticulum – M. Brace, R. Hart, J. Trites, M. Taylor, E. Attia, J. Nasser, HALIFAX, NS

LEARNING OBJECTIVES:1. To compare endoscopic stapling with traditional external surgical approaches for the treatment of Zenker's diverticulum. Specifically:2. To appreciate endoscopic stapling as an effective treatment for Zenker's diverticulum.3. To appreciate the time efficiency advantage of endoscopic stapling provides.4. To appreciate the shorter hospital stay required for patients who have undergone endoscopic stapling.

OBJECTIVE: To compare endoscopic stapling versus external transcervical approaches in the treatment of Zenker's diverticulum. METHOD: A 10-year retrospective institutional review was performed to identify all patients treated for Zenker's diverticulum. Patient age, sex and, duration of symptoms, as well as the treatment type, procedural time, time to oral liquids, length of post-treatment hospital stay, and post-procedural patient satisfaction were recorded and compared. RESULTS: In total 5 patients treated endoscopically were compared to 8 patients treated surgically. There were no significant differences in patient age, sex and duration of symptoms. The external transcervical technique took significantly longer (110.88 minutes ± 57.49) than the staple technique (18.80 minutes ± 4.60), (p=0.001). There was no significant difference in time to full oral liquids (p = 0.134). The post-surgical hospital stay (4.38 days ± 2.07) was significantly longer for the external technique as compared to the staple technique (2.00 days ± 2.24), (p = 0.045). Satisfaction was reported as excellent by patients in all cases, regardless of treatment. CONCLUSIONS: Endoscopic stapling of Zenker's diverticuli achieves comparable operative success and patient satisfaction as traditional external transcervical techniques, with significantly decreased operative times and hospital stays allowing for more efficient use of O.R. resources.

14:37-14:44 Unilateral Tonsillar Enlargement: Is It An Ominous Sign? – Y. Dolev, S. Daniel, P. Campisi, MONTREAL, QC

LEARNING OBJECTIVES:1. To review the literature on tonsillectomy in children with unilateral tonsillar enlargement.2. To highlight that the literature can be misleading in that it places the emphasis on the low incidence of lymphoma of the tonsils rather than on the presenting signs and symptoms. 3. To reinforce the concept that although children who present with unilateral tonsillar enlargement will most likely not have lymphoma of the tonsil due to the low incidence of this malignancy, our case series shows that when they do have lymphoma of the tonsils, they will present with unilateral tonsillar enlargement. Therefore, the presence of unilateral tonsillar enlargement in pediatric population should not be overlooked as has been suggested by some of the literature on the subject.

OBJECTIVE: There is a significant debate over the need for tonsillectomy to rule out lymphoma in cases of unilateral tonsillar enlargement. The aim of this study is to determine whether or not children with tonsillar lymphoma present with unilateral tonsillar enlargement. METHOD: We queried the tumour board registry and pathology records at 2 pediatric tertiary care institution for all cases of tonsillar lymphoma. We examined the clinic, pre-operative and operative notes as well as the pathology results and noted the presenting signs and symptoms. RESULTS: All 10 identified patients presented at their first visit with clinically apparent asymmetry of the tonsils. CONCLUSIONS: We conclude that even though the majority of patients who have unilateral tonsillar enlargement will not have tonsillar lymphoma, most patients with tonsillar lymphoma will have unilateral tonsillar enlargement as one of their presenting signs. Therefore, despite the low incidence of this malignancy in children, careful close follow-up of these patients is warranted given the potentially devastating consequences of missing this diagnosing or prolonging the time to treatment. Moreover, a low level of suspicion should warrant a tonsillectomy.

14:44-14:51 Case Series: Kikuchi's Disease in Vancouver and Its Association with Systemic Erythematous Lupus – P. Pace-Asciak, P. Lee, R. Gascoyne, VANCOUVER, BC

LEARNING OBJECTIVES:1. Learn about what Kikuchi's disease is, how to manage it, and how it can be mistaken for lymphoma2. Learn the prevalence of Kikuchi's disease in Vancouver3. Learn about the association of Kikuchi's disease and Systemic Erythematous Lupus

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We present a case series of Kikuchi’s Fujimoto Disease (KFD), a rare, benign, self-limiting condition that presents with non-specific symptoms making diagnosis difficult. Occasionally, KFD is diagnosed simultaneously, before or after diagnosis with systemic lupus erythematosus (SLE). OBJECTIVES: 1) Increase awareness of this condition among otolaryngologists. 2) Detemine the prevalence of KFD in Vancouver and measure the association of SLE and KFD. 3) Perform a comprehensive literature review to examine the association of SLE and KFD. METHOD: The study is a retrospective chart review of patients diagnosed between 1990-2007. Patients with KFD are contacted to determine whether the development of an auto-immune disease, namely SLE has occurred. RESULTS: Of the forty-one cases that are diagnosed between 1990-2007 by excisional biopsy, thirty five females, and six males have KFD. The average age is 36 with a range (19-67). Notably, none of the cases are children. Our results are comparable to the current literature regarding the association of KFD with SLE. CONCLUSION: We present the second Canadian case series and extensive review of the literature to highlight the clinical & pathological features of this disease and its association with SLE. Few to no studies follow up patients post- Kikuchi’s disease.

14:51-15:00 DISCUSSION

15:00-15:30 COFFEE BREAK & VISIT TO EXHIBITS

CPD Credits – 0.75 hoursWORKSHOP15:30-16:15 Management of Velopharyngeal Insufficiency: The Art and Craft

PANEL: M. Husein, LONDON, ON, J. MacCormick, A., Dworshak-Stokan, OTTAWA, ON

LEARNING OBJECTIVES:1. To understand the concept and implications of velopharyngeal insufficiency as it relates to otolaryngologists2. To understand the multi-disciplinary approach to velopharyngeal insufficiency3. To appreciate the various options, both speech therapy and surgical, in the management of velopharyngeal insufficiency

OBJECTIVE: To discuss the multidisciplinary workup and management of velopharyngeal insufficiency(VPI). METHOD: Two VPI surgeons and a cleft/VPI specialized speech language pathologist will present the workshop. DISCUSSION: There will be a discussion of the perceptual assessment, use of multi-view video-fluoroscopy and video-nasendoscopy in assessing velopharyngeal insufficiency. Further discussion will encompass the various speech and surgical treatment of VPI. There will be multiple videos used to demonstrate the various surgical options in the VPI surgeon’s armamentarium, namely, Furlow palatoplasty, sphincterplasty and the superiorly based pharyngeal flap.

CPD Credits – 0.75 hours WORKSHOP16:15-17:00 Evaluation and Management of Thyroid Nodules and Thyroid Cancer: Updates for the General

Otolaryngologist-Head and Neck Surgeon PANEL: J. Harris, H. Seikaly, EDMONTON, AB, R. Hart, K. Ansari, HALIFAX, NS

LEARNING OBJECTIVES:At the conclusion of this workshop the general otolaryngologist - head and neck surgeon will:1. Be familiar with the current recommendations for the evaluation and management of a patient with a thyroid nodule.2. Understand the treatment goals for thyroid cancer3. Select the appropriate surgical treatment for thyroid nodules and thyroid cancer4. Have seen demonstrations of the surgical technique for various thyroid procedures.

OBJECTIVE: To review the current management of thyroid nodules and thyroid cancer. METHOD: Through didactic teaching, illustrative cases, and audio/visual presentations, the current recommendations for evaluation and management of thyroid nodules and cancer will be reviewed. The American Thyroid Association Guidelines for the management of these patients will form the basis for this workshop. RESULTS: At the conclusion of this workshop participants will have a thorough knowledge of the management process for patients with thyroid nodules and differentiated thyroid cancer. CONCLUSION: Thyroid nodules and thyroid cancers are being seen in increasing frequency by otolaryngolgists. The appropriate evaluation and management of these patients is critical for best patient outcomes.

CPD Credits – 1.0 hoursSATELLITE SYMPOSIUM 17:00-18:00 Septoplasty and Turbinates: A Panel on Treatment and Philosophy

CHAIR: S. Frenkiel, MONTREAL, QC

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PANEL: E. Massoud, HALIFAX, NS, M. Samaha, MONTREAL, QC, J. Korkis, HAMILTON, ON, I. Witterick, TORONTO, ON

LEARNING OBJECTIVES:1. To learn of different philosophies and approaches to septoplasty surgery as practiced by experienced panelists who use varied techniques.2. To discuss techniques of septoplasty to address different septal deformities encountered in clinical practice.3. To share techniques of inferior turbinate surgery used by panelists and audience members, including turbinectomy, turbinate cautery, turbinoplasty and others.

OBJECTIVES: To discuss various techniques available in the surgical management of the deviated nasal septum and inferior turbinate hypertrophy. METHOD: A panel of experts in nasal surgery will be assembled. The panel will emphasize their personal approach and philosophy in dealing with septal and turbinate obstructions. Cases will be presented for discussion.RESULTS: A format encouraging audience participation and discussion will be adopted. Tips and pearls will be shared in a bidirectional fashion between the panelists and the audience with audience members contributing their own experience and techniques. CONCLUSION: Septoplasty and inferior turbinate surgery are among the most commonly performed procedures in Otolaryngology, and are part of most practicing otolaryngologists' surgical activities. The abundance of different techniques used makes a panel discussion with audience participation particularly useful, as most involved may benefit from a tip or pearl learned from colleagues.

This symposium is supported by GLAXOSMITHKLINE through a non-restricted educational grant

Monday, JUNE 2, 2008 - AFTERNOONMary Schaffer Ballroom (C)

CPD Credits – 2.5 hoursPAPER SESSION: RHINOLOGYChair: Dr. Ian Witterick, Toronto, ON

13:30-13:37 Clinical Experience with an Autoregistration Mask in Image Guided Sinus Surgery – A. Chiodo, K. Ngo, O. Smith, W. El-Masri, D. Sommer, TORONTO, ON

LEARNING OBJECTIVES:1. Discuss clinical experience with an optiacl image guided navigation system for sinus surgery.2. Discuss clinical experience with an autoregistration mask for image guided sinus surgery including advantages and disadvantages of this tool.3. Discussion of accuracy of image guided navigation systems

OBJECTIVE: Image guided surgery (IGS) of the paranasal sinsuses has become a valuable tool in endoscopic sinus surgery. Optical image guided systems are widely used and utilize infrared tracking technology. We present our experience with a new auto-registration face mask optical image guided system. DESIGN: Case series SETTING: Toronto East General Hospital and McMaster University Medical Centre. METHOD: Fifty-three patients underwent computer assisted endoscopic sinus surgery using a Stryker Navigation Optical Tracking System. Patients underwent preoperative fine-cut axial computed tomography. At the time of surgery an auto-registration facemask was applied to the patient. MAIN OUTCOME MEASURES: Fiducial registration error (FRE) which is an indicator of the accuracy of the optical system and set up time were recorded. RESULTS: The mean FRE was 0.50 mm +/- 0.15 mm. There were no major orbital or intracranial complications. The average set up time was 5.86 minutes +/- 3.35 minutes. CONCLUSIONS: On review of the literature this new optical system has a measured accuracy superior to other techniques of registering landmarks for image guidance systems. Set up time for the auto-registration mask was minimal. The high accuracy of this registration IGS makes it ideal for sphenoid, frontal, or revision cases where precision is required. The advantage of this type of registration is that the surgeon doesn't have to pick anatomical points on the pre-op CT or patient…

13:37-13:44 Initial Experience Using a New Electromagnetic Surgical Navigation System for Image Guidance During Anterior Skull Base and Complex Sinus Surgery – E. Wright, R. Bhalla, H. Seikaly, J. Harris, R. Broad, EDMONTON, AB

LEARNING OBJECTIVES:At the conclusion of this presentation participants will:1. Have developed a familiarity with the StealthStation AXIEM (Medtronic-Xomed) electromagnetic image guidance system2. Have critically evaluated the usefulness of this new technology for use in complex sinus and anterior skull base surgery

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OBJECTIVES: To retrospectively review our initial experience with a new electromagnetic (EM) navigation system for image guidance during anterior skull base and complex sinus surgery. METHOD: This retrospective chart review of all anterior skull base, endoscopic sinonasal tumour or complex sinus surgeries was conducted between January 2007 and November 2007. RESULTS: To date, a total of 12 patients have been included in the study. Diagnoses included 3 patients with sinonasal malignancies, 4 with juvenile nasopharyngeal angiofibromas, 2 frontal sinus osteomas, and 1 ethmo-orbital ossifying fibroma. In addition, the system was used for 2 patients undergoing revision endoscopic sinus surgery. Allowing for the initial learning curve for system set-up and registration, the system was found to be highly accurate and stable during long cases. Due to its inherent EM technology and discretely placed dynamic reference frame, line-of-site issues were not encountered, a particular advantage when adjunctive, open procedures or craniofacial approaches were required. Metallic disturbance of the EM field by surgical instruments did not interfere with the tracking accuracy. CONCLUSIONS: This new EM surgical navigation system demonstrated significant advantages when used in anterior skull baseand complex sinus surgery and is worthy of continued use and evaluation.

13:44-13:51 Virtual Endoscopy of the Nasal Cavity and Sinuses – S. Frenkiel, R. Glickstein, L. Quoc Huy, A. Seminonov, S. Anand, MONTREAL, QC

LEARNING OBJECTIVES:1. To present the relatively novel technique of virtual endoscopy as it applies to the nose and sinuses. 2. To discuss its advantages and limitations.

Please take note that this is the first presentation of virtual endoscopy at a CSOHNS meeting.

BACKGROUND & PURPOSE: Virtual endoscopy (VE) of the paranasal sinuses and nasal cavities is a relatively newimaging modality in which little has been published regarding its usefulness in identifying key anatomical landmarks and pathological conditions. The aim of this presentation is to present the virtual endoscopic procedure with respect to its value in assessing normal anatomy, abnormal structures and sinonasal pathology. METHOD AND PATIENTS: 25 patients were studies using the virtual technique as part of an overall three dimensional CT reconstruction from the GE 16-slice scanner. Comparisons were made with standard endoscopic clinical evaluation. Video presentations will be used to compare both techniques. RESULTS: Virtual endoscopic examination is an adaquate technique to assess surface anatomy of air containing spaces. There continues to be difficulty in navigating through bone and the technique has difficulty in assessing solid structures. CONCLUSION: VE can provide non- invasive assessment of the nasal cavity and paranasal sinuses. It may assist surgeons in pre and intraoperative planning particularly in cases of a stenotic airway when there is limitation to conventional endoscopy. Further work is needed to enable a more accurate determination of solid lesions.

13:51-14:00 DISCUSSION

14:00-14:07 Is the Detection of Nontypeable Hemophilus Influenza Improved by Using Specific Culture Techniques in Patients with Chronic Rhinosinusitis? – S. Kilty, V. Tremblay, M. Cusson, M. Poisson, M. Desrosiers, MONTREAL, QC

LEARNING OBJECTIVES:1. Become aware of the commonly reported bacterial organisms implicated in CRS.2. Become aware of the culture media used to detect nontypeable Hemophilus influenza(NtHi). 3. Become aware of the potential role of NtHi in CRS.

INTRODUCTION: Staphylococcus aureus and Pseudomonas aeruginosa are principal pathogens recovered in chronic rhinosinusitis (CRS). However, recent reports using molecular techniques have demonstrated a high rate of identification (60-100%) of nontypeable Haemophilus influenzae (NtHi), suggesting that conventional methods do not adequately identify this pathogen. OBJECTIVE: To determine whether present culture methods adequately assess for the presence of NtHi in patients with CRS. METHOD: Prospective study, tertiary academic rhinology practice. For a one month period, all patients undergoing endoscopically guided sinus culture were assessed using both conventional culture media (blood agar with a Staphylococcus aureus streak) and one specifically enriched for detection of NtHi (chocolate agar) and processed by usual protocols. Standard culture techniques for other organisms were also performed concurrently. RESULTS: Only one swab (1/45; 2%) was positive for NtHi. Both culture media grew this organism. CONCLUSIONS: NtHi is not significantly detected in our CRS patient population by conventional culture techniques. The difference between our results and the molecular studies remains unexplained. NtHi may however be present in the form of a biofilm, which would not be detected using conventional techniques. We plan further studies of the bacteriology of CRS using genomic techniques for detection of NtHi to investigate this potentially important phenomenon.

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14:07-14:14 Colonization with Staphylococcus Aureus is Not Ubiquitous in Patient with Nasal Polyposis – C. Cormier, L. Mfuna, P. Boisvert, L.P. Boulet, B. Marie-Eve, S. Vallée-Smedja, M. Desrosiers, MONTREAL, QC

LEARNING OBJECTIVES:At the end of this presentation, members of the audience should be:1) Familiar with the role of S Aureus in the pathogenesis of nasal polyposis2) Familiar with the carriage rate of S Aureus in middle meatal cultures in a prospectively collected population with NP3) Able to identify risk factors for s Aureus carriage in individuals with NP

RATIONALE: A 63% carriage rate for Staphylococcus Aureus (S. Aureus) has been reported in nasal polyposis (Bachert, 2007). This pathogen is believed to produce superantigen which stimulates T and B lymphocytes, leading to development of nasal polyposis. We wished to verify the rate of S. Aureus recovery in a population with nasal polyposis. METHOD: Prospective study, tertiary academic rhinology clinic. Patients being enrolled in a genetic study of nasal polyposis had endoscopic culture of the middle meatus performed as a part of phenotyping. RESULTS: 182/235 enrolled patients had culture results available. 100% had positive cultures, with S. Aureus identified in 32.4%. A trend to increased recovery of S. Aureus was noted with previous surgery (34.9% % vs. 20.0%, p=0.11). In patients with S. Aureus, we noted an increased number of previous surgeries (2.85 vs. 2.14, p=0.05), a trend towards an earlier age at primary surgery, (37.2 vs. 41.0, p=0.1) and lower rate of total serum IgE (144.2 vs. 222.0, p=0.14). No difference was noted for corticosteroid use (p=0.8). CONCLUSION: Staphylococcus Aureus carriage is somewhat increased in nasal polyposis but not frequently enough to implicate superantigen production as a mechanism in all cases. S. Aureus carriage may however reflect a distinct subgroup of nasal polyposis.

14:14-14:21 Total Serum IgE Levels Do Not Correlate With E.S.S. Outcome – S. Al-Ghamdi, H. Yoong, M. Samaha, M. Desrosiers, MONTREAL, QC

LEARNING OBJECTIVES:Total serum IgE is often used as surrogate marker for inflamation in CRS. The origin of this production is not currently known. It could be secondary to either :

. an immunologic response to antigenes present on the surface of sinus mucosa or rather

. a reflection of an unknown constitutional factor(s).We want to study the relation between CRS and total serum IgE levels.

BACKGROUND: Total serum IgE is often used as surrogate marker for inflammation in CRS, however, the origin of IgE production is not known. OBJECTIVE: We want to test the hypothesis that total IgE is a product of the sinonasal inflammation in CRS. As ESS effectively reduces disease load in the sinuses, then IgE should markedly decrease postoperatively. METHOD: Patients scheduled for ESS for severe CRS (as defined by Lund-Mckay score of >11) were prospectively recruited. Blood for total serum IgE were obtained at surgery and 3 months later. Surgical outcome was assessed 3 months post operatively using an Endoscopic scoring system. RESULTS: 41 patients were recruited, 30 patients completed the study. 27/30 ( 90% ) had good surgical outcome at the 3-month point. Median age was 53. 42% had asthma and 38% had environmental allergy. Average Lund-McKay score was 17. Median IgE level was 62 IU/L preoperatively and 66 IU/L postoperatively. Overall there were no significant difference in IgE levels at three months following surgery. CONCLUSION: Total serum IgE does not reflect the disease status of the sinuses and may have only a limited role as a biomarker for disease activity in CRS.

14:21-14:30 DISCUSSION

14:30-14:37 Are Polymorphisms in the Gene for Alpha-1-antitrypsin Associated with Chronic Rhinosinusitis? – S. Kilty, Y. Bosse, L. Mfuna, et al., MONTREAL, QC

LEARNING OBJECTIVES:1. Become acquainted with the manifestations of Alpha-1-antitrypsin deficiency.2. To become aware of the protease/anti-protease paradigm as it applies to CRS.3. To understand the approach for the investigation of potential genetic associations with disease.

INTRODUCTION: Alpha-1-antitrypsin (AAT) is a protease-inhibitor that blocks the effects of the protease neutrophil elastase. Population studies have suggested that a heterozygote status for the gene causing AAT deficiency is an important risk factor for chronic rhinosinusitis (CRS) with polyps. This implies that there may be a genetic predisposition to CRS that correlates with the AAT gene (SERPINA1). OBJECTIVE: To investigate the association between single nucleotide polymorphisms (SNPs) in the SERPINA1 gene and CRS. METHOD: DNA extracted from an existing population of 206 patients with CRS and 196 postal-code matched controls was used. A maximally informative set of SNPs in the SERPINA1 gene were selected from the HapMap dataset and genotyped on the Sequenom platform. RESULTS: A total of 29 out of 30

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SNPs were successfully genotyped (97%). No SNPs were significantly associated with CRS (p>0.05). Subgroup analysis according to severity of CRS did not identify any particular relationships. CONCLUSION: These results demonstrate that the polymorphisms of the SERPINA1 gene that were genotyped are not associated with CRS. These findings do not support the inferences made from previous population studies that were based on protease inhibitor (PI) typing using isoelectric focusing.

14:37-14:44 Polymorphisms in TLR9 Gene Influence Response to Corticosteroids in Severe Chronic Rhinosinusitis – C. Cormier, Y. Bosse, M. Tewfik, L. Mfuna, T. Hudson, M. Desrosiers, MONTREAL, QC

LEARNING OBJECTIVES:At the end of this presentation, the audience will be familiar with:1. The role of Toll-like receptor 9 in the inflammatory process in chronic rhinosinusitis2. The concept of gene polymorphisms in complex diseases such as CRS.3. The possible relationship between TLR9 polymorphisms and response to corticosteroids in patients with refractory chronic rhinosinusitis.

RATIONALE: Decreased levels of TLR9 on sinus mucosal epithelium are noted in a subpopulation of patients with chronic rhinosinusitis (CRS) unresponsive to endoscopic sinus surgery and pre-operative oral corticosteroid therapy. We wished to determine whether polymorphisms in TLR9 influenced response to corticosteroids. METHOD: DNA extracted from a population of 206 patients with severe CRS and 196 postal-code matched controls was used. An informative set of SNPs in the TLR9 gene were selected from the HapMap dataset and genotyped. Stratification of patients according to medication required for disease control was done and standardized algorithm treatment was administered by a single physician: intranasal corticosteroids only (MILD), corticosteroid irrigations (MODERATE) or other agents (oral prednisone, intermittent or continuous antibiotics or uncontrolled disease) (SEVERE).Logistic regression analysis was used to determine association between genotype and phenotype. RESULTS: No difference in genotype frequencies was observed between patients and controls. However, 3 SNPs were associated with response to medication (rs352162: CT allele: Odds ratio (OR) 1.44, CC: OR 1.76, p=0.0005, rs352140: TC: OR 1.12, TT: OR 1.67, p=0.001, rs352143; GA: OR 1.37, GG: OR 1.86, p=0.002). CONCLUSIONS: These results suggest that polymorphisms in TLR9 influence response to corticosteroids in refractory CRS. A second cohort is under study to confirm these results.

14:44-14:51 Cost Benefit of Endoscopic Sinus Surgery in Asthmatic Patients with Chronic Rhinosinusitis – Y. Al Badaai, M. Samaha, MONTREAL, QC

LEARNING OBJECTIVES:1. To illustrate the relationship between chronic rhinosinusitis and asthma as a linked airway disease. 2. To describe the pattern of chronic rhinosinusitis in asthmatic patients.3. To discuss the outcome of endoscopic sinus surgery for chronic rhinosinusitis in asthmatic patients.4. To emphasis the role of endoscopic sinus surgery in asthma control strategy and its cost effectiveness.

OBJECTIVES: To determine the cost benefit of Endoscopic Sinus Surgery (ESS) in asthmatic patients with chronic rhinosinusitis (CRS). METHOD: Prospective cohort study. Subjects were Consecutive patients with Asthma and CRS diagnosis, failed medical treatment and Undergoing Endoscopic Sinus Surgery (ESS). Cost attributable to ESS calculated by including the initial evaluation, preoperative assessment, operating room, recovery room and follow up visits. General health (SF-12 v2) and disease-specific (chronic sinusitis survey (CSS)) outcomes questionnaires were filled out pre-operatively and post-operatively. Comparative analysis with studies looking at asthma control was done. RESULTS: 47 patients with asthma and CRS underwent ESS and completed the surveys. The average improvement of CSS scores was (17 %). The average cost of ESS was $1845 CND. When compared to previous studies, ESS will save 5 hospitalizations per year which translate to around $8000 CND per patient. CONCLUSION: ESS for CRS is a cost efficient treatment modality in asthmatic patients with CRS. This information is important in resources distribution and planning, prioritizing health programs and establishing practice guidelines.

14:51-15:00 DISCUSSION

15:00-15:30 COFFEE & VISIT TO EXHIBITS

CPD Credits – 0.75 hoursWORKSHOP15:30-16:15 From Intention to Impact-How to Become More Involved with Global Health Initiatives

CHAIR: L. McLean, OTTAWA, ON PANEL: B. Westerberg, M. Morrison, N. Shoman, VANCOUVER, J.P. Vaccani, OTTAWA

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LEARNING OBJECTIVES:1. To discuss methods to implement a global health initiative.2. To review a current multidisciplinary and inter-institutional global health initiative in Uganda.3. To understand the limitations involved in a global health initiative.4. To provide mentors and possible resources for those interested in creating or becoming involved in their own global health initiative.5. To understand how participation in a global health initiative may contribute to a resident's training.

RATIONALE: There is a vast disparity in access to health care between and within continents. A large number of people in our world live in oppressive poverty. Global health initiatives are recognized as a valuable resource to close this gap. Humanitarian projects are becoming increasingly prevalent in medicine and many practicing physicians feel the desire to contribute. However, launching or becoming involved in a humanitarian project can sometimes be daunting. OBJECTIVE: This workshop will provide the participant the occasion to discuss global health opportunities, obstacles, motivations and experiences with otolaryngologists who have been involved with past projects (see Section V). INSTRUCTIONAL METHODS: This workshop will be interactive. The participants will be divided into small groups each with a facilitator, and will be asked to discuss known global health opportunities, perceived obstacles and personal motivations for involvement. Each small group will be asked to report back two key insights from their discussion to the larger group. There will then be a 30 minute presentation by the workshop leaders on a multidisciplinary and inter-institutional initiative in Uganda. The presentation will focus on lessons learned on what has worked and what has not worked, why it didn't work, and plans for future work.

CPD Credits – 0.75WORKSHOP16:15-17:00 Complications in Rhinoplasty

PANEL: R. Younger, H. Strecker, A. Bartlett, A., Denton, VANCOUVER, BC, P. Brownrigg, OTTAWA, ON

LEARNING OBJECTIVES:1. Understanding the common complications in rhinoplasty.2. Learning technical aspects of how to avoid or minimize complications in rhinoplasty.3. Faced with a rhinoplasty complication, the panellists will discuss and outline options for management.

Rhinoplasty is a surgical procedure that is performed by many, but mastered by few. Common complications of rhinoplasty will be discussed, and numerous cases will be presented with detailed patient photodocumentation to help understand treatment protocols. Controversy in management options for common rhinoplasty complications will be extensively debated by the panellists including: epistaxis, infection and antibiotics, external nasal deviation-Tip, middle third and bony, nasal obstruction, aesthetic imbalance, nasal scarring, donor site morbidity. Conclusions will be drawn from the panel discussions to help participants employ techniques that will allow avoidance of complications for future Rhinoplasty procedures.

MONDAY, JUNE 2, 2008 - AFTERNOONPyramid Room

CPD Credits – 1.5 hoursPAPER SESSION: HEAD AND NECKChair: Dr. Joseph Dort, Calgary, AB

13:30-13:37 Sentinel Lymph Node Biopsy for Oral Cavity Squamous Cell Carcinoma – S. Popat, N. Rigual, T. Loree, W. Hicks, D. Lamonica, R. Cheney, M. Merzianu, BUFFALO, NY

LEARNING OBJECTIVES:1. Identify the methods to effectively perform sentinel lymph node biopsies of oral cavity squamous cell carcinomas2. Determine the clinical utility and prognosticating value of sentinel lymph node biopsy in oral cavity squamous cell carcinoma

Sentinel lymph node biopsy is part of the paradigm for melanoma and breast cancer investigation and management. It has had limited use in head and neck mucosal disease. Neck nodal metastases is the most important outcome prognosticator for oral cavity squamous cell carcinoma. A significant proportion of clinically N0 patients with oral cavity cancer harbor occult microscopic nodal metastases. For 6 years, we have utilized sentinel lymph node biopsies with preoperative technetium labeled sulfur colloid injection around the tumor to histological stage oral cavity cacers with clinically N0 disease to guide further treatment options. METHOD: 47 patients underwent SLN biopsies obtaining an average of 1.9 SLN's per patient.

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There were 8 patients with a clinical stage of T1, 32 T2 patients and 3 T3 patients. All SLN's were microdisected at 2-3 mm intervals. RESULTS: 40% of patients had N+ disease based on SLN biopsy upstaging their disease. Four of 30 patients (13.3%) with negative SLN biopsies developed lymph nodal metastases in a follow-up period of 6-70 months. Sensitivity was 79% with specificity at 100% and an overall accuracy of 91% accuracy. CONCLUSION: Important technical considerations for the use of SLN biopsy in oral cavity cancer are identified. The procedure is readily performed in a variety of oral cavity tumor locations. In N0 oral cavity squamous cell carcinoma, SLN biopsy is feasible and an accurate predictor of occult neck metastases.

13:37-13:44 Tru-Indications for Core Biopsy, Indications for an Expanded Role for Tru-cut Biopsy in the Head and Neck - J. Franklin, B. Wherli, LONDON, ON

LEARNING OBJECTIVES:1. To Identify indications for core biopsy in the head and neck2. To learn methods to improve the technique of core biopsy and to increase accuracy.3. To understand that core biopsy when utilized correctly is safe and improves resource allocation

BACKGROUND: Tru-cut or core biopsy has long been utilized in the diagnosis of soft tissue sarcomas. With improvements in immunohistochemistry and pathological diagnosis there is a potential expanded role for Tru-cut biopsy for definitive diagnosis in the head and neck without the necessity for open biopsy. PURPOSE: To define indications for tru-cut biopsy in the head and neck. METHOD: Prospective analysis of 23 consecutive Tru-cut biopsies of the head and neck. All patients underwent Fine Needle Aspiration. Patients with planned open biopsy meeting the defined indications underwent a Tru-cut biopsy. Each clinical scenario was analyzed to determine whether the result of the Tru-cut biopsy altered patient management. RESULTS: 23 Consecutive Tru-cut biopsies were analyzed. 21 elicited a diagnostic biopsy. 15 lympoma, 2 salivary gland malignancies, 3 poorly differentiated thyroid malignancies and 1 Nodular Fasciitis. All Diagnostic biopsies altered clinical management. The diagnosis allowed for the appropriate surgery or avoided the necessity for open biopsy. CONCLUSION: Although classically utilized for sarcoma, Tru-cut biopsy is a simple and accurate tool to guide management of head and neck malignancies often alleviating the need for open biopsy. Specific indications for core biopsy are presented.

13:44-13:52 DISCUSSION

13:52-13:59 Discrepancy Between Ultrasonographic and Final Pathology Mesasurements in Thyroid Nodules – L. Sowerby, J. Franklin, C. Chin, J. Yoo, K. Fung, W. Zaleski, LONDON, ON

LEARNING OBJECTIVES: 1. To discuss the error associated with pathologic measurements of thyroid nodules.2. To propose the use of ultrasonographic measurements in making treatment decisions in differentiated thyroid cancer.

BACKGROUND: Staging of differentiated thyroid cancer (DTC) continues to challenge the thyroidologist. Most staging systems use pathological nodule size as a component of staging and this could represent a source of error in classifying disease. OBJECTIVE: Evaluation of the discrepancy between ultrasonographic and final pathology measurements in thyroid nodules. METHOD: A retrospective chart review of all thyroidectomies between 1998 and 2007 by four different surgeons at one centre was completed, identifying 676 nodules in 481 thyroids and 598 thyroid lobes. A comparison of discrepancy and concordance of the largest dimension of the nodule by ultrasonographic and pathologic measurement was made. RESULTS: A median underestimation by pathology of 0.3cm was present, averaging 20% of the nodule size by pathology. This trend was consistent with subgroup analysis for size, pathology and nodularity and was in a normal distribution. Of primary clinical concern, an underestimation by pathology of 0.4cm was present for papillary carcinoma under 1cm. Grouping nodules by size, a concordance of 80% was present for nodules under 1cm. Concordance decreased with increasing nodule size to 40%. CONCLUSION: The recent advances in ultrasound and the constraints of pathology preparation allow an argument to be made for using ultrasonographic measurements in making treatment decisions. Further studies investigating outcome with treatment based on ultrasonographic measurement are warranted.

13:59-14:06 Fine-Needle Aspiration Biopsy of the Thyroid: A Review of Cytopathological Features Predictive of Malignancy – T. Mijovic, O. Gologan, L. Rocho, M. Hier, M. Black, MONTREAL, QC

LEARNING OBJECTIVES:1. Understand the value of specific cytopathological features on fine-needle aspiration biopsies in predicting malignancy of the thyroid.2. Envisage HBME-1 staining as a highly specific marker of thyroid malignancy.3. Consider divergence in pathologic terminology when reading pathology reports.

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OBJECTIVE: To determine the value of specific cytopathological features on fine-needle aspiration specimens in predicting malignancy of the thyroid. MATERIALS AND METHODS: 149 consecutive patients undergoing thyroidectomy from 2005 to 2007 at two McGill University teaching hospitals were reviewed, and further categorized into two groups (benign vs malignant) based on the final histopathological diagnosis. The frequency of specific cytopathological features from fine-needle aspiration biopsy samples were recorded for 108 patients from the first hospital (H1) and 41 patients from the second (H2). RESULTS: At H1, the presence of atypical cells (49% vs 77%, P=.003), anisonucleosis (11% vs 34%, P=.012), hypochromasia (20% vs 53%, P=.001) and irregular nuclear membranes (20% vs 53%, P=.001) correlated with malignancy. These same features were also shown to be significant at H2. HBME-1 staining was available for 53 patients and was positive or focally positive on 61% of the malignant cases (p=.0002) with a specificity of 100%. All biopsies demonstrating intranuclear inclusions were malignant (7/7). CONCLUSION: This study illustrates that atypical cells, anisonucleosis, hypochromasia, irregular nuclear membranes and positive HBME-1 staining on FNA are suggestive of carcinoma. However, variability exists between institutions, as pathologists diverge with regard to their terminology.      

14:06-14:13 Correlation of 665 Thyroid Fine Needle Biopsies with Final Pathology: A Single Institution Experience – J. Franklin, L. Sowerby, C. Chin, K. Fung, J. Yoo, LONDON, ON

LEARNING OBJECTIVES:1. To understand the importance of fine needle aspiration biopsy in thyroid nodular disease2. To understand the categories of aspirates and their clinical applications 3. To know the risk of malignancy with different needle aspirate diagnoses in this large series as well as the largest published series.

INTRODUCTION: Fine Needle Aspiration Biopsy (FNAB) is one of the most useful investigations in the management of thyroid nodular disease. At our institution aspirates are categorized as low, intermediate and high the risk of malignancy Correlation with final pathology is critical and is institutionally dependant. STUDY DESIGN: At a single institution, 665 thyroid nodules with FNAB diagnosis and final surgical pathology were categorized and analyzed for correlation. Risk of malignancy of malignancy was calculated. RESULTS: 665 needle aspirates were taken from the right, left and isthmus (383, 271 and 11respectively). 86 (12.9%) Aspirates were suspicious or positive for malignancy of which 88.4% were positive for malignancy on final pathology. Insufficient material was encountered in only 9.8% of aspirates. 3.7% of benign biopsies revealed malignancy. Indeterminate biopsies carried a 30% risk of malignancy as compared to cystic contents which revealed malignancy in 5.2%. Intermediate risk aspirates were malignant in 9.6% of surgical cases. CONCLUSIONS: High risk aspirates carried a very high specificity for thyroid malignancy. Malignancy rate for the different categories of aspirate at final surgical pathology in this large series are consistent with other published series. Rate of insufficiency was low.

14:13-14:26 DISCUSSION

14:26-14:33 Complementary & Alternative Medicine Use Among Patients Presenting to a Head & Neck Clinic – T. Vyas, R. Hart, J. Trites, J. Nasser, M. Taylor, HALIFAX, NS

LEARNING OBJECTIVES:1. To help guide clinicians in their work-up of patients for surgery and further management and the importance of inquiring about CAM use.2. To help determine the prevalence and significance of CAM use among a patient population, and to determine the types of CAMs used most by patients and the reasons for their use and as such help guide clinicians in counselling patients and any of their misconceptions.3. To help clinicians determine patients' sources of information on CAMs and thus be better informed regarding any potential issues in patient information.

OBJECTIVES: To determine the prevalence of complementary & alternative medicine (CAM) use among patients presenting to a Head and Neck Oncology clinic. METHODS: The study was conducted by administering a questionnaire to 100 new patients after they were seen in the Head and Neck Oncology clinic for their initial consultation. The questionnaire was administered by an Oncology research assistant. The questionnaire assessed the extent of CAM use in this cohort, the types of CAM used and their reasons for use. The results were pooled and analyzed. RESULTS: Preliminary reports reveal that CAM use is prevalent in the population. Reports also show that there are specific CAMs in greater use than others and that there are a wide number of reasons for their use. CONCLUSION: As CAM use among the population is widespread, it is important for clinicians to specifically address their use on initial presentation. Such knowledge will identify patients at risk for complications prior to the initiation of treatment and potentially could reduce patient morbidity and mortality.

14:33-14:40 Multilevel Organ Preservation Strategy in Laryngeal Cancer: An Emerging Paradigm – N. Sadeghi. WASHINGTON, DC

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LEARNING OBJECTIVES:1. To have critical understanding of the literature on laryngeal organ preservation. 2. To understand the role of endoscopic laryngeal tumor surgery in organ preservation.3. To understand patient selection strategies for best method of organ preservation.4. To understand multilevel laryngeal preservation strategy through synthesis of relevant literature.5. To learn on indications for and limitations of endoscopic endolaryngeal cancer surgery

Partial laryngectomy and radiotherapy have been important organ preserving treatments for early laryngeal cancer for overhalf a century. However, for moderately advanced laryngeal cancer, organ preservation only recently became a reality withchemoradiation protocols. With chemoradiation, anatomic organ preservation has become the modus operandi in treatment oflaryngeal cancer at the cost of significant histoanatomic organ injury. The advent of endoscopic endolaryngeal tumorresection has enabled a new era in the management of laryngeal cancer. This new surgical development takes the concept oforgan preservation one step further from anatomic-only preservation to histologic and partial anatomic preservation.Eliminating the long term injury to the larynx and neck from radiotherapy is central in preventing histoanatomic injury. Thesuccessful use of this new paradigm in organ preservation requires higher sophistication in patient selection for amultilayered strategy of organ preservation. The highest level of desired preservation is functional preservation with bothhistologic and partial anatomic preservation through modern surgical approaches. When this is not feasible, the next level ofpreservation is anatomic with nonsurgical strategies at the cost of significant histoanatomic organ injury. The author’sexperience with a series of endoscopically managed laryngeal cancer and an extensive review of the literature will bepresented to illustrate this emerging paradigm.

14:40-14:47 Voice-related Quality of Life Analysis in Laryngectomized Patients - R. Moukarbel, P. Doyle, J. Franklin, J. Yoo, K. Fung, LONDON, ON

LEARNING OBJECTIVES:Vocalization is what characterizes us as humans and analyzing the vocal outcomes in laryngectomized patients is of utmost importance. We will demonstrate the different voice related outcomes as related to the type of voice restoration modality in adition to identifying the effect of different individual and treatment variables on the final outcome of alaryngeal speech.

OBJECTIVE: To compare the voice related quality of life (V-RQOL) outcomes in a cohort of laryngectomees who are using different voice restoration modalities. MATERIALS AND METHODS: A V-RQOL questionnaire database stored at the Alaryngeal Voice and Speech Laboratory at the University of Western Ontario was analyzed for outcomes. RESULTS: 75 patients were analyzed with 24 females and 51 males. There were 15 patients in the esophageal speech (ES) group, 18 in the electrolaryneal speech (ELS) group and 42 in the tracheo-esophageal speech (TES) group. The mean age was 64.1 years. The social-emotional, physical-functional and total scores were significantly better (p<0.05) in the TES group, as compared to the ES, or the ELS groups. Patients in the ELS group were noted to have an improved outcome with time and with older age. This was not seen in the other groups. There was also a trend for age to negatively correlate with the outcomes in the ES group. CONCLUSION: TES shows a better V-RQOL outcome post laryngectomy when compared with other alaryngeal speech modalities. Age and time elapsed post-op may affect voice outcomes with ES and ELS.

14:47-15:00 DISCUSSION

15:00-15:30 COFFEE & VISIT TO EXHIBITS

CPD Credits – 1.5 hoursSPECIAL SEMINAR15:30-17:00 Organ Preservation by Transoral Laser Microsurgery in Cancer of the Upper Aerodigestive Tract -

CHAIR: W. Steiner, GERMANY, J. Harris, EDMONTON, AB

LEARNING OBJECTIVES:At the end of this workshop the participant will understand the role of transoral laser microsurgery for organ preservation inthe upper aerodigestive tract.

TUESDAY, JUNE 3, 2008 - MORNING Mary Schaeffer Ballroom (AB)

CPD Credits – 1.0 hoursSATELLITE SYMPOSIUM 07:00-08:00 Interesting and Challenging Cases in Pediatric Otolaryngology

CHAIR: Daniel, S., MONTREAL, QC

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LEARNING OBJECTIVES:At the end of this workshop, participants will learn the management and controversies surrounding challenging pediatric otolaryngology cases. Entities discussed include congenital neck masses, chronic otorrhea, nasal masses, and ethical dilemmas in pediatrics.

The objective of this workshop is to present interesting and challenging cases encountered in a pediatric otolaryngology setting. Real scenarios will be presented to an expert panel to discuss their approach and management. Audience participation is encouraged.

This symposium is supported by SCHERING PLOUGH through a non-restricted educational grant.

CPD Credits – 2.0 hoursPAPER SESSION – OTOLOGYChair – Dr. A. Zeitouni, Montreal, QC

08:00-08:07 Psychiatric Sequalae of Benign Positional Vertigo BPV – S. Alromaih, A. Hagr, Y. Alhudhail, RIYADH KSA

LEARNING OBJECTIVES:1. Understand the relation between BPV and psychiatric illness.2. Help otolaryngologist to deal with psychiatric sequalae of BPPV.

BACKGROUND: No studies have assessed psychopathology among benign paroxysmal positional vertigo (BPPV) patients only. The Distributing Hospital Anxiety and the General Health Questionnaire allow for evaluation of psychiatric problems associated with physical illness. OBJECTIVE: To assess the psychiatric illness in Saudi patients with BPPV. METHOD: The study is cross-sectional in nature. Institutional ethics committee approval and individual informed consent from study participants will be obtained. RESULTS: Data will be analyzed using SPSS software, comparing different patient scores. P < 0.05 will be considered statistically significant. CONCLUSION: The results will help otolaryngologist to deal with psychiatric sequalae of BPPV.

08:07-08:14 Otolithic Organ Involvement in Gentamicin-Induced Vestibular Ototoxicity – L. Kadhim, M. Zarandy, P. Kessler, J. Rutka, TORONTO, ON

LEARNING OBJECTIVES:Otolitic organ is more resilient to ototoxic agents than other part of the vestibular system. VEMP is to be considered as an additional method of assessment in patients with gentamicin induced vestibulotoxicity and maybe an indicator for severe vestibular damage. A normal VEMP is considered as a good prognostic indicator in patients with gentamicin induced ototoxicity. Saccular Involvement in Gentamicin-Induced Vestibular OtotoxicityOBJECTIVE: To determine the incidence of saccular involvement in ototoxicity and to investigate whether vestibular evoked myogenic potentials (VEMP) are relatively preserved in ototoxicity as compared to caloric responses. METHOD: Retrospective cohort study of patients with systemic gentamicin induced vestibulotoxicity. Pure-tone audiometry, electronystagmography with bithermal caloric testing, VEMP and scleral coil tests were reviewed. RESULTS: Forty six ears were affected. Thirty two% did not elicit a VEMP response, 10% showed undetermined VEMP responses while 68% showed normal VEMP responses. Caloric responses showed abnormalities in 80.5% of tested ears, whereas MSSCT could identify a lesion in 94%. CONCLUSION: Our results provide further evidence that the saccule is more resilient to ototoxic agents than other parts of the vestibular system and hence its involvement suggests a more severe damage. We suggest the VEMP test to be considered as an additional method of assessment in patients with gentamicin-induced ototoxicity.

08:14-08:21 Sniffing Induced Middle Ear Pressure Changes – L. MacLachlan, M. Bance, M. Gulliver, HALIFAX

LEARNING OBJECTIVES:1. Review normal protective mechanisms for negative pressure from nasopharynx2. Review data linking sniffing and CSOM3. To analyze data suggesting normal subjects differ from CSOM patients in nasopharyngeal pressure protection

OBJECTIVES: Sniffing induced negative pressure has been implicated as a cause of middle ear retraction pockets and cholesteatoma, and has been demonstrated to cause negative middle ear presssures in many studies in patients with chronic suppurative otitis media. The impact or prevalance of sniff induced middle ear pressure changes have not been investigated in normal subjects for comparison however. Our objectives were to test this phenomenon in subjects with no middle ear

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disease, and compare to CSOM subjects. METHOD: Tympanometry with a 226 Hz probe tone was used to measure 1) resting middle ear pressures 2) pressures after valsalva 3) Pressures after sniffing vigorously in 20 subjects with no known middle ear disease. A group of patients with known eustachian tube dysfunction were also tested. RESULTS: Of the 20 subjects tested, none showed significant changes in middle ear pressure with sniffing. Seven examples of sniff induced negative pressures in subjects with eustachian tube dysfunction will be presented. CONCLUSIONS: The normal middle ear is protected from nasopharyngeal negative pressure induced by sniffing. This mechanism can break down with eustachian tube dysfunction

08:21-08:29 DISCUSSION

08:29-08:36 Two Sets of Twins with Congenital Endolymphatic Hydrops: A Case for the Hereditary Basis of Endolymphatic Hydrops Based on Diagnosis and Follow-up for 25 years – J. Nedzelski, I. Sherifi, TORONTO, ON

LEARNING OBJECTIVES:1. To present a hypothesis for the hereditary basis of endolymphatic hydrops.2. To present a literature review regarding the etiology of Meniere's disease.3. To present the results of an original retrospective study from a tertiary care referral center regarding the diagnosis and follow-up of two sets of two twins with congenital endolymphatic hydrops.4. To correlate recent connexin and genetic studies with the etiology of the disease in these patients.

INTRODUCTION: Hereditary etiologies comprise 50% of childhood hearing impairments, with syndromic forms comprising one third of these. Over 60 genetic loci which include the connexin gene have been isolated. In this article we present two pairs of monozygotic twins with congenital hearing impairment and endolymphatic hydrops. Although many believe the etiology of endolymphatic hydrops to be multifactorial, several investigators have postulated a hereditary basis. We believe that this is one of the first publications making a case for the genetic development of this entity. MATERIALS AND METHODS: Retrospective case review in a tertiary care referral hospital. The patients were evaluated and followed for over 25 years with audiogram testing, otorhinolaryngological exams, electronystagmography, auditory brainstem response testing, blood tests, connexin genetic testing and temporal bone CT scans. The patients were treated symptomatically and fitted with hearing aids. Three of the four patients received cochlear implants. RESULTS AND DISCUSSION: The development of endolymphatic hydrops in the same ear of each of two identical twin pairs suggests a common origin dating back to the monozygote. Similar vestibular findings in both twin pairs as well as a major hearing loss in the opposite ear suggest the likelihood of this common origin. Connexin testing was undertaken to correlate the genetic basis of this disease entity in both sets of twins.

08:36-08:43 Hearing Abnormalities in Fetal Alcohol Syndrome: A Review of 10 Cases - S. Walen, B. Lange, B. Gibbard, CALGARY, AB

LEARNING OBJECTIVES:1. The types of hearing loss in FAS are discussed with emphasis put on history taking .2. The audiometric tests which may signal a processing problem are discussed.3. Based on the the above two, a rational approach to further testing is formulated.4. Central Auditory Processing Tests are discussed in detail5. Our data explain the impact this has had on our change of practice

OBJECTIVE: FAS is characterized by developmental delay, often complicated by hearing loss. The standard of practice in our institution was pure tone and tympanogram audiometric assessment. We present our findings on the prevalence of central auditory processing disorder in this group, and its effect on our change of practice. METHOD: After full assessment by a developmental pediatrician, and otolaryngologist, full audiometric assessment was done to include pure tone, tympanometry, acoustic reflexes, auditory brainstem response and central auditory processing. RESULTS: Data will be presented to demonstrate a higher incidence of central auditory processing disorder in this patient population. CONCLUSION: More detailed audiometric assessment is necessary in the FAS population. This allows correct teaching strategies to be used, to facilitate education in this disadvantaged patient group.

08:43-08:50 Nerve Recovery Profile Following Injury in the Cerebellopontine Angle Compared to that of the Intratemporal Bone Course Alone - H. Yuen, J. Dorion, J. Nedzelski, TORONTO, ON

LEARNING OBJECTIVES:1. To educate otolaryngologists in the use of a validated facial nerve assessment tool (The Sunnybrook Facial Grading System).2. To propose a possible explanation for the differences in recovery.

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3. To enable the clinician to be able to better advise patients afflicted with severe facial nerve injury at various parts of the nerve course as to likely recovery.     

OBJECTIVE: To establish the facial nerve recovery profile following severe injury within the cerebellopontine angle and compare it to similar injury within the fallopian canal alone. METHOD: A retrospective study of patients who realized a delayed severe facial nerve injury following excision of acoustic neuroma, Bell’s palsy, herpes zoster or temporal bone fracture. All patients realized complete paralysis followed by a recovery interval consistent with axonotomesis. A minimum of 10 patients in each category constitute the study group. All patients were followed for a minimum of one year and had the course of recovery chronicled using the Sunnybrook Facial Grading System. RESULTS AND DISCUSSION: Nutrition to the facial nerve as it courses from the brainstem, through the cerebellopontine angle, the fallopian canal and into the parotid bed is highly dependent on the surface blood supply and the enveloping sheath. The recovery profile of the anatomically intact nerve is highly dependent on how successful these factors are in providing the elements required for recovery. Overall outcomes and possible explanations as to why patients who have injury to the nerve within the fallopian canal alone are better than those in whom the injury was within the cerebellopontine angle are detailed.

08:50-08:58 DISCUSSION

08:58-09:05 The 3D Vibro-Acoustics of the Tuning Fork – A. Ho, B. Katlai, L. Curran, M. Bance, HALIFAX, NS

LEARNING OBJECTIVES:1. To appreciate the different vibrational modes of a 512Hz tuning fork in real-time 3D images. 2. To learn how to optimise the use of a 512Hz tuning fork when using it for Rinne testing. 3. To understand where to hold the 512Hz tuning fork to maximise the delivery of sound by air conduction. 4. To understand where to hold the tuning fork on the skull in order to maximise the delivery of sound by bone conduction to the cochlea.

OBJECTIVES: To investigate the 3D vibrations of a 512Hz tuning fork. To determine how where the fork is held affects vibration decay. To explore the best positioning of a vibrator on the skull to optimize cochlear vibrations. METHOD: Vibrations were measured using a 3D laser doppler scanning vibrometer (LDV) whilst an automated striker periodically struck the tuning fork. We measured the decay time of the tuning fork’s acoustic signal with a calibrated microphone for two tuning fork holding positions. The cochlear promontory was scanned with the LDV whilst a bone conductor stimulated points on the lateral surface of the temporal bone of a dry skull. RESULTS: We demonstrated, for the first time using a non-contact and true 3D method, the different vibrational modes of a tuning fork in real time 3D images. The closer the tuning fork was held to the junction of the tines along its stem, the longer its decay time. Maximal cochlear promontory vibrations were demonstrated when the tuning fork was placed on the mastoid tip. CONCLUSIONS: We showed the vibration responses depend on where the tuning fork is struck and how it is held. The energy transfer to the cochlea depends on where the vibrating source is placed on the skull.

09:05-09:12 Laser Assissted Malleo-vestibulopexy - A Valuable Alternative to Ossiculoplasty? – V. Kisilevsky, N. Bailie, J. Halik, TORONTO, ON

LEARNING OBJECTIVES:1. To improve understanding the mechanisms of conductive hearing loss in middle ear trauma, congenital malformations and otosclerosis,2. To discuss the advantages and weaknesses of various ossicular reconstruction techniques.3. To report a novel technique for surgical correction of conductive hearing loss.

Surgical correction of conductive hearing loss caused by ossicular discontinuity or fixation has evolved significantly since the first recorded procedure in 1901. However, overall the long term results of ossiculoplasty techniques are far from ideal. Ossicular chain reconstruction in the case of incus erosion and/or absent stapes superstructure can be difficult. Revision stapedotomy in the presence of an eroded incus presents a particular challenge in this respect. This paper reports the surgical technique and audiometric results of laser-assisted malleo-vestibulopexy (LAMVP) for congenital or traumatic conductive hearing loss. LAMVP has also proven to be useful in revision stapedotomy. Surgical outcomes are compatible or superior to allograft and xenograft ossiculoplasty. LAMVP offers a valuable adjunct to traditional middle ear reconstruction techniques.

09:12-09:17 DISCUSSION

09:17-09:24 Stapedotomy in Osteogenesis Imperfecta: Results of a New Series – A. Safar, J. Halik, TORONTO, ON

LEARNING OBJECTIVES: To learn more about the disease itself and its effect on hearing and how should we manage this problem safely. The surgical techniques will be explained using the laser stapedotomy which was performed in some cases and also the results we achieved will be compared to those found in literature.

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OBJECTIVES: To retrospectively evaluate the hearing results in surgically treated cases of stapes fixation in patients with osteogenesis imperfecta. STUDY DESIGN: Audiological and clinical analysis of the results of stapes surgery in a consecutive series of 8 ears in 6 patients with osteogenesis imperfecta. SETTING: Tertiary referal center. INTERVENTION: Stapedotomy and reconstruction with Cause Loop Piston, Fluroplastic prosthesis. RESULTS: Overall, a postoperative air-bone gap closure to within 10 dB achieved in almost all of our cases. Postoperative improvement of air-conduction thresholds superior to 20 dB was found in the majority of the cases. The postoperative bone-conduction thresholds were unchanged. In one ear, a cholesteatoma was found and erosion of the ossicles was found where malleovestibulopexy was performed to achieve this result. CONCLUSION: This study shows that safe and successful stapedotomyis possible in cases of stapes fixation in osteogenesis imperfecta.

09:24-09:31 A Novel Method for Predicting Long-term Postoperative Facial Nerve Outcome After Vestibular Schwannoma Surgery – H. Yuen, V. Lin, D. Houlden, J. Nedzelski, J. Chen, TORONTO, ON

LEARNING OBJECTIVES:1. To describe a novel method of predicting long-term facial nerve outcomes in acoustic neuroma surgery2. To evaluate the utility of intraoperative electrophysiological parameters which are individualized to each patient in predicting long-term facial nerve outcome3. From the submission, the audience would understand the difficulties involved with current methods of predicting facial function after acoustic neuroma surgery, and the method described might arguably be the best so far

OBJECTIVES: A novel method of predicting immediate postoperative facial nerve outcomes (IPFNO) as a function of percent maximum amplitude (PMA) was previously described by the authors. Using the same paradigm, long term facial nerve outcomes (LTFNO) at one-year following vestibular schwannoma surgery were analysed in the same patient cohort. PATIENTS AND METHODS: Intraoperative recordings of facial muscles were obtained from 38 patients during vestibular schwannoma surgery using stimulus intensity of 0.05, 0.1, 0.2 and 0.3 mA. Maximum and the percent maximum amplitude responses were recorded. IPFNF and LTFNO were analyzed to determine the optimal facial nerve stimulation protocol. RESULTS: Among patients with percent maximum of > 30%, the positive predictive values for good LTFNO at one year were more than 85% across all stimulus intensities, with 0.3mA demonstrating the best results. The facial function remained good in 23 of 24 patients who had good IPFNF. Similarly, the facial outcomes in 11 of 14 patients with poor IPFNF remained poor at one-year. CONCLUSION: The percent maximum amplitude response of facial nerve stimulation at 0.3mA is a good predictor of both immediate and long-term facial nerve outcome after vestibular schwannoma excision. Immediate postoperative facial function predicts long-term facial outcome.

09:31-09:38 Bilateral Sequential Cochlear Implantation in Post-lingually Deafened Adult – H. Yuen, J. Ostroff, D. Shipp, J. Nedzelski, J. Chen, TORONTO, ON

LEARNING OBJECTIVES:1. To address the clinical question of whether two cochlear implants are better than one2. To elucidate the clinical benefits of unilateral versus bilateral implants especially with regards to hearing in simulated adverse conditions.3. To assess patients' subjective functional outcome and satisfaction with a second implant compared to one.

OBJECTIVE: To evaluate speech perception and subjective benefits of a second sequential cochlear implant (CI) for postlingually deafened adults who are consistent users of a first CI. MATERIALS AND METHOD: This was a prospective study of all second-sided CI recipients over 3 years. Speech perception abilities were assessed in both monaural and bilateral conditions using CNC words, and HINT Sentences in quiet and with noise. Subjective outcomes were evaluated using a questionnaire. RESULTS: Twelve patients underwent a second CI. The mean age at the time of second implantation was 53.0 years ( range = 36.8 – 74.1 years). The mean interval between implantations was 8.3 years (range = 3.0 – 17.3 years). Four of the subjects have the same device while the remaining 8 have different devices in each ear. All 12 subjects use both devices in everyday life. After a minimum follow-up of 6 months, all patients reported improved hearing in quiet and in noise. Objective speech perception measures showed a significant binaural advantage for speech in noise and soft speech. CONCLUSION: Sequential bilateral cochlear implants provide significant improvement in speech perception and subjective benefits compared to unilateral performance even after many years of monaural use and with different devices.

09:38-09:45 Canal Wall Down Mastoidectomy Surgery - Reasons for Failure in the Community vs A Teaching Hospital – A. Safar, J. Rutka, TORONTO, ON

LEARNING OBJECTIVES:1. To evaluate the causes for failure of the open cavity mastoidectomy that will require a revision surgical procedure.

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2. To look for the common causes for failure in the community hospitals vs the teaching hospitals, and how we should contribute in improving the teaching of our residents in order to get less failure rate from the doctors practicing in the community hospitals. 3. To stress the point of who should and who shouldn't perform these type of surgeries.

OBJECTIVES: To study the reasons for failure of an open mastoidectomy cavity (modified radical and radical) to stay dry. PATIENTS AND METHODS: A retrospective review of over than 200 patients underwent canal wall down mastoidectomy in the community that required a revision surgery and in our teaching hospital with an approximate follow-up of one year. Reasons for failure in those referred to the senior auther (JR) from the community were compared to reasons for failure in patients operated by the senior auther. We also reviewed and compared the complications. RESULTS: The number of cases required revision surgery was much higher in those referred from the community hospitals. the causes for failure in the community were mostly related to technical issues such as high facial ridge, inadequate meatoplasty, and recurrent or residual cholesteatoma, whereas in our teaching hospital were due to mucosal disease and failure of epithilialization. CONCLUSION: The incidence of revision mastoidectomy may be decreased if performed with an adequate technique, complete removal of the disease and by an adequate postoperative care and follow-up.

09:45-10:00 DISCUSSION

10:00-10:30 COFFEE BREAK AND VISIT TO EXHIBITORS

10:30-12:00 Annual Business Meeting

12:00-13:15 LUNCH IN THE EXHIBITS AREA

TUESDAY, JUNE 3, 2008 - AFTERNOON Mary Schaffer Ballroom (AB)

CPD Credits – 0.75 hoursWORKSHOP13:15-14:00 My Worst Pediatric Airway Nightmare

CHAIR: S. Daniel, MONTREAL, QC

LEARNING OBJECTIVES:At the end of this workshop, participants will be able to have an approach for the difficult pediatric airway. Entities that will be discussed include tracheo-esophageal fistulas, complex foreign bodies, and tracheal stenosis / lesions.

The objective of this workshop is to present difficult pedatric airway management cases. Real complex pediatric airway scenarios will be presented to an expert panel to discuss their approach and management. Audience participation is encouraged.

CPD Credits – 1.0 hoursWORKSHOP14:00-15:00 ENT and Pregnancy

PANEL: M. Black, M. Samaha, J. Rappaport, R. Payne, MONTREAL, QC

Pregnant women undergo metabolic, hormonal, and physiologic changes that can affect many head and neck structures. In addition, certain otolaryngologic conditions are more common in the pregnant patient. Therefore as otolaryngologists, we need to be aware of these disorders as well as the management issues, both medical and surgical, for the pregnant woman. The objectives of this workshop include: 1) review of physiology of pregnancy as it pertains to the head and neck 2) understand certain ENT manifestations of pregnancy 3) overview of the safety profile of specific commonly used medications and treatments for the gravid women with an ENT disorder or infection 4) provide a clear algorithm for the general otolaryngologists for the management of ENT problems in pregnancy 5) provide educational information and resources available to the otolaryngologists. This workshop will highlight these issues via interactive cases provided by subspecialists in otology, rhinology, laryngology and oncology.

15:00-15:30 COFFEE & VISIT TO EXHIBITS

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TUESDAY, JUNE 3, 2008 - AFTERNOON Mary Schaffer Ballroom (AB)

CPD Credits – 2.5 hoursPAPER SESSION – PEDIATRIC OTOLARYNGOLOGY Chair: Dr. J. MacCormick, Ottawa, ON

15:30-15:37 Wideband Reflectance - A New Technique for the Diagnosis of COME and other Middle Ear Pathology – M. Bromwich, D. Brown, L. Hunter, B. Smith, J. Meinzen-Derr, CINCINNATI, OH

LEARNING OBJECTIVES:After reading the paper the reader should:1) Understand the basic principles of wideband reflectance2) Appreciate the utility of wideband reflectance in clinical application3) Appreciate the limits of wideband reflectance4) Be able to interperet basic power absorption curves and their associated pathology

OBJECTIVE: Wideband Reflectance (WR), a measure of input impedance using a wideband frequency, greatly expands the clinical utility of middle ear measurements beyond what is possible with tympanometry. This study compared WR in children with normal and abnormal middle ear (ME) status and correlated their characteristic impedance patterns with the type of pathology. HYPOTHESIS: Middle ear pathology can be detected and correlated with characteristic patterns produced by Wideband Reflectance. METHOD: Children with normal hearing (n=100) and children with known ME pathology (n=50) were evaluated with audiometry, tympanometry, DPOAE, WR and a clinical otologic exam. The normal hearing children were tested twice by different audiologists to examine test-retest and inter-examiner variability. Patients scheduled for otologic surgery were examined and tested prior to surgery. Intra-operative findings were documented and correlated with wideband reflectometry. RESULTS: Normalized power absorption and impedance curves for each patient were generated. Effects of age, gender, ME status and test-re-test were examined. Characteristic differences were identified between normal and abnormal ears that were correlated with type of ME pathology. CONCLUSIONS: Wideband reflectance is a useful technique for investigating the properties of the middle ear and for identifying middle ear pathology.

15:37-15:44 Laser Doppler Vibrometry: A Novel Technique in Assessing the Middle Ear in Children - C. Szeto, B. Al-Sabah, S. Daniel, MONTREAL, QC

LEARNING OBJECTIVES:1. To introduce and describe the principle and technology behind the use of Laser Doppler Vibrometer (LDV).2. To demonstrate LDV as a possible alternative to tympanometry in descibing the middle ear in the pediatric population.3. To describe and interpret the normative data of tympanic membrane displacement as measured by LDV.

OBJECTIVES: Laser Doppler vibrometry (LDV) is a well established research tool for exploring middle ear physiology. The goal of the study was to assess the feasibility of using LDV as a possible alternative to tympanometry in pediatrics and to collect normative data of tympanic membrane displacement as measured by LDV. Sources of variability and TM displacement analysis were also investigated. METHODS: LDV was used to measure sound induced displacement of the tympanic membrane (TM) near the umbo in 9 normal hearing children with intact TMs and aerated middle ears. TM vibrations were measured for 6 different sound frequencies in the range of 0-4 kHz. RESULTS: There was a trend toward similar curves of frequency versus TM displacement for each set of measurements conducted in our study. No effects of ear sidedness (Left or Right), gender, age were clearly found. All of our subjects tolerated the procedure well and establishment of normative data was accomplished. CONCLUSION: The use of LDV as a potential clinical tool has been shown to be feasible in the pediatric setting. The results obtained from our normative data provide the baseline response for future studies of LDV in assessment of middle ear and TM physiology or pathology in the pediatric population.

15:44-15:51 TBA

15:51-15:58 Choking Prevention: Short-Comings of Traditional Public Education Campaigns and the Need for Web-Based Interactive Teaching Tools for Pre-Teens, Teenagers and Adults – A. Thanboo, T. Nguyen, J. Ludemann, VANCOUVER, BC

LEARNING OBJECTIVES:1. Create awareness about the prevalence of foreign body aspiration and ingestion in the pediatric popluation in BC.2. Review the international history of choking prevention campaigns and perceived reasons for their successes and failures.

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3. Inform attendees about BC Children's Hospital new innovative approach to decrease the number of foreign body aspirations and ingestions internationally through web-based, interactive education of children and adults.OBJECTIVES: To evaluate the effectiveness of the BC Children’s Hospital (BCCH) Safe Start Choking Prevention campaign, which began in 2002 and used newspaper, magazine, radio and television interviews plus pamphlet distribution to educate the public about choking risks, prevention and treatment (CRPT). METHODS: Retrospective analysis of the number of cases of laryngeal, bronchial and esophageal foreign bodies (LBEFB) which required rigid endoscopy under general anaesthesia at BCCH and/or admission to BCCH; comparison of data from January 1997 to December 2002 to January 2003 to August 2007 (to be updated to December 2007). RESULTS: The data demonstrates the ineffectiveness of our traditional media campaign. The number of total operating room visits at BCCH for LBEFB increased marginally after the choking prevention campaign began. Interestingly, the incidence of LBEFB at BCCH was highest during the late spring and early summer months. CONCLUSION: Modifications to our choking prevention campaign is required. Published reports from Isreal and Crete indicate that educational campaigns that included direct teaching of CRPT by Otolaryngologists are highly effective. We are therefore creating an animated video and a comprehensive, interactive website to teach CRPT to pre-teens, teenagers and adults (with prospective validation of knowledge transfer and long-term outcome measurement).

15:58-16:08 DISCUSSION

16:08-16:15 Congenital Tracheal Stenosis Managed Conservatively – R. Ywakim, J. Guillemaud, H. El-Hakim, EDMONTON, AB

LEARNING OBJECTIVES:1. To review the information available on the epidemiology and natural history of congenital tracheal stenosis.2. To discuss the place of conservative management.3. To review a short consecutive case series.

OBJECTIVES: Congenital tracheal stenosis (CTS) is a challenging surgical problem. Its natural history and epidemiology are poorly described. There is scarce information on the cases that might not require surgery. METHOD: A retrospective review of all patients diagnosed with CTS by one pediatric otolaryngology practice was performed. RESULTS: 4-patients (2-girls) were diagnosed consecutively over 5.5-years. The diagnosis was achieved within the first 4-months of life in three and at 13-years in one. Three children presented with difficulty to ventilate in the neonatal intensive care unit. One had been diagnosed with asthma very early in life. Other congenital abnormalities (cardiac, vascular, renal, and gastro-intestinal) were encountered in 3-patients. One child required a tracheostomy due to respiratory failure primarily due to reasons other than the CTS. None required nor their parents opted so far for surgical repair, and conservative management has been pursued. Three patients have been followed for 3-years. CONCLUSIONS: CTS commonly presents immediately after birth or in early infancy with difficulties in intubation and/or ventilation irrespective of the precipitating event. If difficulties to wean from assisted ventilation or in coping with growth and activity requirements are circumvented, the children might not require surgical intervention.

16:15-16:22 A Novel Modification of Slide Tracheoplasty - L. Johnson, HALIFAX, NS.

LEARNING OBJECTIVES:1. To describe a successful, novel modification of slide tracheoplasty for long-segment complete tracheal rings.2. To describe the historic evolution of congenital tracheal stenosis repair.3. To review the diagnostic work-up and management of congenital tracheal stenosis.4. To review the congenital cardiac anomalies associated with congenital tracheal stenosis.5. To discuss the team approach to patient management and the benefit of an aerodigestive team.

Slide tracheoplasty is now the mainstay of therapy for complete tracheal rings. There have been many surgical modificationsproposed for this form of congenital tracheal stenosis. A case of a 9month old patient is presented with a late diagnosis oflong-segment congenital tracheal stenosis extending into the right mainstem bronchus in association with a pulmonary arterysling. This complex case is reviewed and the successful outcome of a modification of slide tracheoplasty is presented. Thehistoric evolution of the surgical technique, usefulness of diagnostic studies and the team approach are also discussed.

16:22-16:29 A Series of Congenital Vallecular Cysts: A Rare Yet Potentially Fatal Cause of Upper Airway Obstruction and Failure to Thrive in the Newborn – N. Sands, S. Anand, J. Manoukian , MONTREAL

LEARNING OBJECTIVES:Our primary objective is to raise the clinical awareness of congenital VC through an illustration of our institutions’ recent experience with this disease. Moreover, we explore potential flaws in the current management of neonatal stridor, while offering strategies to facilitate and expedite the diagnosis of this rare, yet potentially devastating congenital lesion.

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OBJECTIVES: The most probable cause of inspiratory stridor and supralaryngeal airway obstruction in the newborn is laryngomalacia. Commonly found in association with supraglottic prolapse is a laryngeal cyst, including the vallecular cyst, which is a rare, yet potentially lethal cause of respiratory distress in the newborn. In the absence of more alarming presenting signs, the vallecular cyst frequently defies diagnosis. We present a series of illustrative cases to raise awareness of this rare yet lethal congenital disease to help reduce the therapeutic delays that are currently encountered clinically. METHODS: A retrospective case-series of 4 patients diagnosed with vallecular cyst was reviewed. RESULTS: The predominant presenting signs were stridor (4 cases), signs of respiratory distress (3 cases), failure to thrive (3 cases), poor feeding (2 cases) and cyanotic spells (1 case). Age of presentation ranged from 16 days to 8 months. Definitive diagnosis was achieved by flexible laryngocopy. Coexistent laryngomalacia was found in 3 of the 4 cases. Primary outcomes at one month following mursupialization were complete remission in all 4 cases. CONCLUSIONS: The challenge in making an early diagnosis of vallecular cyst, especially when laryngomalacia is comorbid, has been reaffirmed in our case-series. Diagnosis requires a high-index of suspicion in combination with careful inspection of the tongue base with direct examination and/or appropriate imaging modalities.

16:29-16:38 DISCUSSION

16:38-16:45 Does Function Define Form? Moss' Functional Matrix Hypothesis and Sinonasal Development? – P. Mick, P. Moxham, F. Kozak, K. Riding, J. Ludemann, VANCOUVER, BC

LEARNING OBJECTIVES:1. Review craniofacial development.2. Understand Moss' Functional Matrix Hypothesis and its relevance to craniofacial development. 2. Review evidence for and against Moss' Functional Matrix Hypothesis, including our evidence.4. Review other theories of craniofacial development, and why none is fully satisfactory.

OBJECTIVE: Moss' functional matrix hypothesis states that bone development is driven by the operational demands of the surrounding soft tissue. In the case of the nasomaxillary complex, growth would be driven by the respiratory demands of the airway. To test the hypothesis we compared the bony anatomy of the maxilla between atretic and open sides in patients with unilateral choanal atresia. METHOD: Patients with unilateral choanal atresia and pre-operative CT scans were included. Volumetric analysis of maxillary sinuses was performed. The volume of the atretic side was compared to the volume of the

non-atretic side using the paired t-test. RESULTS: Seventeen patients were included. 50% were female. The mean age at the time of the scan was 21 months. One patient had CHARGE syndrome. Preliminary results of nine patients indicate no significant difference between sinus volume on the atretic side compared to the non-atretic side. Eight scans remain to be analyzed. CONCLUSION: Our preliminary data do not support Moss' functional matrix hypothesis, which if true, would result in hypoplastic sinuses on the side of atresia.

16:45-16:52 Incidence of Acute Sinusitis Complications Among Children: A 15 Years Tendency in Quebec – J. Bolduc Begin, A. Lapointe, A. Desroches, C. Giguère, C. Mercier, SHERBROOKE, QC

LEARNING OBJECTIVES:1. To review the risk factors of acute bacterial sinusitis for orbital and intracranial complications. 2. To review the physiopathology of complicated acute bacterial sinusitis, particularly in relation with allergic rhinitis.3. To become familiar with the incidence of pediatric acute bacterial sinusitis complications in Quebec from 1989 to 2004.4. To objectivate the relationship between acute bacterial sinusitis complications and respiratory allergies.

INTRODUCTION: According to literature, orbital and intracranial complications of acute bacterial sinusitis are enhanced by multiple risk factors, including allergic rhinitis. In view of the worldwide increase in the prevalence of respiratory allergies, there may well wonder about the incidence of those complications. OBJECTIVES: To evaluate whether there is an increasing incidence of orbital and intracranial complications of acute bacterial sinusitis among children over a 15-year period in Quebec. Secondarily, to verify the association between the incidence of complicated sinusitis and the season of respiratory allergies (from April to October inclusively). METHOD: A retrospective study of all children (≤ 18 years of age) hospitalized throughout the province for complicated acute bacterial sinusitis from 1989 to 2004 using the Med-Echo database. RESULTS: For the 15-year period studied, the incidence of acute bacterial sinusitis complications was globally stable (p=0.472). Comparing the monthly rate of complications between seasons showed a significantly higher rate during the winter season (adjusted IRR = 1.74, CI 95% [1.47-2.07]; p<0.001). CONCLUSION: Contrary to literature, orbital and intracranial complications of acute bacterial rhinosinusitis among Quebec children is not linked to seasonal allergies and the incidence has been steady for the last 15 years.     16:52-17:00 DISCUSSION

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CPD Credits – 1.0 hoursSATELLITE SYMPOSIUM 17:00-18:00 Eosinophilic Esophagitis in Children: A Primer for OtolaryngologistsCHAIR: PANEL: El-Hakim, H., Persad, R., EDMONTON, QC

LEARNING OBJECTIVES:1. Introduce the audience to the epidemiology. pathophysiology and diagnostic features of eosinophilic esophagitis.2. Discuss the classic gastro-enterological symptom complex in children and the proposed otolaryngological associations.3. Review our pediatric hospital's experience and the model for inter-disciplinary cooperation.4. Point out future research directions.

BACKGROUND: EE has relatively recently been recognized as a cause for food impaction and dysphagia in older children & adolescents. Progressively, its emulation of gastroesophageal reflux disease in younger patients is being recognized. As a result, the incidence is exhibiting an exponential rise and interest in studying the disease is spreading. AIM: To introduce the epidemiology, pathophysiology & diagnostic features of EE; to present cases with classic GI features & otolarygological associations and to review our center's experience. METHOD: 1. Didactic presentations reviewing the world literature2. Case presentations. CONCLUSIONS: EE is a new clinico-pathological entity whose defining features are evolving. Its diagnosis currently rests on histological detection of eosinophilia in biospies from the esophagus. Treatment includes dietary and pharmacological means and endoscopic measures for complicated cases. Future research may prove it to be truly associated with some airway symptoms & signs. Recognizing the diagnosis & its correct management can have an impact on several respiratory disorders.

This symposium is supported by ABBOTT LABORATORIES through a non-restricted educational grant.

TUESDAY, JUNE 3, 2008 - MORNING Mary Schaffer Ballroom (C)

CPD Credits – 1.0 hoursPAPER SESSION – RESEARCH METHODOLOGY & EDUCATION Chair: TBA 08:00-08:07 A Needs Assessment of Undergraduate Education in Otolaryngology Amongst Family Medicine

Residents – M. Brandt, J. Glicksman, J. Parr et al., LONDON, ON

LEARNING OBJECTIVES:1. Attendees will gain an appreciation for the focus of undergraduate medical curricula on Otolaryngology.2. Areas of Otolaryngology where Family Medicine resident's felt "uncomfortable" in making management decisions will be reveiwed.3. Otolaryngology specific conditions and procedures frequently seen and performed by Family physicians where Family medicine residents felt "uncomfortable" and "unpreppared" will be discussed.4. Attendees will better understand the limitations of current undergraduate medical curricula and postgraduate training in Family Medicine and review suggestions for future curricula development.

OBJECTIVES: To investigate the adequacy of otolaryngology teaching in undergraduate medical education (UME) and to determine the general level of comfort of family medicine residents in managing and assessing diseases affecting the ears, nose and throat (ENT). DESIGN: Cross-sectional survey. METHODS: A complete sample of family medicine residents at the University of Western Ontario (n=68) completed a questionnaire inquiring into their exposure to topics in otolaryngology during their UME. They were also asked to comment on their present comfort with knowledge and skills specific to ENT. RESULTS: Family medicine residents suggest that there is generally little ENT training in UME. 66.7% of respondents who received UME in Canada suggested they received very little classroom instruction and 75.6 % received very little clinical ENT instruction. Residents identified specific ENT conditions with which they felt particularly uncomfortable. CONCLUSIONS: This study demonstrated that students receive very little ENT exposure in UME and highlighted specificconditions and procedures that family medicine residents lack confidence in managing and performing.     

08:07-08:14 Diagnosis of Upper Aerodigestive Foreign Bodies: A Major Gap in Medical School Education – D. Dance, D. MacNeil, P. Moxham, J. Ludemann, VANCOUVER, BC

LEARNING OBJECTIVES:

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1. To discuss the adequacy of medical school education on UADFB across North America, and to highlight particularly innovative and effective educational approaches.2. To present one methodology for assessing medical school curriculum coverage of UADFB education which may be applied to evaluating other areas of otolaryngology education.3. To discuss approaches to UADFB education which might fill the current gap, and which may prove useful in other aspects of otolaryngology education.

INTRODUCTION: In the first 8 months of 2007, 8 patients were treated at BC Children's Hospital after a significant delay in the diagnosis of their upper aerodigestive foreign body (UADFB). Despite the history of choking (provided repeatedly by the parents), the diagnosis of the UADFB was delayed by 2 to 4 weeks. This led to parental frustration and increased morbidity, including the need for Intensive Care for 2 patients. The rate of delayed diagnoses of UADFB at BCCH has risen this year to over 20%. METHOD: Survey of recent medical graduates and Associate Deans of Curriculum from North American (NA) Medical Schools, using the Dillman method. RESULTS: Preliminary data suggests that the majority of NA medical students receive little to no formal education regarding UADFB diagnosis or treatment. CONCLUSIONS: Our clinical experience plus the survey data point to a need for systematic Medical School and Continuing Medical education regarding UADFB management. In addition to the publication of clinical practice guidelines on the diagnosis and treatment of UADFB, we propose a novel educational approach, using interactive computerized learning modules, which are under development.

08:14-08:21 Qualitative Impact of An Introductory Course on "The Art of Surgery" on Otolaryngology Resident – V. Brousseau, N. Fanous, E. Brousseau, N. Yammine, K. Shaw, MONTREAL, QC

LEARNING OBJECTIVES: 1. Recognize that current surgical education fails to instruct trainees on a number of para-surgical and surgical skills topics, falsely assuming that this information is already known or taught during the practice of surgery. 2. Understand how we identified lacunas in our training program using a post-course survey technique.3. Realise the applicability and power of the needs assessment survey technique in education program design and development.

OBJECTIVES: Evaluate the pertinence, impact, strengths and weaknesses of the course “The Art of Surgery” designed and delivered by Dr. Nabil Fanous to alleviate some perceived lacunas in surgical education. METHOD: Sixteen months after taking the course, participants (n=8) were asked by a third party to fill a quantitative and qualitative survey evaluating the amount of new material learned; the course’s contribution to improving their skills, to understanding surgical ergonomics and to developing CanMeds roles; and pertinence and necessity of the material to general surgical teaching and training. RESULTS: All residents who completed the course (n=8), irrespective of their year of training, felt this course presented information that was lacking and essential to their training and practice of surgery. Individual sections of the course were highlighted as being most helpful (infiltration, dissection, the steady hand) and areas needing improvement (operating in comfort, safety) were identified. All participants recommended the course and felt that residents from all specialties would benefit from it. CONCLUSION: The survey technique needs assessment is a valuable tool in the evaluation, redesign and evolution of courses for trainees.

08:21-08:28 Is the Podcast Medium, As Viewed on a MP3 Player, Suitable for Viewing and Simultaneously Commenting on Surgical Procedures? – A. Conlin, L. McLean, L. Varpio, OTTAWA, ON

LEARNING OBJECTIVES:1. To describe the development of a surgical Podcast.2. To investigate whether the quality of the surgical Podcast as viewed on a portable MP3 player is sufficient to allow it to be used as a multimedia pedagogical tool.

A Podcast is a digital media file, or series of files, that is distributed over the Internet for playback on portable media players and/or personal computers. In Medicine, the Podcast has become a novel medium for educational initiatives including the distribution of didactic lectures and the demonstration of procedures. However, to date, there is no evidence to confirm that the utilization of relevant Podcast materials improves motor skill learning and/or surgical performance or even if the format is suitable for transfer of surgical video. The purpose of this study is to develop two 10 minute surgical Podcasts in Otolaryngology based on expert-identified themes. The aim of each Podcast will be to highlight the specific aspects of each surgical procedure that practicing surgeons have identified as being challenging to novice learners. The Podcasts will then be evaluated to determine if the Podcast medium is suitable for viewing and simultaneously commenting on surgical procedures. Here, suitability is related to, for example, quality of visual display, size of visual display, and sound quality. If the Podcast is found to be a suitable format, then the next phase of our program of research will be to determine whether the Podcast can be used in the surgical setting to improve learner preparedness in the operating theatre. Implications for medical education will be discussed.

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08:28-08:37 DISCUSSION

08:37-08:44 Evaluation of Meta-analyses in the Otolaryngologic Literature – L. Rudmik, S. Walen, E. Dixon, J. Dort, CALGARY, AB

LEARNING OBJECTIVES:1) To demonstrate the current quality status of meta-analyses in the Otolaryngologic literature2) To introduce the Overall Quality Assessment Questionnaire (OQAQ) as a tool to critically evaluate meta-analyses3) To demonstrate factors associated with high quality meta-analyses4) To demonstrate areas that need to be improved upon when writing a meta-analysis5) To intoduce strategies to improve future meta-analyses in the Otolaryngologic literature

INTRODUCTION: Meta-analyses are frequently used to interpret and summarize data from multiple primary studies on a given topic. However, not all meta-analyses are performed using standardized evidence-based protocols yielding a variation in quality and compromising the validity of study outcomes. METHOD: A literature search using MEDLINE and EMBASE, using 13 key otolaryngologic topic terms, was performed. Limits included: Dates between 1997 and 2007, English language, Meta-analysis, and Human. Inclusion criteria: meta-analytic methodology and one author from the Department of Otolaryngology. Exclusion criteria: Cochrane Reviews, non-otolaryngologic topic, and systematic reviews. 46 articles fulfilled eligibility criteria. In duplicate and independent, 2 reviewers assessed the quality of eligible meta-analyses using a 10-item index called the Overview Quality Assessment Questionnaire. RESULTS: The majority of studies had methodologic flaws (mean score 3.7, scale of 1-7). Variables predicting higher quality meta-analyses were: published in higher impact factor journals (p=0.0033) and authors with previously published meta-analyses (p=0.0014). CONCLUSION: This is the first study evaluating meta-analyses in the Otolaryngologic literature. Publications in journals with higher impact factors and author experience with writing meta-analyses were shown to be associated with higher quality studies. Future meta-analyses can be improved upon by following evidence-based guidelines (incomplete abstract).

08:44-09:00 DISCUSSION

CPD Credits – 1.0 hoursWORKSHOP09:00- 10:00 Life as if the Planet Mattered: How to Work and Live in a Sustainable Way

CHAIR: W. Bell, Canadian Assoc. of Physicians for the Environment, SALMON ARM, BC

Physicians are often pre-occupied with clinical matters, which are addressed one patient at a time. But we work in a societal and global context, which increasingly commands our attentions, through such issues as climate change, peak oil, population growth and pollution. How we practice – as well as how we live in our personal lives—can either exacerbate these problems, or ameliorate them. This workshop will give participants basic information on how to “green” their practices and their lives outside the clinical setting.

10:00-10:30 COFFEE BREAK AND VISIT TO EXHIBITORS

RESIDENT WORKSHOP10:30-11:00 Demystifying the Royal College Examination Process

CHAIRS: Witterick, I., TORONTO, ON Dorion, D., SHERBROOKE, QC

LEARNING OBJECTIVES:1. To discuss the examination process surrounding the Royal College of Physicians and Surgeons' Exam in Otolaryngology.2. To answer common questions and concerns of residets about the examination process.

OBJECTIVES: The Royal College of Physicians and Surgeons’ (RCPSC) Examination in Otolaryngology is the certification examination to practice as an otolaryngologist in Canada. The exam is fraught with high anxiety amongst residents. The goal of this workshop is to describe the exam process for residents in training to help demystify the process. METHOD: Brief presentations by the current Co-Chairs of the Examination Board in Otolaryngology followed by a question and answer period. Specific questions and content of the written and oral exams will not be discussed. RESULTS: Improved knowledge of the exam process for residents in training. CONCLUSIONS: The hope is that this workshop for residents will improve their understanding of the RCPSC otolaryngology exam to help them in their studying and preparation.   .

11:00-11:30 Establishing an ENT PracticeCHAIRS: Maharaj, M., Longridge, N., VANCOUVER, BC

LEARNING OBJECTIVES:

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Attendees will gain familiarity with:1. The critical factors to consider when planning where to establish practice and what style of practice to pursue, including the need to balance professional and personal needs, both for oneself and ones family.2. The components of a good business team, including accounting, legal, insurance, banking, and financial planning advisors.3. The major components that are required in establishing and maintaining an ENT practice as a business, including leasing space, purchasing equipment, hiring/employing/firing staff, choosing medical office software/EMR, and negotiating for OR time and other hospital resources.4. The nature of ongoing overhead expenses involved in a community ENT practice.

The practical steps involved in making the transition from a learner to an independent practitioner have been traditionally inadequately taught in most residency training programs in Canada, including Otolaryngology programs. In recent years, efforts have been made by various individuals to address this shortcoming within our specialty by offering seminars and talks from Otolaryngologists and outside experts on a local or ad-hoc basis. Recently, Dr. Longridge took this process further by presenting this topic to all ENT residents attending last year's CSO meeting, which was generally well-attended and well-received. After discussion with him, it is my hope to collaborate to present this talk again this year, from the perspective of a community Otolaryngologist who has recently started solo practice. Furthermore, it is the hope of both Dr. Longridge and myself that this talk can develop into a formal lecture series that may take on a 3-year cycle to provide more in-depth and comprehensive information to our residents, providing them with the skills necessary to help them address the non-medical challenges in establishing their practice. For example, there may be a focus in one of the talks on financial issues, while the subsequent year’s talk focuses on other business issues, and the third year would focus on practice planning.

12:00-13:15 LUNCH IN THE EXHIBIT AREA

TUESDAY, JUNE 3, 2008 - AFTERNOON Mary Schaffer Ballroom (C)

CPD Credits – 0.75 hoursWORKSHOP13:15-14:00 Managing the Paralyzed Vocal Cord: What Works and What Doesn’t

PANEL: Kost, K., Black, M., Eibling, D., MONTREAL, QC, Morrison, M., VANCOUVER, BC,

LEARNING OBJECTIVES:1. To understand the differential diagnosis of vocal fold paralysis. 2. To understand the appropriate workup for vocal fold paralysis. 3. To appreciate the various management strategies and how to apply them in selected cases.

METHOD: Selected case studies will be used to illustrate key points in the diagnosis, work-up and treatment. Audience participation is welcome and will be solicited. RESULTS: Speech therapy, vocal fold injection (Collagen, Perlane, Fat, etc), medialization thyroplasty (silastic, Gore-Tex, etc), and arytenoid adduction are, amongst others, all valid treament modalities which will be discussed. CONCLUSIONS: While the diagnosis and work-up of vocal fold paralysis are often fairly straightforward, choosing from the treatment options available, may be difficult or confusing. This workshop aims to demystify the treatment of vocal fold paralysis for practising otolaryngologists.

CPD Credits – 1.0 hoursWORKSHOP14:00-15:00 Electronystagmography in 2008

CHAIR: Blakley, B., WINNIPEG, MB

LEARNING OBJECTIVES:After this presentation the participant should be able to:1. Describe the parts of the typical ENG2. Outline what ENG can and cannot do for clinical care3. Identify spontaneous nystagmus, benign positional vertigo, unilateral and bilateral reduction of caloric responses and,4. Identify at least three potential quality control problems that may occur in ENG testing.

Electronystagmography (ENG) is probably the oldest clinical vestibular test in widespread use. There is still much misunderstanding of the use, interpretation and significance of ENG. This presentation will utilize ENG findings from real clinical cases showing normal and abnormal situations. First the components of ENG will be reviwed, then examples of normal and abnormal eye movements will be presented. The evidence for interpretation will be discussed in relation to other modern medical tests.

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15:00-15:30 COFFEE BREAK AND VISIT TO THE EXIBITORS

CPD Credits – 1.5 hoursPAPER SESSION - RHINOLOGYChair: Dr. Erin Wright, Edmonton, AB

15:30-15:37 Site of Attachment of Inverted Papilloma Predicted by CT Findings of Osteitis - A Prospective Study – E. Wright, R. Bhalla, EDMONTON, AB

LEARNING OBJECTIVES:At the conclusion of this presentation participants will:1. Be able to identify the "osteitis sign" on pre-operative CT scan images in patients with inverted papilloma2. Have critically evaluated the usefulness of the 'osteitis sign' in identifying the site of attachment of inverted papilloma

OBJECTIVES: Recently published retrospective data has demonstrated that osteits/neo-osteogenesis present on pre-operative CT scans could be used to accurately predict the site of attachment of inverted papillomas (IP) as found at surgery. We sought to verify these findings in a rigorous, prospective fashion. METHOD: All patients diagnosed with IP and scheduled for surgery had their digital CT images reviewed by the principal investigator and one other reviewer. Information documented included: the presence or absence of osteitis ipsilateral to the tumour as well as the site(s) of osteitis, including the precise anatomic structure involved. Both evaluators then agreed on the most likely site of attachment prior to surgery. RESULTS: Nineteen patients have so far been included in the study. Osteitis was present in 16/19 study participants. Of those participants in whom osteitis was deemed present, the site of attachment was accurately predicted in 15/16 (positive predictive value of the osteitis sign = 94%). CONCLUSION: The vast majority of patients presenting with sinonasal inverted papilloma will have osteitis detectable on their preoperative CT scan. In patients in whom osteitis is detectable on the pre-op CT scan, the site of origin of the IP can be predicted with a high degree of accuracy.

15:37-15:44 Sphenoid Sinus Inverted Papilloma: Prevalence, Clinical Presentation, Evaluation and Management – J. Guillemaud, I. Witterick, TORONTO, ON

LEARNING OBJECTIVES:Inverting papilloma (IP) of the sphenoid sinus is a rare lesion, with a non-specific and insidious presentation that is further complicated by difficult access for adequate examination. Unfortunately, given the intimate anatomic relations between the sphenoid sinus and surrounding structures, sphenoid IP can result in serious sequelae if the diagnosis and management are delayed.1. We will briefly review the epidemiology and pathophysiology of sinonasal inverting papillomas. 2. We will assess and summarize the best available evidence on clinical presentation, prevalence, management and recurrence of this rare lesion.3. Our experience with sphenoid IP is the largest reported to date, and we will discuss our unique experience including technological advances in the diagnosis and surgical management of this challenging lesion.

OBJECTIVES: In conjunction with a review of the English literature, we review our unique experience with inverted papillomas (IP) of the sphenoid sinus to better delineate the clinical presentation, prevalence, management and recurrence of this rare lesion, as compared with IP arising from the more common locations within the nasal cavity and paranasal sinuses. METHODS: A 5-year retrospective chart review of one tertiary-care Otolaryngologist was conducted, including all patients with histologically confirmed sinonasal IP. RESULTS: 71 patients (49males, 22females; mean age 57.17years) were treated for sinonasal IP between Jan/2002–Sept/2007. Nine patients had IP originating in the sphenoid sinus, and the most common presentations were headache (44%), visual disturbances (22%), hearing loss (22%), and asymptomatic (22%). Review of the literature confirms our finding that the most common presenting symptom is headache (52%), followed by nasal obstruction (48%), rhinorrhea (32%), and asymptomatic (16%). CONCLUSIONS: Our experience with IP of the sphenoid sinus is the largest reported in the English literature to date. We have demonstrated a predominance of neurological and visual symptoms in symptomatic patients with sphenoid IP, and suggest these may be early manifestations of sphenoid IP, before the more common sinonasal symptoms develop secondary to infiltration of the nasal cavity and paranasal sinuses.

15:44-15:51 A Comparison of Two Sphenoidotomy Approaches Using a Novel CT Grading System – T. Orton, A. Javer, H. Gheriani, B. Mechor, VANCOUVER, BC

LEARNING OBJECTIVES:1. To review two surgical approaches to the sphenoid sinus and the potential perioperative complications of each.2. To outline a novel CT grading system to guide the sinus surgeon in his or her approach to the sphenoid sinus and describe the complications that we hope to avoid with this grading system.

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3. To provide recommendations as to which operative technique to use for each grade.4. To describe the case that stimulated the creation of this grading system.5. To review the anatomy around the sphenoid sinus.OBJECTIVE: To determine the safest sphenoidotomy technique utilizing a novel CT grading system. There are two sphenoidotomy approaches. The “Bolger” technique enters the sphenoid sinus laterally, preserving the superior turbinate (ST). The “Lanza” technique enters medially with partial resection of the ST. METHOD: A cohort of 22 patients with sphenoid sinus disease underwent sphenoidotomy by the safest intraoperative technique according to the operating surgeon. Patient recruitment will continue up to a target of 50. Each patient was graded with an axial CT of the ST attachment to the sphenoid face. They were graded as type A, B or C based on attachment to the medial, middle, or lateral third of the sphenoid face respectively. A type D grading denotes ST attachment to the orbit. RESULTS: The safest intraoperative technique was determined to be Lanza in 100% of type C attachments and Bolger for 100% of type A. The Lanza approach was used in 29% and the Bolger in 71% of type B attachments. CONCLUSION: We recommend that patients with type A attachments receive the Bolger technique and patients with type C attachments receive the Lanza technique. Type B attachments can be entered with either technique based on the surgeon’s preference.

15:51-16:00 DISCUSSION

16:00-16:07 Does Pterygoplatine Canal Injection with Local Anesthetic and Epinephrine Decrease Bleeding During Endoscopic Sinus Surgry? – S. Al-Ghamdi, M. Samaha, MONTREAL, QC

LEARNING OBJECTIVES:1. To have a knowledge of how pterygopalatine canal injection is performed.2. To see the effect of injecting the pterygopalatine canal on intraoperative bleeding during ESS.

OBJECTIVES: To study the effect of injecting the pterygopalatine canal with Xylocaine and epinephrine on intraoperative bleeding during endoscopic sinus surgery ( ESS ) for chronic rhinosinusitis ( CRS ). METHOD: After ethics committee approval, a prospective, single blinded, randomized study of 30 patients undergoing ESS for CRS with or without nasal polyps was undertaken. Disease extent was symmetrical on both sides as evaluated by the Lund-McKay radiologic scoring system. A pre-operative unilateral injection of 2.5 cc of 1% xylocaine with 1:100,000 epinephrine was performed, with the side of injection selected randomly. The non-injected side served as the control. Operative field bleeding was graded by the operating surgeon, who was blinded to the side injected, every 15 minutes, using a 6-point scale. An itraoperative setup allowing for suction and collection of blood separately for each side was used. Blood loss was recorded separately for each side. RESULTS: Preliminary results and data analysis showed that there is no statistical difference between the injected and the non-injected sides. CONCLUSION: Preoperative injection of the pterygopalatine canal with 1% xylocaine and epinephrine does not seem to alter intraoperative blood loss during ESS.

16:07-16:14 A Prospective, Double-blind Randomized Placebo Controlled Trial to Determine Whether Intra-operative Injection of 0.25% Bupivicaine with 1:200,000 Epinephrine Decreases Intra-operative Blood Loss in Functional Endoscopic Sinus Surgery (FESS) – D. Flamer, H. Gheriani, B. Mechor, A. Javer, VANCOUVER, BC

LEARNING OBJECTIVES:Injection of local anesthetic containing epinephrine into the lateral nasal wall during functional endoscopic sinus surgery (FESS) has been utilized dogmatically to minimize intra-operative blood loss. A potential for complications exists: the use of 0.25% Bupivicaine with 1:200,000 epinephrine during FESS can potentially lead to numerous (reported in the literature) complications, including tachycardia, hypertension, and orbital ischemia (with possible blindness).This study aims to demonstrate, in a placebo controlled trial, that there is no significant difference in intra-operative blood loss when 0.25% Bupivicaine with 1:200,000 epinephrine is used compared to normal saline injection, during FESS. By discontinuing the use of local anesthetic with epinephrine, the associated complications can be avoided.

OBJECTIVE: To compare differences in intra-operative blood loss and operating time when 0.25% Bupivicaine with 1:200,000 epinephrine is injected preoperatively, versus normal saline, during functional endoscopic sinus surgery. METHOD: Patients were randomly assigned to the experimental or control group (30 subjects each). Both groups received injections to the lateral nasal wall on each side. The experimental group received 0.25% Bupivicaine with 1:200,000 epinephrine, and the control group received normal saline. Total estimated blood loss, mean arterial pressure, and duration of surgery were recorded. RESULTS: 21 patients have been enrolled to date (8 males, 13 females). 15 patients have received 0.25% Bupivicaine with 1:200,000 epinephrine (group A) and 6 patients have received normal saline (group B). Patients in group A have a mean age of 56, MAP of 78 mmHg, total estimated blood loss (EBL) of 614 cc, and time of surgery (TOS) 140 minutes. Patients in Group B have a mean age of 57, MAP 72 mmHg, total EBL 435 cc, and TOS 124 minutes.

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CONCLUSIONS: 21 of 60 patients have been enrolled to date. The preliminary status of this study does not allow for analysis at this stage. All subjects are to be enrolled by January 2008.

16:14-16:21 The Effect of Topical Vasoconstrictors on Intra-operative Blood Pressure, Heart Rate and Blood Loss during Endoscopic Sinus Surgery – A. Janjua, I. Witterick, TORONTO, ON

LEARNING OBJECTIVES:1. To determine the potential hemodynamic changes associated with various topical vasoconstrictive agents used prior to routine Endoscopic Sinus Surgery.2. To evaluate whether an improvement in surgical visualization and hemostasis is achieved with the use of topical epinepherine versus topical xylometazoline prior to routine Endoscopic Sinus Surgery.3. To identify the ideal topical vasoconstrictive agent to be used prior to routine Endoscopic Sinus Surgery.     

BACKGROUND: Topical vasoconstrictors are frequently utilized in endoscopic sinus surgery [ESS] to improve blood loss and visualization. Although both topical epinepherine and xylometazoline are in common clinical use, there are no trials assessing their respective advantages and potential side effects. OBJECTIVE: The aim of this randomized clinical trial is to identify the topical vasoconstrictive agent which yields a significant improvement in intra-operative visualization and blood loss without detrimental hemodynamic effects. METHOD: Consecutive patients undergoing routine endoscopic sinus surgery were prospectively enrolled and randomized to receive topical 1:1000 epinepherine or 0.1% xylometazoline. Hemodynamic parameters including heart rate and blood pressure were measured at baseline and at one minute intervals for the first five minutes after administration. Hemodynamic fluctuations, intra-operative blood loss and the adequacy of surgical hemostasis and visualization were recorded, analyzed and compared between the two groups. RESULTS AND CONCLUSION: We will present the quantitative results of the pilot phase of our study to illustrate whether eithervasoconstrictor is associated with significantly improved intra-operative visualization and blood loss, while minimizingdeleterious cardiovascular side effects. Following sufficient enrollment, this study will provide a basis for the evidencedbased selection between common topical vasoconstrictors during routine ESS.

16:21-16:30 DISCUSSION

16:30-16:37 The Use of Antimicrobial Active Manuka Honey (MEDIHONEY™) as an Anti-inflammatory Agent in Endoscopic Sinus Surgery – A. Javer, A. Thamboo, D. Flamer, H. Gheriani, VANCOUVER, BC

LEARNING OBJECTIVES:1) Historical and current use of honey in the medical field2) How Honey is an anti-inflammatory.3) How Manuka Honey can be used in Functional Endoscopic Sinus Surgery

BACKGROUND: During functional endoscopic sinus surgery (FESS), it is standard procedure to irrigate the sinus cavity with saline solution at the end of the procedure. The purpose of this irrigation is to clear the opened sinus cavity of any infectious debris in an effort to maximize healing during the post-operative phase. OBJECTIVE: To determine the effectiveness of Antimicrobial Active Manuka Honey (MEDIHONEY™) as an anti-inflammatory agent used intra-operatively in chronic sinusitis among patients undergoing functional endoscopic sinus surgery (FESS). METHOD: The study was a randomized, double-blind, placebo-controlled, prospective study. Forty consecutive undergoing bilateral FESS had one side irrigated with saline and the other side irrigated with 50/50 mixture of honey and saline. The rest of the surgical procedure and postop care was unchanged. RESULTS: Final results are being tabulated and statistical analysis is pending. CONCLUSION: The Manuka Honey acted as an effective topical anti-inflammatory agent intra-operatively among patients undergoing functional endoscopic sinus surgery.

16:37-16:44 Complication Rates Following Functional Endoscopic Sinus Surgery at the QEII Health Sciences Centre in Halifax, Nova Scotia – M. Al-Gilani, E. Massoud, J. Mills, K. MacDonald, W. Mills, HALIFAX, NS

LEARNING OBJECTIVES:1. Review the current status of FESS complications in a Canadian tertiaty care center.2. Review possible contributing factors to the development of those complications.3. Exchange expertise with the audience regarding FESS complications.

PURPOSE: To investigate complication rates following functional endoscopic sinus surgery (FESS) at the QEII Health Sciences Centre in Halifax, Nova Scotia. METHOD: 208 FESS procedures performed between 2001 and 2004 were reviewed at the Queen Elizabeth II Health Sciences Center in Halifax, Nova Scotia. Logistic regression modeling established the contributions of patients’ demographics, pre-operative management, surgical procedures, operative complications and post-operative follow-up to surgical complications. RESULTS: The overall major complication rate was 4.2%. The most

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serious being CSF leakage (2 cases). Orbital complications were of variable severity (5 cases).Operations with complications (n=26) took longer (96 vs. 71 minutes, p=0.001) and involved greater mean blood losses (238 vs. 98 cc, p=0.001). There were no differences between resident and staff complication rates. CONCLUSION: Functional endoscopic sinus surgery continues to be a safe procedure. The rate of complication in our series is in keeping with that reported in current literature. The only independent predictive variable was length of surgery.

16:44-16:51 Extracranial Complications of Endoscopic Trans-sphenoidal Hypophyseal Surgery: The University of Montreal Experience – S. Kilty, N. McLaughlin, M. Bojanowski, F. Lavigne, MONTREAL, QC

LEARNING OBJECTIVES:1. Become aware of an endoscopic trans-sphenoidal approach to the hypophysis.2. Become aware of the range of extracranial complications that can result from this surgical approach.3. Become aware of ways to minimise the occurrence of extracranial complications and how to prospectively evaluate for these complications in one's own practice.

INTRODUCTION: The use of endoscopes has recently popularised an endonasal trans-sphenoidal approach for the resection of hypophyseal tumors. However, little information has been published about the potential extracranial (intranasal) complications that occur as a result of this approach. OBJECTIVE: To identify, using a large patient series, the extracranial (intranasal) complications which occur as a result of endoscopic trans-spenoidal hypophyseal surgery. METHOD: Retrospective chart review of 135 consecutive hypophyseal cases at a tertiary institution. RESULTS: A variety of extracranial complications occurred post-operatively including prolonged nasal crusting (10%), septal deviation (4%), epistaxis (1%), acute sinusitis (2%), chronic maxillary sinusitis (1%), and synechia formation (9%). There were no patient deaths from an extracranial complication. CONCLUSIONS: The number of intranasal complications in this series is low. The extracranial complications of these procedures are often overshadowed by the possible intracranial complications, but they deserve recognition given their potential morbidity. With the findings from our patient series, we make recommendations in order to minimise the likelihood of intranasal complications following this surgery and we similarly suggest directions for future research and the reporting of intranasal complications resulting from endoscopic hypophyseal surgery.

16:51-17:00 DISCUSSION

TUESDAY, JUNE 3, 2008 - MORNING Pyramid Room

CPD Credits – 2.0 hoursPAPER SESSION – HEAD & NECK SURGERYChair: Dr. Martin Corsten, Ottawa, ON & Dr. Jason Franklin, London, ON

08:00-08:07 Hemithyroidectomy in Total Laryngectomy, Is it Really Indicated? – T. Al-Khatib, M. Hier, MONTREAL, QC

LEARNING OBJECTIVES- To determine if performing a hemithyroidectomy routinely as part of a total laryngectomy is oncologically necessary- To see if the thyroid gland is invaded by laryngeal cancer, necessitating its removal- To look at the incidences of hypothyroidism and hypocalcemia in those patients as complications of

hemithyroidectomy

OBJECTIVES: We are questioning the indication for hemithyroidectomy as a routine part of total laryngectomy.Is the gland involved by direct invasion or metastasis necessitating its removal? METHOD: Retrospective case series of seventy-one laryngectomies for primary or recurrent laryngeal carcinoma performed at both McGill Head and Neck centres between 2001-2006. Ten specimens were excluded because no thyroidectomy was performed. Tumor stage, sub-site, anatomical characteristics, and thyroid gland involvement were analyzed based on pathologic specimens. Pre- and post-operative XRT and thyroid function were also noted. RESULTS: 20 supraglottic, 21 glottic, 15 transglottic and 5 subglottic tumors were analyzed. Subglottic extension >10mm was noted in 22 specimens (36%). Cartilagenous invasion was noted in 37 of our specimens (61%) and LN mets were noted in 12 specimens (20%). One subglottic tumor demonstrated bilateral invasion of the thyroid gland as well as LN metastasis. 33 patients received preoperative XRT, and 28 patients received post-operative XRT with a pre- and post-operative rate of hypothyroidism of 11% and 89% respectively. CONCLUSION: We do not recommend hemithyroidectomy as a routine part of total laryngectomy. Rather, it should be considered for tumors of the subglottis (with SGE>10mm).

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08:07-08:14 Salvage Transoral Laser Microsurgery for Radiation Failure in T1-T2 Laryngeal and Hypopharyngeal Squamous Cell Carcinoma – E. Brown, D. Anderson, VANCOUVER, BC

LEARNING OBJECTIVES:1. To review literature concerning the use of transoral laser microsurgical techniques for radiation failure.2. To present our current series of voice preservation surgery following radiation failure.3. To review cases of post-operative bleeding following TLM in previously radiated patients.

Background: Transoral laser microsurgery (TLM) is increasingly accepted as a treatment option for primary laryngeal carcinomas. However, few publications address the role of TLM as salvage surgery for local recurrence following primary radiation treatment. In our centre, the current standard of care for radiotherapy failure is total laryngectomy. DESIGN: Retrospective medical record review. SETTING: Setting: Tertiary academic centre. RESULT: We present seven cases of primary rT1-rT2 tumors that recurred following radiation. Five of the tumors were laryngeal, while the two others involved the hypopharynx. These patients underwent transoral laser microsurgical resection. Over a mean follow-up of 21.4 months, two patients (29%) developed recurrences. One patient required a total laryngectomy while local control was attained using repeated TLM in the other. Voice preservation was thus achieved in 88% of patients. Complications included two significant post-operative bleeds, one of which required temporary tracheotomy to prevent asphyxiation. CONCLUSIONS: These preliminary results suggest that TLM may represent a voice-preserving intervention for radiotherapy failure prior to total laryngectomy. Delayed post-operative bleeding should be taken seriously and treated with appropriate airway precautions.

08:14-08:21 Complete Frozen Section Margins with Measurable (1 or 5 mm thick) Free Margin for Cancer of the Tongue – P. Gauthier, L. Guertin, I. Arteau-Gauthier, L. Pilon, L. Comeau, A. Allaire, N. Audet, M. Camire, D. Beaudoin, R. Dubé, C. Lussier, QUEBEC CITY, QC

LEARNING OBJECTIVES:1. The participant will know the prognosis of the patient with cancer of the tongue and close, positive or negative margins at the final histological report.2. The participant will learn a technique for complete frozen section for cancer of the tongue until negative margins.3. The parameters of the technique will be explained: time, recurrence rate for these patients, cost…

OBJECTIVE: Tongue cancer is an aggressive cancer especially when the final pathology reports close or positive margins. Our goal is to obtain complete frozen negative margins for each patient. Our experience with 12 squamous cell carcinomas of the tongue (4 T1, 5 T2 and 3 T3) is related. STUDY DESIGN: Review of the literature. We use and analyse the technique, described in our animal experience, in twelve clinical situations. RESULTS: Complete negative frozen margins on four levels were obtained within 1-2 mm of the line of resection for the first six cases. Obtaining complete free margins for a thickness of 5 mm was done for the last six cases. It is longer (90 to 120 minutes) but did not exceed the time necessary to perform the neck dissection. No recurrence was observed. CONCLUSION: Complete and oriented frozen margins of high quality are obtained when using sharp dissection to remove the tumour. We prefer to obtain a 5 mm thick margin which is complete, free and oriented on frozen section. This approach should help improve reduce dramatically the problem of positive and close margins at final pathology, and consequently the rate of local control and survival as well.

08:21-08:28 Bone Impacted Fibula (BIF), a New Technique of Increasing Bone Density for Placing Dental Implants after Osseus Microvascular Reconstruction – A. Mlynarek, H. Seikaly, J. Harris, J. Reiger, J. Wolfaadt, K. Al-Qahtani, EDMONTON, AB

LEARNING OBJECTIVES:1. Present a novel technique of increasing bone density in fibular free flaps: Bone Impaction Fibula (BIF)2. Assess the importance of bone density in placing dental implants 3. Validate the bone impaction fibula modification technique

OBJECTIVE: To assess the importance of increased bone density at the time of dental endosseus implant placement in fibular free flaps post major head and neck oncological resections. STUDY DESIGN: Prospective cohort study. METHOD: All patients who underwent maxiallary or mandibular reconstruction with fibular microvascular free flaps were included in the study. Fibular bones impacted with autologous bone were compared to unmodified fibular bones. Bone density was measured post-operatively using CT scans, and the ease to dental implant placement was assessed by measuring the degree of vibration at the time of the implantation. RESULTS: Bone impacted fibulas were found to have a higher marrow bone density and lower degree of dental implant vibration as compared to the unmodified fibular free flaps. CONCLUSIONS: Bone impaction fibula (BIF) modification of osseus free flaps, presented for the first time in this paper, increases bone density and facilitates the primary osteointegration of dental implants.

08:28-08:40 DISCUSSION

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08:40-08:47 Maxillary Survival Outcomes - J. Yu, D. Cote, J. Chau, A. Mlynarek, H. Seikaly, EDMONTON, AB

LEARNING OBJECTIVES:1. Identify the survival of patients with squamous cell carcinoma of the maxilla treated at a tertiary medical centre.2. Describe the functional outcomes of patients who undergo surgery with free flap reconstruction or obturator reconstruction.

OBJECTIVE: The objective of this paper is to: 1) report on the survival outcomes of patients with malignant tumors of the maxilla; 2) report on the functional outcomes of the different reconstructive methods employed (obturation or free flaps). METHODS: A prospective cohort of patients enrolled from 1990 to 2006 in our Head and Neck multidisciplinary reconstructive clinic were reviewed. Functional outcomes were performed as per our pre-published protocol which includes: modified barium swallow, speech articulation and aeromechanical measurements. RESULTS: The 5 years survival of early stage (1-2) patients and advanced (3-4) were 95% and 85% respectively. All patients had good functional recovery irrespective of the method of reconstruction. CONCLUSIONS: Surgical treatment of maxillary cancer offers good survival and functional outcomes. The rational of the different methods of reconstruction remains controversial.

08:47-08:54 TBA

08:54-09:01 Functional Outcomes After Surgical and Non-surgical Treatment Modalities for Oropharyngeal Carcinoma – A. Mlynarek, J. Harris, H. Seikaly, J. Reiger, D. O’Connell, K. Al-Qahtani, EDMONTON, AB

LEARNING OBJECTIVES:1. Discuss various treatment options for oropharyngeal carcinoma2. Discuss various methods for determining functional outcomes after treatment of H&N cancer3. Compare functional outcomes in patients with oropharyngeal carcinoma who underwent surgery and radiotherapy; surgery and chemoradiotherapy; and chemoradiotherapy alone

OBJECTIVE: To assess speech and swallowing functional outcomes in patients having different treatment modalities for oropharyngeal carcinoma. STUDY DESIGN: Prospective cohort study. METHOD: Acoustical, aeromechanical, and perceptual speech data, as well as swallowing data were gathered for patients treated for oropharyngeal cancer. Three patient groups, matched for TNM stage as well as site of carcinoma, were compared: primary resection and post-operative chemoradiotherapy; primary resection and post-operative radiotherapy; and primary chemoradiotherapy. RESULTS: All three groups of patients had speech and swallowing abnormalities. Irradiation, used primarily and post-operatively, was associated with significantly higher degree of dysfunction. CONCLUSION: All treatment modalities for oropharyngeal carcinoma were associated with some degree of functional dysfunction. Use of irradiation was the most significant predictor of poor functional outcome. Surgical resection was associated with only moderate dysfunction.

09:01-09:10 DISCUSSION

09:10-09:17 Use of Time-resolved Laser-induced Flouroescent Spectroscopy (TR-LIFS) to Evaluate Musocal Pathology in the Hampster Cheek-pouch Carcinogensis Model – G. Farwell, D. Enepekides, J. Park, L. Marcu, H. Stoy, Y. Sun, Y. Sun, S. Tinling, SACRAMENTO, CA

LEARNING OBJECTIVES:1. Understand the basic principles of time-resolved laser-induced fluorescent spectroscopy. 2. Introduce the concept that this technology can be applied to head and neck oncology and may be capable of differentiatingnormal from dysplastic and neoplastic epithelium.

BACKGROUND: Fluorescence spectroscopy and imaging have the potential to provide information about biochemical, functional and structural changes of bio-molecular complexes in tissues that occur as a result of pathological transformation. METHOD: Using the well-described hamster cheek pouch carcinogenesis model, 16 male Syrian hamsters were painted with a known carcinogen 7,12-dimethylbenz[a]anthracene (DMBA) until lesions developed. The laser-induced autofluorescence of the lesions and the normal adjacent tissue was recorded and analyzed. Biopsies were collected from the lesions and hematoxyln and eosin staining was performed. Comparison between histopathology and the spectroscopic signals were made. RESULTS: TR-LIFS spectroscopy and lifetime patterns differed between carcinoma and carcinoma-in-situ, pre-neoplastic lesions, and normal tissues in the hamster cheek pouch model. Spectra at the wavelengths of 380, 460, and 635 provided the most discrimination between the different lesions. CONCLUSIONS: TR-LIFS provides a novel and exciting new technique with the potential to improve our ability to non invasively determine the histopathology of mucosal lesions. Future studies will aim to translate this technique into human head and neck tissues.

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09:17-09:24 Intraoperative Application of Fluorescence Visualization (FV) to Identify Subclinical Extension in High-Risk Oral Lesions – S. Durham, C. Poh, J. Durham, D. Anderson, K. Berean, A. Kung, C. MacAuley, M. Rosin, VANCOUVER, BC

LEARNING OBJECTIVES:The attendee will appreciate the principles of autofluorescence and their application as a real time tool in assessing surgical margins in the operative setting.Recurrence following excision of high-grade dysplasia/carcinoma in situ (HGL) implies the presence of subclinical change at the margins not apparent at surgery, resulting in incomplete excision. FV has a demonstrated ability to identify clinically not apparent oral lesions.

OBJECTIVE: To assess the efficacy of intraoperative FV in detecting high-risk occult tissue extending beyond clinical boundaries of HGL. METHOD: Lesions were delineated under OR illumination and with FV in 35 patients: 22 with HGL and 13 cancers. Geographic mapping within excised tissue was used to co-localize histology with clinically apparent lesion, FVL only margins and surgical margins. RESULTS: Loss of autofluoresence (FVL) was apparent in all 35 lesions. FVL extended beyond clinical boundaries in 95% of HGL. Extension around the lesion perimeter was uneven (1-25 mm) similar to observations in cancers. 35% (13/37) of FVL/clinically negative biopsies from HGLs showed high grade dysplasia; in 5 cases, this change went beyond 10-mm, the conventional margin for cancer. In contrast, none of 35 biopsies from surgical margins, located in areas without FVL or clinical change had HGL and only 4 had mild dysplasia. CONCLUSIONS: Integrating FV in surgery provides a useful tool to better manage HGL through identification of subclinical field change.

09:24-09:31 Use of Ablation fT4:Tg Ratio for Predicting High Risk of Disease Recurrence in Well-differentiated Thyroid Cancer (WDTC) – M. Aron, V. Cote, M. Tamilia, M. Hier, M. Black, X. Zhang, MONTREAL, QC

LEARNING OBJECTIVES: To appreciate the value of early identification of those patients with well-differentiated thyroid cancer at high risk of disease recurrence and to introduce the use of an ablation fT4:Tg ratio, a "tumor-specific" ratio, as a valuable, early tool to help do so.

OBJECTIVE: Identification of an ablation fT4:Tg ratio that could identify those patients at high risk of disease recurrence.Design: Retrospective Analysis. METHOD: 124 patients treated for well WDTC, over a ten-year period, with ablation thyroglobulin >2μg/ml were identified. After excluding those patients followed for <3 months, 92 patients remained for analysis. Ablation fT4 and Tg levels were recorded and patients followed to detect recurrence. A ratio highly predictive of disease recurrence was identified. RESULTS: Ablation fT4:Tg ratios ranged from 0-276%. Throughout follow-up, 39% of reviewed patients developed disease recurrence. 19 (53%) of these patients had ablation fT4:Tg ≤10% and represented 100% of the studied patients with this ablation fT4:Tg ratio. CONCLUSION: A previous study stratified patients with WDTC at high or low risk of disease recurrence based on ablation fT4:Tg ratio of <27% vs ≥27% respectively. We have now identified a fT4:Tg ratio that further stratifies risk of disease recurrence: of all patients with ablation Tg>2μg/ml, 100% with fT4:Tg ratio ≤10% recurred throughout follow-up. This risk stratification tool should be used, with other known prognostic factors, to identify those patients at high risk of disease recurrence to direct resource allocation and follow-up regimens in WDTC.     

09:31-09:40 DISCUSSION

09:40-09:47 Postoperative Concomitant Chemotherapy with Radiotherapy in Advanced Stage Head and Neck Cancer: A Meta Analysis – S. Johnson, A. Al Herabi, M. Corsten, OTTAWA, ON

OBJECTIVE: To evaluate the efficacy of post-operative concomitant chemotherapy (CCT) with radiotherapy vs. radiotherapy alone in stage III or IV Head and Neck Cancer (HNC). METHOD: Using a meta-analysis, we compared the use of post-operative radiation versus CCT with radiotherapy for Stage III and IV HNC (5 studies, total N=1152). The outcomes measured were loco-regional failure, all cause death, and distant metastasis. The odds ratio (OR) with respective confidence intervals (CI) using a fixed effects model were reported. RESULTS: 3 measured outcomes:1) Loco-regional failure: OR in favor of CCT (OR 0.45, 95% CI 0.34-.60) with (P=0.00001).2) All cause death: OR in favor of CCT (OR 0.64, 95% CI 0.50-0.82) with (P=0.0004).3) Distant mets: insignificant difference between the treatment groups (OR 0.86, 95% CI 0.65-1.15) with (P=0.31).CONCLUSION: There is a strong statistically significant improvement in both loco-regional failure and overall survival in patients treated with post-operative CCT with radiotherapy.

09:47-09:54 Post Thyroidectomy Pain – L. Kalmovich, R. Payne, M. Black, M. Hier, MONTREAL, QC

LEARNING OBJECTIVES:

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The level of pain experienced post open thyroidectomy and post operative analgesia requirements has not been prospectively studied.We have undertaken this study in order to have a clearer understanding of this issue. We will also compare the implication of a scalpel, versus diathermy incision; and the retraction vs. incision of the Thyrohyoid muscle.

Conventional thyroidectomy is not considered to be an extremely painful operation(1). Nevertheless, the most common stated advantages to endoscopic thyroidectomy (2, 3) , are reduced postoperative pain and improved cosmetic results (4). OBJECTIVE: To prospectively study the level of pain post open thyroidectomy and post operative analgesia requirements. We will also compare the implication of different surgical techniques on the pain level. METHODS: Prospective screening of 100 patients undergoing thyroidectomy will be conducted. Patients will complete a form containing information as to analgesic drugs taken, and self estimated pain severity through an 11-point numeric rating scale(5). RESULTS: Early data : a prospective analysis of 17 patients was done. Average pain level was 5 on the operative evening, and decreased to 1.5 on POD 6th . 60% of patients experienced pain on the first evening, and 12% at 6th POD. 40% of the patients had no pain at all. Comparison between different surgical techniques and pain levels could not be done due to the small group number, but will be looked at as the sample size enlarges. CONCLUSIONS: Conventional thyroidectomy, causes low to moderate pain in the first 24 hours, which decreases steadily. 60% of the patients experience no pain as early as the 2nd POD.

09:54-10:00 DISCUSSION

10:00-10:30 COFFEE AND VISIT TO EXHIBITS

10:30-12:00 Annual Business Meeting (Mary Schaeffer Ballroom AB)

12:00-13:15 LUNCH & VISIT TO EXHIBITS

TUESDAY, JUNE 3, 2008 - AFTERNOON Pyramid Room

CPD Credits – 0.75 hoursWORKSHOP13:15-14:00 Development of Access to Care and Access to Quality Care Standards in Head and Neck Oncology in

OntarioCHAIRS: J. Irish, R. Gilbert, TORONTO, ON

LEARNING OBJECTIVES:1. The otolaryngologist will understand the systematic approach to the development of practice standards related to access to care and quality of care in head and neck cancer surgery. 2. The otolaryngologist will understand some of the initiatives that have been undertaken in one province to reduce wait times and how these initiatives have been linked to quality improvement initiatives.3. The otolaryngologist will understand the quality standards that have been developed by an Expert Panel for improvement of head and neck cancer surgery.4. The otolaryngologist will understand how to strategically position programs to take full benefit of government policies in the “pay for performance” model in health care funding and delivery.

In 2004, Ontario’s Ministry of Health announced Ontario’s Wait Time Strategy. Investment in increasing cancer surgery volumes has been closely linked with quality improvement initiatives. The Head and Neck Disease site group has now developed practice standards for quality improvement that can now be linked to this surgical investment. As part of this strategy, the Ministry asked for the development of priorization tools and wait time benchmarks. CCO’s Surgical Access to Care Committee and the Head and Neck Site Group worked with the Program in Evidence-Based Care and a panel of experts to develop the wait time targets and quality standards for head and neck oncology. The overall approach to the development of target wait times and quality improvement initiatives had three major elements: 1) A systematic review of published literature to examine the impact of diagnostic and/or surgical delay on patient outcomes and to find published reports defining acceptable or excessive wait times. 2) The development of consensus recommendations by the Committee and 3) Submission of the draft report and recommendations to an Expert Panel for review and comment. The “Pay for Performance” model being adopted by many government jurisdictions will engage clinicians as experts. It is critical that these initiatives be levered to provide system improvements. Specifically, in Ontario these initiatives have resulted in improved access to care and access to quality care for patients.      

CPD Credits – 1.0 hoursWORKSHOP

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14:00-15:00 Parotidectomy in General Practice: Indications and TechniquesPANEL: H. Seikaly, J. Harris, K. Ansari, K. Al-Qahtanai, A. Mlynarek, EDMONTON, AB

LEARNING OBJECTIVES:1. At the end of this course the participant will be able to list the indications for parotidectomy.2. At the end of this course the participant will be able to list the indications for performing a neck dissection with parotidectomy.3. At the end of this course the participant will be able to identify the facial nerve intraoperatively through multiple techniques.4. At the end of this course the participant will become familiar with the common surgical techniques of parotidectomy

This course will review the procedure of parotidectomy and its utility in a general otolaryngology practice. The course will include: 1. A review of the common diseases affecting the parotid gland. 2. A review of the common indications for parotidectomy. 3. Demonstration of the surgical techniques of parotidectomy a. Superficial parotidectomy b. Total parotidectomy c. Parotidectomy and facial nerve reconstructionDVD of the course materials will be provided to all participants.

15:00-15:30 COFFEE BREAK AND VISIT TO THE EXIBITORS CPD Credits – 1.5 hoursPAPER SESSION –FACIAL, PLASTIC & RECONSTRUCTIVE SURGERYChair: Dr. J. Trites, Halifax, NS

15:30-15:37 The "Bikini Lip Reduction" - A Detailed Approach to Hypertrophic Lips – V. Brousseau, N. Fanous, A. Yoskovitch, MONTREAL, QC

LEARNING OBJECTIVES:1. Understand principles of lip aesthetics2. Demonstrate a new, simple, in-office technique of hypertrophic lip reduction

Excessively large lips represent an occasional but significant challenge in aesthetic surgery. Previously described techniques focus largely on simple excision of a strip of tissue to reduce the lips, without specific attention to the resultant lip contour or to the volume relationship between the lips. We describe here a new technique for lip reduction called the “Bikini Lip Reduction”. This technique not only reduces the volume of the lips, but also restores an attractive labial contour, as well as an ideal volume relationship between the upper and lower lips. Because it is based on aesthetic analysis, this technique consistently yields both smaller and more aesthetically appealing lips. Simply stated, the “Bikini Lip Reduction” consists of excision a “Bikini top” (two cups and a middle strap) from the upper lip and a “Bikini bottom” (a triangle) from the lower lip. The aesthetic results and the patient satisfaction achieved through the “Bikini Lip Reduction” technique have been very satisfactory.

15:37-15:44 A Microbiologic Assessment of Multidose Restylane for Facial Augmentation – M. Gilani, J. Balderston, R. Davidson, M. Taylor, HALIFAX, NS

LEARNING OBJECTIVES:1. Review the microbiologic profile of Restylane in facial augmentation2. Recommend the use of Restylane as a multidose injection for facial augmentation

OBJECTIVE: The objective of this study was to perform a comprehensive microbiologic assessment of multidose Restylane for facial augmentation. METHODS: Thirty vials were saved at room temperature following Restylane injection for facial augmentation. The vials were stored from 1 day to 87 days. The cultures were performed under the supervision of a microbiologist. After obtaining the initial culture results, the potential offending organism was directly inoculated into sterile Restylane. RESULTS: Thirty vials were obtained for culture after Restylane injection in 3 different anatomic sites. Negative cultures were obtained in 28 out of 30 vials (93.3%). Two vials were culture positive for oral flora, both of which were used for lip augmentation. Stapylococcus epidermidis was then directly inoculated in two sterile vials of Restylane. In the vial inoculated with 100 cfu/ml of Staphylococcus epidermidis, no bacteria were recovered after 6 hours. In the vial inoculated with 100,000 cfu/ml Staphylococcus epidermidis, 60 cfu/ml of bacteria were recovered after 24 hours. CONCLUSIONS:

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Currently Restylane is not recommended as a multidose vial. Our study demonstrates that even with direct inoculation of bacteria into Restylane itself, we did not obtain significant growth. The two positive cultures were felt to be due to needle contamination and not due to Restylane itself. Restylane (Trade Mark)15:44-15:51 Anatomy, Physiology, and Radiofrequency Ablation for Glabellar Frowning – M. Sardesai, D. Ellis,

TORONTO, ON

LEARNING OBJECTIVES:1. To describe the assessment of glabellar frowning, the anatomy and innervation of the procerus and corrugator muscles, and radiofrequency ablation treatment for glabellar frowning.

METHODS: This paper includes a literature review, description of a novel means for frown assessment, description of anatomic relationships via cadaver dissection, and explanation and evaluation of the technique of radiofrequency ablation of the nerves to frowning. RESULTS AND CONCLUSIONS: There is limited literature to date on this topic. Frown assessment can be both quantitative and qualitative, and validated scales for each are described. There is dual nerve supply to the corrugator and procerus muscles from branches of the frontal nerve and from the angular nerve. Radiofrequency ablation may be an effective technique for temporarily weakening muscle function and reducing glabellar frowning.

15:51-15:58 The Taylor Saddle Effacement (TSE): A New Technique for Correction of the Saddle Nose Deformity – M. Taylor, M. Rigby, HALIFAX, NS

LEARNING OBJECTIVES:1) To discuss management of the saddle nose deformity2) To describe a novel technique for correcting the saddle nose deformity3) To address functional and esthetic issues associated with the saddle nose deformityOBJECTIVE: To describe a novel technique, the Taylor Saddle Effacement (TSE), for correction of the saddle noseDeformity using autologous grafts from the lower lateral cartilages. STUDY DESIGN AND SETTING: A prospectiveevaluation of 6 patients all of whom had the TSE performed. Photographs were taken in combination with completion of arhinoplasty outcomes questionnaire preoperatively and at 6 months. The questionnaire included a Visual Analog Scale (VAS)of nasal breathing as well as a Rhinoplasty Outcomes Evaluation (ROE) of nasal function and esthetics. RESULTS: All 6patients had improvement of both their global nasal airflow on the VAS and on their ROE which were statisticallysignificant. The mean preoperative VAS score was 5.8 compared to our postoperative mean of 8.5 out of a possible 10. MeanROE scores improved from 34.7 to 85.5. At six months, all patients felt that their nasal appearance had improved. CONCLUSION: The Taylor Saddle Effacement is a simple and reliable technique for correction of the saddle nosedeformity. This prospective study has demonstrated improvement both in nasal function and esthetics when it is employed.

15:58-16:10 DISCUSSION

16:10-16:17 Primary closure of the donor site in the radial forearm free flap: a novel approach – M. Corsten, M. Allen, OTTAWA, ON

LEARNING OBJECTIVES:1. To introduce a novel technique to allow primary closure of the donor site in the radial forearm free flap when used for head and neck reconstruction.2. To describe our technique of modifying the closure of the donor site without skin grafting.

OBJECTIVES: To describe our novel technique of achieving primary closure of the donor site in radial forearm free flap reconstruction of head and neck defects. METHODS: We placed Dynastretch bandages (Canica Design Inc.) on the distal forearm of ten patients undergoing radial forearm free flap reconstruction of head and neck defects for 1-2 weeks pre-operatively. We then attempted to close the donor site defect without harvesting a skin graft from the thigh. RESULTS: All patients who used the bandages for one full week had closure accomplished without a skin graft from the thigh. This did require a modification of the closure in some patients. CONCLUSIONS: The need to harvest a separate skin graft for closure of the donor site defect is one of the principal disadvantages of the radial forearm free flap. This simple technique allows primary closure of the donor site and may reduce the disability experienced by the patient when using the radial forearm free flap in head and neck reconstruction.

16:17-16:24 Scapular Free Flaps in Head and Neck Reconstruction – K. Fung, J. White, J. Franklin, J. Yoo, LONDON, ON

LEARNING OBJECTIVES:At the end of the presentation of this paper, participants will - 1. Have increased awareness of reconstructive options for head and neck surgical defects2. Understand some of the specific advantages and disadvantages of scapular free flaps

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3. Have increased insight into the range of defects which are able to be reconstructed with scapular free flaps

OBJECTIVES: To describe the experience of a single institution with the use of scapular free flaps for reconstruction of head and neck surgical defects. METHODS: Retrospective chart review of patients undergoing scapular free flaps in London over a 10 year period from 1997 to 2007. RESULTS: 60 scapular free flaps were performed. 29 fasciocutaneous flaps were used predominantly to reconstruct soft tissue defects in the parotid region or after large tongue resections. Skin paddles of up to 15 x 10 cm were harvested with direct closure of the donor site. 31 osteocutaneous flaps containing up to 12 cm of bone were used to reconstruct oromandibular defects. Osteotomies were performed in 11 patients. 9 had both skin and mucosa closed with the scapular flap. Reoperation for flap compromise was required in 6 cases (10%). Total flap loss occurred in 3 cases (5%), and limited debridement of the skin paddles was required in a further 2 patients. Donor site complications occurred in 12 patients, and loss of shoulder range of motion was noted in 2 patients. CONCLUSIONS: Scapular flaps provide a versatile set of free tissue transfer options which allow successful reconstruction of arange of head and neck surgical defects.

16:24-16:31 The Increasing Use of Double Free Flap Reconstruction: Changing Indications, Challenges, and Prospective Functional Outcomes – J. Guillemaud, J. Harris, H. Seikaly, EDMONTON, AB

LEARNING OBJECTIVES:1. This is a large consecutive series of double free flaps used in microvascular reconstruction. A review of the english literature on the use of double free flaps for head and neck reconstruction will be presented, and the advantages and disadvantages of this technique will be discussed. 2. To review the increasing use of double free flaps in reconstruction of large head and neck defects. The indications for the use of two free flaps for reconstruction of head and neck defects will be discussed, as well as the length of surgery and postoperative stay, complications, and functional outcomes. Advantages and disadvantages of using a double free flap for reconstruction will be discussed.3. An algorithm for the assessment of a patient preoperatively will be presented to help guide reconstruction planning when considering the use of two free flaps, with a goal to optimize both reconstructive and functional outcomes.

OBJECTIVE: In conjunction with a review of the English literature, we review the increasing use in our practice of double free flaps in reconstruction of large head and neck defects. METHOD: A 5-year retrospective chart review in a large head and neck oncology program in a tertiary care hospital. All patients receiving double free flap reconstruction of head and neck defects were included. RESULTS: A consecutive series of 35 patients (24 males, 11 females, mean age 57.79 years) treated during July 2002 – Sept 2007 were included. Indications for surgery were squamous cell carcinoma (71.43%), adenoid cystic carcinoma (8.57%), and functional reconstruction (5.71%). The most common double free flap combination included an osteocutaneous free flap with a fasciocutaneous free flap (88.57%), followed by a musculocutaneous flap with a fasciocutaneous flap (11.43%). CONCLUSIONS: We have demonstrated that with proper patient selection and planning, and by utilizing a two surgical team approach, the length of surgery and complication rate is not significantly increased in double free flap reconstruction cases. Furthermore, we feel that by utilizing two free flaps, the best osseous and soft-tissue elements may be independently selected, yielding a result that is aesthetically and functionally superior to that achievable with one free flap alone.

16:31-16:38 An Adaptable Flap - Using the Hatchet Flap to Reconstruct a Variety of Facial Cutaneous Defects – L. Sowerby, C. Moore, LONDON, ON

LEARNING OBJECTIVES:1. To present the variety of facial defects that can be reconstructed with the hatchet flap.2. To present a modification of the hatchet flap that is highly effective in facial reconstruction with pleasing asthetic results.Background: A single triangular flap with a partial cutaneous pedicle, or hatchet flap, was first described in 1977 by Emmett. This local flap has great versatility for facial reconstruction, yet there has been little published discussion regarding potential applications and/or modifications of the flap.

OBJECTIVE: To discuss the various applications of the hatchet flap in facial reconstruction with case examples and to present a modification used frequently by the senior author. METHOD: Approximately 250 cases of cutaneous lesions have been excised and repaired by the senior author using a modified hatchet flap. It has been used to reconstruct defects in the scalp, eyebrow, lower lid, nasal tip, cheek, mentum and torso. The modified flap consists of two lobes on opposite sides of the defect with a v-to-y closure once rotation is complete and design of the flap will be discussed in detail. CONCLUSION: The hatchet flap is a highly adaptable and versatile local flap with an easy learning curve. It can readily be adapted to respect the facial aesthetic units in reconstruction, providing excellent contour and colour match and can be used to reconstruct very large defects.

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16:38-16:45 Comparative Evaluation of Primary vs. Secondary Tracheoesophageal Puncture Voice Restoration: Acoustic, Psychophysical, and Quality of Life Outcomes – J. Tang, P. Doyle, R. McDonald, et al., LONDON, ON

LEARNING OBJECTIVES:To understand the differences in voice-related quality of life outcomes between different modalities of alaryngeal speech.To understand potential variables that could impact voice outcomes in this patient population.

OBJECTIVES: This study compared acoustic, perceptual, and quality of life measures in two groups of participants who hadundergone tracheoesophageal puncture (TEP) voice restoration. METHOD: Twenty-eight TE speakers served asparticipants; 15 had undergone primary TEP and 13 had undergone secondary TEP. Comprehensive acoustic measures wereobtained from standard voice samples. A group of 25 naïve listeners also rated running speech samples using psychophysicalscaling. All participants also completed the Voice-Related Quality of Life (VRQOL) measures. RESULTS: Acoustic datarevealed differences between primary and secondary groups with considerably more signal variability noted for thosereceiving primary TEP. Perceptual data confirm the acoustic data with more favorable judgments of those in the secondaryTEP group. While individual differences exist for the VRQOL, group differences are not uniformly observed. CONCLUSIONS: Time of TEP does appear to influence the acoustic voice signal and these data are confirmed viaperceptual evaluation by naïve listeners. However, voice differences between the primary and secondary TEP groups do notappear to be manifested at the level of quality of life measures that focus on voice-related changes.

16:45-17:00 DISCUSSION

WEDNESDAY, JUNE 4, 2008 - MORNING Mary Schaffer Ballroom (AB)

CPD Credits – 1.0 hours SATELLITE SYMPOSIUM 07:00-08:00 Salivary Gland Obstruction: Assessment and Management, including Endoscopic Techniques

CHAIR: R. Irvine, VANCOUVER, BCPANEL: D. Sommer, HAMILTON, ON, J. Kolenda, S. Daniel, MONTREAL, QC

LEARNING OBJECTIVES:1. Review the epidemiology and etiology of salivary gland calculi.2. Compare the diagnostic imaging options for the assessment of salivary gland obstruction.3. Gain familiarity with the management options for salivary gland calculi according to size and location, including endoscopic management.4. Discuss the diagnosis and management of pediatric salivary gland obstruction.

Sialolithiasis is a clinical problem often encoured by otolaryngologists, with an incidence of 1 case per 15,000-30,000 people per year. The presentation can vary from episodes of salivary obstruction triggered by meals, to infections of the gland and associated deep neck spaces. In some patients, stones can grow to a considerable size, yet remain asymptomatic. Several imaging modalities for the assessment of obstructive salivary gland disease are available, including ultrasound, sialography, CT and MRI. The relative indications for these imaging modalities will be reviewed. The management of submadibular salivary stones has been unsatisfactory for many patients, as the main option for hilar stones has been gland excision. Likewise, parotid stones have been difficult to manage as neither patients or surgeons are enthusiastic about parotidectomy in this situation. Salivary gland endoscopy has become a reliable technique for the diagnosis and management of many salivary stones. This procedure will be reviewed, including the equipment and technical issues involved, a discussion of the indications, procedure and outcomes. Salivary stones as well as ductal strictures can also occur in the pediatric population, and the role of endoscopy in the management of these problems will be reviewed.

This symposium is supported by NYCOMED through a non-restricted educational grant.

CPD Credits – 1.0 hoursWORKSHOP08:00-09:00 Upper Lid Blepharoplasty for the Otolaryngologist-Head & Neck Surgery

CHAIR: M. Taylor, HALIFAX, NS

LEARNING OBJECTIVES:1) To discuss preoperative assessment of patients seeking upper lid blepharoplasty2) To outline the relevant anatomy of the upper eyelid, orbit and periorbital region3) To discuss in detail the surgical technique for upper lid blepharoplasty

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4) To review postoperative care and potential complications of the procedureOBJECTIVE: To outline the approach to upper lid blepharoplasty for the practising otolaryngologist-head and neck surgeon. METHODS: The workshop will address pre-operative assessment, proper patient selection, operative technique, andpostoperative care.

CPD Credits – 3.0 hoursWORKSHOP09:00-12:00 Non-Melanoma Skin Cancer

CHAIR: M. Hier, MONTREAL, QCPANEL: J. Chaplin, R. Gilbert, J. Harris, N. Jha, C. Keeling, C. Moore, R. Taylor, H. Seikaly,

M. Sepejasco, J. YooLEARNING OBJECTIVES:1) Review epidemiology, etiology of skin cancer2) Consolidate our understanding of the technique and application of Moh’s surgery in the head and neck3) Explore the role of the head and neck surgeon, radiation oncologist and medical oncologist in this patient population4) Develop an approach to reconstruction of the various defects encountered in the management of these cancers

Non-melanoma skin cancer is the most common type of cancer that we encounter in oncology. 20% of North Americans will develop it in their lifetimes and approximately 70-80% will appear in the head and neck region. As head and neck surgeons, we are being consulted to participate in the care of these patients with increasing frequency. The cases are often recurrent, advanced and the disease itself along with the treatment can lead to substantial morbidity and sometimes mortality. Various treatment options exist for the management of these patients. The treatment decision-making as well as the execution of the treatment must be well thought out and multi-disciplinary. This seminar will address the complexities encountered with this interesting patient population and provide an update on novel treatment approaches.

INTRODUCTION – Dr. Michael HierSECTION 1 Dr. Mario Sepejasco - Epidemiology, etiology, diagnosis / Moh’s Surgery – Indications, techniques, cases

SECTION 2 Dr. Michael Hier - Surgical Indications Dr. Naresh Jha - Indications for XRT Dr. Chris Keeling - Role for chemo and novel medical therapeuticsDrs. Corey Moore / Ansari - Local flaps for head and neck Moh’s defects

SECTION 3 MODERATORS – Drs. Hadi Seikaly / John YooPANELISTS – Drs. John Chaplin, Ralph Gilbert, Rick Taylor and Jeff Harris - Reconstruction of large head and neck skin defects

10:00-10:15 COFFEE BREAK

12:00-13:00 LUNCH BREAK

WEDNESDAY, JUNE 4, 2008 - AFTERNOON Mary Schaffer Ballroom (AB)

CPD Credits – 2.0 hoursSPECIAL MINI-WORKSHOP13:00-16:00 Transoral Laser Microsurgery in the Upper Aerodigestive Tract: Early to Advanced Tumors

CHAIR: W. Steiner, GOTTENGEN, GERMANYPANEL: D. Brown, TORONTO, ON, J. Harris, EDMONTON, AB, P. Kerr, WINNIPEG, MB,

M. Taylor, HALIFAX, NS

This symposium is supported by KARL STORZ ENDOSCOPY through a non-restricted educational grant.

WEDNESDAY, JUNE 4, 2008 - MORNING Mary Schaffer Ballroom (C)

CPD Credits – 1.0 hoursWORKSHOP08:15-09:15 A Brief History of Epistaxis: From Salt Pork to Surgicel

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CHAIR: I. Dempsey, HALIFAX, NSLEARNING OBJECTIVES:The objectives for this workshop are: 1. To provide the participant with a current protocol for coagulopathy assessment2. To provide clinical criteria for selection of existing nasal packing materials3. To introduce and discuss indications for use of new thrombin based packing materials.4. To discuss a protocol for epistaxis management in the ER.Epistaxis continues to be one of the most common reasons for urgent otolaryngology consultation. Presentation can vary from a minor nuisance to life threatening hemorrhage. Epistaxis patients frequently have other medical conditions or take multiple medications that impair normal coagulation. Successful management of these patients often requires a combination of medical and surgical treatments and a variety of nasal packing techniques. This one hour workshop will review the evolution of epistaxis management from home remedies to current practice. Coagulation workup and indications for coagulopathy reversal will be discussed. A review of current nasal packing materials and indications for new thrombin based packing materials will follow. Case presentations with discussion will conclude the workshop.

CPD Credits – 1.0 hoursWORKSHOP09:15-10:15 Current Trends in Cochlear Implantation: A Panel Discussion

CHAIR: D. Schramm, OTTAWA, ON

LEARNING OBJECTIVES:To familiarize the clinician with the recent advances in cochlear implantation, in particular:1. the expanded audiologic criteria for implantation2. the trend toward consideration of bilateral cochlear implantation for children3. current meningitis prophylaxis for cochlear implant recipients.Recent advances in cochlear implant technology include:• Expanded audiologic criteria for implantation• Bilateral cochlear implantation for children and adults• Electro-acoustic stimulation• Bimodal stimulation• Meningitis prophylaxis for implant recipients• Cochlear implant reliability monitoringFormat: This panel will discuss aspects of cochlear implantation that are potentially relevant to all otolaryngologists.Surgeons from various cochlear implant centers will describe their current approach to the evaluation and management ofpatients for cochlear implantation.

10:15-10:30 COFFEE BREAK

CPD Credits – 1.0 hoursWORKSHOP10:30-11:30 Maximizing Quality in Your OR: Can it be Done?

CHAIR: K. Kost, MONTREAL, QC, D. Eibling, PITTSBURGH, PA

LEARNING OBJECTIVES:1. To appreciate the impact of teamwork in the OR on outcomes. 2. To identify the major causes of dysfunctional operating rooms. 3. To undestand how to translate workshop suggestions into concrete action.

METHODS: 1. The history of Crew Resource Management (CRM) training in aviation will be presented. 2. Evidence from the aviation industry that supports the importance of team training will be reviewed. 3. Research that identifies the most frequent causes of OR team malfunction will be discussed. 4. Initiatives currently employed to remedy dysfunctional OR teams will be presented along with pecific suggestions forproblem-targeted interventions.

RESULTS: Evidence from non-medical and medical disciplines illustrates the impact of dysfunction within the OR onoutcomes. The importance of collaborative teamwork, a facilitative approach by the team leader, and effectivecommunication of a clear 'game plan' are all key elements in maximizing OR quality and efficiency. Conclusions:Suboptimal

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collaborative teamwork negatively impacts OR quality and efficiency. Missing instruments may lead to frustration andunnecessary delays, a poor or non-existent game plan may result in distracted, disinterested personnel, unable to positivelycontribute to the task at hand. Proactive planning, interactive discussion and formulation of a concrete game plan serve toreduce the possibility of errors and promote a highly functional and efficient OR team.

11:30-13:00 LUNCH BREAK

POSTERS MONDAY & TUESDAY, JUNE 2 & 3, 2008

The Great Hall, Jasper Park Lodge

CPD Credits – 5.0 hoursGENERAL OTOLARYNGOLOGYBOARD G1Potential Life Threatening Complication of Excisional Cervical Lymph Node Biopsy with Concomminant Mediastinal Lymphadenopathy – J. MacLean, F. Baxter, B. Jackson, HAMILTON, ON

LEARNING OBJECTIVES:1. Review the options for tissue diagnosis for cervical lymphadenopathy2. Discuss the peri-operative consideration for patients with mediastinal lymphadenopathy3. Review the pathophysiolog and acute airway management of airway obstruction mediastinal lymphadenopathy.

Excisional lymph node biopsy is a common procedure carried out by otolaryngologists. Life threatening complications in patients undergoing cervival lymph node biopsy with concominant mediastinal lymphadenopathy is well reported in the pediatric, anesthesia and thoracic surgery literature. However there is a lack of such information in the otolaryngology literature. We present such a case and review the pathophysiology, management and diagnostic alternatives.

BOARD G2 Penetrating Neck Injury: Our Retrospective Review – F. Al-Qattan, A. Brook, ARDIYA, KUWAIT

Penetrating neck injuries (PNI) are present in 5-10% of patients with multiple traumas. Mortality rate for PNI ranges from 4-11. The choice between mandatory neck exploration (MNE) and selective surgical management (SSM) remains a major source of controversy. This retrospective study is undertaken to evaluate the clinical picture and management of zone II PNI. All patients with zone II PNI admitted to Al Jahra Hospital between 1994 and 2004 were recruited. Total patients=17 (male=12, female=4). The age range was from 19 to 34 years. Nine sustained stab wounds, two gunshot wounds and six had MVA. Hemorrhage was the most common presenting symptom. Airway and intravenous access was secured in all cases. Fourteen patients underwent MNE out of which three required repair of the UADT. They had hemodynamic instability (HI). Most frequently involved structures include the UADT, great vessels and thyroid-salivary glands. The remaining three had relatively superficial injuries. One patient required revision surgery with CO2 laser for supraglottic stenosis. The management of PNI should take into consideration two therapeutic difficulties: avoiding the immediate lethal complications and preventing long-term complications such as laryngotracheal stenosis. The choice between mandatory neck exploration and selective surgical management depends on many factors. However, patients with homodynamic instability or overt visceral injuries require MNE.

BOARD G3 Is Nasal Audiometry A Reliable Test of Eustachian Tube Function ? – A. Ho, M. Gulliver, D. Kirkpatrick, M. Bance, HALIFAX, NS

LEARNING OBJECTIVES:1. To describe the various techniques of nasal audiometry put forward in recent Japanese literature. 2. To evaluate nasal audiometry as a clinical test for eustachian tube function.

OBJECTIVE: To evaluate nasal audiometry as a test of Eustachian tube function, as described in recent Japanese literature. METHODS: Patients attending our Eustachian Tube(ET) clinic were evaluated using a relatively new test, nasal audiometry. In this test, the auditory thresholds in one ear are measured with masking in the other ear with the sound stimulus presented in the nose. This tests the transfer of acoustic energy across the Eustachian tube to the ear. We tested 10 normal subjects with two different variations of this test, with masker presented through the nose, or the signal presented through the nose. We tested subjects with both hypofunctioning Eustachian tubes (N=6) and patulous Eustachian tube (n=9) with these tests. RESULTS: We have not been able to reproduce the encouraging results described in recent Japanese literature. The sensitivity and specificity of this test is low, and this does not improve upon sonotubometry. We found that most sound

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transfer in normals, and in subjects with disease, was in the higher frequencies. CONCLUSIONS: Its value for clinical practice has not yet been adequately demonstrated. Further evaluation would be required before this test can be recommended for routine use in the clinical setting.

BOARD G4 Deep Neck Space Infections: The Kuwait Experience – A. Hussain, F. Al-Qattani, A. Brook, K. Al-Abdulhadi, MISHREF, KUWAIT

LEARNING OBJECTIVES: The objective of this study is to review the diagnosis and management of DNSI. Despite considerable advances in medicine, deep neck space infections (DNSI) are still potentially life-threatening. If left untreated, they could lead to mediastinitis, aspiration pneumonia, internal jugular vein thrombosis or carotid artery rupture. DNSI is mostly a bacterial infection, where large doses of broad spectrum IV antibiotics and surgery remain the mainstay of treatment. The objective of this study is to review the diagnosis and management of DNSI. Total patients=43 (M=25, F=18).from 1995 till 2006, with the age distribution was between 1 and 73 years. The abscesses were surgically drained in 33 cases while the remainder didn't require surgery. Bacteriology revealed a polymicrobial infection in 31 cases (aerobic-anaerobic), single bacteria in seven and no organism in the remainder. Eleven patients underwent tracheotomy because of respiratory distress. Twelve patients were diabetic. Two patients had hypopharyngeal perforations due to foreign bodies. Nine patients developed sepsis. Fourteen cases required intensive care. There were no postoperative complications. Securing an airway is a priority. Early recognition and immediate surgery are highly recommended. In every DNSI, the possibility of mediastinitis should be entertained. The importance of C-T scan and multidisciplinary approach is underscored. The effectiveness of non-surgical treatment in a selected number of clinically stable patients is noteworthy.

BOARD G5 Necrotizing Fasciitis of the Neck: Diagnosis and Management in Kuwait – A. Hussain, F. Al-Qattani, A. Brook, A. Jafar, MISHREF, KUWAIT

LEARNING OBJECTIVES: NF is a rare infection but very aggressive and requires rapid response which includes debridment. We will go through our experience and share the positive and negative points in our management.

Necrotizing fasciitis (NF) is a life-threatening, bacterial soft tissue infection characterized by progressive necrosis of skin, subcutaneous tissues, and fasciae. The abdominal wall, perineum and extremities are the most common sites of infection, but uncommon for the area of the head and neck with a mortality rate ranging from 22 to 50%. We present a retrospective study on 7 patients whom underwent radical surgical debridement (RSD) between 1995 and 2007. Records of patients with NF treated at Zain, Al-Sabah and Jahra Hospitals between 1996 and 2007 were reviewed. The standard demographic data, clinical, radiologic and endoscopic evidences as well as the surgical procedures were noted. The outcome of surgery was analysed. All patients underwent RSD of the neck. Total patients=7 (M=4, F=3). The age distribution was between 39 and 62 years. All patients were known diabetics. The infection was of dental origin in all cases. The diagnosis was made by plain film and C-T scan of the neck. Six patients were successfully treated with broad spectrum intravenous antibiotics and a RSD while one died of multi-organ system failure. Necrotizing fasciitis carries high morbidity and mortality rates. Early clinical diagnosis, broad spectrum antibiotics and an expeditious, radical surgical debridement remains the mainstay of optimal management.

BOARD G6 A Systematic Evaluation of the Information Available for Patients on the Internet Regarding Obstructive Sleep Apnea - M. Langille, S. Shahnavaz, S. Veldhuyzen Van Zanten, E. Massoud, HALIFAX, NS

LEARNING OBJECTIVES:1. The current study will help educate medical personnel about what many of his or her patients encounter when seeking information on the Internet regarding obstructive sleep apnea. This facilitates effective and efficient communication to educate the patient and to address misconceptions. 2. The study describes the currency, authorship and reading grade level of the websites and suggests why these are important features of websites.3. The study correlates unbiased ranking scales with subjective assessments and compares both of these to previously validated rating scales. 4. The results of the study allow physicians to be better health advocates for patients as it enables them to recommend superior websites to patients. 5. The study highlights the importance of the use of the Internet as an information resource for patients.

The current study evaluated the quality of the internet websites available for patients regarding obstructive sleep apnea. METHODS: The term “obstructive sleep apnea” was used in Google™ and the first 50 websites were evaluated by two

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independent reviewers. Websites had to be written in English and contain general obstructive sleep apnea information. Several methods of evaluation were used: 1) A data quality score consisting of a 65 item checklist. 2) A global quality score out of 10. 3) Reading grade level. 4) Disclosure of authorship and date of last update. RESULTS: 34 websites met the inclusion criteria. Seven websites achieved more than 70% of the data quality score. The average global quality score was 5.5. There was good correlation between the global quality score and the data quality score (r=0.788). There was poor correlation between the data quality score and the Google™ rank order. The average reading grade was 11.0. Eighteen websites (53%) provided a date of last update. CONCLUSION: Several websites scored well with the rating systems but these websites do not necessarily appear early in the Google search results. Websites were frequently written in complex language and many did not include information about authorship or date of last update.

BOARD G7 Practice Environment and Satisfaction Level of Canadian Otolaryngologists – M. Zirkle, TORONTO, ON

LEARNING OBJECTIVES:1. To better understand the work environement of otolaryngologists with respect to hours worked, call duties, and payment methods.2. To compare the work experience of otolaryngologists to other surgical subspecialties.3. To gain insight into the factors that contribute to the satisfaction of otolaryngologists.

INTRODUCTION: Our objective is to understand the work environment and satisfaction of Canadian Otolaryngologists. This was done using data from the National Physicians Survey, and comparing Otolaryngologists to other surgical sub-specialists. METHODS: The National Physicians Study was administered in 2004. Response rates for Otolaryngologists was 33%. Several domains were examined: hours engaged in practice per week, call duties, payment methods and overall satisfaction. These results were compared with other surgical subspecialties. RESULTS: Otolaryngologists work similar hours to colleagues in other surgical specialties, but have a lower call burden with respect to rendering care while on call. Otolaryngologists are more likely to receive payment by fee for service, which is the method they prefer to salary or capitation. Satisfaction with patient interaction was lower than other specialties, but work life balance was highest for Otolaryngology and Ophthalmology. Otolaryngologists were least likely to report being dissatisfied or highly dissatisfied with their career choice. CONCLUSIONS: Otolaryngologists are satisfied with their career choice based on the consistency between expectations and reality of work/life balance and method of payment. The importance of quality of life reflects a larger trend in medical specialty choice, and will continue to make Otolaryngology a desirable field.

BOARD G8 Bilateral Vocal Fold Paralysis Secondary to Botulism: A Case Report – N. Sanjeevan, T. Davids, A. Sharma, P. Campisi, V. Forte, TORONTO, ON

LEARNING OBJECTIVES:1. To review a case presentation of a 6 month old boy presenting with bilateral vocal fold palsy secondary to botulism2. To review idiopathic causes of bilateral vocal fold palsy3. To review the presentation and management of botulism in the pediatric patient4 To raise awareness of botulism in the Otolaryngologic community

A case history of Botulism resulting in acute bilateral vocal fold palsy is presented: Following a short history of general malaise and fever, a 6 month old boy presented to the emergency department with a decreased level of consciousness and stridor that rapidly progressed to a respiratory arrest. The patient was intubated and resuscitated. Initial investigations, including physical examination, preliminary bloodwork, and CT scan were unremarkable. Following a failed trial of extubation (3 days later) manifested by increased work of breathing and stridor, a flexible laryngoscopy revealed bilateral vocal fold palsy and poor gag reflex. Comprehensive neurological exam was within normal limits. Repeat flexible laryngoscopy, with trial of extubation 1 week later, revealed early movement of the right vocal fold. Patient was successfully extubated a week later. Differential diagnosis of idiopathic vocal fold palsy includes: toxins (botulism), metabolic abnormalities, neurologic disorders, and autoimmune/inflammatory processes. Botulinum screening was performed and the assay returned with a positive result. The patient was treated conservatively, and is recovering well.

BOARD G9 Petrous Temporal Bone Anatomy of a Sperm Whale (Physeter macrocephalus) – T. Davids, R. Mount, S. Blaser, R. Harrison, P. Campisi, TORONTO, ON

LEARNING OBJECTIVES:1.To review the process of species identification of the sperm whale from DNA extracted from a temporal bone.2.To review the anatomy of the sperm whale temporal bone (not previously described in the literature).

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3.To review the evolution of the whale mammalian hearing transition from air conduction (land hearing) to bone conduction (water hearing)3.To review the CT imaging of our whale temporal bone and make comparisons to the expected anatomy of the human temporal bone.

The anatomy and physiology of the whale auditory system is such that bone conduction acts as the primary source of sound transmission. The basic structure of the cochlea is not greatly different from other mammalian cochleae. The middle ear cavity is partially filled with air, which likely undergoes great pressure alterations with deep diving. The Tympanic membrane is replaced by a bony structure termed the 'tympanic plate'. In the whale head sound waves vibrate the tympanic plate thereby vibrating the middle ear ossicles and transmitting sound to the oval window and cochlea. This poster describes the acquisition of intact left and right whale temporal bones and the DNA sequencing information that was used to identify the species as Physeter macrocephalus (sperm whale). Computerized tomography (CT imaging) of the bones was performed and anatomic differences relative to the human temporal bone were observed. As expected we found the study bones to be of greater size and density than that expected of the human temporal bone. There was an apparent air filled middle ear space, with intact ossicular chain and cochlea. In addition, the semicircular canals were of notable size suggesting the importance of proprioception in these mammals.

BOARD G10 Familial Paraganglioma Syndrome – A. Knox, J. Harris, R. Liu, H. Seikaly, EDMONTON, AB

LEARNING OBJECTIVES:1. Examine 3 interesting cases of Familial Paraganglioma Syndrome (FPS).2. Compare and contrast the types of genetic mutations involved in FPS with relation to presentation, tumor location, multicentricty, risk of recurrence, risk of metastisis, and risk of transmission to patient offspring.3. Highlight the importance of early detection, treatment and diagnosis in cases of FPS.4. Stress the importance of genetic testing for all first degree relatives of patients with FPS.5. Discuss management of common head and neck paragangliomas associated with FPS.

OBJECTIVES: To examine an interesting case series of Familial Paraganglioma Syndrome. METHODS: Retrospective chart review. RESULTS: These cases demonstrate the importance of early screening, diagnosis, and treatment in Familial Paraganglioma Syndrome (FPS). Indicators of FPS include family history positive for paragangliomas, early onset of tumors, and multiple tumors. The PGL genes indicated in the pathogenesis of FPS encode 3 out of 4 subunits of succinate dehydrogenase within mitochondrial complex II. The patient’s genetic mutation is predictive of tumor location, likelihood for recurrence, rate of metastasis, and risk of transmission to offspring. CONCLUSION: Diagnostic workup of FPS should include angiography, color duplex ultrasound, and genetic testing. Patients diagnosed with FPS should undergo biannual imaging (neck, thorax, abdomen, pelvis) by high resolution CT or MRI as well as annual measurement of blood pressure and urinary catecholamines / metanephrines. Penetrance data suggests that screening at an early age would detect disease in the vast majority of mutation carriers. Therefore all first degree relatives of patients diagnosed with FPS should submit to screening and prompt genetic testing to improve treatment outcomes.

BOARD G11 Severe Upper Airway Injury Following Crack Coaine Ingestion: Case Reports and Review of the Literature – M. Allegretto, A. Morissey, EDMONTON, AB

OBJECTIVES: To review the laryngopharyngeal injuries caused by accidental ingestion of hot metal foreign bodies by crack cocaine smokers. To describe the previously unreported complication of severe upper aerodigestive tract hemorrhage following crack pipe thermal injury to the hypopharynx. METHODS: We describe a series of cases involving patients with airway burns following crack cocaine abuse. Mechanism of injury, presenting symptoms and examination findings are discussed. Clinical course and treatment is reviewed. The previously unreported complication of delayed severe pharyngeal bleeding is presented and surgical treatment to arrest the hemorrhage is described. CONCLUSIONS: Thermal injurty caused by hot metal ingestion in crack cocaine smokers can cause life thretening complications. While airway distress is more common, severe upper aerodigestive tract hemorrhage is possible and may require surgical intervention.

BOARD G12"The Old Hag”: The Cultural Interpretation of Sleep Paralysis in Newfoundland and Labrador – M. Brake, K. Burrage, T. Smith, L. Savoury, B. Lee, ST. JOHN’S, NL

LEARNING OBJECTIVES:1. To review the topic of sleep paralysis including presentation, diagnosis, and treatment.2. To offer a unique perspective of sleep paralysis in terms of Newfoundland culture.3. To raise awareness of the disorder among Otolaryngologists in Canada.

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Sleep paralysis is a well-documented sleep disorder marked by complete or partial skeletal muscle paralysis on waking (hypnopompic paralysis) or on falling asleep (hypnagogic paralysis). Paralysis is often accompanied by hallucinations and a profound sense of terror, impending doom, or panic. Although people affected by this disorder are awake, the associated hallucinations may be interpreted as a dream or nightmare. Despite being well described in the medical literature, many physicians are unaware of the disorder and the symptoms may sometimes be confused with obstructive sleep apnea. Throughout the world, there are many cultural interpretations of Sleep Paralysis. In Newfoundland and Labrador, sleep paralysis is known as “the old hag”. We present the case of a 15 year old boy who was referred to our centre for possible obstructive sleep apnea. He had also been referred to psychiatry, neurology and pediatrics for a possible anxiety disorder. His symptoms however were felt to be in keeping with sleep paralysis and has done well since starting treatment. We will discuss the symptoms, diagnosis, and treatment of sleep paralysis and offer the Newfoundland cultural interpretation of the disorder.

BOARD G13Endoscopic Salivary Gland Calculi Removal: St. Paul’s Hospital Experience – K. Wong, R. Irvine, VANCOUVER, BC

INTRODUCTION: Endoscopic salivary gland calculi removal is a relatively new procedure used to treat sialolithiasis. Utilized predominantly in Europe, this procedure is gaining exposure in North America. This treatment option allows for the potential to remove salivary calculi in select individuals without removing the gland itself. OBJECTIVE: To determine the effectiveness of endoscopic salivary gland calculi removal at St. Paul's Hospital during a 2 year period. (2006-2007) METHODS: A retrospective chart review was conducted. Data was collected that included patient demographics, site of stone, size of stone, multiple or single stones, success of salivary gland stone removal, number of operations, and complications. RESULTS: There were 11 males and 2 females with an average age of 34 years. 6 patients (46%) had successful removal of their salivary gland stone with one operation. Five patients (38%) had parotid gland involvement while 8 (62%) were localized to the submandibular gland. Multiple calculi were seen in 6 patients (46%). Twelve patients (92%) had a pre-operative CT scan to determine the size of the calculus. One patient required prolonged post-operative intubation for swelling of the tongue secondary to irrigation fluid extravasation. CONCLUSIONS: In select patients endoscopic salivary gland calculi removal is an excellent treatment option for salivary calculi.

HEAD AND NECK SURGERYBOARD H1Invasive Melanomas of the Head and Neck: A Retrospective Analysis of the Southern Alberta Experience 1995 – 2004 – M. Hoy, G. Huber, W. Matthews, J. Dort, CALGARY, AB

LEARNING OBJECTIVES:At the conclusion of this presentation the listener will:1. Understand the prevalence of head and neck melanoma in a Canadian province.2. Recognize the common features of head and neck melanoma.3. Learn about the factors associated with improved survival outcomes.

BACKGROUND: Head and neck melanoma (HNM) incidence is increasing and it is therefore an important clinical problem. The purpose of this study was to identify frequency of HNM in Southern Alberta and to understand the outcomes (survival, recurrence) associated with this disease. METHODS: retrospective, chart review using a provincial cancer registry for case identification. RESULTS: Medical records of 549 patients with HNM were reviewed. 182 patients had invasive melanoma while the remainder had noninvasive disease. No patients with noninvasive melanoma died of disease. In the invasive HNM group 5 year, overall and relapse-free survival were 65.1%, 86.6% and 78.4% respectively. Cox proportional-hazards modeling revealed that age, gender, nodular histology and tumour thickness were important predictors of survival. CONCLUSIONS: Survival from HNM can be excellent, particularly if the disease is caught at an early stage. As expected thicker lesions and nodular histology have a poorer survival.

BOARD H2 Thyroid Cancer and Second Primaries – M. Duval, R. Payne, MONTREAL, QC

LEARNING OBJECTIVES:1. Sensibilize the audience to the phenomenon of second primaries in thyroid cancer patients.2. Identify the identity of the most common second primaries developing in thyroid cancer patients.3. Describe the characteristics of patients suffering from thyroid cancer and a second primary.

INTRODUCTION: Many studies have shown that thyroid cancer patients are at an increased risk for having both synchronous or metachronous malignancies, and/or a history of cancer elsewhere in the body. While these studies have looked at multiple factors to explain this phenomenon, to date it remains unexplained. OBJECTIVE: Identify the types of

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non-thyroid malignancies that develop in patients’ diagnosed with thyroid cancer and study the characteristics of these patients. METHODS: The McGill University Health Centre Cancer Registry was consulted and a database consisting of patients diagnosed with thyroid cancer and a second primary between 1991 and 2006 was created. The medical records of the 72 patients included in the database were reviewed retrospectively. RESULTS: 84 malignancies were identified in 72 patients. 10.3% of patients suffering from thyroid malignancy developed a second primary. Patients were on average 57 years old when thyroid cancer was diagnosed and 64% were female. The most common second primaries were breast (15%), lung (13%), gastrointestinal cancer (12%) and lymphoma (10%). CONCLUSION: As thyroid cancer often present as a metachronous malignancy, it would be advisable to screen oncology patients regularly for thyroid cancer and to perform surveillance for other types of cancer in thyroid cancer patients.

BOARD H3 Decreasing Mandibulotomy Related Complications: Simple Solutions – P. Dziegielewski, J. Dimitri, J. Harris, H. Seikaly, EDMONTON, AB

LEARNING OBJECTIVES:1. Review the history and usage of the mandibulotomy2. Review various mandibulotomy techniques3. Describe possible complications with mandibulotomies4. Describe the technique utilized at the University of Alberta5. Demonstrate the types of complications encountered at the University of Alberta and their occurance rates6. Discuss methods for decreasing complications7. Make recommendations for future study

BACKGROUND: Mandibulotomy provides excellent exposure to the posterior oral cavity and oropharynx. Unfortunately, many surgeons continue to shy away from it due to widely varying reported morbidity rates. OBJECTIVES: To assess the safety and efficacy of a unique mandibulotomy protocol. METHODS: Consecutive mandibulotomy cases were retrospectively reviewed. Surgical technique was uniform, consisting of incisor extraction, paramedian stair-step osteotomy, and combination fixation with direct interosseous wiring and a compression mini-plate. The mini-plate was adapted to the post-osteotomized mandible. Outcomes measured included fixation failure, poor healing and total complication rates. Patient, tumor and perioperative variables, such as chemo/radiation therapy, were recorded and analyzed with uni/multi-variate regression analysis for predictive associations. RESULTS: 21(9.5%) mandibulotomy-related complications occurred in 20(9.3%) patients. 4(1.8%) cases of fixation failure, including plate failure, non-union and mal-union, were identified. 17(6.8%) cases of poor healing, including hardware exposure, infection, orocutaneous fistulas and osteoradionecrosis were found. No patient, tumor or perioperative variables were statistically significant predictors of complications. CONCLUSIONS: The mandibulotomy protocol employed provides safe and effective means of accessing the posterior oral cavity and oropharynx. The associated complication rate is very low.

BOARD H4 Volumetric and Multi-dimensional Analysis of Oral Cavity and Oropharyngeal Defects Following Cancer Extirpation Surgery, a Cadaveric Study – A. Mlynarek, H. Seikaly, J. Harris, D. O’Connell, K. Al-Qahtani, P. Dziegielewski, EDMONTON, AB

LEARNING OBJECTIVES:1. Discuss free flap design concepts in head and neck reconstruction.2. Present data of free flap dimensions and shapes necessary for oral and oropharyngeal reconstruction.

OBJECTIVE: To gain knowledge of the 2 and 3 dimensional nature of oral cavity and oropharyngeal defects following oncological resections. To assess the dimensions and the shapes the fasciocutaneous free flaps and locoregional tissue flaps required for reconstruction of these defects. STUDY DESIGN: Anatomic, cadaveric study. METHODS: Partial and total glossectomies, floor of mouth, soft palate, lateral pharyngeal wall and base of tongue excisions were carried out in two cadavers. The resected specimens were then analyzed by assessing their volume, surface area, and contours. RESULTS: The forms and the dimensions of the resected specimens were all found to be irregular and different for the various anatomic sites. CONCLUSION: A better understanding of the 2 and 3 dimensional structure of the defects following cancer extirpation will aid reconstructive surgeons in their ability to reconstruct them using various free tissue transfer and locoregional tissue transfer techniques. Fasciocutaneous free flaps need to be customized and designed specifically for the different defects of the head and neck.

BOARD H5N0 Necks in HNSCC, a 7-Year Retrospective Review of Treatment Modalities and Outcome – M. Hafidh, R. Hart, M. Taylor, J. Trites, J. Nasser, HALIFAX, NS

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LEARNING OBJECTIVES:1. To review the different modalities of of treatment N0 neck. 2. To find out what would happen to the N0 neck if it was observed, treated surgically or treated with radiation.3. The effect of treatent of N0 neck in general on the survival . The impact of each modality of treatemt on disease free survival could also be learned from the study.4. The incidence of N0 necks in each site in head and neck region can also be reported from the study.

OBJECTIVES: Elective treatment of the NO neck in patients with head and neck squamous cell carcinoma(HNSCC) remains a controversial issue. The aims of the study are to review the different modalities used in the treatment of N0 necks. The outcome, whether there is recurrence in the neck or not , was also studies. We also analyzed the survival rate of the studied patients in relation to the outcome of these treatment modalities. METHODS: A retrospective chart review of all patients who HNSCC from 1998 until 2005 was performed. Only patients with N0 necks were included in the study. Data collected includes: site, stage and treatment modality of primary tumours, treatment modality for the neck, and a minimum follow up of 2 years. RESULTS: More than 400 patients had N0 necks. Most of these necks were treated with same modality used in the treatment of the primary tumour. Recurrence rate in the neck was also reported. Further results on survival outcomes including: two year disease-free survival and 5-years overall survival , will also be reported in the study.CONCLUSION: This study showed that elective neck management is indicated for most of HNSCC especially in advanced stages.

BOARD H6 Patient Preferences in Early Glottic Cancer Treatment – M. McNeil, D. Wilke, M. Taylor, HALIFAX, NS

LEARNING OBJECTIVES:1. To review patient options in the treatment of early glottic cancer.2. To summarize the current literature in regards to different treatment modalities and their risks and benefits.3. To understand the role of the patient, radiation oncology, and surgeon in the treatment choice of early glottic cancer.    

OBJECTIVES: Patients with glottic cancers staged Cis–T2 are primarily treated by three modalities: endoscopic resection with CO2 laser, radiation therapy, and open conservation surgery. We sought to review patient choices when presented with a choice between laser resection and radiation. METHODS: Using operative codes and chart reviews, patients who presented with glottic cancer staged Cis - T2 were identified. All patients were seen in a joint Head and Neck Oncology clinic and evaluated by both a Head and Neck surgeon (SMT) and a Radiation Oncologist and offered the choice of both CO2 laser resection and radiation therapy. RESULTS: The patient population included 54 males and 10 females, aged 30-84 (mean = 65.0, standard deviation = 11.2). 11 cases were staged Cis, 21 cases staged T1a, 6 cases staged T1b, and 26 cases were T2. All 64 patients chose CO2 laser resection as opposed to radiation therapy for definitive treatment. CONCLUSIONS: Patients with early glottic cancer prefer CO2 laser treatment when presented with a choice between CO2 laser surgery and radiation therapy. 

BOARD H7 A Comparative Cost Analysis of Laser Cordotomy and Radiation Therapy for Glottic Cancer in Nova Scotia – T. Phillips, B. Hoyt, D. Wilke, R. Hart, J. Trites, M. Taylor, HALIFAX, NS

LEARNING OBJECTIVES:1. To add further information on treatment options for early glottic cancer.2. To discuss cost analysis in treatmnet of early glottic cancer.3. To identify and shed light on limitations of cost analysis within the Canadian Health Care System.

OBJECTIVES: Primary endoscopic laser resection can have comparable results in the treatment of early glottic cancer compared to radiation therapy. Few published studies, none of which are Canadian, have compared the costs of the treatments. Therefore, we reviewed the costs of the two treatments at our tertiary care center in Nova Scotia. METHODS: We determined the cost of endoscopic resection by assessing the average price of OR time, the surgeon's salary, and the price of the average hospital stay. A radiation oncologist was consulted to determine the average cost of 6 weeks of radiation therapy. We also examined the indirect costs of each therapy. RESULTS & CONCLUSIONS: The direct costs of each treatment were found to be similar , however, the indirect costs of radiation therapy was far greater than endoscopic laser resection. This result is due to the cost of travel. lodging, and time off work which occurs from the numerous treatment appointments assoicated with radiation therapy. This result lends further evidence for the use of primary endoscopic laser resection over radiation therapy for the treatment of early glottic cancer.

BOARD H8 Papillary Thyroid Micro-carcinoma - The Incidence and Characterization in 739 Thyroid Specimens – J. Franklin, C. Chin, L. Sowerby, K. Fung, J. Yoo, LONDON, ON

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LEARNING OBJECTIVES:1. To understand the incidence of thyroid micro-carcinoma and incidental micro-carcinomas in thyroid specimens.2. To understand the differences in demorgaphics between thyroid micro-carcinomas and papillary thyroid macro-carcinoma.3. To characerize the size and multifocality of papillary micro-carcinoma.4. To understand that micro-carcinoma is usually low risk however some have high risk characteristics.

INTRODUCTION: Management of papillary thyroid micro-carcinoma (PTMC) is controversial. This study characterizes the incidence and demographics of PTMC. STUDY DESIGN: Retrospective review of 739 consecutive thyroid specimens. RESULTS: Of 739 thyroid specimens, 185 (25.0%) resulted in a diagnosis of PTMC. Interestingly, the incidence was uniform across the study period. Incidental PTMC occurred in 123 (16.6%). Unlike macro-carcinoma the incidence of micro-carcinoma is similar between women (24.5%) and men (27.2%). The average age of patients with PTMC was similar to specimens without PTMC (49.5 and 51.1 years respectively NS). Frequency of patients over the age of 45 was similar (64.9% PTMC, 62.8% non-PTMC NS). The most common indication for surgery was suspicion or known of thyroid cancer (33.5%). 91 (49.2%) Specimens contained multi-focal PTMC. The average size of the largest micro-carcinoma was 3.2mm with only 23.3% larger than 5mm. Lymph nodes were identified in 19 specimens where no macro-carcinoma was identified and lymphadenectomy was not performed. Importantly, of these 19 incidental PTMC with nodes identified 4 (21.1%) were positive for metastasis. CONCLUSIONS: PTMC is common and controversial. The incidence is stable and has different demographics than macro-carcinoma. There is a subset of micro-carcinoma with high risk characteristics.

BOARD H9Clinical Predictors of Malignancy in Follicular, Hurthle Cell, or Indeterminate Lesions of the Thyroid – A. Mendelson, J. Rivera, M. Hier, M. Sherman, N. Garfield, O. Chiparus, M. Black, M. Tamilia, R. Payne, MONTREAL, QC

LEARNING OBJECTIVES:1. To overview the clinical implications of follicular, Hurthle or indeterminate FNA biopsy results of a thyroid nodule.2. To describe the clinical variables which have been cited in previous literature as predictors of malignancy for thyroid nodules.3. To discuss how thyroid nodule multiplicity impacts on the risk of malignancy for follicular, indeterminate, and other thyroid lesions.4. To emphasize the role of atypical FNA biopsy in diagnosing malignant thyroid lesions.

OBJECTIVE: To determine whether clinical variables can be used to predict malignancy for thyroid nodules of either follicular, Hurthle cell, or indeterminate cytology on FNA biopsy. METHODS: Retrospective analysis of 77 consecutive patients selected for total or subtotal thyroidectomy for follicular, Hurthle cell, or indeterminate lesions of the thyroid. Eleven clinical variables, as well as nodule size, multiplicity, and ultrasound calcifications were correlated with final histpathologic diagnosis. RESULTS: The overall rate of malignancy in our series was 61% (n = 47). The rate of malignancy was higher for patients with a positive family history (100% vs 59%), a solitary nodule (73% vs 53%) and intrathyroidal calcifications on ultrasound (71% vs 57%), although none was found statistically significant (p >0.05). Male gender, age >45, radiation exposure to the neck, and nodule size >3cm were not associated with malignancy in our series. Patients who presented with a solitary thyroid nodule and FNA cellular atypia displayed an increased risk of malignancy (p=0.011).CONCLUSION: Clinical variables are generally not accurate predictors of malignancy for follicular, Hurthle cell, or indeterminate lesions of the thyroid. Ultrasound and cytopathologic analysis demonstrate more reliability for surgical selection in these cases.

BOARD H10Surgical Management of a Thyroid Fine-Needle Aspiration Biopsy Diagnosis of “Follicular Neoplasm” – J. Tibbo, M. Corsten, OTTAWA, ON

LEARNING OBJECTIVES:1. To review the results of our study on the management of patients with a FNAB diagnosis of "follicular neoplasm" at our institution.2. To review the rates of benign and malignant final pathology for patients who underwent thyroid surgery for an FNAB diagnosis of "follicular neoplasm".3. To stimulate discussion among the Otolaryngology community on the management of of patients with a FNAB diagnosis of "follicular neoplasm" at their respective institutions.

OBJECTIVES: 1. To determine the percentage of patients who had surgical intervention for a thyroid fine-needle aspiration biopsy (FNAB) diagnosis of “follicular neoplasm” at our institution; 2. To determine the malignancy rate for those who had surgical intervention. METHODS: We retrospectively reviewed records for patients who had a FNAB diagnosis of “follicular neoplasm” from 2002-2005. Records were reviewed from 2002 to October 2007 to determine if patients had surgery. Final pathology reports were reviewed. RESULTS: A total of 213 patients had a FNAB diagnosis of “follicular

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neoplasm”. Of these, 56% (119/213) had documented surgical intervention. Many of the FNABs were ordered by community surgeons, thus, surgical intervention could not be determined. For final pathology, 79% (94/119) were benign, while 21% (25/119) were malignant. Most of the benign lesions were hyperplastic nodules (38.6%, 46/119) or follicular adenomas (33.6%, 40/119). Most of the malignancies were papillary carcinoma (14.3%, 17/119) while the rates were 5% (6/119) and 1.7% (2/119) for follicular carcinoma and Hurthle cell carcinoma, respectively. CONCLUSIONS: A slight majority of patients had surgical intervention for a FNAB diagnosis of “follicular neoplasm”, however, this was likely underestimated. For those who had surgical intervention, we had a malignancy rate of 21%, which was in accordance with the literature.

BOARD H11 Impact of Neck Dissection on Swallowing Function – A. Grewal, S. Hawkins, R. Martin, C. Dreyer, M. McCormack, J. Yoo, J. Franklin, K. Fung, LONDON, ON

LEARNING OBJECTIVES: 1. To investigate whether salvage neck dissection is associated with more severe dysphagia and lower Quality of Life scores in patients initially treated with chemoradiotherapy for oropharyngeal squamous cell carcinoma.2. To establish swallowing-related Quality of Life data in patients requiring salvage neck dissection using the M.D. Anderson Dysphagia Inventory, and the University of Michigan Head and Neck QoL Questionnaire.3. To assess nutritional status in these patient groups using the Patient-Generated Subjective Global Assessment tool.4. To objectively assess swallowing deficits in these patient groups using a standardized Modified Barium Swallow Protocol, evaluated by a panel of experts on multiple parameters including the Penetration-Aspiration Scale.

OBJECTIVES: To determine whether oropharyngeal squamous cell carcinoma (OSCC) survivors having undergone salvage neck dissection (ND) after chemoradiotherapy (CRT) differ in swallowing function and dysphagia-related Quality of Life (QoL) compared to patients requiring CRT only. METHODS: A cross-sectional study of Stage IV OSCC patients, stratified by tumour site into CRT (n=11) and CRT+ND (n=12) groups. Validated subjective tools used include the M.D.Anderson Dysphagia Inventory, Patient-Generated Subjective Global Assessment, and University of Michigan Head and Neck QoL Questionnaire. All patients underwent a standardized Modified Barium Swallow (MBS), evaluated on multiple parameters including the Penetration Aspiration Scale (PAS). RESULTS: Both groups scored closely on Global, Emotional, Functional, Physical, Eating, and Speech survey domains. The CRT+ND group reported higher Pain scores (p=0.07), though not statistically significant. Preliminary MBS analysis reveals 50% of CRT patients experience aspiration and an average PAS score of 2.7, compared to 57% and PAS 3.4 for CRT+ND patients [MBS analysis to be completed Dec 2007]. CONCLUSIONS: Surprisingly, this study suggests that OSCC patients undergoing salvage ND for persistent nodal disease do not report lower dysphagia-related QoL scores than CRT-only patients, perhaps with the exception of treatment-related pain. MBS data reveal half of all patients aspirate, a potentially dangerous complication of treatment.

BOARD H12Left-sided Chylothorax Due to Thoracic Duct Compression by a Large Retrosternal Goiter – J. Paradis, S. Kherani, P. Odell, OTTAWA, ON

LEARNING OBJECTIVES: To understand that large retrosternal goiters can: (1) cause, in rare situations, a chylothorax; and (2) be the initial presentation of a lymphoma.

OBJECTIVES: To understand that large retrosternal goiters can cause, in rare situations, a chylothorax and be the initial presentation of a lymphoma. METHODS: Patient’s charts were reviewed between 2001 until present. RESULTS: We describe a 59 year old male with a 7-year history of a large multinodular goiter of the left thyroid lobe extending down to the clavicle who presented with respiratory distress. CXR revealed a massive left-sided pleural effusion and a thoracentensis confirmed a chylothorax. Imagining indicated that the thyroid mass remained stable in size with no cervical lymphadenopathy, however, it was very close to the C7 vertebral body and possibly compressing the thoracic duct. The patient had two subsequent episodes of chylothorax. After further investigations, a diagnosis of lymphoma was made. Following his radiation treatments a total thyroidectomy is anticipated particularly if the chylothorax does not resolve. CONCLUSIONS: There are no known prior reports of a male with large retrosternal goiter presenting with left sided chylothorax in the literature. Compression of the thoracic duct by the left-sided goiter is the likely etiology for these chylothoraxes. Large lymphomatous goiters, in the absences of cervical lymphadenopathy, may present a number of years prior to diagnosing lymphoma.

BOARD H13 The Natural History of Mandibular Osteoradionecrosis by Serial Panoramic Radiography – J. Trites, M. Brake, R. Hart, M. Taylor, HALIFAX, NS

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LEARNING OBJECTIVES: 1. To review the clinical presentation of mandibular osteoradionecrosis.2. To appreciate the broad spectrum of treatments available for this condition. 3. To recognize that some patients will not receive lasting benefit from non-operative or limited operative treatment, and that this cohort will exhibit progressive disease requiring more comprehensive resection.

Mandibular osteoradionecrosis (ORN) is a late complication of high dose radiation therapy. This can present a formidable burden for patients, many of whom have overcome locally advanced head and neck cancer only to develop dysphagia, chronic pain, trismus, cutaneous fistulae, and rarely, pathologic fracture. We describe a 48-year-old gentleman who presented with progressive trismus, oromandibular pain and odynophagia 24 months after completing concurrent chemoradiation therapy and an integrated neck dissection for a T2N1M0 squamous cell carcinoma of the oropharynx (tongue base). There was no clinical or radiographic evidence of recurrence, and a diagnosis of ORN was supported by biopsies of the mandibular alveolar ridge. We present his serial panoramic mandibular radiography (7 images over 36 months) throughout the full spectrum of treatment, including fastidious oral/dental hygiene, long term antibiotics, hyperbaric oxygen therapy, transoral sequestrectomy and, finally, a segmental mandibulectomy reconstructed with vascularized bone and soft tissue. CONCLUSION: Mandibular ORN can present as great a challenge for the head and neck surgeon as the tumour for which radiotherapy was originally recommended. A spectrum of treatment is available, with surgery generally reserved for more advanced or refractory cases. We document the radiographic development and progression of treated ORN over a period exceeding three years, and culminating in segmental mandibular resection.

BOARD H14 Complete Spontaneous Regression of Node-Positive Merkel Cell Carcinoma of the Upper Face – J. Trites, M. Brace, R. Hart, M. Taylor, HALIFAX, NS

LEARNING OBJECTIVES: 1. To appreciate the typical natural history of Merkel cell carcinoma.2. To be aware of the ability of this unusual tumour to exhibit complete spontaneous regression, even in the context of regional metastasis.

Merkel cell carcinoma (MCC) is a rare cutaneous tumour of neuroendocrine origin. This high grade malignancy is characterized by local recurrence and early lymph node metastasis. The two year survival rate is 50-70%. We describe a 94-year old Caucasian woman who presented with a 4 cm level II neck node nine months following a margin-controlled resection of a MCC of the ipsilateral forehead and brow. Axial CT and fine needle aspiration biopsy confirmed a solitary lymph node metastasis, with no evidence of distant disease. At the time of neck dissection, the mass had regressed substantially in size. Based on the positive cytology, the patient was counselled to proceed with lymphadenectomy as originally planned. The procedure and post-operative course were uneventful. A functional neck dissection of levels I-IV yielded 25 benign lymph nodes and 2 fibrous nodules exhibiting heavy lymphoplasmacytic and histiocytic infiltrates, but no viable tumour. No adjuvant treatment was recommended, and the patient remains disease-free 21 months after surgery. To our knowledge, this represents the 17th case of complete spontaneous regression (CSR) of MCC, and the oldest patient to date. It also supports the observed female preponderance of patients who enjoy CSR. CONCLUSION: MCC is a rare and high grade cutaneous neoplasm. Despite its typical behaviour, MCC has an unusual propensity for complete spontaneous regression, and this phenomenon is not well understood.

BOARD H15Extramedullary Plasmacytoma of the Tongue: Two Cases and a Review of the Literature – V. Biron, H. Brown, W. Blahey, J. D. Bosch, CALGARY, AB

LEARNING OBJECTIVES:1. Pathology of EMP2. Diagnosis and treament of EMP

Extramedullary plasmacytoma (EMP) is a rare plasma cell tumor with a predilection for the head and neck. Although EMP is generally indolent, it requires careful consideration and treatment for its ability to progress to multiple myeloma. We report two cases of EMP located in the base of tongue - an exceedingly rare location for this tumor. One patient was treated by combination of surgery and radiotherapy whereas a second patient was treated by surgery alone. Both patients had excellent outcomes with these different treatment modalities. Given the unusual location of these lesions, there is a paucity of knowledge about the optimal treatment. In this regard, our cases provide novel insight, which is discussed in the context of a literature review.

BOARD H16 Chondrosarcoma of the Cervical Trachea – M. Grandy, R. Hart, J. Trites, D. Bethune, M. Taylor, HALIFAX, NS

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LEARNING OBJECTIVES: 1. Present a rare type of tracheal tumor. 2. Discuss the present case in terms of initial presentation, management and follow-up. 3. Summarize and integrate the findings from this case with the 15 other cases presented in the literature.

Chondrosarcoma of the trachea is exceedingly rare. Currently, only 15 cases of chondrosarcoma of the trachea have been reported in the literature. Fourteen of the 15 cases reported to date occurred in males. The following presentation is a case of a 78-year old woman who presented with airway symptoms as a result of a cervical tracheal chondrosarcoma. The initial presentation/diagnosis, management, and follow-up will be discussed.

BOARD H17 Chondrosarcoma of the Head and Neck: A Report of 11 Cases and Review of the Literature – P. Hong, E. Wainwright, J. Trites, M. Taylor, J. Nasser, M. Bullock, R. Hart, HALIFAX, NS

LEARNING OBJECTIVES:1. Review cases of chondrosarcomas of the head and neck at a tertiary institution.2. Assess management and long-term outcomes in head and neck chondrosarcomas.3. Enhance understanding of head and neck chondrosarcomas via comprehensive review of literature.

OBJECTIVE: Chondrosarcoma is a malignant tumour of mesenchymal origin. They most commonly occur on axial structures and are rarely found in the head and neck. A review of these tumours is carried out focusing on management and outcomes. METHODS: A total of 11 chondrosarcoma cases of the head and neck were retrospectively identified at a tertiary-care teaching centre. RESULTS: There were 7 males and 4 females; ages ranged from 18-77 years. Specific sites included larynx (3), trachea (1), petrous apex (2), skull base (2), cervical spine (1), clivus (1), and cavernous sinus region (1). Eight of the 11 patients had grade I disease (73%), while the remaining 3 (27%) had grade II tumours. None had metastatic disease at presentation. Surgical resection with post-operative radiation therapy was the most widely employed primary treatment (55%); rest of the patients (45%) had surgical resection only. There were 2 recurrences. Salvage surgeries were performed in both. Disease-specific survival was 73% at 5-years. CONCLUSION: Chondrosarcomas are rare tumours of the head and neck. Treatment should be aimed at complete surgical resection with the option of post-operative radiotherapy. They usually portend a favourable long-term prognosis.

LARYNGOLOGYBOARD L1 Spasmodic Dysphonia in Twins: A Case Study – T. Davids, J. Anderson, TORONTO, ON

LEARNING OBJECTIVES: 1. To review a case of twins presenting with adductor spasmotic dysphonia, with a 10 year delay between presentation.2. To review the relevant anatomy and physiology of adductor spasmotic dysphonia.3. To review evidence supporting a hereditary link of adductor spasmotic dysphonia.4. Review the EMG tracings of both case patients pre- and post-treatment with botulinum toxin for adductor spasmotic dysphonia.

Spasmodic dysphonia is a neurogenic dystonia of the larynx with no clear evidence of hereditary linkage. A case study of twins presenting with adductor spasmodic dysphonia is presented. The delay in symptom onset between the two sisters was approximately 10 years. This poster review's the case history, discusses the relevant antomy, etiology, incidence, and possible hereditary conditions associated with adductor spasmotic dysphonia. Laryngeal muscle EMG's of both patients are shown both pre- and post- botulinum toxin administration. Treatment responses, including botox dosing, between twins is discussed.

BOARD L2Life Threatening Paradoxical Vocal Cord Movement in a Newborn Caused by Gastroesophageal Reflux – Z. Abou Chacra, A. Lapointe, MONTREAL, QC

LEARNING OBJECTIVES:1. To familiarize with the following entitiy: paradoxical vocal cord movements (PVCM)2. To recognize PVCM in neonates with gastro-esophageal reflux disease

Paradoxical vocal cord movement (PVCM) is characterized by inspiratory choking and stridor, and is defined as the inappropriate adduction of the true vocal cords during inspiration. Gastroeosophageal reflux (GER) is known as one of the multiple etiologies of PVCM. However, this association has rarely been described in the neonatal population. We present the case of a 2 1/2 week-old male born at term without any stridor or respiratory distress. He was diagnosed with an esophageal

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atresia and a tracheo-esophageal fistula, which was corrected through a right thoracotomy at 1 day of life. Extubation the following day failed because of biphasic stridor and respiratory distress. A rigid laryngoscopy and bronchoscopy at post-operative day #10 showed normal laryngeal and subglottis anatomy, moderate tracheomalacia and bilateral movement of the vocal folds. Extubation was tried again under CPAP. Though stable, the patient had severe sternal and intercostal retractions along with biphasic stridor that prevented lowering of the positive end-expiratory pressure. A flexible endoscopy at bedside showed the vocal cords in adduction and motionless bilaterally. Edema and erythema of the arytenoids and retrocricoid region compatible with reflux laryngitis was also seen. Aggressive antireflux management led to a full recovery within 10 days. PVCM must be considered in cases of neonatal stridor, especially when concomitant pathologies known to be associated with GER are present.

BOARD L3Accent Method of Voice Therapy for Treatment of Severe Muscle Tension Dysphonia: A Case Report – K. Al Malki, N. Abdel Nasser, S. Hassan, M. Farahat, RIYADH, SAUDI ARABIA

LEARNING OBJECTIVES:1. To present a severe form of muscle tension dysphonia.2. To define arytenoidal dysphonia.3. To show that Smith Accent method of voice therapy is effective in treatment of severe muscle tension dysphonia.4. To explain the importance of patient's complience to voice therapy techniques in non-organic dysphonia.5. To demonstrate that acoustic analysis of voice can be useful in showing the effectivness of voice therapy.

OBJECTIVES: To present a severe form of nonorganic dysphonia, the authors termed "Arytenoidal Dysphonia". It was a severe form of muscle tension dysphonia, which was described earlier in literature but with different nomenclature. The outcome of Smith Accent method of voice therapy was also presented. STUDY DESIGN: Case report and brief literature review. METHODS: A case report is presented of a female patient with low pitched and irregular voice since early childhood. She was using her arytenoidal mucosa as a vibrator to produce phonation. CONCLUSION: Smith Accent method of voice therapy is proven to be an effective treatment of arytenoidal dysphonia. KEY WORDS: Larynx; vocal folds; arytenoidal dysphonia; voice therapy.

BOARD L4 Subglottic Stenosis Secondary to Waldenstrom’s Macroglobulinemia – M. Brake, B. Lee, B. Hoyt, M. Brake, M. Taylor, ST. JOHN’S, NL

LEARNING OBJECTIVES:1. Review Waldenstrom’s Macroglobulinemia in terms of epidemiology, symptomatology and treatment.2. Discuss Waldenstrom’s Macroglobulinemia as a differential for subglottic stenosis.

The causes of subglottic stenosis are many and varied, and its management often difficult. Adult onset subglottic stenosis has been well documented and the differential includes trauma, collagen vascular diseases, benign and malignant neoplasms and chronic inflammatory conditions. To our knowledge, we present the first case of subglottic stenosis secondary to Waldenstrom’s Macroglobulinemia, a malignant, infiltrative lymphoproliferative disorder of immunoglobulin M (IgM) producing monoclonal B lymphocytes. In our case, a 57-year-old male presented with a ten-month history of progressive hoarseness associated with a foreign body sensation in his throat, dyspnea on exertion, and stridor. The past medical history was significant only for Waldenstrom’s Macroglobulinemia, diagnosed approximately four years earlier. Direct laryngoscopy demonstrated fullness along the left aryepiglottic fold and false cord, as well as a concentric submucosal mass in the subglottic region. CT imaging showed a pre-epiglottic soft tissue mass which extended inferiorly to the subglottic area. Bloodwork revealed microcytic, hypochromic anemia, mild thrombophilia and elevated IgM. Tissue biopsies were consistent with Waldenstrom’s Macroglobulinemia. The patient was successfully treated with cyclophosphamide and prednisone.

OTOLOGYBOARD O1 How We Do It: The Epley Maneuver Teaching Head Set and Modified Epley Maneuver – J. Keir, J. Tahery, CHESHIRE, UK

LEARNING OBJECTIVES:1. Our head set may be used as a teaching tool in training junior staff and in primary care.2. It is easy to use and is of aid in explaining this conceptually difficult condition to the patient.3. We describe a modification to Epley’s classic canalith repositioning procedure.

We describe both a modified Epley maneuver and an Epley maneuver head set which acts as an aid both when explaining the condition to the patient and as a tool in teaching junior staff. The head set consists of a 3D representation of the vestibular

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system. Three 19cm latex free connecting tubes at an angle of 90 degrees to each other represent the semicircular canals. These are fixed to a hollow plastic cup reflecting the “utricle”. A freely moving ball bearing is placed inside the lumen of the posterior SCC as a substitute for the canalith and to demonstrate its subsequent movement during repositioning. BPPV is a complicated and conceptually difficult condition to describe to patients. We believe the head set provides an easy method to help grasp the condition. In training junior staff it is a valuable aide memoir and focuses the mind on the task of repositioning the canalith through its visualisation of the substitute canalith as it is progressively moved along the semicircular canal into the utricle. It may be used in any setting including primary care or in teaching patients canalith repositioning techniques in those requiring more than one maneuver who will self treat.

BOARD O2One versus Two Bone Anchored Hearing Aids: Audiometric Evaluation and Skull Vibration Characteristics - H. Hafidh, O. Majdalawieh, R. VanWijhe, M. Bance, HALIFAX, NS

LEARNING OBJECTIVES:1. The benefits and drawbacks of bilateral BAHA fitting in patients with moderate to sever mixed hearing loss with a bone curve of more than 40 dB.2. The effect of two versus one BAHA on bone vibration measurements.For many patients with severe mixed hearing loss, a single BAHA is not powerful enough. If we could improve the skull vibrations by using more than one BAHA, this population of patients might be salvaged. The main objective of this study was to evaluate the advantage of fitting two BAHAs by measuring the increase in skull vibration as well as the quantitative improvement in audiological performance. METHODS: Ten patients (group A) with severe bilateral hearing loss who are poor candidates for the BAHA, and five patients (group B) with an implanted BAHA, were tested. Baseline audiometry and free-field hearing thresholds (HTH) were measured for the 15 patients by using standard audiometric procedures. Skull vibrations for group B were measured using a Laser Doppler Vibrometer (LDV). RESULTS: On average, data analysis of group A showed no significant improvement in HTH by using two BAHAs. In the group B patients, there was improvements in HTH across the full frequency range (0.5-4 kHz), however this was significant only at low frequencies (<1 kHz). Skull vibration measurements failed to show any significant improvement by using two BAHAs over one. Statistical analysis showed no strong correlation (R=0.24) between hearing and vibration for group B. CONCLUSIONS: Overall, our study showed that there is no significant improvement of using two BAHAs in patients with severe mixed hearing loss.

BOARD O3Use of Intratympanic Dexamethasone for the Treatment of Langerhans Cell Histiocytosis and Associated Sensorineural Hearing Loss – S. Khalili, T. Batten, ST. JOHN’S, NL

LEARNING OBJECTIVES:1. Educate about Langerhans Cell Histiocytosis.2. Possible novel treatment of Langerhans Cell Histiocytosis with sensorineural hearing loss with intratympanic dexamethasone injections.OBJECTIVE: To evaluate hearing recovery and elimination of Langerhans cell histiocytosis (LCH) infiltrates in the treatment of diagnosed LCH in the temporal bone with sensorineural hearing loss. METHOD: A retrospective case-study analysis of a patient with LCH manifestations in their mastoid processes of bilateral temporal bones that was treated with intratympanic dexamethasone injections. This patient was treated in St. Claire’s Hospital, St. John’s, Newfoundland by the ENT consultants group of Newfoundland. RESULTS: Post-injection of intratympanic dexamethasone, the patient’s hearing loss in the corresponding ear increased from 0 % word discrimination to 68% at 95 dB. The patient’s tympanic membrane was now normal and their middle ear space was now visible via myringotomy. A follow-up biopsy of the lesion showed no evidence of LCH where it had previously been demonstrated and diagnosed by CT and pathology. CONCLUSION: LCH skull manifestations are frequent, particularly in patients with multiorgan involvement. Intratympanic steroid injections like dexamethasone may show a beneficial effect in both improving sensorineural hearing loss and clearing the LCH infiltration.

BOARD O4Towards Standardization of Vestibular Examination - A Novel Body Positioning Device [BPD] – B. Lange, B. Miller, CALGARY, AB

LEARNING OBJECTIVES:1. Recognition that co-morbidities prevent accurate vestibular/assessment. e.g.: 15-30% of patients referred for VNG do not have Dix-Hallpike testing done, because of 'reported back and neck problems, despite BPV being a common diagnosis.2. Vertical canal VOR is poorly understood in the pathogenesis of movement induced vertigo, and up until now not routinely assessed.3. Test and treatments for BPV can be done with demonstration of pathologic nystagmus.4. VNG potentially could be standardized, as there is a wide variation between laboratories in its execution.

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OBJECTIVE: Patients with vestibular symptoms often have comorbid conditions causing difficulty in clinical examination, and unreliable vestibular testing. These morbidities include spinal dysfunction, obesity, anxiety, and motivational issues. For this reason we have developed a novel Body Positioning Device [BPD] and present preliminary data on the benefits and limitations of this examination chair. METHOD: Assessment of the vestibular examination and testing procedures was done by a biomedical industrial design specialist. After calculations of the semicircular canal planes, speeds of patient movement required, and risk assessment to both patient and examiner, the prototype BPD was designed, and then constructed. This consists of a standard roller coaster chair, which allows for complete stability of the patient head and neck. RESULTS: The initial BPD findings shows advantage over conventional methods, which include the patient being able to be moved safely through 360 degrees in all axes. This ability has the potential to assess vertical semicircular canal function. There is also less risk of injury to the patient and examiner. Preliminary normative data will be presented. CONCLUSION: A mechanized BPD has the potential to do an expanded vestibular examination in all patients, even with comorbidities.

PEDIATRIC OTOLARYNGOLOGYBOARD P1The Emerging Role of Escherichia Coli as Deep Neck Space Abscess Pathogen in Immune-competent Children: A Report of 2 Twin Cases – A. Hilal, L. Johnson, G. Corsten, HALIFAX, NS

LEARNING OBJECTIVES:1. Authors believe there is a changing pattern of microbiology responsible for deep neck spaces infection in children.2. Twin siblings may present with exactly similar acquired infection. Environmental or genetic factors could be postulated.3. Unusual or less common organisms causing deep neck space abscess in immune-competent children should also be considered in selecting appropriate antibiotic therapy.4. Management options highly depend on the clinical course as well as imaging in cases of deep neck space abscess.

OBJECTIVES: To emphasise the role of Escherichia coli as an increasingly common cause of suppurative head and neck infection in pediatric age group. METHODS: Authors describe the clinical course of twin pediatric patients who presented with classical picture of deep neck space abscess to the IWK Health Centre, Halifax, Nova Scotia. Demographic data, symptomatology, season of presentation, imaging and microbiology findings and management plans are reviewed. RESULTS: Both cases who were twin brothers, aged 7 years, had Escherichia coli retropharyngeal abscess. They presented only two weeks apart with fairly similar clinical picture. A trial of antibiotic therapy failed to resolve the condition in both cases. Definitive treatment followed by incision and drainage of the abscess in the OR. CT/ MR scans were helpful diagnostic tools. Pus grew Escherichia coli as the sole micro-organism in the twin brothers. CONCLUSION: Although Gram-positive cocci have been mostly reported in the literature as the main cause of deep neck spaces infection including retropharyngeal abscesses, the role of Gram-negative bacilli should not be overlooked. Escherichia coli abscess tend to have a similar clinical, radiological and prognostic course. However, high index of suspicion is needed in order to appropriately tailor the antimicrobial therapy.

BOARD P2Congenital Midline Cervical Cleft: Case Report and Literature Review – Y. AL Badaai, S. Daniel, MONTREAL, QC

LEARNING OBJECTIVES:1. To descripe the clinical features and presentations of congenital midline cervical cleft.2. To emphasis the importance of early surgical intervention to prevent subsequent deformity.3. To compare the clinical features, treatment options and the outcome of all reported cases of congenital midline cervical cleft.

OBJECTIVE: To report a case of Congenital midline cervical cleft (CMCC) and to emphasis the importance of early surgery to prevent cervicofacial deformity. METHODS: We present a case of CMCC in a 6 days old infant. Embryological basis, clinical features, surgical techniques and literature review will be discussed. RESULTS/CASE REPORT: A 6-day-old girl presented to the pediatric otolaryngology clinic with anterior midline neck skin lesion noticed at birth. Physical examinations revealed a midline skin tag-like structure measuring 0.5cm with a fistulous opening at its inferior border below the level of cricoid cartilage. The rest of her head and neck examinations revealed no obvious anomaly. The diagnosis of congenital midline cervical cleft was made. Surgery under general anesthesia was performed at 12 days of life. An elliptical incision was made around the cleft and a complete dissection and excision of the fibrous bands were performed. The skin was closed with a Z-plasty approach. The scar healed well on subsequent follow up visits with no restriction in her neck movements or mandibular growth. CONCLUSION: We advocate early surgery for CMCC to avoid subsequent limitation of the extension of the neck or impairment of mandibular growth.

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BOARD P3Congenital Epulis: An Atypical Case – X. Zhao, S. Chandarana, M. Husein, LONDON, AB

LEARNING OBJECTIVES:1. To discuss the pathology of a congenital epulis.2. To discuss the typical presentation and management of a congenital epulis in the literature.3. To discuss an atypical presentation and subsequent treatment for congenital epulis.Congenital epulis is a rare benign tumor of the newborn. There is a predisposition for females over males and is more common in the maxilla than the mandible. We present a case of a large congenital epulis in a newborn girl. The lesion did not disrupt breathing, but did impair normal feeding and began to bleed spontaneously three days after birth, requiring urgent operative care and transfusion of packed red blood cells. The diagnosis, pathology, and treatment are discussed and compared to the literature.

BOARD P4Lingual Nerve Sheath Myxoma Presenting in a Healthy 14 Year Old Male – J. Paradis, J. Chou, J. Harris, Allegretto, OTTAWA, ON

LEARNING OBJECTIVES:1. To describe a unique presentation of a lingual nerve sheath myxoma (NSM). 2. To review the literature on this rare condition.

OBJECTIVES: To describe a unique presentation of a lingual nerve sheath myxoma (NSM) and to review the literature on this rare condition. METHODS: Retrospective chart and literature review with prospective patient follow up. RESULTS: JP first presented with oral discomfort at the age of 8. At 11, findings of a small lesion along with biopsy led to a diagnosis of median rhomboid glossitis. Three years later, he presented with pain, hoarseness, intermittent lingual bleeding and dysphagia. An enlarged painful lingual mass was noted. MRI and biopsy revealed a homogeneous 5cm lingual mass with whorls and spindle cells along with diffuse expression of S-100 and CD-34. These findings led to a diagnosis of NSM. The patient underwent a total glossectomy and reconstruction with a LRFF. JP progressed well and continues with swallowing rehabilitation. CONCLUSION: Seventeen cases of lingual NSM have been reported in the literature. Among these, only two presented before the age of 10 and none had a presenting symptom of pain. The largest reported NSM was 3cm. We present a case with the largest reported lingual NSM where pain was the presenting symptom. This is also the first case of lingual NSM that was reconstructed with free tissue transfer.

BOARD P5Inflammatory Myofibroblastic Tumor of the Subglottis: A Case in a 5-year-old Child – T. Hart, R. Rassekh, J. Ludemann, P. Moxham, VANCOUVER, BC

LEARNING OBJECTIVES:1. To illustrate a typical presentation of a very rare case of a subglottic inflammatory myofibroblastic tumor in a child.2. To outline the diagnostic workup, including CT and pathology interpretation, and treatment protocol associated with this condition. 3. To provide information and tools for Canadian Otolaryngologists to educate our primary care colleagues about interpreting stridor and wheeze and the significance of the physical finding in developing an appropriate differential diagnosis.

OBJECTIVES: Inflammatory Myofibroblastic Tumors (also known as IMT’s or Inflammatory Pseudotumors) affecting the upper airway are exceedingly rare lesions, particularly in the pediatric subpopulation. To date, less than twenty adults and only two children have been documented with the condition. Here, we describe a third pediatric case, in which a 5-year old boy, presenting with biphasic stridor and dysphonia, was initially diagnosed with asthma and later found to have a subglottic IMT obstructing 80% of his airway. Diagnostic workup, treatment, and post-operative considerations are discussed. METHODS: Case report and review of the literature. RESULTS: After diagnosis, the patient underwent direct laryngoscopy and the mass was completely excised with a CO2 laser. Four years later, the patient remains disease-free with no recurrence of the lesion on follow-up examination. CONCLUSION: Inflammatory myofibroblastic tumors of the subglottis are rare and macroscopically difficult to distinguish from other space-occupying lesions below the vocal chords. Further, the etiology of the condition remains unclear. Radiographic imaging using CT and histopathology are essential in making an accurate diagnosis. However, after careful surgical excision, prognosis is excellent, and IMT recurrence is rare. This case further underscores the importance of improving medical education in the primary care setting with respect to multiphasic stridor and wheeze. 

BOARD P6A Floor of Mouth Teratoid Cyst with Tract in a Newborn – Case Report and Literature Review Unravelling Misquotes in the English Literature – K. Gan, E. Fung, H. Idikio, H. El-Hakim, EDMONTON, AB

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LEARNING OBJECTIVES:1. To report a case of teratoid cyst in the floor of mouth2. To review the literature about the epidemiology3. To identify a case of propagated misquote of literature

Dysontogenetic cysts (DC) are thought to fall into one of three subtypes; epidermoids, dermoids or teratoids. There is no doubt that the floor of mouth is the least common site of presentation of all. Over the last 70 years, fewer than 20 histologically proven cases of floor of mouth teratoids have been described in the English literature. We present an infant with a floor of mouth teratoid with an associated midline tract. The cyst was identified at birth and interfered with feeding. It was surgically excised with no recurrence at 10 month point of follow-up. The literature search revealed that due to misquotes and confusing terminology, false beliefs regarding the epidemiology have been disseminated. Counter to most publications, teratoids of the floor of mouth are most commonly encountered in childhood with only a handful of cases in older age groups. The case is presented along with the literature review.

BOARD P7Airway Obstruction Secondary to Esophageal Mucoceles: 2 Pediatric Cases and a Review of the Literature – E. Fung, K. Gan, A. Lacson, G. Lees, H. El-Hakim, EDMONTON, AB

LEARNING OBJECTIVES:1. To review the literature on development of esophageal mucoceles after exclusion surgery2. To describe 2 rare cases of airway obstruction in children caused by esophageal mucoceles3. Describe management options

Esophageal mucoceles are an exceptionally rare cause of airway obstruction in children. They develop as fluid-filled dilatations of the esophageal remnant following bipolar exclusion of the thoracic esophagus. Only six pediatric cases have been reported previously in the literature. We present two consecutive cases where they caused respiratory distress in different clinical scenarios. Complex co-morbidities, including preceding respiratory dysfunction, complicated the diagnostic process. Bronchoscopy followed by imaging were used to establish the diagnosis. Complete resection of the thoracic esophagus was required for definitive treatment in both patients. A high degree of suspicion, clinical awareness, and appropriate interpretation of diagnostic tests are essential to reach the diagnosis.

BOARD P8The Use of Deflux Injections in the Treatment of Type 1 Laryngeal Clefts: A Case Study – A. Dadgostar, J. MacCormick, OTTAWA, ON

LEARNING OBJECTIVES:1. To become familiar with the current common classification system for posterior laryngeal clefts.2. To recognize the common symptoms of posterior laryngeal clefts.3. To understand the current therapy of type 1 posterior laryngeal clefts, both conservative and surgical.4. To describe the use of Deflux injections as a bulking agent in the endoscopic treatment of type 1 posterior laryngeal clefts.

Laryngeal clefts are rare congenital anomalies that are most commonly characterized by the Benjamin and Inglis classification. Type 1 laryngeal clefts are characterized by supraglottic interarytenoid clefts, where the clefts are above the level of true vocal cords. Endoscopic repair is the current trend for treatment. We present a case of a 6-year-old patient with a type 1 laryngeal cleft who experienced delayed failures of endoscopic repair and subsequently gelfoam injection. We describe the use of Deflux injection, currently used in the treatment of vesicoureteral reflux, as a novel treatment for type 1 laryngeal cleft in our patient. At four months post-injection, the Deflux injection has proven to be the most successful treatment in managing our patient’s chronic cough, recurrent choking, and aspiration.

BOARD P9Balloon Dilatation Repair for Unilateral Choanal Atresia – E. Brown, P. Moxham, VANCOUVER, BC

LEARNING OBJECTIVES:1. To present a novel technique of choanal atresia repair.2. To review published re-stenosis rates of existing choanal atresia repair techniques.3. To review potential complications of choanal atresia dilatation.

Numerous surgical techniques have been proposed to repair choanal atresia. Despite advances in techniques using powered instruments and lasers, re-stenosis rates remain significantly high. Traditional repair techniques such as puncture and dilatation have comparable rates of re-stenosis and are cost effective. Significant disagreement exists among pediatric otolaryngologists regarding the procedure of choice. A two-year old patient with unilateral bony-membranous choanal atresia was treated with puncture and balloon dilatation under direct visualization. The positioning of the balloon was confirmed by

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our standard technique of simultaneous transnasal 0 degree telescopic and nasopharyngeal 120 degree telescopic guidance. The use of a 5 millimetre angiographic balloon dilatation was used to overcome the problem of fixed transnasal dilators which are limited by the anterior nasal dimensions. At one-year follow-up, the nasal cavity remained greater than 50 percent patent. Transnasal balloon dilatation holds promise as a safe, rapid, and cost-effective technique. Once the choanal patency is established, re-dilation with the balloon under endoscopic or fluoroscopic guidance is a possibility. The effect of increased dilatation via the angiographic balloon on re-stenosis and complication rates remains to be shown in a larger series.

BOARD P10Diagnosis and Managament of a Neonatal Intralingual Cyst of Foregut Origin – S. Patel, S. Chandarana, M. Husein, N. Chan, LONDON, ON

LEARNING OBJECTIVES:1. In-utero diagnosis and treatment of congenital oral cavity lesions.2. Neonatal airway management in these cases.3. Role of imaging in the management of potential fetal airway obstruction.

Congenital intralingual cysts of the foregut origin are extremely rare. It is suspected that these cysts form due to a defect in migration of endoderm during the fourth fetal week. These cysts have the potential to compromise fetal airway at time of delivery. We present a case of a 37 week fetus with an intralingual cyst identified by antenatal ultrasound and MRI. Information acquired from the imaging allowed for a controlled delivery with necessary precautions taken to manage an impending airway. The cyst was excised on the eighth day of life, and the patient was discharged with no feeding or airway issues. Significant advances have been made with respect to antenatal imaging. We have reviewed the literature as it pertains to our case, in an attempt to demonstrate the utility of this imaging in making appropriate arrangements for a controlled delivery. Antenatal imaging such as U/S and MRI play a significant role in anticipating an impending airway obstruction in a fetus, and should be considered standard of care.

RHINOLOGYBOARD R1Cerebrospinal Fluid Rhinorrhea: Ten Year Review in Nova Scotia – G. Thompson, E. Massoud, HALIFAX, NS

LEARNING OBJECTIVES:1. To review etiology and classification of CSF rhinorrhea.2. To examine management and treatment outcomes of CSF rhinorrhea at a single tertiary care centre and to compare those results with published data.3. To determine which factors are most predictive of treatment failure.4. To offer guidance in stratifying patients to optimal treatment strategies based on etiology and site of CSF rhinorrhea.

INTRODUCTION: Cerebrospinal fluid (CSF) rhinorrhea presents diagnostic and management challenges due to its diverse etiologies and treatment strategies. Consequently, non-surgical and surgical treatment options are utilized for successful outcomes. METHODS: A comprehensive, consecutive, retrospective review was performed to assess etiology, defect site, management, and outcomes in patients with CSF rhinorrhea at the QE II Health Sciences Center in Halifax, Nova Scotia between 1996 and 2006. RESULTS: Seventy-five CSF leaks occurred in 50 patients. Mean age at diagnosis was 42 + 2.1 years; 60% were male. Iatrogenic and traumatic injuries accounted for 43% and 39% respectively, with the remainder occurring spontaneously. The cribiform plate was the most common site. Conservative therapy was successful in 38% of patients; 62% of patients required surgical repair with either open or endoscopic techniques. Three patients (6%) required both open and endoscopic procedures. Initial treatment was successful in repairing CSF fistulae in 64% of patients. We found elevated BMI and female gender to be associated with spontaneous CSF rhinorrhea. Factors predictive of treatment failure included conservative management, iatrogenic injury to the cribiform plate, and traumatic frontal sinus CSF rhinorrhea. CONCLUSION: Traumatic injury involving the frontal sinus and iatrogenic injury to the cribiform plate are better served with surgery. BOARD R2Paranasal Sinus Bony Structures, Sinus Functioning, and Asthma Severity: Is There a Relationship? – B. Lui, D. Sommer, P. Nair, HAMILTON, ON

LEARNING OBJECTIVES: 1. To review the clinical definition and pathophysiology of sinus disease.2. To review the various staging systems of sinus disease.3. To review current medical literature on the relationship between sinus disease and asthma.4. To discuss the relationship between paranasal sinus anatomy, sinus disease, and asthma severity.

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OBJECTIVE: To characterize the relationship between ostiomeatal obstruction, anatomical variations, and asthma severity with computed tomography (CT) of the paranasal sinuses in patients with prednisone-dependent asthma, patients on high dose inhaled corticosteroids, and mild asthmatics. STUDY DESIGN: A retrospective analysis. METHODS: Patients with mild, moderate, and severe asthma were examined by reviewing their measures of airway inflammation, airflow limitation, and CT sinus scans. The pathological sinus changes in the CT scans were scored using the Lund-Mackay staging system, and several paranasal bony anatomical variations were recorded. These CT sinus measures were in turn correlated with spirometry (FEV1, FEV1/FVC), quantitative analysis of expectorated sputum for eosinophilia, and concentration of nitric oxide in exhaled breath. RESULTS: Analysis currently underway. Final results are pending. SIGNIFICANCE: Better characterization of the relationship between paranasal sinus anatomy, sinus disease, and asthma severity will shed light on possible paranasal sinus predictors of persistent airway eosinophilia and frequent asthma exacerbations. This may help optimize medical and surgical management of paranasal sinus pathology in asthmatic patients.

BOARD R3A Novel Grading System for the Approach to the Sphenoid Sinus – T. Orton, A. Javer, H. Gheriani, B. Mechor, VANCOUVER, BC

LEARNING OBJECTIVES:1. To outline a novel CT grading system to guide the sinus surgeon in his or her approach to the sphenoid. sinus.2. To provide population incidence data of each superior turbinate attachment grade.3. To describe the case that stimulated the creation of this grading system.4. To review the anatomy around the sphenoid sinus and the possible complications of sphenoidotomy.5. To describe the surgical complications that we hope to avoid with this grading system.

OBJECTIVE: To design a novel grading system for the superior turbinate (ST) attachment to the sphenoid face utilizing axial computerized tomography (CT) at the level of the natural sphenoid ostium. We believe that using the ST attachment will minimize perioperative complications. The ST attachment can be graded as either type A, B, or C based on its attachment to the medial, middle or lateral third of the sphenoid face respectively. A type D grading denotes ST attachment to the orbit. METHOD: A cohort of 43 patients undergoing sinus surgery was graded by axial CT. The population incidence for each type was recorded. Patients continue to be recruited up to a target of 100. RESULTS: At present, 45 % were found to have type A attachments, 38 % were found to have type B attachments, 15 % were found to have type C attachments and 1 % were found to have type D attachments. CONCLUSION: We have designed a novel grading system for the attachment of the ST to the sphenoid face. This grading system will be used to recommend one of two endoscopic sphenoidotomy approaches preoperatively to minimize the risk of surgical complication.  

BOARD R4 Rhinoscleroma Case Report and Literature Review – M. Hussain, A. Al-Habib, F. Al-Qattan, MISHREF, KUWAIT

Rhinoscleroma is a chronic, granulomatous infectious disease caused by Klebsiella rhinoscleromatis, which affects the respiratory mucosa, especially the nasal cavity, and if left untreated will extend to the lower respiratory tract. The disease is endemic in some countries of Central America, Asia and some African countries, but rare in South America. We reported a 23 years old male with a complete progressive bilateral nasal obstruction of 3 years duration associated with nasal discharge, anosmia and intermittent epistaxis. The patient was treated surgically and was followed up by a course of medical therapy, with no recurrence after one year. The case and the literature will be reviewed putting in mind that with the ease of transportation and the migration of the population, no disease is limited to a continent any more.   

BOARD R5Endoscopic Resection of Solitary Fibrous Tumours of the Nose and Para-nasal Sinuses - A. Janjua, I. Witterick, TORONTO, ON 

LEARNING OBJECTIVES:1. To illustrate the rare occurrence of solitary fibrous tumours with the nose and other sub-sites of the head and neck.2. To recognize the histologic, immunohistochemical and radiologic feature consistent with solitary fibrous tumours of the nose and para-nasal sinuses.3. To understand the appropriate management and follow-up of solitary fibrous tumours of the sinuses.

Solitary fibrous tumours [SFT] are uncommon neoplasms of mesenchymal origin which were first described as primary spindle-cell tumours of the pleural in 1931. Since that time, infrequent case reports of extra-pleural SFTs have been described including various sub-sites within the head and neck. We describe two cases of endoscopic resection of solitary fibrous tumours of the nasal cavity and ethmoid sinuses. In the course of these case reports, we emphasize the common presenting symptoms, appropriate diagnostic work-up and indicative CT & MRI appearance. Based on these cases and a review of the literature, we aim to highlight the challenges associated with the management of SFTs of the nose and para-nasal sinuses, that

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surgeons managing these tumours should be aware of. These challenges include the histologic and immunohistochemical diagnosis, the difficulty in assessing the aggressivity and malignant potential of these lesions and the appropriate extent of treatment and follow-up of these neoplasms.

BOARD R6Case Report: Anaplastic Large T Cell Lymphoma of the Sinonasal Tract Involving Three Separate Sites – Y. Dolev, J. Manoukian, DOLLARD-DES-ORMEAUX, QC

LEARNING OBJECTIVES: 1. To report a rare case of multifocal ALK-negative anaplastic large T cell lymphoma of the sinonasal tract.2. To highlight the difficulty associated with making the diagnosis of sinonasal lymphoma.3. To highlight the frequent delay to diagnosis associated with sinonasal lymphoma and the reasons for and ways to prevent this delay.4. To highlight the need to take several biopsies from several locations within the sinonasal tract to make the diagnosis of sinonasal lymphoma and prevent further delay to diagnosis.

Sinonasal lymphomas are uncommon malignancies. We report the case of a 17 year old boy who was diagnosed with ALK-negative anaplastic large T cell lymphoma (ALCL) of the sinonasal tract. This is a unique case because of the involvement of three separate sites. It highlights several important concepts related to sinonasal lymphomas including the fact that the diagnosis is often difficult to make, delays to diagnosis are common, and several biopsies are often necessary to reach an accurate diagnosis. Furthermore, we believe this to be the first reported case of ALK-negative anaplastic T cell lymphoma of the sinonasal tract.    BOARD R7 Aneurysmal Bone Cyst of the Nasal Bone – B. Lui, B. Korman, R. Lemckert, HAMILTON, ON

LEARNING OBJECTIVES:1. To review the differential diagnosis of external nasal masses.2. To review the clinical, radiographic and histopathologic features of aneurysmal bone cyst.3. To discuss the various modalities of treatment, including wide surgical excision, curettage with or without bone grafting, and irradiation; in conjunction with a systematic review of the literature.

Aneurysmal bone cysts are rare lesions of the skull and facial bones that typically occur in patients less then 20 years of age, with a predilection for females. Although aneurysmal bone cyst is a non-neoplastic condition with no propensity for metastasis, its potential for rapid growth, considerable destruction of bone, and extension into adjacent soft tissue requires timely diagnosis and aggressive therapy. This is a case of a 10 year old girl who presented with a left external nasal deformity and deviated nasal septum. Computed tomography and histopathology showed typical features of an aneurysmal bone cyst. This is the first reported case of an aneurysmal bone cyst involving the nasal bone in the literature. The rarity of this disease in the ear, nose, and throat area, the clinical presentation, and the removal of this lesion by lateral rhinotomy make this case of interest to otolaryngologists and craniofacial surgeons.

BOARD R8Silent Sinus Syndrome: An Experience with Ten Cases - S. Al-Ghamdi, Y. Al-Badaai, M. Samaha, MONTREAL, QC

LEARNING OBJECTIVES1. To raise the awareness of otolaryngologists to silent sinus syndrome (SSS).2. To shed lights on the presentation, pathophysiology and management of this rare entity.

BACKGROUND: Silent sinus syndrome is a relatively new entity with rare occurrence. The first reported case of maxillary sinus opasification with atelectasis and enophthalmous was reported by Montogomry in 1964. It was not untill 1994 when the term silent sinus syndrome was introduced by Soparker et al. To date there are only 122 cases reported in the English literature. METHODS: We report our own experience of ten cases of SSS from a single institution. This is a retrospective review of the records of patients with silent sinus syndrome. The presenting symptoms, pathophysiology, radiological findings and treatment will be presented. RESULTS: Ten patients who fit the diagnostic criteria were included. All had endoscopic sinus surgery on the maxillary sinus involved. No complications were encountered. None of the patients required corrective orbital or cosmetic procedures. CONCLUSION: Reconstructive procedure to correct floor of the orbit deformity is best done at a second stage if needed at all.

FACIAL PLASTICSBOARD F1

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Upper Lid Blepharoplasty Outcome Study – R. Jaggi, R. Hart, M. Taylor, HALIFAX, NS

OBJECTIVES: The purpose of the study was to assess outcomes following upper lid blepharoplasty. Specifically, the aim of this study was to determine whether a clinically significant difference exists with the use of absorbable rather than non-absorbable sutures when closing an upper blepharoplasty. PATIENTS AND METHODS: A prospective study in which patients undergoing upper blepharoplasty by a single staff surgeon was performed. Closure of the incision was employed using absorbable sutures (6.0 fast absorbing gut) in one eye and non-absorbable sutures (6.0 Nylon) in the opposite. Comparisons were performed by evaluating patient satisfaction and scar assessment at 1 week, three months and one year. RESULTS: Patient satisfaction was high with the use of both absorbable and non-absorbable sutures. Almost all patients with running non-absorbable suture closure were satisfied with their resultant scars. Some patients reported discomfort with the removal of the suture 5 days post-operatively. In the absorbable suture group, patients showed an equally high satisfaction rate. No patients in the study required revisional eyelid surgery. CONCLUSIONS: We found no difference in the resultant scar between absorbable and non-absorbable suture. We did find increased pain in the immediate post-operative period with non-absorbable suture removal. We would, therefore, strongly recommend 6.0 fast absorbing gut for upper eyelid closure due to its excellent resultant scar and reduction of post-operative pain.

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