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Thursday, January 27, 2011 Kierland 1 & 2 TRIOLOGICAL SOCIETY COMBINED SECTIONS MEETING PROGRAM JANUARY 27 - 29, 2011 SCOTTSDALE, ARIZONA THURSDAY, JANUARY 27, 2011 KIERLAND 1 & 2 8:00 WELCOME BY VICE PRESIDENTS David W. Eisele, MD*, San Francisco, CA Western Section Kenneth M. Grundfast, MD*, Boston, MA Eastern Section William W. Shockley, MD*, Chapel Hill, NC Southern Section D. Bradley Welling, MD PhD*, Columbus, OH Middle Section 8:05 Western Section Guest Introductions by David W. Eisele, MD* Guest of Honor: Robert A. Schindler, MD*, San Francisco, CA Citation Awardees: Michael R. Holtel, MD, San Diego, CA Andrew H. Murr, MD*, San Francisco, CA Lisa A. Orloff, MD, San Francisco, CA Joseph C. Sniezek, MD*, Tripler Army Med. Center, HI 8:15 Eastern Section Guest Introductions by Kenneth M. Grundfast, MD* Guest of Honor: Loring W. Pratt, MD*, Fairfield, ME Citation Awardees: Charles D. Bluestone, MD*, Pittsburgh, PA Gregory A. Grillone, MD, Boston, MA Paul A. Levine, MD*, Charlottesville, VA M. Stuart Strong, MD*, Bedford, MA Charles W. Vaughan, MD*, Hingham, MA 8:25 Southern Section Guest Introductions by William W. Shockley, MD* Guest of Honor: Harold C. Pillsbury, MD*, Chapel Hill, NC Citation Awardees: G. Richard Holt, MD*, San Antonio, TX Stephen S. Park, MD*, Charlottesville, VA Fred J. Stucker, MD*, Shreveport, LA Mark C. Weissler, MD*, Chapel Hill, NC 8:35 Middle Section Guest Introductions by D. Bradley Welling, MD PhD* Guest of Honor: David E. Schuller, MD*, Columbus, OH Citation Awardees: Long-Sheng Chang, PhD, Columbus, OH Paul R. Lambert, MD*, Charleston, SC William H. Saunders, MD*, Columbus, OH Gregory J. Wiet, MD, Columbus, OH Introduction of Annual Middle Section Award -1- The George L. Adams, MD Young Faculty Award Timothy E. Hullar, MD FACS, St. Louis, MO 8:50 Introduction of and Address by Triological Society President Gerald S. Berke, MD*, Los Angeles, CA Triological Society Honorable Mention Theses - 2010 9:05 Honorable Mention Award for Triological Society Thesis Manual Control of the Upper Esophageal Sphincter Peter C. Belafsky, MD*, Davis, CA Educational Objective: At the conclusion of the presentation, the participants should be able to discuss how manual control the upper esophageal sphincter may be a possible treatment for profound oropharyngeal dysphagia. Objectives: Oropharyngeal dysphagia (OPD) is common and costly. In order to improve quality of life for patients and costs to soci- ety, better treatments than currently available are needed. The author hypothesized that manual control of the upper esophageal sphinc- ter (UES) is possible by pulling the larynx directly forward with anterior traction on the cricoid cartilage. The purpose of this investigation was to evaluate the effectiveness of manual control of the UES as a possible therapy for OPD. Study Design: Retrospective chart review, medical device development, prospective cadaver trial, prospective animal experiment, and initial human experience. Methods: Charts were reviewed of all persons with OPD who had a traction suture placed by the author around the anterior rim of the cricoid cartilage. The opening of the UES was assessed with and without traction on the suture. The ability of the cricoid suture to improve UES opening was evaluated under fluoroscopy. The swallow expansion device (SED) was designed to manually control the UES. The ability of the SED to manually open the UES was evaluated. The SED was implanted in 10 cadavers, and 5,000 pulls of the device were performed on each specimen to evaluate for gross damage to the cricoid cartilage. The ability of the SED to open the UES was evalu- ated under direct laryngoscopy. The safety and efficacy of the SED was evaluated in an ovine model of OPD. The SED was implanted in eight sheep. Five thousand pulls of the device were performed on each animal weekly for 8 weeks. At the end of the study, damage to the cricoid cartilage was evaluated histologically, and the ability of the SED to open the UES and eliminate aspiration was assessed fluoroscopically. The SED was placed in 1 human with dysphagia. Preliminary experience will be discussed. Results: Six patients with OPD who had a suture placed around the anterior aspect of the cricoid cartilage were identified. Anterior traction on the suture improved UES opening by 0.36 cm (60.19 cm) (P < .01). A titanium coated ferrous implant that secures to the cricoid cartilage was fabricated (SED). An external magnetic device that affixes to the implant across intact skin was developed. Anterior traction of the SED opened the UES in cadavers a mean of 1.16 cm (60.22 cm) (P < .001). Anterior traction on the SED opened the UES in sheep a mean of 1.27 cm (60.36) (P < .001). Aspiration was eliminated in 100% of the animals. The implant became infected and had to be removed in one (12.5%) animal. Remodeling of the cricoid cartilage was evident, but there was no histologic evidence of cartilage damage. Conclusions: Manual control of the upper esophageal sphincter is possible. Simple anterior traction on the suture placed around the cricoid cartilage improved UES opening by 0.36 cm (60.19) in a cohort of dysphagic patients. The swallow expansion device opened the UES of cadav- ers and living sheep to superphysiologic proportions (P < .001). There was no histologic evidence of cricoid damage from prolonged use of the implant. Preliminary human experience will be discussed. 9:15 Honorable Mention Award for Triological Society Thesis Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty Jeffrey H. Spiegel, MD*, Boston, MA Educational Objective: At the conclusion of my presentation, participants should be able to 1) discuss the areas of the face most significant for determining gender; and 2) understand the role of cranioplasty in gender confirming facial surgery. Objectives: 1) Determine the area of the face most significant in identifying female gender; 2) determine if individuals with gender confirming surgery of the face are identified as male or female; 3) review the efficacy and safety of a series of feminizing forehead cran- ioplasties. Study Design: 1) Prospective evaluation of computer simulated changes and postoperative patient images; 2) retrospec- tive review of medical records. Methods: 1) Photographs of men were digitally altered to adjust a) the forehead, b) the nose/lip, c) the jaw. Each change a, b, or c is done in isolation in both frontal and profile views. Subjects were shown the three profile and the three frontal photographs and asked to rate which of each set is the most feminine. 2) Photographs of male-to-female (MTF) transgender patients who may have had forehead, midface, or jaw surgery were shown to subjects. Subjects were asked the gender of the person in each picture. 3) Medical records and operative reports of 168 patients who underwent feminizing forehead cranioplasty were evaluated for surgical technique, and complications. Results: For experiment 1, in frontal views of all subjects the forehead modification was selected as the most feminine while in no cases was the forehead modification selected as least feminine by a majority of respondents. For the profile view, again the forehead modification was selected as most feminine by respondents for the majority of subjects, but sur- prisingly, the strength of the association between frontal modification and femininity, while strongly statistically significant, was more evi- -2- dent in the frontal view. For experiment 2, among transgendered faces shown to viewers, 82% of postoperative forehead modifications were judged as women, 87% of postoperative midface modifications were judged as women, and 85% of postoperative lower faces were judged as women. For section 3, the review of safety and technique in 168 feminizing forehead cranioplasties, there were three basic surgical techniques utilized with only 3 complications for an overall complication rate of 1.8%. Conclusions: Feminization of the fore- head through cranioplasty is safe and has a significant impact in determining the gender of the patient. The strong association between femininity and attractiveness can now be more specifically attributed to the upper third of the face and the interplay of the glabellar promi- nence of the forehead, along with the eyebrow shape and position, and hairline shape and position. These results have strong implica- tions for a paradigm shift in the method of facial analysis used to select aesthetic procedures and illuminate the processes by which fem- ininity and attractiveness are interpreted in faces. First Place Resident Research Awards 9:25 Shirley Baron Resident Research Award (Western Section) Etiologic Factors in Sialolithiasis Kevin C. Huoh, MD, San Francisco, CA; David W. Eisele, MD*, San Francisco, CA Educational Objective: At the conclusion of this presentation, the participants should be able to understand the pathophysiology of sialolithiasis and some potential risk factors for disease. Objectives: The purpose of this study was to investigate the patient factors in a population of patients with sialolithiasis from the United States. Study Design: Retrospective, cohort study. Methods: Charts for all patients diagnosed with sialolithiasis between January 2001 and February 2010 were retrospectively reviewed. Demographic factors, smoking history, comorbid conditions, and medication his- tory were recorded. Statistical analyses were then performed on the collected data. Population prevalences of smoking, diuretic usage, cholelithiasis, and nephrolithiasis were obtained through literature review. Results: A total of 153 patients with sialolithiasis were iden- tified. Of these patients, 125 (82%) had submandibular sialolithiasis and 28 (18%) had parotid sialolithiasis. Positive smoking histories were present in 67 individuals (44%). The observed prevalence of smoking in our state was 13.3% in 2008. Smoking history did not cor- relate with the size of the primary sialolith. Diuretic usage in the cohort was observed at a rate of 20%, higher than reported population rates of diuretic use of 8.7%. The prevalences of cholelithiasis and nephrolithiasis were not different from observed population rates.
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