Department of Otorhinolaryngology - Head and Neck Surgery

UT Health Medical School

ORL Progress Notes

ORL Progress Notes, our second on-line departmental newsletter, provides information about developments in the Department. The newsletter’s target audience includes physicians and health care professionals as well as patients and members of the general public.

Multidisciplinary Virtual Pre-surgical Planning Optimizes the Outcome for an Ameloblastoma Patient

By the time 27-year-old Reginald Durden saw oral and maxillofacial surgeon Nagi Demian, DDS, MD, the ameloblastoma had destroyed his lower jaw. Three surgeries later, Durden has a normal appearance, with scars that are barely visible, and he can talk and chew easily.

Demian-Weinstock-HoExcision of the rare, slow-growing tumor and subsequent reconstruction of Durden’s lower mandible is a story of multidisciplinary collaboration between three surgeons affiliated with the University of Texas Health Science Center at Houston and Memorial Hermann-Texas Medical Center: Dr. Demian, an associate professor of oral and maxillofacial surgery; Etan Weinstock, MD, FACS, an assistant professor of otorhinolaryngology—head and neck surgery; and Tang Ho, MD, FACS, an assistant professor of facial plastic and reconstructive surgery in the Department of Otorhinolaryngology—Head and Neck Surgery. “Because ameloblastoma easily infiltrates and destroys surrounding bony tissues, extensive surgical excision is usually required,” Dr. Demian says. “Reginald’s tumor was large, involving 10 centimeters on both sides of the lower jaw, and it was aggressive. When I first saw him, he had developed extreme asymmetry of the face.”

Classically, few physicians crossed departmental lines for the benefit of the patient. “Today, we’re seeing more interdepartmental collaboration,” Dr. Demian says. “It was clear from my first examination of Reginald that his case would involve a large reconstruction, which would result in a better outcome if oral and maxillofacial surgery, otorhinolaryngology and facial plastic and reconstructive surgery worked together from the start.”

Because they both treat head and neck cancer patients at Lyndon B. Johnson General Hospital, where Dr. Demian is chief of oral and maxillofacial surgery and Dr. Weinstock is chief of otorhinolaryngology, the two surgeons are accustomed to working together to minimize patient trips to the OR. “Each of us has his own specialty and particular skill set, and many of the patients we see require a combination of the two,” Dr. Weinstock says. “We collaborate well, because each of us understands what the other brings to the table. We’ve both become very astute at recognizing when we need to combine forces to produce better outcomes. Together, we’ve done many, many hundreds of cases.”

Durden’s surgery was planned in advance using virtual technology. Because reconstruction would require removal of a segment of the fibula and surrounding tissue and reattachment of the vascular pedicle to the neck, the two surgeons involved Dr. Ho in the case. Using a specially designed virtual surgery planning system and working with a systems engineer in another location, the three physicians teleconferenced remotely on their laptops to map out the procedure using computer simulation.

“What we were planning was essentially a transplant procedure – transplanting Reginald’s fibula and reshaping it to create the new mandible,” Dr. Ho says. “In the process, we have to revascularize the transplanted bone and soft tissue using microvascular surgical techniques under the microscope. Before we had the capability to simulate the surgery using multidisciplinary pre-surgical planning, we had to make multiple bone cuts and continue to reshape them to fit the jaw, which is a time-consuming process. Once tissue has been removed from the leg, we’re in an ischemic time crunch. We want to inset the pedicle in the new location and revascularize it within two hours. With virtual surgery, we can review CT scans of the patient’s leg and face, create 3D models and rotate and manipulate them on the screen. Then we go to the OR with predesigned cutting guides for the fibula that show us exactly where to cut and how much of the leg bone to take, so that we can shape the new mandible as it should look. Preplanning shaves hours off of a very long procedure.”

In November 2011, Dr. Demian did a resection of the ameloblastoma from Durden’s lower mandible through the inside of the mouth, a more difficult approach that avoids external incisions and neck tissue dissection, and provides virgin territory for the larger reconstructive surgery. The net result is cleaner tissue planes and no scarring, which is beneficial to the patient. After the ablative surgery, Dr. Demian placed a temporary plate to replace the large missing segment of jawbone.

While his jaw was healing, Durden remained on a soft-food diet. “It was a very difficult period of time for many reasons,” he says. “I had a newborn son to help care for, and I couldn’t talk or eat normally. I was able to chew a little on the right side of my jaw, where they left three molars. On the left side I had only a plate for a jaw. During that time I lost a lot of weight.”

The reconstruction was the largest of the three surgeries. “Dr. Ho attached the plastic guides to the fibula showing the angle and depth of cuts we needed to make,” Dr. Weinstock says. “While he was working on the leg, I opened the neck working with Dr. Demian, who made sure the remaining teeth were in alignment. Although Reginald had a dramatic resection of the mandible, my job was made easier because Dr. Demian had resected the tumor through the mouth, and the neck was untouched. I dissected out the blood vessels to prepare the mandible and recipient bed for the free flap, and we started our ischemia time. Dr. Ho divided the pedicle from the leg and moved it to the neck, and Dr. Demian helped me align the flap and adapt it to the plate and contour as we had planned. Using a microscope and tiny sutures, Dr. Ho reconnected the arteries and veins we took from the leg to the arteries and veins in the neck. By working simultaneously, we reduced the amount of time the patient was under anesthesia. Everything happened quickly and precisely with minimized ischemia time, which improved the chances of survival of the graft.”

Mandible recon

Fibula

In a third surgery performed in the fall of 2012, Dr. Demian placed dental implants, which were adjusted in early 2013. A denture that clicks over the implants gives Durden good structural stability so he can eat and speak well.

“It was a very difficult experience,” Durden says. “Imagine hearing that you’re going to lose your teeth and jaw. After my initial shock, my doctors made me feel comfortable by explaining everything that would happen. I knew it would be a long process and that I would have to take it step by step to get back to normal. They did an amazing job. When people see me today, they can’t believe I went through all that.”

“Reconstruction of the mandible is a very precise surgery, and virtual preplanning increased our level of precision,” Dr. Weinstock says. “It was a long and frightening experience for Reginald, but the outcome was perfect. It’s an excellent example of the value of multidisciplinary pre-surgical planning in improving patient safety and optimizing the overall surgical outcome.”

UT ORL Progress Notes Archives

  1. Multidisciplinary Virtual Pre-surgical Planning Optimizes the Outcome for an Ameloblastoma Patient
  2. Dr. Fakhri Receives Regents’ Outstanding Teaching Award
  3. IL-33-responsive Innate Lymphoid Cells Are an Important Source of IL-13 in Chronic Rhinosinusitis with Nasal Polyps
  4. Randomized, Double-Blind, Controlled Trial of Oral Antifungal for the Treatment of Fungal-sensitive Chronic Rhinosinusitis with Nasal Polyps
  5. Dr. Fakhri Promoted to Professor of Otolaryngology-Head and Neck Surgery
  6. TLR4 Signaling in the Pathophysiology of Allergic Fungal Rhinosinusitis
  7. Two ORL Faculty Members Named to Texas Super Doctors 2013 List
  8. Transoral Robotic Surgery for the Treatment of Obstructive Sleep Apnea
  9. Lone Star Rhinology Course Attracts a National Audience
  10. Internationally Renowned Otolaryngologist Speaks at 2013 ORL Frontiers
  11. ORL Welcomes New Recruits
  12. UTHealth Otorhinolaryngology Holds Free Cancer Screening Clinic
  13. Two ORL Team Members Named Fellows of the American College of Surgeons
  14. Faculty Named Among Texas Super Doctors Rising Stars
  15. Two ORL Faculty Members Receive Dean’s Teaching Excellence Award
  16. Translational Science Program Working to Identify Therapeutic Targets in Chronic Rhinosinusitis
  17. Preventing Surgical Fires: UTHealth Otolaryngologist Provides Expert Advice for a New FDA Safety Initiative
  18. Improving Survivorship in Head and Neck Cancer: UTHealth Department of Otorhinolaryngology and Institute of Molecular Medicine Partner on CPRIT Research Award
  19. Using Intraoperative Staining to Identify the Parathyroid Adenoma
  20. Otorhinolaryngologists Named to 2012 Best Doctors in America List
  21. Four Studies Evaluate the Effectiveness of Optical Rhinometry
  22. A Collaborative Approach Offers Patients a Less Invasive Alternative for Surgical Excision of Pituitary Tumors
  23. Internationally Renowned Otolaryngologist Speaks at 2012 ORL Frontiers
  24. Ron Karni, MD, Selected Faculty Member of the Year by Graduating Residents
  25. Samer Fakhri, M.D., Receives AAO Foundation Honor Award
  26. Two Audiologists Join UTHealth Otorhinolaryngology
  27. 2012 Residency and Fellowship Update
  28. Five UTHealth Medical Students Matched to Top Choice Otorhinolaryngology Residency Programs
  29. Two ORL Faculty Members Receive Dean’s Teaching Excellence Award
  30. Chair of Otorhinolaryngology Named to Texas Super Doctors 2012 List
  31. Minimally Invasive Surgery for Skull Base Cancer
  32. UTHealth/Memorial Hermann Physician Joins a Medical Mission to Honduras
  33. Online Patient Access Library Offers Medical Information About ENT Diseases & Conditions to Patients
  34. Facial Reanimation Surgery Brightens a Young Boy’s Future
  35. Morphoproteomics: Driving a Shift to Personalized Care for Sinonasal Undifferentiated Carcinoma
  36. Internationally Renowned Otolaryngologist to Speak at 2012 ORL Frontiers
  37. UTHealth Otorhinolaryngology Department Exceeds the National Averages in Quality and Safety
  38. Rhinologist Invited to Serve as Board Examiner in the Middle East
  39. Dr. Citardi Named to the 2011 Texas Super Doctors List
  40. Make Your Voice Count!
  41. Research Update
  42. Advanced Rhinology Concepts CME Attracts a National and International Audience of Otolaryngologists
  43. Outside the Box with Chronic Rhinosinusitis
  44. The Vargas Case: Excision of a Large Benign Goiter
  45. The Reverend Williams Regains His Voice
  46. Nihal Uddin’s Journey to 360-Degree Hearing
  47. Residents Receive Research Grants
  48. Two ORL Faculty Members Receive Dean’s Teaching Excellence Award
  49. Otorhinolaryngologists Named to Best Doctors in America List
  50. Russell Kridel, MD, Reelected to AMA Council Position
  51. From Bench to Bedside: Physician Researcher Amber Luong, MD, PhD Blends Basic Science with Clinical Care
  52. 2011 Advanced Rhinology Concepts Scheduled for November
  53. Internationally Renowned Otolaryngologist Speaks at 2011 ORL Frontiers
  54. Michael Byrd, MD Recruited to UTHealth and Memorial Hermann
  55. UT Physicians Opens Facial Plastic Surgery Clinic in Southwest Houston
  56. UTHealth Audiology Program Expands
  57. 9 UTHealth Medical Students Match in Otorhinolaryngology
  58. Residency and Fellowship Update
  59. Ron Karni, MD Invited to Speak in Panama
  60. Finding the Unknown Primary in Head & Neck Cancer
  61. A Meta-Analysis of Topical Amphotericin B for the Treatment of Chronic Rhinosinusitis
  62. Cytokine Profile Comparison Between Inflamed Sinus Mucosa and Sinonasal Polyps from Chronic Rhinosinusitis
  63. The Distribution of Normal Saline Delivered by Large-Particle Nasal Nebulizer versus Large-Volume/Low-Pressure Squeeze Bottle
  64. Averting the "Limping Larynx" with a Multidisciplinary Approach
  65. Repair of Nasal Obstruction with Functional Septorhinoplasty
  66. Definitive Endoscopic Resection of Inverted Papilloma
  67. Facial Reanimation and Facelift for Facial Paralysis
  68. Mometasone Furoate Gel: A Novel In-Office Treatment of Recalcitrant Postoperative Chronic Rhinosinusitis
  69. Rhinologic Applications of Radiofrequency Coblation
  70. Rhinoplasty for Nasal Obstruction
  71. Producing Quality Outcomes in Thyroid Surgery
  72. Functional Rhinoplasty: Repairing Nasal Valve Obstruction
  73. A Cancer Patient Regains His Voice
  74. Soham Roy, M.D., Named Director of Pediatric Otorhinolaryngology
  75. From Bench to Bedside with New Treatments for Chronic Sinus Disease
  76. Comprehensive Rhinology Program Offers State-of-the-Art Care for Patients with Chronic Rhinosinusitis Refractory to Standard Treatments
  77. Rhinology Update: Advanced Rhinology Concepts CME Scheduled for November
  78. The Comprehensive Voice Program: From Advanced Office-Based Procedures to Community Outreach
  79. Designing the Future: ORL’s New Office Space Features High-Tech Tools
  80. Welcome!

Subscribe to our newsletters

ORL Update UT ORL Update, our first on-line departmental newsletter, summarizes current topics in otorhinolaryngology. The newsletter’s target audience includes both physicians and other healthcare providers, although subscriptions are not limited to members of these groups.

ORL Progress Notes ORL Progress Notes, our second on-line departmental newsletter, provides information about developments in the Department. The newsletter’s target audience includes physicians and healthcare professionals as well as patients and members of the general public.

To subscribe, please fill in your contact information and select the newsletter(s) you would like to receive. Of course, you may opt out of any of the newsletters at any time.