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ENT savors sweet smell of success

Otolaryngology Department Offers Cutting-Edge Care And Comprehensive Treatment

By Nancy Mays
Photography by Sharon Hartbauer

Ten years ago, the University of Kansas embarked on a sweeping journey: to build the region’s most comprehensive otolaryngology department. The goal was not to focus on one or two sub-specialties, but to provide state-of-the-art care in every aspect of the field, from head and neck cancer to voice management.

"When you look at our growth, it’s impressive ... Ten years ago we were a two-person department with no considerable research efforts. Today we have the strongest clinical program in the region and we’re gaining ground nationally with federally funded research," says Douglas Girod, MD, vice chairman and assistant professor of otolaryngology.

"We’re there," says Girod. "We provide the best care, in terms of expertise and facilities, in the region."

Among the department’s hallmark services: The University of Kansas Hospital provides the only multidisciplinary head and neck cancer team in the region. University surgeons are the only area physicians performing laser surgery on voice box cancer. The University’s level of voice management care is unmatched in the area.

Increasingly, the department’s breadth is surpassing the region. The University of Kansas Hospital physicians pioneered a surgical technique that has revolutionized reconstructive surgery for head and neck cancers. Developed by surgeons in orthopedics and otolaryngology, the surgery is performed at The University of Kansas Hospital more than any other hospital in the world.

Such collaborations are among the department’s strengths, says Girod. "The fact that we develop team approaches to treatment and research has greatly benefited our department," he says. "And in the end, that helps the patient."

Among the patients who have benefited from the department’s expertise is Brenda Kraft, of Overland Park. Kraft, 59, was on a five-week Florida vacation when she noticed her eye was persistently red. She visited a doctor there who prescribed antibiotic drops. Her eye cleared up briefly, then worsened. About the same time, her mouth began to ache. A dentist told her she had a sinus infection and prescribed penicillin.

Three months later and back home, the symptoms still nagged her. But now, the left side of Kraft’s face seemed to be slipping. Her eyelid drooped but wouldn’t close all the way. The left side of her mouth formed a frown, but her lips couldn’t close. Her face was like a puzzle, with pieces out of place.

A doctor in Kansas City diagnosed her with Bell’s Palsy, a virus-induced paralysis that often runs its course, however bothersome. The problem with Kraft, though, was that the paralysis wasn’t waning, despite a hodgepodge of treatments, including shocking her face with a flashlight-sized electrical stimulator. "Finally, someone suggested I see a surgeon," says Kraft. "It was getting so uncomfortable to live with that I thought – ‘ Why not?’"

Kraft connected with David Kriet, MD, assistant professor and director of facial plastic and reconstructive surgery in the otolaryngology department at The University of Kansas Hospital. He ran her through a battery of tests to rule out other potential causes for the paralysis, such as a tumor.

"It was a very severe case of facial paralysis," says Kriet. "Without a functioning facial nerve, her entire left face drooped and she was unable to close her eye. She also had trouble talking and eating because her mouth was weak."

His solution? A five-hour facial reconstruction that left Kraft with the face she had before her Florida vacation.

"I feel so much better now," she says, just one month out of surgery. "My eyelid can close. My lips can close."

As a facial plastic surgeon, Kriet performs both cosmetic and reconstructive surgery. His patients vary, from those who want brow lifts to stem the tide of aging to those who need reconstructive surgery following skin cancer.

"With Brenda, we were performing an eyelift, a cheek lift – surgeries cosmetic patients often request – but our goal here was her normal appearance and a functioning face," he says.

To do that, Kriet inserted a gold weight into a surgically created pocket of her eyelid. When Krafts’ eyelid relaxes, gravity pulls the gold weight and eyelid down allowing her to blink. Kraft says the weight is hardly noticeable, like wearing hard contact lenses.

"I think eventually I won’t notice it at all, but it doesn’t matter. I’m just happy my lid closes," she says.

Bell’s Palsy patients run the risk of developing eye ulcerations, even blindness, if their lids won’t close and moisturize the eye.

Kriet also inserted a cheek sling that stretches from her ear to the corner of her mouth. By suspending her mouth in a more normal position, eating and speaking are greatly improved. With time the sling will loosen slightly – like breaking in a pair of shoes – but it is sturdy enough to prevent future sagging. Kraft’s spirits are soaring after the surgery.

"I feel like my old self again," she says. While Kraft’s case may not be routine, it illustrates some of the delicate and highly technical surgical procedures being performed by otolaryngology specialists and sub-specialists at The University of Kansas Hospital.

"For years people thought they had to leave town for difficult procedures," says Albert Merati, MD, assistant professor of otolaryngology. "But there’s nothing in otolaryngology that we don’t do. Any surgical procedure that’s on the horizon can be done here."

Indeed, the spectrum of otolaryngology is vast and The University of Kansas Hospital covers all of it: diseases of the ear and balance, sinus and allergy troubles, facial plastic surgery and oncologic surgery with microvascular reconstruction. The department also oversees special programs focusing on cochlear implants, vestibular rehabilitation and voice disorders. "Our division is broad but we have top notch specialists, too," says Terance Tsue, MD, assistant professor of otolaryngology.

Dissecting the inner ear

Meniere’s disease is an evasive disease, difficult to pin down and characterized in most cases by a fluctuating trio of symptoms: tinnitus, vertigo and a full feeling in the ear. Likewise, there is no known cause, though head trauma is suspected in some cases because football players are prone to develop it. There is no definitive test to determine its presence, which means the disease often goes undetected, leading to permanent hearing loss as well as recurrent dizziness.

But Gregory Ator, MD, associate professor of otolaryngology, is working to change that. As director of The University of Kansas Hospital’s otology clinic, Ator focuses on the workings of the inner ear. In the clinic, Ator and his colleagues see patients that run the gamut from toddlers with chronic ear infections to seniors suffering from hearing loss. But in his research laboratory, Ator collaborates with other KU scientists to develop a test sensitive enough to diagnose the destructive and elusive disease.

"An improvement in diagnostic tools would revolutionize the treatment of Meniere’s disease," he says.

In short, Meniere’s is associated with excessive fluid in the inner ear, affecting both hearing and balance organs. The ear is divided into three parts: external, middle and inner. Sound travels along the external ear canal, causing the eardrum to vibrate.

Three small bones of the middle ear conduct this vibration from the ear-drum to the cochlea portion of the inner ear, which causes waves of fluid in the cochlea to stimulate its delicate hearing cells, known as hair cells. When hair cells move, they generate an electrical current in the auditory nerve, which in turn transmits signals to the brain. Through various interconnections these signals are recognized as sound.

Meniere’s disease disturbs how the inner ear hair cells operate so the electrical current created is not the same, says Ator, though the difference has evaded even the most sophisticated sound processing tools – until now. In collaboration with Mark Chertoff, PhD, Ator is working to develop a new way to analyze those signals. In essence, they are creating a benchmark for normal hearing so deviations from that standard can be detected.

The highly powerful test they are using to read hair cell movement is derived from work on mooring ships to oil platforms.

"We are applying techniques from other fields in new ways," says Ator.

Once completed, the diagnostic test will have enormous implications for the field, he says. With a definitive diagnosis comes early basic treatment, such as a low sodium diet and diuretics to reduce fluid build-up. At present, physicians are often reluctant to pin a disease on patients who complain of vague symptoms like ringing in the ear and occasional dizziness. Often, only the most severe cases are diagnosed.

In some of the Meniere’s patients that Ator and his colleagues see, their balance is so affected that they are referred to the clinic’s vestibular rehabilitation specialist. Here, patients learn to navigate terra firma when they feel as if they’re out at sea. The team develops a customized exercise regimen for each patient to encourage a natural recovery.

"We do everything we can, but the fact is that if it’s caught early, Meniere’s disease is very treatable," says Ator. "That’s our hope for the test."

Revolutionizing surgery

Marilyn Pyle was first diagnosed with cancer of the mouth, neck and tongue in 1997. Over the next two years, the 58-year-old Independence woman had two surgeries, and underwent radiation and chemotherapy. When she spoke, it sounded like gibberish. "No one could understand me," she says.

Her physicians recommended she visit head and neck reconstructive specialists at The University of Kansas Hospital, assuring her they would be able to rebuild a useable jaw. Pyle met with Terance Tsue, MD, assistant professor and residency program director of otolaryngology. Tsue performed an innovative surgical technique he honed that allowed Pyle to speak more clearly. "It’s so much better now," she says.

In fact, The University of Kansas Hospital head and neck reconstructive team, including Tsue, Girod and E.B. Toby, MD, chairman of the section of orthopedic surgery, is conducting workshops on the technique at national meetings across the country. In the past, when surgeons reconstructed the jaw they were only able to use metal plates and/or bone grafts.

In the 1980s, microvascular free flaps became popular, making it possible to borrow tissue from one part of the body to reconstruct another part (bone, muscle and skin). The forearm became a popular donor site, however the arm was rendered useless due to fracture of the radius. "People began thinking so what if my jaw is fixed, I can’t use my arm now," Tsue says. Consequently, the practice was abandoned after its introduction in the 1980s.

Now The University of Kansas Hospital head and neck reconstructive team has revived the technique – with a twist. They glean what is called a "forearm flap," the skin, soft tissue, radial artery and half the radius of the bone from the non-dominant forearm to reconstruct parts of the head, neck or jaw.

The tissue is soft, the bones are fairly large, and the technique works, he says. "It’s a transplant but within the same person." The difference is that the team now inserts a titanium plate into the arm, which strengthens it tremendously and prevents fracture. It has, he says, revolutionized this type of surgery.

There are some 50,000 new head and neck cancers a year in the United States, says Tsue. For those patients, fighting the cancer is one battle, but reconstructing the aftermath is also important. Now that surgeons can use bigger and better reconstructions, they are able to take out bigger tumors.

"That’s the main thing," he says. "being able to remove bigger tumors and maintain the patient’s quality of life."

Girod says he is optimistic that the great strides made by KU’s otolaryngology department in the last decade will continue in the future. Over the past five years, the department has seen a steady increase in grant funding, says Girod, with the hope of more to come. The department is now managing four national grants from the National Institutes of Health and the Veteran’s Administration.

Those are in addition to the host of local and regional grants the department directs. What’s more, says Girod, the addition of research coordinator, Dianne Durham, PhD, provides cohesion to the department’s ability to attract grants and conduct studies. Three research laboratories – all with state-of-the-art equipment – and two clinical laboratories provide the basis for what Girod says promises to be a bright future for The University of Kansas Hospital and its contributions to the otolaryngology field.

"When you look at our growth, it’s impressive," says Girod. "Ten years ago we were a two-person department with no considerable research efforts. Today we have the strongest clinical program in the region and we’re gaining ground nationally with federally funded research. We have 10 medical faculty plus a research coordinator and we’re hoping to add one to two more positions in the next year.

"We’ve achieved our goals but we’re not stopping there. We’re still growing, on every level possible."

Courtesy of University Relations – KUMed Magazine Vol 51, No 1, 2001