METHOD: In this retrospective case series performed at atertiary care center, four patients treated for papillary thyroidcancer between September 2009 and February 2010 werefound to have unusual sites of metastases. We report on thisseries and perform a review of the current literature regardingtypical sites of spread.RESULTS: Metastatic papillary thyroid cancer was found inthe following locations: 1) within the sternocleidomastoidmuscle, 2) occipital skin, skull, dura, and within the internaljugular vein, 3) retropharynx, and 4) in the right atrium. Re-view of current literature demonstrated the most common lo-cations of regional metastases are level VI (77%), followed bylevel III (69%), level IV (66%), and level II (46%) of the deepcervical chain.CONCLUSION: Our patients novel sites of metastatic diseasehave not been depicted in previous reports. In our series allpatients with unusual metastatic disease had a more aggressivecourse, more aggressive histology, less iodine avidity, and hadworse outcomes. Although this disease most often spreads tothe deep cervical chain, atypical sites of distant metastasesshould always be considered in patients presenting with a newmass who have known history of papillary thyroid cancer.

Utility & Pitfalls of CO2 Laser in Transoral Robotic

Surgery

Paul Frake, MD (presenter); Joseph Goodman, MD;Farid Gharagozloo, MD; Nader Sadeghi, MD

OBJECTIVE: 1) Describe the benefits and limitations of cur-rent CO2 laser technology in transoral robotic surgery (TORS).2) Report a case of surgical management of recurrent tonguesquamous cell carcinoma with TORS and CO2 laser to dem-onstrate the utility and pitfalls of the combination of these twotechnologies.METHOD: The combination of 8mm robotic surgical instru-mentation, the da Vinci surgical robot, and Omniguide flexibleCO2 laser fiber were used in the surgical management of abase of tongue tumor.RESULTS: Flexible CO2 laser fiber was used to dissect thelesion with minimal charring of the margins of resection.When electrocautery was used, charring was more pronouncedand this reduced the surgeons ability to visually assess thetissues. Two flexible laser fibers were used to complete thecase. Both fibers eventually suffered mechanical failure due tobending and crimping during attempts to rotate them in thedesired vectors.CONCLUSION: The loss of tactile feedback encountered inrobotic surgery may be compensated for with greater visualinformation at the margins of resection. This can be accom-plished using CO2 laser, which produces less char than tradi-tional electrocautery. As robotic and laser technology contin-ues to develop, smaller instruments and dedicated robotic laseradaptors will enter the marketplace. The optimal laser adaptor

will allow for freedom of motion at the very distal end of therobot arm without damaging the laser fiber. However, whilethese technologies continue to be refined, conventional 8mmrobotic instruments and the flexible CO2 laser fiber can becombined to perform TORS, although the range of motion ofthese laser fibers is not optimal due to crimping and occasionalfiber failure.

Variation of Safety for Tracheal Regeneration with

iPS Cells

Yukio Nomoto, MD (presenter); Takashi Sugino,MD; Tatsuo Nakamura, MD; Koichi Omori, MD

OBJECTIVE: We developed an artificial trachea for use intracheal regeneration therapy and obtained good clinical re-sults. The use of self-derived induced pluripotent stem (iPS)cells can avoid the problems associated with transplant rejec-tion. On the other hand, teratoma formation remains a majorproblem to the clinical application of iPS cells. Differences interatoma formation have been reported depending on cell linesand sites of transplantation(Kyoko Miura, et al, 2009). Forfuture regeneration therapy of the trachea, we examined theteratoma-forming propensity after transplantation into the tra-cheal defects and into the abdominal subcutaneous tissue.METHOD: We cultured mouse iPS cells in artificial materialconsisting of collagen gel and collagen sponge under variousconditions. Artificial materials with cultured iPS cells werethen transplanted into the tracheal defects and into the abdom-inal subcutaneous tissue in nude mice. Teratoma formationwas evaluated histologically.RESULTS: Teratoma including glands, nerves or muscleswas observed in 10 of 11 mice with tracheal defects and in 3of 11 mice with abdominal subcutaneous tissue, respectively.Transplanted iPS cells produced larger teratomas in trachealdefects than those did in the abdominal subcutaneous tissue.CONCLUSION: These results demonstrated that there weredifferences in teratoma formation according to the site oftransplantation. However, potential of iPS cells for the regen-eration of the tracheal wall was suggested through the efficientsurvival of iPS cells in the tracheal defects. All of the variablesaffecting safety must be rigorously evaluated before cell ther-apies based on iPS cells advance to the clinic.

Venous Thromboembolism in Head and Neck

Cancer Patients

Mark Willis, MD (presenter); Luke Buchmann, MD;Brandon Bentz, MD; Jason Hunt, MD

OBJECTIVE: 1) Understand the risk of venous thromboem-bolism in a specific group of head and neck cancer patientswhen compared to nonmalignant controls. 2) Determine whichpatient-specific factors predispose to venous thromboembo-lism.

P210 Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010

METHOD: A retrospective chart review was done on alladvanced stage head and neck cancer patients that underwentfree flap reconstruction over the past five years. All nonmalig-nant thyroid surgical patients during that time were used as acontrol group. The incidence of venous thromboembolism wasdetermined for each group. Among the free flap group, datawas abstracted to determine predisposing factors for clot for-mation. Fishers exact test and logistic regression were per-formed for statistical analyses.RESULTS: Flap patients were more likely to have thrombo-embolism than thyroid patients (p�0.0005). Among the flappatients, factors that predisposed to venous thromboembolismwere younger age (p�0.03) and history of clots (p�0.03).Days in hospital, sex, type of free flap, and prophylactic hep-arin schedule (BID vs TID) were not significantly correlatedwith clot formation.CONCLUSION: Patients undergoing free tissue transfer are aunique patient population in otolaryngology and are at in-creased risk of forming venous thromboembolism compared toother surgical patients in our field, such as thyroid patients.While a history of thromboembolism and younger age at timeof surgery are risk factors for clot formation, length of hospi-talization, type of free flap, and schedule of prophylactic hep-arin were not significantly correlated. Future studies shouldcompare risks of flap patients to advanced stage cancer patientsnot undergoing free tissue transfer.

Voice Study in Total Thyroidectomy with RI

Ablation

Kang Dae Lee, PhD (presenter); Sung Won Kim,MD; Kyung A Kim, PhD; Heon-Soo Park, MD, PhD;Moo Jin Baek, PhD

OBJECTIVE: Radioiodine (RI) ablation is performed in hy-pothyroidism after total thyroidectomy. In this study, the au-thor evaluated the effect of temporary hypothyroidism onvoice.METHOD: The subjects had undergone RI ablation after totalthyroidectomy from January 2008 to June 2009. Voice analy-sis was performed to selected thirty-two subjects (male:9; fe-male:23) prospectively from pre-operation (Pre-OP), pre-ra-dioiodine ablation (Pre-RI) and post-3-month-radioiodineablation (Post-RI).RESULTS: The Visual Analogue Scale showed differences atPre-OP, Pre-RI ablation and Post-RI ablation in female (0.0-0.0; 2.36-0.63; 1.27-0.70, p�0.05). It was increased on Pre-RIablation (2.00-0.00) compared with Pre-OP (0.00-0.00) inmale (p�0.05). The F0 were decreased before RI therapy formale and female (111.34-3.18 Hz; 179.93-16.37 Hz, p�0.05)in comparison with Pre-OP (140.23-1.42Hz; 224.55-13.89Hz).The jitter increased on Pre-RI ablation (0.54-0.15%; 2.31-0.79%, p�0.05) contrast to Pre-OP (0.26-0.07%; 1.29-0.64%),and recovered to the condition of Pre-OP on Post-RI ablation(0.32-0.05%; 1.11-0.52%). The levels of shimmer and NHR of

Pre-RI ablation (4.66-0.96%; 0.15-0.03) were higher thanthose of Pre-OP (3.54-0.98%; 0.11-0.01) and decreased onPost-RI ablation (3.85-1.11%; 0.12-0.01) in female alone(p�0.05). The levels of maximum phonation time and vocalrange profile of Pre-RI ablation(14.96-2.67sec; 319.72-90.98Hz) were lower than those of Pre-OP (19.00-2.24sec;319.72-90.98Hz) and increased on Post-RI ablation (18.87-3.48 sec; 437.70-130.18Hz) in female alone.CONCLUSION: The vocal changes followed by hypothy-roidism were recovered by thyroid hormone replacement ther-apy after RI ablation. These changes of voice were sensitive infemale even if they showed discrepancy on the term factors.Therefore, physicians can explain for patients that they may beundergone dysphonia in hypothyroid state.

Voicing After Laser Laryngeal Cancer Surgery

Nimesh Patel, MBChB, MSc, FRCS (presenter)

OBJECTIVE: This study aimed to investigate which laryngealstructures are involved in voicing after transoral laser resectionof laryngeal cancer. We also aimed to determine the relation-ship of different voicing mechanisms to voice outcomes andthe relationship of type of surgery to voicing mechanism.METHOD: Design: Observational study of patient cohort.Setting: UK Teaching Hospital. Participants: 35 patients thathad undergone endoscopic laser surgery for laryngeal cancer.Outcome Measures: Blinded rating of videolaryngoscopy re-cordings was used to determine the voicing mechanism. Theoutcome measures; VoiSS (patient reported vocal functionrating), GRBAS (perceptual voice rating), Maximum Phona-tory Time (MPT) were related to voicing mechanism.RESULTS: Videolaryngoscopy showed; cords/neocord, ven-tricular folds, arytenoids and/or aryepiglottic folds were in-volved in voicing. Voicing by cordal/neocordal structures iscorrelated with lower grade of dysphonia (rs �-0. 643), lowerVoiSS scores (rs �-0.532) and longer MPT(rs �0.387). Ary-tenoid voicing has higher physical impairment by the VoiSSP-subscale and poorer voice by all measures. Anterior com-missure dissection is more likely to result in arytenoid voicing(rs�0.744).CONCLUSION: Cordal/neocordal voicing after laser surgerygives better voice outcomes. Rehabilitation speech therapy andsurgery, should aim to facilitate this.

VRP for High Pitch Dysphonia Evaluation After

Thyroidectomy

Sung Won Kim, MD (presenter); Soon Bok Kwon,PhD; Kyung A Kim, PhD; Seung Tae Kim, MD; KangDae Lee, PhD

OBJECTIVE: High pitch dysphonia after thyroidectomy dueto injury of the external branch of superior laryngeal nerve(EBSLN) may be a critical complication. However it may be

P211Poster Presentations

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