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Transoral robotic surgery (TORS) is still “in its infancy in pediatrics,” according to Doug Johnston, MD, a pediatric otolaryngology–head and neck surgeon at Lurie Children’s Hospital of Chicago and an assistant professor of otolaryngology–head and neck surgery at the Northwestern University Feinberg School of Medicine in Chicago.
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February 2022The da Vinci robotic system was approved by the U.S. Food and Drug Administration (FDA) for adult laparoscopic surgery in 2000 and FDA approved for transoral use in adults in 2009. Reza Rahbar, DMD, MD, and his colleagues reported the first pediatric transoral surgeries in 2007; after experimenting on four pediatric cadavers, the team successfully used TORS to repair laryngeal clefts in two out of five patients (Arch Otolaryngol Head Neck Surg. 2007;133:46 -50.)
Currently, physicians at fewer than 10 institutions in the United States are performing pediatric TORS, Dr. Johnston said, and the transoral approach is most frequently used to perform lingual tonsillectomy (often, to treat residual sleep apnea post tonsillectomy and post adenoidectomy) or laryngeal cleft repair. Physicians have also used TORS to remove malignant and benign oropharyngeal masses.
Since 2017, a few physicians have also used TORS to treat lingual thyroglossal duct cysts. Dr. Johnston and his team performed the first-ever modified Sistrunk procedure to transorally excise lingual thyroglossal cysts and the central portion of the hyoid bone (Laryngoscope. 2021;131: E1345-1348). The modified Sistrunk procedure can also be used to treat patients with recurrent or residual thyroglossal duct cyst, Dr. Johnston said.
“Using a special MRI sequence, we can detect primary or residual thyroglossal duct cysts in the base of the tongue. That gives us a target for surgery,” Dr. Johnston said. “We remove the tract at the base of the tongue along with the central hyoid bone (if not previously removed) with robotic surgery.”
I expect we are on the threshold of wider applications for using genetic information for patient management. —Kathleen Sie, MD
Patient selection is key to successful pediatric TORS. Surgeons must carefully assess the oral opening and size of the patient’s airway to determine if robotic surgery is feasible. (If you’re worried about oral access, consider endoscopy or bronchoscopy in the office or operating room before deciding upon a surgical approach.) Contraindications include poor mouth opening or a small jaw that prevents good exposure to the oropharynx.
Despite the advances made to date, significant barriers to pediatric TORS remain. Transoral robotic surgery is not yet FDA approved for children. Lack of FDA approval also means that manufacturers are not allowed to offer pediatric TORS training, so it can be difficult for interested surgeons to learn the necessary skills and techniques. Additionally, “there’s not a lot of framework for credentialing” pediatric otolaryngologists who wish to perform TORS, Dr. Johnston said, but he is “more than happy to help interested surgeons through this process by providing support and documentation.”
Yet, TORS offers advantages that are hard to overlook, including a 3D view of the surgical site and the ability to operate with two to three surgical arms that are much smaller than human hands, but offer greater degree of movement than the human wrist. “As time goes on, I think folks will realize that the outcomes with TORS can be at least as good, if not better, than traditional surgeries due to improved visualization and dexterity of tissue handling,” Dr. Johnston said. “I think that will be the ultimate driver for this novel approach.”
Dr. Sie agrees with this assessment. “I think it will be exciting to see what kind of applications emerge,” she said.
Increased Attention to Social Determinants Of Health
Surgery and medical management aren’t sufficient to address otolaryngologic diseases and disorders in children. Insertion of tympanostomy tubes may decrease the amount of fluid behind a child’s ears and improve hearing, but they may not help the child express herself clearly orally. Similarly, medical management of asthma that doesn’t consider the air a child breathes daily—or his family’s ability to access pricey inhalers—won’t be as effective as a holistic, family-centered approach.
According to a 2019 nationwide survey of more than 1,000 parents of children under the age of 18 done by Nemours Children’s Health System, only about one-third of the respondents were asked by a healthcare professional, hospital employee, or insurance provider about issues with safe housing, access to healthy food, access to quality childcare and schools, adequate transportation, or exposure to violence, despite the fact that these issues have a tremendous impact on child health.
Recent research has revealed the interplay between social determinants of health and otolaryngologic care. A 2018 review of healthcare disparities in pediatric otolaryngology found disparities in nearly every subspeciality, with low socioeconomic status, inadequate insurance, and non-White race affecting access to care and clinical outcomes (Laryngoscope. 2018;128:1699-1713). More recently, a 2020 study published in Otolaryngology–Head and Neck Surgery found that White children in Florida who have sensorineural health loss and private health insurance are significantly more likely to undergo cochlear implantation prior to age two than Black or Hispanic children with private health insurance—and just 17.2% of qualifying children with Medicaid received an implant prior to age two (Otolaryngol Head Neck Surg. 2021;164:667-674).
Are we expecting doctors and surgeons to become social workers? No. You don’t have to be the expert, but you ought to be able to direct a family to more information. —Julie Wei, MD
Increasingly, pediatric otolaryngologists are realizing that “it’s not enough to just be a surgeon,” said Julie Wei, MD, president-elect of the American Society of Pediatric Otolaryngology and division chief of otolaryngology at Nemour’s Children’s Health in Florida.
Many pediatric hospitals and practices have started screening families with questionnaires designed to assess social determinants of health. These tools are helpful, but “once we ask the questions, we need to have the resources to respond,” said Dr. Sie. Some hospitals now maintain food pantries, for example.
Dr. Wei’s division has curated a list of early intervention offices by county so all staff members can quickly refer families for speech and communication services. “When a child comes in with a speech delay, it’s not enough to do surgery and place ear tubes,” Dr. Wei said. “It’s incumbent on all of us to understand where the resources are in our communities.”
She also makes it a point to see all patients who arrive late for scheduled appointments. “I refuse to punish a child who has no control over time,” she said, noting that parents may not have access to reliable transportation or adequate time off of work. (One mother, said Dr. Wei, brought in her child an hour and a half past their scheduled appointment time—because the family’s house caught fire.)
“Are we expecting doctors and surgeons to become social workers? No,” Dr. Wei said. “We don’t have time to become experts on social services. You don’t have to be the expert, but you ought to be able to direct a family to more information.”
Jennifer Fink is a freelance medical writer based in Wisconsin.