University of Iowa Head and Neck
Oncologic and Reconstructive Surgery Fellowship
Gerry F. Funk, MD, FACS
Director, Division of Head and Neck Oncology
Henry T. Hoffman, MD, FACS
Kristi Chang, MD
Douglas J. Van Daele, MD, FACS
Nitin A. Pagedar, MD, FACS
Lucy H. Karnell, PhD
Associate Director, Head and Neck Clinical Oncology Research
Divison of Head and Neck Oncology
Department of Otolaryngology – Head and Neck Surgery
University of Iowa College of Medicine, Iowa City,Iowa
This curriculum is written as a guide for the fellow during the clinical Fellowship year at the University of Iowa. The curriculum is built around four core areas that are important to support the success of contemporary head and neck oncologic surgeons:
1) Comprehensive evidence-based knowledge of current treatment options for head and neck tumors
2) Surgical skill in oncologic, skull base, endocrine, and reconstructive procedures
3) Capacity to direct interdisciplinary management of head and neck cancer patients
4) Working knowledge of the principles of conducting sound research.
It is recognized that fellows will enter the program with different levels of knowledge and different interests. It is important to provide the Fellow with latitude to pursue individual interests related to their unique career plans. The Fellowship is designed to provide the Fellow with a core of knowledge and surgical skills organized around the 4 areas outlined above. The curriculum for accumulating this knowledge begins in the month before the Fellowship officially starts with required attendance at the annual Iowa Head and Neck Oncology and Reconstructive Surgery Course. This week-long course includes didactics and cadaver dissection under the supervision of the faculty who will be directing the Fellows work over the ensuing year. During this course the Fellow is introduced to the Iowa Protocols (see reading list below) and given a course syllabus of reading materials organized according to the lectures and prosections. In addition, the Fellow is expected to familiarize himself with the publications listed below.
1. The first educational goal is addressed through a reading program developed for the fellow, which is facilitated by comprehensive access to textbooks and journals through the Department and the Carver College of Medicine. In addition, there are important Internet-based resources, described below with the Reading List, which are of particular interest as repositories of evidence-based guidelines. The Fellow will have access to the online Iowa Head and Neck Protocols, and is encouraged to update chapters of particular interest. See the Reading List below.
2. The second goal addressing surgical skill is addressed primarily in the operating room with the faculty of the Department. The Fellow’s progress in both macrosurgery and microvascular surgery is monitored by the head and neck staff during the year. Appropriate feedback, instruction, constructive criticism, suggestions for further skill development, and suggested reading are provided. In addition, both proctored and independent practice with a simulated microvascular surgical model is required. Microvascular instruments and supervision by Drs. Chang and Pagedar are made available to the new Fellow. Fellows should use the simulation as a means of developing microsurgical skills to facilitate clinical work.
3. The third goal, ability to direct multidisciplinary head and neck cancer care, is addressed weekly at the head and neck cancer tumor board. The Fellow learns through experience and example how to manage patients with colleagues from a variety of surgical and non-surgical fields. The discussion at Tumor Board is carried over into the weekly multidisciplinary clinics with Dr. Gupta of Radiation Oncology and Dr. Doelle of Endocrinology, in which the Fellow routinely participates. This goal is also addressed through the readings, particularly the evidence based guidelines for patient management.
4. The final goal of introducing the fellow to sound research practice occurs in several ways. The Fellow works closely with Dr. Lucy Karnell and the other involved head and neck staff in designing and undertaking one or more research projects. There are regular research meetings of all members of the multidisciplinary head and neck cancer team which encourage joint work. There are many opportunities to collaborate with other researchers within the department and the CollegeofMedicine. The Fellow meets with Drs. Funk and Karnell approximately once per week to monitor the progress. This schedule often involves one or more meetings with a statistician regarding the analysis of data. The final benchmark for this curriculum area is presentation at a national meeting and publication of at least one peer-reviewed article.
NCCN Practice Guidelines for Head and Neck Cancer, http://www.nccn.org.
Cancer Care Ontario Practice Guidelines Initiative. http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=10252#. (Best of the available guideline websites).
American Head and Neck Society Clinical Practice Guidelines for Diagnosis and Management of Cancer of the Head and Neck: http://www.ahns.info/clinicalresources/guidelines.php. (Suggested study of individual papers).
Iowa Head and Neck Protocols: http://wiki.uiowa.edu/display/protocols/home
Hoffman H.T., Karnell L.H., Robinson R.A., Funk G.F., and Menck H.R.: “The National Cancer Data Base Report on Cancer of the Head and Neck.” Arch Otolaryngol. 124(9):951-962, 1998.
Koch B.K., Trask DK, Hoffman H.T., Karnell L.H., Robinson R.A., Zhen W., and Menck H.R.: Commission on Cancer. AmericanCollege of Surgeons. American Cancer Society. “National Survey of Head and Neck Verrucous Carcinoma: Patterns of Presentation, Care and Outcome.” Cancer. 92(1):110-120, 2001.
Funk G.F., End of Life Issues in the Otolaryngology – Head and Neck Surgery Patient. In Calhoun K, Eibling DE, Eds, Geriatric Otolaryngology, Marcel Dekker, NY,NY.
Yao M, Buatti J, Dornfeld KJ, Skwarchuk M, Menda Y, Graham MM, Smith RB, Graham SM, Funk GF, Hoffman HT.: “Is neck dissection necessary when post-radiation PET is negative after radiation treatment for locally advanced head and neck cancer?” Int J Radiat Oncol Biol Phys 1;57(2 Suppl):S244-5, October 2003
Talmi Y.P., Hoffman H.T., Horowitz Z., McCulloch T.M., Funk G.F., Graham S.M., Peleg M., Yahalom R., Teicher S., and Kronenberg J. Patterns of metastases to the upper jugular lymph nodes (the ‘submuscular recess’). Head Neck 1998;20(8):682-6.
Dutton JM, Graham SM, Hoffman HT. Metastatic cancer to the floor of mouth: the lingual lymph nodes. Head Neck 2002 Apr;24(4):401-5.
Pagedar NA, Gilbert RW. Selective neck dissection: a review of the evidence. Oral Oncol 2009 Apr-May;45(4-5):416-20.
Hoffman HT, McCulloch TM, Gustin D, Karnell LH. Organ preservation therapy for advanced-stage laryngeal carcinoma. Otolaryngol Clin North Am 30(1):113-130,
Hoffman HT, Porter K, Karnell LH, et al. Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope. 116(9 Pt 2 Suppl 111):1-13, 2006.
Chao SS, Graham SM, Hoffman HT. Management of pharyngoesophageal spasm with Botox. Otolaryngol Clin North Am 2004 Jun;37(3):559-66.
McCulloch TM, Hoffman HT: “Changing Trends in the Treatment of Laryngeal Cancer.” In Otolaryngology Head and Neck Surgery, Cummings C.W., Fredrickson J.M., Harker L.A., Krause C.J., and Schuller D.E. (eds), Update I, 2nd Edition. Mosby-Year Book, Inc: St. Louis,MO, pp. 11-34, 1995.
Cooley ML, Hoffman HT, Robinson RA: Discrepancies in frozen section mucosal margin tissue in laryngeal squamous cell carcinoma. Head Neck 2002;24(3): 262-7.
Hoffman HT. Review of endoscopic treatment of supraglottic and hypopharyngeal cancer. Otolaryngology Journal Club Journal 1994;1(4):200-202.
Hoffman HT, McCulloch TM. “Management of Early Glottic Carcinoma.” In Otolaryngology--Head and Neck Surgery 3rd ed., Cummings, Fredrickson, Harker, Krause, Richardson, Schuller (eds). Chapter 114 pp 2187-2200, 1998.
Oral Cavity Cancer
Goldstein DP, Hoffman HT, Hellstein JW, Funk GF. “11 Oral Cavity Lesions. 2 Breast, Skin, Soft Tissue, and Neck.” ACS Surgery Online. Souba W.W., Fink M.P., Jurkovich G.J., et al, Eds. WebMD Inc., New York 2004. http://www.acssurgery/. June 2004.
Funk GF, Karnell LH, Robinson RA, et al. Presentation, treatment, and outcome of oral cavity cancer: A National Cancer Data Base report. Head Neck 2002;24:165-180.
Johnson RE, Sigman JD, Funk GF, Robinson RA, Hoffman HT. Quantification of surgical margin shrinkage in the oral cavity. Head Neck 1997;19(4):281-6.
Beaty MM, Funk GF, Karnell LH, McCulloch TM, Graham SM, Hoffman HT. Risk factors for malignancy in adult tonsils. Head Neck 20: 399-403,1998.
Zhen W, Karnell LH, Funk GF, Enke CA, Hoffman HT. Comparison of clinical and pathological stage for squamous cell carcinoma of the base of tongue. Journal of Registry Management 2001;28(4):177-181.
Zhen W, Karnell LH, Hoffman HT, Funk GF, Buatti JM, Menck HR.: “The National Cancer Data Base Report on Squamous Cell Carcinoma of the Base of Tongue. Head Neck 2004 Aug;26(8):660-74.
Hoffman HT, Karnell LH, Shah JP, Ariyan S, Brown GS, Fee WE, Glass AG, Goepfert H, Ossoff RH, and Fremgen AM. Hypopharyngeal cancer patient care evaluation. Laryngoscope 107(8):1005-1017, 1997.
Funk GF, Zbar RIS: Management of pharyngocutaneous fistulae. In Gates GA, ED. Current Therapy in Otolaryngology - Head and Neck Surgery, Sixth Edition. Mosby-Year Book, Inc. Philadelphia,PA, 314-319, 1998.
Salivary Gland Cancer
Hoffman HT, Karnell LH, Robinson RA, Pinkston JA, Menck HR. “National Cancer Data Base report on cancer of the head and neck: acinic cell carcinoma.” Head Neck 1999;21(4):297-309.
Graham S.M., McCulloch T.M., Funk G.F., and Hoffman, H.T.: Comment: “Recurrent Benign Parotid Tumours: The Lesson Not Learned Yet.” ANZ J Surg 69(7):531, 1999.
Hoffman H., Funk G., and Endres D.: “Evaluation and Surgical Treatment of Tumors of the Salivary Glands.” Chapter 54 (pp 1147-1182) In Comprehensive Management of Head and Neck Tumors, 2nd ed. 1999.
Graham S.M., and Hoffman H.T.: “Extratemporal Facial Nerve Injury: Avoidance and Pitfalls.” Chapter XXIII, pp. 199-208. In Monograph: Update on Facial Nerve Disorders, 1999 Cherry Blossom Conference, Shelton C. (ed), published by the AmericanAcademy of Otolaryngology---Head and Neck Surgery Foundation, Inc.
Iseli TA, Karnell LH, Preston TW, Graham SM, Funk GF, Buatti JM, Gupta AK, Robinson RA, Hoffman HT. Facial nerve sacrifice and radiotherapy in parotid adenoid cystic carcinoma. Laryngoscope 2008;118(10):1781-6.
Wellman BJ, Traynelis VC, McCulloch TM, Funk GF, Menezes AH, and Hoffman HT. Midline anterior craniofacial approach for malignancy: results of en bloc versus piecemeal resections. Skull Base Surgery 1999;9(1):41-6.
Simon JH, Zhen W, McCulloch TM, Hoffman HT, Paulino AC, Mayr NA, Buatti JM. Esthesioneuroblastoma: the University of Iowa experience 1978-1998. Laryngoscope 2001;111(3):488-93.
Traynelis V, McCulloch TM, Hoffman HT. "Craniofacial Resection of Neoplasms of the Anterior Skull Base." In Neurosurgical Operative Atlas, Vol. 3 (5), Rengachary S.S. and Wilkins R.H. (eds.). Williams & Wilkins: Baltimore,MD, pp. 329-340, 1993.
Fischer HC, Karnell LH, Hoffman HT, et al. A national survey of sinonasal cancer: Presentation, treatment, and outcome. Journal of Registry Management 2001;28(4):182-189.
Hoffman HT, Robinson RA, Spiess JL, Buatti J. Update in management of head and neck sarcoma. Curr Opin Oncol, Vol. 14, (4):333-341, July 2004
Koch BB, Karnell LH, Hoffman HT, Apostolakis LW, Robinson RA, Zhen W, Menck HR. National Cancer Data Base report on chondrosarcoma of the head and neck. Head Neck 2000;22(4):408-25.
Smith RB, Apostolakis LW, Karnell LH, Koch BB, Robinson RA, Weining Z, et al. “National Cancer Data Base report on osteosarcoma of the head and neck.” Cancer 98:1670-1680, 2003.
Simon JH, Paulino AC, Smith RB*,* Buatti JM. “Prognostic Factors in Head and Neck Rhabdomyosarcoma”. Head and Neck. 2002;24:468-73.
** Hoffman HT, Rojeski M, Funk GF: The solitary thyroid nodule. In Gates GA, Ed. Current Therapy in Otolaryngology-Head and Neck Surgery Mosby-Yearbook, Inc. St. Louis, Missouri, 319-323, 1994.
Pagedar NA, Freeman JL. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2009 Apr;135(4):360-2.
Hoffman HT, Eschwege F, Krause C. "Combined Surgery and Radiotherapy." In Multimodality Therapy for Head and Neck Cancer, Clark J.R. and Snow G.B. (eds). George Thieme Verlag, Stuttgart/New York, 1992.
Markt JC, Gay WD, Salinas TJ. Maxillofacial prosthetics: management of acquired head and neck defects and the radiation oncology patient. In: Cummings: Otolaryngology Head and Neck Surgery, ed 4, Saint Louis,Missouri: Elsevier Health Sciences, Submitted for publication.
Hoffman HT, Quets J, Toshiaki T, Funk GF, McCulloch TM, Graham SM, Robinson RA, Schuster ME, Yuh WT. Functional magnetic resonance imaging using iron oxide particles in characterizing head and neck adenopathy. Laryngoscope 2000;110(9):1425-30.
Graham M, Menda Y. PET Imaging of Head and Neck Cancer. page 261-269 in Nuclear Medicine in Clinical Diagnosis and Treatment, PJ Ell & SS Gambhir, eds, Churchill-Livingston,NY, 2004
Graham MM. Is quantitation necessary for oncological PET studies? Against. Eur J Nucl Med Mol Imaging 29(1):135-138, 2002
Frodel JL, Funk GF, Capper DT, Fridrich KL, Blumer JR, Haller JR, Hoffman HT: Osseointegrated implants in vascularized bone flaps: A comparison of bone thickness in four flap types used in mandibular reconstruction. Plast Reconstr Surg 92:449-455, 1993.
Funk GF, Arcuri MR, Frodel JL: Functional dental rehabilitation of massive palatomaxillary defects: Cases requiring free tissue transfer and osseointegrated implants. Head Neck 20: 38-51, 1998.
Funk GF: Scapular and parascapular free flaps. Facial Plast Surg 12: 57-63, 1996.
Fong BP, Funk GF. Osseous free tissue transfer in head and neck reconstruction. Facial Plast Surg 15: 45-59, 1999.
Funk GF, Valentino J, McCulloch TM, Graham SM, Hoffman HT. Anomalies of forearm vascular anatomy encountered during elevation of the radial forearm flap. Head Neck 1995;17(4):284-92.
Valentino J., Funk G.F., Hoffman H.T., and McCulloch T.M.: “The Communicating Vein and Its Use in the Radial Forearm Free Flap.” Laryngoscope 1996;106(5 Pt 1):648-51.
Heth J.A., Funk, G.F., Karnell L.H., McCulloch T.M., Traynelis V.C., Nerad J.A., Smith R.B., Graham S.M., and Hoffman H.T.: “Free Tissue Transfer and Local Flap Complications in Anterior and Anterolateral Skull Base Surgery.” Head Neck 24(10):901-911, 2002 Oct.
Funk GF, Karnell LH, Whitehead S, Paulino A, Ricks J, Smith RS. Free tissue transfer versus pedicled flap cost in head and neck cancer. Otolaryngol Head Neck Surg 127:205-212,2002.
Shindo M, Fong BP, Karnell LH, et al. The fibula osteocutaneous flap in head and neck reconstruction: A critical evaluation of donor site morbidity. Arch Otolaryngol Head Neck Surg 126: 1467-1472, 2000.
Smith, RB, Thomas, RA, Funk, GF: “Fibula Free Flaps: The Role of Angiography in Patients with Abnormal Pre-operative Color Flow Doppler Studies”. Arch Otolaryngol Head Neck Surg. 2003;129:712-5.
Zbar RI, Funk GF, McCulloch TM, Graham SM, Hoffman HT: “Pectoralis Major Myofascial Flap: A Valuable Tool in Contemporary Head and Neck Reconstruction.” Head Neck 19(5):412-418, 1997.
Pignon JP, Bourhis J, Domenge C, Designé L. Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. MACH-NC Collaborative Group. Meta-Analysis of Chemotherapy on Head and Neck Cancer. Lancet. 2000 Mar 18;355(9208):949-55.
Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med. 2004 May 6;350(19):1937-44.
Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med. 2004 May 6;350(19):1945-52.
Trotti A, Pajak TF, Gwede CK, et al. TAME: development of a new method for summarising adverse events of cancer treatment by the Radiation Therapy Oncology Group. Lancet Oncol. 2007 Jul;8(7):613-24.
Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. 1991 Jun 13;324(24):1685-90.
Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003 Nov 27;349(22):2091-8.
Acland RD, Sabapathy SR. Acland’s Practice Manual for Microvascular Surgery, 3rd Ed. 2008, Indian Society for Surgery of the Hand.
Lewin JS, Barringer DA, May AH, Gillenwater AM, Arnold KA, Roberts DB, Yu P. Functional outcomes after laryngopharyngectomy with anterolateral thigh flap reconstruction. Head Neck. 2006 Feb;28(2):142-9.
Murray DJ, Gilbert RW, Vesely MJ, Novak CB, Zaitlin-Gencher S, Clark JR, Gullane PJ, Neligan PC. Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube. Head Neck. 2007 Feb;29(2):147-54.
Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique. Head Neck. 2008 Jan;30(1):10-20.
Chepeha DB, Teknos TN, Shargorodsky J, et al. Rectangle tongue template for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008 Sep;134(9):993-8.
Chepeha DB, Sacco AG, Erickson VR, et al. Oropharyngoplasty with template-based reconstruction of oropharynx defects. Arch Otolaryngol Head Neck Surg. 2009 Sep;135(9):887-94.
Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent. 2001 Oct;86(4):352-63.
Shellenberger TD, Sturgis EM. Sarcomas of the head and neck region. Curr Oncol Rep. 2009 Mar;11(2):135-42.
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM; American Thyroid Association Guidelines Taskforce. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006 Feb;16(2):109-42.
Hay ID, Thompson GB, Grant CS, et al. Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients. World J Surg. 2002 Aug;26(8):879-85.
Noordzij JP, Lee SL, Bernet VJ, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies. J Am Coll Surg. 2007 Dec;205(6):748-54.