A tale of two head and neck societies

by K. Thomas Robbins, MD, FACS, Memphis, TN, and Ashok Shaha, MD, FACS, New York, NY

On May 13, 1998, the American Society for Head and Neck Surgery (ASHNS) and the Society of Head and Neck Surgeons (SHNS) joined together to form the American Head and Neck Society (AHNS). This is the single largest organization in North America to provide a unified voice to the advancement of research and education in head and neck oncology. The contributions made by the two societies forming the AHNS are significant in the history of surgery in the United States.

The Society of Head and Neck Surgeons was conceived in 1954 by Dr. Hayes Martin, who is considered by many to be the father of modern head and neck tumor surgery. The purpose of the SHNS was to exchange and advance the scientific knowledge relevant to the surgery of head and neck tumors (exclusive of brain surgery) with particular reference to the problem of cancer. Four years later, the American Society of Head and Neck Surgery (ASHNS) was organized with the stated goal to facilitate and advance knowledge relevant to surgical treatment of diseases of the head and neck, including reconstruction and rehabilitation; promote the advancement of the highest professional ethical standards as they pertain to the practice of major head and neck surgeries; and to honor those who have made major contributions to the field of head and neck surgery, or have aided in its advancement. The recent merger by the two societies is the culmination of many years during which each attempted to maintain its autonomy, but through their continued interactions and common interests, the societies have come together.

This article, as outlined by the co-presidents of the AHNS, is intended to provide our surgical colleagues with some insight into the dynamics between the two societies and how members of each finally came to realize that their common goals far exceeded their differences. It is indeed a tale that tells how head and neck surgery has progressed through the centuries to become a major surgical specialty.

Otolaryngology as a separate board specialty was established in 1924. Specialists in this field were primarily occupied with managing infections of the paranasal sinuses, pharynx, and the middle ear space. Prior to antibiotic therapy, their skills in draining abscesses and removing chronically infected mucosa were often necessary to help patients recover. Training programs for otolaryngologists primarily focused on these skills, as well as endoscopic procedures of the larynx, bronchus, and esophagus. This preoccupation with infectious and inflammatory diseases, many of which presented with acute life-threatening situations, served as a barrier to engaging in tumor surgery, something with which their general surgery colleagues were more involved. Furthermore, the training of otolaryngologists was devoid of basic surgical skills, and they were less prepared to manage patients with head and neck tumors. Their initial contributions to the field of head and neck surgery were in the field of laryngeal cancer, probably owing to their skills in endoscopic procedures including laryngoscopy. Early laryngeal cancers were managed through the laryngofissure approach with local excisions. Gordon Buck in 1853 first described this procedure and individuals such as St. Clair Thomson in England and Chevalier Jackson in the United States further promoted this work. Gluck in the 1880s was also a strong advocate of total laryngectomy and even attempted pharyngolaryngectomy, but the mortality rate was substantially high at 25 percent. Eventually, the morbidity and mortality of this operation became less through the continued work of individuals like Cohen at the turn of the century and MacKenty during the first quarter of the 20th century. Otolaryngologists subsequently made significant contributions to the management of laryngeal cancer through the development of partial vertical laryngectomy for glottic cancer and supraglottic laryngectomy for supraglottic cancer, and near-total laryngectomy (Alonso, Ogura, Som, Biller and Pearson).

History of the SHNS

The Society of Head and Neck Surgeons was conceived principally by Dr. Hayes Martin. Dr. Martin was probably the first to uses the term "head and neck surgery." In planning the society, Dr. Martin first consulted with the late Dr. Grant Ward, a creative leader in head and neck surgery at Johns Hopkins Hospital in Baltimore, MD. Together, they composed a list of 50 U.S. surgeons to serve as founding members of the society. Most of the members were trained by Dr. Martin and Dr. Ward.

The first organizational meeting of the Society of Head and Neck Surgeons was held in the spring of 1954. Bylaws were adopted, plans were made for annual meetings, and officers were elected. The founding members elected Dr. Hayes Martin as the first president and he served for three years. Dr. Ward was president for the following two years. Membership grew as more interest in the field of head and neck surgery developed and an increasing number of patients were successfully treated by surgical methods. Newer techniques were perfected and many surgeons received special head and neck training. Any surgeon performing a considerable amount of head and neck tumor surgery was qualified for nomination to the membership. In recent years, the active membership roster included leaders in this field from various specialties of general surgery, plastic surgery, and otolaryngology representing the United States, Canada, and many other countries. A large foreign corresponding membership attested to the worldwide interest and activity of the society. The original scientific papers presented at the annual meeting appeared each year in the American Journal of Surgery.

As the society grew, many plastic surgeons joined the organization, brining with them a special interest in head and neck oncologic surgery and reconstructive surgery. Backamjian popularized the deltopectoral flap. The head and neck services at MD Anderson, Memorial Sloan-Kettering Cancer Center and Roosevelt Park Cancer Institute in Buffalo became world-recognized under the leadership of Richard Jessie, Elliot W. Strong, and Donald Shedd.

The SHNS was initially dominated by general surgeons and plastic surgeons with special interest in head and neck oncologic surgery. However, over the past two decades an increasing number of otolaryngologists have joined this organization, with an increasing membership coming from foreign corresponding members. Similarly, a fair number of general surgeons joined the American Society for Head and Neck Surgery, expressing their interest in caring for patients with head and neck cancer problems. The major accomplishment of both the societies was to recommend a joint training council, under the leadership of John Lore, for the establishment of a fellowship training program in head and neck surgery. The Joint Training Council for Approval of Advanced Training in Head and Neck Oncologic Surgery was thus established.

As the specialty became better established, the American College of Surgeons endorsed the need for head and neck procedures prior to board certification. Even though the two groups had separate background training, there was considerable similarity in their practice and the management of complex head and neck problems. There was more and more collaboration, understanding, mutual respect and scientific interaction over the last two decades. These issues brought the two organizations so close that their executive councils recently decided for unification.

History of the ASHNS

By the middle of the 20th century, there was a growing desire by otolaryngologists to become more involved in head and neck oncologic procedures. A small group of them took it upon themselves to make this commitment through extended training at centers where head and neck oncologic surgery was performed frequenlty. Among these individuals were: Drs. F. Johnson Putney, Edwin W. Cocke, Jr., W. Franklin Keim, George Sisson, and William Trible. Dr. John Conley returned from World War II with significant reconstructive surgical experience, and entered practice with Dr. George Pack in New York City. Other older otolaryngologists saw the future of their specialty in this field, and men like Drs. John Bordley, Jerome Hilger, Chevalier Jackson, Dean Lierle, John Daly, G. Slaughter Fitz-Hugh, Paul Hollinger, Frank Lathrop, Julius McCall and Joe Ogura became involved. Most of these men were directors of the American Board of Otolaryngology and saw the need for training in general surgery for at least one year of general surgical residency as an additional requirement for board certification in otolaryngology.

In the spring of 1957, six young otolaryngologists who had been attending the third annual meeting of the Society of Head and Neck Surgeons in Washington, DC, met to discuss how they could become more involved and recognized for their interest in managing patients with head and neck cancer. These young men were Franklin Keim, John Lore, John Lewis, Edwin Cocke, William Trible and George Sisson. These six young Turks later met the following month while attending the International Congress of Otolaryngology and again discussed the problem of nonrecognition and the inability to become fully recognized members of the SHNS. The possibility of forming a new society was one suggestion, but there was concern about having too many splinter groups within otolaryngology. However, the individuals recognized that to achieve the necessary standard for managing head and neck cancer patients, they would first need to beef up their training program with an additional one, and possibly two, years of general surgery. Subsequently, a study group was formed with the help of other leaders in the field of otolaryngology and a fall meeting for those interested otolaryngologists was planned. This gathering was in essence an organizational meeting held in October 1957, during the time of the annual meeting of the American Academy of Otolaryngology and Ophthalmology (AAOO). Invitations were sent out to some 18 otolaryngologists who had been identified by the original six, inviting them to attend this meeting held in Chicago, IL. The pros and cons of establishing a society for head and neck surgeons for otolaryngologists were thoughtfully debated at that meeting, and finally it was agreed that a preferable form would be a study group under the auspices of the AAOO. This was called the Committee on Head and Neck Surgery, and LeRoy Schall was appointed the first chairman early the following year. Schall was highly respected as a head and neck surgeon of his day. Much of the discussion at that meeting centered on how this group of approximately 25 head and neck surgeons with an otolaryngology background should relate to the AAOO. The advantage of going outside the AAOO would be to identify an organization that was equivalent to and as qualified as the SHNS. After a long and rather exhausting debate in which strong opinions were loudly expressed, a compromise was reached whereby a separate, new society would be organized under the council approved Committee on Head and Neck Surgery. Ground rules were defined for establishing qualifications for membership. Candidates were to present evidence of proficiency in the field of head and neck surgery by submitting a list of 35 operations that were performed the preceding the year. Indeed a very high standard, one that was purposefully made to instill an air of comparability with the SHNS. The first formal meeting of the newly formed Committee for Head and Neck Surgery of the AAOO was held during the spring meeting of the senior otolaryngology societies in 1959 in Hot Springs, VA. Later that year, John Conley was asked to serve as the first president of the organization, which he graciously accepted after some deliberation. Thus, the first annual meeting was held on October 12, 1959, in Chicago, IL, one-and- a-half years after the original six members, worrying over the future of otolaryngology, had conceived the idea of a new society.

Fourteen members of the Founder's Group were present, and included John E. Bordley, Edwin C. Cocke, John J. Conley, John F. Daly, Jerome C. Hilger, Paul H. Holinger, Chevalier L. Jackson, W. Franklin Keim, Frank D. Lathrop, John S. Lewis, Julius W. McCall, Joseph H. Ogura, Joel J. Pressman, and George A. Sisson. A program committee was appointed with Frank Keim as chairman. The committee members were Paul Holinger, William Trible and John Daly. John Daly was also appointed chairman of the first formal credentials committee, with Frank Keim and Jack Lewis as members.

On the recommendation of Paul Holinger, who urged the group to participate more in the American College of Surgeons, it was decided that Fellowship in the ACS would be a prerequisite for membership in the society.

Following the first annual meeting, the executive committee met in New York City in January 1960. It was announced that the AAOO Committee on Head and Neck Surgery had been dissolved by the AAOO council because the American Society for Head and Neck Surgeons had been formed. Throughout the organizational process, George Sisson from Chicago was the person who was instrumental in the origin of the ASHNS. It was his idea and along with the founding members, he promoted it all the way.

Joint efforts

In the early years of the American Society for Head and Neck Surgery, the members were fighting to gain recognition and legitimacy for their area of expertise, one that was being challenged by members of the Society of Head and Neck Surgeons. Although there was significant hostility and distrust between members of both societies, rational individuals from each group recognized that they had similar goals and objectives. Thus, the societies began to interact, initially on an occasional basis but becoming more frequent as time went along. One of the early steps in bridging the gap between the two groups was the agreement to share educational opportunities and to mutually support a developed structure and criteria for training head and neck surgeons. Dr. Jack Lore´, the director of the otolaryngology residency program in Buffalo, NY, and board certified in both general surgery and otolaryngology, deserves much credit for the joint fellowship training in head and neck oncologic surgery. He was the first to head the joint council of the two societies that developed the criteria for training head and neck surgeons. This administrative body remains in effect and today oversees the training of fellows in advanced head and neck oncologic surgery programs at 24 institutions. Dr. Harry Southwick, representing the SHNS, was also instrumental in helping to establish this committee.

The first joint committee was composed of an equal number of members from both societies. They concluded that fellowships should be established for post-residency training and should consist of a balanced oncologic experience with exposure not only to surgery but also to all of the modalities involved in the treatment of the patient with head and neck cancer. Individuals with backgrounds from general surgery, plastic surgery, or otolaryngology were eligible for this postgraduate fellowship.

Joint meetings also became a function of the two societies as the 20th century progressed. The first successful meeting was held in 1973 in Hot Springs, VA, followed by a joint meeting in San Diego, CA, in 1976, and in Toronto, ON, in 1978. Each of these meetings was extremely successful and well attended with outstanding programs. Subsequent joint meetings were held in 1981, 1985, and 1988. It was probably the success of these joint meetings that motivated both societies to consider an international meeting, the first of which was held in 1984 in Baltimore, MD. There have been three other such international meetings, with the nex scheduled to be held in San Francisco, CA, in the year 2000.

As the interactions between head and neck surgeons from each society grew over the years and they came to know each other as friends and colleagues instead of competitors, the two organizations slowly came together. Leaders from each began to join the opposite society, such that a large portion of surgeons eventually held dual membership. Talks of merging the two groups were initiated as early as the late 1970s and were rejuvenated during the 1980s, but without success. It was not until the last international meeting held in Toronto in 1996 that the leadership of both groups again engaged in serious discussion toward merger. Representing the Society of Head and Neck Surgeons, John Saunders, Ronald Spiro, Ashok Shaha, and Keith Heller were appointed to work with Dale Rice, Charlie Cummings, Jonas Johnson, and Tom Robbins, representing the American Society for Head and Neck Surgery. During a key meeting in Washington in the fall of 1997, an agreement was reached by which the committee members unanimously supported the terms for merging the two societies. In May 1998, at a joint meeting of the two groups in Palm Beach, FL, one that had been arranged prior to any knowledge of a merger, the members of SHNS voted to unite with the members of the ASHNS under the new name of the American Head and Neck Society.

Looking ahead

As we move into the next millennium, the field of head and neck oncologic surgery is changing at a rate more rapid than ever. Non-surgical modalities, such as radiation therapy and chemotherapy, are bringing about new approaches to managing patients. Subsequently, it is a field becoming less dominated by surgeons, and the era of the multidisciplinary team has come to the forefront. Advances in surgical procedures such as microvascular free tissue transfer, cranial base surgery, conservation neck surgery, mandibular preservation techniques, conservation laryngeal surgery, and so on, have all come about through the joint efforts of individuals committed to this field. Plastic surgeons, general surgeons, otolaryngologists, and dentists are all striving to achieve the goal of improving patient care. Refinements in radiation therapy, such as brachytherapy, hyperfractionated schemes, three-dimensional conformal techniques, neutron beam therapy, and proton beam therapy have all contributed to the progress. Most recently, chemotherapy has added benefits through neoadjuvant therapy for organ preservation, maintenance systemic chemotherapy, chemopreventive therapy, and chemoradiation. The next significant modality to be added to these refinements will be the use of biologic strategies.

The new millennium will herald head and neck specialists with broader expertise and representing nonsurgical disciplines in addition to the traditional ones. For this reason, the unification of the two head and neck societies is timely. The goals of the new society will continue to be one of education and research while working closely with other national societies and local organizations. There is much work to be done to support the mission. AHNS is providing research funds at an unprecedented level, has joined forces with the Yul Brynner Head and Neck Cancer Foundation to sponsor an annual Head and Neck Cancer Awareness Week, and there is a strong effort to interact internationally with other head and neck societies. Hopefully, through these activities our organization can facilitate progress toward winning the battle for patients afflicted with head and neck cancer.

Bibliography

Goldstein JC, Sisson GA: The history of head and neck surgery. Otolaryn- Head Neck Surg, 115(5):379-385, 1996.

Nelson GR: In search of the first head and neck surgeon. Am Surg, 154:342-346, 1987.

Sisson G (ed): The head and neck story. Chicago, IL: Kascot Media, Inc., 1983.

Shah JP: The making of a specialty. Am J Surg, 176: 398-403, 1996.

Dr. Robbins, AHNS co-president, 1998-1999, is professor and chair, department of otolaryngology-head and neck surgery, University of Tennessee, Memphis.

Dr. Shaha, AHNS co-president, 1998-1999, is professor of surgery, Cornell University Medical Center, and attending surgeon, Memorial Sloan-Kettering Cancer Institute, New York, NY.

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Bulletin of the American College of Surgeons
Vol. 84, No. 7, July 1999

Revised February 17, 2004

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