BackTable ENT & Allergy

In this episode of BackTable ENT, Dr. Demetri Arnaoutakis, a facial plastic surgeon, and host Dr. Gopi Shah discuss planning and execution of in-office facelifts.

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SHOW NOTES

First, Demetri and Gopi begin with discussion of the clinic intake visit. During a first visit, Demetri takes time to understand each patient’s goals and priorities as they relate to their appearances. Using this knowledge, he walks each patient through all possible treatment choices, then helps the patient decide the best path forward. He takes a detailed procedural/surgical history and performs a top-down examination of the patient’s face.

Then, Demetri describes different surgical and non-surgical options to improve facial aesthetics. He divides these options into non-invasive (micro-needling, fillers, Botox), minimally invasive (radiofrequency-assisted lipolysis), and surgical (facelift). Demetri explains multiple approaches to facelift, noting that he tends to prefer a deep-plane approach that mobilizes the superficial musculoaponeurotic system (SMAS). Demetri then shares pearls from his practice about optimal incision sites, the importance of acquiring the right instruments, and the addition of tranexamic acid to tumescent anesthesia to reduce risk of hematoma.

Finally, Demetri outlines his post-operative management. In addition to standard post-operative protocols, his patients undergo hyperbaric oxygen treatment to increase oxygen delivery to tissues and lymphatic massage to aid lymph drainage. The episode wraps up with Demetri’s advice to listeners wanting to improve their cosmetic surgical skills.

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RESOURCES

Dr. Arnaoutakis’ website:

https://www.drdemetrimd.com/

In this week’s episode of Backtable ENT, Dr. Ashley Agan and Dr. Gopi Shah talk with Dr. John Craig, chief of Rhinology and co-director of the Skull Base Center at Henry Ford Health in Detroit, about odontogenic sinusitis (ODS).

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SHOW NOTES

The episode begins by hearing about John’s path to rhinology and his work and research interests in ODS. First, John defines ODS and contrasts it with chronic rhinosinusitis (CRS). He notes that the cardinal symptoms of CRS are the same as ODS but for ODS, these symptoms are unilateral, such as unilateral nasal obstruction, unilateral nasal drainage and unilateral facial pressure. Also, a foul smell is a very common symptom of ODS.

The conversation then transitions to discussing the role of dental history in ruling in ODS. John explains his oral exam process and questions he asks related to a patient’s dental history such as upper dental pain, root canals, extractions, dental implants and dental bridges. Interestingly, current research has shown only 20-40% of patients have dental symptoms such as dental pain. The group discusses how insurance coverage plays a role in the treatment management patients with ODS may undergo, and John notes the importance of collaborating with dental providers for endodontic testing and imaging that includes dental roots.

John further delves into what he is looking for on an endoscopy exam including unilateral purulent drainage from the middle meatus, edema and polyps. CT sinus usually shows unilateral maxillary sinus opacification.

Then, John explains how he groups patients in two groups, treatable and untreatable dental pathologies, to help in deciding management of patients with ODS. Treating the sinus and the treatable dental pathology (i.e.-closure of oroantral fistula) will help the condition resolve in the majority of cases. Timing of treating the dental pathology and sinus surgery is complicated, but taking into account the patient’s symptom burden can help decide timing of these procedures. When there is no treatable dental pathology, management options include antibiotics (to temporize symptoms) and endoscopic sinus surgery (ESS) with 98% success. The episode concludes with the group discussing the role of ESS for ODS.

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RESOURCES

PubMed (Link to John’s list of Publications):

https://pubmed.ncbi.nlm.nih.gov/?term=Craig%20JR&cauthor_id=32656998

In this episode of BackTable ENT, Dr. Mark Courey (chief of otolaryngology at Mount Sinai) and Sarah Schneider (Speech Language Pathologist at UCSF) join host Dr. Gopi Shah to discuss voice care for transgender patients.

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SHOW NOTES

First, Mark and Sarah define terms relevant to transgender healthcare and offer tips on welcoming transgender patients to clinic. They describe how voice care fits into the overall process of transition, and why patients seek care for voice-related concerns at different points in their journey. Gopi asks about collaboration with other specialties, and Mark discusses collaboration with other clinicians in a patient-centered transgender care team.

The conversation then shifts to workup and treatment of voice-related concerns. In Sarah’s experience, trans women present with voice fatigue if they are overly reliant on pitch modulation. By addressing pitch, articulation, rate of speech, volume, and resonance, Sarah helps her patients achieve a more feminine communication style while minimizing physical strain. Mark outlines his physical exam and process of history-taking as they relate to voice concerns. They also address the role of laryngoscopy in transgender patient populations.

Finally, Sarah and Mark address the importance of duration and goals of voice therapy. Both she and Mark emphasize the need to monitor progress over sessions of voice therapy. Delving into surgical management, Mark addresses the indications for, steps in, and complications of voice-modifying surgery. To wrap up, Sarah and Mark encourage listeners to educate their fellow clinicians regarding voice care for transgender patients.

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RESOURCES

https://www.enttoday.org/article/gender-affirmation-surgery-in-california/

https://www.enttoday.org/article/analyzing-the-latest-gender-affirming-care-restrictions-in-state-laws/

Sarah’s Twitter:

https://twitter.com/scharx16

Sarah’s UCSF Profile:

https://transcare.ucsf.edu/team/sarah-schneider

Mark’s Mount Sinai Profile:

https://profiles.mountsinai.org/mark-s-courey

In this episode of BackTable ENT, Dr. Gopi Shah is joined with speech language pathologist (SLP) Sarah Quintana, MS, CCC-SLP from Louisiana State University-Shreveport who specializes in gender-affirming voice, singing, voice rehabilitation, and remote service delivery models. Sarah and Gopi discuss the role of speech language pathology in the care of those with professional voices.

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SHOW NOTES

First, Sarah delves into her background of being a singer and how this influenced her to become an SLP who works with professional voices. Next, they talk about the type of patients Sarah sees at the voice center and how she assesses patients. She expands on the types of questions she asks and explains her systematic approach of using a stroboscope to look at vocal cord function. Next, Sarah and Gopi discuss the other individuals who make up the voice care team and also talk about the distinction between a voice coach, voice trainer, and voice teacher. Additionally, they delineate the roles of voice rehabilitation versus vocal habitation. Sarah also explains how she works with laryngologists to provide multidisciplinary care for professional voice patients.

Finally, Gopi and Sarah close out the episode by discussing voice conservation, the role of equitable healthcare in the field of SLP, and Sarah’s interest in remote service delivery options.

In this episode of BackTable ENT, pediatric otolaryngologists Dr. Anthony Sheyn (St. Jude Children’s Hospital & Le Bonheur Children’s Hospital), Dr. Jeffrey Rastatter (Lurie Children’s Hospital of Chicago), and Dr. Daniel Chelius (Texas Children’s Hospital), discuss challenges and research in health equity in pediatric head and neck cancer care.

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SHOW NOTES

First, the surgeons define the Social Determinants of Health (SDoH) and explain how studying these factors improves care. They share memories of when they first reckoned with health inequities as clinicians. For Dr. Chelius, this was during medical school, when he observed end-stage renal disease patients’ access to dialysis (and thus lifespan) depended on their insurance status, income, and education. Moving into his residency, he realized that similar forces shaped how patients accessed cancer care. As a young attending, Dr. Sheyn noticed that many of his patients missed appointments for logistical or financial reasons, which piqued his interest in characterizing how SDoH influence pediatric cancer care.

Next, the doctors discuss health equity research. Though they’re based at different institutions, the three surgeons collaborate to study how SDoH affect pediatric head and neck cancer outcomes. Dr. Rastatter shares his work identifying how different SDoH– including socioeconomic status, household composition, housing/transportation, and minority/language status – interact to affect access to cancer care. Dr. Chelius speaks to the importance of social work, advanced practice providers, and transportation services in connecting patients to care. The podcast concludes with a discussion of how tertiary care centers can better collaborate with community clinicians to ensure pediatric patients with rare cancers get the workup and treatment they need.

In this episode of BackTable ENT, Dr. Zara Patel, director of endoscopic skull base surgery and professor of otolaryngology at Stanford, joins Dr. Shah to discuss the physiology behind olfactory dysfunction and evidence-based cutting-edge therapies.

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SHOW NOTES

First, Dr. Shah and Dr. Patel outline different patterns of olfactory dysfunction and their etiologies. Damage to the olfactory system can result from inflammation, trauma, or neurodegeneration affecting olfactory bulb neurons. However, smell-based symptoms are common in migraine and seizure auras, so taking a thorough medical history is important in all patients. Also, they review “red-flag” medications contributing to smell loss.

Next, Dr. Shah asks Dr. Patel about the workup of patients with olfactory disturbance. Dr. Patel recommends rigid nasal endoscopy with and without decongestion for all patients with olfactory complaints. Unless another medical issue is suggested from the patient’s history, Dr. Patel does not routinely order labs for smell disturbance. The role of imaging is addressed, including use of MRIs for prognostication.

The doctors then cover evidence-based management of olfactory dysfunction. In cases where inflammation causes olfactory disturbance – such as post-viral etiologies – steroid therapy can help restore smell. To have effect, the drug must reach the olfactory cleft, so Dr. Patel prefers nasal rinses with budesonide over intranasal or oral steroids. Then, Dr. Shah shares her experience treating patients with olfactory training. Dr. Patel explains the neural basis of training and instructs clinicians on how to counsel patients for best outcomes.

Finally, Dr. Patel shares her expertise on hot topics in olfactory research, like the science behind platelet-rich plasma (PRP) for smell loss. She also reviews situations in which dietary supplements can improve symptoms. They end the episode with insights regarding equitable care of patients with smell-based symptoms.

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RESOURCES

Dr. Patel’s Stanford profile

https://profiles.stanford.edu/zara-patel

JAMA Patient Handout on Olfactory Training:

https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2782042

International Consensus Statement on Allergy and Rhinology:

Olfaction https://onlinelibrary.wiley.com/doi/10.1002/alr.22929

In this episode of BackTable ENT, Robert Glazer, executive vice president of ENT and Allergy Associates LLP joins Dr. Ashley Agan to speak about his process for recruiting the next generation of otolaryngologists, things otolaryngologists should look for in choosing a practice to join, and general tips and advice for otolaryngology residents to think of in their plans post residency.

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SHOW NOTES

Dr. Agan begins the episode by having Robert Glazer discuss his background in the healthcare field with over 40 years of healthcare experience in finance and operations, managed care contracting, physician recruitment, and healthcare marketing. Glazer discusses his beginnings in healthcare starting back in 1976 by getting a job as a clerk in NYU medical center in the grants and contracts division, helping physicians fill out grants for their medical research. During his nine years at NYU he went and got his masters degree in public administration with a focus on healthcare, and takes us through how these early jobs and his further promotions, led him to ENT & Allergy Associates LLP.

Next, Glazer explains what he looks for in recruiting otolaryngologists to his practice and advice for resident physicians looking to apply to the job market. Residents should take into consideration different practices and the importance of networking and meeting individuals at a particular practice. Glazer tries to meet candidates in their PGY2 and PGY3 years to get to know them and learn more about why they are interested in being in the NYC region. He also discusses some of the key questions that residents should be asking during the interview trail and discusses the importance of transparency in learning more about a practice.

Lastly, Glazer talks about strategies that he has found to be successful in recruiting new otolaryngologists to his practice and discusses COVID has changed recruitment and how physicians can manage burnout post-COVID.

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RESOURCES

ENT and Allergy Associates, LLP:

https://www.entandallergy.com

In this episode of BackTable ENT, Dr. Shah and Dr. Gauri Mankekar, assistant professor of Otolaryngology at LSU Health Shreveport, discuss cholesteatoma workup and surgical management.

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CHECK OUT OUR SPONSOR

Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, Drs. Shah and Mankekar review the basics of cholesteatoma: types, etiology, clinical presentation, and physical exam findings. Doctors should suspect cholesteatoma when they encounter a patient experiencing painless, malodorous ear drainage. Dr. Mankekar underscores the importance of tailoring the physical exam to each patient’s history and needs. For example, when evaluating children for potential cholesteatoma, she works to gain the child’s trust before examining the ear, sometimes using an initial visit to focus on rapport and deferring the exam to the second visit.

Next, the surgeons address workup of cholesteatoma, which should include audiometry, CT scan, and culture of ear drainage (if present). All patients with cholesteatoma require long-term surveillance, as recurrence can happen more than five years after initial treatment. Dr. Shah advises that doctors approach the topic of surveillance by emphasizing the importance of creating a safe ear. Dr. Mankekar then shares tips on how to help patients understand the chronicity of their disease.

Then, the surgeons discuss cholesteatoma operative techniques. Dr. Mankekar leads listeners through her approach to cholesteatoma surgery, from review of CT scans to supplies used in the OR. Dr. Shah delineates common challenges in ear surgery, such as “hard to reach areas”, and Dr. Mankekar shares technical strategies she uses in the OR. They then review the role of endoscopic tympanoplasty, ossicular chain reconstruction, and canal wall down mastoidectomy. As with her ear exam, Dr. Mankekar closely tailors each operation to the patient’s particular pathology. Finally, Dr. Mankekar summarizes her strategy for patient-centered, long-term management of cholesteatoma.

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RESOURCES

Dr. Mankekar’s Profile:

https://www.ochsnerlsuhs.org/doctors/gauri-mankekar

In this episode of BackTable ENT, Dr. Javan Nation, a pediatric otolaryngologist from Rady’s Children Hospital in San Diego, joins Dr. Shah to speak about the assessment and management of children with complex obstructive sleep apnea.

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SHOW NOTES

Dr. Nation and Gopi begin the episode by discussing some of the presentations and patient populations of young children who may be coming into the office with sleep apnea. Dr. Nation also discusses his approach in conducting a physical exam, including assessing their breathing and posture to identify if a pediatric patient may have sleep apnea.

Next, Drs. Nation and Gopi discuss important history taking skills that will help the larger interdisciplinary team, such as pulmonologist or craniofacial surgeon. Dr. Nation mentions that while controversial for some clinicians, he assesses teeth grinding and thumb sucking at young ages, among other physical exam findings. Dr. Nation evaluates the role of imaging, specifically CT imaging, and explains how he uses these results to communicate to families and patients. Additionally, Dr. Nation explains his approach for looking at sleep study results.

Lastly Dr. Nation summarizes how he uses sleep endoscopy in some patients to decide whether or not to recommend patients for tonsillectomy. He also explores the potential role of hypoglossal nerve stimulator in pediatric patients with sleep apnea and indications for patients getting a tracheostomy for treating obstructive sleep apnea.

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RESOURCES

SENTAC (Society for Ear, Nose, Throat Advancement in Children)

https://sentac.org/

In this episode of BackTable ENT, Dr. Walter Kutz (UT Southwestern, Dallas, TX), and guest Dr. Matthew (Matt) Carlson (Mayo Clinic, Rochester, MN) discuss high-yield research tips for medical students and physicians.

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SHOW NOTES

Dr. Carlson begins the episode by describing how one can approach scholarly activity so that research is genuinely an enjoyable pursuit. Dr. Carlson emphasizes organization throughout all stages, from idea generation to project management. The work of a diverse team – in terms of individual background, skills, and seniority – helps guide good ideas to publication. With this setup, research mirrors medicine’s chain of command: residents mentor medical students on a day-to-day basis, and principal investigators are able to manage on a high level. Both surgeons agree that the skills of statisticians and institutional research coordinators are indispensable for ensuring data quality and working with the IRB, respectively.

Next, Drs. Kutz and Carlson dive deeper into the research process. Dr. Carlson starts projects by diving into PubMed and identifying how his project can address yet-unanswered questions. Drs. Carlson and Kutz discuss resources they employ to insure data and manuscript integrity. Regardless of the manuscript’s topic, clarity of style and good grammar are non-negotiable. From the perspective of a researcher and reviewer, Dr. Carlson finds that sloppy writing leads one to question whether data analysis is similarly disorganized.

Then, Dr. Carlson explains how his research group manages to publish, on average, one manuscript a week. He attributes this productivity to organization, clear expectations for all involved, and genuine enthusiasm for investigation all contribute to this impressive statistic. Dr. Kutz comments that output is better when trainees are encouraged, rather than mandated, to take on research projects. Finally, Drs. Kutz and Carlson discuss how artificial intelligence and open-access journals could alter the research landscape in the near future. As a parting thought, Dr. Carlson encourages listeners to build a good team and be generous with mentees.

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RESOURCES

The Dip: A Little Book that Teaches You When to Quit (and When to Stick), Seth Godin

Grammarly

https://www.grammarly.com/

Dr. Carlson’s Research Profile

https://www.mayo.edu/research/faculty/carlson-matthew-l-m-d/bio-20113086