BackTable ENT & Allergy

In this episode of BackTable ENT, Dr. Agan and UT Southwestern laryngologist Dr. Shumon Dhar discuss new approaches like flexible scope techniques to managing Zenker's diverticulum.

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Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, the doctors summarize flexible endoscopy techniques and hybrid techniques for treating patients with Zenker's diverticulum. They discuss the ideal candidates and how endoscopic Zenker's surgery has changed to achieve better results and lower rates of postoperative complications. Specifically, they discuss the importance of removing the muscular and mucosal septum of the Zenker's pouch to reduce the risk of postoperative complications.

Additionally, they examine the importance of creating a watertight mucosal seal, the use of distal attachment caps, and the importance of getting a good visualization of the septum for a successful surgery. They also discuss the role of intubation and general anesthesia and cover the use of gastrostomy tubes for patients with dysphagia. Next, Dr. Dhar explains the types of advanced energy devices used when performing the myotomy for the treatment of Zenker's diverticulum. He also goes into depth about the learning curve associated with this procedure and discuss the rate limiting factors when considering the wide-spread use of this technique. The doctors then comment on the differences between a Z-POEM, rigid, and flexible endoscopic surgical techniques. Ultimately, Dr. Dhar believes that having a variety of tools at one's disposal to be able to offer patients the best option for their needs is the key to successful treatment.

Finally, they discuss the importance of post-operative care for patients with Zenker's diverticulum. They explore the use of clips, the avoidance of positive pressure, the use of NG tubes, and an ideal post-operative diet.

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RESOURCES

Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology/

In this episode of BackTable ENT, Dr. Shah and Dr. Karuna Dewan discuss diagnosis, workup and medical therapy for chronic cough in adults.

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Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, they discuss the array of surveys used to quantify and assess the severity of the cough, as well as the importance of physical exam and laryngoscopy for an accurate diagnosis. They also outline various diagnoses that could be contributing to the chronic cough.

Next, the critical role of speech pathologists in dysphagia diagnosis and management is explored. Dr. Dewan emphasizes the importance of the scope exam, as well as how speech pathologists are integral to the dysphagia diagnosis. Various testing options are discussed, such as modified barium swallow, esophagram, and pulmonary function testing. She then delves into how to decide which tests are necessary for each patient. Then, they discuss various treatments and medications for chronic coughing, including reflux medications, proton pump inhibitors, and steroids. They explore the importance of taking into account the potential side effects of these medications and of monitoring them closely. Additionally, they evaluate the efficacy of Tessalon perles, over the counter cough suppressants, and the two-arm approach for treating neurogenic cough. They also explain paradoxical vocal cord motion, its symptoms, and how it is treated with therapy and an ipratropium bromide inhaler. Procedures, like the superior laryngeal nerve block injections, may be effective for treating chronic cough.

Finally, the doctors reflect on the use of social media for professional purposes. They consider how to best use Twitter and Instagram to promote oneself, and the importance of having an easily accessible profile on the Internet. They also touch on the importance of developing an online presence in order to stay connected and visible in the professional world.

In this episode of BackTable ENT, Dr. Agan and Dr. Shah invite Dr. Rohan Walvekar, Chair in Head and Neck Surgery at Louisiana State University, to discuss his experience with innovating procedures for sialendoscopy and ranula excision.

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Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

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SHOW NOTES

First, Dr. Walvekar shares his insights on how to differentiate between cysts and sublingual gland masses. He explains the importance of examining the normal side of the floor of the mouth and comparing it to the abnormal side. He also discusses the advantages of using ultrasound in the office and when to consider imaging such as CT or MRI. Finally, he explains the importance of understanding different malformation types when making treatment decisions. Next, Dr. Rohan Walvekar talks about the importance of being familiar with the floor of mouth anatomy to avoid injuring the lingual nerve. He also explains his preferred approach to intubation and emphasizes the importance of examining the papilla.

Familiarity with floor of mouth anatomy is important for safe cannulation of the duct. Dr. Walvekar's stent is designed to have a flange that anchors itself to the floor of the mouth and can be used for both parotid and submandibular ducts. The stent helps to identify the duct and ensure the incision for the sublingual gland removal is made in the right place. Dr. Walvekar explains his approach to decompressing a pseudocyst, which includes transoral dissection and, if needed, aspirating with a thick 18 gauge needle. Finally, he discusses the importance of not injuring the submandibular duct and lingual nerve during closure and the possible use of a transcervical approach if needed.

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RESOURCES

Walvekar Salivary Duct Stent:

https://hoodlabs.com/salivary-management/walvekar-salivary-duct-stent/

In this episode of BackTable ENT, Dr. Walter Kutz and Dr. David Haynes, program director of the Neurotology Fellowship at Vanderbilt University, discuss the importance of mentoring for both ENT trainees and faculty.

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SHOW NOTES

First, Dr. Haynes explores the concept of mastering a skill, the importance of coaching, and deliberate practice. He also talks about the importance of having mentors with adequate standards and expectations, and how having this type of relationship between mentor and mentee requires commitment on both sides. Additionally, he notes that the knowledge passed down from mentors is generational and cumulative. The doctors also discuss the importance of having a growth mindset, which they believe is just as important as having surgical skills. They compare the role of a mentor to that of a coach and explain that even the best athletes have coaches to help them improve. For medical trainees to be coachable, they have to have a positive attitude and willingness to learn. Finally, Dr. Haynes emphasizes the importance of taking classes to learn professionalism.

Then, Dr. Haynes shares stories about his own mentors and discusses how they have had a profound influence on my career. The doctors explain the benefit of having mentors both within and outside their organizations, as well as the difficulty of having a formal mentorship program due to the demands of the medical profession. Finally, they agree that the quality, not the quantity of time, spent with mentors counts.

This week on the BackTable ENT podcast, Dr. Gopi Shah and Dr. Amanda Stapleton, a pediatric otolaryngologist from UPMC Children's Hospital of Pittsburgh, chat about the unique challenges of treating pediatric sinus and skull base diseases, orbital complications, and biofilm-covered Moraxella. They discuss source control, biofilm, and her research focused on the bacteriology of pediatric chronic sinusitis and patients with cystic fibrosis.

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SHOW NOTES

First, they discuss how to recognize the signs and symptoms of pediatric patients who present with orbital or intracranial abscesses and how age and location of the abscess can influence treatment decisions. They also explain how to distinguish between intracranial and orbital abscesses and how to recognize the symptoms of sphenoid sinusitis. Both doctors emphasize the importance of involving infectious disease colleagues to evaluate antibiotic coverage and surgical indications.

Next, the doctors discuss the techniques for sinus surgery, including the use of a scope for visualization, warm irrigations, navigation, and augmented reality systems in the acute setting. Dr. Stapleton also provides tips on when to remove a middle turbinate and the importance of source control, especially in patients under the age of seven. An adenoidectomy may be necessary if the patient has had multiple colds throughout the winter and the decision is made to take down the lamina to drain an abscess pocket.

Finally, the doctors discuss the follow up process for children with chronic sinusitis, which may include office endoscopy and allergy testing, and discuss the rare cases of intracranial abscesses. In addition to being vigilant and proactive in monitoring the potential for repeat infections, imaging to detect any scarring or residual mucosal inflammation that might have resulted from the initial infection is also helpful.

En este episodio de BackTable ENT, Dr. Carlos Torre entrevista al reumatólogo Dr. Juan Chiossone sobre su trayectoria profesional y su manejo de pacientes con problemas neurotológicos.

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SHOW NOTES

Primero, Dr. Chiossone explica su trasfondo médico, que incluye el entrenamiento en varios lugares como Venezuela e Inglaterra. Se dio cuenta de que tenía un interés en la investigación científica y la microcirugía durante su tiempo en la escuela medical en Caracas. Tuvo la oportunidad de estudiar en Cambridge también y explicó cómo buscó sus mentores y el rol integral que tiene su fellowship en su desarrollo como cirujano. Después de su tiempo en Inglaterra, hizo la decisión de quedarse en la medicina académica y explica más sobre las ventajas y desventajas de trabajar en una práctica privada. Dr. Chiossone hace la transición para explicar cómo obtuvo una posición en la Universidad de Miami y las diferencias entre practicar medicina en Venezuela y los Estados Unidos.

Próximamente, los doctores discuten la evaluación de los pacientes con problemas neurotológicos. Dr. Chiossone nota que el tiempo de presentación de los síntomas es importante, independientemente de si es una pérdida auditiva o problemas con el balance. Para los niños, es crítico diagnosticar los problemas temprano porque la falta de tratamiento puede tener un gran impacto por el resto de sus vidas. Para cada condición, es importante explicar la condición al paciente en vocabulario básico y tener un actitud optimista sobre el tratamiento para mitigar la ansiedad y el estrés del paciente.

Además, Dr. Chissone habla sobre su técnica de implantación coclear, su protocolo de inyecciones intratimpánicos, indicaciones para tubos para los oídos, y su reparación de las perforaciones timpánicas. Finalmente, los doctores comparan las ventajas y desventajas de la cirugía microscópica y la cirugía endoscopia y el impacto de los nuevos audífonos de venta libre.

In this episode of BackTable ENT, Dr. Shah interviews pediatric otolaryngologist Dr. Kevin Huoh about intracapsular tonsillectomy, including the postoperative benefits of the procedure and his personal techniques.

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Smith & Nephew ENT Solutions

https://smith-nephew.com

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SHOW NOTES

First, Dr. Huoh explains the principle behind intracapsular tonsillectomy. This technique involves removing the tonsil but leaving the capsule intact to protect muscles of the pharyngeal wall and lateral vessels. When he performs this procedure on patients, he notices that their recovery period is less painful and their lower risk of hemorrhages when compared to extracapsular tonsillectomy patients. According to the literature, there is only 3% risk of tonsil regrowth, but he considers regrowth a safer complication than tonsillar hemorrhage. His postoperative recovery regimen includes Tylenol or Motrin for 24 hours, and his patients can start on a regular diet immediately after surgery. Then, he and Dr. Shah discuss differences between American and European guidelines on intracapsular tonsillectomy.

Next, Dr. Huoh explains the type of equipment he uses and his intracapsular tonsillectomy technique. He encourages surgeons to follow their tonsillar regrowth rate, as this data can inform surgeons on whether they are removing enough tissue during the procedure. Additionally, he also emphasizes that it is never too late to learn a new procedure like intracapsular tonsillectomy. He finds it easy to add on an intracapsular tonsillectomy as a minor procedure if he is already taking a patient to the OR for another surgery because of the minimal risks of the procedure. Finally, Dr. Shah and Dr. Huoh discuss tonsillectomies in adults and children with recurrent peritonsillar abscesses.

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RESOURCES

Smith + Nephew Coblation Technology for Adenotonsillectomy

https://www.smith-nephew.com/en/health-care-professionals/products/ear-nose-and-throat/coblation-technology-for-adenotonsillectomy#overview

In this episode of BackTable ENT, Dr. Shah interviews rhinologist Dr. Jeffrey Suh (UCLA) about cryotherapy as a new treatment for chronic rhinitis.

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Stryker ENT

https://ent.stryker.com

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SHOW NOTES

First, the doctors discuss the typical presentation of a patient with rhinitis. Although all rhinitis patients present with a chief complaint of a runny nose, there are different subtypes of rhinitis, such as allergic rhinitis, gustatory rhinitis, and exercise-induced. Environmental exposures, duration of symptoms, and the presence of other symptoms should be elicited, as differentiating between allergic and non-allergic rhinitis changes treatment options. Next, Dr. Suh explains how he performs a physical exam in rhinitis patients. He uses a rigid endoscope to make sure there is not another cause of rhinitis. He is sure to premedicate patients with a lidocaine and Afrin nasal spray before using the endoscope. CT scans of the sinuses may be helpful if patients have drainage, polyps, or notable inflammation.

In general, Dr. Suh will pursue medical treatment options before considering procedural options. For allergic rhinitis patients, he educates patients about understanding their triggers for allergies and prescribes nasal steroid sprays and antihistamines. In non-allergic rhinitis patients, he recommends ipratropium bromide, which can also be used as a trial to see if cryotherapy would resolve their symptoms. He notes that sprays need to be used for at least 1 month before they show effects and that they should be used 30 minutes before trigger exposure for allergic rhinitis patients. He does not think that saline rinses help much with rhinitis, as they contain no medications to reduce swelling and dampen nerve stimulation.

Next, Dr. Suh explains two procedural options for chronic rhinitis: radioablation therapy and cryotherapy. Both procedures have similar success rates, but he prefers to use cryotherapy in patients with non-allergic rhinitis who have a positive response to ipratropium bromide. The procedure involves inserting balloon a into the middle meatus of the nasal cavity and in order to deliver liquid nitrogen to the nasal mucosa overlying the posterior nasal nerve. He explains different considerations for performing cryotherapy in the office versus in the OR. He also explains his anesthesia protocol and how to mitigate the common post-operative complaint of an “ice cream headache”, which he prophylactically treats with gabapentin. Radiofrequency ablation with the RhinAer procedure also targets the posterior nasal nerve, but it has other complications, like damaging other nerves that allow for the tearing of eyes. He chooses the cryotherapy option more often because it does not require as good visibility as the radiofrequency ablation therapy does.

Finally, he explains his postoperative care regimen which includes starting the patient back on their usual nasal sprays. His patients take 2 weeks to see results, and cryotherapy is effective in 80% of his patients. He notes that patients with recurrent rhinitis may need recurrent treatments.

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RESOURCES

Stryker ENT

https://www.stryker.com/us/en/portfolios/medical-surgical-equipment/ent.html

Stryker ClariFix Cryotherapy

https://clarifix.com/

RhinAer Radiofrequency Ablation

https://rhinaer.com/

In this episode of BackTable ENT, Dr. Varun Varadarajan speaks with Michael Johnson, a business lawyer, about advice for negotiating academic and hospital employment contracts.

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/0aliK0

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SHOW NOTES

First, the doctors talk about the RVU system of compensation used by many hospitals and academic centers. They discuss what the price per RVU means and additional bonuses after the expected RVU goal is met. Michael adds that it may be beneficial to negotiate for more resources to earn more RVUs instead of negotiating more compensation, as the former strategy can lead to higher compensation. Additionally, he notes that subspecialty clinicians and surgeons have more leverage to negotiate their contracts if they are the first subspecialists in a large system. He recommends that physicians start negotiating at least a year in advance of their anticipated start date. They also discuss the compensation models based on productivity versus a flat salary.

Then, the doctors explain how to handle verbal offers from academic centers. Michael recommends talking to multiple employers at a time when starting the hiring process in order to weigh multiple options. However, he recommends physicians to be upfront about where they are interviewing with each employer. He notes that some academic institutions will send a letter of appointment, and not an employment contract, but physicians can still negotiate for firm deal breakers in the letter of appointment. He then explains different clauses in the contracts, such as restrictive covenants (non-compete and non-solicit clauses), non-disclosure agreements, and malpractice tail insurance. He advises against comparing salary offers to the MGMA compensation data, as different jobs require different obligations. Instead, he recommends making sure that the compensation matches the job obligations.

Finally, the doctors end the episode with reviewing common employer tactics, such as pressuring doctors to sign contracts quickly and only offering negotiation on the base salary and signing bonus. Michael explains that it is worthwhile to engage in higher levels of administration in the negotiation process if necessary.

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RESOURCES

Michael Johnson’s Website:

https://www.michaeljohnsonlegal.com/physician-contracts/

Michael Johnson’s Instagram:

https://www.instagram.com/physiciancontracts/

Episode 45- Private Equity: Savior or Existential Threat?

https://www.backtable.com/shows/ent/podcasts/45/private-equity-savior-or-existential-threat