BackTable ENT & Allergy

In this episode of BackTable ENT, Dr. Shah and Dr. Agan interview Dr. Sujana Chandrasekhar, a private practice neurotologist, about diagnosis and treatment of patients with sudden sensorineural hearing loss (SSNHL).

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SHOW NOTES

First, Dr. Chandrasekhar explains the formal definition of sudden hearing loss, which is a loss of 30 dB over 3 consecutive frequencies over 72 hours, and notes that it is usually unilateral. She explains that the time from hearing loss presentation to ENT referral is usually delayed, as many patients attribute their hearing loss to a cold, the flu, or allergies. Frequently, they are also told over phone to take nasal sprays or prescribed amoxicillin. However, severe / profound hearing loss with or without tinnitus and vertigo necessitates immediate ENT consultation. Upon initial presentation, she usually gets a thorough health history, review of systems, and medication list from the patient. Common causes of SSNHL include: pregnancy and other thrombotic states, stroke, injected or intravenous drugs, high dose aspirin, PDE-5 inhibitors, and COVID-19 infection. She also describes how she uses the physical exam to distinguish between conductive and sensorineural hearing loss. First, she checks the outer ear and visualizes the tympanic membrane to look for external pathologies. Then, she utilizes the Weber and Rinne tests on every patient.

Next, she explains her further workup for patients determined to have SSNHL. She emphasizes the need for retrocochlear examination to check for vestibular schwannoma, which is best done through MRI. If patients have MRI contraindications, a CT temporal bone with contrast paired with auditory brainstem response (ABR) testing may be an alternative option. Dr. Chandrasekhar explains that a single ABR test has a low specificity for vestibular schwannomas, missing up to 15-20% diagnoses. She also notes that patients with audiograms showing low frequency hearing loss have a better prognosis than those with high frequency hearing loss. Additional symptoms to look for are otalgia, erythema, healing vesicles, facial palsy, and blebs on the tympanic membrane. These symptoms may point to an infectious cause, such as syphilis, Lyme disease, and herpes zoster. Additionally, children may have syndromic causes of SSNHL.

Dr. Chandrasekhar also explains her treatment options for SSNHL of different severities. For patients with mild and moderate hearing loss, she prescribes an oral prednisone taper, which patients can stop taking if hearing comes back. Intratympanic steroid injections with dexamethasone may be implicated if patients with moderate SSNHL do not respond to oral prednisone. She explains her steroid injection technique as well as tips for how to make patients more comfortable during and after the procedure. For patients with severe SSNHL, she emphasizes the importance of self-training to listen in the affected ear, starting to wear hearing aids early, and considering BAHA devices. Then, the doctors discuss the value of additional therapies for SSNHL, such as acupuncture, hyperbaric oxygen, papaverine, and B vitamins. Finally, she speaks about intratympanic stem cell injections to regrow inner hair cells as an exciting future treatment of sudden hearing loss.

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RESOURCES

She’s on Call Podcast:

https://podcasts.apple.com/us/podcast/shes-on-call-weekly-medical-show/id1582727930

WHO Free Hearing Test:

https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/hearwho

In this episode of BackTable, Dr. Puya Dehgani-Mobaraki, president of Associazione Naso Sano, discusses his research and his experience as a rhinologist with SARS-CoV-2 and its effect on the olfactory system.

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SHOW NOTES

First, Dr. Dehgani-Mobaraki explains the goals of the Associazione Naso Sano, which is to provide community education about rhinologic conditions, distribute research grants to young researchers, and host international grand rounds. Then, he discusses his own experience with SARS-CoV-2. He was infected with the virus in early 2020 and could not be tested because he had no upper respiratory symptoms, only anosmia. He also reflects on the research he did in 2020, which focused on immune adaptation after infection. His research group discovered that there was a strong relationship between antibody production and smell loss. He notes that later variants of the virus became more infectious, but not more lethal. After December 2021, he noticed that the virus mutations led to a different pathway of generating symptoms, resulting in more upper respiratory symptoms and less anosmia. Furthermore, he reminds listeners that smell and taste disorders are not unique to SARS-CoV-2 and can be triggered by Parkinson disease, Alzhiemer disease, brain trauma, and nasal polyposis.

Next, he speaks about his personal experience with treating patients with anosmia. Usually, COVID patients will regain their sense of smell any time from 20 days to 6 months after infection. However, some patients experience longer lasting parosmia, an altered quality of smell, and phantosmia, the perception of smell without stimulus. He notes that these symptoms can be difficult and distressing to patients. Smell and taste disorders can lead to weight loss and psychological disturbances, as these two senses are integral to community formation and pleasure. Although some patients can self-train to live with altered smell and taste, some may require medical consultation for a structured smell re-training plan or medications, such as oral steroids, PRP injections, zinc, or alpha-lipoic acid. Finally, Dr. Dehgani-Mobaraki speaks about his most recent research project, which may suggest that SARS-CoV-2 can reactivate Epstein Barr virus through autoimmune pathways.

In this episode of BackTable, Dr. Ashley Agan and guest co-host Dipan Desai (Johns Hopkins) interview David Goldenberg (Penn State) about evaluation and surgical management of parathyroid disease.

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SHOW NOTES

First, the doctors discuss the typical primary parathyroid disease presentation. Patients often report non-specific symptoms, such as fatigue, abdominal pain, sleep issues. Primary hyperparathyroidism is most common in perimenopausal women and is easily misdiagnosed. However, Dr. Goldenberg notes that an elevated serum calcium and PTH level on labs without other causes are diagnostic of primary hyperthyroidism. It is important to rule out other reasons for an elevated calcium level, such as malignancy, thiazides, and lithium. For borderline patients with slightly high parathyroid and calcium levels, the diagnosis is a clinical decision. Dr. Goldenberg may order more imaging studies or check labs again in 6 months. Furthermore, secondary parathyroidism is related to kidney disease and should be treated medically first.

Dr. Goldenberg utilizes a 4D CT scan to localize the overactive parathyroid gland. He notes that a majority of patients will have a single adenoma. Some may have multiple parathyroid glands affected (e.g. 4 gland hyperplasia), and 1% of his patients will have an aggressive parathyroid carcinoma. Parathyroid carcinoma patients usually present with incredibly high calcium and PTH levels. He notes that 4D CT is the most accurate imaging modality for parathyroid visualization; ultrasound is affected by air and bone and a SPECT scan will not detect small or flat adenomas.

Next, Dr. Goldenberg discusses his surgical technique. He makes a clavicle incision at midline and uses the middle thyroid vein to find parathyroid glands. If he is manipulating the superior thyroid glands, he is careful not to damage the recurrent laryngeal nerve. For a 4 gland exploratory surgery, he finds all 4 glands before taking any of them out in order to make sure he is taking out the right one. He can usually distinguish the parathyroid glands from the surrounding tissues because of their unique brown color. If he is unsure about whether the sample he took out is a parathyroid gland or another type of tissue, he will send frozen sections for pathologic analysis. Other pearls he has are: picking up the parathyroid glands from their capsule to preserve blood supply, always using nerve monitoring, and common anatomical locations for missing parathyroid glands. He checks the PTH level before operating and again 15 minutes after parathyroid gland removal to see if he removed the offending gland. If there is at least 50% drop from the baseline PTH level, he considers the surgery a success.

Then, Dr. Goldenberg summarizes his post-operative care. For patients who underwent exploration surgery, he usually keeps them in hospital for 23 hours. Simple parathyroidectomy patients can be discharged on the same day. Patients also receive a calcium taper with calcium carbonate because of the risk of hungry bone syndrome, a condition where serum calcium is depleted quickly because of rapid bone absorption, leading to hypocalcemic symptoms. Hyperparathyroid symptoms usually abate very quickly after surgery. Finally, he discusses his new textbook and atlas, which contains key points and pearls, quiz questions, annotated bibliographies, and surgical videos about head and neck endocrine surgery.

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RESOURCES

Head & Neck Endocrine Surgery: A Comprehensive Textbook, Surgical, and Video Atlas by Dr. David Goldenberg:

https://shop.thieme.com/Head-Neck-Endocrine-Surgery/9781684201464

In this crossover episode of BackTable, Dr. Eric Gantwerker interviews Dr. Chris Kaufmann and Dr. Marlan Hansen from the University of Iowa about their startup company, iotaMotion, which has developed the first FDA-approved robotic cochlear implant insertion system.

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SHOW NOTES

First, Dr. Kaufmann and Dr. Hansen speak about their backgrounds and interests in entrepreneurship and engineering along with their medical focus. As otolaryngologists, both wanted to find a way to improve cochlear implant insertion in order to preserve cochlea function and structure. Their device, iotaSOFT, robotically assists surgeons during implantation and minimizes the risk of advancing the implant too far within the cochlea. They emphasize that this is a tool to assist surgeons, not change the technique with which they operate. They also note that their primary motivation was to help patients, so they were more concerned about safety and effectiveness rather than market competition and monetization.

Then, they speak about the development path of their product and start up company. They filed for intellectual property rights under the University of Iowa and then formed a startup company that licensed the technology in order to commercialize the device. They discuss how they slowly added more employees and consultants to their company and set phases and goals for hiring and fundraising. Next, they explain challenges they had to overcome, such as the FDA approval process and COVID-19 setbacks on their clinical studies. They noted that iotaSOFT has received support from many surgeons once they understood that the robotic system merely assisted their surgeries without taking any control away from them.

Finally, they discuss future plans for iotaSOFT such as integrating it with other devices and developing it further to be able to reside in the cochlea with the implant.

In this episode of BackTable ENT, Dr. Ashley Agan interviews laryngologist Dr. Inna Husain about diagnosis, treatment, and multidisciplinary care of patients with laryngopharyngeal reflux (LPR).

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SHOW NOTES

First, Dr. Husain defines LPR as acidic and/or non-acidic reflux that causes direct and indirect effects on the upper aerodigestive system. She emphasizes the importance of utilizing subclassifications of LPR and explains the difference between direct acid, direct non-acid, and indirect acid reflux. She notes that each subclassification has different treatment patterns and that overlapping diagnoses can make classification difficult. Another challenge in diagnosing LPR is the need to distinguish chronic problems from isolated episodes. If a patient’s LPR is chronic, she suspects the indirect acid LPR subclassification.

During her primary visit with a patient, she asks key questions related to the root problem or sensation a patient is experiencing, such as mucus dripping, throat clearing, or globus. She notes the frequency and severity of their episodes. She also explains that unilaterality of sensation is unlikely to be LPR, and patients correctly diagnosed with GERD commonly have LPR. After taking an initial patient history, she utilizes flexible laryngoscopy to visualize the throat and rule out other diagnoses, such as polyps or tumors. She notes that she will not be able to see reflux through laryngoscopy, but just signs of throat irritation. Additionally, because there is not one defining visual characteristic of LPR, the imaging results are always interpreted through subjective means; thus, LPR is a diagnosis of exclusion.

For patients suspected to have LPR, Dr. Husain initiates empirical medical therapy. She explains to all her patients lifestyle modifications like cessation of smoking / vaping and reduction of coffee, late night eating, carbonated water, and citric foods. Although the conventional treatment of LPR is acid suppression, she only prescribes patients with proton pump inhibitors if they have acid reflux symptoms because 50% of LPR patients don’t actually improve on the medication. Her PPI regime consists of 40 mg omeprazole in the morning and Pepcid at night for 1-2 months. If patients improve, she slowly tapers them off of the PPI to avoid rebound reflux. If the patients do not improve after 2 months, she will switch to another medication, such as alginate suspensions, a more natural alternative to PPI. Alginate suspensions create a barrier that prevents the upward movement of acid. Contraindications include concurrent use with other acid suppression medications and a history of lower GI issues.

Finally, Dr. Husain discusses the 24-hour pH impedance testing, which is the gold standard for LPR diagnosis. A catheter with a probe is inserted into the patient’s throat and sends continuous pH readings to a monitor the patient carries. Patients return after 24 hours, and she is able to find correlations between patient symptoms and acid reflux and classify the LPR subtype. If she interprets any distal esophageal issues or dysmotility issues, she involves her GI colleagues to explore endoscopic solutions. She ends the episode by explaining her treatment regimen for refractory neurosensory (indirect) reflux, which includes neuromodulators (gabapentin, amitriptyline) or a superior laryngeal nerve block.

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RESOURCES

Dr. Husain’s Twitter:

https://twitter.com/Drinnahusain

Dr. Husain’s Instagram:

@innahusainmd

En este primer episodio español de BackTable ENT, Dr. Carlos Torre entrevista al Dr. Laureano Giraldez sobre sus motivaciones y lecciones de empezar su práctica privada de laringología y cáncer de cabeza y cuello en Puerto Rico.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/zW5bUS

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SHOW NOTES

Primero, Dr. Giraldez discute su motivación y trayectoria de ser otorrinolaringólogo. Creció en una familia de médicos y le gustaba el otorrinolaringólogo debido a la diversidad del campo. Completó la residencia en la Universidad de Puerto Rico y entrenó en laringología en el Emory Voice Center. Entonces, desarrolló un interés en la reconstrucción del cáncer de la cabeza y cuello y añadió una especialización segunda en reconstrucción microvascular después de su entrenamiento en Mount Sinai.

Después, Dr. Giraldez habla sobre el proceso de abrir su propia práctica privada en Puerto Rico después de su cognición de la falta de otorrinolaringólogos puertorriqueños. Él enfatiza la importancia de las principales de organización para un cirujano joven. Cuando empezó, necesitaba preguntar que necesitaba del hospital y de la comunidad. Por ejemplo, reconoció su necesidad de una unidad de cuidados intensivos, la terapia de respiración, y la terapia de rehabilitación. También, él quería hacer cirugía robótica, así que necesitaba tecnología avanzada. Además, hace unas comparaciones entre la práctica privada en los Estados Unidos versus en Puerto Rico. Los doctores también discuten los cambios del campo de otorrinolaringólogo en Puerto Rico y sus colegas que están avanzando en la investigación y las técnicas quirúrgicas

Próximo, Dr. Giraldez habla sobre su población de pacientes. Dice que la mayoría de su práctica pertenece a la laringología y fueron recomendados por sus pacientes anteriores. Usó la red social, las publicaciones, y su sitio web para contactar pacientes nuevos. También, tiene algunos pacientes internacionales que están buscando tratamiento avanzado más barato pero de la misma calidad. Los doctores terminan el episodio con algunos consejos, como el beneficio del cambio y la importancia de ser autocrítico.

In this episode, Dr. Bagrodia discusses cultivating a healthy culture inside and outside of the operating room with Dr. Chris Kane, Dean of Clinical Affairs at UCSD and CEO of the UCSD Physician Group.

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SHOW NOTES

First, the doctors discuss the definition of culture, which Dr. Kane defines as the norms of behavior and relationships within an organization. Culture can include dress code, meeting rules, and punctuality. Most of the time, institutional culture is established in an unspoken way. Dr. Kane emphasizes the importance of having a conscious strategy to create a healthy culture and reiterates that trust is a crucial foundation for motivating cultural changes.

Next, the doctors discuss helping team members find meaning in their work. Dr. Kane recommends that surgeons share patient gratitude with their other colleagues who are not frontline medical workers. He acknowledges his staff’s contributions during meetings and expresses his gratitude through written notes. He also recommends communication training for everybody on his team. Then, he shares tips for assessing organizational culture. He believes that it is most important to ask team members what they think the overarching goal of the institution is and to assess the attrition rate through exit surveys. He emphasizes that behavioral norms matter most, as department leaders often lead by example. One detrimental practice is favoritism, which Dr. Kane regards as disrespectful to other team members. Additionally, he shares his personal experiences with changing cultures at different institutions and utilizing change management theories.

Finally, Dr. Kane shares general leadership advice. He highlights the importance of creating a patient-centered environment, leading by influence rather than authority, and the power of positivity.

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Ashley Agan interview Dr. Al Merati, chief of laryngology at the University of Washington, about the changing demographics of otolaryngology trainees.

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SHOW NOTES

First, the doctors discuss the pros and cons of selecting trainees in a competitive specialty like otolaryngology. Dr. Merati also notes that applicant trends may fluctuate between years and that residency programs are becoming more diverse. He also recommends normalizing all career choices by encouraging professors to support trainees who want to practice community otolaryngology instead of becoming academic otolaryngologists. Although teaching and mentorship are highly valued within the field, he believes that trainees should not have to conceal their career aspirations in order to obtain a residency spot.

Dr. Merati then discusses the importance of considering diverse trainee experiences. He notes that many talented otolaryngology trainees had to overcome hardships, financial difficulties, and lack of medical mentorship to achieve their goals. For this reason, he questions the feasibility of unmatched students taking a research year. He believes that alternative options to a research year, such as accepting a surgical internship or exploring entrepreneurship opportunities, are equally commendable. He notes that although older generations of otolaryngologists may be cautious about nontraditional trainees, younger generations of attendings are excited to explore the potential and curiosity of non-traditional trainees.

Finally, the doctors discuss constant values in otolaryngology. Dr. Merati notes that being caring and communicative to patients and colleagues is universal across every field. He adds that it may be hard to demonstrate these values everyday because of burnout and debt. Additionally, he believes that being a trainee is more difficult than it used to be. In his opinion, current residents have to deal with the constant intrusion of work life into personal life and have a weaker perception of mastery because of the exponential growth of different surgeries and techniques.

Finally he lists the three elements he believes to be the most important steps to keep recruiting talented and passionate trainees: investing in outreach to younger students, normalizing all career paths, and including community otolaryngology in residency curriculum.

In this episode of BackTable ENT, Dr. Gopi Shah interviews Dr. Dhave Setabutr, assistant professor of otolaryngology at Thammasat University, about building a microtia repair program in Bangkok, Thailand.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/Jz2h8d

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SHOW NOTES

First, Dr. Setabutr explains his path through otolaryngology and microtia training and his motivation to move his family and practice to Thailand. Then, he explains how he transitioned from practicing in the United States to practicing in Thailand after he was notified of an opening for an English-speaking otolaryngology professor at a university hospital. He notes that pediatric otolaryngologists are scarce in Thailand, a country of 60-70 million with only 15 fellowship trained pediatric ENTs.

Next, he describes his microtia repair team, which consists of many different specialties, such as a facial plastics surgeon and audiologists. He emphasizes the importance of operating with a co-surgeon in the initial building of a microtia program. Additionally, he delineates differences in the Thai health care system that changed the way he manages his microtia patients. For example, although many of his patients have unilateral microtia, they cannot afford BAHA devices or hearing aids for the contralateral ear because the government does not provide funding for these devices. Also, there is no option to install an FM system in the classroom to amplify sounds for children with hearing deficits. Finally, he only uses rib harvest for reconstruction because it is the most cost-effective technique. Although Thailand has recently implemented universal newborn hearing screenings, many health gaps must be addressed before improving treatments of hearing loss in Thai children.

Then, Dr. Shah and Dr. Setabutr discuss tips on having the initial conversation with parents of a pediatric microtia patient. Because microtia is undetectable on ultrasound, many parents are surprised during the birth of their children. Additionally, parents may have difficulties dealing with this condition because there are no abundant parent support groups for microtia. Dr. Setabutr recommends being able to summarize information in a way parents can understand and to ease their concerns about hearing and development.

Finally, he delves into the technical aspects of microtia repair, including the grading system and surgical procedure. He usually only performs the three-stage surgery on children with grade III microtia who have enough rib cage cartilage to construct a pinna. He keeps the patients in the hospital until their shunts can be removed due to poor wound care resources in Thailand. Finally, he emphasizes the importance of gaining patient and family support before performing the repair surgery.

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The BackTable ENT Podcast is a resource for otolaryngologists to learn tips, techniques, and practical advice on all things ear, nose, and throat. Tune in to the BackTable ENT Podcast every week for candid conversations about rhinology, laryngology, otology, and head and neck surgery.

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In this episode of BackTable ENT, Dr. Soham Roy, chair of pediatric otolaryngology at Children’s Hospital Colorado, invites 2 pediatric otolaryngology chairs, Dr. Daniel Choo (Cincinnati Children’s Hospital) and Dana Thompson (Lurie Children’s Hospital), to discuss their paths to leadership and advice for effective leadership.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/oA7jQe

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SHOW NOTES

First, Dr. Choo and Dr. Thompson discuss their motivations for becoming leaders in pediatric otolaryngology. Dr. Thompson emphasizes the importance of using her voice to create impact in the medical field as a black female physician. Although Dr. Choo was a reluctant leader at first, he now sees himself as a servant leader who finds job and personal satisfaction in uplifting others.

Then, Dr. Roy questions whether leadership is innate or learned. All three doctors agree that leadership can be learned, but potential leaders have to be willing and able to assume the position. Dr. Thompson notes that she gained leadership skills from career leadership programs, her leadership coach, and her MBA. Dr. Choo notes that introverted leaders can also succeed, as leadership places great importance on individual interactions and relationships with people.

Finally, the doctors discuss how to prepare for a leadership role. Effective healthcare leaders identify gaps in healthcare delivery to their patients, know the strengths and weaknesses of their programs, have the courage to show their vulnerability to their staff members, and never forget to point out the impact that their trainees are making every day.