BackTable ENT & Allergy

In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Walter Kutz talk with Dr. Michael Seidman, an AdventHealth neurotologist with a unique interest in complementary and integrative medicine (CIM), about his holistic health approach to treating ENT-related disorders and his supplement company, PEAK 365 Nutrition.

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In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Walter Kutz talk with Dr. Michael Seidman, an AdventHealth neurotologist with a unique interest in complementary and integrative medicine (CIM), about his holistic health approach to treating ENT-related disorders and his supplement company, PEAK 365 Nutrition.

First, Dr. Seidman explains his background in CIM. While attending the University of Michigan for his undergraduate studies, he majored in nutrition at the school of public health and human nutrition. Additionally, when he played professional racquetball, he was introduced to the use of nutritional supplements and the importance of a balanced diet. Since then, he has secured multiple million dollar donations to establish the first center for integrative medicine.

Next, Dr. Seidman explains the CIM philosophy. He believes that conventional medicine and medications are good at resolving the “quick-fix” issues, but a more holistic CIM approach can help patients effectively manage their chronic diseases. Although getting patients to change their unhealthy behaviors can cut healthcare costs in half, he believes that the patients must want to change these behaviors themselves. Dr. Seidman discusses the efficacy of automatic pattern interruption, where the physician helps the patient identify and eliminate triggers of unhealthy behaviors. He notes that diet, exercise, meditation, rest, and optimistic outlook are important pillars of CIM.

Then, Dr. Seidman delves into how CIM can help manage ENT-specific disorders. For Menniere’s disease, he recommends restricting salt and caffeine intake as well as a diuretic, if necessary. He also prescribes his Menniere’s patients 24 mg of betahistine a day, taken three times in 8 mg capsules. He notes that hearing loss can be stalled or reversed by red wine extract, but this has only been proven to work in mice. Finally, he recommends a ginkgo supplement for tinnitus. However, he warns listeners that not all ginkgo is the same quality, and that patients should look for the product in knowledgeable supplement stores, not drug stores.

Finally, Dr. Seidman discusses his motivation for starting his own monthly supplement company, PEAK 365 Nutrition, and the health benefits his supplements provide. Additionally, he encourages doctors to explore referring their patients to licensed and quality acupuncturists, chiropractors, and hypnotists.

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RESOURCES

Dr. Seidman’s Youtube Channel:

https://www.youtube.com/channel/UChWOA4mPaq4Pa0Mi4jv2n3w

Peak 365 website:

​​https://peak365nutrition.com/

In this episode, Drs. Aaron Fritts and Eric Gantwerker interview Dr. Tamir Wolf, a trauma surgeon and founder of Theator, an artificial intelligence company that links intraoperative decision making with patient outcomes.

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Dr. Wolf describes how his experience as a trauma surgeon with the Navy SEALs shaped his perspective on high acuity situations and surgical guidance. He realized that augmented decision making in trauma settings could help him and others perform better. Additionally, he had experiences with seeing family and coworkers undergoing the same procedure, but with drastically different outcomes due to variability in surgery and clinical management. With these ideas in mind, he started Theator. The company offers a software that seamlessly integrates into existing operating room video technology in minimally invasive robotic and laparoscopic procedures. The technology captures data over decision points and key milestones that have eventual impacts on patient outcomes. The data is then analyzed to find patterns and translated to best practices.

Dr. Wolf hopes that this aggregate of video data from multiple surgeons and institutions can provide evidence-based training for surgeons to operate at a safer level. Dr. Wolf emphasizes that Theator’s overall mission is to increase transparency in the operating room and break out of the traditional surgical apprentice training model. Ideally, trainees who are preparing for surgeries could draw on the experiences of thousands of surgeons in different places. Additionally, hospitals could gain information about their internal processes and address inefficiencies and safety gaps.

We discuss challenges in implementation, such as surgeons’ reluctance to be recorded, competition within the artificial intelligence space, and limitations for implementation in fluoroscopic imaging. Dr. Wolf also outlines Theator’s trajectory and the single most important factor to its success— the company culture. He emphasizes the need to hire competent and trustworthy people who can innovate and self-direct.

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RESOURCES

Theator:

https://theator.io/

Dr. Tamir Wolf LinkedIn:

https://www.linkedin.com/in/tamirwolf

OR Black Box & Trauma Black Box:

https://www.surgicalsafety.com/

Disparities in Access to High-Volume Surgeons Within High-Volume Hospitals for Hysterectomy:

https://journals.lww.com/greenjournal/Abstract/2021/08000/Disparities_in_Access_to_High_Volume_Surgeons.7.aspx

No Rules Rules: Netflix and the Culture of Reinvention: https://www.amazon.com/No-Rules-Netflix-Culture-Reinvention/dp/1984877860

BackTable Innovation Ep. 7: Improving Access to Stroke Care Using AI with Dr. Chris Mansi: https://www.backtable.com/shows/innovation/podcasts/7/vizai-improving-access-to-stroke-care-using-ai

In this episode of BackTable ENT, Dr. Shah and Dr. Agan discuss the role of lifestyle medicine and non-pharmacological therapy in otolaryngology with Dr. Jessica Lee, a general ENT who is certified in lifestyle medicine.

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First, Dr. Lee explains the philosophy behind lifestyle medicine. The purpose of the field is to treat and/or reverse chronic ailments using basic pillars, such as plant based nutrition, quality sleep, emotional connections, avoidance of risky substances, adequate physical activity, etc. Certification in lifestyle medicine is open to all board-certified physicians. Dr. Lee underwent 1.5 years of preparation, which included 30 hours of CME courses online and 10 hours of in person CME. At the end of her program, she was required to pass a board certification exam. Her initial motivation for obtaining her lifestyle medicine certification stemmed from a realization that many ENT concerns were a result of systemic chronic diseases. Dr. Lee views her lifestyle medicine approach as a partnership between her, her patient, and their PCP. Before she offers lifestyle medicine counseling separate from ENT counseling, she always ensures that the patient is open to pursuing this approach.

Next, the doctors discuss diet, the most evidence-based pillar of lifestyle medicine. In this field of medicine, the best diet is plant-based. Dr. Lee notes that a “plant-based” diet does not mean vegetarian or vegan, but instead just a plant-heavy diet. Additionally, she recommends reducing alcohol use and starting a low histamine diet for patients with chronic inflammation. However, she emphasizes to always set an endpoint to restrictive diets in order to effectively find a good threshold for the patient. For laryngopharyngeal reflux, she recommends eliminating nighttime ice cream snacks and alcoholic beverages.

Then, the doctors discuss effective approaches to smoking cessation. Dr. Lee emphasizes the importance of discussing support systems with patients wanting to quit smoking. Additionally, she agrees that the most effective smoking cessation therapy is a combination of nicotine replacement and group counseling. Although the effects of marijuana and vaping as substitutes for cigarettes are not widely studied, Dr. Lee notes that marijuana can be an irritant and vaping can cause lung injury.

Another pillar of lifestyle medicine is emotional health. Through cognitive behavior therapy, she has been able to mitigate her patients’ symptoms of tinnitus and globus pharyngeus. Additionally, she does not prescribe medications for anxiety or depression, as research has shown that daily physical activity is equivalent to daily medications for mild to moderate depression. Regarding adequate sleep, Dr. Lee warns doctors not to correlate the number of hours the patient spends in bed with the number of hours they spend asleep. She acknowledges that health tracker devices can be helpful for tracking sleep hours and dysfunction. Finally, she advises doctors who are interested in lifestyle medicine to refer their patients to specialists who share the same philosophy for consistent continuation of care.

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RESOURCES

Oto Tinnitus Management App:

https://www.joinoto.com/

In this special crossover BackTable episode, Dr. Aaron Fritts and Dr. Julie Wei talk with Dr. Gerry Mattia, Chiropractor and Director of Rehabilitation of ViscoGen Clinic in Orlando, Florida.

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SHOW NOTES

First, Dr. Mattia recounts his journey to becoming a chiropractor, beginning with his medical history of aortic stenosis fixed by a chiropractor, his decision to enter chiropractic school, and starting his independent practice after graduation. Then, he explains how he deals with patients presenting with degenerative disc disease with spinal stenosis, which was the issue he resolved in Dr. Wei. A herniated disc is the most common cause of degenerative disc disease. The standard chiropractic treatment is cervical decompression to help the disc restore itself. Dr. Mattia also uses a level 4 laser to rehydrate the disc. For optimal results, he recommends that patients see him 4 times a week for 6 to 8 weeks in order to fully lift the pressure off of the brachial plexus. He notes that good chiropractors will use the correct formulas and appropriate technology while adjusting the patient gently.

Next, the doctors delve into why many physicians are wary of chiropractors, which is rooted in a 1988 legal case that prohibited doctors from referring their patients to chiropractors. Dr. Mattia encourages physicians to seek therapy before medical issues develop into very severe conditions. Additionally, Dr. Wei notes that medical culture often encourages physicians to put the health of their patients before theirs.

Then, Dr. Mattia discusses how younger people and surgeons can improve their neck health. He notes that excessive cell phone use can reverse the cervical curve, causing people to lose their normal lordotic curve, a structure which usually prevents compression. He also recommends strengthening the muscles in the neck and shoulders, sleeping with a cervical pillow, and going to a good chiropractor to get routine adjustments. Dr. Wei recommends avoiding slouching and adjusting screens to eye-level in OR. Both Dr. Wei and Dr. Mattia agree that maintaining a healthy body weight will have positive benefits on spinal health.

Finally, Dr. Mattia recommends which qualities to focus on when finding a good chiropractor. He recommends looking for an experienced, passionate family practice chiropractor. As a word of caution, he warns listeners to never let a chiropractor adjust them without reviewing their X-ray imaging first.

In this episode of BackTable ENT, Dr. Agan and Dr. Shah discuss nasal valve collapse and repair with Dr. Moustafa Mourad, a New York City-based facial plastic and reconstructive surgeon.

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SHOW NOTES

First, Dr. Mourad delineates how he evaluates patients presenting with possible nasal valve collapse. There are two sets of nasal valves, an internal set and an external set. The tell tale signs of nasal valve collapse is dynamic nasal airway obstruction, a situation in which airflow is affected by deep breathing or structural rearrangement by the patient is required to breathe more easily. Internal nasal valve collapse patients usually find relief with structural rearrangements, such as blowing up their cheeks in order to breathe or using nasal strips. External nasal valve collapse patients find difficulty in breathing while exercising. Diagnosis of nasal valve collapse can also be complicated because many breathing problems are multifactorial. Therefore, otolaryngologists must be thorough in their initial evaluations and choose which causes to prioritize.

Dr. Mourad also explains risk factors for nasal valve collapse. Because nasal cartilage grows weaker overtime, older patients are more likely to experience valve collapse. Younger patients presenting with valve collapse will most likely have had previous nasal surgeries, such as septoplasties and rhinoplasties. Other risk factors for valve collapse include trauma of the nasal tip or dorsum, avid athletes, and the Caucasian ethnicity (because of thinner and more cephalically oriented nasal cartilages).

Next, Dr. Mourad discusses how he conducts the physical exam. He always scopes patients to look for abnormal anatomy or signs of allergies. Then, he has the patient breath while observing each of their nostrils. He observes the nostrils before and after the administration of decongestant. If the patient has a very good response to the decongestant, he starts to investigate for evidence of allergies, turbinate hypertrophy, and irritation–all of which can be treated by medical therapy. Then, he observes the patient breathing and nasal pinching as he lifts up the nasal tip and performs a caudal maneuver on the patient’s nose. Finally, he takes photos and maps out the patient’s internal and external anatomy. Dr. Mourad only considers surgical repair if the patient’s complaint can be traced back to an anatomical abnormality.

Then, Dr. Mourad walks through his surgical technique for nasal valve collapse. For an internal valve repair, he uses a simple endonasal approach. However, whether he uses an open or closed approach for an external nasal valve repair depends on the type of cartilage defect. As external valve repairs have aesthetic impacts, it is important to warn patients about changes in appearance beforehand. Additionally, Dr. Mourad prefers to obtain his implanted cartilage graft directly from the patient’s rib, as cadaver rib may warp and ear cartilage may not be strong enough. He uses a taper needle to suture spreader graft because it allows him to be more gentle with the cartilage. He does not typically recommend synthetic nasal implants to patients, as they can become infected, but still educates patients about all their options. For anesthetic, he mixes a solution of lidocaine with epinephrine and tranexamic acid to reduce post-operative swelling.

Finally, Dr. Mourad discusses his post-operative care regimen for nasal valve surgery.

In this episode of BackTable ENT, Dr. Varun Varadarajan and Dr. Gopi Shah discuss their personal advice and stories of navigating the challenges of a dual physician household with Dr. Bill Collins, chief of Pediatric Otolaryngology at the University of Florida College of Medicine.

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SHOW NOTES

In this episode of BackTable ENT, Dr. Varun Varadarajan and Dr. Gopi Shah discuss their personal advice and stories of navigating the challenges of a dual physician household with Dr. Bill Collins, chief of Pediatric Otolaryngology at the University of Florida College of Medicine.

First, the doctors discuss the considerations involved in deciding to participate in the couples match. They agree that it is best to keep larger cities with multiple programs in mind when forming a rank list but note that the match can also be complicated if one partner is choosing to pursue a more competitive specialty. Additionally, although staying together would be ideal, couples might not have another choice besides engaging in a long-distance relationship during residency and fellowship. Dr. Collins highlights the importance of finding program directors and other mentors who can help to maintain value in relationships during training. During residency applications and beyond, he emphasizes that communication, honesty, and compromise are key to sustaining a strong relationship.

Next, they discuss raising children in dual physician households. All three doctors agree that there is no “perfect” time to have children because it depends on the circumstances and preferences of every couple. If a couple wanted to have a child during both of their residencies, they would also have to consider the long uncontrollable hours of residency as well as the need for extensive child care. Additionally, Dr. Collins emphasizes that physician schedules will remain busy, even after residency, so it is important to schedule concrete family time sooner than later. Dr. Shah mentions the difficulty surgeons have with separating work from home and Dr. Varadarajan encourages them to devote quality time to their kids before getting on their phones to answer emails and finish notes.

Lastly, the doctors consider scenarios in which one partner is seeking a job change. Although being further along in their careers and having older children may complicate the job search and moving demands, all three doctors agree that decisions should be made for the overall good of the family. Thus, all factors and possibilities should be considered and discussed. Finally, Dr. Shah emphasizes the importance of having discussions about family planning with medical residents and medical students in order to open channels for advice and mentorship.

In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Gopi Shah discuss the complications of ear tubes and differences in adult and pediatric ear tube management.

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In this episode of BackTable ENT, Dr. Walter Kutz interviews otologist Dr. Hamid Djalilian about the link between the hearing/vestibular disorders and migraines.

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Theresa Richard, SLP educates us on the best approach to evaluating the adult patient with swallowing difficulty, including the importance and challenges of obtaining high quality assessments, and recommendations for therapy.

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DI4MDs

Protect your most valuable asset, the skill and ability to practice your medical specialty. Be prepared by establishing a specialty specific disability insurance policy from the experts at DI4MDs. Contact them today at www.Di4MDS.com or call 888-934-4637.

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In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, and Theresa Richard, a board-certified speech language specialist (SLP) in swallowing and swallowing disorders, about diagnosing and managing adult dysphagia.

First, Richard speaks about starting Mobile Dysphagia Diagnostics, a company that provides mobile FEES studies, her experience with having a son with a swallowing disorder, and her recent career shift towards providing speech-language education for her colleagues. Then, she discusses the two primary swallowing imaging studies: the modified barium study (MBS) and fiberoptic endoscopic evaluation of swallowing (FEES). MBS, also known as video fluoroscopy, was traditionally the gold standard for swallowing imagery. It is the superior imaging technique for detecting esophageal issues and provides a better understanding of the oral phase of swallowing. Richard prefers to use FEES first because it provides a live picture of laryngeal and pharyngeal structures. It is useful in patients with secretion issues and post-head and neck cancer surgery patients. Mobile FEES is also an option, which involves an endoscope with recording capabilities and a laptop.

Next, Richard discusses how to work up a patient with dysphagia. She starts with taking a thorough history and asks the patient about their dietary routine, and their medical and surgical history. Common medications that may cause dysphagia are muscle relaxants, L-DOPA, and medications that can cause dry mouth, such as scopolamine patches. Next, she discusses eating habits, with special considerations for cultural practices, age, and disability status. She notes that functional swallowing can look different for individual patients. Patients who repetitively aspirate may have recurrent pneumonia and require further evaluation. The first basic test she performs is watching her patients swallow 3 ounces of water. If they cannot swallow the three ounces, she moves to imaging studies. If they can swallow the three ounces, she escalates the test and starts to give the patients thicker liquids and different food types.

Some patients with dysphagia may require special considerations, such as ICU patients, patients with nasogastric (NG) tubes, and head and neck cancer patients.

Finally, Richard discusses how ENTs can help SLPs by providing a solid case history and being available for communication throughout the patient’s therapy. She also discusses a new type of therapy, adult neuromuscular stimulation, but notes that the parameters may be dangerous and not FDA approved.

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RESOURCES

“So You’re Having Trouble Swallowing” by Theresa Richard

https://theresarichard.com/so-youre-having-trouble-swallowing/

Theresa Richard Blog

https://theresarichard.com/blog/

Swallow Your Pride Podcast

https://podcast.theresarichard.com/

We talk with Dr. Julie Wei about what it means to connect with a mentor, the challenges of finding the right fit, and how mentoring relationships will grow and change throughout our career and undoubtedly contribute to overall wellness.

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In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, and Dr. Julie Wei discuss the benefits and evolution of mentorship in the medical field.

First, Dr. Wei shares her personal definition of mentorship. Traditionally, mentorship involves a dyad: one junior and one senior partner with the knowledge. However, she challenges this dynamic by broadening the definition of mentorship by coining the term “co-mentorship”, a term that encompasses the mentor’s ability to learn from the mentee and the experience of reflecting as well. The doctors also discuss the challenges of finding mentors after training, since the natural hierarchy of academic medicine is not present. Dr. Wei encourages ENTs to attend society meetings and seek multidisciplinary mentors and mentees in different fields. She mentions that she has served as a mentor for respiratory techs and nurses as well.

Next, the doctors explore the idea of work-life balance. Dr. Wei disagrees with the consistent compartmentalization of career and personal wellness and prefers to advocate for and use the term “work-life integration” instead. She also recommends unconventional meeting platforms, such as Zoom, phone calls, and “walking meetings” in order to build relationships. Peer support groups can also be helpful, but the optimal size of the group may depend on the issue being discussed. Additionally, Dr. Wei observes that more female physicians today are able to share their struggles and vulnerabilities openly with their trainees and patients, thus building stronger relationships. She also talks about the importance of allies and notes that mentors and mentees do not have to have all of the same shared experiences–both can still be sources of insight and wisdom for each other.

Finally, the three doctors reflect on their personal experiences with mentorship and executive coaching.

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RESOURCES

“Leadership, Engagement, and Well Being” by Julie Wei

https://www.enttoday.org/article/leadership-engagement-and-well-being/3/?singlepage=1

A Healthier Wei

https://www.drjuliewei.com/pages/a-healthier-wei

Acid Reflux in Children

https://www.drjuliewei.com/pages/acid-reflux-in-children#:~:text=Acid%20Reflux%20in%20Children%3A%20A,Julie%20Wei&text=CONGESTION%2C%20COUGH%20%2B%20CROUP-,Co%2Dauthored%20by%20Dr.,symptoms%20this%20condition%20can%20create.