BackTable ENT & Allergy

Dr. Romaine Johnson tells us about The Simulation Program for open airway and foreign body training at UT Southwestern, including how he got it started, how it's being used, and what steps go into making a successful course.

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In this episode of BackTable ENT, Dr. Shah and Dr. Agan discuss simulation programs for complex pediatric airway surgery with Dr. Romaine Johnson from UT Southwestern.

First, Dr. Johnson explains his motivation to start an airway simulation program. In the past, he noticed that emergency airway obstructions were suboptimal educational experiences for his junior residents, so he wanted to create a space in which trainees could build the confidence to prevent severe laryngospasms and bronchospasms and develop familiarity with tools during airway obstruction cases.

Next, Dr. Johnson dives into the airway obstruction course details. He uses live animal simulations because it creates a more realistic situation and provides residents with the tactile sensation of removing a foreign body from tissue. Additionally, with a pig model, trainees are able to observe more audio and visual cues such as monitor statistics and skin color. In order to use live animals, he coordinates closely with anesthesiologists and veterinarians. Dr. Johnson recommends attending simulation courses at least twice a year, as repetition is the most effective method of learning procedural techniques in emergency situations. In addition to guiding residents through removing the foreign body, he encourages residents to play other roles, such as techs and anesthesiologists, to grasp a more complete understanding of the different tasks of each profession involved in airway management.

Finally, Dr. Johnson compares the use of simulations in emergency procedures and routine procedures. For emergency procedures, he emphasizes the importance of finding high-fidelity models. However, in routine procedures that educate trainees on decision making, Dr. Johnson concedes that perfect models are not necessary. He ends the episode by concluding that simulation education is not only beneficial for residents, but also for private practice physicians and academic attendings in order to keep their skills sharp.

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RESOURCES

Airway Reconstruction Surgical Dissection Manual:

https://www.pluralpublishing.com/publications/airway-reconstruction-surgical-dissection-manual

Dr. Joe Walter Kutz talks with Dr. Jed Grisel about practice patterns treating patients with hearing loss, as well as the correlation between hearing loss and cognitive decline, and how best to screen these patients.

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In this episode, otolaryngologist Dr. Jed Grisel joins neurotologist Dr. Walter Kutz to discuss the link between hearing and cognition, counseling families about treatment outcomes, and practice building opportunities for ENT/audiology clinics.

Dr. Grisel describes changing trends in the hearing care market, such as direct-to-consumer marketing and over the counter hearing aids, which can alter patients’ relationships with ENTs. He emphasizes that these low cost options make hearing care more accessible to patients. They also provide otolaryngologists with the stimulus to branch out into new service lines and position themselves as comprehensive hearing experts. His clinic has recently added cognitive screening to their diagnostic workup. Dr. Grisel highlights the advantages of cognitive screening, which include a better understanding of the patient experience, more effective management of patient and family expectations, and relationship building with primary care providers.

The doctors also talk about the implementation process of cognitive testing in ENT/audiology clinics. Dr. Grisel shares his practice’s experience with cognitive screening kiosks that minimize the requirements for patient dexterity.

As healthcare advances, more and more people are living longer and reaching ages of hearing loss onset. The doctors discuss what it means to have more years of sensory deprivation and how ENTs can offer interventions to reduce the patient’s cognitive load and improve overall cognitive function.

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RESOURCES

Texoma ENT and Allergy:

https://www.texomaentandallergy.com/

Dementia Prevention, Intervention, and Care: 2020 Report of the Lancet Commission:

https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext

We talk with Vestibular Therapist Matthew Johnston about the workup of dizziness and setting up patients for success with Vestibular Rehab.

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In this episode, physical therapist Matthew Johnston joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the process of vestibular evaluation, rehabilitation, and long-term care.

First, Matthew speaks about the importance of obtaining a thorough past medical history to identify the patient’s onset, duration, and aggravators/alleviators of dizziness. These responses help him set up a physical examination, which includes the Vestibulo-Ocular (VOR) Cancellation test, the Clinical Test of Sensory Interaction in Balance (CTSIB), and the Dix-Hallpike test. All of these diagnostic tools help him evaluate the patient’s vestibulo-ocular reflex and check for nystagmus.

Matthew distinguishes between Benign Paroxysmal Positional Vertigo (BPPV) and other conditions of vestibular hypofunction such as Meniere’s Disease and vestibular neuronitis. While the former is curable, the latter conditions are more chronic and complex, so it is important to manage patient expectations and emphasize symptom alleviation. Overall, Matthew believes that identifying the affected ear canal and specifically matching the treatment to the canal is the most efficient way to treat patients.

We close by talking about ways to improve the patient’s physical therapy experience, through prescribed anti-nausea medications, maintenance exercises done in the home, and partnership between ENTs and physical therapists.

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RESOURCES

Excel Physical Therapy: https://excelphysicaltherapy.com/

Dr. David Goldenberg talks with us about the management of thyroid nodules, including workup, imaging and patient counseling.

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In this episode, head & neck surgical oncologist Dr. David Goldenberg joins Dr. Gopi Shah and Dr. Ashley Agan to discuss diagnosis, treatment, and follow up for various types of thyroid nodules in adults.

First, Dr. Goldenberg describes his workup for thyroid nodules, which includes palpation, ultrasound, and TSH levels. He emphasizes that a thyroid ultrasound must involve the scanning of both sides of the neck in order to make comparisons between normal and abnormal findings. After evaluating the ultrasound and having open dialogue with pathologists and radiologists, his team decides if Fine Needle Aspiration (FNA) is necessary. The doctors discuss how to counsel patients when FNA yields indeterminate results. The course of further treatment and surveillance should take into account the patient’s risk tolerance, the presence/absence of compressive symptoms, and the patient’s ability to return for a later biopsy.

Dr. Goldenberg describes how the use of molecular testing is becoming more common in diagnosing thyroid cancers. Specifically, the BRAF mutation usually signifies thyroid cancer, and the TERT mutation signifies a very aggressive form of thyroid cancer.

Finally, the doctors discuss surgical decision-making between a full thyroidectomy and a partial lobectomy. Dr. Goldenberg focuses on damage to the recurrent laryngeal nerve as potential complication and emphasizes the importance of justified interventions and continual surveillance.

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RESOURCES

“Head and Neck Endocrine Surgery” by Dr. David Goldenberg:

https://www.thieme.com/books-main/otolaryngology/product/6136-head-neck-endocrine-surgery

We talk with Dr. Bradley Block, creator and host of The Physician's Guide to Doctoring Podcast, about optimizing communication to improve workflow and for better patient care.

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In this episode, Dr. Bradley Block joins Dr. Gopi Shah and Dr. Ashley Agan to discuss tips for trust building and nonverbal communication with patients.

Dr. Block starts by sharing how he facilitates introductions at the beginning of a visit. He identifies himself as the doctor, and asks the patient about their preferred name and pronouns. Then, he acknowledges the patient’s discomfort and/or pain associated with their chief complaint. These patient-centered approaches help build trust and ensure the patient’s voice is being heard.

Nonverbal communication can also build trust. Dr. Block recommends moving computers to the side to ensure that they are not impeding communication. Additionally, patients will often mirror the physician’s level of engagement. One way to show engagement is to repeat the patient's words back to them.

Finally, we discuss methods of communication with disgruntled patients. For example, asking them to verbalize their specific concerns can make them feel seen and heard. Dr. Block emphasizes that in order to be effective, communication strategies must be consistent across all providers and staff in the clinic.

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RESOURCES

Physician’s Guide to Doctoring (Dr. Block’s podcast): https://physiciansguidetodoctoring.com/

Dr. Block’s Twitter: @PhysiciansGuide

We talk with Dr. Anita Jeyakumar about her approach to Single Sided Deafness in Children, including workup, treatment and long-term care.

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In this episode, pediatric otolaryngologist Dr. Anita Jeyakumar joins Dr. Gopi Shah and Dr. Ashley Agan to discuss screening, counseling, and treatment options for single sided deafness in children.

Dr. Jeyakumar starts by outlining referral patterns for single sided deafness, which can arise from newborn or pediatric hearing screenings. When counseling families on the importance of close monitoring and early intervention, Dr. Jeyakumar believes that it is crucial to fully explain how hearing loss can affect academic success, social interactions, and general safety: When a child has retained normal hearing in one ear, their speech is usually unaffected. However, the child will likely struggle with cognitive overload and cognitive fatigue when relying solely on the hearing ear. The child can also feel overwhelmed with trying to hear in noisy social situations. As the child gets older, untreated hearing loss can also put them at risk in potentially hazardous scenarios, such as crossing busy intersections, and eventually, driving.

The doctors discuss imaging modalities such as CT and MRI. Dr. Jeyakumar prefers MRI, since it can identify hypoplastic and aplastic auditory nerves.

Finally, the doctors highlight a range of treatment options, including the use of CROS hearing aids, bone conduction hearing aids, and cochlear implantation. With all of these technologies, it is important to keep in mind the patient’s age, infection risk, cosmetic concerns, and insurance coverage. Dr. Jeyakumar emphasizes that staying in contact with the family is important, as children may need treatment adjustments due to changes in schooling and geographic location.

Join us to celebrate BackTable ENT's First Year Podiversary with co-hosts Dr. Gopi Shah and Dr. Ashley Agan! We take a look back at the year and discuss some of our favorite episodes as well as progress towards wellness since our first episode. Thank you to our amazing guests and loyal listeners!

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In this episode, our hosts Dr. Ashley Agan and Dr. Gopi Shah reflect on the first year of the BackTable ENT podcast. They highlight colleagues that have shared their expertise on a wide variety of ENT topics, noting that organic conversations have brought valuable insight to the show. Additionally, they review the results of a listener survey and use feedback to generate new ideas for future episodes.

We’d like to give a special thanks to our listeners! We love hearing your thoughts and feedback, which can be submitted through our website, https://www.backtable.com/shows/ent/ . Stay tuned for more exciting episodes!

We talk with Dr. Carrie Francis about her passion for guiding personal and professional development for physicians, trainees and students, while helping them build a strategy of authentic alignment between their career goals and purpose.

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In this episode, Dr. Carrie Francis joins Dr. Gopi Shah and Dr. Ashley Agan to discuss her philosophy of mentoring and her goal of fostering diversity and inclusion within the field of otolaryngology.

Dr. Francis begins by defining “mentoring” and “coaching,” noting that mentorship stems from specific expertise in a topic, but coaching can offer more general guidance. The roles are not mutually exclusive, and both can help learners in their career path. She emphasizes that mentors should encourage learners to set personal goals, which can be difficult in medicine, a field where milestones are often externally determined by institutions. The doctors weigh the differences between organic and assigned mentoring relationships; however, both require constant reflection and evaluation to serve the needs of both parties.

Next, Dr. Francis describes the art of giving feedback. While summative feedback is helpful at the end of a period, timely feedback helps the learner adjust their behaviors sooner. She encourages mentors to plan appropriate times and places to give feedback effectively and respectfully.

Finally, the doctors discuss diversity and inclusivity challenges in our field and ways that residency programs can capture individuals from the “leaky pipeline.” This starts with departments’ commitment to defining their values and conducting holistic evaluations of applicants.

We talk with Rhinologist Dr. Ashleigh Halderman about Revision Endoscopic Sinus Surgery, including patient selection, pre-op planning, and endoscopic technique.

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In this episode, Dr. Ashleigh Halderman joins Dr. Gopi Shah and Dr. Ashley Agan to discuss preoperative, procedural, and postoperative considerations for revision sinus surgery.

Dr. Halderman begins by describing her patient workup, which includes learning about the patient’s history with sinus problems and surgeries. It is critical to learn about the patient’s current maintenance regimen and whether it includes sinus rinses, steroids, and/or antibiotics. Dr. Halderman aims to teach patients how to maximize medical management techniques before performing a revision surgery. She discusses the steroids and antibiotics that she usually prescribes and her patient education technique for nasal rinses.

In addition, she conducts physical and endoscopic exams and obtains a preoperative CAT scan. She emphasizes that the CAT scan is important for determining the extent of the prior surgery and guiding future plans. Sometimes, the scan reveals that a patient’s symptoms are not sinus-driven (i.e. recurrent viral infections), leading her to consider options besides surgery.

Finally, the doctors discuss operative technique. Revision surgeries may be challenging due to abnormal anatomy and scarring, so Dr. Halderman advises surgeons to utilize image guidance and look for anatomical landmarks.

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RESOURCES

The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery:

https://pubmed.ncbi.nlm.nih.gov/26991922/

We talk with Dr. Carrie Nieman about improving hearing health disparities among older adults, particularly among vulnerable populations. Her practice and research focuses on an innovative, community-delivered approach to affordable, accessible hearing care.

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In this episode of BackTable ENT, Dr. Mark Williams joins Dr. Gopi Shah and Dr. Ashley Agan to discuss various diagnoses for voice problems, treatment options, and special considerations for treating singers.

Dr. Williams always begins a workup by taking a full history which includes questions about patterns in voice changes and pain. These questions help specify the type of voice change beyond the umbrella term of “hoarseness.” He describes the differences between examinations with a rigid laryngoscope, a flexible fiberoptic laryngoscope, and videostroboscopy (allows for observation of vocal fold vibration). He also performs laryngeal palpation to check for muscle tension dysphonia.

When discussing treatment, Dr. Williams speaks about the importance of getting allergies under control, to allow patients the best quality of voice possible. He prefers nasal steroid sprays over antihistamines. Dr. Williams also describes indications for microlaryngeal surgery, such as polyps and cysts. Dr. Williams notes that voice problems may have an underlying cause that is hidden by compensatory behaviors, which end up causing more issues than the original pathology. In these instances, voice therapy can help break harmful habits. Finally, by merging his experience as an otolaryngologist and a gospel singer, he shares insights on counseling singers about steroid shots, vocal hygiene, and voice rest.

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RESOURCES

Dr. Williams’ Website: https://www.drmarkwill.com/medicine/