BackTable ENT & Allergy

We talk with Dr. Mark Williams about building his solo ENT practice, taking care of recording artists in Nashville, and aligning his own music, medicine and ministry.

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In this episode of BackTable ENT, Dr. Carrie Nieman joins Dr. Gopi Shah and Dr. Ashley Agan to discuss disparities in hearing care for older adults and different care models to address these.

Dr. Nieman begins the show by sharing some striking statistics: of the 26 million older Americans who currently experience a clinically significant degree of hearing loss, only 3 million actually use hearing aids. Disparities in hearing care may arise from individual factors such as financial situation and patient education, but they can also arise from structural factors like physical distance from ENTs and audiologists.

Dr. Nieman believes that the conventional model of clinic-based hearing care can be augmented by different models of care delivery, specifically one that makes use of community health workers. She describes the HEARS (Hearing Health Equity Through Accessible Research and Solutions) Program that she developed and how her team trained older adult peer mentors to guide patients through education about over-the-counter hearing devices, communication strategies, and living with hearing loss. She emphasizes that these devices can be a gateway that leads patients to feel more comfortable with hearing aids later on.

For ENTs looking to reduce hearing care disparities, Dr. Nieman recommends that they learn how their patients want to engage with the world, provide patients with multiple options for hearing care, and collaborate with other players who are working towards the same goal.

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RESOURCES

HEARS Program: https://jhucochlearcenter.org/hears-hearing-equality-through-accessible-research-solutions.html

Access HEARS: http://accesshears.com/

Hearing Loss Association of America: https://www.hearingloss.org/

Dr. Nieman’s Twitter: @CarrieNiemanMD

We talk with Dr. Sarah Saxon about Facial Feminization Surgery, including the range of procedures, patient selection, and technique.

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In this episode, Dr. Sarah Saxon joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the variety of facial feminization surgeries and important considerations for treating transgender patients.

Dr. Saxon defines “facial feminization surgeries” as a group of procedures that are geared towards feminizing the face. She highlights the fact that feminizing a patient’s appearance often aligns with striving for a more youthful appearance. Therefore, feminizing procedures can include facelifts, skin resurfacing, and skin tightening with radiofrequency. Additionally, Dr. Saxon describes her techniques for chondrolaryngoplasty (also known as tracheal shave), mandibular contouring, and type 3 cranioplasty. She also discusses post-operative care with exosome injections at incision sites and steroids.

Throughout this episode, Dr. Saxon offers advice for providers who treat transgender patients. From a pre-operative standpoint, she advises surgeons to ensure that their patients are off of hormone therapy during the two weeks prior to surgery in order to reduce the risk of DVT. She also encourages providers to ask about patients’ preferred pronouns and avoid making assumptions about their patients. Above all, she emphasizes that providers should be open-minded and recognize that patient care is a dynamic learning process throughout their entire careers.

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RESOURCES

Dr. Saxon’s Website: https://saxonmd.com/

Dr. Saxon’s Instagram: @saxonmd, @breathe_atx, @breathe_dallas

We talk with Dr. Matthew Ryan about diagnosis and management of Allergic Rhinitis, as well as Immunotherapy as a potential treatment option.

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In this episode, Dr. Matthew Ryan joins Dr. Gopi Shah and Dr. Ashley Agan to discuss symptoms and comorbidities of allergic rhinitis, as well as current treatments such as decongestants, antihistamines, steroids, and immunotherapy.

The methods of allergy testing (prick test, intradermal test, and blood draw) are clinically interchangeable, with skin tests being the cheapest. Unfortunately, there are nuances in interpreting allergy test results, and a patient’s symptom complex may have a great deal of variability. There may not be correlation between a patient’s symptoms and their allergy test results. While an allergy test can be helpful, chronic rhinitis can be diagnosed and treated without testing.

As a first-line therapy for allergic rhinitis, Dr. Ryan will prescribe a combination of a nasal steroid spray and a nasal antihistamine spray, and then follow up with the patient to see if these help with symptom relief. The doctors also talk about treating allergic rhinitis and medication considerations in subgroups such as children and patients with nasal polyps, asthma, and hypertension.

For patients who still struggle with symptom control, the doctors discuss two types of immunotherapy, subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both have advantages and disadvantages based on available clinical data, status of FDA approval, insurance coverage, and convenience for the patient.

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RESOURCES

Central Compartment Atopic Disease: https://pubmed.ncbi.nlm.nih.gov/28716173/

We talk with Dr. David Cognetti about sialendoscopy including the importance of patient selection as well as tips and tricks for success.

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In this episode, Dr. David Cognetti joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the workup for salivary gland obstruction and inflammation, the emerging use of sialendoscopy, and different approaches to sialolithotomy.

First, the doctors highlight key aspects of physical examination: observing swelling around the glands, bimanually palpating for stones, and massaging the glands to observe the quantity and quality of saliva produced. For imaging, Dr. Cognetti typically orders CT for suspected stones and MRI for suspected inflammatory disorders. He describes the process of sialography, noting that the outcome may be technician-dependent. The doctors also discuss inflammatory cases where laboratory tests may be appropriate and can reveal autoimmune disorders.

Then, Dr. Cognetti describes his preferred sialendoscopy tools and how he uses them to cannulate and dilate the parotid and submandibular ducts during surgery. He emphasizes the fragile nature of the scopes and the need to protect them from damage. For sialolithotomy, he describes various methods of lithotripsy and ways to prevent thermal damage. He also discusses how he deals with duct perforation and how he decides whether or not to use stents.

The doctors bring up management of patient expectations throughout the episode, as outcomes may vary depending on the individual’s history of stone recurrence.

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RESOURCES

“Sonopalpation: A Novel Application of Ultrasound for Detection of Submandibular Calculi” - https://journals.sagepub.com/doi/10.1177/0194599814545736?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

“Limited Distal Sialodochotomy to Facilitate Sialendoscopy of the Submandibular Duct” - https://onlinelibrary.wiley.com/doi/full/10.1002/lary.23801

4th Annual Jefferson Sialendoscopy Course- https://cme.jefferson.edu/content/sialendoscopy2021#group-tabs-node-course-default1

We talk with Dr. Nina Shapiro about the importance of effective communication of medical information to patients, and helping them avoid bad medical advice. She is author of the book "Hype: A Doctor's Guide to Medical Myths, Exaggerated Claims, and Bad Advice - How to Tell What's Real and What's Not".

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In this episode, pediatric otolaryngologist and author Dr. Nina Shapiro joins Dr. Gopi Shah and Dr. Ashley Agan to discuss writing for non-medical audiences, addressing health misinformation, and overcoming our own physician biases.

Dr. Shapiro discusses her journey towards authorship. As her children entered school, she had begun communicating information about common ENT issues to other parents. This passion evolved into writing op-eds, blog articles, and eventually, books. Her audiences are both medical and non-medical, and she discusses the differences in writing for each type.

We talk about concepts from her newest book, “Hype,” which aims to address popular health concerns, de-bunk media myths, and encourage readers to be intelligent consumers of health information and products. We dive into “The Curse of the Original Belief,” the idea that we are biased towards seeking out new information that confirms what we already believe.

Dr. Shapiro offers guidance for physicians when they converse with patients who have been misinformed by Internet sources. Her overall strategy is to listen to patients’ fears, be patient, and follow up with them. Finally, she encourages all practitioners to keep an open mind and stay flexible, as new research can change long-standing beliefs and recommendations.

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RESOURCES

Dr. Shapiro’s website and books- http://drninashapiro.com/

Dr. Shapiro’s Instagram, Twitter, and Facebook: @DrNinaShaprio

We talk with Dr. Andrew Day about the Human Papillomavirus (HPV) and Oropharyngeal Cancers.

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In this episode, head & neck surgical oncologist Dr. Andrew Day joins Dr. Gopi Shah and Dr. Ashley Agan in discussing the screening, treatments, prevention, and current research over HPV-positive oropharyngeal cancers.

We begin by discussing the ubiquitous Human Papillomavirus (HPV) and identifying high-risk strains. While there is still a lot of research to be done over this virus, Dr. Day describes the estimated prevalence of HPV in the adult population and available screening methods. He brings up the possibility of latent infections and differences in individuals’ immunogenic responses.

Moving into HPV-mediated cancers, Dr. Day distinguishes HPV-positive from HPV-negative head & neck cancers and discusses the differences in presentation and treatment for each type. HPV-positive oropharyngeal cancers usually present as neck masses with no other clear risk factors, and they can be confirmed through ultrasound-guided fine needle aspiration biopsy. Treatment options include various combinations of transoral robotic surgery, transoral laser microsurgery, chemotherapy, and radiation.

Finally, we discuss patient education over HPV and its associated cancers. We address patient inquiries about tonsillectomy as a preventative measure, advice for partners/spouses of HPV-positive cancer patients, and otolaryngologists’ role in raising awareness of the HPV vaccine (Gardasil 9).

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RESOURCES

CDC HPV Vaccine Recommendations: https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html

We talk with Dr. Prashant Malhotra from Nationwide Children’s Hospital about Pediatric Cochlear Implants, including workup and patient selection.

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In this episode, pediatric otolaryngologist Dr. Prashant Malhotra and our hosts discuss hearing evaluations, pediatric cochlear implants, surgery considerations for patients with inner ear malformations, and patient/family education.

To start, Dr. Malhotra describes how pediatric cochlear implantation candidates present to him in terms of age and test results. He guides us through his diagnostic workup, which includes a questionnaire, physical exam, imaging, CMV IgG test, connexin test, and next-generation genetic sequencing. Dr. Malhotra also describes collaboration between otolaryngologists, audiologists, and social workers within his multidisciplinary cochlear implant center.

Next, we cover cochlear implantation in children with inner ear malformations, such as CHARGE syndrome and EVA syndrome. These cases present the challenge of abnormal cochleas and higher CSF pressure. Dr. Malhotra also discusses treatment considerations for patients with single-sided deafness and post-lingual deafness. Additionally, he discusses long-term complications of cochlear implants. Complications can include pain, vertigo, acute otitis media (OM) episodes, and meningitis.

Finally, we expand our discussion to encompass patient and family education. This last segment covers topics such as childhood vaccination awareness, benefits of early hearing screenings, management of family expectations, and tracking academic milestones in pediatric cochlear implantation patients.

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RESOURCES

American Cochlear Implant Alliance (ACIA)- https://www.acialliance.org/

General information about cochlear implants.

AG Bell- https://www.agbell.org/Families

Online resource for families seeking information about speech development and Auditory Verbal Therapy (AVT).

We talk with Laura Matrka MD and Mark Gerber MD about their approaches to airway surgery, including endoscopic vs open, tips on technique, and the importance of communication in the OR.

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In this episode, Dr. Laura Matrka and Dr. Mark Gerber join Dr. Romaine Johnson and Dr. Gopi Shah to discuss airway surgery.

The evaluation of adult and pediatric patients requiring airway surgery is outlined. Key components include a thorough flexible scope exam, direct laryngoscopy/bronchoscopy and a detailed airway history. Deciding between an endoscopic and open approach depends on several factors including airway anatomy, surgical history, acuity of the procedure, and presence of a tracheostomy.

Dr. Matrka and Dr. Gerber review essential equipment for airway surgery - their “airway toolbox” – which can include a subglottic scope, bronchoscope, tracheoscope, or a drill depending on the extent of their procedure. The discussion then turns towards the selection of suture between PDS and Prolene. Dr. Johnson states that he has had less wound dehiscence, but more granulation tissue when using PDS as compared to Prolene.

Lastly, the panel describes technological improvements they would like to see in the coming years. All agree that new approaches to visualize what trainees are observing would significantly improve education and patient care. The panel concludes by discussing the importance of communication in the operating room, and the benefit of protocols in facilitating effective teamwork.

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RESOURCES

American Society of Pediatric Otolaryngology: https://aspo.us

Communication Protocol for Airway Surgery from Dr. Matrka and colleagues: https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.28271

We talk with Steven Goudy MD, MBA about his clinical practice and research emphasis on cleft palate care in children at Emory Healthcare, as well as some tips on trying projects/adventures outside of clinical medicine.

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In this episode, pediatric otolaryngologist Dr. Steven Goudy joins Dr. Gopi Shah and Dr. Ashley Agan to discuss diagnosis, treatment, follow-up care, and family education for children with cleft lips and cleft palates.

To start, we define cleft lip and cleft palate based on abnormalities in fetal developments. Then, we cover the timeline for identification and treatment of these conditions. Dr. Goudy emphasizes that cleft lip and cleft palate can have a large effect on basic needs such as feeding. While cleft lip repair can be performed early, it is best to wait until the 1-year mark for cleft palate repair. We discuss treatment of different variations of these conditions, including incomplete and bilateral cleft lips. As we move into post-surgical care, we cover Eustachian tube dysfunctions and post-surgical hearing screenings. Dr. Goudy also discusses co-morbid issues and the process of counseling families through genetic testing.

Dr. Goudy highlights the importance of multidisciplinary care. Within his cleft clinic, the surgeons work with audiologists, speech pathologists, geneticists, dentists, and social workers. He discusses barriers to care for patients who live in rural areas and how his team works to overcome them.

Finally, Dr. Goudy describes his own adventure in medicine, which extends beyond treating cleft lip and cleft palate. As he shares how he got started in translational research, he gives tips for assembling a research team and finding good mentors. He also explains how he addresses common parent concerns by starting a pediatric nasal suction device company, Dr. Noze Best.

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RESOURCES

American Cleft Palate Association- https://acpa-cpf.org/

Babies Can’t Wait- https://dph.georgia.gov/babies-cant-wait

Georgia’s early intervention program that offers a variety of coordinated services for infants and toddlers with special needs.

Dr. Noze Best- https://www.drnozebest.com/

Dr. Adam Luginbuhl from Thomas Jefferson University Hospitals gives us the 101 on Immunotherapy as a treatment option for Head and Neck Cancer.

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In this episode, Dr. Adam Luginbuhl joins Dr. Gopi Shah and Dr. Ashley Agan to discuss immunotherapy for treatment of head and neck cancer.

Dr. Luginbuhl describes the basics of cancer immunotherapy which aims to harness the body’s intrinsic immune system to target cancer cells. He provides an overview of the main checkpoint inhibitors (CTLA-4, PD-1, PDL-1) and their mechanisms of action. He also highlights new research developments aimed at exploring the role of immunotherapy as a neoadjuvant prior to surgery.

He then discusses the challenges in recruiting for clinical trials whereby he must find the balance between offering promising new treatments with limited evidence and traditional therapies. He states that the main contraindication and side-effect of immunotherapy is auto-immunity.

He emphasizes that the journey with head and neck cancer does not end after treatment. Since the head and neck region is vital to our interactions with the world – our appearance, our voice, our ability to eat and drink – he states that treatment should not only be focused on clearing cancer, but also maintaining patient quality-of-life.

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RESOURCES

Review Articles: Immunotherapy for Head and Neck Cancer:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586169/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749717/

National Cancer Databases:

National Comprehensive Cancer Network: https://www.nccn.org

American Head and Neck Society: https://www.ahns.info

National Cancer Institute: https://www.cancer.gov