BackTable ENT & Allergy

Dr. Scott Fortune talks with us about how he built an Office Based Rhinology practice (now a Center of Excellence), including a how-to on safely performing procedures in the office.

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In this episode, Dr. Scott Fortune joins Dr. Gopi Shah and Dr. Ashley Agan to discuss office-based rhinology procedures.

Dr. Fortune provides an overview of the procedures he performs in the office setting. He outlines the pre-procedure evaluation of patients including the use of validated clinical questionnaires (i.e. SNOT, NOSE scores etc..), a thorough history and physical exam, and necessary imaging studies. Once a full workup has been completed, the severity of disease is assessed as in-office procedures are tailored towards mild- to moderate-severity disease.

Dr. Fortune emphasizes that proper anesthesia is the most important factor in ensuring a successful in-office procedure. He goes into depth on the pre-, intra-, and post-operative anesthesia considerations for different procedures and patient comorbidities and reviews his own anesthesia protocol.

Lastly, Dr. Fortune discusses the logistical factors including equipment, procedure room set-up, staff training, and scheduling. He also describes the peer-to-peer training opportunities that he provides at his practice for other physicians interested in learning about in-office procedures.

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RESOURCES

Dr. Fortune’s Email Address: [email protected]

Dr. Fortune’s Twitter Handle: @DrScottFortune

Website: https://www.myallergyent.com

American Academy of Otolaryngology Head and Neck Surgery FLEX Curriculum:

https://www.entnet.org/content/flex

We chat with Dr. Brandon Isaacson and Dr. Alejandro Rivas on the topic of Endoscopic Ear Surgery, including tips and tricks for success, as well as pitfalls to avoid.

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In this episode, Dr. Alejandro Rivas and Dr. Brandon Isaacson join Dr. Gopi Shah and Dr. Ashley Agan to discuss endoscopic ear surgery.

Dr. Rivas and Dr. Isaacson describe the evolution of endoscopic ear surgery and its adoption in the United States. They emphasize the utility of the endoscopic approach for visualization of the middle ear.

They then delve into indications and anatomic considerations when selecting the endoscopic approach. Dr. Isaacson states that for most diseases limited to the middle ear, he uses the endoscopic approach. For extensive mastoid disease, aggressive cholesteatomas, or skull base disorders, he prefers the microscope. Dr. Rivas touches upon his guidelines for selecting his approach for cholesteatomas and notes that the presence of ossicular or lateral canal erosion or an ossified mastoid typically preclude his use of the endoscope. He then highlights the benefit of the endoscopic approach in congenital, pediatric, and revision procedures. The advantages of both the endoscopic and microscopic approaches are also considered.

The discussion then focuses on optimal pre-operative and anesthesia set up to limit bleeding in endoscopic ear surgery. Lastly, the role of using endoscopes for a thorough ear exam is emphasized.

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RESOURCES

Dr. Rivas Twitter Handle: @Alejorivasc

Dr. Isaacson’s YouTube Channel: https://www.youtube.com/channel/UC43ovy9FzRT9OtBF2tUDjsg

International Working Group of Endoscopic Ear Surgery:

https://iwgees.org

Online Dissecting Course from Sydney:

https://sydneyearendoscopy.com/free-online-dissection-guide/

Dr. Isaacson and colleague’s work on endoscopic ear surgery outcomes in pediatric ossiculoplasty:

https://onlinelibrary.wiley.com/doi/10.1002/lary.28526

We talk with Dr. Rachel St. John and Dr. Walter Kutz about Congenital Hearing Loss including causes, available treatments, and counseling.

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In this episode, Dr. Rachel St. John and Dr. Walter Kutz join hosts Dr. Ashley Agan and Dr. Gopi Shah to discuss congenital hearing loss.

Dr. St. John and Dr. Kutz outline the newborn hearing screening process and describe the benefits of both the traditional otoacoustic emission (OAE) test and auditory brainstem response (ABR) test for different conditions. They emphasize the importance of imaging in patients with late-onset and/or asymmetric hearing loss. The factors that influence the selection of imaging modality are also discussed.

Next, the diagnosis and management of hearing loss in children with auditory neuropathy, cytomegalovirus, and meningitis are reviewed. The potential role of cochlear implantation (CI) in each of these conditions is highlighted. Dr. St. John and Dr. Kutz emphasize that the journey following CI varies for each child, and that it often takes time to reap the benefits of the procedure. Lastly, Dr. St. John stresses the importance of early language exposure – through multiple mediums – to ensure that children do not miss out on crucial early brain development.

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RESOURCES

Dr. Walter Kutz’s Twitter Handle: @EarDoc1

UT Southwestern Cytomegalovirus Screening Study (CHIMES Study):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5260148/

We speak with Dr. Jacob Hunter about Adult Cochlear Implantation, including patient workup and counseling, surgical tips and tricks, and post procedure followup.

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In this episode, Dr. Jacob Hunter joins hosts Dr. Ashley Agan and Dr. Gopi Shah to discuss cochlear implantation in adults.

Dr. Hunter outlines the indications for cochlear implantation and walks us through the evaluation process to assess candidacy in adults. He emphasizes the importance of patient counseling in setting expectations for post-implantation hearing. He also describes routine preoperative imaging weighing the relative strengths of CT vs MRI.

The discussion then delves into the nuances of cochlear implant devices focusing on factors such as electrode length, stiffness, and shape as well as hearing aid compatibility. The major surgical approaches are then reviewed along with potential surgical complications. Lastly, the disparities in access to cochlear implantation and hearing care in adults are highlighted.

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RESOURCES

Disparities in Cochlear Implantation:

Dr. Hunter and Colleagues at UT Southwestern:

https://journals.sagepub.com/doi/abs/10.1177/0003489419888232

Dr. Samy and Colleagues at University of Cincinnati:

https://journals.lww.com/co-otolaryngology/Abstract/2017/10000/Closing_the_gap_in_cochlear_implant_access_for.7.aspx

Disparities in Hearing Care:

Dr. Carrie Nieman and Colleagues at Johns Hopkins:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363549/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881797/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4826391/

The video version of this Podcast has closed captions on YouTube:

https://youtu.be/3IHUMhH9x0E

Dr. Romaine Johnson from Children's Health in Dallas, TX brings together an all-star panel of pediatric ENT's to discuss the importance of continuous improvement of Quality and Safety in Pediatric ENT. Guests include Dr. Soham Roy, Dr. Jennifer Lavin and Dr. Jonathan Ida.

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In this episode, Dr. Soham Roy, Dr. Jennifer Lavin, and Dr. Jonathan Ida join hosts Dr. Romaine Johnson and Dr. Gopi Shah to discuss quality improvement (QI) and safety in pediatric ENT.

Dr. Roy emphasizes the importance of transforming quality metrics data into personalized stories to help convey the significance of QI efforts. The panel discusses best practices including a focus on understanding the nuances of a problem prior to identifying solutions, implementing solutions in a manner in which deviations are made more difficult, and maintaining a commitment to continual QI which is a cyclical process with no defined endpoint.

The discussion then evolves to highlight the impact of the COVID pandemic on QI efforts, the urgency with which protocols were developed in its immediate aftermath, as well as looking towards the impact of the pandemic on future care delivery. The panel delves into the ongoing need for studies to explore the gaps in knowledge which are often identified in clinical consensus statements. They conclude by providing advice on how to align QI efforts with broader institutional goals.

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RESOURCES

Tracheostomy During COVID-19 Pandemic:

https://journals.sagepub.com/doi/full/10.1177/0194599820961985

American Academic of Otolaryngology-Head and Neck Surgery Patient Safety and Quality Improvement Committee Report:

https://bulletin.entnet.org/article/committee-report-psqi/

We speak with Dr. Patricia Loftus from UCSF Otolaryngology - Head & Neck Surgery discussing her clinical and surgical approach to treating Nasal Polyps.

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In this episode, Dr. Patricia Loftus joins Dr. Gopi Shah and Dr. Ashley Agan to outline the diagnosis and management of patients with nasal polyps. They identify common presenting symptoms and physical exam findings as well as discuss the roles of imaging, culture, and biopsy.

Medical management including the risks and benefits of antibiotics and oral steroids are reviewed. Endoscopic surgical approaches and their utility in different clinical presentations are described. Pre-, peri- and post-operative considerations are also discussed.

The discussion then evolves to focus on conditions that clinicians should be aware of including allergic fungal sinusitis (AFS), cystic fibrosis (CF), primary ciliary dyskinesia (PCD), and central compartment atopic disease (CCAD). Finally, they highlight recent developments in management including the role of biologic therapies such as Dupixent.

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RESOURCES

Dr. Loftus’ Email Address: [email protected]

Women in Rhinology Twitter Handle: @Women_Rhinology

Women in Rhinology Instagram: @women_in_rhinology

Biologics for Nasal Polyps: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013513.pub2/full

We talk to Dr. Dana Crosby about early career leadership insight.

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In this episode, Dr. Dana Crosby joins hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss leadership in Otolaryngology and how to navigate and build a program from the ground up.

Dr. Crosby describes her initial experiences post-Rhinology fellowship starting to build up a small Otolaryngology division into a department as a co-Chair. She discusses the importance of identifying good mentors and resilience in starting out. She continues to speak to the importance of navigating through the best interests of both all the faculty involved as well as the department. Additionally, the importance of reading and constantly learning from books and other resources as such is vital to complement the experiential learning.

Dr. Crosby continues to talk about different leadership styles and how they complement each other. She describes a style of allowing everyone to have input, while being aware that certain situations call for quick decision making. She also mentions how best to manage disagreements through open discussion and compromise. Dr. Crosby closes out by discussing the implementation of leadership curriculums in training at all different levels. Although residency is incredibly busy, dedicated leadership skill discussions may be beneficial. Lastly, she ends with the key points about being yourself, leading by example, and being open to new opportunities and learning from each one.

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RESOURCES

Dr. Crosby’s Email: [email protected]

Leadership Books: Good to Great, James Collins

We talk to Dr. Cherie-Ann Nathan about her pathway to Chair of Otolaryngology Head & Neck Surgery at LSU Shreveport, inspiration and challenges along the way, and making the most of opportunities in building a successful career.

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In this episode, Dr. Cherie-Ann Nathan joins hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss career inspiration and learning to thrive with an inspiring attitude.

Dr. Nathan describes her initial journey into Head and Neck Cancer through inspirations she had as a child growing up in Mumbai and going to medical school, through her research at Johns Hopkins in Head and Neck Cancer, followed by residency at UCSD and current chair of Otolaryngology at LSU-Shreveport. She describes the importance of being able to balance your professional life and with your personal life and using that to guide career decisions. She then discusses how her interest in Head and Neck Cancer, inspired when she was younger, spurred her dedicated research undertakings and progress at LSU-Shreveport, funded by the National Cancer Institute and the NIH.

Dr. Nathan continues to speak about job satisfaction and being able to balance saying yes to opportunities but knowing when to say no; balance is key though hard to attain at times. She then continues to stress the importance of intentionality and dedication to research early on in careers and navigating the world of academic research, including mentorship, grants, and networking. Additionally, being open to network with different institutions and resilience in the setting of rejection in research, with learning and persistence, is vital to a successful research career.

Dr. Nathan rounds up the discussion in speaking about her experience as a woman in Otolaryngology, becoming a Chairwoman, and the various challenges that come with leadership positions, noting the progress that women in Otolaryngology have made with and will continue to. She ends by stressing the importance of consistent hard work and to start early, and in loving what you do, the motivation to do so is endless.

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RESOURCES

Dr. Nathan’s Email: [email protected]

We talk with Dr. Rachel St. John from Children's Health about the importance of early language access and collaborative care for children who are deaf or hard of hearing.

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In this episode, Dr. Rachel St. John joins our hosts Dr. Ashley Agan and Dr. Gopi Shah to speak about different aspects of care for Deaf and Hard of Hearing children, from counseling to medical treatment.

Dr. St. John first speaks about what a comprehensive evaluation of a deaf child entails; from counseling the patient and their families, to educating families about current and future management, and rounding it off with the importance and effectiveness of collaborating with a multidisciplinary approach. She continues to talk specifics in terms of work-up regarding labs, imaging, and the possibility of genetic testing. A key aspect of this decision making is in speaking with families and understanding what their priorities and goals are and working as a team to set realistic ones.

The discussion continues while touching on specific causes of pediatric hearing loss, including Enlarged Vestibular Aqueduct among others, and the management and treatment thereof. Dr. St. John also speaks about counseling the patient as well and taking into account their age and giving guidance to setting realistic expectations, both in their school and home life.

Lastly, Dr. St. John discusses the importance of early language intervention and stresses the importance of introducing some aspect of language into the child’s development as early as possible, regardless of hearing loss or not. The early years can be vital for learning and chidren have a narrow window for language development; early intervention can greatly improve learning later down in life in Deaf and Hard of Hearing children.

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RESOURCES

Family Focus Center website - https://www.childrens.com/specialties-services/specialty-centers-and-programs/ear-nose-and-throat/programs-and-services/ffc-for-deaf-and-hard-of-hearing-children

American Academy of Pediatrics, Early Hearing Detection and Intervention - https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/PEHDIC/Pages/Early-Hearing-Detection-and-Intervention.aspx

Dr. D.J. Verret teaches us what he's learned over the years getting a practice up and running: "when you start out, start out lean!"

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In this episode, Dr. DJ Verret joins our hosts Dr. Gopi Shah and Dr. Ashley Agan to talk about how to successfully start and manage a private practice.

Dr. DJ Verret starts off by discussing what drew him to private practice and facial plastic surgery after deciding on Otolaryngology as a residency choice. He speaks about the details in starting out and the difficulties of the nuances. One detail he mentions is that it is important to assess all the possibilities of practice models, whether that is practice sharing, group practices, or other such models that may best fit your goals. He continues to discuss the importance of taking advantage of employers, such as CEO’s, about possible arrangements for new practice models. Dr. DJ Verret then moves to speak about experience being an important teaching factor in learning the financial ins and outs. He also discusses aspects that can help setting up a practice, including practice management companies, healthcare lawyers, CPA’s, and ideas about the future direction of the practice.

The discussion continues into the steps taken to start a practice, from creating an EIN for the company to commercial real estate in finding an appropriate practice location. Next steps include considerations for practice equipment specifically for your practice type. Important things to keep in mind when purchasing equipment and location is starting out lean, both space and equipment wise. Given the natural limitation of time, it is better to start small to where a practice is financially manageable. Time management is a key aspect discussed, in deciding how much you want to do on your own vs how much you’re willing to delegate to others.

Dr. DJ Verret rounds off the discussion by speaking about practice management vs clinical time. He discusses how to manage overhead, employee roles, and dedicating time to practice management each week, including tracking practice progress on a quarterly basis. A combination of timely and financial efficiency is key in running a successful practice.

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RESOURCES

Dr. DJ Verret’s Podcast: https://askmemd.buzzsprout.com/

Dr. DJ Verret’s Website: https://innovationsfps.com/