BackTable ENT & Allergy

Dr. Felicity Lenes-Voit from Dallas Children's Health discusses her approach to diagnosis and treatment of Tongue-Tie, or Ankyloglossia, in the infant.

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In this episode, Dr. Felicity Lenes-Voit joins our hosts Dr. Gopi Shah and Dr. Ashley Again to speak about Tongue-Tie, or Ankyloglossia, and its comprehensive management.

Dr. Lenes-Voit starts the discussion by describing what Tongue-Tie is and how to conduct an initial evaluation and workup. She describes the importance of lactation consultation and the effects tongue-tie can have on both mother and baby. The discussion then continues to discuss physical examination as an important aspect of the workup and how best to determine the extent of the ankyloglossia, while also factoring in the weight of the child as a key aspect of workup.

Next, Dr. Lenes-Voit and our hosts discuss points to keep in mind when considering frenectomy as a correcting procedure, which include conducting a thorough lactation evaluation prior to making that decision. Speech impairments are also a potential worry from parents and, as a controversial topic in frenectomy evaluations, should be clarified with families. Other risks and benefits are further discussed such as timing of intervention and the use of general anesthesia at certain ages. This portion of the discussion ends with Dr. Lenes-Voit talking about the different operative techniques that can be employed as well as tips for smooth procedures.

Lastly, the discussion concludes with Dr. Lenes-Voit speaking to the importance of counseling and a multidisciplinary approach with mothers of tongue-tie patients. The team effort between ENT’s, pediatricians, and lactation and breastfeeding consultants is key in the comprehensive management for both mother and baby. Setting realistic goals and expectations, especially for new mothers, will be beneficial and something to incorporate with each patient.

Dr. Eric Cerrati from University of Utah Health gives us his pearls and pitfalls using social media to promote his clinical practice.

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In this episode, our hosts Dr. Ashley Agan and Dr. Gopi Shah are joined by Dr. Eric Cerrati to discuss the different ways to promote a practice and the increasing role of social media in professional development.

Dr. Cerrati initially starts by describing how he set up his academic practice in Facial Plastic Surgery with a mix of cosmetic patients as well as reconstructive. He highlights the importance of outside marketing in addition to being affiliated with an academic center. These two can be different and both have pros and cons. He describes the use of Instagram and Facebook in marketing with somewhat a private practice mindset. The use of social media has also grown during the COVID pandemic due to an increased need to reach out to prospective interested students in programs across the country. Dr. Cerrati speaks then about the details, including demographics, that can be reached based on the specific social media platform used. He does highlight the importance of consistency and the way one chooses to present themselves on a social media platform. Balancing that which is appropriate for social media can be challenging, with the overarching theme of being honest and ethical. Patient consent is vital prior to sharing any form of media regarding them.

Dr. Cerrati goes on to talk about the risks of putting yourself out there and being in the constant public eye and risks that come with. In addition to social media, he continues to discuss the importance of building good collegial relationships with fellow physicians and taking care of patients referred to you while being respectful to the referring provider.

The discussion ends on the impact COVID has had on a private practice cosmetic setup, including considerations for COVID testing, role of virtual visits, and evaluation for surgery and follow-ups post-op. Dr. Cerrati ends on the important note of remaining flexible and continuing to work hard in the face of adversity, and growth will come.

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RESOURCES

Dr. Cerrati’s Instagram: @Dr.Cerrati

Dr. Cerrati’s Website: www.drericcerrati.com

We speak with Dallas Children's Hospital's Section Chief Dr. Ron Mitchell about Management of Pediatric OSA.

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In this episode, Dr. Ron Mitchell, a Pediatric Otolaryngologist, joins our hosts Dr. Gopi Shah and Dr. Ashley Agan to speak about pediatric Obstructive Sleep Apnea (OSA) and its evaluation and management.

Dr. Mitchell starts off the discussion by speaking about the importance of sleep and initial presentations and symptoms of sleep apnea in children, including apneic episodes, fatigue, and inattention as well as studies that recommend tonsillectomy for pediatric OSA. Dr. Mitchell then speaks about a current study underway that looks at OSA in pediatric patients with mild symptoms and the indications of surgery and if it is necessary in all patients. It is analyzing patients undergoing medical therapies, including Montelukast, nasal steroids, and others to evaluate efficacy against surgery. Specific indications and situations are also discussed. Dr. Mitchell notes that initially, with patients with mild symptoms, a sleep study may not be necessary. On the other hand, those undergoing high risk surgery or other developmental delay may need a sleep study, with observation and symptoms being the primary method of evaluation of progress. It is important to assess goals of the family prior to making the decision to obtain a sleep study with shared decision making.

Dr. Mitchell then speaks about the impact of COVID on obtaining sleep studies and the effects on evaluation of pediatric OSA. He then indicates that home sleep studies may not be beneficial to obtain in the pediatric population, unlike in adults. The discussion continues onto the topic of tonsil size and the variable effect it can have on pediatric OSA. The history of tonsillectomies is further discussed with possible causes for the increase in the number of tonsillectomies for sleep related problems.

The discussion rounds out on the important consideration of patients who undergo surgery with tonsillectomy and adenoidectomy with persistent OSA. Dr. Mitchell mentions possible etiologies (adenoid regrowth, nasal obstruction, etc.) which can be evaluated with nasal endoscopy and managed with nasal steroids. Weight loss in overweight and obese patients may also be beneficial. Other important considerations would be in patients with Down Syndrome, due to the difficulty of implementing CPAP and other managements. In these patients, sleep MRI is useful in determining the site of airway obstruction, usually at the tongue base, with additional surgery being useful for them.

Dr. Romaine Johnson talks us through the challenges of pediatric tracheostomy care and the importance of building high reliability tracheostomy teams.

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In this episode, Dr. Romaine Johnson joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the essentials of building a successful pediatric tracheostomy program and the importance of a multidisciplinary team. He emphasizes that the triage and management of pediatric tracheostomy patients must be approached through the lens of long-term care.

He states that essential members of the multidisciplinary pediatric tracheostomy team include pediatric pulmonologists, advanced practice nurses/nurse practitioners, respiratory and speech therapists, as well as social workers and case managers. Dr. Johnson also describes his multidisciplinary clinic set up through which patients are able to see all members of their care team at a single visit, thereby improving the quality and safety of care.

Dr. Johnson provides some key insights into the management of inherited pediatric tracheostomies with regards to how and when to up-size a trach as well as the role of palliative care in complex pediatric tracheostomy cases. Finally, we go into some notes on how to manage bleeding complications in pediatric tracheostomy patients, including the role of a pulmonary sick plan, and management of anterior/posterior tracheal erosions.

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RESOURCES

Dr. Johnson’s YouTube Channel

https://www.youtube.com/channel/UCMyWMjLbWbi_jM_tk7-57eg

Dr. Johnson regularly posts procedure videos, as well as videos from the Harry Barnes society virtual grand round series.

Dr. Ashley Agan and Dr. Gopi Shah talk with Dr. Joe Walter Kutz about the management of Eustachian Tube Disorders, including pearls and pitfalls on treating the "clogged ear".

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In this episode, Dr. Walter Kutz joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the essentials of caring for patients with chronic eustachian tube disorders. They emphasize that the diagnosis of patients with chronic eustachian tube disorders can be challenging. Patient history is often the driving factor in evaluation of these patients, but objective measures such as tympanograms can aid in the diagnostic process.

They describe in detail the differentiating features of patulous eustachian tube, a commonly missed diagnosis with a similar presentation as eustachian tube dysfunction. The best practices for evaluation of patulous eustachian tube are outlined, including the ideal set up for otoscopic and endoscopic nasal exams. They also touch on the treatment options for patulous eustachian tube, giving insight into procedure details as well as complications.

The discussion then evolves to focus on more complicated cases of eustachian tube dysfunction, including patients with atrophic tympanic membranes as well as those refractory to tympanostomy tube placement. The efficacy and challenges of eustachian tube targeted procedures such as balloon dilation are reviewed. The role of allergy evaluations in management and care of eustachian tube dysfunction patients are also considered. Finally, they touch briefly on some notes on the diagnosis of eosinophilic otitis media and superior canal dehiscence.

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RESOURCES

Dr. Kutz’s Website: https://utswmed.org/doctors/joe-kutz/

Dr. Kutz’s Twitter Handle: @EarDoc1

Dr. Kutz’s Instagram Handle: @walterkutzmd

PatulEND - Patulend.com

IR Sabeen Dhand and ENT Ashley Agan discuss management of Epistaxis, including how to effectively pack the nose, and when SPA ligation or arterial embolization are necessary. Dr. Dhand also describes his arterial embolization technique, including important pitfalls to avoid.

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In this episode, Dr. Sabeen Dhand, an Interventional Radiologist, joins our hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss epistaxis and the evaluation and management of different causes of epistaxis.

Dr. Agan and Dr. Dhand start the discussion by bringing up common presentations of epistaxis from both an ENT standpoint as well as IR; with the usual presentation being initially to ENT with possible referral to IR for embolization. They then continue to speak about initial treatments for epistaxis in the ED, which entails use of pressure, Afrin, and nasal packing or cauterization. If those measures aren’t sufficient, further examination in the OR may be warranted to find specific location and cause. In the case of a posterior nosebleed, usually from the sphenopalatine artery (SPA), with brisk bleeding and/or failure of ligation, SPA embolization by IR may be of use. Dr. Dhand mentions a contraindication for SPA embolization in the case of the ophthalmic artery anastomosis between the Internal Carotid Artery and External Carotid Artery due to risk of stroke and blindness. Different sources of bleeding should also be evaluated.

The discussion rounds off with the summarization of initial treatment of epistaxis. Two important considerations include proper nasal packing, pushing back into the nose and not straight up, as well as avoiding compressing nasal structures and causing necrosis and further mucosal irritation increasing bleeding risk.

We talk with Dr. Eric Gantwerker about tips and strategies to make medical education and teaching more effective.

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In this episode, our hosts Dr. Ashley Agan and Dr. Gopi Shah are joined by Dr. Eric Gantwerker to speak about medical education and the nuances involved along different levels of training.

Dr. Gantwerker begins by discussing different possible teaching and learning styles. One idea he speaks about is cognitive load, which describes that a novice only has a certain amount of attention and cognitive attention they can focus on a topic. He also mentions the ideas of “chunking” and “zone of proximal development”; these ideas combine the ideas of constantly challenging learners with gradual responsibility and allowing the learner to repeat the same activity or action repetitively while slowly increasing the amount of activity involved as well. This keeps people in a challenged enough state to where they struggle, but not enough to where it is completely out of their ability to succeed. Dr. Gantwerker then rounds off the process by having a debriefing session afterwards, in which feedback is exchanged between both student and teacher on how the experience went. This allows for tailor-made teaching experiences for students and establishing rapport between students and teachers.

The discussion continues in what Dr. Gantwerker focuses on during the teaching process. He mentions the concept of “Line, Speed, Beauty”, which highlights the importance of first mastering basics, followed by increasing efficiency, and the aspect of beauty which naturally follows. Dr. Gantwerker ends the discussion by highlighting different learning techniques, including organizational thinking, thorough understanding, and experiential learning. He then speaks about challenges faced in current virtual environments and how to manage them.

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RESOURCES

Level Ex Learning App: www.levelex.com

Dr. Gantwerker’s Twitter Handle: @DrEricGant

Dr. Ashley Agan and Dr. Gopi Shah talk wellness in life and practice!

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In this episode, hosts Dr. Ashley Agan and Dr. Gopi Shah discuss the important topic of wellness, what it is, and how to incorporate it into our professional lives.

They begin by discussing what exactly wellness is and what it entails. Wellness can be different for different people, but essentially it comes down to taking care of yourself before you take care of others. As this can be hard to do in such a service-oriented career, dedicating time to it is important to be able to recharge, whether that be spending time with family, exercising, or just intentionally relaxing. Dr. Shah and Dr. Agan continue to talk about time management and how to incorporate wellness into busy lives in medical school, residency, and beyond. Balancing may not always be easy but taking time for yourself is just as important as the time you dedicate to others.

Our hosts then continue to speak to the impact COVID-19 has had on the physician community and wellness. One of the biggest factors it has had is regarding the human-to-human connection that is gratifying and often motivating during patient encounters. Dealing with those challenges has taken its toll, but one that both providers and patients are learning to manage together.

Lastly, Dr. Agan and Dr. Shah conclude by discussing specific examples of incorporating wellness. They speak about groups, such as Wellness in Oto, and other ways to keep in touch, whether that be with mentors or trainees, to check in on each other and make sure everyone is doing well and taking the time to take care of themselves during an otherwise challenging time. As well as keeping in touch with others, keeping in touch with yourself is just as important and reflecting is often a great way to do just that.

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RESOURCES

Backtable ENT Twitter and Instagram handle: @_backtableENT