Medical Intel

Treating cancer on the head or neck can seem intimidating, as people fear surgery could leave unwanted scars around their face. However, with the techniques we use today, people often end up cancer-free with very few changes to their appearance.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me today.

Host: Today we're discussing reconstructive surgery for head and neck cancers. When a patient has cancer in such a visible area of the body, it's important for them to have options to not only remove the cancer, but also keep them looking like themselves after surgery. Dr. Giurintano, what are some of the more common cancers for which patients might need reconstructive surgery after treatment?

Dr. Giurintano: So, while approximately 90 percent of cancers that occur in the head and neck region are a type of cancer called squamous cell carcinoma, this type of cancer can affect multiple areas within the head and neck. Some examples include the tongue, the jaw bones, the palate, the inner surface of the cheeks, the back of the throat, carotid or saliva glands, and the voice box. Oftentimes, the surgery required to remove tumors from these locations results in very large, noticeable defects that affect not only the patient's physical appearance but oftentimes their ability to speak, breathe or swallow. More recently, legendary Buffalo Bills quarterback Jim Kelly has been in the news for his fight against head and neck cancer. His cancer was a squamous cell carcinoma located in the maxilla, or the upper jaw bone, and he initially underwent treatment consisting of chemotherapy and radiation therapy but unfortunately developed a recurrence of the cancer after his initial treatment. Because of this, surgery was performed to remove the recurrent cancer in his upper jaw bone and the salvage setting. And, in a patient who's previously had radiation therapy, it's very difficult for this area to heal after surgery and the result leaves a communication between the mouth and the nose, which can make speech abnormal, as well as swallowing. So, Jim Kelly underwent his surgery in New York by Dr. Mark Urken, who's one of the most nationally known and most experienced surgeons, using what we call free flaps to reconstruct head and neck defects. So, a free flap is a piece of tissue that's harvested from an area of the body outside of the head and neck, that often consists of either skin, fascia, muscle, bone, fat or a combination of all of these. And, it's a piece of tissue that can be harvested with an artery and a vein that can supply blood to this piece of muscle or bone or fat. We can then take that tissue from the leg or the arm or the thigh and then transfer that up into the defect site and use it to reconstruct things like the tongue, the voice box or the jaw bone. Then, using a microscope, under very high magnification, we can actually sew the artery and the vein that are from the flap to an artery and a vein in the neck and that will actually provide that piece of tissue with its own blood supply. This is especially important in head and neck cancers because most of our patients receive radiation therapy as part of their treatment and without a robust, healthy blood supply, most pieces of tissue will die from the radiation therapy. We do know these pieces of tissue have a robust vascular supply and that they can withstand the radiation treatment, leading to very good results in reconstructing the donor site defect. In Mr. Kelly's case, Dr. Urken performed what's called a fibula free flap. And that's when a piece of bone from the lower leg, called the fibula, is harvested with some overlying skin and an artery and a vein and he was actually able to use that bone to recontour the upper jawbone that was missing after the surgery. And he was able to use the skin from the flap to seal the hole in the palate so that Mr. Kelly was able to talk, eat and look normal essentially. In Mr. Kelly's case, he was then able to have titanium dental implants inserted into that bone so that he could actually have teeth in his upper jaw again. And, if anyone's seen him in the news lately, they did a fantastic job and he looks almost the exact same as he did before surgery. And, that is really the ultimate goal of cancer and reconstructive surgery nowadays.

Host: How do patients feel when they learn that their appearance might be affected by the surgery that will remove their cancer?

Dr. Giurintano: So, patients often feel a mixture of emotions. Receiving a diagnosis that you have cancer is very difficult. And, to add on to that diagnosis that you might require major surgery that might result in a physical deformity can be even more devastating to patients. Our facial structure is often a major part of our identity and it can be very psychologically devastating to learn that your visual appearance might be affected. This goes for the voice, as well. We all have unique voices that we can recognize very distinctly. And the possibility that you might lose your own unique voice can be very devastating to patients. In the past, patients would often have these tumors removed without any technology to reconstruct them and this could lead to crippling deformities that were very easily noticeable upon first glance. And this has a major psychological impact on patients. Some can often lead to depression and anxiety in our cancer patients. And while it's impossible to perform a surgery that's completely scar-less, all surgery requires at least an incision, today we have advanced techniques that limit the deformity that's caused by removing cancers from the head and neck. We also have to give credit to the body itself. The body is pretty incredible in that anytime we take skin from the arm or the leg and we place it into the mouth, the body can actually recognize this change in the environment that the skin is in and it actually begins to change the cell types of that flap. And through a process that we call mucosalization, the flap actually begins to take on the appearance of the native tongue or the native surface of the mouth. In many of these patients, when you see them one or two years down the road, it is actually very difficult to tell which piece of tissue in the mouth came from the arm or the leg. It just looks like normal tissue.

Host: Is the reconstruction procedure performed separately from the cancer surgery?

Dr. Giurintano: So, we actually work together in what we call a two-team approach so that we can both remove the cancer and reconstruct the defect at the same time. This means that while the ablative, or the cancer removing surgeon, is working in the head and neck to take the cancer out, the reconstructive surgeon is, at the same time, working on the arm or the leg to harvest the flap so that as soon as the cancer is removed and the defect is made, the reconstructive surgeon can then take that flap, remove it from the arm or the leg and begin in-setting it into the defect. So, by doing the cases in this manner, we can typically finish an entire cancer removal and reconstruction in anywhere from 6 to 10 hours. Back whenever these types of surgeries were invented 20 or 30 years ago, the cases could often go over 24 hours. So, it's actually been a big advance in our medical practice that we can finish these cases generally in under 12 hours. Our goal, essentially, is to limit the time the patient has to spend on the operating table under general anesthesia and to try to get patients back on their feet as quickly as possible after surgery to help quicken the recovery process.

Host: What does a patient have to do to prepare for head and neck surgery with a reconstruction?

Dr. Giurintano: Most of the preparation, from the patient standpoint, is more mental and emotional. We recommend that they have a good support system in place, whether it's family or friends, to help them cope with the psychological impact of undergoing a major surgery and a, typically, 7 to 10-day hospitalization. There are some tests that we may perform in our clinic or in the radiology suite before we schedule a patient for a free flap. Nowadays we really try to tailor what type of free flap we are doing individually to each patient. In the past, physicians would often do one flap as their main flap, regardless of what the defect was or what the patient's lifestyle included. But nowadays, for example, say if a patient of mine was a classically trained pianist and they wanted to continue playing piano after their surgery, I would be very hesitant to take any tissue from around their forearm or wrist. I would not want to interfere with their ability to play the piano at all. So instead I would go to a different donor site, either the side of the body or the leg. I'd take a similar piece of tissue and contour this to match the defect site. Occasionally, some patients require some tests such as angiography. This is a special test performed in the radiology suite to determine if the blood vessels are good enough to support a flap. For the fibula flap, especially - that's a flap of the bone called the fibula in the lower leg that we often use to reconstruct the jaw- we know that there's 3 distinct blood vessels that carry blood into the lower part of the leg to supply the foot. By taking the fibula, we have to take one of those blood vessels out to apply the flap, leaving 2 blood vessels to supply the leg. Normal patients - this is not a problem to remove this blood vessel. However, some patients only have 1 or 2 blood vessels supplying the lower leg, not 3. In these cases, it could be potentially disastrous to take the 1 blood vessel that's supplying the lower leg. So, in this type of flap, we'll always do a test before to make sure that the blood vessels are sufficient to sustain the flap. But otherwise, typically, we do not have many other special tests that are required before pursuing a major reconstruction.

Host: How long is the recovery time for these patients?

Dr. Giurintano: So, in general, our patients who undergo free flap reconstructions generally spend the first two days after surgery in the intensive care unit setting. During this time, it's not that they're so sick they require a stay in the intensive care unit. It's actually that we have to frequently check the blood vessels supplying the flap to ensure that the blood is flowing to the flap and that the flap is getting the nutrients that it needs. Once the first two days have passed, as long as the patient is doing well, they often go to the floor. And from that point on, most patients spend anywhere from 3 to 5 days on the floor, receiving basic medical care as they recover. Oftentimes they're receiving physical therapy or occupational therapy during this time to recover their strength. And all of the basic preparations for that patient to go home are being arranged. Typically, if all goes well during the surgery and during the hospitalization, most patients spend about 5 to 7 days total in the hospital and then either go home or sometimes go to a lower level of care, such as a rehabilitation facility to help regain their strength before they're ready to go home. Once at home or in a rehab facility, it still takes a couple of weeks for the patients to completely recover. And, in general, the entire recovery process takes about 4 to 6 weeks total. But, most patients are back swallowing, speaking, and doing normal activities within 2 weeks of surgery.

Host: What additional treatment or care do patients need after reconstructive surgery?

Dr. Giurintano: Depending on the complexity of the case and how the hospitalization proceeds, some patients are able to go straight home and essentially require very minimal extra care. Occasionally, patients require the placement of feeding tubes or tracheostomy tubes. Tracheostomy tubes are special breathing tubes that are inserted into the neck that some patients may require because, occasionally, there's too much swelling or the flap is too bulky inside of the mouth for them to breathe or to swallow well. Generally, this is a short-term procedure that patients do not require permanently, but sometimes this may require some extra care by a home health nurse or at a rehabilitation facility. Occasionally, if patients have trouble swallowing in the post-operative period and we a concerned that they might accidentally aspirate their foods, a tube can be placed into the stomach to help facilitate nutrition while they're recovering. And, generally, this is also a short-term procedure that most patients are able to have removed after 6 to 8 weeks.

Host: How do the surgeons at MedStar Washington Hospital Center help patients achieve the best cancer related outcomes and cosmetic outcomes with these complex procedures?

Dr. Giurintano: So, at MedStar Washington Hospital Center, we work together as a team. Our team includes multiple members within the department of otolaryngology head and neck surgery. And this includes both ablative cancer surgeons (so those are surgeons who remove the cancer), reconstructive surgeons (such as myself), as well as facial plastic and reconstructive surgeons (so these are surgeons who are specially trained in cosmetic procedures of the head and neck). In caring for these patients, we, as surgeons, are responsible for the removal and the reconstruction of their cancer and the subsequent defects. But, in treating their cancer, we also share equal responsibility with our colleagues in the departments of radiation oncology and medical oncology. There are some types of head and neck cancer that can be managed through surgery alone, but most patients who have a head and neck cancer will also require either radiation therapy or chemotherapy as part of their treatment algorithm. We actually have a regular meeting at the MedStar Washington Hospital Center where the surgeons (such as myself), the medical oncologists, the radiation oncologists, the speech pathologists, the pathologists and the radiologists all meet to discuss new patients who have been diagnosed with cancer, as well as patients that have recently been treated for their cancers. And, during this meeting, which is what we call a multidisciplinary treatment conference, we are able to actually stage each patient's cancer. We're able to decide on a treatment that best suits that patient's cancer. And, we're able to put all of the right consults and all of the right steps in order so that patient can begin their treatment as soon as possible.

Host: Could you share the story of a patient who had a particularly successful outcome?

Dr. Giurintano: Yes. A patient, who had recently had several previous head and neck cancers, presented to the MedStar Washington Hospital Center, in my partner, Dr. Matt Pierce's, clinic. This patient had previously undergone multiple surgeries and he had essentially received the maximum dose of radiation therapy that the body could receive in that area. And, unfortunately, there was a new cancer that had developed. This was a very devastating diagnosis to him, as he was a cancer survivor already. But, we were able to perform, essentially, a removal of the entire voice box and the entire back wall of the throat and then reconstruct that with tissue from his upper thigh. And, he had an absolutely amazing postoperative course. He was out of the hospital by postoperative day number 7. And this gentleman, who had not swallowed in 6 months, we had just obtained a swallow study to evaluate how the flap had healed, and he was able to swallow again - well - for the first time in 6 months. So, he was a particularly good outcome and we were very pleased with how he healed.

Host: Thanks for joining us today, Dr. Giurintano.

Dr. Giurintano: It was my pleasure. Thank you so much for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

The adrenal glands respond to signals from the nervous system and produce hormones that regulate many of the body's normal responses. Dr. Erin Felger discusses what happens when a tumor develops on the adrenal glands and how we treat it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thanks for joining us, Dr. Felger.

Dr. Felger: Thank you for having me.

Host: Today we're discussing adrenal surgery, or procedures to remove the adrenal glands. Dr. Felger, to begin with, what do the adrenal glands do?

Dr. Felger: The adrenal glands are located on the kidney. The adrenal glands make different hormones that help regulate different systems in your body. A hormone that everyone is familiar with is adrenaline and that is one of the main hormones that the adrenal gland makes.

Host: What symptoms might cause a patient to visit their doctor and ultimately lead to a diagnosis of an adrenal problem?

Dr. Felger: Well, it depends if the adrenal tumor is producing hormones or if it is not producing hormones. If it is what we call a functional tumor, the patient may have high blood pressure, headaches, palpitations, skin changes, weight gain, diabetes, fatigue or weakness. If the tumor is not producing hormone, the patient may not have and likely won't have any symptoms at all.

Host: Why might a patient need to have the adrenal glands removed?

Dr. Felger: Usually, we only remove one adrenal gland. It's very rare to have bilateral tumors that need to be removed from those adrenal glands. One adrenal gland with a tumor usually needs to be removed for one of two reasons, the first being that the tumor is producing hormone and causing the patient to be sick or the tumor is too large in size and needs to be removed because of concern for cancer.

Host: How do you advise patients to prepare for adrenal surgery?

Dr. Felger: Again, it's first having a consultation with your surgeon and then following the steps that need to be completed prior to surgery, which usually include labs, EKG, physical, extra imaging and any clearances that need to be had by other physicians.

Host: What does recovery entail after a procedure?

Dr. Felger: Recovery is very straightforward for adrenal procedures that are done laparoscopically or retroperitoneally. The patient is able to eat and walk and do most regular activities except for heavy lifting. Laparoscopic adrenal surgery is done from the belly side and it includes using a camera and small instruments and small incisions to remove the adrenal gland and the tumor. Retroperitoneal adrenal surgery uses a camera and small instruments and incisions but is done from the back and not the front.

Host: Do patients need additional therapies after surgery?

Dr. Felger: It depends on what type of adrenal tumor a patient has. They may need to have follow-up with their endocrinologist to adjust medications. They may need further imaging studies and potentially treatment if they have a cancer.

Host: What sort of medications would they patients have to take ongoing?

Dr. Felger: Depending on the type of adrenal tumor, some patients may need to take long-term steroids in order to have normal function until their other adrenal gland wakes up. Other patients may need to have further imaging or frequent follow-ups and, potentially, medication if they have a cancer.

Host: Could you share a success story of a patient who overcame adrenal issues, thanks in part to surgery?

Dr. Felger: Yes. I had one patient who was a young man and he had excessively high blood pressures and was taking multiple medications and it was affecting his activities of daily living. His doctor did a full work up and found an adrenal tumor on one side. He came to see me and I completed the work up and had a good discussion with him about the operation to remove the adrenal tumor. I explained to him that it would hopefully help his high blood pressure but it may not cure it completely. The patient had the operation and he did very well during the surgery and afterwards. When he came back for his postoperative visit, he was doing quite well and he was off all of his blood pressure medications and he was quite thrilled because he was already getting back to his activities of daily living that he had been unable to do prior to the surgery.

Host: Why should a patient come to MedStar Washington Hospital Center for their care?

Dr. Felger: We have a multidisciplinary approach with our adrenal patients. They can be seen by our endocrinologists as well as have nuclear medicine studies done and then follow-up with the surgical team. We do an excellent volume of adrenal surgery at our institution and we are trained in both laparoscopic and retroperitoneal approaches so we can offer as many options as possible to our patients.

Host: Thanks for joining us today, Dr. Felger.

Dr. Felger: Thank you again for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Caregivers can spot dementia in numerous ways, ranging from a loved one forgetting about their favorite television program to suddenly not remembering to pay their bills on time. Learn who Dr. Cesar Torres says is most at risk of dementia and how to manage it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Cesar Torres, a geriatric and house-call doctor at MedStar Washington Hospital Center. Thank you for joining us, Dr. Torres.

Dr. Torres: Good afternoon.

Host: Today we're discussing dementia, a neurological condition that tends to develop in older adults and is characterized by memory loss and confusion. Dr. Torres, could you start by discussing how dementia develops in the brain?

Dr. Torres: Certainly. Dementia develops as a result of the production of a neurotoxic protein called beta amyloid and, as a result of accumulation of this protein, nerve cells in certain areas start to die, specifically the memory centers of the brain - the hippocampus, the parietal lobe - and, as a result, people start to experience neurocognitive deficits. The most dramatic ones tend to be in the memory realm, but there are other cognitive deficits that also develop. And these eventually lead to significant social dysfunction and impairment, and it's, unfortunately, very progressive.

Host: Are there any populations of people who are at increased risk for dementia?

Dr. Torres: Well, the number one risk factor for dementia is age. The older you are, the higher the prevalence. Recent estimates - generally, by the time you're 70-75, there's upwards of a 20 percent prevalence rate. Dementia encompasses a few different pathologies. There's Alzheimer's dementia, there's Vascular dementia, there is a dementia associated with Parkinson's, there's a Lewy body dementia and there are some other much more esoteric subtypes. The vast majority are Alzheimer's-type dementia, generally in the range of 60, 70 percent. After that, Vascular dementia rounds off the list, mostly around 15 to nearly 20 percent. And then, all the others. So, each one tends to have certain predispositions. For Alzheimer's, there's a genetic predisposition. It's not 100 percent correlative, but there is a genetic predisposition and it can run in families. Vascular dementia tends to affect folks who have vascular disease - hypertension, coronary artery disease, people who are more prone to strokes. Brain trauma can predispose people to another subtype of dementia, and there's a lot of focus now on this Traumatic encephalopathy that we see in a lot of professional, high-contact sports. Some of the other more esoteric subtypes - probably more of a genetic predisposition. So, as far as high-risk groups are concerned, that's not an all inclusive list but there are certain groups that are at greater risk. But like I said, age is the number one risk factor. So, if people could stop growing old, we wouldn't have a problem.

Host: In these high-risk individuals and these aging individuals, what are some of the warning signs of dementia that families should start watching for?

Dr. Torres: That's a very good question and unfortunately, it's also a very broad question. Generally, the onset of Alzheimer's tends to be extremely subtle. You'll tend to see problems with the acquisition of new knowledge or new information, the retention of new knowledge and new information. A family member asks how to get to a grocery store over and over again, in spite of having been there not too recently. You can see difficulty with social functioning as well, as the disease progresses. An individual who was extremely capable of managing their finances suddenly forgets to pay their bills and the electricity gets turned off. As things progress, now you can see personality changes. Sometimes the person starts to retreat into themselves - more withdrawn as some awareness of the social dysfunction starts to creep into their consciousness. Generally, the family will feel something isn't quite right with their loved one and that's when they actually probably bring it to the attention of their primary care physician or caregiver. The social functioning piece becomes more dramatic and is more distressing for folks, and they tend to pick up on that fairly quickly because it's a dramatic departure from previous level of functioning.

Host: If someone notices that a loved one is showing signs of dementia, where should they turn for help?

Dr. Torres: Generally, most primary care physicians can do at least the initial screening. This generally can include blood tests, neuro imaging - in the form of a CT scan or an MRI. There are some blood tests that can also help rule out reversible causes of memory loss. But generally, the primary care physician should be the first point of contact.

Host: Are there any treatment options available to help patients with dementia manage their symptoms or reverse the condition?

Dr. Torres: Well, unfortunately, we have no way to reverse it at the current time. And that's the Holy Grail. There have been many, many, many attempts to find drugs and various treatments but none have really been successful up to this point. As far as medications to modify the progression of the disease, there are a few, the most famous one being Donepezil, trade name Aricept and Namenda, generic Memantine. If you make a diagnosis of dementia, you don't automatically use the medication. It's best to have a conversation with the patient and the family and to decide whether or not the patient has reached the stage where they would benefit from this medication because all of these medicines has toxicity. What the medicines offer, really, are slowing the progression. And, you may see unfortunately temporary improvements in certain memory functions. But, unfortunately, over time, the effect diminishes and the disease starts to progress again. If you look at it on a bell curve, most folks will fall in the middle. They will get some, but there are those who can get a lot and there are some who, unfortunately, don't get anything. The middle is where the bulk of the patients will fall. But on an individual, case by case basis, you can get a substantial amount of improvement. The biggest benefit, I feel, from starting treatment with these medications is time. You buy time. And time is very precious for people. So, on the basis of that, if we're at a relatively early enough stage, I think it's a worthwhile choice.

Host: You mentioned a couple of different potential causes for dementia. What can patients do to reduce their risk of developing it?

Dr. Torres: We have looked at lots and lots of different options - herbal medications, anti-inflammatories, Vitamin E - and the list goes on. But, to date, the only two things that I can recommend honestly? A healthy lifestyle and daily exercise. Daily exercise actually has evidence behind it. So, among all the other benefits that a person can obtain from daily exercise, prevention of dementia is another one. There was a sub-analysis of the Women's Health Initiative Study that was done a few years ago that looked at the impact of exercise and noted that it reduced their relative risk by about 40 percent, as a result of daily cardiovascular exercise. The reasons for that, the mechanism behind it - still remains a bit unclear but I suspect it has to do with just overall benefits of exercise and physical activity. And it doesn't need strenuous exercise also, but some form of daily cardiovascular exercise would be a great benefit. Well, I would recommend being very judicious with alcohol intake. There is an Alcoholic dementia that exists. Otherwise, avoiding smoking. Smoking can lead to vascular problems that can lead to Vascular dementia. Good sleep, weight control - things like that.

Host: How do the dementia experts in the geriatrics program and the house-call program at MedStar Washington Hospital Center help patients and families achieve optimal outcomes?

Dr. Torres: The number one way is in the diagnosis of the condition because sometimes it can present atypically. Sometimes it can present, as I said, very subtly. So, sometimes it has to be teased out. And again, it's time. We can gain time for better interactions, more complete interactions with the patient and the family member. And there are a few conditions that can masquerade like dementia that we can treat and reverse the symptoms that we associate with dementia - the memory loss. The one that is most well known is depression. Depression can manifest itself as a type of dementia with memory loss, with loss of concentration, with apathy, as well. And so by treating that, the patient -- effectively treating that -- the patient can regain their function and their memory.

Host: Could you give us an example of how you care for a dementia patient through the house-call program?

Dr. Torres: Well, we have a very focussed approach with really educating and helping the caregiver meet the needs and ease the process for the patient. There's usually a lot of frustration that the caregiver feels with their loved one as the disease progresses. And the deficits become more and more overwhelming. So, we tend to review behavioral techniques that can ease the tension in the household. We can help them with treating comorbidities to maximize their time at home. And we do everything we can to help the patient age in place, which is often a great benefit for everyone - avoids unnecessary trips to the emergency department, unnecessary hospitalizations.

Host: Thanks for joining us today, Dr. Torres.

Dr. Torres: It was my pleasure.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Transcatheter Aortic Valve Replacement (TAVR) has come a long way since it was introduced in the U.S. in 2007, as doctors' experience and technological advancements have improved. But the medical community still has work to do. Dr. Toby Rogers discusses the current and future state of TAVR.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rogers.

Dr. Rogers: It's a pleasure to be here.

Host: Today we're discussing the future of transcatheter aortic valve replacement, or TAVR. TAVR is a treatment for patients with aortic stenosis, or narrowing of the aortic valve. Dr. Rogers, could you discuss how a doctor can replace an aortic valve without open-heart surgery?

Dr. Rogers: That's a great question and it's one that every patient wants to know. So, I think open-heart surgery makes sense. You open the chest, you stop the heart from beating, you cut out the old valve, you sew in a new one, you restart the heart beating again, you sew the chest up, and you have a new heart valve. TAVR is very different. In fact, we don't actually take the old valve out at all. And, what we do is we thread a new valve through the artery from the leg, all the way up to the heart, and then we open the new valve inside the old one, just pushing the old one out of the way, and we leave the new valve behind, opening and closing inside the old one. And, the beauty of this is that obviously we're able to that, as I said, thread it from the leg, without having to do open-heart surgery, without having to stop the heart from beating, without having to even put the patient asleep. And so, it's much less invasive and much less of a stress on the body.

Host: What are some of the improvements in TAVR that you've witnessed or been a part of in your practice?

Dr. Rogers: So, I think you can divide the benefits into two broad areas. The first is technology. So, we are now on to the third generation of TAVR valves, meaning that the companies that develop these, and the doctors and scientists that work with them, have gone through three iterations now, or improvements, on the valve technology. And each iteration, each new improvement, has brought dramatic improvements to the whole procedure. Specifically, the catheters that we deliver the valves through from the groin have gotten smaller and smaller. And the smaller a catheter, the less invasive the procedure and the more patients are able to have this procedure because even patients now with very small...even patients with some blockages in the arteries down to the legs, are able to have TAVR whereas in the past they wouldn't have been able to do so. There've also been some key technology improvements that reduce the need for pacemakers after the procedure, that reduce the risk leaking of blood around the new valve after the procedure. And, we know that all of these things put together make for a much more durable and lasting result. And then, the second area that there've been improvements is just in our comfort and our experience with the procedure. To the point that when we started doing TAVR, we actually used to put all the patients asleep with general anesthetic. We used to have an echo probe, an ultrasound probe, down the esophagus so that we could monitor the heart very, very carefully during the procedure. And, with experience, we've learned that those things are actually not necessary. And so now we do TAVR, as I mentioned before, under just a little bit of sedation. We don't put patients to sleep. And we don't even need the ultrasound probe to guide the procedure anymore. We can do the whole thing using x-rays, which is must less invasive. And so, if you put these technology advances and the procedural advances and experience together, it makes for a much less invasive...in fact, we use the word "minimally invasive" approach to TAVR now, and all of those things put together make for better outcomes, faster recovery, shorter time in hospital, and overall better results.

Host: Even with all of those amazing benefits, what do you think should be improved in the next generation of TAVR?

Dr. Rogers: So, we have great devices to replace TAVR valves that are tight, meaning they've gotten tighter and tighter over time. We see a lot of patients who have leaky valves, and actually, we don't have great technology for those yet. That technology is just coming along and MedStar is actually one of just two hospitals in the country that is testing a new valve for this specific problem. But up until now, we've really been in a bind in that these patients with leaky aortic valves, we've had to say, "Sorry, we don't have a minimally invasive treatment for you. Open-heart surgery is your only option." So, that's one area where I think there is definitely room for improvement. I mentioned the size of the catheters. Smaller catheters are always better because it makes for an even more minimally invasive procedure, so I anticipate that in years to come these catheters and devices will get even smaller, and I think that's only a benefit for patients. There's been a lot of work to improve how well these heart valves sit inside diseased aortic valves that aren't completely round, and aortic valves that had a lot of calcium in them, which is something that we commonly see. And, those patients are particularly prone to having electrical conduction problems after TAVR, and needing pacemakers. And so, there's still a lot of work to be done, I think, to improve the technologies so that patients really don't need pacemakers after TAVR because again, if you do need a pacemaker, that often extends the time you've been in hospital and it's an additional procedure that you have to undergo.

Host: What do you think will be the biggest challenges or barriers in improving or providing TAVR in the future?

Dr. Rogers: So actually, I think the answer to that question doesn't have much to do with TAVR technology or the procedure itself. It's about access and availability to TAVR. If you live in a big city that has a hospital like MedStar Washington Hospital Center that does TAVR, and you have aortic stenosis, then there is a hospital just down the road that can provide you this treatment. If you live far from a big city, then often your local hospital doesn't have access to this technology because it is still a specialist procedure. And so, there are a lot of patients out there across the country who live far from hospitals and don't have access to this. And so, I think there are a lot of patients who could benefit from this treatment, if only it was close to them. So, one of the big challenges we have going forwards, is finding a way to give patients access, to educate patients that TAVR is available, that open-heart surgery isn't the only choice and then also, find ways to either bring the technology closer to where they live or find ways to make it easy for them to travel to where the technology is.

Host: How will you and your colleagues help overcome these challenges?

Dr. Rogers: The first answer has always got to be education. We have to educate other doctors that this is available so that doctors outside in the community, when they see patients, know that these options are available. As I said, this technology is moving very quickly and, those of us who work in this day to day, have to work very hard to keep abreast of all the new advances and the new technologies. And so, we have to work very hard to help other doctors who aren't TAVR doctors to understand what's available, what's changed, what's new. And then, that allows those doctors to teach their patients, "Look. These are the options for you." As I said to you before, there are many areas in the country where patients live many hours from a hospital that offers TAVR and so, those patients may be tempted to say, "Well, I'll stay close to home and have open-heart surgery," when we all know that if you're an elderly patient with lots of other medical problems, TAVR is a better option for you. And so, I think education's got to be the first try. And then, at a bigger level, we have to think, as a society, "How do we improve access to these technologies?"

Host: Why is MedStar Washington Hospital Center uniquely positioned to offer TAVR?

Dr. Rogers: So, MedStar Washington Hospital Center has been at the forefront of TAVR since it was first introduced to the United States over a decade ago. And, we have great experience with all of the TAVR technology, right from the very early days. We've been involved in all of the major clinical trials of TAVR. We've run our own clinical trials, most recently in low-risk patients, so patients who would otherwise undergo surgery. And, we also - because of this - we have access to all the new technologies, so when a new valve becomes available, either under clinical trial or for just commercial use, as a hospital, we get access to that very early. And clearly that gives us an option when a patient comes to us to say that we have not just one option we have many options for you. And, I think research drives our day-to-day mission and that can only make patient care better.

Host: Thanks for joining us today, Dr. Rogers.

Dr. Rogers: Thank you.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Skin cancer is common in the head and neck area because of exposure to ultraviolet (UV) radiation from the sun. Dr. Jonathan Giurintano discusses the most common types of skin cancers and how we treat them.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.

Dr. Giurintano: Thank you so much for having me today.

Host: Today we're discussing treatment options for skin cancers of the head and neck. Dr. Giurintano, how common are skin cancers of the head and neck compared to skin cancers that affect other areas of the body?

Dr. Giurintano: Skin cancers in the head and neck region are extremely, extremely common. The most common types of skin cancers (these are basal cell carcinomas, squamous cell carcinomas and melanomas), are found in areas of the body that receive exposure to the UV radiation from the sun. As the head and neck are the most frequently sun-exposed areas of the body, it follows that these are also extremely common areas that we see skin cancers, often occurring on the scalp, the face, the ears, nose, cheeks or on the neck.

Host: In less visible areas of the body, cancerous moles, spots and other tissues often are removed. How do you approach treatment of the very visible tissue of the head and neck?

Dr. Giurintano: So, it's similar to other areas of the body, especially for larger skin cancers. The best treatment is typically surgical excision. Our colleagues, the dermatologists, are often times specially trained to perform a procedure called Mohs micrographic surgery. So, this is actually a very special type of surgery in which the skin cancer is removed and normal appearing skin around the periphery of the skin cancer, and this is sectioned by the dermatopathologist and looked at under the microscope at the time of the surgery to confirm that there is no further cancer cell present. By doing this, the dermatologists are able to not only completely excise all cancerous cells from the region of the skin cancer, but oftentimes are able to limit the amount of normal skin that must be sacrificed in order to completely resect the skin cancer. In areas such as the nose, the ears or the cheeks, there oftentimes is not much elasticity to the skin that allows for the defect in the skin to be closed simply. Other times, the defect might be closed simply, however the resultant scar might result in an unattractive cosmetic appearance. So, for these types of patients, we do have special ways that we can rearrange the tissue on the face in order to not only reconstruct the defect left behind by the resection of the skin cancer, but also do so in a way that the scar is camouflaged and has the most cosmetically appealing appearance.

Dr. Giurintano: Well, basal cell and squamous cell carcinoma are the most common types of skin cancers that we treat. Other skin cancers such as melanoma require different types of treatment.

Host: What makes treatment different for melanoma?

Dr. Giurintano: So, one of the concerning features of melanoma is that we really cannot do Mohs micrographic surgery for melanomas. Whereas Mohs surgery relies on freezing the samples of normal skin from around the periphery of the tumor and looking at that sample under the microscope with very good success rates for ruling out the presence of cancerous cells, we know that that technology does not work quite as well for melanoma cells. As a result, most melanomas require pretty large resections. So, not only do you excise the melanoma itself, but oftentimes we excise at least one centimeter of normal appearing tissue around the periphery of the melanoma up to two centimeters of normal appearing tissue, dependent on how deep the melanoma is traveling underneath the skin. So, what initially starts out as a very small defect in the face, might soon become a defect that measures 4 or 5 centimeters and needs a major reconstruction. Another facet of melanoma is that it tends to spread very easily to lymph nodes in the neck. So, anytime patients have a melanoma in the head and neck region, very commonly we want to know what is the status of the lymph nodes in the neck. One of the special tools we have for helping determine the lymph node status in the neck is something called sentinel lymph node biopsy. So, this is a special procedure where, on the day of the surgery, before the melanoma is removed, the area around the melanoma is actually injected with a dye that has kind of a radioactive uptake. And then after the melanoma is excised, we can then actually go down to the neck and determine where the lymph nodes are that that melanoma was draining to. So, instead of having to do a large incision to take out all the lymph nodes in the neck without knowing if any of the lymph nodes are positive, we can actually pinpoint only one or two lymph nodes that we know the melanoma would have most likely been draining to and we can go take those lymph nodes out and then look at those lymph nodes under the microscope. And if those lymph nodes do not have any evidence of melanoma, then we know that it's generally safe to watch the neck and not perform any major surgery or give any other therapeutic treatments. So, if that lymph node is involved with tumor, then we could go into the neck, make the incision larger and do a complete neck dissection or complete removal of the lymph nodes in the neck to help prevent recurrence of the melanoma in the future.

Host: Can these cancers spread to other parts of the body?

Dr. Giurintano: Yes. So, that is where my job as a head and neck cancer surgeon often takes the most importance in treating patients with skin cancers. For some people, they might have a small skin cancer on the scalp or on the ear. This is removed by a Mohs surgeon, with negative margins. The area is closed, the patient's happy, and then 5 or 6 months down the road, that patient might develop a small lump in the parotid gland or in the neck. In short, yes, these skin cancers can also send metastasis to the lymph nodes in the face and lymph nodes in the neck. And whenever these lymph nodes do occur, they can often become very aggressive and distort the tissue surrounding them. So, my job as a head and neck surgeon in dealing with skin cancers, often occurs once the skin cancer has spread or metastasized to lymph nodes. And my job is to go into the neck or into the parotid gland and to remove these lymph nodes to remove all the cancer that has spread.

Host: How do you recommend that patients prepare for treatment?

Dr. Giurintano: A large part of the preparation for these patients is mental and emotional. Oftentimes, when the Mohs surgeon performs their portion of the procedure, which is the removal of the skin cancer, the resultant defect might be left in place with a bandage over it so that they can then be reconstructed secondarily by an otolaryngologist or by a facial plastic surgeon. It can be very distressing for patients to see a large hole in their face immediately after surgery, but they must be assured that this will be reconstructed in a manner that is both cosmetically appealing and functional. Occasionally, in order to repair defects in the skin on some parts of the nose, we have to take tissue from adjacent sites on the face, such as the skin on the forehead, and use that skin to resurface the lining of the nose. In order to do that sort of procedure, what's called a local tissue flap, the patient has a very odd appearance immediately after surgery as the piece of skin still has a bridge connecting it where the artery, that is supplying the skin flap, is running. This can result in a very strange physical appearance for the 3 to 4 weeks immediately after reconstructive surgery while the skin is healing in to place on the nose. However, we have to encourage the patient that within 6 weeks, a second procedure is performed where that skin bridge is removed, and the remaining tissue is reoriented so that there is a normal cosmetic appearance with only a minor scar present on the forehead.

Host: What does recovery from head and neck skin cancer treatment entail?

Dr. Giurintano: So, aside from the actual recovery from surgery, which is often performed either on an outpatient basis or maybe with a 1 to 2 day hospital stay, if the lymph nodes in the neck need to be removed, recovery from head and neck skin cancer treatment, most importantly, requires a very close follow-up, with either an otolaryngologist or a dermatologist, in the future to ensure that no other areas of skin cancer arise within the head and neck. While it is impossible to completely reverse the many decades of damage the UV radiation from the sun has often done to patients' skin, it is never too late to begin applying sunscreen and to do precautionary measures to help limit the amount of damage to the remaining skin and to help prevent further skin cancers from occurring in the future.

Host: You mentioned sunscreen. Are there any other prevention tips that you can offer to people in the community?

Dr. Giurintano: So, aside from wearing sunscreen daily, which should be part of all of our daily routines anytime we go out - the face, the ears, and, especially for men who might be balding, application of sunscreen on the scalp, a few other very good preventative measures are to wear a wide brimmed hat if you are going to be out in regular sun exposure and to not only apply sunscreen whenever it's sunny outside. Even if it's cloudy outside, the UV radiation from the sun can still cause damage to the skin, so sunscreen in encouraged and recommended anytime patients are going to be outside.

Host: Could you share a story about a patient who had a particularly successful outcome after skin cancer treatment?

Dr. Giurintano: So, I previously had a patient who was actually a transplant patient - previously had a kidney transplant - and, as part of his transplant protocol, he was required to take immunosuppressive drugs to ensure that the body did not reject the transplanted kidney. The unfortunate thing about immunosuppressive drugs is that if a cancer does develop in the body, the immune system is not present to help fight that cancer and it can spread very rapidly. So, I previously had a patient who was a transplant recipient, who developed what was initially a very small skin cancer present on his left face that very rapidly increased in size, to the point where nearly the entirety of his left face was involved with the skin cancer within only a few weeks. This patient required a large radical resection of the tumor as well as the underlying parotid gland and the lymph nodes in the neck. In this patient, we actually used a free flap (so, that's a piece of tissue from the thigh that we connected with an artery and a vein in the neck), and we used that tissue from the leg to resurface the skin, fat and parotid gland that was resected during the cancer resection. And, the patient had an excellent cosmetic appearance afterwards and was able to complete radiation therapy and chemotherapy, and since that time, has not had any further skin cancers develop.

Host: Why is MedStar Washington Hospital Center the best place for patients to come to receive treatment for skin cancers of the head and neck?

Dr. Giurintano: MedStar Washington Hospital Center is an excellent place to come for head and neck skin cancer treatment as we have all the tools necessary to handle the most minor skin cancers up to the most complicated of skin cancers. While many small skin cancers can be handled in the community setting, for those type skin cancers which become very aggressive and which might invade locally into structures of the face - this includes the muscles of the face, the parotid gland or the large saliva glands on the side of the face and even the facial nerve, the nerve that controls all facial movements on one side of the face - for all these patients, even if the tumor is involving these structures, we have the surgical capability as well as the capability to provide adjuvant radiation therapy and chemotherapy, for even the most aggressive skin cancers to help patients have not only the best oncologic outcome possible but also the best cosmetic and physical outcome possible.

Host: Thanks for joining us today, Dr. Giurintano.

Dr. Giurintano: It was a pleasure. Thank you so much for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Symptoms of bunions include pain, restricted movement of the big toe, swelling and redness. Dr. Ali Rahnama discusses what causes bunions and how we treat them.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama.

Dr. Rahnama: Thank you for having me. It's a pleasure.

Host: Today we're discussing bunions, which are painful, bony lumps that can develop at the base of the big toes. Dr. Rahnama, what's going on within a patient's foot when a bunion forms?

Dr. Rahnama: So, as you very nicely said, a bunion is a large bump at the base of the great toe joint that forms. There are multiple reasons that can contribute to a bunion's development. We think that, for the most part, the average patient that we see with bunions, it's likely hereditary in nature. Most experts will agree that shoe gear and high heels and tight shoes - while they can exacerbate or make it more painful or symptomatic, they're likely not the cause of why a bunion would form.

Host: Often, people think of older adults as most likely to develop bunions. Is that accurate?

Dr. Rahnama: Well, it's true that by the time most people present for help and evaluation of their bunion, the bunion can become prominent and painful as early as the teen years. And, this is usually a condition called juvenile hallux valgus. These individuals are usually hypermobile or ligamentously lax, think of highly flexible people. So, to answer your question, no. The bunion can really affect people of all ages.

Host: Do patients usually know what's going on with their foot, or are they surprised by the diagnosis when they come see you?

Dr. Rahnama: No, this is actually one of those things where usually people know exactly what is going on when they come and present to us. They're really looking more so for an answer on what they can do about the pain and discomfort that they're experiencing, more than wondering what's going on. Pain is the number one thing at the base of the great toe joint. A lot of times it becomes red and hot and swollen, particularly after they do have to be in a pair of tight shoes. We see this a lot in females but certainly we do see it in our male patients as well. A lot of times, because of that bony prominence or protuberance that's there, the body will produce a small bursa sac as a little cushioning or type-mechanism to help protect itself and so, that even, a lot of times, makes the bunion seem larger, more prominent than it actually is.

Host: Sort of like a blister?

Dr. Rahnama: Similar, but it's more...it's on the inside. It's inflammatory tissue. The actual skin around the great toe joint can become thickened. So, these things can all contribute to the bunion becoming or appearing larger than it actually is.

Host: Could having a bunion indicate that something else is going on within the foot?

Dr. Rahnama: Absolutely. A lot of times, we can see that a bunion comes hand-in-hand with a larger orthopedic or foot and ankle deformity, such as a flat foot or a tightening or contracture of the heel cord, can contribute to the bunion's formation as well.

Host: What are the most effective treatment options for bunions?

Dr. Rahnama: We can try things like toe spacers, shoe inserts, oral anti-inflammatories, topical anti-inflammatories to start, but none of these things will actually get rid of the bunion. They may just help with simply alleviating the pain that the patient is experiencing. The most definitive way to treat them is by surgically correcting them. But one thing I will add is that, at least my philosophy when it comes to bunions, is that I will try not to operate on a patient who's telling me that the bunion's not painful. So, we try to typically stay away from cosmetic foot surgery. That's something that I will not do. If it's not bothering you and it doesn't hurt, my recommendation is to leave it alone.

Host: Is there any long-lasting ramifications for leaving a bunion untreated?

Dr. Rahnama: The biggest thing with that is that not having a symptomatic bunion fixed or repaired can do two things - the pain can become worse with time and the bunion can become worse with time. So, those are the two big things that I would caution patients when it comes to their bunion. The third thing is that, over time, the great toe joint can actually become arthritic. And so, if they wait too long, instead of having bunion corrective surgery, that they would have to have fusion of that great toe joint. And, while most patients do well with that, it would be great to avoid that with a lesser procedure, if possible.

Host: During or after treatment, what activity restrictions should patients expect?

Dr. Rahnama: Well, after surgery, depending on the type of bunion procedure that they've needed to have, some patients would be able to start weight-bearing, in a surgical boot, as soon as the day after surgery. In patients who have to undergo a slightly larger procedure because of how bad their bunion may be, they need to stay non-weight-bearing on the operative extremity, or foot, for a period of time, typically no more than 3 or 4 weeks.

Host: Is treatment typically "one and done," or do bunions often return?

Dr. Rahnama: It depends on the type of treatment that they had. Bunions can certainly return after surgery but there are surgical procedures that we can choose so that it gives the patient the best chance at not having a recurrence of the deformity. Those procedure sometimes may take a little longer for the healing of the patient and they may require them to remain non-weight-bearing, or staying off of the foot, for maybe a few more weeks. But, in the long run, particularly if they're younger, those juvenile hallux valgus patients, as an example that we talked about a little earlier, if we DO do the slightly larger procedure, it can avoid a recurrence as they get older, into their 40s, 50s.

Host: Could you describe a general bunion removal or a bunion treatment procedure?

Dr. Rahnama: So, if you look at a textbook on foot and ankle surgery, you can find over a hundred ways to surgically correct a bunion. The most common two procedures, I would say, are head procedures, is what we call them. It's when we physically shave the bump down with the saw in the operating room and then we make small cuts in the bone and shift the bone over, and we typically fixate it with one or two screws. That is a smaller procedure. Patients are typically able to weight-bear almost immediately after surgery. But again, that is the smaller of the two procedures. But, if a patient has that done and they have a really severe bunion or if they're very young, they're always susceptible to having a recurrence. The slightly larger procedure is where we fuse the joint that is distoproximal, or towards the midfoot. Patients are a lot of times surprised to see that we want to go after an area of the foot that doesn't appear to be symptomatic for them. But that joint is really where the root of the bunion is. And so, if we can correct the bunion at that level and fuse the joint end close to the midfoot, then straighten out the bone, then we avoid a recurrence.

Host: Can you recall a patient who had particularly bad bunions but was able to return to an active lifestyle?

Dr. Rahnama: I would say that, luckily, most of our patients who undergo bunion surgery are able to get back to not only the things they want to do, but also wearing the type of shoes that they want to wear without discomfort. Really, the aim of the surgery is to be able to help them have a better quality of life to begin with so that's why we decide to proceed with it to begin with.

Host: Why should someone with bunions consult with the foot and ankle surgeons at MedStar Washington Hospital Center?

Dr. Rahnama: I think it's really important for patients to be able to consult with a specialist who can help the patient choose the best procedure that's right for them. And, I would say that we have a very highly skilled team of surgeons here, more than equipped to deal with patients and their foot and ankle needs.

Host: Thanks for joining us today, Dr. Rahnama.

Dr. Rahnama: Thank you so much for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Transoral thyroid surgery is a procedure we use to remove thyroid nodules by going through the mouth, as opposed to making incisions in the neck. Dr. Erin Felger discusses who's a candidate and what recovery is like.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Erin Felger, an endocrine surgeon at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Felger.

Dr. Felger: Thank you for having me.

Host: Today we're discussing transoral thyroid procedures, or thyroid surgeries done through the mouth instead of through open incisions in the neck. Dr. Felger, why would a doctor recommend a transoral thyroid procedure instead of a traditional approach?

Dr. Felger: The main reason that someone would offer a transoral procedure to their patient or an endocrinologist would offer to have a patient seen for transoral procedures is because of scar issues. These can be scar issues related to a medical problem like hypertrophy or keloid, which a number of people in our population have, or scar issues that are psychological, in that nobody wants to have a scar on their neck.

Host: What symptoms do patients share with their doctors that ultimately lead to a diagnosis of thyroid issues?

Dr. Felger: It depends on the type of thyroid issue. The main symptoms that people usually discuss are symptoms of fatigue, constipation, hair loss, skin changes - which are all associated with hypothyroidism, or anxiety, racing heart, heat intolerance - which are due to hyperthyroidism. With respect to surgical issues, the most common symptoms are symptoms related to compression of the thyroid because of its size and they include voice changes, swallowing difficulties or inability to lay flat at night.

Host: What are some of the most common conditions for which the transoral approach is most effective?

Dr. Felger: For most patients, the best reason to have a transoral thyroid approach is, again, for the scar issues. But in terms of actual disease processis, almost any disease process could be taken care of through a transoral approach. The best options are a solitary nodule or a small thyroid cancer, on occasion parathyroids and, very rarely, a large multinodular goiter.

Host: How does the conversation go when you start talking about surgical approaches for your patients?

Dr. Felger: Basically, I start the conversation with explaining why they would be a good candidate for the operation. I also tell them that there is a standard operation so that they hear that there's another way to do it. And then I go into the details about how many we've done, what the procedure is and how it differs in terms of pain control and postoperative care afterwards. And honestly, there isn't that much that's different between the two procedures when I'm talking to patients, except for the oral care with the transoral approach. Everything else is very similar.

Host: What does a patient have to do to prepare for surgery?

Dr. Felger: The patient needs to have been seen by the surgeon for their initial consult. And at that time, the surgeon will be giving the patient a list of items that need to be completed prior to the day of surgery. Those usually include labs, EKG, and a preoperative physical at a minimum. The surgeon may require other testing to be done, which might include imaging or a biopsy.

Host: How long is the recovery time after a transoral thyroid procedure?

Dr. Felger: In general, I tell everyone it's a week, but most patients feel really good after a couple days. But, I also want them to understand that it's not going to be perfect for a period of time, which is usually around a week, so that's why I give that as my standard approach. After surgery, patients can expect to have some swallowing difficulty, secondary to the breathing tube. They can expect to have numbness around the mouth where the incisions are placed, as well as on the chin. The chin numbness can last for several months but it does resolve after a period of time which is different for each patient.

Host: What additional treatment or care do patients need after surgery?

Dr. Felger: For transoral patients, they do have to do an oral care regimen until they come back for their first postoperative visit, which just includes a salt water swish and spit after each meal and at bedtime.

Host: Could you share a story of a patient who had a successful outcome?

Dr. Felger: I had a wonderful lady who I saw in my clinic who has terrible hypertrophy with her other scars from other surgeries. She was very concerned about having a scar on her neck that would be visible with this medical problem. She had a nodule that was quite large that needed to be removed. And she and I talked about doing the transoral approach and she was very interested in it. She was hesitant at first to sign up for surgery but ultimately, after discussing with her family, she decided to have the transoral approach. Her surgery went wonderfully and she came back to see me the week after the operation for her first postoperative visit and she was thrilled. She said, "I know that my chin is numb, my mouth doesn't feel quite right yet. If I had it to do over again, I'd do it this way again. I have no scar on my neck."

Host: Why is MedStar Washington Hospital Center the best place to seek care for thyroid conditions?

Dr. Felger: We have the best multidisciplinary group in the region. We work with our endocrinologists, our nuclear medicine doctors and our radiologists to provide the most comprehensive care available for any thyroid condition. From the standpoint of doing transoral thyroid surgery, we're the only hospital in the DC and Maryland area that is doing this procedure. And, again, we have a comprehensive team that we work with so that the transoral procedure can be done as successfully as possible.

Host: Thanks for joining us today, Dr. Felger.

Dr. Felger: Thank you.

Many adults are caregivers for elderly relatives. Dr. Cesar Torres discusses common problems these caregivers face and his best tips to keep elderly loved ones safe.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Cesar Torres, a geriatric and house-call doctor at MedStar Washington Hospital Center. Thank you for joining us, Dr. Torres.

Dr. Torres: My pleasure.

Host: Today we're discussing advice for adults caring for older relatives. Dr. Torres, in terms of safety, what are some of the key areas of concern that caregivers often worry about?

Dr. Torres: I think the number one area would be falling. Falls can lead to very life altering fractures, specifically fractures of the hip. And, study after study has shown that a hip fracture will have significant effect on mortality rates. Your odds of dying within the first year of a hip fracture are, unfortunately, quite high. Falls, household accidents - the ability to communicate with loved ones in case of a household accident is something that a lot of caregivers worry about. But if I had to rank it, I would put the risk of a fall as the number one thing that really keeps up everybody at night.

Host: Is this concern just for seniors with medical conditions such as dementia or heart disease?

Dr. Torres: No. All seniors are at risk for it. There are a lot of different reasons for this. There are sensory inputs into increasing the fall risk, such as loss of vision or impaired vision. There's a loss of proprioception - by that I mean balance. There's a loss of muscle strengths, so the elder will literally not be able to lift their feet high enough to clear very simple obstacles in their path and so they end up falling or tripping. There's also the problem with improper medication or over-medication, which we, unfortunately, as physicians, sometimes contribute to and then we have to be mindful of, to try to avoid and mitigate the risk.

Host: What would be the risks involved with over-medication?

Dr. Torres: Well, some medications, and there are over-the-counter medications also that are guilty of this, predispose elderly patients to sedation, dizziness, and these increase the fall risk. By that, medications like over-the-counter sleep aids, Benadryl, antihistamines - they can impair the elderly patient's ability to manage their household environment.

Host: What can seniors and their caregivers do to reduce the risk of falls at home?

Dr. Torres: I think the biggest thing I see, in doing house calls, is reducing the amount of clutter in the house - throw rugs, items just left on the floor. All of these are potential obstacles and they can lead to a very bad fall that can result in a fracture. Lighting - improving the lighting for seniors is also a great help. Making sure that they're wearing their glasses. Some folks really do not like wearing glasses. Having handrails. Trying to minimize the need for an elder to go up and down stairs - moving them onto a single floor may also prevent a fall.

Host: They seem like really common sense type things that anybody should follow.

Dr. Torres: But, they get overlooked because they are so common. Sometimes you need that person who comes in to your home and is taking care of your mother or father and she has to point it out and that little bit of added emphasis leads to a change.

Host: How do the geriatrics and house-call experts at MedStar Washington Hospital Center help patients and families care for their aging loved ones at home?

Dr. Torres: Well, since we travel to the home, we have a good sense of what are the environmental obstacles in the home. As part of our program, we'll do environmental assessment and we'll make specific recommendations, making sure that all the sensory inputs are optimized for the senior also go a long way. And we can make referrals to eye doctors, ophthalmologists, otolaryngologists, and they can help with making sure the senior's sight and hearing are improved to the maximal point that they can.

Host: Are there any additional general tips that you would give to families who are caring for aging loved ones at home?

Dr. Torres: I would foster open communication as to what your loved one needs help with, okay? Don't just assume that they're doing OK because they're not calling you for help. A lot of times what we see is that the elder will do everything they can NOT to bother their family members. And, the more open the communication, the more likely you are to know when there is a problem. And I think that goes a long way. Another safety issue that seniors and their families face is the issue of driving. The ability to drive does change with age, but just because a person is of a certain age, that does not necessarily mean that they can't drive. But the issue is one that needs to be explored as the person ages. Don't just assume because the person just renews their license automatically that they can actually drive. There are laws - they vary from state to state - that can help but the family should periodically check in. Reaction time diminishes as the person ages. There are the visual changes. There are the hearing changes. There can be significant osteoarthritis of the cervical spine that prevents the elder from turning their head. Driving safety is something that really needs to be a top priority - not just for the patient themselves but for the society at large. The District of Columbia, fortunately after a certain age, there are requirements that the driver undergo vision testing as well as getting the authorization to drive from their primary care physician. So, that's something I am in favor of.

Host: What are some of the more common conditions you're seeing in these older adults as you're going out on house calls?

Dr. Torres: Chronic pain from degenerative joint disease such as arthritis. Hypertension. Diabetes. Obesity. Mood disorders. Sleep apnea. Chronic kidney disease. Heart attack and stroke.

Host: So, when you're making your house calls and seeing your aging parents, are you seeing issues with medication adherence?

Dr. Torres: Unfortunately, we can. We try to reduce that as much as possible by physically, visually looking at each one of their pill bottles. And, that's something that, I'm happy to say, that's becoming much more of a common practice. When the elderly patient comes in to see their primary care physician, they should be instructed to bring all their medicines in their favorite paper bag. We call it the brown bag. The major problem with adherence is the difficulty with remembering complicated medication regimens. Medications that have to be taken three times a day, generally, are extremely difficult. So, yes, adherence is an issue. The more that the physician can simplify the regimen, the better the outcome will be. Some of the tips I can offer: pill boxes can be a help. Any form of reminder, be it visual or even auditory - I mean, there are lots of apps out there that can be programmed to give reminders to take medications. But generally, just being aware that the loved one is on some type of medication regimen. Generally, that'll spin off into the appropriate technique to make sure that they are getting their medications.

Host: Could you share the story of a family that maybe had a particularly stressful time at home that you were able to help through your program?

Dr. Torres: A patient who was living by herself. The apartment was less than optimal. She had no handicap accommodations. And, I basically, through a series of letters, we were able to help her move into a handicap accessible apartment with more than reasonable accommodations. And, she had been experiencing some mild depression that was starting to impact her adherence to the medication regimens. But that improved dramatically once she was able to move and that was just on the basis of the move itself, into a much safer environment, a much more friendly environment.

Host: Thanks for joining us today, Dr. Torres.

Dr. Torres: My pleasure.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Adult circumcisions are common in the Mid-Atlantic for men who never received a circumcision as a baby boy. The reasoning? Some men feel self-conscious about the way they look, while others develop skin conditions. Dr. Krishnan Venkatesan discusses the procedure and what men can expect during recovery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Krishnan Venkatesan, Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome, Dr. Venkatesan.

Dr. Krishnan Venkatesan: Hi. Thank you for having me.

Host: Today we're discussing adult circumcision, a reconstructive procedure that, while not widely discussed, is growing in popularity among men in the Mid-Atlantic region. Dr. Venkatesan, could you start by explaining what circumcision is for listeners who might not know?

Dr. Venkatesan: Of course. Circumcision is basically removal of excess foreskin from the shaft of the penis. It can be done for many different reasons, which I think we'll delve into later in this conversation.

Host: So, in the U.S., circumcision is typically performed on baby boys, so why are more men requesting the procedure, as adults, when they've been uncircumcised all their lives?

Dr. Venkatesan: There could be many reasons to undergo circumcision as an adult. Sometimes there are specific medical conditions. One is called phimosis, where the foreskin is actually tight and can trap urine underneath the skin and cause inflammation or infection of the head of the penis or the skin or even in the urinary tract. Sometimes, if they have warts or genital warts, men may want circumcision to have those removed. There are also other skin conditions. Lichen sclerosus is an immune mediated skin condition. We actually don't know exactly what causes it, but basically, it can cause some scarring of the foreskin so the skin gets very tight around the shaft of the penis and onto the head of the penis and some patients may even feel that the head of the penis itself, the skin has lost its elasticity and instead of having a lot of small folds, it's very flat and shiny, and some patients even will experience itching of the head of the penis, especially after sex, or even some fissures, like cracks in the skin, that can get very irritated after sex or even if the area is manipulated too much. In about twenty percent of those patients, they can also involve the opening of the penis where men urinate from and this can have other implications along the urinary tract, as well. All in all, circumcision is popular here in the U.S. and it's not practiced that widely in the rest of the world. So, there are otherwise some social reasons that men tend to request circumcision, mainly because they're self-conscious about being in a locker room or in a team shower or something, if they play sports, where some men may be circumcised, and some are not and they don't really want to stick out.

Host: Do you ever have men come in who are concerned what their partners might think or their sexual partners might think? Could you address that?

Dr. Venkatesan: Yeah, absolutely. And that kind of goes along that social line that because, overwhelmingly, large number of men are circumcised in the U.S., men may worry that female partners may find it unusual or abnormal and because of that, they may feel more self-conscious about it. And they may also find that it's less pleasing in intercourse or, in some cases, they may find that it's uncomfortable for intercourse because the skin is getting irritated or something.

Host: If a man grows up this way his whole life, he's uncircumcised his whole life, if he chooses to remain uncircumcised, are there any health implications to be concerned about there?

Dr. Venkatesan: No. There is evidence that suggests that circumcision at a young age, before puberty, can have some protective effect as far as decreasing the risk of penile cancer. But, in adult men who have already undergone puberty, there's no significant benefit to circumcision at that point. The cancer of the penis is very rare, regardless, so as long as they maintain good hygiene and examine themselves reasonably frequently, then they should be able to avoid any serious problems from something like cancer of the penis. I would also like to say that, in other parts of the world, not the U.S., that circumcision sometimes is used as a means of HIV prevention or prevention of transmitting any other sexually transmitted diseases. That has been shown to have a benefit in places where HIV is endemic, like in Africa, but from a medical standpoint, otherwise, there's no reason that it has to be done in childhood.

Host: Approximately how many adult circumcisions are performed at MedStar Washington Hospital Center each year?

Dr. Venkatesan: I'd say we probably do somewhere between fifty and a hundred a year, between myself and all of my colleagues. Like I said, there's a wide number of reasons that we do them. Some are more for social reasons and others are for specific medical problems.

Host: Could you describe your patient population for adult circumcision? Are these men young adults, middle-aged, teenagers?

Dr. Venkatesan: Yeah. There's a wide range of men who come in seeking circumcision. Quite often, there are young men in their late teens or early twenties who were not circumcised as children but, as they are moving out of home or becoming sexually active and exploring that realm, so to speak, they recognize that they're different from their friends or colleagues and they want to have less inhibitions or less to be self-conscious about it, and they come in seeking it. And, similarly, there are men with medical conditions that can occur at any age, including tightness of the foreskin, or other skin conditions like lichen sclerosus, that need circumcision for actual medical treatment. And there's no specific age range where it's right or wrong for them to come in to seek that treatment.

Host: What questions do patients or their partners ask about adult circumcision?

Dr. Venkatesan: The main question they ask, of course, is whether it will be painful. And, like any surgery, there will be some discomfort initially, but typically the healing period is relatively short and within a month after surgery most men are back in normal function and form. I think the main other questions are whether it will cause any effect on sexual function or urination. And, typically, it shouldn't have any effect of either of those things.

Host: What are some of the risks that are involved with adult circumcision?

Dr. Venkatesan: The risks involved with circumcision include general risks of any surgery, like infection and bleeding, and then, of course, risks associated with the specific area we're operating on. So, there's always a risk of needing further surgery if the patient is not happy with the cosmetic outcome. And also, risks of the stitches coming apart or having some scarring requiring further surgery. There's a pretty low chance of any deeper structures in the penis being affected, like the urinary tract, or any nerves that would provide some function for sexual function or anything like that or sensation. Of course, there are risks with any anesthesia, as well.

Host: What does a patient have to do to prepare for this procedure?

Dr. Venkatesan: I would think that the main preparation really ought to be consulting with their urologist beforehand and understanding the risks of the procedure, the indications for the procedure, and the expected recovery. But other than that, there's nothing they need to do at home as far as physical preparation or diet or anything like that.

Host: Could you describe how the procedure's performed?

Dr. Venkatesan: Yeah, absolutely. We basically make two parallel incisions around the circumference of the penis - one upstream from the skin we want to remove and one downstream from the skin we want to remove. And, then we basically unwrap that part of the skin off of the shaft of the penis. And, then the two edges that are remaining, we sew them back together.

Host: What does recovery entail? For example, are there restrictions for having sex, using the bathroom, or exercising?

Dr. Venkatesan: The recovery usually does entail some activity restrictions. We don't typically leave a catheter or anything like that, so the patient should be able to urinate on their own immediately after surgery and use the restroom, otherwise, without difficulty. I do typically ask my patients to refrain from any sexual activities for about four weeks while the stitches and the incision are healing up. And similarly, for that first couple of weeks, I'd like them to avoid any heavy exercise mainly to avoid any sweating or strain or stress on the incision that might affect it's healing. We typically do send patients home with some pain medication and some antibiotics. The expectation, for the most part, is that patients generally will not need any narcotic pain medication beyond one week after surgery. By that point, they're usually up and around doing most of their normal activities, aside from the other activity restrictions that I had described. And, usually by that point, aside from specific, unique jobs that may require further activity restrictions, most patients will usually be able to go back to work within that one week.

Host: Could you share a story from your practice? Perhaps you had a man come in requesting this procedure and was incredibly happy with the results?

Dr. Venkatesan: Yeah. I can recall specifically one man who was in his 50s and diabetic and, as I had described earlier, he had a very tight foreskin so he was getting frequent infections with urine getting trapped between the skin and the head of the penis. And, once we did a circumcision, he was basically infection-free and symptom-free and he was able to maintain much better hygiene there and, overall, was quite happy with the results within a month after surgery.

Host: Like anybody, men would have a specific hygiene regimen prior to being circumcised. Is there anything in that regimen that would have to change or that they would do differently after they were circumcised?

Dr. Venkatesan: No. So, I suspect and expect that hygiene maintenance after circumcision should actually be easier than before circumcision basically because, before circumcision, men would have to pull back the foreskin and really ensure that every crevice and fold of skin is properly cleaned and scrubbed. After circumcision, there's no excess skin, so the skin covering the shaft of the penis basically has a very smooth transition and should be very easy to clean. Everything's that there, visible to the eye, can be cleaned easily and there's... much easier not to miss anything.

Host: Why is MedStar Washington Hospital Center uniquely positioned to take care of men who want to have circumcision as an adult?

Dr. Venkatesan: I think we're in a strong, unique position to take care of adult men requiring circumcision because we are a tertiary care referral center in our Dept. of Urology. We see patients with very complex problems including complicated skin conditions that require circumcision and reconstruction of the penile shaft and skin. And we see a wide range of men, even ranging to men with no significant problems but who have straightforward circumcisions. But, based on our skill set and the complexity of things that we do and the volume that we do, I think that we are positioned well to offer patients good preoperative counseling and good postoperative outcomes.

Host: Thanks for joining us today, Dr. Venkatesan.

Dr. Venkatesan: My pleasure.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Sleep apnea, or when patients temporarily stop breathing during sleep, can be cured with corrective jaw surgery. Dr. Ravi Agarwal explains how it works and what to expect during recovery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Ravi Agarwal, an oral and maxillofacial surgeon and the residency program director for the Department of Oral and Maxillofacial Surgery at MedStar Washington Hospital Center. Welcome, Dr. Agarwal.

Dr. Ravi Agarwal: Thanks for having me here today.

Host: Today we're discussing corrective jaw surgery for obstructive sleep apnea and breathing issues. Dr. Agarwal, how is the jaw related to breathing conditions such as obstructive sleep apnea?

Dr. Agarwal: Great question! Most people do not realize that the top jaw and the bottom jaw do more than just allow us to eat and chew. These bones also serve as attachments to a lot of muscles around the face and neck, which support both the tongue and the airway. For example, patients who have an obstructed upper jaw may also have a narrowed nose, making breathing through their nose more difficult. Or, patients with small lower jaws will have a smaller area for their tongue to sit in and have more tongue obstruction while they're sleeping, leading to obstructive sleep apnea.

Host: Could you describe your patient population for this type of corrective jaw surgery?

Dr. Agarwal: There are two different populations that we see for corrective jaw surgery. The first population are those patients who have jaw deformities, like underbites, deep bites, jaw asymmetries, or usually working with an orthodontist for braces and ultimately would need jaw surgery to correct the alignment of their jaws. These patients often have issues like difficulty with chewing, breathing problems, speech problems, jaw pain, and even concerns about their appearance. All of these complaints we are able to adjust with corrective jaw surgery. As you can imagine, a significant portion of these patients are teenagers, young adults - but we are starting to see a lot of adults who wish to undergo the same procedures. The second population that we see are patients with obstructive sleep apnea or breathing issues related to sleeping. They have a diagnosis of sleep apnea and they acknowledge that they stop breathing at night and have a lot of associated problems with that, such as excessive daytime fatigue, sleepiness, unable to perform their jobs, have fallen asleep while driving. Most of these patients are working with a medical provider. They maybe have tried CPAP, the mask that they wear at nighttime to help them breath. But many of them find this problematic and look for a surgical solution. As I mentioned, the relationship of the jaws to the airway, corrective jaw surgery - those same procedures can be used to advance the jaws, which would help open up the airway.

Host: When we're thinking about these two different patient populations, how do you decide whether jaw surgery is appropriate for them?

Dr. Agarwal: There's a lot of factors that we look at when we evaluate a patient. Most often, if there's an anatomic abnormality that we can detect, they may be a good candidate for jaw surgery. We determine that by 1) a clinical examination - looking at their mouth, looking at their teeth, looking at the shape of their face, the shapes of the bones. We also utilize x-rays, 3 dimensional x-rays, to look at the size of their airways, the dimensions of the airways, and the dimensions of their jaws. Based on their problems, and what we see clinically, we can discuss with the patient if they're a candidate for corrective jaw surgery.

Host: Could you describe how these types of surgeries are performed?

Dr. Agarwal: Corrective jaw surgery is a surgery that's done all from inside the mouth. A significant number of patients will probably be working with an orthodontist, so they may have braces - which we actually use during the surgery. What we do is we make incisions in the gums around the jaws, we access the bones, and we use specialized instruments to make cuts in the bone. Once these bones are split, we're able to reposition them in a new predicted position using splints that we had made before the surgery. The bones are then stabilized with small plates and screws, which you won't feel or know they're there and we then use dissolvable stitches to close the gums. The surgery is done under general anesthesia in the operating room and most patients will have an overnight stay in the hospital.

Host: Is there anything that patients have to do to prepare for surgery, perhaps the day of or getting any tests beforehand?

Dr. Agarwal: In general, patients who are getting corrective jaw surgery are undergoing a preoperative medical clearance, very similar to other major surgeries that are happening. Preparation is different, depending on what the patient's desires are. Someone who wants to straighten their teeth and straighten their bite with the corrective jaw surgery to help their breathing, may be in braces and have undergone orthodontics for one to two years prior to even having the surgery. When they're in that situation, we work closely with the orthodontist to make sure everything is done correctly prior to taking them to the operating room for the surgery.

Host: How long does recovery typically take and are there any restrictions for eating, talking or exercising afterward?

Dr. Agarwal: The recovery for corrective jaw surgery starts immediately after surgery. Usually there's an overnight stay in the hospital, where we're monitoring them to make sure they're recovering well. But once they get home, there are a few restrictions. Most patients will need about two weeks at home due to the amount of swelling they'll have. During those two weeks, we ask that they do not do any heavy lifting or exercises. But they can do daily activities such as washing the dishes, cleaning, and housework. After two weeks, most patients can start doing light exercise. But generally, we wait to six weeks before they can perform full physical activities. In terms of their diet, obviously we're doing a lot of work inside the mouth and the bones of the jaws, and so patients will need to be on a full liquid diet for six weeks.

Host: What about teenagers who are playing sports? How long do they have to sit out?

Dr. Agarwal: For most sports we ask them to sit out for about six weeks. But, after two to three weeks, they definitely will be able to do light physical activities such as jogging and light weights. After six weeks they can return to full sports. The only caveat to that is patients or teenagers who play sports where facial injuries are common. In those situations, I may ask that they refrain from those sports for three months, because at that point the bones have really matured and there's no further risk to them.

Host: Are these patients sitting with their jaws wired shut?

Dr. Agarwal: Nope. Patients jaws are not generally wired shut after this type of procedure. Using the techniques we utilize today and the plates and screws that we use, we're able to not have to wire a patient's jaw shut.

Host: Obviously there are some things that you can't control - so, the way your jaw is built, your anatomy. But for something like obstructive sleep apnea, is there anything that patients can do to reduce their risk for needing surgery or that they can do to improve their condition otherwise?

Dr. Agarwal: You know, obstructive sleep apnea is definitely a multifactorial medical disease. A vast majority of patients, it may be related to weight, size - so exercise, weight loss would be some of the biggest things that could help reduce their chance of developing or having obstructive sleep apnea. There are non-surgical treatments for obstructive sleep apnea. The biggest one is CPAP. But for patients who don't tolerate CPAP, there are options for oral appliances. These are devices that are generally made by dental or dental providers that would fit into their mouth and, essentially, shift their bottom jaw forward while they're sleeping at night. By shifting the bottom jaw forward, it opens up the airway and reduces the obstructive sleep apnea.

Host: Could you describe some of the benefits of this type of surgery?

Dr. Agarwal: There are a lot of benefits to corrective jaw surgery. Obviously, getting the teeth and the jaws in a better position, patients are able to chew better, chew more efficiently, some of their speech problems may be improved. If they have concerns about pain, having the jaws in a better position can reduce their pain. And obviously, like we discussed, breathing. There are other nice results that come from jaw surgery such as an improved smile and an improved facial appearance. One of the things we keep in mind when we're doing jaw surgeries - how to improve their facial harmony. So, patients often have more confidence about themselves and appreciate the way they appear. However, with all the benefits, there are side effects to every surgery that we perform. Outside of the recovery that we discussed earlier, one of the side effects of corrective jaw surgery is that patients may have some numbness of their lips, teeth and gums, as when we are working in these bones, the sensory nerves are in that region. After one year though, a vast majority of patients have no issues related to the numbness.

Host: Could you share a treatment success story from your practice?

Dr. Agarwal: As you can imagine, there are a lot of treatment successes when you do corrective jaw surgery to help someone breath. One that comes to my mind was a gentleman we took care of who came to his consultation with his family and his kids. And, the patient was trying to explain to me about how he struggled with sleeping and snoring. And then his young child just drops everything and says, "Daddy snores really loud!" And the dad just looks at me and says, "See? I really have a problem with sleeping." And, you know, a few weeks after surgery, I see him for his post-op and I said, "How are those kids doing with the sleeping?" He says, "It's peaceful in the house. Everybody's so happy that I can breathe and I'm not snoring anymore." And these are the things that really, really...why we enjoy doing this procedure because it really can be life changing, both from a functional standpoint but even from a family standpoint.

Host: What are some of those other issues that you can help correct when you do these types of surgeries, either for the patient or their quality of life at home?

Dr. Agarwal: In the teenage years, if there's a jaw deformity, there are a lot of psychosocial components - that a patient may have trouble at school with their appearance or may have lack of self-confidence. And, corrective jaw surgery, I've seen, has changed the way a patient will present themselves afterwards. They're excited, they have a lot more confidence, they're doing better at school. As well as those who are concerned about being able to chew and chew efficiently and get a lot of jaw fatigue. By getting the teeth and jaws in a better alignment, those problems will go away.

Host: Why is MedStar Washington Hospital Center the best place to receive corrective jaw surgery?

Dr. Agarwal: Our hospital is one of the rare institutions in the region that have a dedicated oral and maxillofacial surgeon working. We are one of the busiest centers in the region when it comes to corrective jaw surgery. You will not find a center in the state of Virginia or Maryland that does more jaw surgery than we do. With that comes experience. We've seen a lot of different types of deformities, we've really advanced our skills in specializing in corrective jaw surgery. One of the technologies we use is taking 3D CT scans and performing virtual planning, working with a third party provider, for us to virtually plan your surgery before you're in the operating room so that we can pick up on, 'are there are going to be any issues and are we going to be happy with the outcome that we're providing.' The other reason to consider choosing our team is that we're in a large hospital that has access to every specialty and we take care of some of the most complex patients in the region. So, having a team approach to all surgeries is really beneficial to outcomes.

Host: Thanks for joining us today, Dr. Agarwal.

Dr. Agarwal: Thank you for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.