BackTable ENT: Recent Episodes
BackTable ENT
The BackTable ENT Podcast is a resource for otolaryngologists to learn tips, techniques, and practical advice on all things ear, nose, and throat. Tune in to the BackTable ENT Podcast every week for candid conversations about rhinology, laryngology, otology, and head and neck surgery.
In this episode of BackTable ENT, Dr. Eli Gordin, microvascular surgeon at UT Southwestern, joins hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss free flap surgery. This high-yield episode walks listeners through the basics of microvascular surgery, from indications to management of surgical complications.
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SHOW NOTES
First, the surgeons discuss pre-operative management of free flap patients. The most common indications for microvascular surgery in otolaryngology include head & neck cancers. In his pre-operative clinic visits with free flap patients, Eli answers questions about surgery, hospital stay, and recovery. In his experience, patients often don’t understand the extensive nature of these surgeries prior to this visit, so he spends time explaining what a flap is and what the hospital course will look like.
Then, Eli speaks about his experience with virtual surgical planning, which entails remote meetings with engineers. He admits that the learning curve to virtual surgical planning is steep, but that contemplating reconstruction with the help of virtual planning helps him better account for details at the time of surgery. Gopi and Ashley then inquire about surgery and peri-operative management of these patients. Eli addresses vital topics including surgical technique, fluid management, and thrombosis risk.
Finally, the podcast addresses post-operative management of free flap patients. Eli briefly outlines his free flap protocol, emphasizing physical exam signs that indicate need for an OR takeback. He leaves listeners with an important insight: when surgeons have any doubts regarding the viability of a flap, they must return to the OR quickly: the best look they can get at a troubled flap is the one obtained in the OR.
In this week’s episode of Backtable ENT, Dr. Ashley Agan and Dr. Gopi Shah talk with Dr. John Craig, chief of Rhinology and co-director of the Skull Base Center at Henry Ford Health in Detroit, about odontogenic sinusitis (ODS).
SHOW NOTES
The episode begins by hearing about John’s path to rhinology and his work and research interests in ODS. First, John defines ODS and contrasts it with chronic rhinosinusitis (CRS). He notes that the cardinal symptoms of CRS are the same as ODS but for ODS, these symptoms are unilateral, such as unilateral nasal obstruction, unilateral nasal drainage and unilateral facial pressure. Also, a foul smell is a very common symptom of ODS.
The conversation then transitions to discussing the role of dental history in ruling in ODS. John explains his oral exam process and questions he asks related to a patient’s dental history such as upper dental pain, root canals, extractions, dental implants and dental bridges. Interestingly, current research has shown only 20-40% of patients have dental symptoms such as dental pain. The group discusses how insurance coverage plays a role in the treatment management patients with ODS may undergo, and John notes the importance of collaborating with dental providers for endodontic testing and imaging that includes dental roots.
John further delves into what he is looking for on an endoscopy exam including unilateral purulent drainage from the middle meatus, edema and polyps. CT sinus usually shows unilateral maxillary sinus opacification.
Then, John explains how he groups patients in two groups, treatable and untreatable dental pathologies, to help in deciding management of patients with ODS. Treating the sinus and the treatable dental pathology (i.e.-closure of oroantral fistula) will help the condition resolve in the majority of cases. Timing of treating the dental pathology and sinus surgery is complicated, but taking into account the patient’s symptom burden can help decide timing of these procedures. When there is no treatable dental pathology, management options include antibiotics (to temporize symptoms) and endoscopic sinus surgery (ESS) with 98% success. The episode concludes with the group discussing the role of ESS for ODS.
RESOURCES
PubMed (Link to John’s list of Publications): https://pubmed.ncbi.nlm.nih.gov/?term=Craig%20JR&cauthor_id=32656998
In this episode of BackTable ENT, Dr. Mark Courey (chief of otolaryngology at Mount Sinai) and Sarah Schneider (Speech Language Pathologist at UCSF) join host Dr. Gopi Shah to discuss voice care for transgender patients.
SHOW NOTES
First, Mark and Sarah define terms relevant to transgender healthcare and offer tips on welcoming transgender patients to clinic. They describe how voice care fits into the overall process of transition, and why patients seek care for voice-related concerns at different points in their journey. Gopi asks about collaboration with other specialties, and Mark discusses collaboration with other clinicians in a patient-centered transgender care team.
The conversation then shifts to workup and treatment of voice-related concerns. In Sarah’s experience, trans women present with voice fatigue if they are overly reliant on pitch modulation. By addressing pitch, articulation, rate of speech, volume, and resonance, Sarah helps her patients achieve a more feminine communication style while minimizing physical strain. Mark outlines his physical exam and process of history-taking as they relate to voice concerns. They also address the role of laryngoscopy in transgender patient populations.
Finally, Sarah and Mark address the importance of duration and goals of voice therapy. Both she and Mark emphasize the need to monitor progress over sessions of voice therapy. Delving into surgical management, Mark addresses the indications for, steps in, and complications of voice-modifying surgery. To wrap up, Sarah and Mark encourage listeners to educate their fellow clinicians regarding voice care for transgender patients.
RESOURCES
Sarah’s Twitter: https://twitter.com/scharx16
Sarah’s UCSF Profile: https://transcare.ucsf.edu/team/sarah-schneider
Mark’s Mount Sinai Profile: https://profiles.mountsinai.org/mark-s-courey
In this episode of BackTable ENT, pediatric otolaryngologists Dr. Anthony Sheyn (St. Jude Children’s Hospital & Le Bonheur Children’s Hospital), Dr. Jeffrey Rastatter (Lurie Children’s Hospital of Chicago), and Dr. Daniel Chelius (Texas Children’s Hospital), discuss challenges and research in health equity in pediatric head and neck cancer care.
SHOW NOTES
First, the surgeons define the Social Determinants of Health (SDoH) and explain how studying these factors improves care. They share memories of when they first reckoned with health inequities as clinicians. For Dr. Chelius, this was during medical school, when he observed end-stage renal disease patients’ access to dialysis (and thus lifespan) depended on their insurance status, income, and education. Moving into his residency, he realized that similar forces shaped how patients accessed cancer care. As a young attending, Dr. Sheyn noticed that many of his patients missed appointments for logistical or financial reasons, which piqued his interest in characterizing how SDoH influence pediatric cancer care.
Next, the doctors discuss health equity research. Though they’re based at different institutions, the three surgeons collaborate to study how SDoH affect pediatric head and neck cancer outcomes. Dr. Rastatter shares his work identifying how different SDoH– including socioeconomic status, household composition, housing/transportation, and minority/language status – interact to affect access to cancer care. Dr. Chelius speaks to the importance of social work, advanced practice providers, and transportation services in connecting patients to care. The podcast concludes with a discussion of how tertiary care centers can better collaborate with community clinicians to ensure pediatric patients with rare cancers get the workup and treatment they need.
In this episode of BackTable ENT, Robert Glazer, executive vice president of ENT and Allergy Associates LLP joins Dr. Ashley Agan to speak about his process for recruiting the next generation of Otolaryngologists, things Otolaryngologists should look for in choosing a practice to join, and general tips and advice for Otolaryngology residents to think of in their plans post residency.
SHOW NOTES
Dr. Agan begins the episode by having Robert Glazer discuss his background in the healthcare field with over 40 years of healthcare experience in finance and operations, managed care contracting, physician recruitment, and healthcare marketing. Glazer discusses his beginnings in healthcare starting back in 1976 by getting a job as a clerk in NYU medical center in the grants and contracts division, helping physicians fill out grants for their medical research. During his nine years at NYU he went and got his masters degree in public administration with a focus on healthcare, and takes us through how these early jobs and his further promotions, led him to ENT & Allergy Associates LLP.
Next, Glazer explains what he looks for in recruiting Otolaryngologists to his practice and also brings up advice for resident physicians looking to apply to the job market, things to take in consideration when applying for jobs in different practices, and references the importance of networking and meeting individuals at a particular practice. Glazer says that he tries to meet candidates in their PGY2 and PGY3 years to get to know candidates and learn more about why they are interested in being the NYC region and also discusses some of the key questions that residents should be asking during the interview trail and discusses the importance of transparency in learning more about a practice.
Lastly, Glazer talks strategies that he has found to be successful in recruiting new Otolaryngologists to his practice and has a discussion on how COVID has changed recruitment and how physicians can manage burnout post-COVID.
RESOURCES
ENT and Allergy Associates, LLP: https://www.entandallergy.com/
In this episode of BackTable ENT, Dr. Shah and Dr. Gauri Mankekar, assistant professor of Otolaryngology at LSU Health Shreveport, discuss cholesteatoma workup and surgical management.
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SHOW NOTES
First, Drs. Shah and Mankekar review the basics of cholesteatoma: types, etiology, clinical presentation, and physical exam findings. Doctors should suspect cholesteatoma when they encounter a patient experiencing painless, malodorous ear drainage. Dr. Mankekar underscores the importance of tailoring the physical exam to each patient’s history and needs. For example, when evaluating children for potential cholesteatoma, she works to gain the child’s trust before examining the ear, sometimes using an initial visit to focus on rapport and deferring the exam to the second visit.
Next, the surgeons address workup of cholesteatoma, which should include audiometry, CT scan, and culture of ear drainage (if present). All patients with cholesteatoma require long-term surveillance, as recurrence can happen more than five years after initial treatment. Dr. Shah advises that doctors approach the topic of surveillance by emphasizing the importance of creating a safe ear. Dr. Mankekar then shares tips on how to help patients understand the chronicity of their disease.
Then, the surgeons discuss cholesteatoma operative techniques. Dr. Mankekar leads listeners through her approach to cholesteatoma surgery, from review of CT scans to supplies used in the OR. Dr. Shah delineates common challenges in ear surgery, such as “hard to reach areas”, and Dr. Mankekar shares technical strategies she uses in the OR. They then review the role of endoscopic tympanoplasty, ossicular chain reconstruction, and canal wall down mastoidectomy. As with her ear exam, Dr. Mankekar closely tailors each operation to the patient’s particular pathology. Finally, Dr. Mankekar summarizes her strategy for patient-centered, long-term management of cholesteatoma.
RESOURCES
Dr. Mankekar’s Profile: https://www.ochsnerlsuhs.org/doctors/gauri-mankekar
In this episode of BackTable ENT, Dr. Walter Kutz (UT Southwestern, Dallas, TX), and guest Dr. Matthew (Matt) Carlson (Mayo Clinic, Rochester, MN) discuss high-yield research tips for medical students and physicians.
SHOW NOTES
Dr. Carlson begins the episode by describing how one can approach scholarly activity so that research is genuinely an enjoyable pursuit. Dr. Carlson emphasizes organization throughout all stages, from idea generation to project management. The work of a diverse team – in terms of individual background, skills, and seniority – helps guide good ideas to publication. With this setup, research mirrors medicine’s chain of command: residents mentor medical students on a day-to-day basis, and principal investigators are able to manage on a high level. Both surgeons agree that the skills of statisticians and institutional research coordinators are indispensable for ensuring data quality and working with the IRB, respectively.
Next, Drs. Kutz and Carlson dive deeper into the research process. Dr. Carlson starts projects by diving into PubMed and identifying how his project can address yet-unanswered questions. Drs. Carlson and Kutz discuss resources they employ to insure data and manuscript integrity. Regardless of the manuscript’s topic, clarity of style and good grammar are non-negotiable. From the perspective of a researcher and reviewer, Dr. Carlson finds that sloppy writing leads one to question whether data analysis is similarly disorganized.
Then, Dr. Carlson explains how his research group manages to publish, on average, one manuscript a week. He attributes this productivity to organization, clear expectations for all involved, and genuine enthusiasm for investigation all contribute to this impressive statistic. Dr. Kutz comments that output is better when trainees are encouraged, rather than mandated, to take on research projects. Finally, Drs. Kutz and Carlson discuss how artificial intelligence and open-access journals could alter the research landscape in the near future. As a parting thought, Dr. Carlson encourages listeners to build a good team and be generous with mentees.
RESOURCES
The Dip: A Little Book that Teaches You When to Quit (and When to Stick), Seth Godin
Grammarly https://www.grammarly.com/
Dr. Carlson’s Research Profile https://www.mayo.edu/research/faculty/carlson-matthew-l-m-d/bio-20113086
In this episode of BackTable ENT, Dr. Soham Roy, chair of pediatric otolaryngology at Children’s Hospital Colorado, invites 2 pediatric otolaryngology chairs, Dr. Daniel Choo (Cincinnati Children’s Hospital) and Dana Thompson (Lurie Children’s Hospital), to discuss their paths to leadership and advice for effective leadership.
SHOW NOTES
First, Dr. Choo and Dr. Thompson discuss their motivations for becoming leaders in pediatric otolaryngology. Dr. Thompson emphasizes the importance of using her voice to create impact in the medical field as a black female physician. Although Dr. Choo was a reluctant leader at first, he now sees himself as a servant leader who finds job and personal satisfaction in uplifting others.
Then, Dr. Roy questions whether leadership is innate or learned. All three doctors agree that leadership can be learned, but potential leaders have to be willing and able to assume the position. Dr. Thompson notes that she gained leadership skills from career leadership programs, her leadership coach, and her MBA. Dr. Choo notes that introverted leaders can also succeed, as leadership places great importance on individual interactions and relationships with people.
Finally, the doctors discuss how to prepare for a leadership role. Effective healthcare leaders identify gaps in healthcare delivery to their patients, know the strengths and weaknesses of their programs, have the courage to show their vulnerability to their staff members, and never forget to point out the impact that their trainees are making every day.
In this episode, Dr. Stan McClurg, a private practice rhinologist at Ascentist Healthcare in Kansas City, shares his approach to diagnosis and treatment of chronic rhinitis patients using the in-office RhinAer procedure.
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SHOW NOTES
First, Dr. McClurg talks us through his patient base. When he initially started as a rhinologist, he would get referrals for patients with persistent rhinitis after a procedure. Before in-office procedures for chronic rhinitis were developed, he recommended ipratropium bromide spray to patients and referred them for allergy testing. However, his recent patient referrals have been for isolated chronic rhinitis (defined by consistent rhinorrhea for more than 4 weeks) with no other ENT problems. With these patients, he performs allergy skin testing to make sure the diagnosis is not really allergic rhinitis that can be treated with desensitization therapy. He also uses a rigid nasal endoscope to check the patient’s nose for colored purulence and polyps, two clues that can point to a diagnosis other than chronic rhinitis. When he scopes his patient, he does not use a decongestant spray and uses a small endoscope to avoid patient discomfort. If he believes that a patient has chronic rhinitis, he will perform a ipratropium bromide challenge; he asks patients to use the spray for 1 month. If their symptoms are mitigated by the spray, then he is more optimistic that an in-office procedure will mitigate the chronic rhinitis. If the patient fails the trial, the secretions are probably coming from a source other than the nose, and the diagnosis is unlikely to be chronic rhinitis.
Next, Dr. McClurg speaks about different in-office treatments for chronic rhinitis. He first explains his experience with ClariFix, a procedure that uses cryoablation to freeze the posterior nasal nerve. He has found that 40% of his patients experience the known side effect of post-treatment headache. Additionally, some of them may have crusting in the sphenopalatine region that causes post-nasal drip. Since then, he has switched to using the RhinAer system, which delivers radioablation through a stylus to treat the posterior nasal nerve more aggressively. It also has the capability of treating the inferior turbinate. Dr. McClurg notes that patients with normal nasal anatomy and a good ipratropium bromide response are the best candidates for this procedure. 80% of his patients see a favorable result after surgery.
He then describes his RhinAer in-office procedure. He does these procedures in exam rooms in order to help with flow of his day and make his patients more comfortable. He only uses lidocaine to anesthetize the patient, as he has found that epinephrine causes tachycardia and anxiety. The procedure, including anesthesia time, takes him about 10 minutes. However, he adds that he has performed this procedure in the OR as an adjunct procedure after a septoplasty or a rhinoplasty.
Finally, he describes his recommendations for postoperative care. He encourages his patients to do daily saline rinses. He notes it takes about 6-8 weeks for the RhinAer procedure to show a good response. During this time, he recommends that patients use ipratropium bromide concurrently in order to obtain an optimal response.
In this episode of BackTable ENT, Dr. Varun Varadarajan interviews Dr. Edward Dodson, President of Project Ear and a neurotologist at the Ohio State University Wexner Medical Center, about his humanitarian efforts in the Dominican Republic.
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SHOW NOTES
Dr. Dodson was first introduced to Project Ear when he joined his mentor and Project Ear founder, Dr. Paul Lambert, on a mission trip to Dominican Republic in 1995 to perform ear surgeries. Although they could only operate on 12 patients, seeing hundreds of patients waiting in line for medical care was eye-opening for him.
Dr. Dodson then shares about preparations needed for the Project Ear medical mission trips. He emphasizes the importance of their local neurotologist liaison, Dr. Roberto Batista, who helped Project Ear by performing preoperative and postoperative care for patients in exchange for equipment. In the first years of the organization, the doctors had to learn which supplies to bring and how to store them as well as how to organize staff and supplies in order to pass through customs. Dr. Dodson notes that he used to sterilize wasted equipment from American ORs during their first trips. Later, Project Ear was able to partner with Ohio State University and could give credit to residents who participated on the trips and negotiate time for employees to travel. Because the mission hospital they worked with allowed trainees, he was allowed to take senior level American residents to the Dominican Republic. Furthermore, Dr. Dodson also sought out to teach DR residents independently at another hospital and brought them new medical equipment. This initiative led DR residents to be granted permission to participate in Project Ear surgeries as well as rotate at Ohio State. Currently, multiple ENT subspecialties, besides neurotology, and audiology are now represented within Project Ear.
Next, Dr. Dodson speaks about Dominican Republic-related topics. He explains that the most common ear conditions he sees are chronic draining ears, perforation, cholesteatomas, congenital atresia, stapedectomy, and otosclerosis. When the COVID-19 pandemic hit, he and his Project Ear colleagues started teaching via Zoom through giving lectures and Grand Rounds talks to Dominican Republic residents. Dr. Dodson and Dr. Varadarajan also reflect on the open-mindedness and creativity required to operate in a resource-limited environment. Dr. Dodson also explains about how he navigated relationships with local ENT doctors in the area.
Finally, he shares advice and resources for doctors looking to start their own medical mission trips. He emphasizes the importance of understanding the time it takes to plan and lead a trip as well as determining that your medical services are actually wanted in the country.
RESOURCES
Project Ear https://projectear.org/
Coalition for Global Hearing Health https://coalitionforglobalhearinghealth.org/
AAO-HNSF Humanitarian Efforts List https://www.entnet.org/get-involved/humanitarian-efforts/
In this episode of BackTable ENT, Dr. Gopi Shah discusses 3D imaging and other surgical technology with Dr. Cristobal Langdon, an academic and private practice rhinologist and skull base surgeon working at Hospital Sant Joan de Déu Barcelona.
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SHOW NOTES
First, Dr. Langdon speaks about common conditions he treats as a skull base surgeon, such as Rathke cleft cysts and craniopharyngiomas. Most of his referrals come from neurosurgeons and opthamologists once the decision to take a transnasal approach over an open approach is made.
Next, he talks about pre-operative preparations. During his initial patient visit, he scopes his patients with a flexible scope and tries to record every scope procedure for educational and planning purposes. Every patient receives an MRI, and a CT scan is usually already obtained. Dr. Langdon does not prescribe any antibiotics or corticosteroids before surgery. Then, he discusses how he uses 3D models for surgical planning. For him, 3D models are useful in deciding between different surgical approaches and practicing difficult surgeries. He requests that his models are made true to size by biomedical engineers. He also tells his engineering team which structures need to be constructed (i.e.-nerves, carotid arteries, etc.). Then, Dr. Shah and Dr. Langdon discuss the implications of virtual reality for surgical education.
Then, the doctors discuss the use of technology in the operating room. Dr. Langdon does not often use image guidance. He sometimes uses neurosurgical guidance, but warns against becoming dependent on technology and not learning patient anatomy well. He thinks image-guided instruments are nice, but not necessary to have. Like Dr. Shah, he uses intrathecal fluorescein to look for CSF leaks. Then, the doctors also discuss the pros and cons of different types of flaps and packing.
Finally, Dr. Langdon speaks about his postoperative saline regimen. He recommends that all his pediatric patients use at least 100 mL for each side every 12 hours. Dr. Shah likes to show the patient and their families educational videos of sinus rinses before surgery so they are prepared postoperatively. Both doctors concede that synechiae (scar tissue) may form in kids, but they rarely take pediatric patients back to the OR for debridement.
RESOURCES
Dr. Langdon’s Youtube https://www.youtube.com/c/BarcelonaRhinologySchool
In this episode of BackTable ENT, Dr. Julie Wei, Dr. Alain Sabri (Mayo Clinic Abu Dhabi), and Dr. Kerry Olsen (Mayo Clinic Rochester) discuss personal and professional strategies to overcome physician burnout.
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SHOW NOTES
First, the doctors discuss their personal motivations for engaging in wellness. For Dr. Sabri, wellness evolved as his career matured. Eventually, he moved abroad and studied cross-cultural practices of wellness. For Dr. Kerry, leadership roles forced him to have concern about the wellness of his employees, leading him to create his own company, 12 For Health. For Dr. Wei, a medical condition forced her to think about her life outside of the OR. All three doctors agree that head and neck surgeons have one of the highest burnout rates and the first step to solving this problem is recognizing burnout as a problem and not being ashamed of it.
Then, they discuss the impact that corporate influence has on medicine and physician wellness. Many physicians may feel stuck in a system they have no say in. Dr. Olsen encourages healthcare corporations to prioritize patient and physician welfare over finances while Dr. Sabri encourages institutional leadership to actually listen and elicit change when their physicians provide feedback. Dr. Olsen then explains how raising salaries to justify longer hours actually incentivizes doctors to cut their hours and makes it easier for them to leave. Additionally, both Dr. Wei and Dr. Sabri agree that the feelings of burnout can fluctuate from day to day.
Next, the doctors emphasize the importance of feeling valued as a physician and engaging in self-care techniques. Dr. Olsen advocates for training physicians to be leaders who get to know their team well and recognizes good work at an appropriate time. Dr. Sabri criticizes the American “hyper statistical” view that does not respect people for the work they do. He advises physicians to select the right institution for them and have the courage to walk away and reinvent themselves in new positions when they feel like they are not receiving the respect they deserve. Self-care techniques the doctors recommend from personal experience are: re-reading patient and mentee thank you notes, meditation, stretching, team sports, having a coffee with a friend, and learning how to say no to excess work and toxic relationships.
Finally, the doctors discuss how institutional leadership can help women surgeons succeed and prevent burnout. Dr. Olsen adds that leadership needs to change if the current leaders are not effective and explains ways to form effective work units.
In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak about allergic fungal rhinosinusitis with Dr. Amber Luong, vice president of the American Rhinology Society and professor of otolaryngology at McGovern Medical School.
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SHOW NOTES
Allergic fungal sinusitis (AFS) is a subtype of chronic rhinosinusitis with nasal polyps that present with allergic inflammation against fungal antigens. It has some unique features, such as very expanded sinus cavities and a thick, sticky mucin. Oftentimes, patients have an allergy sensitivity and elevated IgE levels in the thousands. Diagnosis is usually made based on the Bent and Kuhn Classification, which is based on clinical/phenotypic criteria. However, Dr. Luong notes that AFS can have geographically diverse presentations. She has noticed that there is a higher AFS prevalence in the South because of the more hot and humid weather. Looking towards the future, she predicts that molecular pathophysiology will be more important in diagnosis, as distinction between the AFS endotypes can serve as targets for therapy. Her research laboratory works on finding these molecular targets.
Next, the doctors discuss typical AFS patient presentations. Dr. Luong usually sees young patients in their 20s with unilateral disease. If they have bilateral disease and other symptoms, it is most likely cystic fibrosis, not AFS. Additionally, AFS patients will have expanded sinuses on CT that may cause a mild headache. Dr. Shah adds that in severe cases, smell and vision loss is possible. However, AFS generally has a low symptom burden because patients get used to the symptoms. Dr. Luong notes that she usually only orders a CT scan. No MRI is needed unless other complications are noted (vision loss, meningitis, skull base / cranial nerve invasion). She orders labs like CBC with differential and total IgE levels.
Next, she shares surgical pearls for treating AFS. She believes that the first surgery is critical to controlling the disease and preventing recurrence. She performs a full FESS on the impacted side and inserts a PROPEL stent that releases steroids locally. Because the sinuses are difficult to clear, she uses angled scopes, warm saline, and the hydrodebrider to complete this task. Although the microdebrider with navigation can be helpful, she doesn’t really use it.
Finally, she shares her steroid regimen. She prescribes at least 40 mg of prednisone in adult patients 3-4 days before surgery. Postoperatively, she prescribes an oral steroid taper starting at 30 mg and decreasing the dosage by 10 mg each week. Additionally, she gives her patients a post-operative nasal rinse that consists of mupirocin and budesonide. She emphasizes the importance of making the postoperative regimen as easy as possible to ensure daily compliance. Finally, the doctors discuss trends in AFS patient follow up.
In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Mandan Kandula, founder of ADVENT, an ENT private medical practice, about embracing in-office procedures and building an efficient ENT private practice.
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SHOW NOTES
First, Dr. Kandula talks about his journey to becoming a private practice ENT doctor. He became a proponent of office-based treatments when he opened up his solo private practice and has carried this approach into his expansion of ADVENT. Another approach he takes in his medical practice is simplifying all airway problems to identify the defect in the “breathing triangle”, a term he coined for the nose and throat. In order to identify the airway problem in patients, Dr. Kandula emphasizes the importance of defining a healthy airway, which he defines as normal anatomy and lining. Additionally, he notes that ENTs must assess the nose, throat, and sinuses together before choosing a treatment plan for the patient.
Another approach he takes in his medical practice is training nurse practitioners and physician assistants to deal with purely medical ENT matters, such as triage, intake, histories, and physicals. He even trains his NPs and PAs to perform scope examinations and to administer local anesthetic. Dr. Kandula prefers to free up time for his ENT surgeons to have extended conversations with patients and operate in the office or in the OR. However, he emphasizes the importance of having well-trained NPs and PAs. He also outsources sleep study reads to be more efficient.
The doctors then discuss treatments for obstructive sleep apnea. Dr. Kandula usually sees OSA patients who have already tried non-surgical options, such as nasal rinses and sprays. For OSA that is caused by an anatomical issue, he notes that turbinate hypertrophy is the most common cause. For these cases, he will perform a thorough turbinate reduction. He also obtains CT imaging to view the sinuses in order to assess if they are affecting airway patency.
Finally, Dr. Kandula speaks about challenges with insurance with regards to in-office procedures. His office usually takes the lead in dealing with insurance authorizations and repealing insurance denials. He explains that it is more difficult for academic ENTs to change to in-office procedures. Another challenge that doctors might face is the high cost of in-office equipment. He recommends working with industry and getting loans to help offset the financial burden of medical technology.
In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Colleen Plein about functional nasal breathing in the treatment of facial pain, sleep apnea, postural defects, and improving general quality of life.
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In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Kutz interview Dr. Marc Bennett, a Vanderbilt University ENT professor, about the importance of quality improvement, and initiatives and tips for quality initiative research.
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SHOW NOTES
First, Dr. Bennett delineates his path to quality improvement research and education. His father was involved in quality improvement in the pharmaceutical industry, and he was always interested in systems-based improvement. Additionally, he was encouraged by a mentor to find a niche outside of clinical medicine.
Next, the doctors discuss collaboration with hospitals and medical schools to encourage more quality improvement initiatives. For enticing hospital systems to care about quality initiatives, Dr. Bennett recommends showing them that administrative data is very important for financial and billing reasons as well as hospital rankings, which are important to patients and the public. Additionally, he encourages medical school lecturers and residency directors to incorporate quality improvement projects and measures in their trainee curriculums. For students and residents with a vested interest in quality improvement, identifying a mentor and starting with a simple project is the best way to explore the research field.
Next, Dr. Bennett discusses important aspects of quality improvement research. First, he highlights the importance of using run charts to compare mortality and complications across populations over time. Run charts can be further analyzed to see differences between different providers, statistical significance, and outliers. When collecting data from electronic health records, he collaborates with billing departments in order to identify relevant CPT codes. He also notes that the AAO-HNSF collects self-reported data from individual institutions as well. Then, he uses data analysis programs like Vizient and Leapfrog to organize and interpret data.
Finally, Dr. Bennett shares how otolaryngologists can improve quality of care in their everyday practice, most notably through proper documentation. He discusses the pros and cons of using dot phrases and emphasizes the importance of standardization of format and coding.
RESOURCES
Vizient: https://www.vizientinc.com/
Leapfrog: https://www.leapfroggroup.org/
In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Seilesh Babu discuss Eustachian tube dysfunction and balloon dilation as a therapeutic option.
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SHOW NOTES
First, Dr. Babu provides background on Eustachian tube dysfunction. In kids and adults, Eustachian tube dysfunction can present as a sensation of “ear fullness”, recurrent fluid in the ear, or discomfort with pressure challenges, such as flying or scuba diving. Medical management involves nasal steroids, allergy medications, anti-reflux medications, avoidance of allergens, and doing a modified Valsalva maneuver at home. Additionally, ear tubes and balloon dilation are procedural options.
Next, Dr. Babu explains his workup for Eustachian tube dysfunction patients. He takes a thorough patient history and examines the patient’s tympanic membrane, nasopharynx, and serous outflow using a flexible scope. He orders an audiogram for all of his patients but notes that tympanograms are not as critical. For patients with discomfort during pressure challenges, he will consider doing a balloon dilation or placing an ear tube. For patients presenting with “ear fullness”, a more in-depth examination must be done through a trial tympanostomy tube or a myringotomy.
He also looks for red flags, which indicate Eustachian tube dysfunction may not be the correct etiology for their ear symptoms. These red flags include: aggravation of symptoms upon tube insertion, symptoms of dizziness and vertigo, autophony, and pulsatile tinnitus. Although it is rare, a diagnosis of Patulous Eustachian tube dysfunction must be considered. If the patient does not have these red flags and has had multiple ear tubes without symptom relief, they may be a good candidate for balloon dilation.
Dr. Babu then delineates his procedure for a Eustachian tube balloon dilation. He performs this procedure in the OR using the Acclarent AERA Eustachian tube dilation system. He inflates the balloon to achieve a pressure of 12 atm, keeps it dilated for 2 minutes, then removes the instrument. Some procedural pearls he shares are: putting the scope and balloon in at the same time to minimize bleeding in the nasopharynx and guiding the instruments in a lateral direction towards the external ear canal. He usually waits 2-3 weeks before reassessing the patient for recurrent symptoms. Upon discharge, he encourages patients to avoid nose blowing and Valsalva maneuvers, as these actions can cause a pneumothorax or pneumomediastinum. Common postoperative symptoms include minor nose bleeds and the sensation of a sore throat. Dr. Babu usually performs the balloon dilation in conjunction with other OR procedures, such as myringotomies and tympanoplasties, for efficacy.
Finally, the doctors discuss the specifics of billing for the Eustachian tube dilation procedure. In recent years, a specific billing code has been assigned for balloon dilation, and insurance companies are beginning to authorize this procedure for a variety of patients.
Devices discussed in this podcast are currently available in the US only.
Acclarent, Inc. 223616-220810
RESOURCES
Acclarent: https://www.jnjmedtech.com/en-US/companies/acclarent
AERA® Esutachian Tube Balloon Dilation System: https://www.jnjmedtech.com/en-US/product/Acclarent-aera-eustachian-tube-balloon-dilation-system
Howard, A., Babu, S., Haupert, M., & Thottam, P. J. (2021). Balloon Eustachian Tuboplasty in Pediatric Patients: Is it Safe?. The Laryngoscope, 131(7), 1657–1662. https://doi.org/10.1002/lary.29241
In this episode of BackTable ENT, Dr. Shah and Dr. Agan discuss the role of lifestyle medicine and non-pharmacological therapy in otolaryngology with Dr. Jessica Lee, a general ENT who is certified in lifestyle medicine.
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SHOW NOTES
First, Dr. Lee explains the philosophy behind lifestyle medicine. The purpose of the field is to treat and/or reverse chronic ailments using basic pillars, such as plant based nutrition, quality sleep, emotional connections, avoidance of risky substances, adequate physical activity, etc. Certification in lifestyle medicine is open to all board-certified physicians. Dr. Lee underwent 1.5 years of preparation, which included 30 hours of CME courses online and 10 hours of in person CME. At the end of her program, she was required to pass a board certification exam. Her initial motivation for obtaining her lifestyle medicine certification stemmed from a realization that many ENT concerns were a result of systemic chronic diseases. Dr. Lee views her lifestyle medicine approach as a partnership between her, her patient, and their PCP. Before she offers lifestyle medicine counseling separate from ENT counseling, she always ensures that the patient is open to pursuing this approach.
Next, the doctors discuss diet, the most evidence-based pillar of lifestyle medicine. In this field of medicine, the best diet is plant-based. Dr. Lee notes that a “plant-based” diet does not mean vegetarian or vegan, but instead just a plant-heavy diet. Additionally, she recommends reducing alcohol use and starting a low histamine diet for patients with chronic inflammation. However, she emphasizes to always set an endpoint to restrictive diets in order to effectively find a good threshold for the patient. For laryngopharyngeal reflux, she recommends eliminating nighttime ice cream snacks and alcoholic beverages.
Then, the doctors discuss effective approaches to smoking cessation. Dr. Lee emphasizes the importance of discussing support systems with patients wanting to quit smoking. Additionally, she agrees that the most effective smoking cessation therapy is a combination of nicotine replacement and group counseling. Although the effects of marijuana and vaping as substitutes for cigarettes are not widely studied, Dr. Lee notes that marijuana can be an irritant and vaping can cause lung injury.
Another pillar of lifestyle medicine is emotional health. Through cognitive behavior therapy, she has been able to mitigate her patients’ symptoms of tinnitus and globus pharyngeus. Additionally, she does not prescribe medications for anxiety or depression, as research has shown that daily physical activity is equivalent to daily medications for mild to moderate depression. Regarding adequate sleep, Dr. Lee warns doctors not to correlate the number of hours the patient spends in bed with the number of hours they spend asleep. She acknowledges that health tracker devices can be helpful for tracking sleep hours and dysfunction. Finally, she advises doctors who are interested in lifestyle medicine to refer their patients to specialists who share the same philosophy for consistent continuation of care.
RESOURCES
Oto Tinnitus Management App: https://www.joinoto.com/
In this special crossover BackTable episode, Dr. Aaron Fritts and Dr. Julie Wei talk with Dr. Gerry Mattia, Chiropractor and Director of Rehabilitation of ViscoGen Clinic in Orlando, Florida.
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First, Dr. Mattia recounts his journey to becoming a chiropractor, beginning with his medical history of aortic stenosis fixed by a chiropractor, his decision to enter chiropractic school, and starting his independent practice after graduation. Then, he explains how he deals with patients presenting with degenerative disc disease with spinal stenosis, which was the issue he resolved in Dr. Wei. A herniated disc is the most common cause of degenerative disc disease. The standard chiropractic treatment is cervical decompression to help the disc restore itself. Dr. Mattia also uses a level 4 laser to rehydrate the disc. For optimal results, he recommends that patients see him 4 times a week for 6 to 8 weeks in order to fully lift the pressure off of the brachial plexus. He notes that good chiropractors will use the correct formulas and appropriate technology while adjusting the patient gently.
Next, the doctors delve into why many physicians are wary of chiropractors, which is rooted in a 1988 legal case that prohibited doctors from referring their patients to chiropractors. Dr. Mattia encourages physicians to seek therapy before medical issues develop into very severe conditions. Additionally, Dr. Wei notes that medical culture often encourages physicians to put the health of their patients before theirs.
Then, Dr. Mattia discusses how younger people and surgeons can improve their neck health. He notes that excessive cell phone use can reverse the cervical curve, causing people to lose their normal lordotic curve, a structure which usually prevents compression. He also recommends strengthening the muscles in the neck and shoulders, sleeping with a cervical pillow, and going to a good chiropractor to get routine adjustments. Dr. Wei recommends avoiding slouching and adjusting screens to eye-level in OR. Both Dr. Wei and Dr. Mattia agree that maintaining a healthy body weight will have positive benefits on spinal health.
Finally, Dr. Mattia recommends which qualities to focus on when finding a good chiropractor. He recommends looking for an experienced, passionate family practice chiropractor. As a word of caution, he warns listeners to never let a chiropractor adjust them without reviewing their X-ray imaging first.
In this episode of BackTable ENT, Dr. Agan and Dr. Shah discuss nasal valve collapse and repair with Dr. Moustafa Mourad, a New York City-based facial plastic and reconstructive surgeon.
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First, Dr. Mourad delineates how he evaluates patients presenting with possible nasal valve collapse. There are two sets of nasal valves, an internal set and an external set. The tell tale signs of nasal valve collapse is dynamic nasal airway obstruction, a situation in which airflow is affected by deep breathing or structural rearrangement by the patient is required to breathe more easily. Internal nasal valve collapse patients usually find relief with structural rearrangements, such as blowing up their cheeks in order to breathe or using nasal strips. External nasal valve collapse patients find difficulty in breathing while exercising. Diagnosis of nasal valve collapse can also be complicated because many breathing problems are multifactorial. Therefore, otolaryngologists must be thorough in their initial evaluations and choose which causes to prioritize.
Dr. Mourad also explains risk factors for nasal valve collapse. Because nasal cartilage grows weaker overtime, older patients are more likely to experience valve collapse. Younger patients presenting with valve collapse will most likely have had previous nasal surgeries, such as septoplasties and rhinoplasties. Other risk factors for valve collapse include trauma of the nasal tip or dorsum, avid athletes, and the Caucasian ethnicity (because of thinner and more cephalically oriented nasal cartilages).
Next, Dr. Mourad discusses how he conducts the physical exam. He always scopes patients to look for abnormal anatomy or signs of allergies. Then, he has the patient breath while observing each of their nostrils. He observes the nostrils before and after the administration of decongestant. If the patient has a very good response to the decongestant, he starts to investigate for evidence of allergies, turbinate hypertrophy, and irritation–all of which can be treated by medical therapy. Then, he observes the patient breathing and nasal pinching as he lifts up the nasal tip and performs a caudal maneuver on the patient’s nose. Finally, he takes photos and maps out the patient’s internal and external anatomy. Dr. Mourad only considers surgical repair if the patient’s complaint can be traced back to an anatomical abnormality.
Then, Dr. Mourad walks through his surgical technique for nasal valve collapse. For an internal valve repair, he uses a simple endonasal approach. However, whether he uses an open or closed approach for an external nasal valve repair depends on the type of cartilage defect. As external valve repairs have aesthetic impacts, it is important to warn patients about changes in appearance beforehand. Additionally, Dr. Mourad prefers to obtain his implanted cartilage graft directly from the patient’s rib, as cadaver rib may warp and ear cartilage may not be strong enough. He uses a taper needle to suture spreader graft because it allows him to be more gentle with the cartilage. He does not typically recommend synthetic nasal implants to patients, as they can become infected, but still educates patients about all their options. For anesthetic, he mixes a solution of lidocaine with epinephrine and tranexamic acid to reduce post-operative swelling.
Finally, Dr. Mourad discusses his post-operative care regimen for nasal valve surgery.
In this episode of BackTable ENT, Dr. Walter Kutz interviews otologist Dr. Hamid Djalilian about the link between the hearing/vestibular disorders and migraines.
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Theresa Richard, SLP educates us on the best approach to evaluating the adult patient with swallowing difficulty, including the importance and challenges of obtaining high quality assessments, and recommendations for therapy.
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In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, and Theresa Richard, a board-certified speech language specialist (SLP) in swallowing and swallowing disorders, about diagnosing and managing adult dysphagia.
First, Richard speaks about starting Mobile Dysphagia Diagnostics, a company that provides mobile FEES studies, her experience with having a son with a swallowing disorder, and her recent career shift towards providing speech-language education for her colleagues. Then, she discusses the two primary swallowing imaging studies: the modified barium study (MBS) and fiberoptic endoscopic evaluation of swallowing (FEES). MBS, also known as video fluoroscopy, was traditionally the gold standard for swallowing imagery. It is the superior imaging technique for detecting esophageal issues and provides a better understanding of the oral phase of swallowing. Richard prefers to use FEES first because it provides a live picture of laryngeal and pharyngeal structures. It is useful in patients with secretion issues and post-head and neck cancer surgery patients. Mobile FEES is also an option, which involves an endoscope with recording capabilities and a laptop.
Next, Richard discusses how to work up a patient with dysphagia. She starts with taking a thorough history and asks the patient about their dietary routine, and their medical and surgical history. Common medications that may cause dysphagia are muscle relaxants, L-DOPA, and medications that can cause dry mouth, such as scopolamine patches. Next, she discusses eating habits, with special considerations for cultural practices, age, and disability status. She notes that functional swallowing can look different for individual patients. Patients who repetitively aspirate may have recurrent pneumonia and require further evaluation. The first basic test she performs is watching her patients swallow 3 ounces of water. If they cannot swallow the three ounces, she moves to imaging studies. If they can swallow the three ounces, she escalates the test and starts to give the patients thicker liquids and different food types.
Some patients with dysphagia may require special considerations, such as ICU patients, patients with nasogastric (NG) tubes, and head and neck cancer patients.
Finally, Richard discusses how ENTs can help SLPs by providing a solid case history and being available for communication throughout the patient’s therapy. She also discusses a new type of therapy, adult neuromuscular stimulation, but notes that the parameters may be dangerous and not FDA approved.
RESOURCES
“So You’re Having Trouble Swallowing” by Theresa Richard https://theresarichard.com/so-youre-having-trouble-swallowing/
Theresa Richard Blog https://theresarichard.com/blog/
Swallow Your Pride Podcast https://podcast.theresarichard.com/
We talk with Dr. Julie Wei about what it means to connect with a mentor, the challenges of finding the right fit, and how mentoring relationships will grow and change throughout our career and undoubtedly contribute to overall wellness.
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In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, and Dr. Julie Wei discuss the benefits and evolution of mentorship in the medical field.
First, Dr. Wei shares her personal definition of mentorship. Traditionally, mentorship involves a dyad: one junior and one senior partner with the knowledge. However, she challenges this dynamic by broadening the definition of mentorship by coining the term “co-mentorship”, a term that encompasses the mentor’s ability to learn from the mentee and the experience of reflecting as well. The doctors also discuss the challenges of finding mentors after training, since the natural hierarchy of academic medicine is not present. Dr. Wei encourages ENTs to attend society meetings and seek multidisciplinary mentors and mentees in different fields. She mentions that she has served as a mentor for respiratory techs and nurses as well.
Next, the doctors explore the idea of work-life balance. Dr. Wei disagrees with the consistent compartmentalization of career and personal wellness and prefers to advocate for and use the term “work-life integration” instead. She also recommends unconventional meeting platforms, such as Zoom, phone calls, and “walking meetings” in order to build relationships. Peer support groups can also be helpful, but the optimal size of the group may depend on the issue being discussed. Additionally, Dr. Wei observes that more female physicians today are able to share their struggles and vulnerabilities openly with their trainees and patients, thus building stronger relationships. She also talks about the importance of allies and notes that mentors and mentees do not have to have all of the same shared experiences–both can still be sources of insight and wisdom for each other.
Finally, the three doctors reflect on their personal experiences with mentorship and executive coaching.
RESOURCES
“Leadership, Engagement, and Well Being” by Julie Wei https://www.enttoday.org/article/leadership-engagement-and-well-being/3/?singlepage=1
A Healthier Wei https://www.drjuliewei.com/pages/a-healthier-wei
Acid Reflux in Children https://www.drjuliewei.com/pages/acid-reflux-in-children#:~:text=Acid%20Reflux%20in%20Children%3A%20A,Julie%20Wei&text=CONGESTION%2C%20COUGH%20%2B%20CROUP-,Co%2Dauthored%20by%20Dr.,symptoms%20this%20condition%20can%20create.
We talk with Dr. Allison Royer about locums opportunities for otolaryngologists, why locums is becoming more popular amongst ENTs, and how to get started as a locums physician.
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In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Ashley Agan interview Dr. Allison Royer, a private practice ENT who co-founded ENT Surgery Solutions, a staffing company that organizes ENT locums.
First, Dr. Royer shares her transition from being a hospital-employed ENT to becoming a locum physician with her husband. Once they met other locum physicians and heard about their experiences, they decided to start their own locum staffing company. Dr. Royer believes ENT Surgery Solutions is unique because it is managed directly by ENT physicians; Dr. Royer and her husband directly work with the doctors they employ to find work opportunities that will fit their unique needs. Although ENT Surgery Solutions is primarily Midwest-based, it is quickly expanding in the West and South.
Next, Dr. Royer transitions to discussing why many doctors are moving toward locums work. She explains that because many small private practice groups and community hospitals have been bought by hospital systems, there are now significant call burdens needing to be covered by small ENT groups. For this reason, many ENTs decide to do locums in order to balance work and life. Additionally, with locums, doctors don’t have to renegotiate their salaries or their call schedules. Finally, Dr. Royer highlights that locums are fun for her because she likes to work in different hospitals and ORs and see different patient populations and pathology.
RESOURCES
ENT Surgery Solutions https://www.entlocums.com/
We talk Naso Sano Associazione founder Puya Dehgani Mobaraki about the importance of connecting with Otolaryngologists around the world for education, how social media has made this possible, and the impact of listening to the needs of the future generation.
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In this episode of BackTable ENT, Dr. Gopi Shah talks with Dr. Puya Dehgani-Mobaraki, founder and president of Associazione Naso Sano, a global non-profit organization that provides free education for otorhinolaryngology and head and neck cancer physicians and trainees.
Naso Sano supports international trainees by providing them with grants for instrument kits, dissection courses, and textbooks. Dr. Dehgani-Mobaraki emphasizes the importance of surveying trainees to determine which resources and educational opportunities will best help them achieve their future goals. Another important aspect of Naso Sano is the virtual grand rounds. Although organization of these sessions can be challenging due to differing time zones, Naso Sano grand rounds sessions have reached attendance levels of up to 1000 participants. These sessions are available on a variety of platforms, including Facebook, Youtube, and Twitch. Dr. Dehgani-Mobaraki lets the medical and public community decide the topics they would like to learn about, which has included cystic fibrosis, anatomy and dissection courses, and many more diverse subjects.
Finally, the doctors discuss the duty of physicians to use their credibility and knowledge to address human rights violations and gender inequality in healthcare. Both doctors agree that marginalized populations still do not receive adequate healthcare and that small conversations with colleagues and trainees can have a great impact in resolving these matters.
RESOURCES
Dr. Dehgani-Mobaraki Twitter: https://twitter.com/puyadehganimd
Naso Sano Twitter: https://twitter.com/nasosano
Naso Sano Website: https://www.nasosano.it/
In this episode Dr. Eric Gantwerker talks with Dr. Steve Goudy about the importance of finding and thoroughly researching pain points for patients and their families, to then drive innovative solutions.
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We talk with Dr. Ashley Sikand and Dr. Brian Weeks about performing In-Office Sinus procedures, including differences in technique, and keeping up with the latest technologies.
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SHOW NOTES
In this episode of BackTable ENT, Dr. Gopi Shah talks with Dr. Ashley Sikand (Nevada Sinus Relief in Las Vegas, NV) and Dr. Brian Weeks (SENTA Clinic in San Diego, CA) about tips for starting in-office procedures and forming effective industry partnerships.
First, Dr. Sikand and Dr. Weeks outline their motivations for entering the medical device industry space and serving as consultants for Acclarent, an otolaryngology medical device company. Next, they summarize the types of nasal conditions they can treat with an office-based procedure. These conditions include: deviated nasal septum, nasal valve disorders, turbinate obstructions, nasal polyps, and chronic rhinitis. They note that these procedures have only been made possible due to advances in anesthesia and blocking techniques. Although anesthesia varies based on the type of procedure, anesthesia for sinus work in general consists of three steps: anxiolysis (lorazepam or benzodiazepine), topical anesthesia (lidocaine and tetracaine), and infiltrative anesthesia (sphenopalatine block).
Patient selection criteria is also very important when considering good candidates for office-based procedures. The doctors note that younger patients may have more apprehension towards in office procedures. Additionally, if a patient presents with a complex condition that requires multiple procedures, operating in the OR may be a better option. With experience, surgeons will be able to discern whether an in-office procedure is possible for different types of patients.
Finally, the doctors emphasize how important good in-office resources are. The starting toolbox for an otolaryngologist should contain: a good endoscopic system, a camera, an instrument tray, effective suction, and an image guidance system. Knowing the room set up is a crucial requirement as well. Although the doctors admit that young otolaryngologists may not have the capital to purchase all the essentials, they encourage them to leverage their industry connections by inviting representatives to bring different equipment for demonstrations first. Finally, they end by advocating for doctors to critically evaluate medical technology using their medical education and training before adopting a device into their standard practice.
Special guest The White Coat Investor James M. Dahle talks with Christopher Beck about where physicians can start when it comes to financial literacy, including common financial mistakes docs make when start practicing, a primer on mortgage rates, and tips on insurance.
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In this episode, White Coat Investor founder Dr. James Dahle and our host Dr. Chris Beck discuss strategies for physicians seeking to manage their personal finances and gain financial freedom.
First, Dr. Dahle explains the reasoning behind the famous quote, “live like a resident.” He explains that for an early career physician, their greatest wealth-building tool is their income. The income jump from residency to attending years can be extremely useful for quickly paying off student loans. Then, he moves on to discuss another way to resolve student debt, the Public Service Loan Forgiveness (PSLF) program. This option is ideal for physicians who have spent a significant amount of time working for a nonprofit institution (for example, during training and in academic medicine).
Dr. Dahle advises all physicians to reflect on their priorities when deciding where to allocate their assets. Possible categories could include retirement funds, 529 college savings funds, payment of high-interest debt, and emergency funds. We talk about the power of having a written plan to stay on track with financial goals and prevent ourselves from making rash decisions.
Next, we discuss different financial vehicles that can provide benefits for physicians. The “back door Roth IRA” strategy allows for yearly contributions to a tax-free retirement fund, even when a physician’s income exceeds the maximum limit for the conventional Roth IRA. Additionally, the funds in a Health Savings Account (HSA) can be used for investment, and then withdrawn at a later date, penalty-free. Dr. Dahle explains the difference between fixed rate and variable rate mortgages, noting that the latter is better for short-term loans because interest rates are unlikely to dramatically increase from year to year. Finally, Dr. Dahle covers the advantages of buying disability insurance as a way to protect physician income, especially for those working in procedural specialties.
RESOURCES
White Coat Investor: https://www.whitecoatinvestor.com/
White Coat Investor Podcast: https://www.whitecoatinvestor.com/wci-podcast/
White Coat Investor Email: editor@whitecoatinvestor.com
Passive Income MD: https://passiveincomemd.com/
Physician on FIRE: https://www.physicianonfire.com/
In this episode of BackTable ENT, Dr. Gopi Shah talks with Miami-based otolaryngologist Dr. Carlos Torre (Sleep, Snoring & Sinus Clinic of Florida) about his journey to building an adult sleep practice and management of sleep disorders, such as sleep apnea and insomnia.
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First, Dr. Torre shares his personal experience in the field of sleep medicine. He explains his path to becoming board-certified in otolaryngology, sleep study, and sleep medicine, and obesity medicine. During his sleep surgery fellowship, he was fortunate to train with good mentors who showed him a diversity of techniques and procedures to treat sleep disorders. Driven by his entrepreneurial mindset, he eventually transitioned to his own solo private practice in August 2021.
Next, the doctors discuss how to work up an adult patient initially presenting with snoring. Dr. Torre first evaluates the presence and severity of the patient’s symptoms as well as other comorbidities. Next, he orders a home sleep study to confirm the diagnosis of sleep apnea and interprets the sleep studies himself. Many cases of sleep apnea can be resolved nonsurgically through nasal breathing training if the patients are chronic mouth breathers. Nasal breathing training is a type of myofunctional therapy that incorporates exercises such as correct tongue positioning, strengthening of facial muscles, and palatal coupling. Besides nasal breathing training, he recommends CPAP for every patient with obstructive sleep apnea. He prefers to perform surgery conservatively. Thus, he will only consider surgery (tonsil removal, septum deviation surgery) if the patient has failed CPAP therapy for a prolonged period of time and he will use surgery as a tool to optimize CPAP instead of aggressively trying to cure the patient’s sleep apnea. Dr. Torre mentions that nightly dental appliances are also a treatment option.
Finally, Dr. Torre acknowledges that general wellness plays an integral role in sleep hygiene. The most common comorbidity associated with sleep apnea is obesity. He recommends fasting and eating early dinners to patients presenting with obesity-related sleep disorders. He also explains how meditation can help relieve anxiety and depression in patients suffering from insomnia. Dr. Torre ends the episode by emphasizing the benefits of multidisciplinary care for patients with sleep disorders.
In this episode we talk with Dr. Matthew Hensler about Hypoglossal Nerve Stimulation for treating Adult Obstructive Sleep Apnea (OSA), including how he learned the procedure, patient selection, procedure tips, and advice on building a successful program.
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SHOW NOTES
First, Dr. Hensler explains the initial workup for a snoring patient. In this history, he addresses the impact snoring has on the patient’s quality of life and also assesses the environmental factors that may be responsible for the snoring, such as lack of sleep and alcohol consumption. Then, during the physical exam, he checks for anatomical reasons for snoring, such as large tonsils and a deviated septum. From the history and physical exam, he is able to classify patients into two categories: primary snorers (without sleep apnea) and snorers with sleep apnea. He recommends that all patients complaining of snoring obtain a sleep study.
Dr. Hensler then explains his criteria for choosing good hypoglossal nerve stimulator candidates. He recommends choosing patients with an Apnea Hypopnea Index (AHI) score between 15-65, a BMI of less than 31, and patients who have less than 25% of apnea attributed to mixed and central apnea. Because the CPAP machine is still the gold standard treatment for treatment of OSA, he usually only recommends this surgery to patients who have failed CPAP treatment already.
Next, Dr. Hensler explains the mechanics behind the hypoglossal nerve stimulator, which only treats obstructive sleep apnea. During the implantation surgery, the first incision is made in the right chest for placement of the processor. The processor is attached to a sensor lead that feeds into the rib cage space between the external and internal intercostal muscles. A second submandibular incision is made below the submandibular gland to place the stimulator lead. When the sensor lead in the rib cage senses the patient breathing, it relays a message to the stimulatory lead, which stimulates the protrusive branches of the hypoglossal nerve to fire and push the tongue outwards. The surgery can be performed in an outpatient setting andlasts less than 2 hours. Patients can start turning on the device before they sleep 3-5 weeks after implantation. Finally, Dr. Hensler obtains a 3 month follow up sleep study in order to monitor improvement in AHI scores.
Post-operative complications like infection and pain are possible. Dr. Hensler prescribes his patients with a short duration of narcotics for submandibular pain and a 7-day course of antibiotics to prevent infection. Because of chest involvement during surgery, a pneumothorax is another post-operative complication. A chest X-ray should always be ordered after surgery to rule out this possibility. Finally, it is important to note that patients with a hypoglossal nerve stimulator are unable to undergo MRI scans involving their right chests because of the battery in the processor.
In this episode Dr. Kumar and Dr. Bennett discuss various levels of racism found in healthcare, and share allegories of racism as outlined by Dr. Camara P. Jones, including the gardeners tale.
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In this episode, guest host Dr. Vishal Kumar interviews Dr. Ayanna Bennett about how to train ourselves to recognize perpetuated health disparities within the medical system and how we can actively work to dismantle them.
The doctors first talk about understanding racism on an institutional level, which results in a “machine” that selectively delivers better and worse aspects of healthcare to different populations. Dr. Bennett emphasizes that every disease process shows race disparities not because of inherent biological differences in racial groups, but because of unequal frequencies and quality of contact with healthcare systems.
Throughout the episode, they reference the allegories of Dr. Camara Jones, a physician-epidemiologist and civil rights activist. These allegories provide a framework for discussing nature vs. nurture for health outcomes and also privilege defined as the lack of barriers to entry.
In terms of actionable steps that providers can take toward reducing health inequity, Dr. Bennett encourages us to learn and engage with the communities that they serve. She advises us to be “counter-stereotypical” and show interest in patients’ lives outside of the healthcare setting. Finally, she calls us to analyze the impact that our institutions have on maintaining the health of the community as a whole, rather than solely focusing on individual patients.
RESOURCES
The Gardener’s Tale Allegory by Dr. Camara Jones: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/
Tedx Talk by Dr. Camara Jones: https://www.youtube.com/watch?v=GNhcY6fTyBM
In this episode we talk with Dr. Reena Mehta about her experiences building a solo Allergy practice from scratch, including finding a space, staffing, essential equipment, and a successful marketing strategy.
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In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Ashley Agan talk with Dr. Reena Mehta about her path to starting her own allergy private practice, including tips on successful budgeting, hiring practices, advertising, and maintaining a work-life balance as a solo physician.
FIrst, Dr. Mehta reflects on her personal journey to starting her own private practice. Although she started her post-graduate career in academic medicine, she transitioned to a group private practice. She then decided to open a solo private practice in order to practice medicine in the location and way she had always wanted to. In order to assess the feasibility of this idea, she consulted her network of private practice physicians. Then, she did market research to understand the location and demographics of the area in which she was planning to open her practice. Finally, she was able to find a space to rent, formulate a budget, apply for a loan, and start staffing her practice.
Dr. Mehta acknowledges that cost projections and staffing were the two most difficult aspects of starting her solo private practice. There were many costs associated with private practice that she had to account for, such as rent, staff salaries, equipment, website and marketing, electronic health records, and insurance credentialing. Fortunately, she received help from advice forums for private practice doctors as well as American Academy of Allergy, Asthma, & Immunology (AAAI) resources. Next, Dr. Mehta recounts the difficulties of staffing her practice, including unpredictability and high turnover during the peak of the COVID-19 pandemic. She notes that learning to not take staffing issues personally, hiring younger and motivated employees, and using a hiring service such as Zip Recruiter and Indeed really helped her be successful in hiring the right candidates.
Finally, Dr. Mehta discusses how she maintains a healthy work-life balance. As a solo private practitioner, she is able to close her clinic when she wants to but is still available via telehealth visits and remote consulting with her staff. One method she has found to be helpful is to hire second year fellows to manage emergency allergy events and give allergy shots to patients when she is on leave.
All-star panel Daniel Chelius, Jeff C. Rastatter, and Anthony Sheyn discuss the challenges and importance of building centers of excellence for pediatric head and neck cancer.
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In this episode of BackTable ENT, Dr. Gopi Shah leads a panel discussion about building centers of excellence for pediatric head and neck tumors. She invites Dr. Daniel Chelius (Baylor College of Medicine/Texas Children’s Hospital), Dr. Jeff C. Rastatter (Feinberg School of Medicine, Lurie Children’s Hospital), and Dr. Anthony Sheyn (University of Tennessee Medical School, St. Jude Children’s Hospital) to speak about their experiences and advice for establishing these centers of excellence.
First, the three panelists discuss their career paths to becoming pediatric head and neck cancer surgeons. Then, they share their motivations for building these centers of excellence at their own institutions. All of them realized the importance of routing complex and rare pediatric cancer cases to centralized hospitals and experienced surgeons who saw high volumes of the same cases. Additionally, they saw the need for multidisciplinary collaboration with surgeons in the fields of plastic surgery and oncology. Finally, these centers of excellence facilitate the formation of multidisciplinary tumor boards for pediatric cancer cases.
Additionally, they discuss the important elements they needed to form their centers of excellence of pediatric head and neck tumors. First, they needed support within their own otolaryngology division for a shared vision of division specialization and focused expertise. They also needed to form strong relationships with different specialties, namely pediatric plastic surgery and pediatric general surgery. Another important aspect was the institutional commitment of the affiliated children’s hospitals, which were tasked with patient outreach referrals. Finally, each center of excellence needed to be an open environment in which asking for advice and thinking outside of the box was encouraged.
We talk with Ashley Brown, SLP about how to approach the infant with feeding difficulties, including common causes and workup, therapeutic options, and the importance of family counseling and education.
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In this episode of BackTable ENT, Dr. Gopi Shah interviews Ashley Brown, a speech language pathologist (SLP) at Children’s Health Hospital in Dallas, about the evaluation and management of the infant with dysphagia.
An infant with dysphagia, or difficulty in swallowing, can present with many symptoms, but most commonly failure to thrive, refusing to feed, incomplete feeding, and aspiration. When primarily assessing these patients, a complete history must be taken. Standard questions cover the chief complaint, the birth history, observations of a typical feed routine, and parent concerns. Next, a holistic exam is conducted. Speech language pathologists will often observe an infant’s posture, tone, trunk support, and range of motion of the mouth and tongue. If necessary, instrumental studies, like a flexible endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallow study, can be performed. A FEES visualizes the pharyngeal space and is recommended for breastfeeding babies, NPO babies, head and neck cancer babies. A videofluoroscopic swallow study visualizes the oral and esophageal space and gives a better picture of flow rate consistency.
Infant dysphagia can result from many etiologies, but some of the most common roots are: abnormalities in oral structure (e.g. tongue tie). problems with tone (e.g. injury to the recurrent laryngeal nerve), syndromes (e.g. Trisomy 21, DiGeorge Syndrome), laryngeal cleft, and laryngomalacia. Furthermore, GERD and nasal obstruction (e.g. pyriform aperture stenosis, choanal atresia) can also cause dysphagia.
Although some deformities can be surgically fixed, most infants with dysphagia will either improve with maturity or through feeding therapy sessions with speech language pathologists. In these sessions, SLPs work with infants to train their sensory cues and motor skills through exercises such as oral motor stretches, sour/cold stimulation, facial taping, lip rounding, and neuromuscular stimulation. It is just as important to provide family counseling and parent training as it is to train the infant patients during these sessions.
Pediatric airway surgeon Dr. Michael Rutter and I discuss risk-taking and effective market analysis in entrepreneurship. In the operating room, Dr. Rutter cultivates a congenial OR environment and often seeks ideas from other team members with different areas of expertise. These problem solving-driven conversations often result in pioneering new airway surgery techniques. In the medical device sphere, he outlines his journey of creating a tracheal balloon dilation device, explaining how he obtained intellectual property rights, cleared FDA regulations, and marketed the product.
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In this episode, pediatric airway surgeon Dr. Michael Rutter and our host Dr. Eric Gantwerker discuss risk-taking and effective market analysis in entrepreneurship.
Dr. Rutter shares about his career path from medical school, to orthopedic surgery training, to his current hybrid role in otolaryngology and device entrepreneurship. Interestingly, his experience in orthopedic surgery has inspired him to adopt orthopedic tools and techniques in solving complex ENT cases. He elaborates on this idea of borrowing concepts from other fields, saying that he cultivates a congenial OR environment and often seeks ideas from other team members with different areas of expertise. These problem solving-driven conversations often result in pioneering of new airway surgery techniques.
As we transition to discussing product development, Dr. Rutter outlines his twelve year journey of creating a balloon dilator for the trachea, explaining how he obtained intellectual property rights, cleared FDA regulations, and marketed the product. When in a competitive marketplace, he highlights the benefits of conducting a non-inferiority (“Pollyanna”) study combined with attractive value propositions. Finally, he discusses the reality that some good ideas will not necessarily be successful, due to insufficient market size or extremely high costs of research and development. We conclude on the point that an entrepreneur must evaluate the balance between benefits gained and losses incurred when bringing their product to market.
We talk with Dr. Cecelia Damask and Dr. Matt Ryan about the role of Biologics for Nasal Polyps, including patient selection and its place in the treatment plan.
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In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, Dr. Cecelia Damask (Lake Mary ENT and Allergy), and Dr. Matt Ryan (UT Southwestern Otolaryngology) discuss the growing role of biologics for nasal polyps.
Biologics are monoclonal antibodies that block T2-mediated immune responses (IL-3, IL-4, IL-13, IgE). They are administered subcutaneously and follow various dosing regimens. Biologics are a viable treatment option in patients with recurrent nasal polyps who have failed conventional therapies, such as high doses of antihistamines, topical steroids, and systemic steroids. It is still considered as a last line treatment because of the high cost associated with production of monoclonal antibodies.
However, not all patients with recurrent nasal polyps are good candidates for biologics. The patient must present with a specific endotype––the T2-mediated etiology. T2-mediated patients can be identified through their high responsiveness to steroid therapy, positive history for allergic asthma and atopic dermatitis, and high peripheral eosinophil and serum IgE levels on a CBC with differential. In a surgery-naive patient with a temporary steroid response, it is best to perform sinus surgery first in order to widen the nasal mucosal surface area for efficient delivery of topical therapies. However, if post-surgical intranasal steroid sprays and saline irrigations are ineffective, biologics should be considered. It is best to avoid surgery and skip straight to biologics in patients with comorbid conditions that prevent surgery, patients with severe asthma, and patients with high peripheral IgE counts (>1000).
Once the decision to start biologic therapy is made, many factors have to be considered, such as insurance pre-authorization, administration methods, and frequency of dosing. Each biologic manufacturer has a “hub” that assists physicians and patients in navigating biologic dosing, delivery, and insurance paperwork. They will often have co-pay assistance programs for patient benefit as well. Common side effects observed in biologic trials are arthralgia, injection site inflammation, oropharyngeal pain, and headaches. However, all the doctors agree that these side effects are more mild than those of long-term systemic steroid use, which include avascular necrosis, cataracts, sepsis, and thromboembolic events.
Picking which biologic to prescribe is a clinical decision because they have not been subjected to comparative trials yet. The three biologics currently on the market are: Dupilumab (anti-IL-4 receptor), Omalizumab (anti-IgE), and Mepolizumab (anti-IL-5 receptor). All work to prevent T2 immune signaling by targeting different receptors. Factoring in comorbid conditions, payer systems, and dosing regimens can help a physician choose the best biologic for a nasal polyps patient.
In this special collaborative episode, guest host Dr. Bradley Block talks with Dr William Blythe and Dr. Drew Locandro about the pros and cons of private equity, including a discussion of the key things to think about when considering selling your practice.
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In this episode of BackTable ENT, Dr. Bradley Block from ENT and Allergy interviews Dr. Drew Locandro (Northwest ENT and Allergy Center) and Dr. Bill Blythe (East Alabama Ear, Nose & Throat) about the benefits and pitfalls of opening their private practices to private equity companies.
Private equity can provide many benefits to community practitioners. Outside investment can contribute more money to marketing and hiring new supportive positions. Additionally, it also levels the playing field for older and younger doctors in the practice in the context of objective management. Finally, private equity firms can take care of administrative duties, such as billing and accounting, thus increasing the free time available to physicians.
On the other hand, retaining complete ownership of a medical practice can provide physicians with more satisfaction and decrease rates of burnout. Dr. Blythe notes that a physician can still retain total ownership of his practice but still outsource basic administrative duties, such as general accounting.
Finally, the doctors discuss the concept of a “second bite” deal. Oftentimes, the original smaller private equity firm will sell the medical practice to a larger private equity firm for a profit. Risks of the “second bite” include undervaluation of the practice as well as loss of physician control. However, Dr. Locandro notes that the second sale may also be financially beneficial for the physician stakeholders as well.
Dr Keith Matheny tells us how he first got involved in entrepreneurial pursuits, including starting a global purchasing organization for ENT's, as well as advice on where to start when you have a great idea for a new device!
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In this episode of BackTable ENT, Dr. Shah and Dr. Agan interview Dr. Keith Matheny, a physician-entrepreneur and a fellow ENT.
First, Dr. Matheny discusses his personal device innovation and business journey. He started medical practice with no formal business background or training and had to learn these skills on-the-job during his first private practice job. After observing the need in his field for business consulting, he created US ENT, a formal consulting company, to help other ENT practices grow and develop different departments. US ENT later transformed into a group purchasing organization and was able to partner with medical suppliers to give physicians discounts on materials. During this time, he was also able to test new ENT devices and provide his input to large medical device companies; these experiences prompted him to venture into the field of device innovation and begin patenting his ideas.
Acquiring knowledgeable and supportive partners is essential for developing new devices. Dr. Matheny recommends reaching out to device representatives of major medical device companies in order to be introduced to their business development teams. However, he notes that major medical device companies do not specialize in early-stage development. For this reason, partnering with a startup business may be more productive when developing a product prototype. For every person an innovator discusses his idea with, a non-disclosure agreement (NDA) should be signed in order to ensure the integrity of information sharing. Additionally, innovators should file a patent as soon as they have a solid idea; patent lawyers are useful resources and can help innovators find angles that make their ideas different from previous devices. Although Dr. Mathey encourages innovators to seek funding from healthcare investors, venture capitalists, and private equity companies, he warns listeners against letting outside forces take control over a majority of their company.
Once a prototype is created, the product can be tested in the setting of a medical practice through the proper IRB channels. It is important to follow FDA regulations during this time period. For devices that are similar to pre-existing devices on the market, they can be classified as Class I exempt devices if all predicate devices are listed in the application. Approval for Class I exempt devices will follow in a few short months. However, for brand new devices, a formal study will need to be conducted before it can be used in human patients, thus invoking a longer approval time.
RESOURCES
Dr, Matheny’s Linkedin: https://www.linkedin.com/in/keith-matheny-38250811/
US ENT: https://usent.com/
Septum Solutions: https://septumsolutions.com
Sleep Vigil: https://www.sleepvigil.com/
Romaine Johnson asks society leaders Gaelyn Garrett, Seth Dailey and Ron Mitchell about why otolaryngology societies are worth joining, including addressing questions that young ENT's have about the value of a membership.
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In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Johnson discuss the benefits and challenges of joining ENT societies in a panel discussion with Dr. Ron Mitchell (American Society of Pediatric Otolaryngology), Dr. Gaelyn Garrett (Triological Society), and Dr. Seth Dailey (American Broncho-Esophagological Association).
ENT societies can bring many professional opportunities to network and find mentorship outside of their own institutions. Society meetings can also advance research interests, as attendees can seek advice about research topics and find research funding and travel grants. Finally, ENT society members have a sense of belonging to a “tribe”, or a family of like-minded individuals who share the same goals for advancing their practice as well as community health.
Nevertheless, as ENT societies grow in scale, there is potential for more challenges to develop. For example, younger members may feel that their voices are not being heard, as there can be a leadership-member gap at society meetings. Additionally, financial barriers and admission requirements may deter new members from joining. Finally, many ENT societies remain academically focused and seem irrelevant to community practitioners.
RESOURCES
American Society of Pediatric Otolaryngology: https://aspo.us/
Triological Society: https://www.triological.org/
American Broncho-Esophagological Association: https://www.abea.net/
Emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.
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In this episode, emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.
Dr. Pensa starts by outlining her personal experience with a twelve year-long malpractice suit, which inspired her to start her own podcast, “Doctors and Litigation: The L Word.” She says that despite the fact that most physicians will face lawsuits in their career, there is a current lack of physician-centered educational resources over malpractice litigation. To combat this, she encourages physicians to share their experiences and learn from one another.
The doctors walk through major steps of a lawsuit, starting with the process of getting served with papers. Dr. Pensa emphasizes that it is important to recognize that this step could be used as the first tactical move in a lawsuit and designed to make physicians feel uneasy. The next step after getting served should always be to call the insurance carrier and have them start the process of initiating a claim. Dr. Pensa strongly advises against accessing or editing patient charts after getting served, as these actions are recorded in the EMR and can be used against the physician. Finally, Dr. Pensa discusses the process of deposition and how it serves as both a fact-finding mission and a strategic way to distort a physician’s words. She recommends practicing with lawyers to answer deposition questions clearly and concisely.
Throughout the episode, the doctors highlight the importance of maintaining one’s mental health during the litigation process. They advise listeners to seek support from friends, family, colleagues, and professionals, as long as the specific details of the case are not discussed. To close, Dr. Pensa reminds the audience that malpractice lawsuits usually have financial motivations, and they may not be an accurate representation of a physician’s competence or compassion for patients.
RESOURCES
Doctors and Litigation: The L Word: https://doctorsandlitigation.com/
“The Defendant” by Sarah Charles: https://www.amazon.com/Defendant-Sarah-Charles/dp/0394746635
“Adverse Events, Stress, and Litigation” by Sarah Charles: https://www.amazon.com/Adverse-Events-Stress-Litigation-Physicians/dp/0195171489
“How to Survive a Medical Malpractice Lawsuit” by Ilene Brenner: https://www.amazon.com/How-Survive-Medical-Malpractice-Lawsuit-ebook/dp/B005C65X2M
“When Good Doctors Get Sued” by Angela Dodge and Steven Fitzer: https://www.amazon.com/When-Good-Doctors-Get-Sued/dp/0977751104
We talk with Dr. Varun Varadarajan about how to find the right job for you, including pearls and pitfalls to avoid. Varun provides valuable insight based on his experiences with cold-calling groups, negotiating contracts, and important questions to ask at every interviews.
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In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Varun Varadarajan discuss tips for finding the right physician job.
First, Dr. Varadarajan shares his personal journey to finding his job as a neurotologist and skull base surgeon in a private practice located in Denver, Colorado. He started to job hunt for a private practice position after matching to fellowship, which was two years before finishing his training. However, he notes that this timeline may be too early for jobs in academic medicine. Although physicians can apply for jobs through word of mouth and job postings, he and Dr. Shah note that cold calling can also be effective.
Next, the doctors discuss the changes in job hunting that occurred as a result of the COVID-19 pandemic. During the pandemic, some job opportunities vanished because of decreased funding and patient volume in clinics. Dr. Varadarajan and Dr. Shah also summarize the types of questions that should be asked during and after a private practice interview. Some red flags are: multiple associates who never made partner, high turnover rates, big buy-in amounts for partnership, and non-transparency with finances. Dr. Varadarajan also shares the resources he used during the employment process; he had a local lawyer with experience who reviewed his contract beforehand and received mentorship from academic faculty and his former co-residents.
Finally, Dr. Shah discusses tips for academic job hunting. One difference between private practice and academic job hunting is that in the latter, the consideration of how much research time and clinical time doctors want to prioritize becomes an important decision. Dr. Shah also took into consideration her family life, and ultimately decided on a job at UT Southwestern because of the great ENT department faculty and mentors.
Dr. Ashley Agan sits down with the eustachian tube expert Dr. Dennis Poe to discuss his approach to management and treatment of eustachian tube dysfunction.
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In this episode of BackTable ENT, Dr. Agan discusses eustachian tube disorders with Dr. Dennis Poe, professor of otolaryngology at Harvard Medical School.
First, the doctors discuss the difference between the two main types of Eustachian tube disorders: obstructive dysfunctions and Patulous dysfunctions. Obstructive dysfunctions are a result of pathologies that cause inflamed or clogged Eustachian tubes, while Patulous dysfunctions are a result of the Eustachian tube remaining perpetually open.
Obstructive and Patulous dysfunctions can be clinically differentiated. Patulous dysfunctions commonly experience extraordinary loud noises, variable pressure sensation, aural fullness, habitual sniffing, relief upon using the Valsalva maneuver, and autophony. Although autophony is not pathognomonic for Patulous dysfunction, it can give otolaryngologists a clue for a potential Patulous dysfunction diagnosis. Obstructive dysfunction patients commonly experience negative pressure in tympanic membrane, fluid in middle ear, scarring, and fixed retraction pockets.
Otolaryngologists can also insert an endoscope through the nose to perform a physical examination on Eustachian tube disorder patients. Dr. Poe recommends that otolaryngologists obtain a longitudinal view of the Eustachian tube lumen to observe the cartilaginous and membranous walls and the quality of the valve. He recommends using the MEELO assessment (mucus production, erythema, edema, lymphoid hyperplasia, and opening quality) to grade Eustachian tube disorder patients on a scale of 1-4, with 4 being the most severe dysfunction. He cautions against using tympanograms for diagnoses because of their inaccuracy.
Eustachian tube disorders can be treated with medication. Because the most common etiology of obstructive Eustachian tube disorder is allergic rhinitis, Dr. Poe starts with allergy testing to identify possible allergens. He notes that topical nasal steroids and nasal drops are effective, but may be difficult for patients to self-administer. For this reason, patient education is very important. If medications do not work after 6 weeks, Dr. Poe recommends performing a balloon dilation of the Eustachian tube. The length of balloon dilation depends on the MEELO grading scale. If obstructive Eustachian tube dysfunction patients are a grade 3 or 4 with moderate to severe inflammatory disease and a significantly compromised valve, he dilates for the full two minutes. If they are a grade 2 or low grade 3 with a lesser disease, he only dilates for one and a half minutes or even one minute. Because pediatric patients are very sensitive to balloons, he never goes above one and a half minutes in pediatric patients. Finally, he notes that Patulous Eustachian tube dysfunction patients can be surgically treated via a transtympanic tripod-shaped angiocatheter procedure.
RESOURCES
Eustachian Tube Disorder Questionnaire: https://earandsinusinstitute.com/online-questionnaires/etdq-7-questionnaire/ Xhance Nasal Spray: https://www.xhancehcp.com/
We talk with Dr. Brianne Roby from Children's Minnesota about airway evaluation and surgical management of the infant with retro/micrognathia.
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First, the doctors discuss the difference between micrognathia and retrognathia, two terms that are commonly and incorrectly interchanged. Micrognathia refers to an infant having a small mandible, while retrognathia means the infant’s mandible is normal sized, but just recessed.
Dr. Roby usually makes the distinction through physical examination by feeling the angle and body of the mandible. In infants with retrognathia, she is able to feel a long body and defined angle in the mandible. She notes that diagnosis of micrognathia will most likely be postnatal, as obtaining a perfect sagittal view for measurement of inferior facial angle in a prenatal ultrasound is very difficult. However, she notes that polyhydramnios, or excess accumulation of amniotic fluid, is a significant indicator of an underdeveloped fetal jaw.
In her initial evaluation of an infant with micrognathia, she first confirms that the infant is stable and in optimal position. Then, she examines the infant for other comorbidities and syndromic developments. Although Stickler syndrome is the most common syndrome associated with micrognathia, Pierre-Robin sequence and Treacher Collins syndrome can also cause micrognathia. Before scoping the infant, she prefers to familiarize herself with the infant’s anatomy and feeding/breathing patterns first. In order to do this, she collaborates with the NICU staff and encourages them to informally document the infant’s behavior. Then, she will insert a bedside flexible scope through the infant’s nose to confirm that the infant has glossoptosis and not just a benign enlarged tongue base. She emphasizes that a surgeon should always confirm that there are no other airway malformations before performing surgery to place a mandibular distractor. Besides glossoptosis, other important indicators for mandibular distraction are airway obstruction and feeding difficulties. Dr. Roby only performs mandibular distractions on babies that are gestationally full term (37-38 wks) and weighing over 2 kg.
Next, Dr. Roby shares her tips for mandibular distraction surgery. Her general approach is to secure the airway first and then insert the distractor. She emphasizes that preparation for airway emergencies is the most important intraoperative consideration. She prefers to have an experienced anesthesiologist on hand and multiple methods to secure an infant’s airway, including nasotracheal intubation, oral intubation, a Glidescope, a Telescope, flexible fiberoptic nasal intubation, a tracheostomy set, and manual ventilation. The longer time it takes to secure an infant’s airway, the higher the risk of spontaneous laryngospasm and bleeding.
The otolaryngologist can either place an internal or external distractor. For an internal distractor, the plates and screws are placed under the skin so only the distraction arm is visible. This device can only distract in one direction, so it is commonly used in Pierre-Robin sequence infants. External distractors contain hardware that must be inserted externally and can distract in multiple directions. Dr. Roby prefers to place an internal distractor to minimize scarring and maximize parent and nurse comfort.
After the distractor is placed, it must be rotated daily to open the mandible. Dr. Roby turns the pins twice a day by 2 mm; she does 1 mm in the morning and 1 mm in the night. Her goal is to achieve a 12-14 mm distraction and a slight underbite in most infants. After achieving this distance, the plates have to be left in for 10 weeks in order for the bone to harden. After 10 weeks, she removes the distractor and observes the infant for improvement in feeding.
Dr. Romaine Johnson tells us about The Simulation Program for open airway and foreign body training at UT Southwestern, including how he got it started, how it's being used, and what steps go into making a successful course.
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In this episode of BackTable ENT, Dr. Shah and Dr. Agan discuss simulation programs for complex pediatric airway surgery with Dr. Romaine Johnson from UT Southwestern.
First, Dr. Johnson explains his motivation to start an airway simulation program. In the past, he noticed that emergency airway obstructions were suboptimal educational experiences for his junior residents, so he wanted to create a space in which trainees could build the confidence to prevent severe laryngospasms and bronchospasms and develop familiarity with tools during airway obstruction cases.
Next, Dr. Johnson dives into the airway obstruction course details. He uses live animal simulations because it creates a more realistic situation and provides residents with the tactile sensation of removing a foreign body from tissue. Additionally, with a pig model, trainees are able to observe more audio and visual cues such as monitor statistics and skin color. In order to use live animals, he coordinates closely with anesthesiologists and veterinarians. Dr. Johnson recommends attending simulation courses at least twice a year, as repetition is the most effective method of learning procedural techniques in emergency situations. In addition to guiding residents through removing the foreign body, he encourages residents to play other roles, such as techs and anesthesiologists, to grasp a more complete understanding of the different tasks of each profession involved in airway management.
Finally, Dr. Johnson compares the use of simulations in emergency procedures and routine procedures. For emergency procedures, he emphasizes the importance of finding high-fidelity models. However, in routine procedures that educate trainees on decision making, Dr. Johnson concedes that perfect models are not necessary. He ends the episode by concluding that simulation education is not only beneficial for residents, but also for private practice physicians and academic attendings in order to keep their skills sharp.
RESOURCES
Airway Reconstruction Surgical Dissection Manual: https://www.pluralpublishing.com/publications/airway-reconstruction-surgical-dissection-manual
Dr. Joe Walter Kutz talks with Dr. Jed Grisel about practice patterns treating patients with hearing loss, as well as the correlation between hearing loss and cognitive decline, and how best to screen these patients.
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In this episode, otolaryngologist Dr. Jed Grisel joins neurotologist Dr. Walter Kutz to discuss the link between hearing and cognition, counseling families about treatment outcomes, and practice building opportunities for ENT/audiology clinics.
Dr. Grisel describes changing trends in the hearing care market, such as direct-to-consumer marketing and over the counter hearing aids, which can alter patients’ relationships with ENTs. He emphasizes that these low cost options make hearing care more accessible to patients. They also provide otolaryngologists with the stimulus to branch out into new service lines and position themselves as comprehensive hearing experts. His clinic has recently added cognitive screening to their diagnostic workup. Dr. Grisel highlights the advantages of cognitive screening, which include a better understanding of the patient experience, more effective management of patient and family expectations, and relationship building with primary care providers.
The doctors also talk about the implementation process of cognitive testing in ENT/audiology clinics. Dr. Grisel shares his practice’s experience with cognitive screening kiosks that minimize the requirements for patient dexterity.
As healthcare advances, more and more people are living longer and reaching ages of hearing loss onset. The doctors discuss what it means to have more years of sensory deprivation and how ENTs can offer interventions to reduce the patient’s cognitive load and improve overall cognitive function.
RESOURCES
Texoma ENT and Allergy: https://www.texomaentandallergy.com/
Dementia Prevention, Intervention, and Care: 2020 Report of the Lancet Commission: https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext
We talk with Vestibular Therapist Matthew Johnston about the workup of dizziness and setting up patients for success with Vestibular Rehab.
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In this episode, physical therapist Matthew Johnston joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the process of vestibular evaluation, rehabilitation, and long-term care.
First, Matthew speaks about the importance of obtaining a thorough past medical history to identify the patient’s onset, duration, and aggravators/alleviators of dizziness. These responses help him set up a physical examination, which includes the Vestibulo-Ocular (VOR) Cancellation test, the Clinical Test of Sensory Interaction in Balance (CTSIB), and the Dix-Hallpike test. All of these diagnostic tools help him evaluate the patient’s vestibulo-ocular reflex and check for nystagmus.
Matthew distinguishes between Benign Paroxysmal Positional Vertigo (BPPV) and other conditions of vestibular hypofunction such as Meniere’s Disease and vestibular neuronitis. While the former is curable, the latter conditions are more chronic and complex, so it is important to manage patient expectations and emphasize symptom alleviation. Overall, Matthew believes that identifying the affected ear canal and specifically matching the treatment to the canal is the most efficient way to treat patients.
We close by talking about ways to improve the patient’s physical therapy experience, through prescribed anti-nausea medications, maintenance exercises done in the home, and partnership between ENTs and physical therapists.
RESOURCES
Excel Physical Therapy: https://excelphysicaltherapy.com/
Dr. David Goldenberg talks with us about the management of thyroid nodules, including workup, imaging and patient counseling.
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In this episode, head & neck surgical oncologist Dr. David Goldenberg joins Dr. Gopi Shah and Dr. Ashley Agan to discuss diagnosis, treatment, and follow up for various types of thyroid nodules in adults.
First, Dr. Goldenberg describes his workup for thyroid nodules, which includes palpation, ultrasound, and TSH levels. He emphasizes that a thyroid ultrasound must involve the scanning of both sides of the neck in order to make comparisons between normal and abnormal findings. After evaluating the ultrasound and having open dialogue with pathologists and radiologists, his team decides if Fine Needle Aspiration (FNA) is necessary. The doctors discuss how to counsel patients when FNA yields indeterminate results. The course of further treatment and surveillance should take into account the patient’s risk tolerance, the presence/absence of compressive symptoms, and the patient’s ability to return for a later biopsy.
Dr. Goldenberg describes how the use of molecular testing is becoming more common in diagnosing thyroid cancers. Specifically, the BRAF mutation usually signifies thyroid cancer, and the TERT mutation signifies a very aggressive form of thyroid cancer.
Finally, the doctors discuss surgical decision-making between a full thyroidectomy and a partial lobectomy. Dr. Goldenberg focuses on damage to the recurrent laryngeal nerve as potential complication and emphasizes the importance of justified interventions and continual surveillance.
RESOURCES
“Head and Neck Endocrine Surgery” by Dr. David Goldenberg: https://www.thieme.com/books-main/otolaryngology/product/6136-head-neck-endocrine-surgery
We talk with Dr. Bradley Block, creator and host of The Physician's Guide to Doctoring Podcast, about optimizing communication to improve workflow and for better patient care.
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In this episode, Dr. Bradley Block joins Dr. Gopi Shah and Dr. Ashley Agan to discuss tips for trust building and nonverbal communication with patients.
Dr. Block starts by sharing how he facilitates introductions at the beginning of a visit. He identifies himself as the doctor, and asks the patient about their preferred name and pronouns. Then, he acknowledges the patient’s discomfort and/or pain associated with their chief complaint. These patient-centered approaches help build trust and ensure the patient’s voice is being heard.
Nonverbal communication can also build trust. Dr. Block recommends moving computers to the side to ensure that they are not impeding communication. Additionally, patients will often mirror the physician’s level of engagement. One way to show engagement is to repeat the patient's words back to them.
Finally, we discuss methods of communication with disgruntled patients. For example, asking them to verbalize their specific concerns can make them feel seen and heard. Dr. Block emphasizes that in order to be effective, communication strategies must be consistent across all providers and staff in the clinic.
RESOURCES
Physician’s Guide to Doctoring (Dr. Block’s podcast): https://physiciansguidetodoctoring.com/ Dr. Block’s Twitter: @PhysiciansGuide
We talk with Dr. Anita Jeyakumar about her approach to Single Sided Deafness in Children, including workup, treatment and long-term care.
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In this episode, pediatric otolaryngologist Dr. Anita Jeyakumar joins Dr. Gopi Shah and Dr. Ashley Agan to discuss screening, counseling, and treatment options for single sided deafness in children.
Dr. Jeyakumar starts by outlining referral patterns for single sided deafness, which can arise from newborn or pediatric hearing screenings. When counseling families on the importance of close monitoring and early intervention, Dr. Jeyakumar believes that it is crucial to fully explain how hearing loss can affect academic success, social interactions, and general safety: When a child has retained normal hearing in one ear, their speech is usually unaffected. However, the child will likely struggle with cognitive overload and cognitive fatigue when relying solely on the hearing ear. The child can also feel overwhelmed with trying to hear in noisy social situations. As the child gets older, untreated hearing loss can also put them at risk in potentially hazardous scenarios, such as crossing busy intersections, and eventually, driving.
The doctors discuss imaging modalities such as CT and MRI. Dr. Jeyakumar prefers MRI, since it can identify hypoplastic and aplastic auditory nerves.
Finally, the doctors highlight a range of treatment options, including the use of CROS hearing aids, bone conduction hearing aids, and cochlear implantation. With all of these technologies, it is important to keep in mind the patient’s age, infection risk, cosmetic concerns, and insurance coverage. Dr. Jeyakumar emphasizes that staying in contact with the family is important, as children may need treatment adjustments due to changes in schooling and geographic location.
Join us to celebrate BackTable ENT's First Year Podiversary with co-hosts Dr. Gopi Shah and Dr. Ashley Agan! We take a look back at the year and discuss some of our favorite episodes as well as progress towards wellness since our first episode. Thank you to our amazing guests and loyal listeners!
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In this episode, our hosts Dr. Ashley Agan and Dr. Gopi Shah reflect on the first year of the BackTable ENT podcast. They highlight colleagues that have shared their expertise on a wide variety of ENT topics, noting that organic conversations have brought valuable insight to the show. Additionally, they review the results of a listener survey and use feedback to generate new ideas for future episodes.
We’d like to give a special thanks to our listeners! We love hearing your thoughts and feedback, which can be submitted through our website, https://www.backtable.com/shows/ent/ . Stay tuned for more exciting episodes!
We talk with Dr. Carrie Francis about her passion for guiding personal and professional development for physicians, trainees and students, while helping them build a strategy of authentic alignment between their career goals and purpose.
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In this episode, Dr. Carrie Francis joins Dr. Gopi Shah and Dr. Ashley Agan to discuss her philosophy of mentoring and her goal of fostering diversity and inclusion within the field of otolaryngology.
Dr. Francis begins by defining “mentoring” and “coaching,” noting that mentorship stems from specific expertise in a topic, but coaching can offer more general guidance. The roles are not mutually exclusive, and both can help learners in their career path. She emphasizes that mentors should encourage learners to set personal goals, which can be difficult in medicine, a field where milestones are often externally determined by institutions. The doctors weigh the differences between organic and assigned mentoring relationships; however, both require constant reflection and evaluation to serve the needs of both parties.
Next, Dr. Francis describes the art of giving feedback. While summative feedback is helpful at the end of a period, timely feedback helps the learner adjust their behaviors sooner. She encourages mentors to plan appropriate times and places to give feedback effectively and respectfully.
Finally, the doctors discuss diversity and inclusivity challenges in our field and ways that residency programs can capture individuals from the “leaky pipeline.” This starts with departments’ commitment to defining their values and conducting holistic evaluations of applicants.
We talk with Rhinologist Dr. Ashleigh Halderman about Revision Endoscopic Sinus Surgery, including patient selection, pre-op planning, and endoscopic technique.
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In this episode, Dr. Ashleigh Halderman joins Dr. Gopi Shah and Dr. Ashley Agan to discuss preoperative, procedural, and postoperative considerations for revision sinus surgery.
Dr. Halderman begins by describing her patient workup, which includes learning about the patient’s history with sinus problems and surgeries. It is critical to learn about the patient’s current maintenance regimen and whether it includes sinus rinses, steroids, and/or antibiotics. Dr. Halderman aims to teach patients how to maximize medical management techniques before performing a revision surgery. She discusses the steroids and antibiotics that she usually prescribes and her patient education technique for nasal rinses.
In addition, she conducts physical and endoscopic exams and obtains a preoperative CAT scan. She emphasizes that the CAT scan is important for determining the extent of the prior surgery and guiding future plans. Sometimes, the scan reveals that a patient’s symptoms are not sinus-driven (i.e. recurrent viral infections), leading her to consider options besides surgery.
Finally, the doctors discuss operative technique. Revision surgeries may be challenging due to abnormal anatomy and scarring, so Dr. Halderman advises surgeons to utilize image guidance and look for anatomical landmarks.
RESOURCES
The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery: https://pubmed.ncbi.nlm.nih.gov/26991922/
We talk with Dr. Carrie Nieman about improving hearing health disparities among older adults, particularly among vulnerable populations. Her practice and research focuses on an innovative, community-delivered approach to affordable, accessible hearing care.
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In this episode of BackTable ENT, Dr. Mark Williams joins Dr. Gopi Shah and Dr. Ashley Agan to discuss various diagnoses for voice problems, treatment options, and special considerations for treating singers.
Dr. Williams always begins a workup by taking a full history which includes questions about patterns in voice changes and pain. These questions help specify the type of voice change beyond the umbrella term of “hoarseness.” He describes the differences between examinations with a rigid laryngoscope, a flexible fiberoptic laryngoscope, and videostroboscopy (allows for observation of vocal fold vibration). He also performs laryngeal palpation to check for muscle tension dysphonia.
When discussing treatment, Dr. Williams speaks about the importance of getting allergies under control, to allow patients the best quality of voice possible. He prefers nasal steroid sprays over antihistamines. Dr. Williams also describes indications for microlaryngeal surgery, such as polyps and cysts. Dr. Williams notes that voice problems may have an underlying cause that is hidden by compensatory behaviors, which end up causing more issues than the original pathology. In these instances, voice therapy can help break harmful habits. Finally, by merging his experience as an otolaryngologist and a gospel singer, he shares insights on counseling singers about steroid shots, vocal hygiene, and voice rest.
RESOURCES
Dr. Williams’ Website: https://www.drmarkwill.com/medicine/
We talk with Dr. Mark Williams about building his solo ENT practice, taking care of recording artists in Nashville, and aligning his own music, medicine and ministry.
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In this episode of BackTable ENT, Dr. Carrie Nieman joins Dr. Gopi Shah and Dr. Ashley Agan to discuss disparities in hearing care for older adults and different care models to address these.
Dr. Nieman begins the show by sharing some striking statistics: of the 26 million older Americans who currently experience a clinically significant degree of hearing loss, only 3 million actually use hearing aids. Disparities in hearing care may arise from individual factors such as financial situation and patient education, but they can also arise from structural factors like physical distance from ENTs and audiologists.
Dr. Nieman believes that the conventional model of clinic-based hearing care can be augmented by different models of care delivery, specifically one that makes use of community health workers. She describes the HEARS (Hearing Health Equity Through Accessible Research and Solutions) Program that she developed and how her team trained older adult peer mentors to guide patients through education about over-the-counter hearing devices, communication strategies, and living with hearing loss. She emphasizes that these devices can be a gateway that leads patients to feel more comfortable with hearing aids later on.
For ENTs looking to reduce hearing care disparities, Dr. Nieman recommends that they learn how their patients want to engage with the world, provide patients with multiple options for hearing care, and collaborate with other players who are working towards the same goal.
RESOURCES
HEARS Program: https://jhucochlearcenter.org/hears-hearing-equality-through-accessible-research-solutions.html
Access HEARS: http://accesshears.com/
Hearing Loss Association of America: https://www.hearingloss.org/
Dr. Nieman’s Twitter: @CarrieNiemanMD
We talk with Dr. Sarah Saxon about Facial Feminization Surgery, including the range of procedures, patient selection, and technique.
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In this episode, Dr. Sarah Saxon joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the variety of facial feminization surgeries and important considerations for treating transgender patients.
Dr. Saxon defines “facial feminization surgeries” as a group of procedures that are geared towards feminizing the face. She highlights the fact that feminizing a patient’s appearance often aligns with striving for a more youthful appearance. Therefore, feminizing procedures can include facelifts, skin resurfacing, and skin tightening with radiofrequency. Additionally, Dr. Saxon describes her techniques for chondrolaryngoplasty (also known as tracheal shave), mandibular contouring, and type 3 cranioplasty. She also discusses post-operative care with exosome injections at incision sites and steroids.
Throughout this episode, Dr. Saxon offers advice for providers who treat transgender patients. From a pre-operative standpoint, she advises surgeons to ensure that their patients are off of hormone therapy during the two weeks prior to surgery in order to reduce the risk of DVT. She also encourages providers to ask about patients’ preferred pronouns and avoid making assumptions about their patients. Above all, she emphasizes that providers should be open-minded and recognize that patient care is a dynamic learning process throughout their entire careers.
RESOURCES
Dr. Saxon’s Website: https://saxonmd.com/ Dr. Saxon’s Instagram: @saxonmd, @breathe_atx, @breathe_dallas
We talk with Dr. Matthew Ryan about diagnosis and management of Allergic Rhinitis, as well as Immunotherapy as a potential treatment option.
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In this episode, Dr. Matthew Ryan joins Dr. Gopi Shah and Dr. Ashley Agan to discuss symptoms and comorbidities of allergic rhinitis, as well as current treatments such as decongestants, antihistamines, steroids, and immunotherapy.
The methods of allergy testing (prick test, intradermal test, and blood draw) are clinically interchangeable, with skin tests being the cheapest. Unfortunately, there are nuances in interpreting allergy test results, and a patient’s symptom complex may have a great deal of variability. There may not be correlation between a patient’s symptoms and their allergy test results. While an allergy test can be helpful, chronic rhinitis can be diagnosed and treated without testing.
As a first-line therapy for allergic rhinitis, Dr. Ryan will prescribe a combination of a nasal steroid spray and a nasal antihistamine spray, and then follow up with the patient to see if these help with symptom relief. The doctors also talk about treating allergic rhinitis and medication considerations in subgroups such as children and patients with nasal polyps, asthma, and hypertension.
For patients who still struggle with symptom control, the doctors discuss two types of immunotherapy, subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both have advantages and disadvantages based on available clinical data, status of FDA approval, insurance coverage, and convenience for the patient.
RESOURCES
Central Compartment Atopic Disease: https://pubmed.ncbi.nlm.nih.gov/28716173/
We talk with Dr. David Cognetti about sialendoscopy including the importance of patient selection as well as tips and tricks for success.
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In this episode, Dr. David Cognetti joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the workup for salivary gland obstruction and inflammation, the emerging use of sialendoscopy, and different approaches to sialolithotomy.
First, the doctors highlight key aspects of physical examination: observing swelling around the glands, bimanually palpating for stones, and massaging the glands to observe the quantity and quality of saliva produced. For imaging, Dr. Cognetti typically orders CT for suspected stones and MRI for suspected inflammatory disorders. He describes the process of sialography, noting that the outcome may be technician-dependent. The doctors also discuss inflammatory cases where laboratory tests may be appropriate and can reveal autoimmune disorders.
Then, Dr. Cognetti describes his preferred sialendoscopy tools and how he uses them to cannulate and dilate the parotid and submandibular ducts during surgery. He emphasizes the fragile nature of the scopes and the need to protect them from damage. For sialolithotomy, he describes various methods of lithotripsy and ways to prevent thermal damage. He also discusses how he deals with duct perforation and how he decides whether or not to use stents.
The doctors bring up management of patient expectations throughout the episode, as outcomes may vary depending on the individual’s history of stone recurrence.
RESOURCES
“Sonopalpation: A Novel Application of Ultrasound for Detection of Submandibular Calculi” - https://journals.sagepub.com/doi/10.1177/0194599814545736?url_ver=Z39.88-2003𝔯_id=ori:rid:crossref.org𝔯_dat=cr_pub%20%200pubmed
“Limited Distal Sialodochotomy to Facilitate Sialendoscopy of the Submandibular Duct” - https://onlinelibrary.wiley.com/doi/full/10.1002/lary.23801
4th Annual Jefferson Sialendoscopy Course- https://cme.jefferson.edu/content/sialendoscopy2021#group-tabs-node-course-default1
We talk with Dr. Nina Shapiro about the importance of effective communication of medical information to patients, and helping them avoid bad medical advice. She is author of the book "Hype: A Doctor's Guide to Medical Myths, Exaggerated Claims, and Bad Advice - How to Tell What's Real and What's Not".
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In this episode, pediatric otolaryngologist and author Dr. Nina Shapiro joins Dr. Gopi Shah and Dr. Ashley Agan to discuss writing for non-medical audiences, addressing health misinformation, and overcoming our own physician biases.
Dr. Shapiro discusses her journey towards authorship. As her children entered school, she had begun communicating information about common ENT issues to other parents. This passion evolved into writing op-eds, blog articles, and eventually, books. Her audiences are both medical and non-medical, and she discusses the differences in writing for each type.
We talk about concepts from her newest book, “Hype,” which aims to address popular health concerns, de-bunk media myths, and encourage readers to be intelligent consumers of health information and products. We dive into “The Curse of the Original Belief,” the idea that we are biased towards seeking out new information that confirms what we already believe.
Dr. Shapiro offers guidance for physicians when they converse with patients who have been misinformed by Internet sources. Her overall strategy is to listen to patients’ fears, be patient, and follow up with them. Finally, she encourages all practitioners to keep an open mind and stay flexible, as new research can change long-standing beliefs and recommendations.
RESOURCES
Dr. Shapiro’s website and books- http://drninashapiro.com/
Dr. Shapiro’s Instagram, Twitter, and Facebook: @DrNinaShaprio
We talk with Dr. Andrew Day about the Human Papillomavirus (HPV) and Oropharyngeal Cancers.
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In this episode, head & neck surgical oncologist Dr. Andrew Day joins Dr. Gopi Shah and Dr. Ashley Agan in discussing the screening, treatments, prevention, and current research over HPV-positive oropharyngeal cancers.
We begin by discussing the ubiquitous Human Papillomavirus (HPV) and identifying high-risk strains. While there is still a lot of research to be done over this virus, Dr. Day describes the estimated prevalence of HPV in the adult population and available screening methods. He brings up the possibility of latent infections and differences in individuals’ immunogenic responses.
Moving into HPV-mediated cancers, Dr. Day distinguishes HPV-positive from HPV-negative head & neck cancers and discusses the differences in presentation and treatment for each type. HPV-positive oropharyngeal cancers usually present as neck masses with no other clear risk factors, and they can be confirmed through ultrasound-guided fine needle aspiration biopsy. Treatment options include various combinations of transoral robotic surgery, transoral laser microsurgery, chemotherapy, and radiation.
Finally, we discuss patient education over HPV and its associated cancers. We address patient inquiries about tonsillectomy as a preventative measure, advice for partners/spouses of HPV-positive cancer patients, and otolaryngologists’ role in raising awareness of the HPV vaccine (Gardasil 9).
RESOURCES
CDC HPV Vaccine Recommendations: https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html
We talk with Dr. Prashant Malhotra from Nationwide Children’s Hospital about Pediatric Cochlear Implants, including workup and patient selection.
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In this episode, pediatric otolaryngologist Dr. Prashant Malhotra and our hosts discuss hearing evaluations, pediatric cochlear implants, surgery considerations for patients with inner ear malformations, and patient/family education.
To start, Dr. Malhotra describes how pediatric cochlear implantation candidates present to him in terms of age and test results. He guides us through his diagnostic workup, which includes a questionnaire, physical exam, imaging, CMV IgG test, connexin test, and next-generation genetic sequencing. Dr. Malhotra also describes collaboration between otolaryngologists, audiologists, and social workers within his multidisciplinary cochlear implant center.
Next, we cover cochlear implantation in children with inner ear malformations, such as CHARGE syndrome and EVA syndrome. These cases present the challenge of abnormal cochleas and higher CSF pressure. Dr. Malhotra also discusses treatment considerations for patients with single-sided deafness and post-lingual deafness. Additionally, he discusses long-term complications of cochlear implants. Complications can include pain, vertigo, acute otitis media (OM) episodes, and meningitis.
Finally, we expand our discussion to encompass patient and family education. This last segment covers topics such as childhood vaccination awareness, benefits of early hearing screenings, management of family expectations, and tracking academic milestones in pediatric cochlear implantation patients.
RESOURCES
American Cochlear Implant Alliance (ACIA)- https://www.acialliance.org/ General information about cochlear implants.
AG Bell- https://www.agbell.org/Families Online resource for families seeking information about speech development and Auditory Verbal Therapy (AVT).
We talk with Laura Matrka MD and Mark Gerber MD about their approaches to airway surgery, including endoscopic vs open, tips on technique, and the importance of communication in the OR.
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In this episode, Dr. Laura Matrka and Dr. Mark Gerber join Dr. Romaine Johnson and Dr. Gopi Shah to discuss airway surgery.
The evaluation of adult and pediatric patients requiring airway surgery is outlined. Key components include a thorough flexible scope exam, direct laryngoscopy/bronchoscopy and a detailed airway history. Deciding between an endoscopic and open approach depends on several factors including airway anatomy, surgical history, acuity of the procedure, and presence of a tracheostomy.
Dr. Matrka and Dr. Gerber review essential equipment for airway surgery - their “airway toolbox” – which can include a subglottic scope, bronchoscope, tracheoscope, or a drill depending on the extent of their procedure. The discussion then turns towards the selection of suture between PDS and Prolene. Dr. Johnson states that he has had less wound dehiscence, but more granulation tissue when using PDS as compared to Prolene.
Lastly, the panel describes technological improvements they would like to see in the coming years. All agree that new approaches to visualize what trainees are observing would significantly improve education and patient care. The panel concludes by discussing the importance of communication in the operating room, and the benefit of protocols in facilitating effective teamwork.
RESOURCES
American Society of Pediatric Otolaryngology: https://aspo.us
Communication Protocol for Airway Surgery from Dr. Matrka and colleagues: https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.28271
We talk with Steven Goudy MD, MBA about his clinical practice and research emphasis on cleft palate care in children at Emory Healthcare, as well as some tips on trying projects/adventures outside of clinical medicine.
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In this episode, pediatric otolaryngologist Dr. Steven Goudy joins Dr. Gopi Shah and Dr. Ashley Agan to discuss diagnosis, treatment, follow-up care, and family education for children with cleft lips and cleft palates.
To start, we define cleft lip and cleft palate based on abnormalities in fetal developments. Then, we cover the timeline for identification and treatment of these conditions. Dr. Goudy emphasizes that cleft lip and cleft palate can have a large effect on basic needs such as feeding. While cleft lip repair can be performed early, it is best to wait until the 1-year mark for cleft palate repair. We discuss treatment of different variations of these conditions, including incomplete and bilateral cleft lips. As we move into post-surgical care, we cover Eustachian tube dysfunctions and post-surgical hearing screenings. Dr. Goudy also discusses co-morbid issues and the process of counseling families through genetic testing.
Dr. Goudy highlights the importance of multidisciplinary care. Within his cleft clinic, the surgeons work with audiologists, speech pathologists, geneticists, dentists, and social workers. He discusses barriers to care for patients who live in rural areas and how his team works to overcome them.
Finally, Dr. Goudy describes his own adventure in medicine, which extends beyond treating cleft lip and cleft palate. As he shares how he got started in translational research, he gives tips for assembling a research team and finding good mentors. He also explains how he addresses common parent concerns by starting a pediatric nasal suction device company, Dr. Noze Best.
RESOURCES
American Cleft Palate Association- https://acpa-cpf.org/
Babies Can’t Wait- https://dph.georgia.gov/babies-cant-wait Georgia’s early intervention program that offers a variety of coordinated services for infants and toddlers with special needs.
Dr. Noze Best- https://www.drnozebest.com/
Dr. Adam Luginbuhl from Thomas Jefferson University Hospitals gives us the 101 on Immunotherapy as a treatment option for Head and Neck Cancer.
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In this episode, Dr. Adam Luginbuhl joins Dr. Gopi Shah and Dr. Ashley Agan to discuss immunotherapy for treatment of head and neck cancer.
Dr. Luginbuhl describes the basics of cancer immunotherapy which aims to harness the body’s intrinsic immune system to target cancer cells. He provides an overview of the main checkpoint inhibitors (CTLA-4, PD-1, PDL-1) and their mechanisms of action. He also highlights new research developments aimed at exploring the role of immunotherapy as a neoadjuvant prior to surgery.
He then discusses the challenges in recruiting for clinical trials whereby he must find the balance between offering promising new treatments with limited evidence and traditional therapies. He states that the main contraindication and side-effect of immunotherapy is auto-immunity.
He emphasizes that the journey with head and neck cancer does not end after treatment. Since the head and neck region is vital to our interactions with the world – our appearance, our voice, our ability to eat and drink – he states that treatment should not only be focused on clearing cancer, but also maintaining patient quality-of-life.
RESOURCES
Review Articles: Immunotherapy for Head and Neck Cancer: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586169/ 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749717/
National Cancer Databases:
National Comprehensive Cancer Network: https://www.nccn.org American Head and Neck Society: https://www.ahns.info National Cancer Institute: https://www.cancer.gov
Dr. Scott Fortune talks with us about how he built an Office Based Rhinology practice (now a Center of Excellence), including a how-to on safely performing procedures in the office.
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In this episode, Dr. Scott Fortune joins Dr. Gopi Shah and Dr. Ashley Agan to discuss office-based rhinology procedures.
Dr. Fortune provides an overview of the procedures he performs in the office setting. He outlines the pre-procedure evaluation of patients including the use of validated clinical questionnaires (i.e. SNOT, NOSE scores etc..), a thorough history and physical exam, and necessary imaging studies. Once a full workup has been completed, the severity of disease is assessed as in-office procedures are tailored towards mild- to moderate-severity disease.
Dr. Fortune emphasizes that proper anesthesia is the most important factor in ensuring a successful in-office procedure. He goes into depth on the pre-, intra-, and post-operative anesthesia considerations for different procedures and patient comorbidities and reviews his own anesthesia protocol.
Lastly, Dr. Fortune discusses the logistical factors including equipment, procedure room set-up, staff training, and scheduling. He also describes the peer-to-peer training opportunities that he provides at his practice for other physicians interested in learning about in-office procedures.
RESOURCES
Dr. Fortune’s Email Address: sfentallergy@yahoo.com
Dr. Fortune’s Twitter Handle: @DrScottFortune
Website: https://www.myallergyent.com
American Academy of Otolaryngology Head and Neck Surgery FLEX Curriculum: https://www.entnet.org/content/flex
We chat with Dr. Brandon Isaacson and Dr. Alejandro Rivas on the topic of Endoscopic Ear Surgery, including tips and tricks for success, as well as pitfalls to avoid.
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In this episode, Dr. Alejandro Rivas and Dr. Brandon Isaacson join Dr. Gopi Shah and Dr. Ashley Agan to discuss endoscopic ear surgery.
Dr. Rivas and Dr. Isaacson describe the evolution of endoscopic ear surgery and its adoption in the United States. They emphasize the utility of the endoscopic approach for visualization of the middle ear.
They then delve into indications and anatomic considerations when selecting the endoscopic approach. Dr. Isaacson states that for most diseases limited to the middle ear, he uses the endoscopic approach. For extensive mastoid disease, aggressive cholesteatomas, or skull base disorders, he prefers the microscope. Dr. Rivas touches upon his guidelines for selecting his approach for cholesteatomas and notes that the presence of ossicular or lateral canal erosion or an ossified mastoid typically preclude his use of the endoscope. He then highlights the benefit of the endoscopic approach in congenital, pediatric, and revision procedures. The advantages of both the endoscopic and microscopic approaches are also considered.
The discussion then focuses on optimal pre-operative and anesthesia set up to limit bleeding in endoscopic ear surgery. Lastly, the role of using endoscopes for a thorough ear exam is emphasized.
RESOURCES
Dr. Rivas Twitter Handle: @Alejorivasc
Dr. Isaacson’s YouTube Channel: https://www.youtube.com/channel/UC43ovy9FzRT9OtBF2tUDjsg
International Working Group of Endoscopic Ear Surgery: https://iwgees.org
Online Dissecting Course from Sydney: https://sydneyearendoscopy.com/free-online-dissection-guide/
Dr. Isaacson and colleague’s work on endoscopic ear surgery outcomes in pediatric ossiculoplasty: https://onlinelibrary.wiley.com/doi/10.1002/lary.28526
We talk with Dr. Rachel St. John and Dr. Walter Kutz about Congenital Hearing Loss including causes, available treatments, and counseling.
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In this episode, Dr. Rachel St. John and Dr. Walter Kutz join hosts Dr. Ashley Agan and Dr. Gopi Shah to discuss congenital hearing loss.
Dr. St. John and Dr. Kutz outline the newborn hearing screening process and describe the benefits of both the traditional otoacoustic emission (OAE) test and auditory brainstem response (ABR) test for different conditions. They emphasize the importance of imaging in patients with late-onset and/or asymmetric hearing loss. The factors that influence the selection of imaging modality are also discussed.
Next, the diagnosis and management of hearing loss in children with auditory neuropathy, cytomegalovirus, and meningitis are reviewed. The potential role of cochlear implantation (CI) in each of these conditions is highlighted. Dr. St. John and Dr. Kutz emphasize that the journey following CI varies for each child, and that it often takes time to reap the benefits of the procedure. Lastly, Dr. St. John stresses the importance of early language exposure – through multiple mediums – to ensure that children do not miss out on crucial early brain development.
RESOURCES
Dr. Walter Kutz’s Twitter Handle: @EarDoc1
UT Southwestern Cytomegalovirus Screening Study (CHIMES Study): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5260148/
We speak with Dr. Jacob Hunter about Adult Cochlear Implantation, including patient workup and counseling, surgical tips and tricks, and post procedure followup.
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In this episode, Dr. Jacob Hunter joins hosts Dr. Ashley Agan and Dr. Gopi Shah to discuss cochlear implantation in adults.
Dr. Hunter outlines the indications for cochlear implantation and walks us through the evaluation process to assess candidacy in adults. He emphasizes the importance of patient counseling in setting expectations for post-implantation hearing. He also describes routine preoperative imaging weighing the relative strengths of CT vs MRI.
The discussion then delves into the nuances of cochlear implant devices focusing on factors such as electrode length, stiffness, and shape as well as hearing aid compatibility. The major surgical approaches are then reviewed along with potential surgical complications. Lastly, the disparities in access to cochlear implantation and hearing care in adults are highlighted.
RESOURCES
Disparities in Cochlear Implantation: Dr. Hunter and Colleagues at UT Southwestern: https://journals.sagepub.com/doi/abs/10.1177/0003489419888232
Dr. Samy and Colleagues at University of Cincinnati: https://journals.lww.com/co-otolaryngology/Abstract/2017/10000/Closing_the_gap_in_cochlear_implant_access_for.7.aspx
Disparities in Hearing Care: Dr. Carrie Nieman and Colleagues at Johns Hopkins: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363549/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881797/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4826391/
The video version of this Podcast has closed captions on YouTube: https://youtu.be/3IHUMhH9x0E
Dr. Romaine Johnson from Children's Health in Dallas, TX brings together an all-star panel of pediatric ENT's to discuss the importance of continuous improvement of Quality and Safety in Pediatric ENT. Guests include Dr. Soham Roy, Dr. Jennifer Lavin and Dr. Jonathan Ida.
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In this episode, Dr. Soham Roy, Dr. Jennifer Lavin, and Dr. Jonathan Ida join hosts Dr. Romaine Johnson and Dr. Gopi Shah to discuss quality improvement (QI) and safety in pediatric ENT.
Dr. Roy emphasizes the importance of transforming quality metrics data into personalized stories to help convey the significance of QI efforts. The panel discusses best practices including a focus on understanding the nuances of a problem prior to identifying solutions, implementing solutions in a manner in which deviations are made more difficult, and maintaining a commitment to continual QI which is a cyclical process with no defined endpoint.
The discussion then evolves to highlight the impact of the COVID pandemic on QI efforts, the urgency with which protocols were developed in its immediate aftermath, as well as looking towards the impact of the pandemic on future care delivery. The panel delves into the ongoing need for studies to explore the gaps in knowledge which are often identified in clinical consensus statements. They conclude by providing advice on how to align QI efforts with broader institutional goals.
RESOURCES
Tracheostomy During COVID-19 Pandemic: https://journals.sagepub.com/doi/full/10.1177/0194599820961985
American Academic of Otolaryngology-Head and Neck Surgery Patient Safety and Quality Improvement Committee Report: https://bulletin.entnet.org/article/committee-report-psqi/
We speak with Dr. Patricia Loftus from UCSF Otolaryngology - Head & Neck Surgery discussing her clinical and surgical approach to treating Nasal Polyps.
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In this episode, Dr. Patricia Loftus joins Dr. Gopi Shah and Dr. Ashley Agan to outline the diagnosis and management of patients with nasal polyps. They identify common presenting symptoms and physical exam findings as well as discuss the roles of imaging, culture, and biopsy.
Medical management including the risks and benefits of antibiotics and oral steroids are reviewed. Endoscopic surgical approaches and their utility in different clinical presentations are described. Pre-, peri- and post-operative considerations are also discussed.
The discussion then evolves to focus on conditions that clinicians should be aware of including allergic fungal sinusitis (AFS), cystic fibrosis (CF), primary ciliary dyskinesia (PCD), and central compartment atopic disease (CCAD). Finally, they highlight recent developments in management including the role of biologic therapies such as Dupixent.
RESOURCES
Dr. Loftus’ Email Address: Patricia.Loftus@UCSF.edu
Women in Rhinology Twitter Handle: @Women_Rhinology Women in Rhinology Instagram: @women_in_rhinology
Biologics for Nasal Polyps: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013513.pub2/full
We talk to Dr. Dana Crosby about early career leadership insight.
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In this episode, Dr. Dana Crosby joins hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss leadership in Otolaryngology and how to navigate and build a program from the ground up.
Dr. Crosby describes her initial experiences post-Rhinology fellowship starting to build up a small Otolaryngology division into a department as a co-Chair. She discusses the importance of identifying good mentors and resilience in starting out. She continues to speak to the importance of navigating through the best interests of both all the faculty involved as well as the department. Additionally, the importance of reading and constantly learning from books and other resources as such is vital to complement the experiential learning.
Dr. Crosby continues to talk about different leadership styles and how they complement each other. She describes a style of allowing everyone to have input, while being aware that certain situations call for quick decision making. She also mentions how best to manage disagreements through open discussion and compromise. Dr. Crosby closes out by discussing the implementation of leadership curriculums in training at all different levels. Although residency is incredibly busy, dedicated leadership skill discussions may be beneficial. Lastly, she ends with the key points about being yourself, leading by example, and being open to new opportunities and learning from each one.
RESOURCES
Dr. Crosby’s Email: dcrosby53@siumed.edu
Leadership Books: Good to Great, James Collins
We talk to Dr. Cherie-Ann Nathan about her pathway to Chair of Otolaryngology Head & Neck Surgery at LSU Shreveport, inspiration and challenges along the way, and making the most of opportunities in building a successful career.
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In this episode, Dr. Cherie-Ann Nathan joins hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss career inspiration and learning to thrive with an inspiring attitude.
Dr. Nathan describes her initial journey into Head and Neck Cancer through inspirations she had as a child growing up in Mumbai and going to medical school, through her research at Johns Hopkins in Head and Neck Cancer, followed by residency at UCSD and current chair of Otolaryngology at LSU-Shreveport. She describes the importance of being able to balance your professional life and with your personal life and using that to guide career decisions. She then discusses how her interest in Head and Neck Cancer, inspired when she was younger, spurred her dedicated research undertakings and progress at LSU-Shreveport, funded by the National Cancer Institute and the NIH.
Dr. Nathan continues to speak about job satisfaction and being able to balance saying yes to opportunities but knowing when to say no; balance is key though hard to attain at times. She then continues to stress the importance of intentionality and dedication to research early on in careers and navigating the world of academic research, including mentorship, grants, and networking. Additionally, being open to network with different institutions and resilience in the setting of rejection in research, with learning and persistence, is vital to a successful research career.
Dr. Nathan rounds up the discussion in speaking about her experience as a woman in Otolaryngology, becoming a Chairwoman, and the various challenges that come with leadership positions, noting the progress that women in Otolaryngology have made with and will continue to. She ends by stressing the importance of consistent hard work and to start early, and in loving what you do, the motivation to do so is endless.
RESOURCES
Dr. Nathan’s Email: cnatha@lsuhsc.edu
We talk with Dr. Rachel St. John from Children's Health about the importance of early language access and collaborative care for children who are deaf or hard of hearing.
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In this episode, Dr. Rachel St. John joins our hosts Dr. Ashley Agan and Dr. Gopi Shah to speak about different aspects of care for Deaf and Hard of Hearing children, from counseling to medical treatment.
Dr. St. John first speaks about what a comprehensive evaluation of a deaf child entails; from counseling the patient and their families, to educating families about current and future management, and rounding it off with the importance and effectiveness of collaborating with a multidisciplinary approach. She continues to talk specifics in terms of work-up regarding labs, imaging, and the possibility of genetic testing. A key aspect of this decision making is in speaking with families and understanding what their priorities and goals are and working as a team to set realistic ones.
The discussion continues while touching on specific causes of pediatric hearing loss, including Enlarged Vestibular Aqueduct among others, and the management and treatment thereof. Dr. St. John also speaks about counseling the patient as well and taking into account their age and giving guidance to setting realistic expectations, both in their school and home life.
Lastly, Dr. St. John discusses the importance of early language intervention and stresses the importance of introducing some aspect of language into the child’s development as early as possible, regardless of hearing loss or not. The early years can be vital for learning and chidren have a narrow window for language development; early intervention can greatly improve learning later down in life in Deaf and Hard of Hearing children.
RESOURCES
Family Focus Center website - https://www.childrens.com/specialties-services/specialty-centers-and-programs/ear-nose-and-throat/programs-and-services/ffc-for-deaf-and-hard-of-hearing-children American Academy of Pediatrics, Early Hearing Detection and Intervention - https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/PEHDIC/Pages/Early-Hearing-Detection-and-Intervention.aspx
Dr. D.J. Verret teaches us what he's learned over the years getting a practice up and running: "when you start out, start out lean!"
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In this episode, Dr. DJ Verret joins our hosts Dr. Gopi Shah and Dr. Ashley Agan to talk about how to successfully start and manage a private practice.
Dr. DJ Verret starts off by discussing what drew him to private practice and facial plastic surgery after deciding on Otolaryngology as a residency choice. He speaks about the details in starting out and the difficulties of the nuances. One detail he mentions is that it is important to assess all the possibilities of practice models, whether that is practice sharing, group practices, or other such models that may best fit your goals. He continues to discuss the importance of taking advantage of employers, such as CEO’s, about possible arrangements for new practice models. Dr. DJ Verret then moves to speak about experience being an important teaching factor in learning the financial ins and outs. He also discusses aspects that can help setting up a practice, including practice management companies, healthcare lawyers, CPA’s, and ideas about the future direction of the practice.
The discussion continues into the steps taken to start a practice, from creating an EIN for the company to commercial real estate in finding an appropriate practice location. Next steps include considerations for practice equipment specifically for your practice type. Important things to keep in mind when purchasing equipment and location is starting out lean, both space and equipment wise. Given the natural limitation of time, it is better to start small to where a practice is financially manageable. Time management is a key aspect discussed, in deciding how much you want to do on your own vs how much you’re willing to delegate to others.
Dr. DJ Verret rounds off the discussion by speaking about practice management vs clinical time. He discusses how to manage overhead, employee roles, and dedicating time to practice management each week, including tracking practice progress on a quarterly basis. A combination of timely and financial efficiency is key in running a successful practice.
RESOURCES
Dr. DJ Verret’s Podcast: https://askmemd.buzzsprout.com/ Dr. DJ Verret’s Website: https://innovationsfps.com/
Dr. Felicity Lenes-Voit from Dallas Children's Health discusses her approach to diagnosis and treatment of Tongue-Tie, or Ankyloglossia, in the infant.
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In this episode, Dr. Felicity Lenes-Voit joins our hosts Dr. Gopi Shah and Dr. Ashley Again to speak about Tongue-Tie, or Ankyloglossia, and its comprehensive management.
Dr. Lenes-Voit starts the discussion by describing what Tongue-Tie is and how to conduct an initial evaluation and workup. She describes the importance of lactation consultation and the effects tongue-tie can have on both mother and baby. The discussion then continues to discuss physical examination as an important aspect of the workup and how best to determine the extent of the ankyloglossia, while also factoring in the weight of the child as a key aspect of workup.
Next, Dr. Lenes-Voit and our hosts discuss points to keep in mind when considering frenectomy as a correcting procedure, which include conducting a thorough lactation evaluation prior to making that decision. Speech impairments are also a potential worry from parents and, as a controversial topic in frenectomy evaluations, should be clarified with families. Other risks and benefits are further discussed such as timing of intervention and the use of general anesthesia at certain ages. This portion of the discussion ends with Dr. Lenes-Voit talking about the different operative techniques that can be employed as well as tips for smooth procedures.
Lastly, the discussion concludes with Dr. Lenes-Voit speaking to the importance of counseling and a multidisciplinary approach with mothers of tongue-tie patients. The team effort between ENT’s, pediatricians, and lactation and breastfeeding consultants is key in the comprehensive management for both mother and baby. Setting realistic goals and expectations, especially for new mothers, will be beneficial and something to incorporate with each patient.
Dr. Eric Cerrati from University of Utah Health gives us his pearls and pitfalls using social media to promote his clinical practice.
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In this episode, our hosts Dr. Ashley Agan and Dr. Gopi Shah are joined by Dr. Eric Cerrati to discuss the different ways to promote a practice and the increasing role of social media in professional development.
Dr. Cerrati initially starts by describing how he set up his academic practice in Facial Plastic Surgery with a mix of cosmetic patients as well as reconstructive. He highlights the importance of outside marketing in addition to being affiliated with an academic center. These two can be different and both have pros and cons. He describes the use of Instagram and Facebook in marketing with somewhat a private practice mindset. The use of social media has also grown during the COVID pandemic due to an increased need to reach out to prospective interested students in programs across the country. Dr. Cerrati speaks then about the details, including demographics, that can be reached based on the specific social media platform used. He does highlight the importance of consistency and the way one chooses to present themselves on a social media platform. Balancing that which is appropriate for social media can be challenging, with the overarching theme of being honest and ethical. Patient consent is vital prior to sharing any form of media regarding them.
Dr. Cerrati goes on to talk about the risks of putting yourself out there and being in the constant public eye and risks that come with. In addition to social media, he continues to discuss the importance of building good collegial relationships with fellow physicians and taking care of patients referred to you while being respectful to the referring provider.
The discussion ends on the impact COVID has had on a private practice cosmetic setup, including considerations for COVID testing, role of virtual visits, and evaluation for surgery and follow-ups post-op. Dr. Cerrati ends on the important note of remaining flexible and continuing to work hard in the face of adversity, and growth will come.
RESOURCES
Dr. Cerrati’s Instagram: @Dr.Cerrati Dr. Cerrati’s Website: www.drericcerrati.com
We speak with Dallas Children's Hospital's Section Chief Dr. Ron Mitchell about Management of Pediatric OSA.
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In this episode, Dr. Ron Mitchell, a Pediatric Otolaryngologist, joins our hosts Dr. Gopi Shah and Dr. Ashley Agan to speak about pediatric Obstructive Sleep Apnea (OSA) and its evaluation and management.
Dr. Mitchell starts off the discussion by speaking about the importance of sleep and initial presentations and symptoms of sleep apnea in children, including apneic episodes, fatigue, and inattention as well as studies that recommend tonsillectomy for pediatric OSA. Dr. Mitchell then speaks about a current study underway that looks at OSA in pediatric patients with mild symptoms and the indications of surgery and if it is necessary in all patients. It is analyzing patients undergoing medical therapies, including Montelukast, nasal steroids, and others to evaluate efficacy against surgery. Specific indications and situations are also discussed. Dr. Mitchell notes that initially, with patients with mild symptoms, a sleep study may not be necessary. On the other hand, those undergoing high risk surgery or other developmental delay may need a sleep study, with observation and symptoms being the primary method of evaluation of progress. It is important to assess goals of the family prior to making the decision to obtain a sleep study with shared decision making.
Dr. Mitchell then speaks about the impact of COVID on obtaining sleep studies and the effects on evaluation of pediatric OSA. He then indicates that home sleep studies may not be beneficial to obtain in the pediatric population, unlike in adults. The discussion continues onto the topic of tonsil size and the variable effect it can have on pediatric OSA. The history of tonsillectomies is further discussed with possible causes for the increase in the number of tonsillectomies for sleep related problems.
The discussion rounds out on the important consideration of patients who undergo surgery with tonsillectomy and adenoidectomy with persistent OSA. Dr. Mitchell mentions possible etiologies (adenoid regrowth, nasal obstruction, etc.) which can be evaluated with nasal endoscopy and managed with nasal steroids. Weight loss in overweight and obese patients may also be beneficial. Other important considerations would be in patients with Down Syndrome, due to the difficulty of implementing CPAP and other managements. In these patients, sleep MRI is useful in determining the site of airway obstruction, usually at the tongue base, with additional surgery being useful for them.
Dr. Romaine Johnson talks us through the challenges of pediatric tracheostomy care and the importance of building high reliability tracheostomy teams.
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In this episode, Dr. Romaine Johnson joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the essentials of building a successful pediatric tracheostomy program and the importance of a multidisciplinary team. He emphasizes that the triage and management of pediatric tracheostomy patients must be approached through the lens of long-term care.
He states that essential members of the multidisciplinary pediatric tracheostomy team include pediatric pulmonologists, advanced practice nurses/nurse practitioners, respiratory and speech therapists, as well as social workers and case managers. Dr. Johnson also describes his multidisciplinary clinic set up through which patients are able to see all members of their care team at a single visit, thereby improving the quality and safety of care.
Dr. Johnson provides some key insights into the management of inherited pediatric tracheostomies with regards to how and when to up-size a trach as well as the role of palliative care in complex pediatric tracheostomy cases. Finally, we go into some notes on how to manage bleeding complications in pediatric tracheostomy patients, including the role of a pulmonary sick plan, and management of anterior/posterior tracheal erosions.
RESOURCES
Dr. Johnson’s YouTube Channel https://www.youtube.com/channel/UCMyWMjLbWbi_jM_tk7-57eg Dr. Johnson regularly posts procedure videos, as well as videos from the Harry Barnes society virtual grand round series.
Dr. Ashley Agan and Dr. Gopi Shah talk with Dr. Joe Walter Kutz about the management of Eustachian Tube Disorders, including pearls and pitfalls on treating the "clogged ear".
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SHOW NOTES
In this episode, Dr. Walter Kutz joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the essentials of caring for patients with chronic eustachian tube disorders. They emphasize that the diagnosis of patients with chronic eustachian tube disorders can be challenging. Patient history is often the driving factor in evaluation of these patients, but objective measures such as tympanograms can aid in the diagnostic process.
They describe in detail the differentiating features of patulous eustachian tube, a commonly missed diagnosis with a similar presentation as eustachian tube dysfunction. The best practices for evaluation of patulous eustachian tube are outlined, including the ideal set up for otoscopic and endoscopic nasal exams. They also touch on the treatment options for patulous eustachian tube, giving insight into procedure details as well as complications.
The discussion then evolves to focus on more complicated cases of eustachian tube dysfunction, including patients with atrophic tympanic membranes as well as those refractory to tympanostomy tube placement. The efficacy and challenges of eustachian tube targeted procedures such as balloon dilation are reviewed. The role of allergy evaluations in management and care of eustachian tube dysfunction patients are also considered. Finally, they touch briefly on some notes on the diagnosis of eosinophilic otitis media and superior canal dehiscence.
RESOURCES
Dr. Kutz’s Website: https://utswmed.org/doctors/joe-kutz/ Dr. Kutz’s Twitter Handle: @EarDoc1 Dr. Kutz’s Instagram Handle: @walterkutzmd PatulEND - Patulend.com
IR Sabeen Dhand and ENT Ashley Agan discuss management of Epistaxis, including how to effectively pack the nose, and when SPA ligation or arterial embolization are necessary. Dr. Dhand also describes his arterial embolization technique, including important pitfalls to avoid.
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In this episode, Dr. Sabeen Dhand, an Interventional Radiologist, joins our hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss epistaxis and the evaluation and management of different causes of epistaxis.
Dr. Agan and Dr. Dhand start the discussion by bringing up common presentations of epistaxis from both an ENT standpoint as well as IR; with the usual presentation being initially to ENT with possible referral to IR for embolization. They then continue to speak about initial treatments for epistaxis in the ED, which entails use of pressure, Afrin, and nasal packing or cauterization. If those measures aren’t sufficient, further examination in the OR may be warranted to find specific location and cause. In the case of a posterior nosebleed, usually from the sphenopalatine artery (SPA), with brisk bleeding and/or failure of ligation, SPA embolization by IR may be of use. Dr. Dhand mentions a contraindication for SPA embolization in the case of the ophthalmic artery anastomosis between the Internal Carotid Artery and External Carotid Artery due to risk of stroke and blindness. Different sources of bleeding should also be evaluated.
The discussion rounds off with the summarization of initial treatment of epistaxis. Two important considerations include proper nasal packing, pushing back into the nose and not straight up, as well as avoiding compressing nasal structures and causing necrosis and further mucosal irritation increasing bleeding risk.
We talk with Dr. Eric Gantwerker about tips and strategies to make medical education and teaching more effective.
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In this episode, our hosts Dr. Ashley Agan and Dr. Gopi Shah are joined by Dr. Eric Gantwerker to speak about medical education and the nuances involved along different levels of training.
Dr. Gantwerker begins by discussing different possible teaching and learning styles. One idea he speaks about is cognitive load, which describes that a novice only has a certain amount of attention and cognitive attention they can focus on a topic. He also mentions the ideas of “chunking” and “zone of proximal development”; these ideas combine the ideas of constantly challenging learners with gradual responsibility and allowing the learner to repeat the same activity or action repetitively while slowly increasing the amount of activity involved as well. This keeps people in a challenged enough state to where they struggle, but not enough to where it is completely out of their ability to succeed. Dr. Gantwerker then rounds off the process by having a debriefing session afterwards, in which feedback is exchanged between both student and teacher on how the experience went. This allows for tailor-made teaching experiences for students and establishing rapport between students and teachers.
The discussion continues in what Dr. Gantwerker focuses on during the teaching process. He mentions the concept of “Line, Speed, Beauty”, which highlights the importance of first mastering basics, followed by increasing efficiency, and the aspect of beauty which naturally follows. Dr. Gantwerker ends the discussion by highlighting different learning techniques, including organizational thinking, thorough understanding, and experiential learning. He then speaks about challenges faced in current virtual environments and how to manage them.
RESOURCES
Level Ex Learning App: www.levelex.com
Dr. Gantwerker’s Twitter Handle: @DrEricGant
Dr. Ashley Agan and Dr. Gopi Shah talk wellness in life and practice!
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In this episode, hosts Dr. Ashley Agan and Dr. Gopi Shah discuss the important topic of wellness, what it is, and how to incorporate it into our professional lives.
They begin by discussing what exactly wellness is and what it entails. Wellness can be different for different people, but essentially it comes down to taking care of yourself before you take care of others. As this can be hard to do in such a service-oriented career, dedicating time to it is important to be able to recharge, whether that be spending time with family, exercising, or just intentionally relaxing. Dr. Shah and Dr. Agan continue to talk about time management and how to incorporate wellness into busy lives in medical school, residency, and beyond. Balancing may not always be easy but taking time for yourself is just as important as the time you dedicate to others.
Our hosts then continue to speak to the impact COVID-19 has had on the physician community and wellness. One of the biggest factors it has had is regarding the human-to-human connection that is gratifying and often motivating during patient encounters. Dealing with those challenges has taken its toll, but one that both providers and patients are learning to manage together.
Lastly, Dr. Agan and Dr. Shah conclude by discussing specific examples of incorporating wellness. They speak about groups, such as Wellness in Oto, and other ways to keep in touch, whether that be with mentors or trainees, to check in on each other and make sure everyone is doing well and taking the time to take care of themselves during an otherwise challenging time. As well as keeping in touch with others, keeping in touch with yourself is just as important and reflecting is often a great way to do just that.
RESOURCES
Backtable ENT Twitter and Instagram handle: @_backtableENT