Letter from the Editor: Otolaryngology Must Address Diversity, Gender Bias

Cultural conditioning shapes who we think we are at any given point in our lives. Few are those who ever challenge or outgrow the beliefs that have been instilled by family and society during those early years.—Mooji

I have always advised students to avoid the doctors’ lounge, especially those filled with pessimistic physicians who talk about how medicine is not what it used to be or reminisce about how the good old days were so much better. Unfortunately, this attitude is non-productive, is highly contagious, and reinforces old biases and behaviors. I worry about becoming one of those physicians. If I resist change in medicine, is it really different this time or am I just getting old?

While I was fortunate to be involved in our specialty’s leadership at a young age, it was obvious at the time that our leaders did not reflect the reality of my medical school experience in Ann Arbor or residency training in Houston.

In March 2007, at the AAO–HNS annual advocacy conference in Washington, D.C., during Richard Miyamoto’s presidency, I attended a meeting of multiple otolaryngology organization presidents. Everyone was discussing issues within the specialty, most of which were focused on clinical topics, specialty politics, or reimbursement problems. Duane Taylor and Lisa Perry-Gilkes, representing the National Medical Association’s otolaryngology section and the Harry Barnes Society, raised concerns about diversity, health literacy, and cultural competency in our specialty. In the room, these topics seemed out of place and were not further discussed. Yet, their comments clearly resonated with the Academy leadership and quickly led to the development of the Academy’s first diversity policy and the creation of the inaugural Diversity Committee. Around the same time, Sonya Malekzadeh and others led the creation of the Section for Women in Otolaryngology. Both groups were immediately given representation in the Academy’s Board of Directors.

When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem.

These impactful efforts, reflecting the leadership of many people over the years, opened a new era in an important ongoing conversation within our specialty. Unfortunately, the people who would benefit the most from receiving this information are the most likely to ignore relevant communications or close their minds to the benefits of different perspectives, equity, or new ways of doing things. People who are committed to change and moving forward bear the responsibility to learn, teach, and reach out to help others. Together, we need to develop better ways to frame the benefits to bring along those who are not ready. This is how change works, and there is still a lot of work to do.

Life and medicine are continuously changing at a seemingly accelerating pace. When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem. We need to open our minds, try to understand
perspectives that are unfamiliar or uncomfortable, and embrace change. Change will never end. We will never get “there.” We are fortunate to have many exceptionally talented and inspiring colleagues who can help us along this journey. They encourage us to improve and help us provide more effective care to our patients.

This issue of ENTtoday highlights ongoing critical issues related to diversity/inclusion, gender bias, and health literacy within otolaryngology–head and neck surgery. The articles include interviews with many leaders in our field who are actively addressing these issues. Erin O’Brien’s viewpoint on the gender gap in otolaryngology provides a timely update. She makes the point, which can be generalized to many problems facing the specialty, that leaders need to participate in order to address these issues, and affected groups cannot be expected to achieve parity without the support and effort of those with the power to make changes. Duane Taylor, now the current president-elect of the AAO–HNS, discusses the importance of the well-informed patient and the Academy’s new tools to help physicians and patients.

As a specialty, let’s not get stuck in the doctor’s lounge; as leaders in medicine, we should stay open minded, be active and honest participants in these conversations, embrace change, and drive our specialty forward to its ultimate potential.

Ronald B. Kuppersmith, MD, MBA
Deputy Editor, ENTtoday

ENT Today

How Far Women Have Come in Otolaryngology Compensation Parity and What Needs to Happen Next

On these pages in 2010, Linda Brodsky, MD, discussed the gender gap in compensation and leadership positions in otolaryngology (ENTtoday. February 1, 2010. Available here). How far have we come since she highlighted issues of gender inequity nearly a decade ago?

In the two decades since I was a medical student rotating in otolaryngology, women have made progress in leadership roles in our academic societies and training programs. However, progress toward equity in our specialty has not come quickly enough.

A pay gap still exists in salaries for women in otolaryngology. In 2004, Jennifer Grandis, MD, a professor of otolaryngology–head and neck surgery at the University of California San Francisco, reported a 15% to 20% gender pay gap even after controlling for confounding variables (Arch Otolaryngol Head Neck Surg. 2004;130:695–702). More recent data suggests this pay disparity persists. The 2018 Medscape survey of full-time otolaryngologists found that women were paid $75,000 (19%) less than men. A 2016 study of 10,000 university physicians also found a pay gap for female physicians despite controlling for experience, faculty rank, specialty, research productivity, and clinical volume, with surgical specialties demonstrating the largest absolute adjusted sex differences in salary (JAMA Intern Med. 2016;176:1294–1304) (See “Sex Differences in Physician Salary and Rank in U.S. Public Medical Schools,” below).

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ENT Today

Gender Differences and Work–Life Integration among Head and Neck Surgeons

As a whole, head and neck surgeons are highly satisfied with their career choice. Fewer women, however, are lacking in senior academic positions, and more remain unmarried with fewer children when compared with their male counterparts. This is the main finding of a study that assessed the association of gender difference with the perceived quality of life among head and neck surgeons (JAMA Otolaryngol Head Neck Surg [published online ahead of print March 21, 2019]. doi: 10.1001/jamaoto.2019.0104).

Investigators sent a web-based survey to members of the American Head and Neck Society to assess daily lifestyle and quality of life. The survey consisted of 37 questions on demographics, academic status, mentorship experience, daily lifestyle, family life, personal health, and job satisfaction. Of the 261 respondents, 71 (27.2%) were women and 190 (72.8%) men. By age, 38 (71%) women were between 30 and 50 years of age compared to 93 (49%) men and one woman was older than 60 years compared to 24 (18%) of men aged 60 to 70 years and six (3.2%) older than 70 years.

Following are the key findings of the study:

  • Most worked in an academic institution: 66 (92.5%) women and 152 (80%) men.
  • Associate professors: 20/64 (31%) women and 37/152 (24%) men.
  • Professors: 18/64 (28%) women and 72/152 (47%) men.
  • Department chairs: 4 (6.2%) women and 23 (17.6%) men.
  • Single (not in a long-term relationship or divorced): 18 (25%) women and 6 (3.25%) men.
  • Children: mean of 1.18 (median of 1) for women and mean of 2.29 (median of 2) for men.
  • Mean age of having a first child: 35.1 years for women, 31.9 years for men.
  • Felt family life was limited compared to other otolaryngological subspecialties: 45 (67.2%) of women and 117 (61.9%) of men.

Despite these disparities, both women and men reported a good work-life balance (55.2% and 53.4%, respectively).“In spite of head and neck surgery being a highly demanding subspecialty within otolaryngology, women and men report equivalently high levels of satisfaction with their career choice,” said senior author Amy Chen, MD, MPH, Willard and Lillian Hackerman Professor and Vice Chair for Faculty Development, department of otolaryngology, head and neck surgery at Emory University School of Medicine in Atlanta. “However, we as a specialty need to improve women’s representation in senior leadership.”

“The lower rates of married women and fewer children among women head and neck surgeons deserve further examination in order to ensure that these women have joy in their home life,” she added.

ENT Today

How Otolaryngology Programs Are Working to Create a More Diverse Workforce

Increased diversity among medical professionals helps counteract the fears of racism, inequality, and other issues that may prevent patients of color from seeking out health care. A more diverse workforce also helps healthcare professionals learn from one another as the field expands to include people with differing backgrounds and perspectives.

For David Brown, MD, associate vice president and associate dean for health equity and inclusion and associate professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor, diversity’s benefits are rooted deeply in his career. He recalled a story one of his African-American residents told him when the resident first had to perform a tracheotomy on a child as an early-career otolaryngologist. The resident went to introduce himself to the patient’s family before beginning the procedure. Seeing that the resident was a person of color like themselves “created a sense of relief and trust,” he said.
“Seeing me, they said they didn’t feel like their child would be experimented on,” the resident told him.

Many marginalized communities have distrust of the healthcare system.“Having people who share their identities helps to foster stronger trust and communication and can lead to fewer healthcare disparities,” Dr. Brown added. Physicians of various ethnicities can help patients feel more comfortable, believing that the provider more fully understands their own cultural perspectives. Without that understanding, a patient’s lack of trust can be perceived as refusal to adhere to a physician’s orders.

As a result, “I no longer call a patient a non-compliant patient; if they don’t show up, you need to ask why,” said Dr. Brown. “Sometimes, they have transportation issues or there’s been a death in the family. If you are more open and more inclusive, you can find out more of the root cause, rather than just assuming they didn’t show up because they are ‘bad’ people.”

Efforts by medical schools and specialty associations and organizations to increase diversity helps build understanding among different groups of people, as well as improve the field of otolaryngology overall. Candidates with different backgrounds, perspectives, and experiences begin to fill the pipeline into medical schools, residencies, fellowships, and beyond.

“I would say [the subject of diversity] has become more front and center in the last few years, because the Accreditation Council for Graduate Medical Education has made it a priority to ask about the diversity composition of resident trainees,” said Cristina Cabrera-Muffly, MD, associate professor and residency program director in the department of otolaryngology at the University of Colorado School of Medicine in Aurora. “Unfortunately, otolaryngology has one of the lowest rates of underrepresented minorities (URM) among medical and surgical residencies.”

Diversity in the Workplace

Top Row: Carrie Francis, MD; David Brown, MD; Zainab Farzal, MD. Bottom Row: Cristina Cabrera-Muffly, MD; Duane Taylor, MD; Oneida Arosarena, MD

Top Row: Carrie Francis, MD; David Brown, MD; Zainab Farzal, MD. Bottom Row: Cristina Cabrera-Muffly, MD; Duane Taylor, MD; Oneida Arosarena, MD

The benefits of diversity in all workplaces, not just medicine, have been publicized. In 2013, the Harvard Business Review reported that diversity, both inherent (including the characteristics one is born with such as gender, ethnicity, and sexual orientation), and acquired (traits such as knowledge learned while living outside the country where one was raised), “unlocks innovation and drives market growth—a finding that should intensify efforts to ensure that executive ranks both embody and embrace the power of differences,” wrote Sylvia Ann Hewlett, the lead author of the study (Harvard Bus Rev. Published December 2013.).

A 2018 study of diversity in venture capital firms, also published in the Harvard Business Review, found that “diversity significantly improves financial performance… and even though the desire to associate with similar people—a tendency academics call homophily—can bring social benefits to those who exhibit it, including a sense of shared culture and belonging, it can also lead investors and firms to leave a lot of money on the table,” wrote lead author Paul Gompers (Harvard Bus Rev. Published July 2018. Available at: hbr.org/2018/07/the-other-diversity-dividend). And, finally, a 2004 study published in the Proceedings of the National Academy of the Sciences found that “groups of diverse problem solvers can outperform groups of high-ability problem solvers” (PNAS. 2004;101:16385–16389).

“From a social justice standpoint, increasing diversity in the physician workforce has been shown to reduce health disparities,” said Oneida Arosarena, MD, associate dean for diversity and inclusion at the Lewis Katz School of Medicine and a professor of otolaryngology at Temple University in Philadelphia.

What is medicine, and otolaryngology in particular, doing to address diversity in the field?

Diversity in Education

Different academic institutions are taking similar approaches to identifying the best candidates for their medical schools, even when those applicants might not be obvious by traditional measures. At Temple University, which in 2015 established its office of health equity, diversity and inclusion, a diversity council works among all members of the health system community to help address concerns among racial, ethnic, and gender minorities, and also implemented implicit bias training for the medical school’s admissions team. As a result, applicants are considered for admission under holistic review, which analyzes everything about a candidate, rather than merely looking for high marks on standardized tests.

“Traditional medical school and residency committees would just screen people with a cutoff based on a score on the MCATs or USMLE Step 1 test,” said Dr. Arosarena. “But by doing that, you really eliminate people who are great candidates but are not great test takers. Instead, we look at grades as a measure of academic performance, leadership qualities such as whether the candidate was involved as a leader in sports or other organizations, and also humanitarian qualities, such as how involved they were in the community.”

The process also considers how far a candidate has come to achieve what they have achieved. “If both your parents are doctors, it’s not so great a stretch to think you might be a doctor,” said Dr. Arosarena. “If you come from a single-parent and/or a low-income home, you had a lot to overcome to get to the point where you are applying to medical school.”

Holistic review takes longer than simply scanning through test scores for acceptance, and it requires more people to sit on the application committee. But more voices in the process produces a more diverse group of accepted applicants. In 2016, when Temple began using holistic review, there were six accepted URM applicants, out of a total of 210. Today, classes average between 20 and 30 URM.

The University of Michigan Medical School in Ann Arbor is currently three years into a five-year diversity, equity, and inclusion plan to improve diversity at every level so that the climate is more inclusive of all people, said Dr. Brown. Various initiatives, such as training in unconscious bias and other educational efforts, grants for diversity projects by different members of the Michigan community, and mentoring opportunities, all help to increase awareness about the importance of a diverse academic community. All medical departments are asked to attend the Student National Medical Association’s (SNMA) annual conference, where medical students can learn more about different clinical opportunities with the medical school. The students have the opportunity to work through medical simulations alongside Michigan medical faculty and residents.

At Michigan, about 20% of medical students each year are URM, said Dr. Brown, and that number has gone up about 1% each year for the past four years. The percentage of URM residents has doubled in the past three years, from 3% to 6.5% identifying as Black, Latino, Pacific Islander and/or Native American, he added.

Diversity in Otolaryngology

Otolaryngology, like other specialties, is eager to attract the brightest people to the field. To that end, there are several initiatives from organizations such as the Society of University Otolaryngologists (SUO) and the American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS).

Mentoring, coaching, and early exposure to the field of otolaryngology help bring more ethnically and culturally diverse talent and voices into the otolaryngology field, said Carrie L. Francis, MD, SUO’s diversity chair and associate professor and assistant dean of student affairs in the department of otolaryngology, head and neck surgery at the University of Kansas Medical Center in Kansas City. “Having an otolaryngology presence in medical school is helpful and harkens back to early exposure.” The society does this by developing relationships with various medical student associations and historically Black colleges such as Morehouse and Meharry Medical College as well as the SNMA and the Latino Medical Student Association.

Dr. Cabrera-Muffly cites mentoring as a way to increase diversity in the field of otolaryngology. “It’s important at all levels of the pipeline,” she said. “We need to mentor students to join our field, provide support to residents during their training, and ensure continued mentorship for URM faculty so that they will stay in academics to be examples for the next generation.”

Mentors needn’t be minorities themselves, either, she added. “As a Latina in otolaryngology, my mentors have not all been female or Latino, but they have made a huge impact in my life regardless.” Irrespective of their background or ethnicity, a senior-level person who has made her/his way through the otolaryngology field has a lot to offer earlier-career otolaryngologists. “Most senior faculty are not URM, but chances are that they will be in the position to mentor URM students and residents as the numbers increase.”

Without those increases, “we are doing a disservice to our patients and we are leaving talent on the table,” said Dr. Cabrera-Muffly. “If we discriminate against any group, we leave out the potential world-changing contributions of that group.”


Cheryl Alkon is a freelance medical writer based in Massachusetts.

Key Points

  • Efforts to increase diversity help build understanding and improve the field of otolaryngology overall.
  • Academic institutions are implementing implicit bias training for medical school admissions teams.
  • Mentoring, coaching, and early exposure to the field help attract more ethnically and culturally diverse talent and voices.

Ways to Increase Diversity in Otolaryngology

  1. Implement implicit bias training for medical school admissions teams: Doing so helps widen the scope when considering candidates for medical school admission. Holistic review, a process that analyzes everything about a candidate and not merely high marks on standardized tests, can help identify diverse candidates who can show a clear interest in medicine or ripe potential that may not be obvious if test scores and grades don’t meet a specific measure.
  2. Make mentoring a priority: Formal relationships between senior and junior-level otolaryngologists is a crucial way to help bring more diverse people to the field, though if collaborations happen on their own, that is fine, too. “Some of the best relationships happen organically, but we can assign them until people find their own mentors, because it’s important for all leaders to provide mentorship,” said Cristina Cabrera-Muffly, M., associate professor and residency program director, department of otolaryngology at the University of Colorado School of Medicine. “As a Latina in otolaryngology, several of my mentors have not been female or Latino, but they made a huge impact in my life regardless.”
  3. Find opportunities to showcase early exposure to otolaryngology as a specialty: SUO has developed relationships with historically black colleges and minority student organizations so that there is an SUO presence at annual national conference and regional events, said Dr. Francis. Having SUO available as a resource for earlier career medical students allows them to learn about the field of otolaryngology and to have enough information about it to properly consider it as a specialty.—CA

The Drawbacks of Lower Rates of Diversity

Without concentrated efforts to increase diversity in the otolaryngology field, let alone in medicine itself, the profession won’t reflect the patient population it serves and won’t benefit from new ideas that come from different perspectives, experts say.

That ultimately limits opportunities for both patient care and research and widens health disparities across different populations.

“If we don’t do it, we will do the same old things and hear the same old voices,” said David Brown, MD, associate vice president and associate dean for health equity and inclusion and associate professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor.

Michigan’s intent is to take the best care of patients and attract the best in the field for career opportunities. “If we are seen as monolithic, and people feel they are different, they won’t have a sense of belonging and won’t want to be a part of the team,” he said. “Instead, we want to make it so that anyone can be a part of our team.”

Efforts to identify promising candidates for medical school, residencies, fellowships, and medical careers should be intentional. “The medical profession loses out on the richness of what makes us different” if diversity isn’t encouraged, said Carrie L. Francis, MD, SUO’s Diversity Committee chair and associate professor and assistant dean of student affairs in the department of otolaryngology, head and neck surgery at the University of Kansas Medical Center in Kansas City. That includes diversity of culture, the richness of thought, “and everything else related to innovation,” she said.

ENT Today

Professional Voice Care May Reduce Vocal Disorders in Children

The vocal training and regular examinations by otolaryngologists that children who sing in choirs receive may pay off beyond voice training to benefit their overall vocal health, according to data from a recently published study that showed voice disorders were less common in a cohort of children singing in a choir compared to children who did not (JAMA Otolaryngol Head Neck Surg [published online ahead of print March 14, 2019]. doi: 10.1001/jamaoto.2019.0066).

“These findings suggest that there is a negative association between singing in a children’s choir and the presence of voice disorders,” said lead author of the study, Pedro Clarós, MD, PhD, who is with the Clarós Otorhinolaryngology Clinic in Barcelona, Spain.

The prospective cohort study was conducted to more fully examine whether an association exists between the development of vocal disorders and children who sing in a choir. According to the study authors, examination of this association in prepubescent children is lacking. To fill that gap, investigators enrolled 1,495 children (aged 8 to 14 years) from four local schools in Barcelona, Spain between October 2016 and April 2018. Of the children enrolled, 752 sang in a children’s choir and 743 children did not. Children in the choirs sang for a mean time of 7.5 hours per week for 2.5 years.

All children underwent videolaryngoscopy followed by videostroboscopy to assess the effect of singing or not singing in a choir on voice disorders (primary outcome). The study also looked at voice symptom complaints using surveys and the GRBAS (grade, roughness, breathiness, asthenia, strain) scale measurements (secondary outcomes).

The study found 12 voice disorders that were more common among the children who did not sing compared to those who did (32.4% vs 15.6%), with both functional voice disorders and organic voice disorders occurring more frequently in the non-singing children than the singing children (20.2% vs. 9.4% and 12.2% and 6.1%, respectively). Voice complaints or dysphonia were also higher in the children who did not sing in choirs compared to those who did (28.9% vs 21.0%) as reported by both the children and their parents, teachers, and choir directors. Muscle tension dysphonia (MTD) accounted for the largest difference between the two groups overall (17.2% vs. 8.4%) followed by psychogenic dysphonia (3.0% vs. 1.1%) and vocal fold nodules (7.9% vs. 4.0%).

These findings suggest that professional voice care that includes speech therapists and frequent otorhinolaryngologic examinations may be an important intervention to prevent or reduce voice disorders in children who sing in choirs, according to Dr. Clarós.

He also underscored that similar interventions to promote good voice care are important for all children, including non-singing children, particularly given the influence of good voice care over the long term on both the personal and professional lives of people. “The importance of voice care is particularly salient in children because they do not control their behavior or voice as well as adults and therefore are more vulnerable to possible voice trauma,” he said. “We believe it is crucial to introduce the same solicitude for voice in non-singing children.”

ENT Today

UAS Successful Treatment for OSA When Compared with TORS

How do transoral robotic surgery (TORS) and upper airway stimulation (UAS) compare for treating tongue base obstruction contributing to obstructive sleep apnea (OSA)?

Bottom line: UAS is successful in treating OSA, showing improved outcomes, length of stay, and readmission compared to TORS.

Background: TORS tongue base reduction utilizes robotic instrumentation to perform a lingual tonsillectomy combined with midline glossectomy and supraglottoplasty. With UAS, the hypoglossal nerve is selectively stimulated to induce muscle tone in the upper airway, relieving obstruction and reducing apnea and hypopnea burden; there is also evidence that it improves obstruction at the velum through coupling of the palatoglossus muscle.

Study design: Retrospective review of 100 patients (24 TORS, 76 UAS) from the senior authors’ surgical database who were treated between January 2011 and July 2017.

Setting: Thomas Jefferson University, Philadelphia.

Synopsis: Thirty-seven TORS and 94 UAS were performed. In the TORS cohort, 16 underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 35.70 and 80.50, respectively. In the UAS cohort, 14 patients underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 36.64 and 80.27, respectively. The mean postoperative AHI and O2 desaturation nadir in the TORS cohort were 20.05 and 84.10, respectively. The surgical success rate, patients who reached an AHI less than 15, and patients who reached and AHI less than 5 were 54.17%, 50.00%, and 20.83%, respectively. The mean postoperative AHI and O2 desaturation nadir of the UAS cohort were 7.20 and 88.77, respectively. Surgical success rate, patients who reached an AHI less than 15, and patients who reached an AHI less than 5 were 86.84, 89.47, and 59.21, respectively. TORS cohort patients had a mean length of hospital stay of 1.33 days; four patients had a 30-day unplanned readmission for dehydration and pain control. All UAS cohort patients underwent ambulatory surgery, and no patients were readmitted to the hospital. There were no major complications in either group. Limitations included a less-direct comparison between UAS and TORS due to the multilevel nature of UAS.

Citation: Huntley C, Topf MC, Christopher V, et al. Comparing upper airway stimulation to transoral robotic base of tongue resection for treatment of obstructive sleep apnea. Laryngoscope. 2019;129:1010–1013.

ENT Today

Tranexamic Acid Could Decrease Operative Time, Intraoperative Blood Loss in ESS

How effective is systemic tranexamic acid compared to a control in blood loss, operative time, and surgical field and incidence of postoperative emesis and thromboembolism in endoscopic sinus surgery (ESS)?

Bottom line: The systemic administration of tranexamic acid could decrease operative time and intraoperative blood loss, increasing the satisfaction of surgeons. It did not provoke intraoperative hemodynamic instability, postoperative emetic events, or coagulation profile abnormality.

Background: Because the nose and paranasal sinuses are highly vascularized, surgery there may cause significant bleeding, making identification of important anatomic landmarks and structures difficult, increasing intraoperative complication risks and prolonging operating time. Tranexamic acid can decrease intraoperative bleeding. Although it is usually well tolerated, nausea and vomiting are known common side effects, and hypotension has been observed during rapid intravenous administration.

Study design: Literature review of seven studies comprising 562 participants, comparing perioperative tranexamic acid administration (treatment group) with a placebo (control group).

Setting: PubMed, SCOPUS, Embase, the Web of Science, Google Scholar, and the Cochrane database; search results are from their inception to July 2018.

Synopsis: Outcomes of interest were intraoperative morbidities, including surgical time, operative bleeding, and hypotension; postoperative morbidities such as nausea and vomiting; and coagulation profiles. Operative time, intraoperative blood loss, and the surgical field score were statistically lower in the treatment group than in the control group. Surgeon satisfaction was statistically higher in the treatment group than in the control group. There was no significant difference between the groups in intraoperative blood pressure. The incidence of postoperative nausea and vomiting and thrombotic accident showed no significant differences between the groups. Platelet count, prothrombin time, and partial thromboplastin time showed no significant differences between the groups. In sensitivity analyses that evaluated the differences in the pooled estimates by repeating the meta-analyses with a different study omitted each time, all results were consistent with the outcomes previously found. Limitations included a lack of consideration of external factors such as polyps versus no polyps, revision versus primary, and usage of other hemostatic agents because the analysis was performed based on the statistical measurements of the figures.

Citation: Kim DH, Kim S, Kang H, Jin HJ, Hwang SH. Efficacy of tranexamic acid on operative bleeding in endoscopic sinus surgery: a meta-analysis and systematic review. Laryngoscope. 2019;129:800–807.

ENT Today

Is Hearing Preserved Following Radiotherapy for Vestibular Schwannoma?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

A common question by patients with newly diagnosed vestibular schwannomas (VS) is, “Which treatment will best preserve my hearing?” Currently, management of this benign tumor arising from the eighth cranial nerve sheath includes three broad options: observation with serial imaging, microsurgery, and radiotherapy. There are no high-quality, prospective controlled trials comparing outcomes among these three treatment modalities. Therefore, treatment recommendations are largely based on data from single-institution case series. As outcomes of tumor control and facial nerve preservation have improved with modern surgical and radiotherapy techniques, the possibility of hearing preservation (HP) often plays a significant role for patients and physicians making treatment decisions.

The heterogeneity of data poses a major challenge to providing accurate estimates of hearing preservation rates with radiotherapy for VS. Indications for treatment and inclusion criteria vary widely by institution. Radiation may be delivered in a single dose or as many as 30. The radiation source may be cobalt (e.g., GammaKnife surgery [GKS]) or a linear accelerator (e.g., CyberKnife). The methods for reproducing localization differ between techniques as well. Moreover, hearing outcomes are not standardized. For example, some publications simply report the patient’s subjective ability to use the telephone at the first post-treatment visit, whereas other studies utilize audiograms to provide an objective measure of hearing in the treated ear. Traditionally, serviceable hearing has been defined as pure-tone audiometry (PTA) < 50 db with speech discrimination scores (SDS) > 50%, corresponding to American Academy of Otolaryngology–Head and Neck Surgery class A or B, or Garner-Robertson (GR) grade 1 or 2. These differences result in widely varied rates of hearing preservation (between 10% and 90%) after radiotherapy for VS.

Best Practice

The level of evidence of reviewed articles is low. Given that the field involves rapidly developing technology, this is not surprising. Moreover, synthesis of data from case series is vitally important, as controlled studies comparing radiotherapy against microsurgery or conservative management would logistically be very challenging. Evidence from modern, highly conformal, low-dose radiation techniques demonstrate that long-term hearing preservation rates are poor; an approximately 80% hearing preservation rate at two years posttreatment falls to approximately 23% at 10 years. Although radiation therapy provides patients with satisfactory short-term hearing preservation, this treatment modality does not reliably preserve hearing in the long term. It is important when assessing publications in this field to thoroughly scrutinize the methodology, systems of hearing classification, and time to follow-up to provide patients with the most accurate estimations of hearing preservation (Laryngoscope. 2019;129:775–776).

ENT Today

Letter from the Editor: Medicine’s March Madness

As part of our mission to focus on physician wellness, we thought it would be fun to have an issue focused on a theme many of us use as a vehicle for work-life balance: sports! Finding stories and sources around this subject was not difficult. When we came up with the idea to write a story on otolaryngologists who served as team physicians for professional sports teams, we had more than 10 surgeons to speak to. We have otolaryngologists who have been professional athletes, Olympic athletes, and major boosters of athletic teams, and we even have one otolaryngologist who has had the experience of hiring and firing a Division I football coach and athletic director. College athletics is a passion for many otolaryngologists (just ask any Ohio State alumnus), and March Madness is college basketball’s three-week long tournament that consumes the work force and has even the non-sports aficionado searching the internet for tips on how to best fill out their office pool bracket.

So what is the otolaryngology version of March Madness? That would have to be the Otolaryngology Residency Match, which also takes place in March of every calendar year. The residency match is similar to March Madness in many ways. The college basketball season is five months long and comes down to three weeks to crown the champion. Months of residency interviews, letter writing, and phone calls come down to one day to find out who we will spend the next five years training.

Teams such as the University of Virginia, a No. 1 seed in 2018 that many expected to win the National Championship, lost in the first round to tiny UMBC, learning the hard way that you can never take anyone for granted. Otolaryngology as a specialty learned a similar lesson. For as long as I can remember, otolaryngology has been one of the most competitive residencies to match into. As a specialty, we enjoyed having the best and brightest apply to our programs. In fact, the match got so competitive that otolaryngology soon began to get a reputation amongst medical students and deans of medical schools. Students who didn’t have top Step 1 scores and grades were dissuaded from applying. We subjected the students to special interviews and made them submit written paragraphs in order to select the most competitive applicants. There was an air of superiority that filled many of our programs, as we rested on our laurels and stopped looking for talented medical students, assuming they would come to us. Because of this, the applicant pool, albeit as talented as ever, shrunk in size, and for two years, we were left with more residency spots than applicants.

In sports as well as in medicine, learning from our failures is a hallmark of resilience. In 2019, the University of Virginia again entered the tournament as a No. 1 seed. This time they came prepared and have since won their first two games of the tournament. Otolaryngology learned a lesson from the 2018 match, as we quickly began to acknowledge our missteps and look for ways to improve our match results. We began to understand that there are many more things other than a high Step 1 score that go into making a wonderful otolaryngology resident. Departments made tremendous efforts to reinvigorate their student interest groups and began new programs to expose pre-clinical students to the field. We began to show our appreciation to the applicants during interviews. Instead of the usual box lunch, programs were treating applicants to five-course steak dinners and guided tours of their campuses and cities. Much like the UVA basketball team, our efforts have been rewarded, as we have seen an explosion in the number of applicants. We have again become one of the most competitive specialties, and the residency match of 2019 was an extremely successful one for the field.

Much like the winner of this year’s tournament, we should take the time to celebrate our achievements but know that we can’t rest on our laurels. To continue this success, we must continue to work hard to find and attract students who are talented, diverse, and hungry for success.

Thanks for reading, and I look forward to connecting next month.

—Alex

ENT Today

Medical SEO Considerations

medical seo
You want your medical website to show up at the top of Google’s search results. Why? Because 73 percent of patients turn to search engines when finding a health practitioner, and 89 percent of consumers turn to a search engine when they’re looking to solve their healthcare queries. Since 55 percent of searchers click on one of the first three entries, if your hospital or treatment center isn’t in the top three, you’re losing patients to your competitors.

What Is Medical SEO?

To put it simply, medical SEO is the process of increasing your medical website’s search engine rankings so that your physicians and treatment centers can reach more patients looking for their services.

Why Invest in Medical SEO?

Let’s be honest—the old way of doing things hasn’t worked for quite some time. Thanks to the digital evolution of consumer services, patients look for new hospitals, physicians, and treatment centers online—frequently from a mobile device. Since 55 percent of searchers won’t go past the first three organic results, if you’re not investing in SEO you’re giving away clicks to the competition.

Some doctors think taking out pay per click (PPC) ads on Ads is enough. I get it—PPC ads are a great way to demand attention from searchers if you’re already strapped for time and don’t have what you need to crank out 1,000 pages of rich content.

That’s the wrong way of looking at it. Taking out PPC ads instead of SEO is like putting a band-aid over a deep gash. It may solve some problems in the short-term, but you’ve got to figure something else out for sustainable results. When it comes down to it, content marketing gets three times the leads per dollar spent than paid search ads.

How to Use Medical SEO to Get Your Healthcare Company to the Top of Google’s Search Results
There’s a reason certain things make it to the top of Google’s search results. Google outputs search results based on an algorithm designed to provide the most relevant links and answers to search queries. While there are more than 200 actual ranking factors that go into the algorithm, in general:

Your medical website needs to be fast, secure, and mobile friendly
You need plenty of pages of quality content optimized for medical SEO
You need to pick the right medical keywords
Your web pages need medical schema and optimized title tags and meta descriptions
You need optimized images and videos
You need plenty of off-site authority builders like social signals, quality backlinks, and directory citations
Your Google My Business page needs to be 100% filled out

Additional Medical SEO Tips…

YOUR MEDICAL WEBSITE NEEDS TO BE FAST, SECURE, AND MOBILE FRIENDLY
YOU NEED QUALITY HEALTHCARE CONTENT OPTIMIZED FOR MEDICAL SEO
YOU NEED TO PICK THE RIGHT INDUSTRY KEYWORDS