Do Preoperative Corticosteroids Benefit Patients with Chronic Rhinosinusitis with Nasal Polyposis?

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

Optimizing the surgical field in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) increases the chances for a safe and efficient surgery. Preoperative medical management, anesthetic choice, patient positioning, and topical vasoconstrictors are methods currently used to mitigate cumbersome bleeding during surgery. Decreased bleeding improves the quality of the optical cavity, thereby enhancing visualization of nearby critical structures.
Pretreatment with corticosteroids is a common practice with the theory that decreased preoperative mucosal inflammation and edema results in less blood loss and better surgical visualization. Several randomized trials have addressed the efficacy of CRSwNP pretreatment with corticosteroids with respect to bleeding loss and surgical field quality.

Best Practice

Preoperative treatment of patients with CRSwNP undergoing endoscopic sinus surgery with corticosteroids is indicated and beneficial. Pretreatment with corticosteroids shortens operative time, likely decreases bleeding, and improves the quality of the surgical field allowing for safe and efficient surgery. There are known risks of administration of systemic corticosteroids, and clinicians must take these into account when evaluating an individual patient. Additionally, future studies are needed to determine the optimal dose and duration of treatment (Laryngoscope. 2019;129:773–774).

Table 1. Summary of Management of Pediatric Obstructive Sleep Apnea

(click for larger image) Table 1. Summary of Management of Pediatric
Obstructive Sleep Apnea

ENT Today

Clinical Judgment: Balancing Evidence-Based Medicine and Patient Self-Determination

Clinical Scenario: You are seeing a patient, Henry Jones, in your faculty clinic with a second-year otolaryngology resident. Mr. Jones is a 78-year-old gentleman who was referred by a neurology colleague for the evaluation of an incidental finding seen on an MR scan obtained during the course of a late-onset Alzheimer’s disease workup. The neurologist sent both the scan images and the neuro-radiologist’s report, which stated that, in addition to some early changes suggestive of neurodegeneration, there is a 3-mm presumed acoustic tumor in the right internal auditory canal.

The resident evaluated and examined the patient prior to presenting him to you, and you confirm the history, signs, symptoms, and examination findings with your own evaluation. Mr. Jones and his wife explain that he has had some hearing loss that has been present since his discharge from the military, where he completed 21 years as an aircraft mechanic. When pressed, he indicates that perhaps his hearing is worse in the right ear, but not substantially so. The tuning fork tests at 512 Hertz were normal. The neurological examination, including neuro-vestibular, facial, and oculomotor tests, was unremarkable. The patient states that he has had some occasional imbalance, but no falls and no vertigo. His neurology consultation was primarily for memory loss. You feel that he appears to be competent in his judgment. Before the patient is escorted to the audiometry suite, he emphatically states that he is not interested in any surgery or radiation at this time, which is what the neurologist had mentioned to him.

You and the resident return to discuss the findings with the patient, and review the MR scan, the audiogram, the history, and physical findings. An onsite audiogram demonstrates bilateral noise-induced hearing loss with a downward slope from 1000 Hertz, slightly worse in the right ear. When queried about what should be the recommended course of action for the patient, the resident excitedly tells you that, with a small tumor, either surgery or radiation therapy would be indicated. He further shows you printouts of several systematic reviews that support early intervention to lessen the effects of the mass on auditory and vestibular function. You remind him that the patient stated he did not want surgery or radiation treatments, but the resident makes his case for intervention—“We’re here to cure disease, aren’t we? And, we know much better than the patient what treatment is called for.” It is clearly time for a teaching moment.

How would you handle this moment?


Discussion

The current state of patient care has been significantly influenced by the expansion of, and reliance on, evidence—acquired through outcome studies, systematic reviews, higher-level research, and other scientific work. There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care? Past generations of physicians relied heavily on the history, physical examination, fundamental diagnostic tests, and subsequent discussions with patients about the physician’s diagnosis and recommended treatment. While technological advances have greatly enhanced physicians’ diagnostic capabilities, some feel that it may have been at the sacrifice of an extensive physical examination and patient-physician discussions. The profession now has become increasingly reliant upon algorithmic medicine, which outlines, to a significant degree of complexity, protocols and best practices, which are designed to reduce variance in patient care across the population and are based on available evidence acquired through scientific studies. The specialty of otolaryngology-head and neck surgery, along with every specialty through the efforts of groups of experts, reviews the available data for many diseases and disorders and develops practice guidelines which inform the otolaryngologist-head and neck surgeon in her/his clinical decision-making. How the individual otolaryngologist utilizes the recommendations, evidence, and data in the care of an individual patient is called “clinical judgment.”

What then, are the elements of clinical judgment that come to play in our care of patients? There are many synonyms for clinical judgment, and many authors have proposed various elements. This author believes that there are four major elements in clinical judgment that eventually lead to the therapeutic plan for a patient. These are:

  • Knowledge;
  • Critical thinking and interpretation;
  • Patient self-determination; and
  • Shared decision-making.

Impacting each element of clinical judgment is the acquisition of experience.

The first fundamental step is the acquisition of knowledge—the knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more—acquired over the long course of education, training, and practice. This author often tells medical students and residents that the acquisition of knowledge is an ethical responsibility to patients and fundamental to their care. It is driven by an ultimate obligation to patients to know as much as humanly possible about the diseases and disorders across our entire specialty. The patient expects us to know the information, or to seek the information as we develop a recommendation for their care. Knowledge in medicine is always changing; therefore, we must continue to learn new knowledge throughout our professional career—it is not trite to repeat the mantra “life-long learning.”

Every act we perform in the course of evaluating a patient is knowledge acquisition—the history and physical examination is appreciated in the context of our knowledge of normal versus abnormal findings; our appreciation of various facial expressions and body language that can be interpreted in the light of the patient’s response to her/his health concerns; an understanding of side effects and adverse reactions of pharmaco-therapeutics—and we both consciously and unconsciously add these observations to our database of clinical medicine.

There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care?

The second important element of clinical judgment is the dyad of critical thinking and interpretation. This dyad is informed by our knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies. The history and physical examination give rise to a differential diagnosis set, and from there we work with pertinent evidence to determine how to proceed with diagnostic testing. One can approach the critical thinking either pragmatically or open-mindedly, casting a narrow diagnostic net or a wide one. We are primarily biological scientists, so we can use the scientific method to follow the trail of evidence to the point of reasonable confidence in our interpretation in the context of population-based studies.

The third element of clinical judgment is decision-making. This is the culmination of acquisition of knowledge about the patient (history, physical examination, diagnostic studies, interpretation of the evidence, and critical thinking leading to a presumptive diagnosis) and the consideration of what recommendation(s) should be made to the patient for her/his consideration. The impact of clinical experience is quite important here, for the experienced otolaryngologist has an internal database of similar compilations of symptoms, signs, findings, and diagnoses that inform her/him what should be recommended to a given patient.

At times, the evidence-based recommendations will fit nicely with our working diagnosis, and the course of recommended action to the patient will be clear-cut. With other patients, some uncertainty in the diagnosis and management may be present—so how to deal with, or manage, uncertainty becomes our challenge. Some uncertainty is part and parcel of even the most refined scientific study, and when dealing with human illness, uncertainty may often play a role—uncertainty in how you should proceed in formulating a therapeutic recommendation, and uncertainty in how the patient will consider and respond to your recommendations. Herein lies the fourth element of clinical judgment—patient self-determination.

© BlurryMe / shutterstock.com

© BlurryMe / shutterstock.com

The primary ethical principle in patient care is often said to be “autonomy,” which is the right of patients to make their own decisions about their health care, in the context of unbiased explanation of the options and their basis by the clinician. In earlier times, where information technology was not prevalent, the physician held sway over the recommendations, for she/he had the information. Now, many patients are so much more prepared to make their own decisions, based on their own information, as well as what their otolaryngologist has explained to them. That doesn’t mean that the otolaryngologist has to compromise her/his professional integrity for a patient’s decision, but rather to accept a patient’s wishes after all information has been given and all professional recommendations have been discussed.

In most clinical encounters, physicians utilize some form of “shared decision-making” with patients that usually results in an acceptable therapeutic plan to both patient and physician. In shared decision-making, the physician explores the patient’s personal and health values, which can have a tremendous influence on what therapeutic plan will be acceptable to the patient. Other important factors may be religious and cultural preferences/influences, or constraints due to social, economic, or financial burdens. The otolaryngologist has an obligation to mitigate any “solvable” constraint, but also an obligation to understand and support the patient’s wishes, as long as they are professionally ethical. Gaining experience in dealing with patients, particularly in complex diseases and difficult therapies, can be helpful in developing a shared plan for the patient’s care.

In this clinical scenario, Mr. Jones is an older gentleman with the likely diagnosis of a progressive neurodegenerative disorder. Indeed, he does have a small tumor in the internal auditory canal, but his symptoms at this time are minimal from this tumor. You should discuss patient autonomy and clinical judgment with the resident, and point out that you could achieve a shared decision with the patient and his wife by accepting his decision to not have an intervention, and by offering to follow him closely for new signs or symptoms that may call for revisiting a potential intervention if indicated in the future. At this time, the patient appears to be competent to make his own healthcare decisions, and to cognitively understand the risks and benefits of observing a small acoustic tumor over time. Take the time to answer the patient’s and his wife’s questions to their satisfaction in the resident’s presence. Through appropriate and experienced clinical judgment, you will have followed an acceptable course of professionalism and ethics, supported the patient’s wishes, and shared an appropriate decision with the patient. You also may have impacted the resident’s understanding of clinical judgment.


Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.

Hospitalists as Test Subjects

  1. Knowledge: The knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more acquired over the course of education, training, and practice.
  2. Critical Thinking and Interpretation: Physician knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies.
  3. Decision-Making: The culmination of acquisition of knowledge about the patient and the consideration of what recommendation(s) should be made to the patient for her/his consideration.
  4. Patient Self-Determination: Acceptance of a patient’s wishes after all information has been given and all professional recommendations have been discussed.

ENT Today

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.”

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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.

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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.

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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).

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