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

Virtual Surgical Planning and Custom Implants Can Help Treat Complex Facial Trauma

Advanced technology such as virtual surgical planning (VSP) and 3D-printed implants are helping otolaryngologists treat patients with complex facial trauma with more accuracy for improved outcomes.

Oral and maxillofacial surgeons use computer-generated modeling to plan for complex reconstructive procedures and order custom implants from manufacturers for patients who have facial bone loss due to trauma, cancer, or congenital deformities, said Shaun C. Desai, MD, associate residency program director and assistant professor of otolaryngology–head and neck surgery at Johns Hopkins School of Medicine in Baltimore. “We use the 3D technology for more complex cases, such as patients with complex loss of the maxilla or mandible or the skull. For a more complex defect, you can create a shape using the technology, and use it as a guide to make the bone cuts,” said Dr. Desai. “You can be more precise as you take a straight, long bone like the fibula and cut it into the shape of a jawbone. Even now, we often eyeball this technique, and there is asymmetry as a result. It takes a lot of time and surgical expertise. This technology gives you a more precise cut. You basically create a plan for where you will make the cuts into bone before you begin the surgery.”

Scan-Guided Surgery and Custom Implants

First, computed tomography (CT) scans are taken of the damaged facial areas. The surgeon analyzes these images using software designed for virtual surgical planning, said Dr. Desai. The data may also be sent to an engineer at a manufacturer to 3D print customized implants.

“If a patient has a facial fracture, such as a cheekbone that has collapsed, if you don’t fix it quickly, it can heal like that,” said Dr. Desai. The patient may require multiple revision surgeries as a result. To avoid this outcome, “we can use CT scanning to mirror the bad, damaged side of their face to the good side, and repair those maxillofacial injuries.”

VSP is useful for collaboration with an oral surgeon to perform reconstructive surgery on the maxilla, where both specialists use 3D software technology to guide the dental procedure and 3D printing of customized dental implants, said Dr. Desai.

With his patient’s CT scan data on his computer screen, J. David Kriet, MD, director of facial plastic and reconstructive surgery at the University of Kansas Medical Center in Kansas City, can examine a malpositioned cheekbone and orbit (such as a zygomaticomaxillary complex fracture) and then measure the patient’s “good side.”

“We can take the right half of the CT in virtual space and flip it over to map out a mirror image. That becomes our plan,” he said. “We can create an orbital implant using the mirrored image. We could either take an implant off the shelf or work with an engineer at a manufacturer to design a custom, patient-specific implant. By doing this, there are a number of advantages. We can do planning and create the implant before we get to the operating room. The time saved often offsets the more expensive implant. The less time we have a patient under anesthesia, the better,” he said.

Dr. Kriet has been using these technologies to plan for many oral and maxillofacial reconstructive surgeries for seven years. While 3D printing and VSP using CT scans are not yet the standard of care, these tools improve accuracy in more complex surgical cases, and they lower the risk of long-term discomfort or deformity for patients, he said.

Improved Outcomes

Image Courtesy of J. David Kriet, mD

Working model of frontal reconstruction.
Image Courtesy of J. David Kriet, mD

Do these technological advances really improve patient outcomes? In a 2016 retrospective review of 92 patients who underwent osteocutaneous free flap reconstruction of the mandible at a single cancer center from 2002 to 2013, researchers compared outcomes for 43 patients whose surgery was based on prefabricated models to those for 49 patients who had preoperative CT-guided surgical plans (Plast Reconstr Surg. 2016;137:619–623). The authors concluded that VSP refined mandible reconstruction with osteocutaneous free flaps through patient-specific cutting guides, improved reconstruction accuracy, and decreased operating time.

Christopher F. Viozzi, MD, DDS, an oral and maxillofacial surgeon at the Mayo Clinic in Rochester, Minn., uses these technologies to plan for many different procedures, including surgical reconstruction for patients who have had cancer, benign tumors that destroyed bone and soft tissue, or congenital deformities.

“In my own practice, I use [VSP] to plan for craniofacial surgery, including skeletal and soft tissue deformities. We try to normalize the bone and tissue as much as we can,” said Dr. Viozzi. “We use 3D models for virtual surgical planning all the time and for all sorts of operations, not just post-traumatic surgery. This technology is actually used more often for facial reconstruction than for post-traumatic corrections. To clarify, there are specific patients who come into the clinic with severe facial traumas and acute injuries. We will use computer-generated data to plan for their surgery.”

CT scans are used to help surgeons understand how their patient’s anatomy may vary from that of a normal patient, said Dr. Viozzi. He and his surgical team take precise measurements of the patient’s face or jaw and examine the patient’s unique facial symmetry. “We use this technology to see how an injured side of the face looks compared to the other, uninjured, side to help us plan for the surgery. The data can be used to create a model through 3D printing. There is a use for this in planning for acute, early treatment of a trauma patient as well, and we use the CT data for surgical navigation. We can use this data to pinpoint where certain things are located on or within the bony structures of a patient’s face,” said Dr. Viozzi.

Efficiency and Accuracy

VSP could reduce overall treatment time for patients with facial trauma or deformities because it improves the accuracy and quality of reconstructive surgery, not because it makes the surgery faster, said Dr. Viozzi. “Surgery has nothing to do with speed. We want to be efficient, careful, thoughtful, and accurate. We want to go into surgery with an accurate, well-thought-out plan. We want to do the procedure once, and get the patient to the end of the surgery as close to the surgical plan as we can,” said Dr. Viozzi.

Post-traumatic surgery patients often undergo multiple revision surgeries if the first surgery was performed incorrectly or if other factors prevented prompt treatment, and their bones have healed in incorrect positions, he added. “So, 3D technology can help us virtually plan the surgery, and 3D modeling can help us plan for revision surgery too.”

In a 2017 study of 10 patients who required orthognathic surgery, researchers found that VSP using CT and surface scanning of the upper and lower dental arch to generate 3D models of their skulls, as well as computer-aided design of fabricated surgical splints, improved surgical accuracy and facilitated planning (J Craniomaxillofac Surg. 2017;45:1962–1970).

To treat a patient with cancer in the mandible, Dr. Viozzi may work with a multidisciplinary team to virtually plan what portions of the jaw need to be removed along with the tumor and how to reconstruct the defect with a portion of the patient’s fibula, and to work with a prosthodontist to pinpoint where dental implants will be placed. “This approach takes a patient from an 18-to-24-month, multistep process to one surgery. It will make that surgery and time in the operating room longer for us, but it makes the surgery process more efficient for the patient,” he said.

Customized implants or plates based on CT scan data can be made in about one to three weeks, said Dr. Desai. Costs seem to be going down, and he believes they reduce operating time and improve aesthetic results. “These implants look more symmetrical. Outcomes, in terms of cosmesis, are improved. This may be subjective, but I get better results from it,” said Dr. Desai. “There is definitely a role for this technology, and people are still learning to use it. They are finding more indications for it.” He predicts that these technologies will become more widely available, cheaper, and available on a quicker turnaround.

Oral and maxillofacial reconstructive surgery can positively impact a patient’s quality of life, because facial defects or asymmetry are visible to others every day, said Dr. Viozzi. “Virtual surgical planning fits in perfectly with the concept of patient-specific and personalized medicine. It’s a perfect example of that, and for providing service to the patient with the lowest overall cost, morbidity, and complication possible.” 


Susan Bernstein is a freelance medical writer based in Georgia.

VSP and Custom Implants: Any Cons?

Custom implants secured.

Custom implants secured.
Image courtesy of J. David Kriet, MD

Are there any potential pitfalls for VSP or 3D-printed implant customization that head and neck surgeons should know about? In a retrospective analysis of 54 virtually planned craniofacial surgeries performed from July 2012 to October 2016 at the University of Montreal Teaching Hospitals, researchers analyzed surgical errors. The study included 46 orthognathic surgeries and eight free bone transfers (Plast Reconstr Surg Glob Open. 2018;6:e1443).

While 85% of the orthognathic virtual surgical plans were completely adhered to by surgeons, 11% of the VSPs were partially adhered to and 4% of the VSPs were abandoned, they found. Reasons for partially or totally abandoning the plan included poor communication between surgeon and engineer, poor appreciation for condyle placement on preoperative scans, soft-tissue impedance to bony movement, rapid tumor progression, and poor preoperative assessment of anatomy.

The study’s authors concluded that while VSP is a useful tool for craniofacial surgery, improving outcomes and decreasing operative time, surgeons must be aware of potential pitfalls. They called for more surgical training and experience with these technologies.

ENT Today

Otolaryngologists Discuss Keys to Treating Top Athletes

For James Kearney, MD, an interaction with professional athletes began as it does for most people: with passion, but from a distance. In 1974, the Philadelphia Flyers, his hometown hockey team, won the Stanley Cup, sparking city-wide euphoria.

“One of my enduring childhood memories was going out in front of my house when the Flyers won the Stanley Cup … and cars were beeping, people were jubilant,” Dr. Kearney said. “It was the first championship in Philadelphia in a long, long time, and the entire city had rallied behind the Flyers, who are a gritty bunch of players that Philadelphia could really identify with. From then on, I was a hockey fan.”

Now, Dr. Kearney, chairman of otorhinolaryngology at Pennsylvania Hospital of the University of Pennsylvania Health System, treats members of the Flyers team for otolaryngology conditions. As a physician, his interaction with the world-class athletes is much different than the connection he had with them when he was young. In the exam room, he’s no longer at a distance. He’s close up.

When it comes to being a fan, though, Dr. Kearney stays relatively dispassionate. A friendly remark about a recent game might be OK, but autograph seeking is not. Otolaryngologists who treat professional athletes say that, while they are aware of the stakes that are involved, a crucial part of the job is treating professional athletes as they would other people—as patients first.

They also emphasize availability and, when necessary, discretion. “You can’t let the celebrity aspect of it overwhelm your willingness to take care of this individual as a human being who needed your help as a physician and not as somebody who is a public figure,” said Dr. Kearney, who also provided care for the Philadelphia Eagles football team for two decades until 2018. “You need to treat them as real human beings.”

Medical Conditions

© Wikipedia/Keith Allison

Pro athletes frequently need custom-made protective masks so that they can continue to play while facial injuries heal.
© Wikipedia/Keith Allison

In terms of the care provided, there is a lot of overlap between professional athletes and other patients, otolaryngologists say. While a hockey or basketball player might be more likely than an average patient to come in with a laceration or a facial bone fracture, otolaryngologists typically see conditions that are run-of-the-mill—from sinus infections to chronic tonsillitis to earwax build-up.

“Most of the injuries or problems I see in these patients are not something that is an injury or a condition unique to a professional athlete,” said Christopher Larsen, MD, associate professor of general otolaryngology at the University of Kansas, who provides care for the Kansas City Royals baseball team and Kansas City Chiefs football team. “It’s more common conditions that every human being gets; it just so happens that it’s occurring in a professional athlete.” For these conditions, athletes receive the same treatment as most other patients would, otolaryngologists say.

Dr. Larsen said he screens baseball players for oral cancer, provides antihistamines for allergies, chooses topical steroid spray or surgery for swollen turbinates, and performs routine sinus, nasal, and throat surgeries on players who fail maximal medical management.

Many football players, and some baseball players, struggle with snoring and obstructive sleep apnea (OSA), which interrupts sleep and can have a big effect on focus and performance, he said. But in his experience, professional athletes struggle just as much with adherence to and tolerance of continuous positive airway pressure (CPAP) for OSA as other patients do.

During spring training, some players on the Royals team develop nosebleeds because they are unaccustomed to the dryness of the Arizona desert air, he said.

Pro athletes frequently need custom-made protective masks so that they can continue to play while facial injuries heal, and at Detroit’s Henry Ford Health System, some of their faces are pre-scanned so that the 3D printing process for the masks can be started right away, said Lamont Jones, MD, MBA, vice chair of otolaryngology, head and neck surgery at the Henry Ford, who treats members of the Detroit Pistons basketball team, Detroit Lions football team, and Detroit Tigers baseball team.

Pressure to Perform

With players being paid millions of dollars to perform on the field, otolaryngologists acknowledge there can be at least implicit pressure to get players back on the field quickly, although not nearly as much as orthopedic surgeons face in treating injuries such as, say, Achilles tendon tears or knee injuries. But they say they have to stay mindful of their obligation to the health of the person in front of them.

“As physicians, the key to remember is the patient is your first priority and then, as long as you remember that, you do what’s best for the patient and counsel them appropriately,” Dr. Larsen said. “Should they choose to do something outside of your guidelines or your recommendation, it’s only going to potentially be fraught with complications or problems…. What I know for a fact working with the Kansas City Royals is that it’s a team approach. The athletic trainers, physical therapists, physicians, and surgeons really work together as a team, and there’s constant communication, because at the end of the day, the investment is in the player and their future. Bringing them back too soon, or rushing them back to the field, is not always going to be in their best long-term interest.”

Sometimes, there can be conflicts of interest for a physician. “Somebody else is paying [the athletes] a lot of money to perform, and every time they are injured, they are not performing,” Dr. Kearney said. “And that is an issue for the team; it can be a competitive issue, it can be a financial issue. So there can be some conflicts of interest that come in particularly for physicians who are being
compensated by the team…. There can be a conflict in that they are being paid by the team that wants the athlete back on the field, but your obligation to the athlete is to provide what is best for them.”

While most otolaryngologists downplay the pressures they feel taking care of these athletes, they say there is a certain amount of pressure performing surgery on a player. “You treat every patient the same, and to say differently I don’t think is right,” Dr. Larsen said. “The flip side to that is, sure, you’re a little extra amped up that morning.”

Dr. Jones said surgeries are the most difficult scenarios he faces when treating pro athletes or celebrities. “In general, we want good outcomes, and sometimes if you have a high-profile player, it’s not that you would do anything differently, but the potential for, let’s say, good or bad publicity just magnifies itself,” he said. “In the era of social media, it’s easy for a routine or non-routine outcome to really be publicized.”

Privacy

The goal of a good outcome remains the same regardless of the public profile of the patient, but physicians say their centers do take steps to shield players from unwanted attention. Henry Ford  employs a concierge who coordinates care among physicians, the player, and the team, Dr. Jones said. Sometimes, he said, players are able to enter at a different location than the general public. Sometimes, he goes to see them rather than having them come to the medical center. “It depends on the person,” Dr. Jones said. “Some players are escorted; they may come in through a back entrance. For some of the players, I’ve actually gone to the sports arenas to evaluate them.”

Dr. Kearney said professional athletes coming to see him are typically not forced to stay in the main waiting area. “They are susceptible to their illnesses becoming public spectacle,” he said. “So if they’re coming into your office to be seen, if you keep them waiting out in your waiting area, it can be awkward for the athlete. People will wind up coming up to them, asking [them] to sign autographs or asking questions about why they’re seeing the doctor, things that people would not normally do to another patient. … I have always tried to go out of my way to help to preserve these athletes’ privacy.”

Professionalism and Availability

With time, otolaryngologists said it gets easier to regard the dynamic with a pro athlete as a typical physician–patient relationship, without worrying that inclinations as a fan will get in the way. Any references to their performance, they say, should be only for the purpose of rapport, much as they might converse with any other patient.

After a seven-foot-tall basketball player had a nasal bone fracture, Dr. Jones kidded him that he might have avoided the injury if only he had stood up tall and hadn’t had to bend down all that distance to pick the basketball up off the court. And, after a high draft pick in football had an unfavorable outing in his Eagles debut and got booed on his home field, Dr. Kearney good-naturedly told him, “Welcome to Philly.”

In the end, though, it’s professionalism that should guide the way, they say.

An indispensable ingredient in taking care of pro athletes is being available when they need care, they say. Usually, they can treat the player when needed. But if not, they find someone who can. “The nice thing about being in a large group practice is that we have redundancy,” said Dr. Jones at Henry Ford. “So, if for some reason I’m not available, there’s usually somebody available who can address the issue.”

“When I was in medical school, an otolaryngologist told me the three keys to success are availability, affability, and ability—in that order,” Dr. Larsen said. “And at the end of the day, even before I was associated with the Royals or any professional sports players, I would try to always be available for my patients and try to see as many people as I possibly could in a day while taking good care of them. And I think applying that philosophy … goes a long way with patients.”


Thomas Collins is a freelance medical writer based in Florida.

ENT Today

Nimodipine May Improve Vocal Fold or Facial Motion After Injury

Is nimodipine effective for neuroprotection following cranial nerve injury?

Bottom line: Nimodipine significantly increased the odds of vocal fold motion and facial recovery after injury.

Background: Nimodipine is a calcium channel blocker that has been used to treat hypertension and vasospasm. Various otolaryngology studies suggest that nimodipine exerts a neuroprotective effect on injured neurons, but the exact mechanism remains unknown and no large, multi-institutional clinical trials exist to investigate its efficacy for treatment of various cranial nerve injuries.

Study design: Literature review of nine studies ranging in date from January 1, 1987, to October 11, 2017.

Setting: PubMed, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, Clinical Trials.gov, WHO International Clinical Trials Registry Platform, and EU Clinical Trials Register databases.

Synopsis: Overall, nimodipine-treated patients had significantly higher odds of recovering vocal fold or facial motion compared with controls. Nimodipine efficacy on vocal fold motion recovery following recurrent laryngeal nerve (RLN) injury was assessed in three studies; nimodipine treatment was associated with a statistically significant increase in odds of vocal fold motion recovery at three to six months after RLN injury. Nimodipine efficacy on facial motion recovery following facial nerve injury was assessed in three studies; nimodipine treatment was associated with a statistically significant moderate increase in odds of facial motion recovery at six to 12 months after vestibular schwannoma surgery. The effect of nimodipine on symptoms relating to the cochleovestibular nerve was investigated in three trials, which showed general improvement of patient-reported symptoms of subjective tinnitus and vertigo; study methodology and outcome measures were too heterogeneous to be combined for meta-analysis, however. Of the nine studies, five reported on adverse events associated with nimodipine treatment, with the most common being drowsiness and dizziness, likely secondary to hypotension. Limitations included heterogeneity of some of the studies related to the cochleovestibular nerve.

Citation: Lin RJ, Klein-Fedyshin M, Rosen CA. Nimodipine improves vocal fold and facial motion recovery after injury: a systematic review and meta-analysis.
Laryngoscope. 2019;129:943–951.

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