Are All Cases of Sinusitis the Same?

Ongoing and emerging research is providing a fuller picture of chronic rhinosinusitis (CRS) as a spectrum of diseases that goes beyond the current clinical phenotyping, based largely on the presence or absence of nasal polyps, to a deeper recognition of distinct subtypes of the disease based on pathogenic mechanisms.

It is hoped that research into these subtypes will lead to the ability to use them as biomarkers to better predict how best to treat patients with CRS, particularly given the rapid development and availability of biologic agents aimed at targeting specific pathologic mechanisms of disease.

The need for improved tailored treatments for people with CRS is highlighted by the sheer number of people with sinusitis symptoms, a limited ability to adequately treat these patients based on symptoms, and the current reliance on the presence or absence of polyps. “The epidemiology of CRS is still a work in progress, but studies suggest that a huge number of people, probably 39 million in this country, have the symptoms of chronic rhinosinusitis,” said Robert Kern, MD, chair of the department of otolaryngology–head and neck surgery at Northwestern Feinberg School of Medicine in Chicago, “Of those, I would estimate that perhaps 26 million or so really have sinusitis, confirmed by computed tomography, of which only approximately six million have polyps.”

Although targeting patients with polyps for treatment with intranasal and oral corticosteroids is the standard treatment approach, its impact on outcomes is less than satisfactory, he said. “Phenotyping or clinical evaluation alone has made only a limited impact on clinical care, or even the ability to tell a patient if they will do well or not on a given treatment,” he said.

To improve clinical outcomes, researchers like Dr. Kern are looking beyond clinical patterns of sinusitis into the patterns of tissue inflammation as a guide to better improve their ability to identify the patient subsets who will benefit from specific treatments. Called endotyping, the research looks at the underlying pathogenic mechanisms of disease, an approach that is similar to research that has already been conducted in the study of asthma and other atopic diseases.

For clinicians, this research, combined with ongoing studies into more advanced phenotyping based on attributes such as age and geography, highlights the need to look at CRS not as a singular disease, but as one with distinct clinical presentations and disparate—probably related—pathogenic mechanisms. “It is important to understand that all CRS patients are different,” said Justin H. Turner, MD, PhD, associate professor of otolaryngology–head and neck surgery at Vanderbilt University in Nashville. “CRS is a clinical syndrome, and patients may present very differently and have variable responses to medical and surgical interventions.”

Robert Kern, MDIn the future, we will be able to subdivide patient groups more precisely, and that will lead to rolling out precision, personalized medicine in which we can really predict from mucus or a blood sample how to treat patients. —Robert Kern, MD

Clinical Patterns and Subtypes

Although the presence or absence of nasal polyps is the cornerstone on which the current treatment of CRS is based, additional information on the clinical patterns of CRS is emerging that provides more direction for clinicians. These data point toward clinical indicators such as age, geography, ethnicity, and others associated with different underlying pathogenic mechanisms of CRS and, therefore, support the use of endotyping.

One area of research suggests the importance of age in distinguishing the type of inflammation and its potential impact on treatment outcomes. Dr. Turner and his colleagues recently published a study in which they found that older people with CRS had elevated tissue and mucus levels of pro-inflammatory cytokines associated with innate immune system dysfunction, were more likely to harbor colonizing bacteria in the sinonasal tract, and had more neutrophilic inflammation regardless of polyp status or other clinical variables when compared with younger patients (J Allergy Clin Immunol. 2019;143:990–1002). “Older CRS patients may appear similar to younger patients on physical exam but differ in many other ways,” said Dr. Turner. “Given the unique inflammatory signature that we have identified in older patients, we feel that it is essential that age be taken into account when planning treatment approaches.”

Specifically, when examining tissue and mucus specimens of 147 patients ranging in age from 18 to 78 years who underwent sinus surgery for CRS, the investigators found that the inflammatory signature of a subgroup of patients older than age 60 was very different from that found in patients younger than 60. Whereas the inflammatory signature in the younger patients was characterized by a group of cytokines (Th2-associated) found in most CRS in North America, these cytokines were not significantly elevated in older patients. Rather, the inflammatory signature in the older patients was associated with a neutrophilic proinflammatory response characterized by an elevation in cytokines linked to the body’s innate immune function and acute and chronic inflammatory response. “You don’t see an elevation in those cytokines until around age 60, and then from that age on, there’s a progressive increase in the levels of those cytokines seen in the mucus and tissue of those patients,” said Dr. Turner.

One important implication of this finding is that current treatment approaches for CRS may be less effective in older patients. “Neutrophilic inflammation is typically less responsive to topical and systematic corticosteroids,” said Dr. Turner. “This would suggest that great care should be taken when prescribing repeated courses of oral steroids in older patients, and strongly suggests the need for alternative therapies to more effectively target this vulnerable population.”

Another area of research shows that people with CRS living in Asian countries are likely to have more neutrophilic inflammation than people living in Europe/North American countries. For example, a 2017 study found that most people with CRS in Europe/North America (80%) have nasal polyps characterized by increases in eosinophilic cytokines (type 2 inflammation), compared to 20% in China and 60% in Korea or Thailand (J Allergy Clin Immunol. 2017;140:1230–1239).

According to Amber Luong, MD, PhD, associate professor in the department of otorhinolaryngology–head and neck surgery at McGovern Medical School of The University of Texas Health Science Center at Houston, the differences in the types of inflammation found in nasal polyps in these geographical populations highlights the fact that while people with CRS can look clinically similar (i.e., have the presence of nasal polyps), they are very different molecularly.

Justin H. Turner, MDAll CRS patients are different. CRS is a clinical syndrome and patients may present very differently and have variable responses to medical and surgical interventions. —Justin H. Turner, MD

She emphasized, however, that this is not an ethnic difference per se, adding that nasal polyps in second generation Asians with CRS living in Northern America or Europe are starting to look molecularly similar to nasal polyps in the populations of these countries. “This observation suggests that environmental exposure plays a critical role in driving the type of immune response contributing to rhinosinusitis,” she said. On the other hand, she cited a 2018 study that found that variations in cut-off levels of eosinophil numbers used to diagnose eosinophilic versus neutrophilic chronic rhinosinusitis may contribute to some of the differences in the percent of eosinophilic versus neutrophilic CRS between eastern and western countries (Curr Allergy Asthma Rep. 2018;18:46). Nonetheless, she added, the 2017 study highlights the fact that not all polyps are the same at a molecular level.

To that end, she said the research is pointing toward the future. “Maybe down the road you can take a biopsy sample that helps us to endotype our patients with chronic sinusitis,” she said.

For Noam A. Cohen, MD, PhD, director of rhinology research in the department of otorhinolaryngology–head and neck surgery at Perelman School of Medicine at the University of Pennsylvania in Philadelphia, another important component of what he sees as a multifactorial approach to explaining CRS is looking at taste receptors and the role they play in the development of the disease.

In studies published in 2012 and 2014, he and his colleagues showed that people with sensitive bitter taste receptors are less likely to develop a subtype of CRS based on the genetically determined function of these taste receptors (J Clin Invest. 2012;122:4145–4159; J Clin Invest. 2014;124:1393–1405). The research showed that one bitter taste receptor detects the molecule secreted by gram-negative bacteria that subsequently stimulate an immediate defense (nitric oxide production) in the cells lining the sinuses, which kills and clears out bacteria that play a common role in sinusitis. “What the receptor triggers is like a switch turned on in response to the bacteria, which not only kills the bacteria but sweeps the dead bugs away,” said Dr. Cohen.

Where this gets interesting, he said, is that there are a lot of genetic differences in the ability of people to taste bitter molecules. “Over the past five to six years, we’ve been able to show that patients in whom this bitter taste receptor doesn’t work are at much higher risk for developing gram-negative sinusitis,” he said.

With this finding, Dr. Cohen and his colleagues then looked at whether you could use the presence or absence of functioning bitter taste receptors to predict surgical outcomes, and they found that a subset of CRS patients without the functioning receptor were at higher risk for sub-optimal surgical outcomes.

Currently, Dr. Cohen and his colleagues are gearing up to launch a clinical trial to see whether it is possible for patients with CRS to forego conventional antibiotics after activation of their multiple bitter taste receptors and natural defense mechanism against the bacteria that cause rhinosinusitis.

Patterns of Inflammation

The potential to identify specific molecular biomarkers of CRS to individualize treatment is being advanced through research on CRS endotyping, through which investigators are looking at the patterns of inflammation in the tissue of nasal polyps in people with CRS. “We still rely on phenotypes in the clinic,” said Dr. Kern, “but we can gaze at the future in terms of endotyping.”

A recent study by Dr. Kern and colleagues that looked at the presence of subsets of innate lymphoid cells (ILCs) found that the subset ILC2 may play an important role in the development of type 2 inflammation found in patients with CRS and nasal polyps (Immun Inflammation Dis. 2017;5:233–243). In the study, the investigators used multiple techniques to look at the presence of subsets of ILCs in patients with CRS, both with and without nasal polyps. ILCs, along with T-helper lymphocytes, produce high levels of cytokines that are present in distinct patterns in the tissue. These patterns will likely define the clinically relevant endotypes, each of which will respond differently to current treatment options. Type 2 inflammation, defined by the presence of elevated type 2 cytokines (IL-4, 5 and 13), is present in the vast majority of patients with CRS with nasal polyps. This Type 2 endotype—or, more likely, a group of related type 2 endotypes—has been particularly difficult to treat, with a high recurrence rate after both medical and surgical therapy. Type 1 and Type 3 inflammations are less common and likely more responsive to treatment. In CRS patients without polyps, the inflammation is more heterogeneous, but a large percentage still exhibit Type 2 inflammation.

Figure 1. Unique Inflammatory Signatures in Aged CRS Patients. Reprinted from J Allergy Clin Immunol. 2019;143:990–1002, Copyright 2019, with permission from Elsevier.

Figure 1. Unique Inflammatory Signatures in Aged CRS Patients.
Reprinted from J Allergy Clin Immunol. 2019;143:990–1002, Copyright 2019, with permission from Elsevier.

According to Dr. Kern, each pattern of inflammation will likely respond differently to various treatment options in ways that should be predictable. “We are still working this out,” he said, emphasizing that the research is only relevant if it has clinical application—that is, if it can shed light on the natural history of the disease, help predict who will respond to what treatment, and determine which patients will do well on a given treatment.

For Dr. Kern and others, this is the direction in which CRS treatments are heading. “In the future, we will be able to subdivide patient groups more precisely, and that will lead to rolling out precision, personalized medicine in which we can really predict from mucus or a blood sample how to treat patients,” he said.

Underscoring the need for further research is the emergence of biologic agents that can target specific mechanisms of disease, a treatment already used for patients with asthma. This advance is on the doorstep for patients with CRS. Dr. Kern pointed to results of a study recently presented at the American Academy of Allergy, Asthma and Immunology (AAAI) meeting in February 2019 that showed the safety and efficacy of the biologic agent dupilumab for nasal polyps (“Efficacy and safety of dupilumab in patients with chronic rhinosinusitis with nasal polyps: results from the randomized phase 3 SINUS-24 study”).

According to Dr. Kern, the biologic agent will hopefully gain approval from the Food and Drug Administration for treatment of nasal polyps sometime later this year, representing a major advance in the ability to manage patients with severe CRS with nasal polyps. 

Mary Beth Nierengarten is a freelance medical writer based in Minnesota.

ENT Today

Basic Science Departments Struggle Amid Financial, Staffing Challenges

Basic science departments serve three key missions: to conduct research, to teach graduate students in basic science fields, and to teach medical students. But basic science departments at academic institutions are hurting. They face challenges such as insufficient funding, dwindling faculty numbers, shrinking curriculum, and limited research space. Ultimately, these challenges negatively impact the medical field in a variety of ways.

Funding Issues

Basic science departments are predominantly funded by grants to support research. Typically, these departments don’t have a means to create revenue on their own, as clinical departments do through compensation for clinical work. “While there may be some state funding for specific investigators, these salary lines are few and far between and certainly aren’t enough to support a complete and modern department,” said Andrew Murr, MD, professor and chair of the department of otolaryngology–head and neck surgery at the University of California, San Francisco. “Endowed positions sometimes exist to help with support, but basic science departments have little interaction with the public, so raising money through philanthropy is less likely,” he added.

Although there have been significant improvements in the federal government’s budget for the National Institutes of Health (NIH) in recent years, when adjusted for inflation, the budget is still smaller than it was in 2003. “Basic scientists have experienced 15 years with no growth in available resources, with terrible pay lines from NIH and National Science Foundation grants,” said Ross McKinney, MD, chief scientific officer of the Association of American Medical Colleges (AAMC).

Wendell G. Yarbrough, MD, MMHC, a professor and chair of otolaryngology/head and neck surgery at the University of North Carolina at Chapel Hill, had similar sentiments. “Many NIH institutes are funding applications in the single-digit percentiles, and when grants are funded they oftentimes aren’t large enough for the proposed research to be completed,” he said. In addition, salary caps on NIH grants create another funding gap. Funding from clinical sources or schools of medicine are also under pressure due to decreased reimbursement for clinical activity, so making up for lost funding is particularly challenging.

Dr. Murr added that with funding becoming increasingly tight for NIH awards, the funding line is becoming more exclusive, so fewer young scientists can get comfortably and firmly established. Furthermore, “if a researcher has an extremely compelling grant but their institution’s environment isn’t devoted to their topic of interest, they may be left out of funding,” he said.

Wendell G. Yarbrough, MD, MMHCThe erosion of academic pursuits in schools of medicine risks the leadership roles that schools have held and will ultimately slow innovation that would benefit patients. —Wendell G. Yarbrough, MD, MMHC

Dwindling Faculty Numbers

Developing and maintaining fruitful collaborations among clinical and basic science researchers is critical to a strong research program—especially collaborations that lead to translational and clinical research that directly benefits patient outcomes, said Judy R. Dubno, PhD, director of research in the department of otolaryngology–head and neck surgery at the Medical University of South Carolina in Charleston. But both basic science and clinical researchers face challenges in dedicating effort to collaborations and translational research, given the pressure to maintain their individual research programs with funding and their clinical practices.

A thriving research program also requires a strong infrastructure, including administrative personnel to assist with grant management, continually growing and changing policy and regulatory requirements, and other essential administrative tasks essential for conducting research, all of which add to overhead costs, Dr. Dubno said.

Finally, there is an urgent need for basic science faculty, departments, and medical schools to support the unique requirements of physician–scientists, Dr. Dubno added. To ensure the continued growth of the science that underlies otolaryngology health and disease, basic science faculty in otolaryngology–head and neck surgery departments must fully participate in an enriched educational and scientific environment that values research and research training as high priorities.

Given the limited funding that medical schools receive and the low rates of grant awards, bridge funding, a form of temporary and immediate funding for investigators whose grants have lapsed, is becoming more commonplace. Consequently, faculty members may not be able to continue their research if bridge funding is not available, Dr. Yarbrough said.

Limited funding for research has resulted in little or no growth in the number of faculty in basic science departments. AAMC data show that there were roughly the same 20,000 faculty in basic science departments in toto across the United States over the last decade. In 2009, there were 18,526 basic science faculty, and in 2018 there were 19,732—a 7% increase. However, at the same time there was a 21% increase in the number of medical schools.

Figure 1. NIH Research Appropriations 1995–2019 in Current and Constant Dollars. Source: NIH

Figure 1. NIH Research Appropriations 1995–2019 in Current and Constant Dollars.
Source: NIH

A related challenge stems from the fact that the median age for a medical school faculty member as of 2015 was around 50. Although staffing shortages aren’t a current problem, aging faculty are holding positions that could be filled by more recent graduates, but those slots aren’t available due to caps on the number of tenure-track salary lines.

Furthermore, Dr. Murr pointed out that losing scientists to industry is commonplace. “The biopharmaceutical industry can often pick off successful professors who are well established or successful post docs who are daunted by the extraordinary costs and pressures to set up a laboratory,” he added.

Shrinking Curriculum

Historically, basic scientists taught medical students in the first two years of the medical school curriculum. The standard model was that a faculty member would give a few lectures and perhaps run a course in their area of expertise. Students learned information through lecturing, but most schools are now moving to models that involve team-based learning or a problems-based curriculum, and some schools have completely eliminated lectures. As a result, the medical student teaching justification for basic science faculty has diminished substantially, and some schools are shifting dollars from basic science departments to the medical student teaching program.

Dr. McKinney added that teaching graduate students in the basic sciences continues to be an important role for basic science departments, a function supported by tuition dollars and by grants. However, attrition of faculty at some graduate schools means that programs are losing the critical mass of faculty necessary to sustain a basic science graduate program.

The lack of stable, long-term funding also makes it difficult to build and expand new programs and recruit and retain basic science faculty, Dr. Dubno said.

On the positive side, doctoral degree graduates in the biomedical sciences are very employable, Dr. McKinney said. The majority of them go into jobs that aren’t within academia, but rather in industry, government, or research.

Space Limitations

Departments also struggle with limited availability of high-quality space for clinical and basic science laboratories, Dr. Dubno said. Additionally, available space is rarely co-located with space designated for clinical faculty or basic science faculty who work in different sub-disciplines, which reduces opportunities for effective collaborations among clinicians and basic science faculty. Similarly, equipment, up-to-date technologies, and necessary renovations may be lacking due to limited intramural or extramural funding.

The Greater Impact

The balance among clinical care, education, and research is being tilted toward clinical care—which is the major source of income for a school and its affiliated hospitals. This results in a lower emphasis on and fewer funds invested in the basic sciences. “The intermediate to long-term risk is that academic basic science departments become more marginalized with fewer investigators,” Dr. Yarbrough said. “The erosion of academic pursuits in schools of medicine risks the leadership roles that schools have held and will ultimately slow innovation that would benefit patients.”

Dr. McKinney said that huge opportunities to improve care in hearing restoration and communications disorders will require more knowledge of how the brain processes acoustic signals at everything from the cellular level to the neuronal networks that respond and interpret the information. “But if basic science departments suffer, progress will be limited,” he said.

Because they have close relationships with basic science departments through collaborative research, shared faculty, and curricula that emphasize the intersection of basic and clinical knowledge, otolaryngology departments will face challenges for maintaining academic and educational missions. “Diminution of basic departments will make these challenges more acute,” Dr. Yarbrough said. “Strong basic science departments within medical schools are needed to train the next generation of otolaryngologists and to partner with otolaryngology faculty to advance our understanding and treatment of diseases of the upper aerodigestive tract.”

Karen Appold is a freelance medical writer based in New Jersey.

Key Points

  • The balance among clinical care, education, and research is tilting toward clinical care.
  • Limited funding for research has resulted in little or no growth in the number of faculty in basic science departments.
  • The lack of long-term funding makes it difficult to build new programs.

Six Ways to Help Basic Science Departments Regain Vitality

Keeping basic science departments running optimally is a growing challenge, but experts say some things can be done to help them regain their strength. Here are six suggestions.

  1. Support funding for the NIH. “There have been meaningful, greater-than-the-rate-of-inflation increases in the NIH budget each year since 2015,” Dr. McKinney said. “That has helped to heal the damage done by years of inadequate funding.” But schools of medicine will need to continue to support basic science financially, because NIH grants have never paid the full cost of basic science research. NIH funding is critical for basic science, and without it there won’t be the types of new ideas necessary for translation into novel clinical applications.
  2. Form partnerships. Basic science departments can partner with industry and clinical departments to increase research portfolios that are closer to clinical implementation, which could open new funding sources, said Dr. Yarbrough. In addition, academic hospitals and centers within medical schools should continue to invest wisely in basic science departments.
  3. Promote effective communication. Teach students to communicate their research to others in a clear, concise way. “We need the public (taxpayers) to understand what basic scientists do,” Dr. McKinney said. “Their support is necessary to sustain the basic science culture.”
  4. Ask public relations offices to avoid hyped language. “Hype can ultimately hurt basic science departments,” Dr. McKinney said. “The public will lose trust in science if they’re constantly being bombarded with false claims like there’s a new cure for cancer. When taxpayers lose their faith, funding will dry up.”
  5. Train doctors of philosophy to be flexible. “Don’t just train doctors of philosophy to be the next generation of faculty, train them to be the next generation of researchers for whatever environment they may find themselves, such as academia, industry, or government,” Dr. McKinney said.
  6. Help develop better pathways for junior investigators. “We need to make it easier to have a good career in basic science,” Dr. McKinney added. “This means that schools need to provide adequate resources to financially support junior faculty until they’re able to get federal grant funding.”

ENT Today

New Research and Education at COSM 2019

AUSTIN, Texas—In May, Triological Society members and other attendees came together for the society’s 122nd Annual Meeting to share research and foster new ideas within the field of otolaryngology. The 2019 Triological Society Annual Meeting, held in conjunction with the Combined Otolaryngology Spring Meetings (COSM), welcomed 470 attendees plus residents and medical students, who joined discussions, heard panelists debate, and viewed an extensive array of scientific posters.

Nearly 900 residents and medical students attended COSM, many of whom were offered the opportunity to present clinical and research papers and posters during the society meetings. “I attended the conference to learn about the newest developments in otology and to support the excellent work of some of the medical students and residents with whom I work,” said Aaron Moberly, MD, an assistant professor in the division of otology, neurotology, and cranial base surgery in the department of otolaryngology–head and neck surgery at  The Ohio State University Wexner Medical Center in Columbus.

During the Triological Society’s scientific sessions, 65 podium presentations and seven panels were given. More than 160 posters were presented as a part of a combined poster session. The Triological Society again funded travel grants to fellows, residents, and medical students selected to present oral and poster presentations during the Society’s scientific sessions.

Presidential Address: A Patient’s Perspective on HNC

Sigsbee Duck, RPh, MD, said that he has had an incredible year as the president of the Triological Society. His presidential speech was made “to simply remind all otolaryngologists how important empathy and caring are for our cancer patients. I am just laying out the stark and personal reality of being a head and neck cancer patient first hand and the feelings associated with the treatment process.” He went on to thank all of his head and neck surgery colleagues who selflessly care for patients like him on a daily basis.

Dr. Duck definitely understands the importance of empathy and caring for cancer patients, as he himself is a head and neck cancer survivor. “On the morning of March 9, 2015, I was getting ready for work, shaving actually, when I felt a mass in my right upper neck. Denial set in and I convinced myself that it was an infection.” He put himself on antibiotics and after a few doses he realized it was not going down and seemed to be larger. Becoming quite concerned, he called the Huntsman Cancer in Salt Lake City and drove three hours from Wyoming the same Thursday for a biopsy. The physician told him the ultrasound characteristics appeared benign and to come back in one month if the mass was still present for a FNA. He responded, “I’m here now, so please proceed.” He did and the next Monday the endocrinologist called to inform him “you have metastatic epidermoid carcinoma.” Reality quickly set in.

“This couldn’t be happening to me,” Dr. Duck thought. He was asked to be back at the Huntsman on Wednesday for a PET scan, but as he had NCAA basketball tournament tickets in Kentucky the following weekend, he opted to wait a week and meet his family to let the reality of a totally surrealistic situation settle in. The next week the PET scan was completed. With his surgeon, Dr. Jason Hunt’s hand on his shoulder, he was informed he had a “large tonsillar carcinoma with neck metastasis.”

Dr. Duck underwent a radical tonsillectomy and a modified RND the next day. “I was still in denial,” he said. “Five hours later reality took hold when I awakened to find an NG tube, a Foley, a JP drain, an IV between the toes on my right foot, an inability to swallow and complete anesthesia from my mid cheek to my clavicle. When I finally woke up, reality once again hit and I sat up with a very kind nurse and cried for about three hours. Then came swallowing therapy and ultimately tubes were removed one at a time as my wife and I waited for the pathology reports to assure clear margins and positive testing for HPV and P-16.” He was blessed to have these findings. The day he left the hospital, a Basset Hound therapy dog came by to visit and he realized that “it’s the small things that really mean the most to patients.”

Sigsbee W. Duck, MDAs physicians, we must take extra time with our cancer patients. We must show genuine empathy. —Sigsbee W. Duck, MD

“Emotions run amuck while going through cancer treatment and they are very difficult to control,” Dr. Duck found out. “When I finally returned to work in Wyoming prior to radiation therapy, I was not successful—or nice. I was curt and downright rude. I had not realized the emotional toll cancer takes on patients.”

Radiation therapy was next. “Despite having sent hundreds of patients for these treatments, it was at this point that I realized that I really didn’t know anything about it. Now, more than ever, I genuinely admire my cancer patients, particularly the ones without the financial means or family support like I was blessed to have who must complete this therapy.” Dr. Duck recalled an older man who sat next to him before his first radiation treatment. “He had been told his radiation was palliative and to get his affairs in order. He asked why I was there and I told him and he said good luck. The next day, he was not there and I never saw him again. It is sad and disconcerting to see all these patients every day, and suddenly they are not there anymore.”

On his last day of radiation, the waiting room was full and he was informed that the machine was down. “I figured my options were to get mad, sulk, or cry. Well, I’m a crier,” he said. The other patients with whom he had bonded huddled around him for support, the machine was ultimately repaired and with radiation therapy completed, he finally left the Huntsman.

Dr. Duck’s long and emotionally difficult experience with surgery and radiation were not only grueling, but also educational. “The post-traumatic effects of surgery and radiation therapy, especially as radiation is over-utilized to treat this disease, particularly when used in conjunction with chemotherapy, are very real,” Dr. Duck stated. “And radiation is definitely the gift that keeps on giving—for the rest of your life. Your taste is permanently altered, you have pain and cramping with exercise, and you can never taste or swallow effectively.”

“And there is a stigma associated with HPV H&N cancer. Even my colleagues make jokes about sexual transmission. I had been married for 33 years, and I found no humor in their jokes,” he said. “Frankly, who knows what  bacteria any of us are harboring as otolaryngologists? My entire family has been tested and cleared and we have received the HPV vaccine including the P-16 and P-18 strains.

“No matter how many H&N cancer patients  you have cared for, always remember the absolute feelings of fear and helplessness that your patients experience. As physicians, we must take extra time with our cancer patients. We must show genuine empathy. Sit down by the bed as if you are not busy. These days, I share my experience with my patients and it reassures them in a positive way.” Dr. Duck added. “Most importantly, an opportunity to convey information to a patient’s family and exude a feeling of optimism and trust as to the care we are taking of their loved ones, is one of the greatest opportunities we have as physicians—to demonstrate compassion and caring through simple communication and basic kindness.”

Dr. Duck’s hard-earned message is this: “As cancer patients we are always looking over our shoulders; fear, anxiety, and reality are always lurking. More than ever [these patients] need a physician who is sensitive to that reality and who can show genuine empathy and caring.” 

Elizabeth Hofheinz is a freelance medical writer based in Louisiana.

Upcoming Triological Society Meetings

Combined Sections Meeting
January 23-25, 2020
Coronado, Calif.

123rd Annual Meeting at COSM
April 24-25, 2020
Atlanta, Ga.

Visit for more information.

ENT Today

Tips to Help You Regain Your Sense of Self

When I was 10, my family and I lived in rural Pennsylvania. I had three siblings and we made our own fun. We climbed trees, made friends with spiders, and played with the neighbor’s horse until the fence broke and it almost stepped on my baby brother. We mostly played outside to stay out of trouble, but inside could be equally entertaining. There were inside rules—no running, quiet voices, no bouncy ball—which were sometimes circumvented, but almost universally obeyed.

One day, left to my own devices, 10-year-old me disobeyed one of the more sacrosanct decrees of my household: Thou shalt not climb on the cabinets. My need for fun eclipsed my innate desire to follow the rules and up, up, up I went. A moment basking in the glow of my success was followed by panic. My mom was on the porch and would enter the house momentarily. I jumped. White hot pain exploded in my left foot. It had landed, big toe first, in an open box of Legos. I stifled a scream and fell to the floor. “What on earth is going on?” my mom asked. “I think I stubbed my toe,” I lied.

My parents were confused as to how a stubbed toe could cause so much pain, as were the emergency department physicians who evaluated me when my agony had not subsided several hours later. However, I was now committed to my lie and kept retelling the same story. We were reassured that nothing was wrong. My stubbed big toe would heal up just fine on its own. And heal it did, only an inch shorter and fused at the proximal and distal interphalangeal joints. I am reminded of my trivial childhood decision to lie every time I put on a pair of shoes, one of which will forever either be too big or too small. It makes me wonder if the truth and a plaster cast may have been the better option. I also wonder how, without the benefit of time, wisdom, and retrospection, we can know this in advance.

For me, this is also true when it comes to the decisions we make daily. Some decisions are like a mask we put on. Ten-year-old me wanted her “good girl,” rule-following mask to stay intact more than she wanted to have her toe properly addressed. That same year, we fifth graders were eligible to join the school band. During an informational session, they told us that the flute was one of the more difficult instruments to learn. I heard nothing else; that was all I needed to know. Another layer of my mask at the time was proving that I could excel at all the difficult things. Flute it was, regardless of whether or not another instrument would have brought me more joy. The elements of our masks may be genetic, learned, taught, or arise from trauma or other experiences. They are almost always well intentioned.

However, I believe that the mask analogy isn’t entirely accurate. These things do not make up our masks; they make up our casts. They are put on to protect us or to help us move with more ease through our circumstances. There are plenty of resources available to show us how to add layers to our casts. Facebook and Instagram have taught a generation to post smiling pictures showcasing “Living Your Best Life.” The importance of this careful curation of visual snippets of your life is to project the image of who you want the world to think you are. Peeling away the layers and exposing what’s underneath is not nearly as publicized or glamorous.

Jennifer A. Villwock, MDI was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other. —Jennifer A. Villwock, MD

I recently gave a local TEDx talk. Some of what I said you might have read before in my last wellness column (ENTtoday. 2018;13:1). Some of it was new. The gist of the talk was about the importance of the stories we tell ourselves about our experiences, illustrated by examples from my life as a surgeon. Some people told me my talk moved them to tears. Several that knew me during the difficult stages in my life that I talked about said, “I was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other.” I didn’t say anything that most of us haven’t experienced. I just peeled back a tiny bit of one of my casts.

So what happens if you don’t take a cast off or if you don’t know how? It gets itchy. Probably a little smelly too. The strength underneath can atrophy, the skin turning pale. As time progresses, it can take not only an increasing amount of effort, but also courage, to try and take off the cast. Because of this, we may elect to accept the itch. I wonder if more of us were willing to peel back our casts with an attitude of, “Hey, look at this. Isn’t this strange, but also normal considering what we’ve been through? Won’t it be cool to watch this limb rehabilitate and be strong again?”—would we all be healthier as a community?

Because the location and substance of our casts can be so different, generic one-size-fits-all wellness advice can fall short. For example, online wellness modules are typically not universally well received. At best, one size fits some. Additionally, this type of well-intentioned advice can be counterproductive. If you absolutely cannot sit still, hearing that you need to do sitting meditation daily may just create stress and angst and another plaster layer on your cast as you try to comply. Similarly, I dislike running; my marathon-running partner is my exercise-kryptonite. The “couples who sweat together, stay together” mantra does not apply to us; trying to follow it would harm our relationship.

Do you know where your casts end and your own skin begins? As you head to bed and reflect on your day, maybe catching a glimpse of yourself in the mirror, do you ever get that nagging sensation that you’re not who you wanted to be? Great news! This is your own subtle call to action and tomorrow is another opportunity to be the better person you had hoped you would be today. The only question now is what to do with that sensation. Perhaps consider answering the following questions for yourself and experiment with implementing the answers in your own life:

  • What foods do you actually enjoy eating that also healthfully fuel your body? Eat those things. If you don’t know, ask for help. Your health insurance may include free health coaching or nutrition perks. Maybe organize a healthy potluck or meal exchange.
  • What activities do you enjoy that move your body and keep you active? Do more of that. If you don’t know, consider signing up for a random class or take advantage of a Groupon offer.
  • Feeling too introverted or embarrassed for an exercise class? Sign up for a two-week free trial of one of the many exercise apps available.
  • Do you have a hobby or interest? Nurture it. Can’t remember what you find fun? Ask a friend or colleague for a recommendation or to come with you to a random community event. (I recommend children’s musical theater. There are few things cuter than a multitude of 5-year olds singing Disney songs!)
  • Do you like to create? Decide to make something and, if you don’t already know how, watch a YouTube video and learn (if you’re interested in crochet, check out Wooly Wonders crochet channel ϑ). If you realize you hate the process halfway through, give yourself permission to quit!
  • What new horizons would you like to explore through music or literature? Ask a friend if they’ve come across any up and coming artists or find an open mic night. Maybe join, or start, a book club.

And to you medical students and residents reading, or anyone else who’s overwhelmed with their exceptionally busy life, actively thinking to yourself, “I do not have the time, or the money, for any of your suggestions,” I see you. I hear you. I understand. Perhaps a follow-up question to the ones above may be, “What is the smallest next step I can take towards those goals?” Could you carry almonds or other nuts in your white coat pocket to have a healthy snack option? Can you commit to taking the stairs up one more flight of stairs than you normally would while rounding on patients? Can you sneak away for five minutes in between consults to go stand in a patch of sunlight and take 10 deep breaths? Could you focus on having one genuine, human interaction with another person per day?

As you consider these options, be kind to yourself as you experiment. Not everything is going to feel “right.” It may take some time to remember who you are under all the layers and after all the years of focusing on your training and the welfare of others. Try to avoid “should-ing all over yourself” and doing things out of guilt because they’re what you think you’re supposed to do, lest they drain you while adding another layer of plaster.

“Love takes off casts* that we fear we cannot live without and know we cannot live within.”—James Baldwin

*original quote: “Love takes off masks…” 

Dr. Villwock is an assistant professor of  otolaryngology–head and neck surgery in the division of rhinology and skull base surgery at the University of Kansas Medical Center in Kansas City. She is also a member of the ENTtoday editorial advisory board.

Call to Action

How you can explore your sense of self:

  • Sign up for a class or take advantage of a Groupon offer.
  • Organize a healthy potluck or meal exchange.
  • Sign up for a trial with one of the many exercise apps available.
  • Ask a friend or colleague to accompany you to a random community event.
  • Decide to make something and, if you don’t already know how, watch a video online.
  • Join—or start—a book club.
  • If you know you don’t like something, allow yourself to say no, and try to let go of feeling guilty.

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

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: 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

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.”


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.

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