New Consensus Statement on Balloon Dilation of the Eustachian Tube

The American Academy of Otolaryngology–Head and Neck Surgery recently published a set of clinical statements on the indications for and appropriate use of balloon dilation of the Eustachian tube (BDET) for adult patients (aged 18 years and older) with obstructive Eustachian tube dysfunction (OETD). Published June 4, 2019 in Otolaryngology-Head and Neck Surgery, “Clinical Consensus Statements: Balloon Dilation of the Eustachian Tube” was compiled by a panel of experts in response to the increasing rates of use of this technology for treatment of OETD by otolaryngologists and the need for some guidance given evidence gaps regarding its use.

“Balloon dilation of the Eustachian tube holds promise for the management of OETD, but because it is new territory for most clinicians an official statement was deemed necessary to reduce variations in care and prevent misapplication of this technology,” said Edward D. McCoul, MD, MPH, associate professor and director of rhinology and sinus surgery in the department of otorhinolaryngology at the Ochsner Clinic in New Orleans and a coauthor of the statement. “This statement calls attention to the current state of the literature as interpreted by experts in the field.”

The consensus statement offers 28 specific points of guidance categorized into the areas of patient criteria, perioperative considerations, and outcomes. Dr. McCoul highlighted a number of key areas he thought may be new to otolaryngologists and therefore particularly useful.

Patient criteria: Accurate diagnosis of OETD prior to considering BDET is critical given the variable and nonspecific symptoms that patients may present with. Along with a careful history, the panel emphasized the need to identify any underlying extrinsic causes of OETC such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux for which targeted treatment could also improve OETC. If any of these comorbid conditions are found, the panel recommends treating them prior to offering BDET.

The panel also emphasized the need for nasal endoscopy prior to consideration of BDET. “Nasal endoscopy and tympanometry are important to include when evaluating a patient for the presence of OETD,” said Dr. McCoul, underscoring the need to rule out other causes of ear fullness, including patulous Eustachian tube dysfunction.

Perioperative considerations: The panel underscored that tympanostomy tube placement is not a mandatory prerequisite for performing BDET. In addition, the panel stated that BDET should be considered an alternative to tympanostomy tube placement for treating OETD.

Outcomes: To determine outcomes, the panel noted the most reliable outcome measure is a standardized questionnaire (the Eustachian Tube Dysfunction Questionnaire-7) to record patient-reported symptoms using.
The statement also discusses and highlights clinical areas for which no consensus could be reached. Dr. McCoul highlighted a few: the extent of optimal medical therapy prior to offering BDT remains unclear, and additional objective outcome measures are still needed.

Overall, the consensus statement offers clinicians a guide to what experts currently agree on regarding the role and implementation of BDET for OETD. The authors hope that application of the statements will reduce variation in how BDET is currently used for OETD and increase the quality of care.

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Timothy Smith Appointed Editor-In-Chief of IFAR

In May 2020, Timothy L. Smith, MD, MPH, will succeed David W. Kennedy, MD as editor-in-chief of the journal The International Forum of Allergy & Rhinology (IFAR).

Published by Wiley and launched in 2011, IFAR is the official publication of the American Rhinologic Society and the American Academy of Otolaryngic Allergy. Dr. Smith brings extensive experience IFAR. “I am acutely aware of the challenges researchers face and extensive efforts they put forth in the quest to advance our knowledge and our specialty,” said Dr. Smith. “I will lead a review process that is fair, impartial, and collegial, and one that identifies the best work deserving of publication and serves its readership.”

Dr. Smith is Professor and Vice Chair in the department of otolaryngology–head and neck surgery at the Oregon Health & Science University and an active member in a number of professional organizations. He is a Past President of the American Rhinologic Society, has been elected to the Board of Directors for the American Academy of Otolaryngology–Head and Neck Surgery and to the American Board of Otolaryngology–Head and Neck Surgery, and has served on the editorial boards of numerous otolaryngology journals and publications including as an associate editor for IFAR, JAMA Otolaryngology–Head and Neck Surgery, and ENTtoday. Dr. Smith has also published more than 300 peer-reviewed articles and other scientific publications.

Dr. Smith emphasized that he will work toward maintaining and growing the strong reputation of IFAR. “IFAR will be the informational centerpiece for cutting edge discovery and innovation, best practices, and commentary and debate, for clinicians and researchers worldwide with interest in the fields of rhinology, endoscopic cranial base, otolaryngic allergy, and associated disorders,” he said.

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

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

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

Following are the key findings of the study:

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

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

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

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Professional Voice Care May Reduce Vocal Disorders in Children

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

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

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

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

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

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

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

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