BackTable ENT & Allergy – Details, episodes & analysis

From cable grafts to free muscle transfer, surgical treatments for facial paralysis are evolving quickly. In this episode of the Backtable ENT Podcast, Dr. Myriam Loyo Li, facial plastic surgeon at OHSU, joins guest host Dr. Shiayin Yang of Vanderbilt to discuss dynamic procedures for facial paralysis. --- This podcast is supported by: BackTable + ENT https://www.backtable.com/shows/ent --- SYNPOSIS First, the surgeons review workup of flaccid and non-flaccid (synkinetic) facial paralysis. Then, they review the principles of facial reanimation. Topics such as nerve graft selection and staged surgery are covered. Dr. Loyo Li explains her timelines for staged surgery and how patient characteristics affect her decision planning. Finally, the surgeons discuss free muscle transfer – an exciting new technique in the world of facial plastic surgery – to treat facial paralysis. --- TIMESTAMPS 00:00 - Introduction 02:48 - Evaluating and Managing Flaccid Facial Palsy 05:18 - Imaging and Treatment Pathways 07:16 - Nerve Grafting Techniques and Preferences 10:08 - Challenges and Innovations in Facial Reanimation 25:50 - Patient-Centered Approaches and Decision Making 37:30 - Evaluating Facial Nerve Recovery 43:25 - Timing and Criteria for Nerve Transfers 46:41 - Free Muscle Transfer Techniques 49:47 - Innovations in Cross Facial Nerve Grafts 01:06:04 - Exploring Free Strap Muscle Transfers 01:14:05 - The Future of Facial Reanimation --- RESOURCES Dr. Loyo Li’s OHSU Profile: https://www.ohsu.edu/providers/myriam-loyoli-md-mcr Dr. Yang’s Vanderbilt Profile: https://www.vanderbilthealth.com/doctors/yang-shiayin

It’s not an overstatement to say that surgeons from The House Clinic revolutionized otology / neurotology in the second half of the twentieth century. In this episode of the BackTable ENT podcast, Dr. John House, son of the clinic’s founder, Howard, discusses the clinic’s fabled history with guest host Dr. Walter Kutz (UT Southwestern). --- SYNPOSIS Dr. House recounts his father’s journey traveling the world to learn from renowned otolaryngologists, ultimately settling in Los Angeles where he established his practice. Working with his brother William, Howard started a clinic that popularized innovative treatments for otosclerosis, acoustic neuroma, and sensorineural hearing loss. While innovations like Howard’s cochlear implant and John’s House’s House-Brackmann Facial Nerve Grading Scale faced resistance at first, they eventually won widespread acceptance. The episode concludes with Dr. Kutz’s moving personal reflection on his time as a fellow at the House Clinic. --- TIMESTAMPS 00:00 - Introduction 05:41 - Dr. Howard House’s Path to Neurotology 17:14 - Dr. Bill House’s Passion Project: The Cochlear Implant 28:39 - Development of the House-Brackmann Facial Nerve Grading System 38:49 - The Evolution of Stapes Surgery 45:14 - House Alumnus Dr. Walter Kutz’s Journey --- RESOURCES Dr. John House’s House Clinic Profile: https://www.houseclinic.com/home/meet-the-team/profile/john-william-house-1/ Dr. Walter Kutz’s UT Southwestern Profile: https://utswmed.org/doctors/joe-kutz/

Facial nerve injury affects each patient in a unique way. Accordingly, surgical treatment of facial paralysis must be meticulously planned and personalized. In this episode, Dr. Shiayin Yang, Associate Professor of Otolaryngology at Vanderbilt University, addresses management of synkinesis and static procedures for flaccid facial palsy with host Dr. Ashley Agan. --- CHECK OUT OUR SPONSOR PearsonRavitz https://pearsonravitz.com/backtable --- SYNPOSIS First, Dr. Yang reviews the difference between flaccid and non-flaccid (including synkinetic) facial paralysis. She describes her approach to facial paralysis, which includes clarifying the patient’s diagnosis and thoroughly examining the facial nerve function. Dr. Yang then transitions the conversation to surgical solutions, emphasizing dual goals of restoring symmetry and function. She divides her discussion to first tackle synkinesis and then static procedures for flaccid paralysis. Procedures discussed include Botox, brow lift, blepharoplasty, myectomy, and neurectomy as well as lower eyelid and midface procedures and temporalis tendon transfer. While surgical approaches to the two conditions differ, eye protection represents an important theme throughout. The episode concludes with Dr. Yang’s pearls for approaching these complex surgical problems and a reminder of how facial paralysis affects patients’ emotional health. --- TIMESTAMPS 00:00 - Introduction 02:36 - Understanding Flaccid & Non-Flaccid Facial Paralysis 07:13 - Botox for Facial Synkinesis 12:38 - History-Taking & Physical Exam in Facial Paralysis 15:07 - Surgical Management of Synkinesis 30:47 - Patient Counseling and Motivation 32:47 - Static Procedures for Flaccid Facial Palsy 37:26 - Nuances of Peri-Ocular Procedures 43:42 - Lower Eyelid & Midface Considerations 53:00 - Dynamic Surgery Options 56:56 - Final Surgical Pearls --- RESOURCES Dr. Shiayin Yang’s Vanderbilt University Profile: https://www.vanderbilthealth.com/doctors/yang-shiayin BackTable ENT Episode 151- Navigating Synkinesis: From Diagnosis to Comprehensive Care with Dr. Shiayin Yang https://open.spotify.com/episode/1JucnHB8tNC5qRW6u82ie8?si=ba729d3f3e164d6f

In this episode of BackTable ENT, Dr. Gopi Shah, Dr. Romaine Johnson (UT Southwestern), and Dr. Alex Chiu (University of Kansas) discuss health disparities research and the Health Equity Collaborative. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/ZkIxQ0 --- SHOW NOTES First, Dr. Chiu explains the difference between equality and equity. Equality is giving everyone the same resources to reach a goal, while equity is giving people different resources based on their different background and obstacles to reach a goal. Health equity emphasizes the importance of the provider focusing on interpersonal relationships and caregivers of patients, not just on their patients as individuals. Dr. Johnson explains that although there are many research studies that prove the existence of inequalities, there are not enough research studies centered on how specific interventions can reduce disparities. Then, Dr. Chiu explains the Health Equity Collaborative, an initiative to drive more health equity research in the field of ENT across different institutions. The collaborative was started in February 2022 in Kansas City. Dr. Chiu and his team quickly realized that they did not have the adequate volume of patients needed to achieve a sizable impact, so they reached out to more ENT researchers in different cities. The collaborative uses qualitative research methods, such as the qualitative structured interview, and then formulates objective metrics to analyze the results. Future goals of the collaborative include gaining the support of societies and using their evidence to change policies and advocate for minority patients. Dr. Chiu also explains obstacles he had to overcome when forming the collaborative and the benefit of working with a diverse team. Finally, Dr. Chiu shares how his disparity research has affected his medical practice by making him a more patient physician. He listens closer to his patients to try and understand his patients’ decisions and non-compliance before judging them. He is also inspired by research initiatives from other medical specialties.

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Julie Wei, president of the American Society of Pediatric Otolaryngology, discuss how lifestyle medicine can resolve common chronic pediatric ENT complaints. --- SHOW NOTES First, Dr. Wei explains the “milk and cookie disease”, a condition she coined that relates to a triad of symptoms in children that include chronic cough, nasal congestion, and rhinorrhea. In her practice, she noted that consuming dairy and sugar products close to bedtime was directly correlated with the triad of symptoms. Thus, she emphasizes that diet is the main pillar in lifestyle medicine in children. She then explains her general workup for pediatric patients. She notes that pediatric ENT patients often have multiple complaints, so it is helpful to categorize each as chronic or acute. She always asks how many total ounces of milk the child consumes in a day, the type of milk, and the timing of dairy consumption. She has noticed that excess consumption of sugary beverages, yogurt products, and flavored milk have correlated with increased ENT complaints in children. However, Dr. Wei emphasizes the importance of educating parents about a diet of moderation instead of judging or shaming them. Dr. Wei notes that in teenagers, sleep hygiene is even more important and that eating is tied to emotions and mental states. She encourages pediatric ENTs to share previous patient stories and to be familiar with the American Academy of Pediatrics guidelines. Other techniques for family counseling include: prioritizing key changes for a short duration and giving specific action items. She also explains how she created a pilot study and discovered that increased sugar consumption correlated with increased inflammatory cytokines. Finally, she discusses her published books, blog posts, and online courses about the importance of lifestyle medicine in pediatric ENT. --- RESOURCES “A Healthier Wei” by Julie Wei https://www.drjuliewei.com/pages/a-healthier-wei Dr. Julie Wei’s Blog https://www.drjuliewei.com/blogs/news Dr. Julie Wei’s Online Courses https://drjuliewei.mykajabi.com/

In this episode of BackTable ENT, Dr. Gopi Shah discusses a lean approach to pediatric airway foreign body aspiration with Dr. Wolfgang Stehr, a pediatric surgeon and medical director of surgery at Presbyterian Healthcare in Albuquerque. --- SHOW NOTES First, the doctors discuss the typical presentation of a pediatric patient who has aspirated an object. They agree that the most common scenario is a toddler choking on a nut, but older kids can also be affected. Dr. Shah notes that although severe aspiration cases can result in respiratory distress, most patients often look fine upon arrival to the ER. For this reason, an experienced clinician should listen for whistling sounds from the bronchi or the lack of breath sounds. Because X-rays can fail to visualize the object, witnessed history of a child choking is very important to consider. Differential diagnoses include reactive airway disease, asthma, pneumonia, and a viral URI. Next, Dr. Stehr discusses how he implemented the lean process improvement system into the foreign body aspiration bronchoscopy procedure at his hospital. He was motivated to develop a more efficient process after realizing that the most difficult part about a bronchoscopy was putting together the equipment. The lean system is built on the principle that there needs to be a correct order for standardized steps in a procedure in order to reduce waste and train staff more efficiently. He used the “5 S’s” to organize the equipment in the ENT cart, which stands for: sort, set an order, shine, standardize, sustain. Additionally, he gives tips for physicians wanting to start their own quality improvement programs, such as including staff in decision making, having the most resistant stakeholder in the room first, prioritizing the case of patient safety, and inviting collaboration between different specialties when appropriate. He mentions that it is helpful to have a lean expert guide the quality improvement process in the beginning; eventually this third party consultant will train an internal employee to manage the lean process themselves. He also discusses the kaizen workshop, in which his team broke down a process, evaluated each step, and put it back together in a more efficient way. PDSA (Plan, Do, Study, Act) is another helpful framework he recommends. Finally, he discusses how he measured the efficacy of his lean intervention. He used surrogate measures of time and success, which included watching techs and nurses assemble bronchoscopy equipment while timing them and seeing how many drawers they had to open to gather all the materials. Although he had favorable results, he emphasizes the importance of always being open to new ideas for improvement.

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Amal Isaiah, a pediatric otolaryngologist at the University of Maryland, discuss how to apply to US residency programs as an international medical graduate (IMG) and the unique challenges applicants may face during the process. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/FnL1R4 --- SHOW NOTES First, Dr. Isaiah recaps his medical journey, which took him from India to the UK for a PhD, and then to the US for residency and fellowship. Then, he explains what IMG applicants can do to strengthen their applications before applying. He emphasizes the importance of making connections to the American programs through doing research work. These positions can be obtained through cold calling and emails, but he notes that there are also tenures and society fellowships available. Unfortunately, many of these positions are usually unpaid. Dr. Isaiah recommends that international medical students pursue postgraduate training in their home country and spend 5-6 years in the United States doing research before applying to US residency programs. There is a less common, alternative way to match into residency by first completing an unaccredited US fellowship program and then applying for residency. Dr. Shah and Dr. Isaiah also discuss board exams for IMGs, which include Step 1, Step 2, and Educational Commission for Foreign Medical Graduates (ECFMG) certifications. They agree that letters of recommendation and personal statements are important. Dr. Isaiah recommends that IMG applicants read US applicant essays and have their mentors look over their essays for language and grammar revisions. Finally, the doctors discuss the different types of visas that are needed for IMG residents and attendings (i.e.- H-1 visa, J-1 visa) and differences between visas, sponsorships, and green cards. He notes that the process of obtaining a visa has been made more challenging by the COVID-19 pandemic. --- RESOURCES ASPO Fellowships https://aspo.us/page/fellowshiplisting Dr. Isaiah’s LinkedIn Profile https://www.linkedin.com/in/amal-isaiah-a6a71b6/

In this episode of BackTable ENT, Dr. Gopi Shah, Dr. Ashley Agan, and Dr. Sarah Bowe discuss new developments in the ENT residency match process as well as advice for future applicants. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/aXEKIr --- SHOW NOTES First, the doctors explain new policies in the match process. In 2015, the merging of osteopathic and allopathic accreditation systems began, which led to a single accreditation system combining osteopathic and allopathic accreditation in 2021. In 2022, the USMLE Step 1 exam switched to a pass/fail system from a numerical scoring system. The doctors note that although Step 1 scores used to be an application filter, research has shown that there is no correlation between scores and success during residency. Dr. Bowe notes that many programs deemed it necessary to filter using Step 1 scores because residency applications take a long time to read through. Additionally, standardized test scores do correlate well with board passage rates. Dr. Agan mentions that programs may use Step 2 scores as a replacement for Step 1 scores, leading some applicants to feel conflicted about having a Step 2 score before submitting their ERAS application. However, there have not been set Step 2 metrics for filtering applicants yet. Next, the doctors discuss reading through applications from a program perspective. Dr. Bowe explains that bigger programs have bigger faculty, which means more application readers are available. Some programs will set unique filters to screen for IMG applicants or career goals. Then, she discusses the use of the new signaling program, an initiative that distributes applicants a certain number of tokens to indicate their programs of interest. Signaling can equalize the playing field for applicants who do not have a home ENT program or do not have the resources to do as many sub-internship and away rotations as they would like. Additionally, signaling may serve as a surrogate application cap for programs. Finally, the doctors explain other parts of the residency application, such as letters of recommendation, research, and gap years. Because almost every ENT applicant is listed as “above average” on the standardized application, Dr. Bowe emphasizes the importance of the narrative sections of letters. Additionally, many programs allow additional space on the application to let students explain more about their background and hardships. Dr. Bowe concedes that research is important on an application, but it depends on the resources of each applicant’s home institutions as well as their non-academic priorities, like part-time jobs. Additionally, in her opinion, a gap year to do research should only be taken if the applicant is aspiring to be a clinician scientist. Dr. Shah emphasizes the importance of taking a gap year because of personal interest, not for a stronger application. Finally, Dr. Agan speaks about differences between in-person and virtual interviews. There are cons of virtual interviews, such as interview hoarding and lack of interpersonal and environmental connection, but benefits include lowering expenses and environmental impact. --- RESOURCES Head Mirror Website https://www.headmirror.com/ National Otolaryngology Interest Group https://www.headmirror.com/noig ENT in a Nutshell Podcast: https://podcasts.apple.com/us/podcast/headmirrors-ent-in-a-nutshell/id1504305051

In this episode of BackTable ENT, Dr. Julie Wei brings Taymi Santiago, a human resources partner, about the process and benefits of taking a leave of absence. --- SHOW NOTES First, Santiago recounts why she chose a career in HR, which gave her the ability to support others. She explains various reasons for taking a leave of absence, such as personal illness or illness of loved one, maternity/paternity leave, bereavement, education, adoption/foster care, care of elderly parents, and many more. She notes that physicians often ask for a leave of absence when their situation is already dire and there are no other options. Dr. Wei adds that many physicians may feel guilty for feeling like they have abandoned their patients and burdening their colleagues. Next, Dr. Wei and Taymi discuss the basics of taking a leave of absence. Dr. Wei notes that HR may have negative connotations for physicians. However, Santiago explains that HR departments deal with behavioral issues and conflict management, but help with much more than just employee relations. Generally, a leave of absence is considered to be 12 weeks within 12 months that can be taken off in a continuous or fragmented pattern. They also discuss the various types of leaves that are available, such as short term leave, long term leave, and FMLA. One distinction Santiago makes is the difference between in-house versus third party leave management. For companies that outsource third parties to manage leave of absence paperwork, employees may miss out on company-specific benefits due to a lack of knowledge. For this reason, she recommends that physicians know the contact information of HR personnel at their own company. Dr. Wei and Santiago also emphasize the two most important aspects of a leave of absence, which are job protection and wage benefit replacements. Finally, they end the discussion by discussing the harmful consequences of not prioritizing physician wellness.

In this episode of BackTable ENT, Dr. Julie Wei discusses navigating disability insurance as a physician with Dr. Stephanie Pearson, a former OB/GYN who started her own personal insurance brokerage firm. --- SHOW NOTES First, Dr. Pearson shares about her struggle with disability. Early in her career, she suffered a traumatic injury that led to the development of a frozen shoulder and ended her clinical practice. Her group disability insurance did not cover work-related injuries, and she had to sue in order to receive her worker’s compensation insurance. She did not feel like she was properly educated about insurance policy and was promptly terminated from her OB/GYN job after her medical leave was over. Her emotional recovery was challenging, but she found support from her spouse, children, and dog. She eventually found her identity outside of her role as a physician, which helped ease her guilt of being a financial burden on her family. Her personal disability journey motivated her to co-found a personal insurance brokerage firm with an insurance broker. PearsonRavitz was started five and a half years ago and has nationwide clients, the majority of whom are medical professionals. She frequently gives online and in-person lectures about the importance of buying disability insurance to residents and new attendings. Dr. Wei agrees and compares working in a surgical subspecialty to physical labor, as repetitive motions may increase injury risk. Both doctors agree that standardized education for residents and medical students about disability insurance is needed. Some common myths that Dr. Pearson debunks the myths that group insurance benefits are adequate, healthy doctors do not need insurance coverage, and residents cannot afford disability insurance. Finally, the doctors end the episode by discussing unique health concerns of female surgeons, such as Infertility risk and delivery complications. --- RESOURCES PearsonRavitz https://pearsonravitz.com/