Severe shortages of iodinated contrast media used in computed tomography (CT), which peaked this spring due to a COVID-19-related shutdown of a GE Healthcare plant in Shanghai, China, have resolved based on the company’s recent announcement that the facility has returned to full production.
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September 2022Although several practitioners contacted by ENTtoday said they were fortunate in having steered clear of the shortages, even during their peak, they stressed that, given the unpredictable nature of the healthcare supply chain, it’s critically important to consider ways to effectively navigate future contrast shortfalls.
That unpredictability was underscored in a July 15, 2022, press release from GE Healthcare. Despite continuing to operate at full capacity, “we expect some ongoing reduced availability … as we continue to restabilize global supply,” the company noted. “We continue to keep our customers informed so they can plan accordingly.”
Clinical Community Effects
Marlan Hansen, MD, chair and professor of otolaryngology at University of Iowa Healthcare in Iowa City, said his center did not experience any shortages of contrasted CT scans. “It wasn’t just me personally; I queried our other head and neck surgeons, and none of them reported significant problems,” said Dr. Hansen. “We were very fortunate.”
The larger clinical community, however, was not unaffected. “Many hospitals in our area had a very difficult time getting access to CT scans because of the contrast shortage,” he noted. “They ended up sending a lot of their patients to us, and we would do the scans.”
Still, given the unsettled nature of the iodinated contrast supply chain, otolaryngologists should be considering when it may be appropriate to switch to alternative scanning modalities, Dr. Hansen said. Although he acknowledged that gadolinium-based contrast agents, which are used for magnetic resonance imaging (MRI), are most often cited in this context, he noted that there are several caveats.
“Could I use an MRI instead? Sure, in selected cases,” he said. “But for many of the skull base surgeries I perform, I need CTs to visualize the bony structures involved. If I’m trying to really nail down the type and extent of bony destruction present, such as mandible erosion, I wouldn’t want to be in a position of relying exclusively on MRI for that.”
MRI also faces some logistical hurdles. First and foremost, they take much longer to perform—between 20 and 90 minutes, versus about 15 minutes for a CT scan, Dr. Hansen noted. “If you have to funnel all of your contrasted scans onto an MR scanner, there’s going to be a logjam and you won’t be able to get all the necessary studies done.”
Patient preference is another factor that makes a switch to MRIs problematic. “For the MRI, patients are placed in a tight tube, and some can get claustrophobic, especially when the scan is focused around the head and neck region,” he added. “If it’s your arm or your knee, that’s one thing. But if it’s your head, some patients just won’t tolerate the loud banging of the MRI.”
Many hospitals in our area had a very difficult time getting access to CT scans because of the contrast shortage. They ended up sending a lot of their patients to us, and we would do the scans. —Marlan Hansen, MD
Making the best decisions on imaging during a contrast media shortage also depends on the type of tumors and surgical procedures involved. “We do a lot of surgery for benign tumors such as vestibular schwannomas, meningiomas, and glomus tumors,” Dr. Hansen said. “They can be locally aggressive, but they’re pretty slow growing and aren’t going to metastasize. Delaying a procedure for your preferred imaging modality is an option—even up to several months is workable.
“That’s certainly not the case for my colleagues in head and neck surgery who are dealing with malignancies,” he stressed. “They require interventions withing a few weeks of diagnosis, because soon something that was resectable may no longer be resectable, or a mass that’s early stage may rapidly progress to an advanced stage.”
In such cases, “time is of the essence, and contrast media shortages can really become difficult and more fraught to navigate,” he said.
When MRIs May Be Preferred
One such colleague, Nadia G. Mohyuddin, MD, an associate professor of clinical otolaryngology at the Houston Methodist Research Institute in Texas, agreed that timely access to scans is critical for head and neck cancer patients, who represent a large portion of her patient base. Fortunately, she noted, her practice was not affected by the iodinated contrast shortage.
“When we ordered them, we would sometimes get notices in our EMR [electronic medical record] saying that the contrast is in short supply,” she said. “But I never had a scenario where they eventually denied my request for an iodinated scan.”
Even if CT scans become scarce, Dr. Mohyuddin voiced fewer concerns than Dr. Hansen over the prospect of switching to MRIs. In fact, she noted that MRI is her preferred agent for certain types of pathology. “When I’m dealing with nasopharyngeal carcinomas, sinonasal malignancies, or tumors of the sinuses that have the potential to spread into the intracranial location, and also salivary gland tumors, MRI is my preferred imaging modality,” she said.
Dr. Mohyuddin does, however, share Dr. Hansen’s view that CT scans do have an edge in imaging certain bony tissues. In such cases, “CT scans may be a bit better at delineating frank cortical bone involvement or erosion,” she said. “But an MRI is helpful as well in this setting— for example, when we look at bone marrow enhancement. An MRI can complement and be synergistic with a CT scan, and in some cases may be superior to a CT scan for a particular type of disease pathology.”
There’s also the option of ordering a CT scan without contrast for certain procedures, which will still yield useful information on bony tissue involvement to guide surgery, Dr. Mohyuddin noted. “If, for example, you are concerned about blood supply or arterial circulation, where there may be vessels feeding a tumor, you could probably still identify that information with an MRI,” she said. “I think one can work around the restrictions of not having contrast when you’re looking at particular types of tissue interfaces.”
Are there instances where a CT scan backlog could negatively impact practice? “In isolated cases, perhaps,” Dr. Mohyuddin said. CT angiograms, she explained, require a significant amount of iodinated contrast media and are useful for visualizing arterial and venous circulation in head and neck tumors. “If you had to do a preoperative CT scan with an angiography, the contrast iodinated contrast is going to be more heavily utilized,” she said. “That could be a restriction in terms of obtaining an appropriate analysis of your patient.”
Ultrasound imaging is another alternative to CT scans that is of great value for identifying various head and neck masses, Dr. Mohyuddin said. “It has very little morbidity, is readily available, and is quite capable of visualizing lymph nodes and thyroid nodules, among other structures,” she stressed. “And, depending on your ultrasonographer and your radiologist, the ability to read ultrasounds should be more widely available than for other imaging modalities. If you’re in a bind due to contrast shortages, or you’re in an environment where you have limited resources, don’t leave ultrasound on the sidelines.”
Contrast Shortages and Otolaryngology Practices
Douglas D. Reh, MD, the director of clinical research at the Centers for Advanced ENT Care, LLC, with locations in Baltimore and Hunt Valley, Md., is another example of a practitioner who was able to successfully navigate the iodinated scan shortage. He also sees value in being ready for the next shortfall.
“We were very fortunate in never having any patient for whom we could not obtain a CT scan,” Dr. Reh told ENTtoday. “As per self-referral laws pertaining to private medical practices in Maryland, we cannot own scanning equipment. So, we farm out our scans to different radiology companies, and they were able to meet the needs of our practitioners and patients.”
Dr. Reh echoed the fact that, given the unpredictable nature of healthcare supply chain logistics, future shortages of iodinated contrast agents for CT scans may well occur. If that were to happen, questions of whether to delay procedures could come up.
“Fortunately, a lot of the CT scans we order are for noncritical procedures,” he said. “But if we had a patient who required an urgent CT scan, I’m very confident that, in most cases, we could switch to MRI and get enough diagnostic information to proceed.”
The other option would be to first order a noncontrast CT scan, review the information obtained regarding bony windows and other key structures, and then order an MRI with gadolinium. “This basically gives you all of the information you need for the case,” Dr. Reh said.
As for some practitioners’ preference for CT scans in skull base surgery, this has not been Dr. Reh’s experience. “When I was at Johns Hopkins, where we did lot of those types of surgeries,” he said, “I found that MRIs actually excel at showing soft tissue windows and demonstrate to a much better degree than CT scans the location of the tumor and its extent of invasion. It’s pretty much the gold standard for figuring out where the tumor’s going, and I think most skullbased surgeons feel that way.
“Having said that, however, like most people, surgeons are creatures of habit, and they like what they like when it comes to diagnostic and surgical tools,” he added. “I can see how shortages could be a negative in terms of choice and comfort.”
David Bronstein is a freelance medical writer based in New Jersey.
Beyond Contrast Shortages
The iodinated contrast media shortage isn’t the first time the supply chain for head and neck surgery procedures has broken down. Other medication and device shortages can cause headaches in otolaryngology offices.
For Marlan Hansen, MD, chair and professor of otolaryngology at University of Iowa Healthcare in Iowa City, all of these shortages underscore just how fragile the healthcare supply chain has been, particularly during the COVID-19 pandemic, when he saw first-hand the disruption caused by shortages of personal protective equipment and other key items. He also cited past shortages of external processors and batteries needed for optimal cochlear implant function.
Lidocaine with epinephrine. Nadia G. Mohyuddin, MD, an associate professor of clinical otolaryngology at the Houston Methodist Research Institute in Texas, said that shortages of 1% lidocaine with epinephrine have been a problem because it’s such a commonly used item for in-office otolaryngology procedures, including obtaining small biopsies in the mouth or tonsil region or removing skin lesions.
“Not having lidocaine with epinephrine is challenging,” she said. “You can still provide appropriate anesthetic to a patient by giving them a lidocaine injection, but you may not be able to get the degree of hemostasis or blood control as you would if it had epinephrine in it.
“Usually, these procedures aren’t very bloody to begin with, however” she added. “You can still most likely be able to obtain the biopsy that you need and do the procedure with just plain lidocaine if you had to.”
Douglas D. Reh, MD, the director of clinical research at the Centers for Advanced ENT Care, LLC, with locations in Baltimore and Hunt Valley, Md., also experienced shortages of lidocaine with epinephrine, which he and his colleagues responded to by conserving and rationing these topical anesthetic agents. “We had to be very conservative in how we used our injections,” he said, citing, as an example, storing unused syringes that were still sterile in refrigerators so that they could be saved for another patient.
(As of August 9, 2022, the American Society of Health-System Pharmacists Drug Shortages List [bit.ly/3R4O4ev] included 19 different products containing lidocaine with epinephrine, all manufactured either by Pfizer or Fresenius Kabi. Formulations included 0.5%, 1%, 1.5%, 2% strengths in 20-mL to 50-mL vials.)
Tympanostomy tubes. Dr. Reh added yet another shortage to the list: his preferred tympanostomy tubes for in-office use, which he found to be very frustrating. “I definitely had to do some juggling of supplies with my surgery center for several months, which could have easily caused some delays,” he said.
To prevent future shortages, should there be federal reserves of critical medical equipment and supplies, “like we have for vaccines, or beyond that, for grain and gas and other essentials?” Dr. Hansen asked. “Maybe that’s something that we as head and neck surgeons need to look at. Because what if the next shortage is of bone cement or some other key tool that we use to treat our patients surgically? That would really hit home hard. Like it or not, we do have an important stake in keeping the supply chain as intact as possible.”