Tackling Controversial Issues in Otolaryngology

Experts gave guidance on how to tackle four areas important to otolaryngologists and head and neck surgeons during a “controversies” session held during the Triological Society Combined Sections Meeting.

Congenital Aural Atresia

Bradley Kesser, MD, professor of otolaryngology-head and neck surgery at the University of Virginia in Charlottesville, discussed a controversial clinical question: whether bone conduction hearing devices (BCHDs) should be used in all children with unilateral congenital aural atresia (CAA). While these devices are crucial to support speech and language development in children with bilateral CAA, he said that the literature suggests they might not be necessary for all children with unilateral CAA.

A study in which Dr. Kesser was involved found that none of the 40 children with unilateral CAA repeated a grade in school, but families did seek out resources to help their children, including amplification, speech therapy, and independent education plans arranged with their school districts (Laryngoscope. 2013;123:2270-2275).

Dr. Kesser said his approach is never to discourage families from trying a BCHD, but they certainly shouldn’t be made to feel guilty for not having their children use one. “I tell parents: ‘We have enough battles to fight with our children—making your 5-year-old wear a bone conductor for eight hours a day doesn’t necessarily need to be one of [them],’” he said. But, he emphasized, it’s crucial to monitor academic progress, speech and language development, and hearing, and to put in place resources to support a child’s academic success.

Middle Turbinate and Headache

Ashutosh Kacker, MD, professor of clinical otolaryngology at Weill Cornell Medical College in New York, said that one of the most difficult issues involving the middle turbinate is whether or not surgical treatment can improve headache. “Not everyone believes in it, (and) there’s a lack of good quality studies,” he said.

There is some suggestion in the literature that surgical treatment of the concha bullosa yields better results than medical care (Eur Rev Med Pharmacol Sci. 2015;19:2327-2330).

In a study with the highest-quality evidence Dr. Kacker could find, researchers reported that surgical resection of contact points, including resection of the middle turbinate concha bullosa, had the best results for patients with Type 3 migraine (Plast Reconstr Surg. 2017;13:184-189). Unfortunately, he said, no predictors have been identified to help predict surgical success with regard to Type 3 migraine.

As a specialty, we must be proactive in preserving our relevance in a health system that would increasingly value our contributions to the health of an increasingly diverse population. The selection process should reflect the kind of resident we’re trying to attract. —Howard Francis, MD, MBA

Neck Dissection vs. Parotidectomy for Positive Sentinel Lymph Node

Carol Bradford, MD, executive vice dean for academic affairs at the University of Michigan Medical School in Ann Arbor, said that conversations with melanoma patients about neck dissection used to be simple: Neck dissection, parotidectomy, or both should be performed when a patient has a positive sentinel node; if not, the patient should be watched closely.

New data has given doctors and patients more to think about. The MSLT-II (Multicenter Selective Lymphadenectomy Trial II) assessed whether completion lymph node dissection gave a benefit compared to post-operative diligent ultrasound monitoring of the draining nodal basins in patients with a positive sentinel lymph node (N Engl J Med. 2017;376:2211-2222). Data from approximately 2,000 patients found no difference in three-year melanoma-specific survival between patients who were dissected and those who were only observed. But researchers also found that the rate of disease-free survival was higher in the dissection group, and that the cumulative incidence of non-sentinel nodal metastases was higher in the observation group.

“Somewhere between 10% and 20% of patients will have a positive non-sentinel node,” Dr. Bradford said. “We know that most of those patients ultimately will relapse in the nodal basin…. The question is, do you take that node out early or do you watch and wait and take it out later?”

Resident Selection

Howard Francis, MD, MBA, chief of head and neck surgery and communication sciences at Duke University in Durham, N.C., said that otolaryngology programs might want to reassess how they evaluate residency applicants, considering the decline in application numbers and evidence that the admission process might overemphasize cognitive ability at the expense of other important traits.

Dr. Francis said the process tends to be skewed toward good test-takers and those with higher socioeconomic backgrounds, leading to a perception of elitism, a less diverse medical specialty, and an even further decline in applications to otolaryngology residency programs due to medical students’ fear that they have little chance of acceptance. “As a specialty, we must be proactive in preserving our relevance in a health system that would increasingly value our contributions to the health of an increasingly diverse population,” he said. “The selection process should reflect the kind of resident we’re trying to attract.”

Traditional factors in choosing residents don’t always translate into quality residents, he said. Dr. Francis shared published data showing that once med school graduates hit USMLE scores of 200 to 220, there’s a high likelihood they’ll pass the boards. (Otolaryngol Head Neck Surg. 2017;156:985-990).

Upgrades to the selection process, such as structured behavior-based interviewing and interpersonal simulations, combined with less emphasis on test scores in initial application screening, could help reverse declines in number of applications and attract more students with important characteristics such as integrity and the ability to work in a team, Dr. Francis said. “What we should look at is broadening our selection criteria beyond purely academics,” he said. “I think that our U.S. medical graduates are generally very well-prepared and that we should make it clear to medical students and vice deans of education that our field is interested in selecting candidates based on a more holistic evaluation of cognitive and affective domains.”

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Tom Collins is a freelance medical writer based in Florida.