Fall 2019 - Soundings Newsletter

Soundings PUBLISHED IN THE INTEREST OF OUR MEMBERS AND THEIR PATIENTS

President’s Message Secondly, I would like to thank the Scientific Session Planning Committee, and especially the Program Chairs, Dr. Jessyka Lighthall and Dr. Colin Huntley, on another successful annual meeting in Hershey. We had a great multidisciplinary session on cutaneous malignancy, a discussion of wellness and the challenges of aging surgeons, as well as “chalk talks” on a variety of brief, high-impact topics relevant to many of our practices. As in the past, the oral abstract presentations and ever-popular resident Jeopardy session rounded out the second day.

Johnathan D. McGinn, MD, FACS PAO-HNS President

I look forward to our 2020

Fall is in full swing with gentler temperatures and beautiful colors. It is a great time to be in Pennsylvania. As always it is also a great time to be an Otolaryngologist and serve our patients in their needs for specialty medical and surgical care of the head and neck.

I am excited as I begin my term as president of the Pennsylvania Academy of Otolaryngology - Head & Neck Surgery to be able to lead the charge in advocacy for you and your patients.

beautiful Nemacolin Resort

Firstly, I would like to extend gratitude to Dr. Soliman on behalf of our Academy for his dedicated service as president over the last two years. His steadfast leadership and counsel have helped further the cause of our patients and the profession in Pennsylvania. His successes were numerous, but challenges do persist, and we will continue to fight the assaults from all directions to ensure high quality and safe care for our patients.

Annual Meeting at the This year Thomas Jefferson University is to be congratulated, having dominated the day with the Conchal Bowl award, as well as receiving both oral presentation awards and the second-place poster award. University of Pittsburgh Medical Center took the first-place poster award. The Second Annual Women in Otolaryngology Session was held, with Dr. Cecilia Schmalbach giving an excellent presentation on mentorship. We also were honored again by the attendance of Dr. James Denneny, AAO-HNS Executive Vice President, who was awarded the Helen Krause, MD Distinguished Service Award. Dr. Ahmed Soliman, Immediate Past President, delivered Dr. Thomas Kennedy a special recognition award for his service to the specialty and our state during his career. I look forward to our 2020 Annual Meeting at the beautiful Nemacolin Resort, and anticipate a great session under the leadership of our Program Chairs, Drs. Colin Huntley and Pamela Roehm.

Thirdly, I would like to update you on our ongoing efforts in advocacy. We continue to work closely with our national Academy and PAMED on key issues affecting our state. We recently partnered with the AAO-HNSF to write a letter of support for House Bill 1220, advocating for patient education regarding CMV infection and its role in hearing loss, with provision for early testing based on hearing loss or parental concern. Dr. Maurits Boon, our new Sleep Medicine Committee Chair, and Dr. Richard Ferraro, our Patient Advocacy Chair, have been engaged in efforts to ensure fair insurance coverage policies for hypoglossal nerve stimulation implants.

We also continue efforts to maintain our specialty’s presence on the Pennsylvania Speech and Audiology Board. Some legislative relief has been written regarding consent issues and discussion is ongoing regarding venue change concerns. We will keep you updated as these further develop.

We continue to engage our government relations firm, Milliron & Goodman, to keep us informed of key legislative issues impacting our patients and specialty, as well as supporting those groups on the Hill.

I also want to extend congratulations to Dr. Karen Rizzo on her election as Secretary of the American Academy of Otolaryngology - Head & Neck Surgery Board of Governors. Always a strong advocate for otolaryngologists and our patients, this new role as a BOG officer will allow her even greater opportunity to serve our specialty in this grassroots organization. The BOG continues to grow in the important role as liaison between local, state and national specialty societies and the Board of Directors of the AAO-HNSF. I encourage all PAO-HNS members to consider

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President’s Message Continued from page 1

attending the BOG Meeting May 1-3, 2020, The Westin Alexandria Old Town, Alexandria, VA. I think you would find it informative.

Finally, I wanted to thank you for entrusting me with this role in your state Academy. I look forward to hearing of your concerns and challenges and collaborating on solutions for the betterment of our patients and specialty.

Contents | Fall 2019 1 President’s Message 3 Board of Governors Update 4 Legislative Update 5 Top Physicians Under 40 8 Sleep Medicine 10 Pseudohypoacusis: An Underrecognized Condition 15 Auricular Pseudocyst

ANNUAL MEETING 2019 Exhibitors Hall

President Johnathan D. McGinn, MD, FACS Penn State Hershey Otolaryngology-Head & Neck Surgery 500 University Dr., Ste. 400 UPC, H091 Hershey, PA 17033-2360 President-Elect David M. Cognetti, MD, FACS Otolaryngology-Head & Neck Surgery 925 Chestnut St Fl 6 Philadelphia PA 19107-4204 Secretary-Treasurer Jessyka G. Lighthall, MD Penn State Hershey Otolaryngology-Head & Neck Surgery 500 University Dr., Ste. 400 UPC, H091 Hershey, PA 17033-2360 Administrative Office 777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 717-558-7750 ext. 1519 717-558-7841 (fax) Visit our website at www.otopa.org

Soundings accepts classified advertisements; however, there is no guarantee that they will be published. All submissions are subject to review. The advertisement should be of interest/pertain to otolaryngologists, their practice, and health care in Pennsylvania. Submissions that are selfpromotionalor commercial in nature will not be accepted. Publication of advertising does not imply endorsement of the products advertised or the statements contained in such advertising by Soundings or the PAO-HNS. The opinions expressed in this newsletter do not necessarily reflect the opinion of PAO-HNS.

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AAO-HNS Board of Governors Update exchange with Academy Governors and Legislative Representatives via phone conferences or webinars to foster society awareness and engagement was touted. The establishment of the Regional Representatives Program to help connect members and promote engagement within the regions and AAO-HNS was embraced.

Karen A. Rizzo, MD, FACS Governor The BOG held its annual meeting during the AAO-HNSF 2019 Annual Meeting & OTO Experience in New Orleans.

The importance of maintaining frequent communication and ongoing dialogue between the BOG and grassroot members was stressed. The #BOGENT has been adopted as a way to highlight specific efforts on Twitter. The importance of promoting frequent information

The AAO-HNSF hosted U.S. Senator Bill Cassidy, MD, R-LA, as a guest speaker at the Advocacy Leadership Breakfast.

He shared his thoughts on the growing debate surrounding surprise medical bills, drug pricing reforms and the need for increased transparency in our healthcare system. Our Academy also joined the Partner’s Coalition in sending a letter to the President supporting the removal of all non-tobacco-flavored e-cigarettes from the market. The AAO-HNS has signed a letter urging Congress to take action on Prior Authorization and expressed strong support for HR 3107 which improved seniors’ timely access to care. The Academy worked with PAO-

HNS in sending a letter of support to the Pennsylvania House’s Human Services Committee in support of CMV education and newborn screening.

The AAO-HNS asks for members to access the action alert on its Advocacy website, www.entadvocacy.org, and send letters to Congress to say “NO” to HR 4056/ SR 2446 that allows audiologists to be designated as “practitioners” and have direct access to Medicare beneficiaries without a physician referral.

The importance of maintaining and optimizing communication between the PAO-HNS and the AAO-HNS to stay informed of issues impacting our specialty remains vitally important. All are encouraged to stay engaged and consider contributing to the ENT PAC. The Spring BOG Leadership meeting will be held on May 1-3, 2020 in Alexandria, VA. Consider attending to be updated on national healthcare initiatives, networking and reconnecting with colleagues and earn CME credits.

ANNUAL MEETING 2019 Enjoying the picnic events.

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Legislative Update

In mid-September lawmakers from both the House and Senate chambers returned to Harrisburg for the fall legislative session.

The remaining days for the fall session schedule are listed below as well as the House schedule for spring 2020.

The following is an update on PAO-HNS priority areas.

E-cigarettes/vaping Earlier this session, Representative Kathy Rapp (R-Warren) introduced House Bill 97 which would amend the Crimes Code by adding “electronic nicotine delivery systems” (ENDS) to the sections that currently make it illegal to sell tobacco products to minors and, for students, to use tobacco products on school grounds. The penalties will be the same as the penalties that apply to the sale and use of tobacco products under current law. HB 97 passed the House unanimously and is currently in the Senate Judiciary Committee.

On the Senate side, Senator Mario Scavello (R-Monroe) introduced Senate Bill 473, which is similar to Rep. Rapp’s bill, however it increases the legal age to purchase tobacco products to 21 years of age. The bill passed the state Senate 43-6.

At this time, the bill has not been referred to a House committee.

Hospital Regulations At the time of this writing, the hospital regulations have not been made public.

During the Health Policy Board meeting on July 31st, Dr. Levine announced that a draft of the regulations was in the Governor’s office for review. She stated that the review process would take 30-60 days, after which time the regulations would be passed along to the Attorney General who will also have 30-60 days to review the draft. After that, we’d expect the proposed draft regulations to be published in the PA Bulletin for a 30-day public comment period.

2019 SENATE FALL SESSION SCHEDULE October

21, 22, 23, 28, 29, 30 November

18, 19, 20 December

16, 17, 18 2019 HOUSE FALL SESSION SCHEDULE October

21, 22, 23, 28, 29, 30 November

12, 13, 14, 18, 19, 20 December

9, 10, 11, 16, 17, 18 2020 HOUSE SPRING SESSION SCHEDULE January

7 (non-voting), 13, 14, 15, 21, 22 February

3, 4, 5 March

16, 17, 18, 23, 24, 25 April

6, 7, 8, 14, 15, 16 May

4, 5, 6, 11, 12, 13, 18, 19, 20

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The proposed draft regulations are over 500 pages, including preamble, proposed changes and analysis. The Department of Health is anticipating an approximately 18-month process; however, it is important to note that there is a two-year time clock on regulations. Should that two-year deadline pass without a final rulemaking, the department would have to start the regulatory process from the beginning.

Hearing Aid Dispensing Law We are also in the early stages of updating some portions of the Hearing Aid Dispensary Law. These updates will largely modernize the law, which has not been examined since 1998. In fact, some provisions directly conflict with the previously negotiated audiology licensure law, Act 106 of 2014. Stakeholder meetings are occurring on this potential re-write and no official language has been made public. We will keep you updated as things progress.

Grassroots Advocacy Last, but certainly not least, we’d like to remind you of the importance of forming a relationship with your local legislators.

If you have not yet contacted the legislators representing where you live, or where you practice, be sure to reach out and do so today! A strong grassroots network is critical to achieving success. If you aren’t sure who your lawmakers are, or if you aren’t sure how to reach them, please contact us at Milliron Goodman and we’ll make sure we get you connected to the right people.

Winners were nominated by colleagues and ultimately selected by a statewide committee of Pennsylvania Medical Society members.

To appear on the list, physicians must practice in Pennsylvania and be under the age of 40 on Dec. 31, 2019. The 42 physicians on the 2019 list represent 19 different medical specialties and live in 19 different cities. Photos of the recipients are available at https://www.pamedsoc.org/newsroom/ Top40. Three of the 42 physicians are PAO-HNS members.

Elizabeth Cottrill, MD, Philadelphia

Joshua Dunklebarger, MD, Chambersburg

Brian McGettigan, MD, Philadelphia

An otolaryngologist with Jefferson Health, Dr. Cottrill stands out for her leadership and her ability to inspire her colleagues. She is establishing herself as a leader in the treatment of complex thyroid diseases. Dr. Cottrill also serves as a role model and mentor for Jefferson’s medical students and residents. She has organized several Women in Otolaryngology events that brought together several universities in the Philadelphia region.

Dr. Dunklebarger is an otolaryngologist with Summit ENT and Hearing Services, part of WellSpan Health. He was named chairman of surgery for his health system in 2018 and serves on the Hospital Board of Directors. Dr. Dunklebarger has led Facebook Live educational live events for his organization. He is known in his community both for his clinical skill and for his willingness to go the extra mile for patients and colleagues.

Dr. McGettigan is an otolaryngologist with Jefferson Health. He has been a key part of his health system’s efforts to create a high quality and uniform health care delivery system in the Delaware Valley. Dr. McGettigan serves as a faculty member at Thomas Jefferson University’s Department of Otolaryngology-Head and Neck Surgery.

Congratulations!

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Advancements in Transcanal Endoscopic Ear Surgery Michael Jonathan Clark, MD Since Littmann perfected the otologic microscope in 1951, microscopic transcanal, endaural and post auricular approaches using the microscope have been the gold standard for otologic surgery.1 Publications evaluating the benefit of endoscopes to assist in examination of the ear canal and middle ear date back to the 1960s with the focus on providing a better visualization of the tympanic membrane and middle ear.2,3 Initially the endoscope was limited to evaluating retraction pockets, peeking through a tympanic membrane perforation or improving the evaluation in a diagnostic myringotomy. However, thinner ridged telescopic equipment combined with high definition surgical camera systems have been the catalyst for steady advancement in implementing this technology to develop minimally invasive techniques for surgical management of the middle ear. The increasing adoption of this endoscopic ear surgery (EES) has seen with it an increase in publications, presentations and training courses.3 As with any new technique, EES comes with a substantial learning curve, requiring one-handed techniques in order to hold the endoscope in the non-dominant hand as well as adapting to the loss of depth perception traditionally provided by the binocular microscope.

Even with a standard 3mm Hopkin’s rod, the most obvious advantage of EES is improved visibility compared to the microscope. As illustrated in Figure 1, the anatomic structures of the ear canal will obstruct the view with the microscope and only objects with a direct line of site can be clearly visualized.4,5 Improving access through wider incisions and drilling bone are often required with microscopic surgery, and certain locations including the sinus tympani and lateral epitympanum still may not be visualized completely with the microscope due to the inability to obtain a direct line of site. The endoscope can be placed much closer and angled to view around the anatomic structures, allowing clear lighting and visibility in the hypotympanum, epitympanum and sinus tympani. Generally, a 0 degree telescope

is sufficient as it has a wide field of view, however a 30 or 45 degree endoscope can improve visibility into the sinus tympani as well as into the antrum of the mastoid.6 A standard single-chip camera system is generally not considered sufficient due to “red-out� that occurs in confined areas with even minor amounts of bleeding. A 3CCD (triple charge-coupled device) camera provides better optics and is not prone to the distortion from bleeding in the field of view.6 Standard middle ear instrumentation will generally suffice for tympanoplasties, ossicular reconstruction and even stapedectomy; however, additional specialized curved instruments designed for accessing the epitympanum are now available to aid in cholesteatoma removal without the need for mastoidectomy.

Figure 1. Microscopic (A) and endoscopic (B, C) images of the middle ear.

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Many courses, often including cadaver labs, are offered throughout the country to help surgeons gain basic understanding and hands-on experience with the technique. It is generally recommended that a novice surgeon begin with endoscopic myringotomies with tube placement or simple underlay tympanoplasties in ideal patients with wide ear canals and normal anatomy before advancing to more challenging cases with cholesteatoma, inflammation, drainage or granulation tissue.6 Some surgeons consider raising the tympanomeatal flap as one of the more challenging techniques to learn.

Injecting the ear canal prior to surgical prep, use of cottonoid pledgets soaked in epinephrine (1:1000), and saline irrigation for obtaining hemostasis often help overcome the primary challenge of one handed surgery, as the non-dominant hand in microscopic surgery was almost always used for continuous suction to manage bleeding. Also, placing the patient in reverse trendelenburg position and maintaining good communication with the anesthesia team to closely monitor the patient’s blood pressure and run slightly hypotensive, if possible, will all aid in minimizing the bleeding as the flap is being raised. New instruments have been designed that combine suction into a round knife or flap knife, but these only provide limited suction to clear the dissection field, so it is still essential to minimize bleeding form the flap incision. Once access to the middle ear is obtained, the bleeding often becomes easier to manage with pledgets, and the tympanomeatal flap can be elevated off of the malleus to provide full visibility of the middle ear and attic. As a surgeon gains familiarity with EES techniques, he/she often find that the integrity of the tympanomeatal flap is improved compared to microscopic techniques.6 Little, if any bone removal is needed for visualization of the epitympanum, and often the sinus tympani can be completely visualized with a 0 degree telescope.

Sufficient graft material can be harvested from the tragus and the graft can be placed under the entire perforation with confidence, even in anterior perforations with the enhanced visualization of the endoscope. Recent publications have supported that ESS is not only less invasive, requires less removal of healthy tissue, shorter operative times, improved

cosmetic outcomes, but also has improved rate of closure of tympanic membrane perforations and similar hearing results.4 The greatest advantage of EES over microscopic techniques is the possibility of performing minimally invasive surgery for removal of cholesteatoma. It is obvious that the improved visibility provides a clear advantage in managing cholesteatoma confined to the middle ear and a post auricular incision can be readily avoided.

However, studies have also supported that EES provides better visibility of anterior epitympanic spaces, retrotympanum and protympanum over post auricular and transmastoid approaches with the microscope.7 Any cholesteatoma that can be clearly seen and removed with EES out of the epitympanum allows the surgeon to forgo a mastoidectomy for visualization of the antrum and epitympanum as often required with microscopic techniques.

A recent publication of a systematic review of the literature included seven studies reporting results on over 500 patients who underwent EES, with 57% of the surgery performed as an exclusive endoscopic transcanal procedure and the remaining 43% undergoing a combined approach requiring a mastoidectomy.

Evaluation of the results determined that using EES in part, if not the entire case reduced residual and/or recurrent disease to 9.3% which is considered less than generally reported for microscopic canal wall intact surgery of at least 20%.7 Often a mastoidectomy is required not for visualization, but because the disease extends beyond the reach of curved instruments that can be passed through the external canal in EES. If a mastoidectomy is required, it is specifically for the removal of disease that has entered into the mastoid, and not for visualization and removal of disease in the anterior epitympanum and/or sinus tympani.

The implementation of EES for stapedectomy remains and area of controversy as the microscopic visualization of the stapes is almost always obtained with drilling or curetting only a small amount of bone from the posterior superior ear canal. Some surgeons feel that the improved visualization obtained with EES does not justify the loss of two-handed techniques in the case of stapedectomy. However, a recent study did show that endoscopic techniques required less curetting or drilling of the

ear canal, had less post-operative pain and there was no difference in operative time, post-operative hearing results, or dizziness.5 It is important to stress that stapedectomy should only be attempted endoscopically by surgeons who have gained significant experience with EES techniques. Evidence does suggest that with experienced surgeons, the outcomes are as good as with microscopic techniques with possible decreased post-operative pain.

In conclusion, the endoscope allows significant improvement in visibility of the middle ear through smaller incisions.

Evidence from recent publications continue to show outcomes, including clearing disease in cholesteatoma, tympanic membrane closure and hearing outcomes equivalent, if not improved over microscopic surgery. Still, surgical procedures requiring mastoidectomy will continue to utilize the microscope and two-handed techniques, including labyrinthectomy, cochlear implantation, facial nerve decompression, and endolymphatic sac surgery. The future of otologic surgery will likely require expertise on both endoscopic and microscopic techniques, along with clinical judgement of when either technique will provide the best overall outcome for the patient.

References: 1. Mudry A. The history of the microscope for use in ear surgery. Am J Otol 2000;21(6)877-86.

2. Mer SB, Derbyshire AJ, Brushenko A, Pontarelli DA. Fiberoptic endotoscopes for examining the middle ear.

Archives of Otolaryngology 1967;85(4):387-93.

3. Lea J. General overview of endoscopic ear surgery: advantages and principles. ENT and Audiology News 2016;25(2):38-40.

4. Akyigit A, Sakallioglu O, Karlidag T. Endoscopic tympanoplasty. Journal of Otology 2017;12(2)62-67.

5. Kojima H, Komori M, Chikazawa S et al. Comparison between endoscopic and microscopic stapes surgery.

Laryngoscope 2014;124(1)266-71.

6. Mijovic T, Lea J. Training and Education in Endoscopic Ear Surgery. Current Otorhinolaryngology Reports 2015;3:193-9.

7. Presutti L. Gioacchini FM. Alicandri-Ciufelli M. et al. Results of endoscopic middle ear surgery for cholesteatoma treatment: a systematic review. Acta Otorhinolaryngol Ital. 2014;34(3):153-57.

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Sleep Medicine Sleep Disorders: When It’s Not Just OSA Suraj Kedarisetty, MD PGY4 Temple University Hospital Obstructive sleep apnea (OSA) is one of the most common medical conditions in America, with 6.4 million diagnoses per year in 2010.1 Continuous positive airway pressure (CPAP) is an effective treatment to improve sleep and is the initial treatment of choice. Otolaryngologists generally become involved in the care of patients with OSA for a surgical consultation, particularly when patients complain of CPAP intolerance. In addition, the causes of OSA are multifactorial and not purely anatomical.2 Due to this heterogeneity, there are a variety of possible surgical treatments. However, prior to surgical correction, the clinician must determine why the patient is CPAP intolerant. Many patients with OSA may have other comorbid sleep conditions, and this may underlie CPAP intolerance or inefficacy.3 While the patient may objectively score better on questionnaires or sleep study post CPAP use, the subjective feeling of sleepiness should clue the clinician to question the adequacy of treatment. There are a number of conditions which can lead to daytime sleepiness during CPAP use (Table 1). The most common cause of persistent sleepiness is inadequate CPAP treatment either due to improper titration or patient intolerance of CPAP. Titration involves assessing for adequate positive pressures, proper mask fit, adequate humidification, and assessment of overall comfort.4 Complaints of air leak, skin breakdown, excess noise and dry mouth can easily be addressed with appropriate troubleshooting. Causes of patient intolerance of CPAP include anxiety or phobia of the CPAP, which can be addressed with desensitization or psychotherapy. Finally, some patients may be reluctant to use the machine due to negative social connotations.5 This is especially important when considering surgeries that can reduce AHI without complete cure such as a tonsillectomy or UPPP, since the patient may still require CPAP use after surgery.

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Another common cause of persistent sleepiness is insufficient sleep duration.6 Generally, with CPAP use sleep efficiency is improved so the patient should feel more rested even with the same amount of sleep. However, some patients may be still have inadequate duration of sleep, which definitely cannot be addressed surgically.

Simple interventions such as a sleep diary and sleep hygiene discussion can assist in understanding a patient’s sleep schedule.7 Uncommonly, patients seeking further treatment for their OSA may actually be suffering from comorbid medical conditions complicating the symptoms. For example, periodic limb movement disorder (PLMD) and restless leg syndrome (RLS) are common comorbidities found in OSA patients. Many of these conditions are underdiagnosed because they cannot be adequately evaluated on a home study.

However, there is no direct evidence that patients with RLS or PLMS have reduced day time sleepiness, even if they are associated with arousals.8–10 Therefore, the impact of these conditions on OSA is still unclear. Still, it is worthwhile to consider assessment and treatment of symptomatic RLS. In contrast, patients with comorbid narcolepsy can have significant symptomatology. A hallmark symptom of narcolepsy is cataplexy, the sudden physical collapse generally triggered by a strong emotional response. Despite the clarity of these symptoms, Sansa,

et al reported a 24.8% prevalence of OSA in patients with narcolepsy, 30% of whom were initially diagnosed solely with OSA.11 Even in patients with cataplexy, the mean delay in diagnosis of narcolepsy was 4.1 years.12,13 Thus, when there is a high suspicion of narcolepsy, the clinician should question the patient about common narcolepsy symptoms such as cataplexy, sleep paralysis, and hypnagogic hallucinations.14 It is recommended to perform a complete sleep study and a mean sleep latency test (MSLT) to identify those patients with reduced sleep latency, suggestive of narcolepsy. This test should be performed while the patient is on CPAP.15 Another common disorder associated with OSA is depression. Up to 40% of patients with OSA have been treated for depression.16 Patients with OSA have more intense depressive symptoms.17 Excessive sleepiness in patients with OSA is worse in those who have depression.18 Medications with sedative effects such as benzodiazepines may contribute to OSA symptoms. There is evidence that CPAP treatment improves certain mood disorders.19,20 Finally, a patient’s subjective sleep quality is influenced by mood.21 When a patient has co-existing depressive symptoms, sleep surgery may be inadequate to improve symptomatology.

Obstructive sleep apnea is a heterogeneous disease. Most patients greatly benefit from CPAP treatment.

Table 1: Common Causes of Daytime Sleepiness Despite CPAP use in OSA patients CPAP mask tolerance issues

•Depression •Narcolepsy and idiopathic •Restless leg syndrome •Circadian rhythm wake disorders •Kleine-Levin syndrome

Insufficient sleep

• Poor sleep hygiene • Anxiety/phobia to trust doctor

Comorbid medical conditions

•Rhinitis •Leaks •Skin lesions •Conjunctivitis •Xerostomia Continued on page 9

Sleep Medicine However, not all who continue to have symptoms with CPAP or who do not tolerate CPAP will benefit from surgery.

Ruling out a number of factors ranging from incorrect mask size to comorbid medical conditions is critical in optimizing the impact of surgery on controlling this diverse disease.

References: 1. N amen AM, Chatterjee A, Huang KE, Feldman SR, Haponik EF. Recognition of sleep apnea is increasing analysis of trends in two large, representative databases of outpatient practice. Ann Am Thorac Soc. 2016;13(11):2027-2034. doi:10.1513/ AnnalsATS.201603-152OC 2. E ckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea: Identification of novel therapeutic targets. Am J Respir Crit Care Med. 2013;188(8):996-1004. doi:10.1164/ rccm.201303-0448OC 3. Santamaria J, Iranzo A, Ma Montserrat J, de Pablo J. Persistent sleepiness in CPAP treated obstructive sleep apnea patients: Evaluation and treatment. Sleep Med Rev. 2007;11(3):195-207. doi:10.1016/j.smrv.2007.02.005 4. B ureau MP, Sériès F. Comparison of two inlaboratory titration methods to determine effective pressure levels in patients with obstructive sleep apnoea. Thorax. 2000;55(9):741-745. doi:10.1136/thorax.55.9.741 5. Carberry JC, Amatoury J, Eckert DJ. Personalized Management Approach for Obstructive Sleep Apnea. Chest. 2017;(July):1-12. doi:10.1016/j. chest.2017.06.011 6. K ryger MH, Roth T (Tom), Dement WC. Principles and Practice of Sleep Medicine. Elsevier/Saunders; 2005.

7. Tachikawa R, Minami T, Matsumoto T, et al. Changes in Habitual Sleep Duration after Continuous Positive Airway Pressure for Obstructive Sleep Apnea. Ann Am Thorac Soc. 2017;14(6):986-993. doi:10.1513/ AnnalsATS.201610-816OC 8. C hervin RD. Periodic leg movements and sleepiness in patients evaluated for sleep-disordered breathing.

Am J Respir Crit Care Med. 2001;164(8 Pt 1):14541458. doi:10.1164/ajrccm.164.8.2011062 9. B liwise DL. Periodic Leg Movements in Sleep and Restless Legs Syndrome: Considerations in Geriatrics. Sleep Med Clin. 2006;1(2):263-271. doi:10.1016/j.jsmc.2006.04.005 10. M orisson F, Décary A, Petit D, Lavigne G, Malo J, Montplaisir J. Daytime sleepiness and EEG spectral analysis in apneic patients before and after treatment with continuous positive airway

pressure. Chest. 2001;119(1):45-52. doi:10.1378/ chest.119.1.45 11. Sansa G, Iranzo A, Santamaria J. Obstructive sleep apnea in narcolepsy. Sleep Med. 2010;11(1):9395. doi:10.1016/j.sleep.2009.02.009 12. T horpy MJ. Thorpy MJ (2012). Classification of Sleep Disorders. Neurotherapeutics. https://doi.org/10.1007/s13311-012-01456. Neurotherapeutics. 2012;9:687-701. doi:10.1007/s13311-012-0145-6 13. Hublin C, Partinen M, Kaprio J, Koskenvuo M, Guilleminault C. Epidemiology of narcolepsy.

Sleep. 1994;17(8 Suppl):S7-12. doi:10.1093/ sleep/17.suppl_8.s7 14. D auvilliers Y, Barateau L. Narcolepsy and Other Central Hypersomnias. Continuum (Minneap Minn). 2017;23(4, Sleep Neurology):989-1004. doi:10.1212/CON.0000000000000492 15. C hervin RD, Aldrich MS. Sleep onset REM periods during multiple sleep latency tests in patients evaluated for sleep apnea. Am J Respir Crit Care Med. 2000;161(2 Pt 1):426-431. doi:10.1164/ ajrccm.161.2.9905071 16. S chwartz DJ, Kohler WC, Karatinos G. Symptoms of depression in individuals with obstructive sleep apnea may be amenable to treatment with continuous positive airway pressure.

Chest. 2005;128(3):1304-1309. doi:10.1378/ chest.128.3.1304 17. Aikens JE, Mendelson WB. A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea.

Sleep. 1999;22(3):355-359. doi:10.1093/ sleep/22.3.355 18. B ixler EO, Vgontzas AN, Lin H-M, Calhoun SL, Vela-Bueno A, Kales A. Excessive daytime sleepiness in a general population sample: the role of sleep apnea, age, obesity, diabetes, and depression. J Clin Endocrinol Metab.

2005;90(8):4510-4515. doi:10.1210/jc.20050035 19. S ánchez AI, Buela-Casal G, Bermúdez MP, CasasMaldonado F. The effects of continuous positive air pressure treatment on anxiety and depression levels in apnea patients. Psychiatry Clin Neurosci.

2001;55(6):641-646. doi:10.1046/j.14401819.2001.00918.x 20. E ngleman HM, Cheshire KE, Deary IJ, Douglas NJ. Daytime sleepiness, cognitive performance and mood after continuous positive airway pressure for the sleep apnoea/hypopnoea syndrome. Thorax.

1993;48(9):911-914. doi:10.1136/thx.48.9.911 21. W ells RD, Day RC, Carney RM, Freedland KE, Duntley SP. Depression predicts self-reported sleep quality in patients with obstructive sleep apnea. Psychosom Med. 66(5):692-697. doi:10.1097/01.psy.0000140002.84288.e1

Benefits of a multi-disciplinary care team for the obstructive sleep apnea patient.

Maurits S. Boon, MD Associate Professor Residency Program Director Otolaryngology Head and Neck Surgery Thomas Jefferson University Hospital Obstructive sleep apnea (OSA) is a disease process linked to multiple medical comorbidities. While continuous positive airway pressure (CPAP) therapy remains a first line treatment for most patients with this condition, tolerance of this modality is limited. Many patients are unable or unwilling to utilize it to a degree that would limit the risk of comorbidities and provide symptomatic control. As a consequence, multiple alternative therapies have emerged in an effort to reduce disease burden and improve quality of life. Some of these alternative options include: oral appliance therapy, surgical modification of the airway, skeletal surgery, and upper airway stimulation. Other alternative management options are also being developed and evaluated.

OSA has a complex pathophysiology with multiple factors linked to the cause of disease. As a consequence, no isolated treatment can be expected to universally benefit all patients. With this in mind, patients would benefit from a multi-disciplinary team approach to optimize their care. Members of this multidisciplinary team would include: Sleep Medicine, Otolaryngology, Dental Sleep Medicine, Oral and Maxillofacial Surgery and weight loss specialists (including Bariatric Surgery).

The Otolaryngologist has a pivotal role in this team given their knowledge of upper airway anatomy and physiology and the unique ability to Continued on page 11 SOUNDINGS | Fall 2019

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Pseudohypoacusis: An Underrecognized Condition Benjamin Liba, MD Resident - Department of Otolaryngology – Head and Neck Surgery, Temple University School of Medicine Pamela C. Roehm, MD, PhD Department of Otolaryngology – Head and Neck Surgery, Temple University School of Medicine The inability to hear affects nearly 538 million people worldwide1 and can be caused by a number of disorders, including congenital hearing loss, acoustic trauma, infection, and aging. Nonorganic hearing loss is less frequently discussed and often underdiagnosed. This condition is known by a number of terms including pseudohypoacusis, psychogenic hearing loss, functional hearing loss, non-organic hearing loss, and exaggerated hearing loss, but there are subtle differences between these terms. Identifying individuals with non-organic hearing loss requires cooperation between physicians and audiologists and requires a holistic view of the patient.

Pseudohypoacusis results from psychogenic causes of hearing deficits or malingering/feigning. Psychogenic hearing loss has an underlying subconscious cause (hysteria or conversion disorder). These patients experience impaired hearing and truly believe the hearing loss is real. Patients who are malingering or feigning the hearing loss do not believe they have a hearing loss but feign it with varied skill. Malingering is motivated by financial or other/additional benefits which may be either real or perceived and is commonly associated with workmen’s compensation claims or insurance claims It is also more frequent in healthcare workers, who can sometimes be the most effective at feigning hearing loss.

Exaggerated hearing loss is seen in patients who have an underlying organic hearing loss and can be related to psychogenic causes or malingering which cause the patient’s measured audiographic thresholds to increase past the levels indicated by his/her underlying organic loss. Some cases of exaggerated hearing loss may also be the result of underlying societal or ethnic expectations and interpretations of their underlying organic hearing loss.

Reports of cases of psychogenic hearing loss are scarce. In 1965, Trier and Levy compared characteristics of veterans with organic hearing loss compared to those with functional hearing impairments. They found those with non-organic hearing loss had a lower average IQ and had a significantly lower annual income. In addition, those with functional hearing loss experienced more emotional disturbances, nervousness, submissiveness, and preoccupation with their hearing problems.

The authors concluded that the patients experienced general

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feelings of inadequacy and these beliefs led to an exaggeration of their impairments in order to obtain monetary compensation.2 More recently, Ban et al., reviewed seven patients examined in their institution over a ten-year period that experienced sudden-onset hearing loss thought to be due to psychogenic in origin. All of these patients suffered from a psychological condition such as attention deficit hyperactivity disorder, major depressive disorder, conversion disorder, and panic disorder. Importantly, after treatment with conservative measures including psychotherapy, six of these patients experienced complete recovery and one showed at least a partial improvement.3 Other case reports have been published but review only single patients and lack follow-up information.4,5 Typical behavioral characteristics of those feigning hearing loss are the exaggeration of behaviors and complaints that they associate with people who have hearing loss. This includes fixating on the lips of the speaker and turning their heads to help hear the person that is speaking. Their complaints will be vague and related to their hearing problems. These patients typically have lower educational levels.6 Up to 10-50% of deliberate feigning occurs in those seeking compensation.7 Typical examples of this can include patients involved in injury-related lawsuits, veterans seeking compensation and payment from the VA, and patients seeking workers compensation payments. In addition to monetary benefits, these patients may find other real or perceived benefits from their nonorganic hearing loss including special attention, preferential treatment/considerations, and support in a host of social and occupational life situations.

Typical behavioral characteristics of those feigning hearing loss are the exaggeration of behaviors and complaints that they associate with people who have hearing loss.

Audiometry is a key tool that can identify patients with nonorganic hearing loss. On pure tone audiometry these patients often respond with an internalized reference level or anchor with an idiosyncratic loudness level.8 Therefore, for these patients, they will not respond unless a certain stimulus level has been reached. This leads to linear appearing audiograms with an inverse relationship between the functional component of the hearing loss and the underlying true hearing level. Nearly two-thirds of inorganic hearing losses are bilateral.8,9 Bilaterality in these cases results from the relative ease of making similar false responses to audiometric signals in both ears.

These patients also believe that hearing losses should be bilateral.

Continued on page 11

Continued from page 10

A number of specific tests have been developed to aid in the identification of patient with non-organic hearing loss.9 A method that is easy and reliable is the comparison of speech reception threshold and pure tone average. A discrepancy of greater than 10 dB is indicative of nonorganic hearing loss.8–10 Objective evaluations of hearing can also be used to diagnosis nonorganic hearing loss.

Otoacoustic emissions (DPOAEs and TEOAEs) are rapidly performed in the clinic setting and can help identify true hearing thresholds for patients who have normal middle ear function and organic hearing losses no greater than 50 dB HL and are rapidly performed in the clinic setting. Brainstem auditory evoked potentials (also known as auditory brainstem responses) are useful for patients with underlying conductive and/or more severe sensorineural hearing losses.

Threshold ABR can be used to reliably fit hearing aids.

While hearing loss is a very common problem, unrecognized functional components may confound the patients’ presentation.

Accurately diagnosing patients with non-organic hearing loss not only saves resources but also ensures these patients are getting the help they require.

Benefits of a multi-disciplinary care team for the obstructive sleep apnea patient.

Continued from page 9

perform comprehensive examination of this area.

A multi-disciplinary team approach offers numerous benefits to the management of patients with OSA. Evaluation with a comprehensive upper airway examination allows for identification of potentially easily treatable causes of OSA. It also allows for discovery of anatomical characteristics that may make some treatment modalities less effective. Additionally, patients would receive comprehensive care in which they can be exposed to all options for management of their disease.

The multidisciplinary team can offer multimodality treatment that can be required for optimal disease control. Finally, patients are more likely to be engaged in their own treatment, which can limit the potential to be lost to follow up.

References: 1. S tevens G, Flaxman S, Brunskill E, Mascarenhas M, Mathers CD, Finucane M. Global and regional hearing impairment prevalence: an analysis of 42 studies in 29 countries. Eur J Public Health. 2013;23(1):146-152. doi:10.1093/eurpub/ckr176 2. T rier T, Levy R. Social and psychological characteristics of veterans with functional hearing loss. J Aud Res. 1965;5:241-255.

3. B an J-H, Jin SM. A clinical analysis of psychogenic sudden deafness. Otolaryngol Head Neck Surg. 2006;134(6):970-974. doi:10.1016/j.otohns.2005.11.045 4. M onsell EM, Herzon FS. Functional hearing loss presenting as sudden hearing loss: a case report. Am J Otol. 1984;5(5):407-410.

5. S adjadi R, Quigg M. Simultaneous nonepileptic spells and nonorganic hearing loss: A case of comorbid psychogenic symptoms. Epilepsy Behav case reports. 2014;2:46-48. doi:10.1016/j.ebcr.2013.12.005 6. M ahdavi ME, Mokari N, Amiri Z. Educational Level and Pseudohypacusis in MedicoLegal compensation Claims: A Retrospective Study. Arch Iran Med. 2011;14:58-60.

The model does exist in which patients who are intolerant of CPAP can be seen in a clinic setting in which all of the involved specialties will evaluate the patient in a single day and develop a consensus management plan. While this represents the ideal paradigm for treatment of this population, it is not always a feasible option at all centers. However, it is still possible to involve multiple specialists in a care team and pursue the best care for our patients.

7. Jerger J, Jerger S. Functional Hearing Disorder: Auditory Disorders. Austín, Tx PRO-ED. 1981:51-58.

8. C HAIKLIN JB, VENTRY IM, BARRETT LS, SKALBECK GA. Pure-tone threshold patterns observed in functional hearing loss. Laryngoscope, Sept 1959, Vol69, pp1165-79.

1959.

9. G elfand 1948-|author SA. Essentials of Audiology / Stanley A. Gelfand. Fourth edition.

New York, New York : Thieme, 2016.; 2016.

10. G elfand SA, Silman S. Functional components and resolved thresholds in patients with unilateral nonorganic hearing loss. Br J Audiol. 1993;27(1):29-34.

New Members Lauren G Bogdan, MD

Member In Training

Tiffany P Hwa, MD

Member In Training

Mattie R Rosi-Schumacher, MD

Member In Training

William L Valentino, MD

Member In Training

Jena Patel, BS

Member In Training

Sejal J Shah

Member In Training

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Patient Safety PA Patient Saf Advis 2017 Jun;14(2):80-83

Bridging the Gap between Work-as-Imagined and Work-as-Done Author Ellen S Deutsch, MD, MS, FACS, FAAP, CPPS Editor, Pennsylvania Patient Safety Advisory Medical Director, Pennsylvania Patient Safety Authority

Work-as-Imagined and Work-as-Done

To improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesizing information from a patient's history and physical examination or from a handoff; performing tests or procedures; administering medications; and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results. Sometimes this work does not unfold in the way that was anticipated. Perhaps the patient's condition is more complicated than usual, or perhaps a needed resource—a medication, a piece of equipment, available operating room time, or a consultant—is not readily available. Perhaps there is time pressure, or we encounter distractions and interruptions.

Healthcare providers often complete tasks that are necessary for patient care despite obstacles in their path, and without necessarily reporting, let alone fixing, those obstacles.

Efforts to improve healthcare work will not succeed without recognizing that there is a difference between a theoretical construct of "work-asimagined" and the reality of "work-as-done" (see Figure). Work-as-imagined is the illusory ideal state. Hollnagel describes work-as-imagined as what designers, managers, regulators, and authorities believe happens or should happen, which becomes the basis for design, training, and control. In contrast, work-as-done is what truly occurs and what people actually do during patient care.1 Figure. Facets of the Work Process

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Continued on page 13

Patient Safety: Bridging the Gap between Work-as-Imagined and Work-as-Done Continued from page 12

Although a complete and perfect understanding of work-as-done is a worthy goal, healthcare delivery is a complex adaptive system that is in constant evolution with fluid, dynamic changes.2-6 Complete understanding is an unattainable ideal. Work-as-imagined provides information based on conceptual processes; it can offer a valuable hypothetical construct of the work in question, and may be used to develop theoretical concepts and generalizable guidance. Work-as-imagined may not reflect actual conditions that impact patient care at the "sharp end," the point in patient care that directly impacts patients. However, exploring the gap between work-as-imagined and work-as-done does afford opportunities to look at work through a variety of lenses, each of which provides complementary information.

Each lens has attributes and limitations; a preliminary exploration of several potential lenses, such as "work-as-documented" and "work-as-observed," follows.

With the blossoming of computer science, discrete event simulation can be used to analyze patient flow, predict demands for services, and mathematically model the impact of interventions on patient care processes. Standardized parameters for process components can be manipulated to calculate the effect of increasing patient volume or restructuring patient flow processes (e.g., change the triage process, add an ultrasound machine). Discrete event simulation can facilitate analysis of nonlinear interactions between variables and their intermediary agents; this could be considered "work-as-abstracted."7 "Work-as-observed" occurs when care providers know they are being watched, whether informally by trainees or colleagues during patient care, or formally, such as during evaluations (e.g., certification examinations) or as participants in research. The well-known Hawthorne effect posits that participants modify their actions when they know they are being observed.8 As a consequence, the work that occurs during, for example, executive walkrounds, may not fully represent the work that occurs in normal situations.

Documentation, fundamentally linked to patient care activities, serves many masters. Documentation is used to communicate meaningful patient care information, support billing, and provide medicolegal information. The accuracy and completeness of "work-as-documented" may be impacted by the skills and memory of the person documenting, the ease or challenge of the documentation process, and the temporal distance between the patient care event and the opportunity to document. When a scribe is added to the documentation process, opportunities for incomplete understanding and miscommunication may arise. Understanding work-as-done by using administrative databases, chart audits, and trigger tools9-12 relies on work-as-documented.

Claims are written demands for compensation for medical injury, which may be submitted by patients and their families because they have been advised to sue; because they perceive physician dishonesty; because they seek information, resources for future medical costs, or revenge; or for other reasons.13,14 "Work-as-claimed" is a lagging indicator, often reflecting occurrences that are several years old.13,15 The relationship between medical malpractice events and medical malpractice claims is complicated and nonlinear.14 Some claims are without merit, whereas the majority of patients who sustain a medical injury as a result of negligence do not sue.13 Simulation uses manikins or other equipment to replicate patient care experiences, allowing healthcare workers to practice their skills without direct risk to patients.16 Simulations conducted in situ, in actual patient care settings, provide a way to study and improve patient care processes while concurrently enhancing both team and individual patient care skills.17 A limitless variety of patient care processes can be simulated. Simulations may range from simple tasks such as transporting a patient into a new patient care area or conducting a handoff, to complex tasks such as preparing to implement a new electronic health record module, implementing and maintaining a patient on extracorporeal membrane oxygenation (ECMO), activating a protocol for massive transfusion, or conducting a disaster drill.18-21 "Work-assimulated," including skilled debriefing, may come the closest to replicating work-as-done, particularly for uncommon events.22 Because healthcare delivery is a complex adaptive system, understanding work-as-done is a daunting task, and no single perspective will provide the whole truth. In an extensive review of the advantages and limitations of different methods used to monitor patient safety, Sun asserts, ". . .different methods for detecting patient safety problems overlap very little in the safety problems they detect. These methods complement each other and should be used in combination to provide a comprehensive safety picture of the health care organization."23 Recognizing the attributes and limitations of each patient safety lens can help facilities develop a more comprehensive and realistic understanding of work-as-done, which can then inform efforts to improve patient safety.

Notes 1. Hollnagel E. Prologue: Why do our expectations of how work should be done never correspond exactly to how work is done? In: Braithwaite J, Wears RL, Hollnagel E, editors. Resilient Health Care. Vol. 3. Reconciling work-as-imagined and work-as-done. Boca Raton (FL): CRC Press, Taylor & Francis Group; 2017. p. xvii-xxv.

2. Vincent C. Patient safety. 2nd ed. Boca Raton (FL): CRC Press; 2010. 432 p.

3. Dekker S. Drift into failure: from hunting broken components to understanding complex systems. Farnham (UK): Ashgate Publishing, Ltd.; 2012.

4. Deutsch ES. More than complicated, healthcare delivery is complex, adaptive, and evolving. Pa Patient Saf Advis. 2016 Mar;13(1):39-40. http://patientsafety.pa.gov/ADVISORIES/ Pages/201603_39.aspx.

5. G ell-Mann M. Complex adaptive systems. In: Cowan G, Pines D, Meltzer D, editors. Complexity: metaphors, models, and reality. Boston (MA): Addison-Wesley; 1994. p. 17-45.

6. Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001 Sep 15;323(7313):625-8. PMID: 11557716. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1121189/.

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7. Day TE, Al-Roubaie AR, Goldlust EJ. Decreased length of stay after addition of healthcare provider in emergency department triage: a comparison between computer-simulated and real-world interventions. Emerg Med J. 2013 Feb;30(2):134-8. Also available: http://dx.doi.org/10.1136/emermed-2012-201113. PMID: 22398851.

8. Sedgwick P, Greenwood N. Understanding the Hawthorne effect. BMJ. 2015 Sep 04;351:h4672. PMID: 26341898. http://www.bmj.com/content/351/bmj.h4672.long.

9. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011 Apr;30(4):581-9. PMID: 21471476.

10. Mattsson TO, Knudsen JL, Lauritsen J, Brixen K, Herrstedt J. Assessment of the global trigger tool to measure, monitor and evaluate patient safety in cancer patients: reliability concerns are raised. BMJ Qual Saf. 2013 Jul;22(7):571-9. Also available: http://dx.doi.org/10.1136/bmjqs-2012-001219. PMID: 23447657.

11. Murphy DR, Meyer AN, Bhise V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Computerized triggers of big data to detect delays in follow-up of chest imaging results. Chest. 2016 Sep;150(3):613-20. Also available: https://dx.doi.org/10.1016/j.chest.2016.05.001.

12. Westbrook JI, Li L, Lehnbom EC, Baysari MT, Braithwaite J, Burke R, Conn C, Day RO. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care. 2015 Feb;27(1):1-9. Also available: http://dx.doi.org/10.1093/ intqhc/mzu098. PMID: 25583702.

13. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, Puopolo AL, Brennan TA. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-33. Also available: http://dx.doi.org/10.1056/NEJMsa054479. PMID: 16687715.

14. Rothstein MA. Currents in contemporary bioethics. Health care reform and medical malpractice claims. J Law Med Ethics. 2010 Winter;38(4):871-4. Also available: http://dx.doi. org/10.1111/j.1748-720X.2010.00540.x. PMID: 21105950.

15. Kreidler M. 2016 Medical malpractice annual report. Olympia (WA): Washington State Office of the Insurance Commissioner; 2016 Sep 1. 86 p. Also available: https://www. insurance.wa.gov/about-oic/reports/commissioner-reports/documents/2016-med-mal-annual-report.pdf 16. Deutsch ES. Simulation in otolaryngology: smart dummies and more. Otolaryngol Head Neck Surg. 2011 Dec;145(6):899-903. Also available: http://dx.doi. org/10.1177/0194599811424862. PMID: 21965444.

17. Lockman JL, Ambardekar A, Deutsch ES. Chapter 2.2. Optimizing education with in situ simulation. In: Palaganas JC, Maxworthy JC, Epps CA, Mancini ME, editors. Defining excellence in simulation programs. Philadelphia (PA): Wolters Kluwer; 2015. p. 90-8.

18. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new healthcare teams and new facilities. Simul Healthc. 2011 Jun;6(3):125-33. Also available: http://dx.doi.org/10.1097/SIH.0b013e31820dff30. PMID: 21383646.

19. Patterson MD, Blike GT, Nadkarni VM. In situ simulation: challenges and results. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: new directions and alternative approaches. Vol. 3. Performance and tools. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008.

20. Patterson MD, Geis GL, LeMaster T, Wears RL. Impact of multidisciplinary simulation-based training on patient safety in a paediatric emergency department. BMJ Qual Saf. 2013 May;22(5):383-93. Also available: http://dx.doi.org/10.1136/bmjqs-2012-000951. PMID: 23258388.

21. Weintraub AY, Deutsch ES, Hales RL, Buchanan NA, Rock WL, Rehman MA. Using high-technology simulators to prepare anesthesia providers before implementation of a new electronic health record module: a technical report. Anesth Analg. 2017 Jun;124(6):1815-9. PMID: 28207594.

22. Patterson M, Deutsch ES, Jacobson L. Chapter 13: Closing the gap between work-as-imagined and work-as-done. In: Braithwaite J, Wears RL, Hollnagel E, editors. Resilient health care. Vol. 3. Reconciling work-as-imagined and work-as-done. Boca Raton (FL): CRC Press, Taylor & Francis Group; 2017. p. 143-52.

23. Sun F. Chapter 36: Monitoring patient safety problems. In: Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Evidence report/technology assessment no. 211, Agency for Healthcare Research and Quality. Evid Rep Technol Assess (Full Rep). 2013 Mar;(211):1-945. Also available: https://www.ncbi.nlm.nih.gov/books/NBK133411/#ch36.s9

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at http://patientsafety.pa.gov.

2020 Annual Scientific Meeting June 12-13•Nemocolin Woodlands Resort, Farmington, PA

14 SOUNDINGS | Fall 2019

Auricular Pseudocyst

Michael P. Ondik, MD Princeton Eye and Ear Co-Chair, PAO-HNS Facial Plastic & Reconstructive Surgery Committee Auricular pseudocyst is a benign swelling of the auricle that may, upon initial evaluation, appear similar to its counterpart, the auricular hematoma.

Unlike an auricular hematoma, an auricular pseudocyst rarely presents as a result of an acute traumatic event.

Typically, patients may describe minor repeated trauma such as rubbing their ears, wearing tight helmets, or lying on the affected side when sleeping.

On examination, the lesion will appear swollen and compressible and may or may not be tender. Any portion of the cartilaginous ear may be affected. There will rarely be any overlying ecchymosis.

The lesion is more common in males and is prevalent in the Chinese population.

Needle aspiration will reveal thin, strawcolored fluid (sometimes serosanguinous).

Incision and exploration of the cavity will show that the fluid is trapped between two leaflets of auricular cartilage. Histological examination will show there is no epithelial lining present within the cavity.

There are several theories on the origination of the pseudocyst. Some believe that the pseudocyst forms due to embryonic dysplasia of the cartilage leading to potential cystic spaces.

Others feel that the cysts form due to fragmentation of the cartilage due to repeated minor traumas.

Treatment is directed at removing the fluid and preventing accumulation which may

ultimately lead to permanent ear deformity.

The recurrence rate after treatment is typically much higher than auricular hematoma. Multiple techniques have been described and many feel that it is best to combine techniques. Reported techniques include simple needle aspiration, using a circular punch to provide a large drainage hole in the inferior aspect of the cavity, placement of bolsters, catheter drain placement with irrigation and excision of the anterior leaflet of cartilage (the rationale for removing the anterior leaflet of cartilage is that the fluid is being secreted from perichondrium present in the anterior wall).

Some authors also advocate using injectable agents including trichloroacetic acid, injection of intralesional steroids and intralesional injection of minocycline.

One should use caution in using repeated injections of steroids since it may lead to auricular deformity.

In summary, an auricular pseudocyst may appear similar to an auricular hematoma, but typically occurs without a strong history of antecedent trauma and without discoloration of the overlying skin.

The fluid is trapped between cartilage leaflets rather than a space between the perichondrium and cartilage. Recognizing this entity is important because successful treatment may require a more aggressive treatment course than auricular hematoma.

ANNUAL MEETING 2019 Award Winners

Dr. Soliman and Awardee Rep. Bryan Cutler

Dr. Soliman and Awardee Dr. James Denneny

Sources: Abdel Tawab HM, Tabook SMS. Incision and Drainage with Daily Irrigation for the Treatment of Auricular Pseudocyst. Int Arch Otorhinolaryngol. 2019 Apr;23(2):178-183

Dr. Soliman and Awardee Dr. Thomas Kennedy

Beutler BD, Cohen PR. Pseudocyst of the auricle in patients with movement disorders: report of two patients with ataxia-associated auricular pseudocysts. Dermatol Pract Concept. 2015 Oct 31;5(4):59-64.

Han A, Li LJ, Mirmirani P. Successful treatment of auricular pseudocyst using a surgical bolster: a case report and review of the literature. Cutis. 2006 Feb;77(2):102-4.

Shan Y, Xu J, Cai C, Wang S, Zhang H. Novel modified surgical treatment of auricular pseudocyst using plastic sheet compression. Otolaryngol Head Neck Surg. 2014 Dec;151(6):934-8

Dr. Soliman and Awardee Linda Carroll, PhD

SOUNDINGS | Fall 2019

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PRSRT STD US POSTAGE PAID HARRISBURG PA PERMIT NO 922 777 East Park Drive PO Box 8820 Harrisburg, PA 17105

AWARDS 2019 PAO-HNS Awards

ABSTRACT WINNERS

Community Service Citation

1st Place Oral The Honorable Bryan D. Cutler, JD, BS R.T.R Ms. Kelly Daniels Citation of Distinguished Service Sidney Kimmel Medical Linda M. Carroll, PhD College at Thomas Jefferson University Helen Krause, MD Distinguished Service Award A Computer-Learning James C. Denneny, III, MD Neural Network Algorithm for Service as President the Radiographic Assessment of Thyroid Nodules: A Pilot Study Ahmed M.S. Soliman, MD Award of Recognition 2nd Place Oral Thomas L. Kennedy, MD, FACS Chandala Chitguppi, MD Thomas Jefferson University Hospital JEOPARDY – CONCHAL BOWL Assessment of cranial Thomas Jefferson University Hospital base repair techniques •Brian Swendseid, MD in a validated cadaveric •Mark Chaskes, MD CPAP model

•Jared Goldfarb, MD

1st Place Poster Thomas Kaffenberger, MD University of Pittsburgh Medical Center Innervation of the Cricothyroid Muscle by the Recurrent Laryngeal Nerve and Implications for Clinical Practice 2nd Place Poster Ms. Kelly Daniels Sidney Kimmel Medical College at Thomas Jefferson University Impact of gender on upper airway stimulation outcomes.