President’s Message

Soundings FALL 2020

PUBLISHED IN THE INTEREST OF OUR MEMBERS AND THEIR PATIENTS

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

I very much hope this Fall Newsletter finds you and yours to be well. I know these are stressful times for many of us. We are dealing with new challenges in our return to practice during the COVID era and establishing some form of a normalcy in the care of our patients, all while our nation struggles with issues far beyond the current pandemic. While we realize that many hurdles exist in healing our nation medically and socially, we also should realize we have novel opportunities for substantive changes. PAOHNS will remain vigilant in seeking opportunities to support all our members and our patients.

Despite all the recent challenges faced, celebration and praise are in order for the Program Committee and Chairs of the PAOHNS Annual Scientific Meeting. As you know, the Annual Meeting was converted quite swiftly from the planned event at Nemacolin resort to a virtual format. Because of the hard work and tireless preparation of Drs. Huntley and Roehm, along with our PAMED staff of Ms. Jessica Winger and Ms. Ariel Jones, the meeting was a great success. I received a lot of unsolicited positive feedback on how smooth the meeting flowed, and the content provided despite the challenges of not being in-person. While I hope we all get to see one another in Hershey next summer, I also feel confident we can provide high-quality, impactful CME in the virtual format, if necessary. A lot of great information was shared by our presenters and panel members. We even had a little bit of fun - Drs. Purdy and Gniady, along with the help of Dr. Cognetti, created an engaging virtual resident trivia event. The PENNedy Twins team (Dr. Will Kennedy and Dr. Ravi Shah) from University of Pennsylvania triumphed over their peers to take home the coveted Conchal Bowl along with a monetary award. The scientific abstracts and posters were strong again this year, with awardees from Thomas Jefferson University, Penn State, and University of Pittsburgh. Congratulations to all.

I also feel confident we can

provide high-quality, impactful CME in the virtual format

While COVID pandemic has dominated the landscape in the legislature, the important issues of preauthorization, surprise patient billing, and other important issues have not gone away, but may have been delayed. However, other topics like telemedicine, scope of practice, and access to PPE remain very important to our membership. PAOHNS continues to support efforts to direct these topics in a direction that is best for our patients and our membership.

As I prepare my President’s Message, I typically look back through prior Soundings to gain some ideas of how to best convey our society’s successes and future goals. While reviewing the Fall 2017 issue, I found an article by our incoming President, Dr. David Cognetti, discussing telemedicine in otolaryngology. In the piece, he discusses his institution’s successes and challenges at that time in creating a telehealth program. In 2017, I had viewed telemedicine as a tool to provide care to those in remote locations without access to a specialist. In retrospect, I applaud this team’s prescient insights into the value of telemedicine for care of those far less remote. Recently, we have been separated from our patients not necessarily by the issues of hundreds of miles in distance, but instead by the needs for social distancing, protection of the vulnerable, and even the protection of our staff and ourselves. Yet patients need our help, and telemedicine may serve a role in providing that care in many circumstances. That is why PAOHNS continues to support, along with PAMED, the extension of telemedicine options, along with fair reimbursement, beyond the limits of Governor Wolf’s emergency declaration. Challenges do exist however, as the recently submitted bills supporting continued telemedicine efforts were passed in both the House and Senate, but vetoed by the Governor related to prohibitions in the bill related to telemedicine and abortion. While new legislation is not expected this year, we will support efforts to reintroduce such in next session.

PPE availability has been a challenge for many otolaryngologists in recent months, especially given our uniquely vulnerable practice based on personal proximity to patients’ mucosal surfaces and instrumentation of the airway. While some hospitals have fared reasonably well through PPE conservation, PPE reprocessing, and broader COVID testing capacity, community practices have sometimes struggled. Governor Wolf had asked the PEMA to prioritize PPE stockpiles for hospitals and health systems.

We have supported PAMED’s ongoing efforts to request the Governor release needed PPE to independent practices, especially given a potential second wave of COVID occurs this fall.

During the state of emergency, many practice restrictions were temporarily lifted to maintain Pennsylvanians’ access to care, reduce burdens on first-line providers, and permit alternative models of care delivery. Unfortunately, some groups have made efforts to use these wellintended efforts to erode the scope of practice, established to insure a safe physician-led health care team. HB2779 has been introduced to extend the supervision waiver for advanced practice clinicians for one year beyond the end of Governor’s Wolf’s state of emergency. While I understand no PA hospital needed to waive this requirement even at the peak of the pandemic, the suspension of written agreements, record review by physicians, and prescribing outside of formulary for APC’s represents an unnecessary and potentially dangerous change for our patients. This bill is currently being opposed by PAMED and members of the Specialty Leadership Cabinet, and we will continue to monitor any concerning trends in support.

While we have weathered the first wave of COVID and successful held our first virtual meeting, we know that challenges will continue to arise and PAOHNS will be there to assist our membership and their patients in meeting those issues. In that light, you should expect to receive an invitation to a membership survey as we enter the fall to gauge satisfaction with what we are doing and seeking input from members as to what we may do to further support our specialty in the state. We look forward to hearing your perspectives and suggestions for the future.

Thank you for the honor to serve as your Society’s President and please reach out with concerns and issues.

Sincerely, Johnathan D. McGinn, MD 1 President’s Message 3 Dysphonia & Vocal Fold Necrosis 4 BOG Update 7 Tongue Ties 9 Standardization Pro and Con

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 selfpromotional or 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.

Dysphonia & Vocal Fold Necrosis in Patients Treated with Anti-VEGF Chemotherapeutic Agents

Anita Sulibhavi, MD Senthuran Tharmalingam, MD, MSc Liane McCarroll, MS, CCC-SLP/L Ahmed M.S. Soliman, MD

First purified and cloned in 1989, vascular endothelial growth factor (VEGF) is an important signaling molecule critical for vascular survival, angiogenesis, endothelial migration, and permeability.1,2 It is part of the system which restores oxygen supplies to tissues when blood circulation is inadequate by promoting new blood vessel formation. Tumors need oxygen to survive and at first, they are able to obtain enough oxygen by co-opting the surrounding vasculature. However, when a tumor becomes too large to be sufficiently supplied by the existing vasculature, an “angiogenic switch” is turned on, VEGF is produced in the tumor cells thereby creating its own vasculature for an oxygen supply. These properties make it a convenient target for anti-tumor medications which work by blocking the process of tumor angiogenesis.

Several anti VEGF medications are currently available for the treatment of advanced gastrointestinal, lung, renal, brain, thyroid and gynecological malignancies. They include bevacizumab, apatinib, cabozantinib, pazopanib, ramucirumab, Sorafenib, sunitinib, vandetanib, and ziv-aflibercept Unfortunately, it is impossible to direct the effects of these agents to specific sites when they are administered systemically.1,2 The larynx contains a high concentration of VEGF receptors making its microvasculature particularly sensitive to the action of VEGF inhibitors.3,4 Although, the effect of VEGF inhibition has not been directly studied in the larynx, Baffert et al, demonstrated a 19% decrease in tracheal capillaries at 7 days and a 30% decrease at 21 days after VEGF inhibition using a murine model. Subsequent regrowth of capillaries was noted following cessation of treatment.5

Common side effects of VEGF inhibitors are primarily gastrointestinal and include dry mouth, loss of appetite, nausea, vomiting and diarrhea. Vocal fold necrosis is a rare side effect of VEGF inhibitors with only 2 reported cases in the literature.3,4 We have seen two additional cases of vocal cord necrosis after bevacizumab use at our institution. Although, it is difficult to predict which patients will develop dysphonia, women may be at greater risk due to their thinner lamina propria.3 Both previously reported patients of vocal fold necrosis following bevacizumab and our two patients have been women.

The onset of symptoms after initiation of bevacizumab is variable. Both previously reported cases had symptom onset approximately 3 weeks after starting therapy. Our patients however developed symptoms at one and two years after starting bevacizumab. The fact that both previously reported cases were on a combination regimen of bevacizumab plus another chemotherapeutic agent, may have enhanced the anti-VEGF effect and resulted in earlier injury to the vocal folds.3,4 This demonstrates the broad range of time within which this side effects can manifest and that many additional factors may influence this timing.

Treatment for the vocal fold necrosis has thus far consisted of cessation of bevacizumab. Voice symptoms may be reversible as early as one to two weeks after discontinuation.3 Of the two previously reported cases; only one patient had recovery of their voice at the time of the report. The other patient did not discontinue the bevacizumab and remained dysphonic 6 weeks after initial evaluation.3,4 Both of our patients had improvement of their stroboscopic exam and voice quality after bevacizumab cessation, although one had a slow improvement while the other had nearcomplete resolution of symptoms at two months. As dysphonia is not life threatening, it is important to weigh the risks of treatment cessation. As anti-VEGF medications are being more widely use, it is important for otolaryngologists to be aware of this potential complication.

References: 1. Dvorak H, F, Detmar M, Claffey K, P, Nagy J, A, van de Water L, Senger D, R: Vascular Permeability Factor/

Vascular Endothelial Growth Factor: An Important

Mediator of Angiogenesis in Malignancy and

Inflammation. Int Arch Allergy Immunol 1995;107:233235. doi: 10.1159/000236988

2. Kazazi-Hyseni F, Beijnen JH, Schellens JH.

Bevacizumab. Oncologist. 2010;15(8):819–825. doi:10.1634/theoncologist.2009-0317

3. Caruso AM, Meyer TK, Allen CT. Hoarseness After

Metastatic Colon Cancer Treatment. JAMA Otolaryngol

Head Neck Surg. 2014;140(9):881–882. doi:10.1001/ jamaoto.2014.1766

4. Hartl DM, Bahleda R, Hollebecque A, Bosq J,

Massard C, Soria JC. Bevacizumab-induced laryngeal necrosis. Annals of Oncology. 2011;23(1):276-278. doi:10.1093/annonc/mdr515

5. F. Baffert, T. Le, B. Sennino, et al. Cellular changes in normal blood capillaries undergoing regression after inhibition of VEGF signaling. Am J Physiol Heart Circ

Physiol. 2006;290:H547-H559.