Fall 2021 Soundings, the Newsletter of PAO-HNS

Soundings FALL 2021

PUBLISHED IN THE INTEREST OF OUR MEMBERS AND THEIR PATIENTS

President’s Message

David Cognetti, MD, FACS PAO-HNS President Welcome to Fall Soundings! Fall has always been one of my favorite times of the year in Pennsylvania and I hope all are enjoying the beauty of the change of seasons. I am excited to start my term as the President of the Pennsylvania Academy of Otolaryngology (PAO) – Head and Neck Surgery. It seems like just yesterday that I attended my first PAO annual meeting as a resident. I am grateful for the impact that PAO has had on my professional development, and I am proud of the work that our academy does to serve our patients and members.

I am thrilled to be joined by Dr. Jessyka Lighthall, President-elect and Dr. Colin Huntley, Secretary/Treasurer, in carrying the great tradition of our academy forward.

A special thank you is in order for Dr. Jonathan McGinn, immediate Past President, for his leadership and service these past 2 years. It has been an eventful 2 years, and Dr. McGinn skillfully and stoically guided us through the challenges of the COVID-19 pandemic.

This included the rapid conversion to a

virtual annual meeting in 2020 and a highly successful virtual annual meeting in 2021. In addition, Dr. McGinn led a reassessment of our organization’s association management group. After considering proposals from several high-quality management groups, we were pleased to extend our relationship with Total Excellence in Association Management (TEAM), a division of the Pennsylvania Medical Society. The renegotiated contract with PAMED TEAM led by Dr. McGinn, has positioned PAO well for the future. I am grateful for the partnership and assistance of Ariel Jones and Lauren Martini, of TEAM, in my new position.

Our Annual Meeting is always a highlight of PAO and this year did not disappoint.

Our annual meeting is always a highlight of PAO and this year did not disappoint.

Special thank you to Program CoChairs, Drs. Pamela Roehm and Andrew McCall, for leading the successful virtual event. Attendance was robust, with representation from private practices and academic institutions from across the state. Dr. Carol Bradford, President of the American Academy of Otolaryngology —Head and Neck Surgery and Dean of the College of Medicine at the Ohio State University, gave the Women in Otolaryngology keynote address. Her talk titled “Put On Your Own Oxygen Mask Before Helping Others” was inspiring and provided strategies to address burnout and other challenges to physician wellness. Congratulations to the resident team from University of Pittsburgh Medical Center (UPMC), on the Conchal Bowl

award for winning the Jeopardy session.

Congratulations to Kelly Daniels, MD from UPMC and Max Hennessey, MD from Penn State for winning first and second place in the Oral Presentations. PAO also recognizes this year’s well-deserving awardees. The Community Service Citation Award was awarded to the Honorable Kerry A. Benninghoff and the Distinguished Service Award was given to Tamara L. Wasserman-Wincko, M.S. The Helen Krause, MD Distinguished Service Award was awarded to Dr. Jonathan McGinn.

We are all greatly looking forward to returning to an in person meeting in Hershey on June 18-19, 2022!

Advocacy efforts for our members and patients continue with our new Government Relations partner through our PAMED TEAM relationship. Deborah Shoemaker, our lobbyist, worked with members of PAO to craft a letter demanding that insurance companies and medical equipment vendors provide remediation for our patients on CPAP facing challenges due to the Phillips Respironics recall. We continue to work closely with AAO-HNS and PAMED to address key issues affecting our state. Please see Deborah’s update in this issue and consider contributing to our PAC. A major initiative of this year is to enhance our academy’s committee structure to increase involvement and engagement of new and existing members across the state.

This idea was hatched by Dr. McGinn and I am thrilled to carry it forward because of the impact that the PAO had on me in my early career. We hope to inspire more active participation amonst members from trainees through retirees and would welcome all interested in being involved.

More information on how to volunteer for Continued on page 2

President’s Message Continued from page 1

committee positions will follow in the coming months.

In closing, I am grateful to be entrusted with the role of President of this great academy and I am excited for what our future holds.

Otolaryngology is a special field because of our innovative and caring physicians and our diverse and grateful patients. Pennsylvania is a special place to be an Otolaryngologist because of the dedication and effort of all of you. Please do not hesitate to reach out with any suggestions for how the PAO can further enhance the care of our patients and continue the advancement of our specialty.

Contents | Fall 2021 1 President’s Message 3 Dorsal Preservation Rhinoplasty 4 BOG Update 5 New Board Members 6 Legislative Update 8 Safety: What Went Right—What Went Wrong 10 PAO Annual Meeting

Thank you David Cognetti, MD, FACS PAO-HNS President

President David M. Cognetti, MD, FACS Otolaryngology-Head & Neck Surgery Thomas Jefferson University 925 Chestnut St Fl 6 Philadelphia PA 19107-4204 President-Elect Jessyka G. Lighthall, MD Penn State Hershey Otolaryngology-Head & Neck Surgery 500 University Dr., Ste. 400 UPC, H091 Hershey, PA 17033-2360 Secretary-Treasurer Colin T Huntley MD Otolaryngology-Head & Neck Surgery Thomas Jefferson University 925 Chestnut St Fl 6 Philadelphia, PA 19107-4204 Administrative Office 400 Winding Creek Blvd.

Mechanicsburg, PA 17050-1885 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 self-promotional 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.

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Diltiazem as a novel therapy for a chronic cough subtype Keith R. Conti, MD Ronak Modi, MD Aaron Jaworek, MD Introduction Despite adherence to guidelines and initiating appropriate treatment algorithms, 46% of patients with chronic cough evaluated in secondary care settings continued to have an “unexplained” cough,1 suggesting the need for a more thorough understanding of underlying mechanisms and treatment options.

Case Report The patient is a 72-year-old woman who presented to the tertiary referral laryngology office with a past medical history of exercise induced asthma, environmental allergies, and traumatic brain injury (TBI) 4 years prior. She had a persistent cough that started with upper respiratory tract infection nine months after her TBI. She completed antibiotics with resolution of all symptoms except for the cough. Social history was significant for a remote history of cigarette smoking until quitting 45 years ago.

The cough was described as mostly dry, occurring daily, and worse with talking, when sitting in her car, and when getting out of bed in the morning. It was not worse after meals, with exertion, with cold air, or strong odors. She denied dyspnea and dysphagia except for occasional effortful swallows. She denied heartburn, chest pain, and regurgitation. She reported occasional sensations of mucous and post-nasal drip without throat clearing, globus, or sore throat. She had been evaluated previously by two pulmonologists, an allergist, and another laryngologist.

Prior therapeutic trials with minimal or no benefit included over-the-counter cough suppressants, gabapentin 600mg twice daily, lansoprazole 60mg before breakfast, oral antihistamines (first and second generation), intranasal antihistamine, intranasal corticosteroid, ipratropium nasal spray, and corticosteroid/albuterol inhalers.

Prednisone was helpful, however, the cough would return once discontinued.

Pantoprazole 40mg before breakfast with ranitidine 300mg at bedtime and a low acid diet had resulted in decreased reflux symptom index from 27 to 18, but the cough did not improve.

Comprehensive head and neck examination with strobovideolaryngoscopy and laryngeal sensory testing revealed a reflux finding score of 11 (positive score > 11), mild right vocal fold paresis, and slightly diminished laryngeal adductor reflex responses bilaterally. Additional diagnostic workup was normal including chest x-ray, labs (thyroid stimulating hormone, free T4, anti-nuclear antibody, rheumatoid factor, mycoplasma titer, gluten sensitivity panel, and lyme titer), fractional exhaled nitric oxide, and esophagogastroduodenoscopy (EGD) with biopsies. Cough and breathing retraining therapy by a speech-language pathologist fellowship trained in voice was pursued which provided some relief with cough.

Twenty-four hour multichannel intraluminal impedance with dual pH sensors and esophageal high-resolution manometry (HRM)

were performed while taking pantoprazole 40 mg before breakfast and ranitidine 300 mg at bedtime. The impedance test showed 42 reflux events with 12 acid (pH< 4) events, and three events of laryngopharyngeal reflux. Ten out of the 33 reported coughs were preceded by reflux with a symptom index of 30% (positive if >50%), and a symptom association probability of 100% (positive if >95%). Hypercontractile esophagus (HE) was noted on HRM with an elevated distal contractile integral (DCI) in five of 10 swallows. A DCI >8000 mmHg·sec·cm is considered elevated with HE defined as two or more swallows having elevated DCI. The average integrated relaxation pressure (IRP) was within normal range, making achalasia unlikely. She was started on diltiazem 60 mg three times daily by gastroenterology to treat HE. At follow up, she reported >50% improvement in her cough since starting diltiazem. She stated that she was no longer coughing during the day or from triggers like sitting in her car. Her satisfaction with improvement in cough severity and normal EGD resulted in a decrease in acid suppression therapy to ranitidine 150mg at bedtime with sustained benefit.

On the left is high resolution esophageal manometry (HRM) for one out of ten swallows prior to diltiazem pharmacotherapy. The color corresponds to amount of pressure, in mmHg, in each of the four contractile segments: upper esophageal sphincter (UES) (1st segment), esophageal body (2nd and 3rd segments), and lower esophageal sphincter (LES) (4th segment). On the right a corresponding line plot depicting pressure, in mmHg, versus time, in seconds.

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Diltiazem as a novel therapy for a chronic cough subtype Continued from page 3

Discussion Diltiazem is a non-dihydropyridine (nonDHP) calcium channel blocker (CCB) that affects both vascular smooth muscle and cardiac muscle function, and it has been shown to be an effective treatment for certain cardiovascular diseases. Typically, CCBs are avoided in patients with reflux to prevent worsening of reflux symptoms. Its effect on esophageal motility and lower esophageal sphincter (LES) pressure have been recognized for some time.2 One study showed that DHP CCBs were associated with a 2.7-fold increase in reflux symptoms compared to non-DHP CCBs.3 Moreover, onset of new reflux symptoms and symptom exacerbation occurred least with diltiazem.

We present, to our knowledge, the first report of chronic cough with HE treated with the CCB diltiazem. Historically, CCBs have been implicated in worsening reflux disease by decreasing LES tone. As a result, chronic cough due to reflux can be exacerbated with CCB use. In cases when chronic cough is accompanied by HE confirmed on HRM, a trial of diltiazem may be considered as a therapeutic option with the least potential for reflux symptom exacerbation.

Reference List 1. Pavord ID, Chung KF. Management of chronic cough. Lancet.

2008;371(9621):1375-1384.

2. Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation.

Gastroenterology. 1982;83(5):963-969.

3. Hughes J, Lockhart J, Joyce A. Do calcium antagonists contribute to gastro-oesophageal reflux disease and concomitant noncardiac chest pain? Br J Clin Pharmacol. 2007;64(1):83-89.

WELCOME! New Members Sarah Benyo Keith Conti Cecilia Freeman Paul Johnson

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Angela Powell Jacqueline Tucker Aykut Unsal

Case Report: Juvenile Nasopharyngeal Angiofibroma and a Call for Communication Keith R. Conti, MD, Jameson M. Petrochko MD2, Jeffrey C. Bedrosian, MD, Jarrod A. Keeler, MD Introduction Understanding and management of the juvenile nasopharyngeal angiofibroma (JNA) has expanded over the past two decades. The classic presentation of JNA is a triad of epistaxis, unilateral nasal obstruction, and a nasopharyngeal mass1. Most cases of epistaxis are appropriately managed without specialist referral; however, certain symptom constellations require further investigation.

Most cases of epistaxis are due to local inflammation, infection, or trauma2-3.

Epistaxis that is recurrent, severe, refractory, and posterior in origin merits otolaryngology referral, as would any physical exam findings suggestive of a mass or other structural lesion2-3.

Case Report We describe the case of a patient, NE, who presented with a JNA at the age of 17 with no significant past medical history or tobacco use. His family history is significant only for lymphoma in his mother. He initially presented to the St. Luke’s University Hospital Emergency Department in August 2017 with a 1-month history of nasal/sinus congestion, frequent epistaxis, and bloody postnasal drip that was not relieved with oral acetaminophen/phenylephrine. He was treated for environmental allergies with loratadine, cetirizine, and intravenous dexamethasone in the ED and discharged with instructions to use over the counter nasal fluticasone and follow up with otolaryngology as an outpatient.

Nasal endoscopy revealed enlarged left middle turbinate with complete obstruction of left choanae, floor of nose, and narrowing of right choanae.

Computer tomograph of the soft tissue of the neck with contrast showed an intensely enhancing mass arising within the posterior aspect of the left nasal cavity and nasopharynx with expansion of the left pterygopalatine fossa, bony erosion and destruction of the posterior wall of the maxillary sinus, inferior wall of the sphenoid sinus, and superior aspect of the pterygoid plate without intracranial extension (Figure 1 A, B). These findings were suggestive of JNA. A magnetic resonance image (MRI) of the face with and without gadolinium enhancement was performed and supported the diagnosis of JNA (Figure 1 C, D).

The patient underwent pre-operative embolization of the ipsilateral facial, sphenopalatine, and internal maxillary arteries supplying the tumor. Surgery was performed the next day using image guidance and a two-surgeon team. Significant bleeding was encountered from the pterygoid venous plexus. Estimated blood loss was 2000 mL and a total of four units of packed red blood cells and two units of fresh frozen plasma were transfused intraoperatively.

NE was sent to the intensive care unit and was extubated the following morning. He was discharged in good condition on POD three with no neurological deficits. The pathology

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Case Report: Juvenile Nasopharyngeal Angiofibroma and a Call for Communication Continued from page 5

report confirmed nasopharyngeal angiofibroma. He is 18 months postsurgery without complications or signs of recurrence.

Discussion Diagnosis of rare entities such as this will depend on thorough history and physical examination and consideration of a broad differential. After the initial examination, partnering with our subspecialty colleagues becomes imperative for ongoing patient discussion and education. In our case, the patient was referred to otolaryngology as a precaution with low initial clinical suspicion for JNA. Communication requires participation by all parties; therefore, subspecialists must welcome patients sent as a precaution. Once a diagnosis is confirmed, successful management will depend upon the ability between providers to coordinate and optimize

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an individualized treatment plan to reduce operative blood loss and minimize the chances of recurrence.

The mean time from initial symptom(s) to diagnosis has been estimated to be 14 months, a significant amount of time for the rapidly evolving adolescent4. The mental, physical, and social impact of 14 months of potentially embarrassing symptoms and uncertainty cannot be understated. The diagnosis of a tumor, although benign, is likely to add stress at an often-insecure age.

In conclusion, JNA is a diagnostic challenge that requires scrutinization of a complete history and physical examination to determine when further investigation of epistaxis is warranted. The position and nature of the tumor as well as the literature suggest that the optimal method for management requires an interdisciplinary approach.

Reference List 1. Martins MBB, de Lima FVF, Mendonça CA, de Jesus EPF, Santos ACG, Barreto VMP, et al.

Nasopharyngeal angiofibroma: Our experience and literature review.

Int Arch Otorhinolaryngol. 2013 Jan;17(1):14–9.

2. M cInerny TK, Adam HM, Campbell DE, DeWitt TG, Foy JM, Kamat DM. American Academy of Pediatrics textbook of pediatric care. 2nd ed.

Washington: American Academy Of Pediatrics; 2017.

3. Shaw KN, Bachur RG. Fleisher & Ludwigs textbook of pediatric emergency medicine. 7th ed.

Philadelphia: Wolters Kluwer; 2016.

4. Paris

J, Guelfucci B, Moulin G, Zanaret M, Triglia JM. Diagnosis and treatment of juvenile nasopharyngeal angiofibroma.

Eur Arch Otorhinolaryngol. 2001 Mar;258(3):120–4.

To Hack or Not to Hack?

Neerav Goyal, MD, MPH; Ellen S Deutsch, MD, MS On behalf of the PAO-HNS Patient Safety Committee

Introduction A hack is a "simple and clever tip or technique for accomplishing some familiar task more easily and efficiently."1 In healthcare, we often use the term "workaround," to describe actions that bypass standard processes in order to solve problems in the moment. The intent of a workaround is to achieve a healthcare delivery goal more readily or efficiently by circumventing real or perceived workflow obstacles.2 We discuss the advantages and disadvantages of workarounds and conclude with areas of agreement.

PRO

CON

No matter how carefully we plan our work each day, it is likely that we will have to make adjustments as the day proceeds. A resource that we need may be unavailable: equipment may be broken, supplies may have run out, staff may be committed other tasks. Or each of those resources may be available and functioning well, but there are just too few of them. Because the need to provide care for our patients never stops, we frequently figure out ways to bypass system constraints - we develop workarounds that accomplish patient care despite system limitations.

Workarounds, or methods which circumvent established processes, can lead to significant patient safety concerns.

Standardized processes designed to support efficient systems can sometimes impose barriers to day-to-day efficiency or the ability of an individual in the health system to complete their work. It is easy in these situations to identify a workaround that allows for more efficient care delivery in the immediate setting, however this may also create hazards. In 2018, ECRI Institute listed workarounds among the top 10 patient safety concerns for healthcare organizations.9

The need for workarounds is most evident during a crisis, such as a mass casualty incident, in which providers and institutions are unable to adhere to conventional standards of care3 and improvisation is needed.4,5 Investigation of responses to mass casualty incidents, such as the Beirut Port explosion in 2020 and the Formosa Fun Coast Dust Explosion in Taiwan in 2015, revealed that modifications of standard processes were implemented by administrators, patient care teams, and individual clinicians.4,6 Examples of ad hoc adaptations included using non-traditional spaces for patient care, simplifying documentation processes, spontaneously reorganizing clinical teams, and “liberating” supplies from other patient care units.4,6 Workarounds are ubiquitous but less visible in daily work when there is no crisis but there are still persistent pressures to optimize efficiency and minimize workload7 despite poorly performing work systems.8 In fact, healthcare workers are often so good at workarounds that the magnitude of underlying system problems remains hidden.8

One example of the problems that workarounds can create relates to patient flow through a health system for appointments, referrals, and diagnostic tests. Many of us in our day-to-day work strive to maximize patient satisfaction, and in the setting of a diagnosis necessitating urgent care, try our best to get patients treated quickly. We may call other offices directly, “phone a friend,” or use other backchannels to get the earliest possible appointment. While this achieves the immediate goal for the patient, by not using an established process, the inefficiency of that process is never identified on a systems level. Instead of developing and implementing a standardized process to address urgent consults or orders, the use of workarounds will make the system appear to be functioning effectively and will force the continued use of the workaround as opposed to stimulating an improvement in the standardized process. Attempts to improve efficiency can also be taken to an extreme. A 2019 NYT article reported that nurses were hiding medications on their units because the pharmacy was taking too long to deliver medications needed by patients.10 As an isolated example, Continued on page 8

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To Hack or Not to Hack?

Continued from page 7

In an example of a workaround leading to an improved process, the “brief operative note” necessary in the Post-Anesthesia Care Unit (PACU), and the completed formal operative note for the same routine procedure were combined into one document. With the use of electronic health record capabilities, both the brief and the formal operative notes could be completed and available when the patient arrived in the PACU. This provided all the necessary and required information in an easy-to-read format and completed procedural documentation requirements more quickly than previous processes while eliminating duplication of documentation elements. However, initially this workaround conflicted with organizational policy which described two required documents. To the organization’s credit, the value of the workaround was appreciated, and policies were changed to legitimize this improved process.

the patient safety implications of this situation are clear. However, this example also speaks to the missed opportunity to improve the systemic process by which pharmacy was delivering medications to inpatients.

Healthcare technology workarounds are plentiful and also can create hazards. In response to complex login passwords, users may post their password alongside their computer, leading to the potential for a significant data breach. In response to IV pumps with built in “smart technology” which malfunctions or is difficult to program, care teams may bypass the ostensible safety features instead of improving the programming or reporting the malfunction.

In all of these situations, workarounds are a way to accomplish work when “work as done” does not achieve the efficiency or functionality of “work as imagined” for designed processes.

However, continuing to use a workaround camouflages problematic processes. If leadership is unaware of shortcomings, they won’t allocate resources to fix the problems.

Agreement Workarounds should be viewed as learning opportunities. In one workaround analysis, it was discovered that nurses were unable to use the mandated barcode medication administration system correctly because of a lack of internet connectivity in some patient care areas.11 No amount of “retraining” the nurses would have corrected that underlying problem but studying the workaround and identifying and mitigating a technologic limitation contributed to a more effective remedy. Some workarounds bring to light system shortcomings, others provide potential system improvements. Simulations that replicate patient care processes,12 and interviews conducted with respect for local expertise are among the methods that can be used to discover, develop, and test system improvements. Crucially, the surfacing and studying of workarounds can provide valuable information about how to improve patient care processes.

References: 1. Merriam-Webster. (n.d.). Life hack. In Merriam-Webster.com dictionary. Accessed 4 October 2021, from https://www.merriam-webster.com/dictionary/life%20hack 2. Deutsch ES. Workarounds: Trash or Treasure? Pa Patient Saf Advis 2017 Sep;14(3).

3. Brous E. Crisis Standards of Care. Am J Nurs 2021 Jul 1;121(7):51-54. doi: 10.1097/01.NAJ.0000758504.14938.01.

4. Hallal A, Andraos R, Saad GA, Boyajian T, Hoballah J. Mass casualty management during a pandemic surge: The American University of Beirut Medical Center experience. Semin Vasc Surg.

2021 Jun;34(2):51-59. PMID: 34144748 doi: 10.1053/j.semvascsurg.2021.04.005. Epub 2021 May 25.

5. Vincent C, Amalberti R. Safer Healthcare: Strategies for the Real World. 2016. New York, NY: SpringerOpen 6. Chuang S, Woods DD, Ting Hsieh-Wei. Cook RI, Hsu J-C. Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion. Disaster Med Public Health Prep. 2020 Aug;14(4):467-476. PMID: 31439072 doi: 10.1017/dmp.2019.69. Epub 2019 Aug 23.

7. Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Quality & safety in health care. 2005;14:130-4.

8. Tucker AL. Workarounds and resiliency on the front lines of health care. Rockville (MD): Agency for Healthcare Research and Quality; 2009 Aug. 6 p.

9. Top 10 Patient Safety Concerns for Healthcare Organizations 2018. https://www.ecri.org/EmailResources/PSRQ/Top10/2018_PSTop10_ExecutiveBrief.pdf accessed 4 October2021.

10. Brown T. The American Medical System is One Giant Workaround. https://www.nytimes.com/2019/09/05/opinion/hospital-workaround-health-care.html accessed 4 October2021 11. Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. Near-Miss Event Analysis Enhances the Barcode Medication Administration Process. Pa Patient Saf Advis 2017 Dec;14(4).

12. S tone K. Exploring Workarounds: The Role of Simulation to Build Resilience. In Comprehensive Healthcare Simulation: Improving Healthcare Systems. Eds: Deutsch ES, Perry SJ, Gurnaney HG. Springer 2021

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Evaluation of Water Absorbent Polymer Beads as a Head and Neck Foreign Body in Children Harleen Sethi, DO; Brigitte Wilkens; Pamela Roehm, MD, PhD Superabsorbent polymer (SAP) beads were developed for agricultural use for the purposes of water retention in soil and their use has subsequently been diversified. Since the advent of their use in children’s toys, including sensory tables for children, SAP beads have been identified as potential ingested and inhaled foreign bodies. Two case reports have identified these objects as external auditory canal foreign bodies.

Following removal of SAP beads from 3 patients within the past year in the Pediatric Otolaryngology clinic, we studied the physical characteristics of these foreign bodies and compared these measurements to sizes of the external auditory canal and nasal airway in children and adults.

Physical changes in SAP bead dimensions were measured through time in Photoshop after a) saturating bead with water or b) after withdrawal of bead from water. All measurements were duplicated in 3-6 beads through multiple trials of beads which had been sorted by coloration (clear, pink, or purple). Unhydrated SAP beads (Orbeez) were hydrated with water. Measurements of bead size were performed at regular timed intervals Figure 1. Hydration of SAP beads

Bead sizes plateaued at 360 minutes Figure 2. Time Course of Hydration

Plot of average bead diameter after hydration. Bead sizes plateaued at 360 minutes. following hydration. Maximum size of hydrated beads was significantly larger for pink and clear v. purple beads. Maximum hydrated sizes of all beads were significantly larger than average adult external auditory canal width (0.24-0.92 cm) and the average adult nasal cavity width (0.3-0.7 cm).

Fully hydrated beads were removed from water and bead size was measured at regular timed intervals. Plot shows average bead diameter over all repetitions. Bead sizes began to significantly decrease at 6 hours and arrived at dehydrated widths at 24 hours.

Figure 3. Dehydration of SAP Beads

Bead sizes increased dramatically after hydration. Beads shown prior to addition to water (0’), at 6 hours (360’) and at 24 hours (1440’) after hydration.

In our study, SAP beads rapidly increase in size in solution reaching sizes larger than the average adult external auditory canal width (0.24-0.92 cm) and larger than most adult nasal airway widths (inferior turbinate to nasal septum, = 0.30.7 cm) within minutes of hydration. SAP beads decrease in size very gradually over time after removal from hydrating fluids. Review of the medical literature revealed 3 patients who had SAP bead foreign bodies in the head and neck, all within the ear. All patients had resulting tympanic membrane perforations and 2 had ossicular erosion and one had profound hearing loss and profound auditory and vestibular loss due to otic capsule erosion from the SAP bead.

The damage to otologic structures was attributed to attempted removal with irrigation and otologic drops. Thus, removal of these expansile objects in the head and neck should be performed in an expedited fashion with blunt instrumentation or suction rather than with irrigation.

References 1. Sterling, M., Murnick, J., & Mudd, P. (2016). Destructive Otologic foreign body: dangers of the expanding bead.

JAMA Otolaryngology–Head & Neck Surgery, 142(9), 919-920.

2. Ramgopal, S., Ramprasad, V. H., Manole, M. D., & Maguire, R. C. (2019). Expansile superabsorbent polymer ball foreign body in the ear.

The Journal of emergency medicine, 56(6), e115-e117.

Plot of average bead diameter after removal from solution.

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Fluorescence-guided Surgery: an overview and an institutional experience Emma De Ravin, BS Karthik Rajasekaran, MD Jason G Newman, MD Despite improvements in other surgical subspecialties, positive margin rates on final pathology in head and neck oncologic procedures remain high (up to 30%).1 Negative margin status is associated with improved survival and progression-free survival, and is the single most important prognosticator in head and neck cancer.2 As a result, head and neck oncologic surgeons are beginning to explore novel fluorescence-guided surgery (FGS) techniques to improve margin clearance rates and reduce iatrogenic neurovascular injury. FGS is the process of injecting patients with fluorescent contrast agents that target and highlight a tissue of interest, i.e., a tumor, blood vessel, or nerve bundle.

When struck with a specific excitation wavelength, these probes emit near-infrared (NIR) light visible using specialized imaging systems, enabling realtime intraoperative nerve visualization, tumor localization, and tumor margin delineation.

The last 10 years have seen remarkable progress in optical imaging techniques via novel fluorophore development, NIR camera advancement, and clinical trials. Currently, as far as we know, four NIR contrast agents are being studied in head and neck cancer: indocyanine green (ICG), Cyanine 5.5 (Cy5.5), IRDye800CW, and zw800-1.3 ICG is a non-targeted fluorophore that is widely used for multiple non margin-enhancing procedures and has been applied to intraoperative angiography, oncologic procedures, sentinel lymph node resection, and hepatic function testing.4 Unlike ICG, both IRDye800CW and zw800

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are conjugated with other molecules to increase their specificity and improve tumor targeting: while IRDye800 is often conjugated with chemotherapeutic agents such as anti-epidermal growth factor receptor (EGFR) monoclonal antibodies (panitumumab, cetuximab), zw800 has been conjugated to cyclo-[Arg-GlyAsp], a drug that binds to tumor surface antigens.3,5 There are multiple ongoing clinical trials at our institution working to advance intraoperative molecular imaging techniques across numerous specialties.6 However, these techniques are still in their infancy—as of yet, of the above fluorescent contrast agents, only ICG is FDA-approved for biomedical purposes and thus remains the most widely used fluorophore in head and neck surgery.

Our group previously demonstrated that NIR imaging of high-dose ICG injected 24 hours preoperatively, a novel technique called Second Window ICG (SWIG), could be used for intraoperative identification of head and neck lesions and regional metastasis: ICG has an 86% and 100% sensitivity in primary head and neck cancers and metastatic lymph nodes, respectively.7 In a small proof of concept case series of six patients, we recently demonstrated the efficacy of ICG imaging during transoral robotic surgery. Furthermore, in two of the six cases, NIR imaging was able to identify occult neoplasm that was not otherwise visible under white light, indicating that intraoperative NIR imaging may be useful in the surgical management of head and neck carcinoma of an unknown primary (unpublished data, August 2021). We are currently performing immunohistochemistry studies on fixed surgical tissue specimens to further understand the localization of ICG on the tissue and cellular level.

Though SWIG has demonstrated some promise in head and neck squamous cell

carcinoma (HNSCC), one limitation of ICG is that it has no molecular targeting abilities, and instead relies on the enhanced permeability and retention effect, which stipulates that ICG accumulates within neoplasms due to disrupted intratumoral vasculature and lymphatic drainage.8 We are currently also participating in a clinical trial for HNSCC investigating ONM-100 (OncoNano Medicine, Southlake, TX), a drug that applies ICG in a novel configuration, in which ICG is encased in a pH-sensitive micelle that dissociates within the acidic tumor microenvironment. This enables more targeted localization of the ICG fluorophore, as it is only released intratumorally. ONM-100 demonstrated clear demarcation of fluorescence at all doses tested in Phase 1a of the trial.9 Now in Phase 2a, we are currently evaluating ONM-100 administered 24 hours preoperatively in the imaging of Stage II-IV HNSCC Continued on page 11

Fluorescence-guided Surgery: an overview and an institutional experience Continued from page 10

Figure 1. NIR imaging system setup during TORS. In this photo, a patient (left, below blue drapes) is undergoing transoral robotic surgery (TORS) for squamous cell carcinoma of the tonsil. Dr. Karthik Rajasekaran is viewing the fluorescent imaging of ONM-100 on the screen to help define the extent of the tumor.

4. Alander, J. T. et al. A Review of Indocyanine Green Fluorescent Imaging in Surgery. International Journal of Biomedical Imaging vol.

2012 1–26 (2012).

5. de Valk, K. S. et al. First-in-Human Assessment of cRGD-ZW800-1, a Zwitterionic, Integrin-Targeted, NearInfrared Fluorescent Peptide in Colon Carcinoma. Clin. Cancer Res. 26, 3990–3998 (2020).

6. Azari, F. et al. Intraoperative molecular imaging clinical trials: a review of 2020 conference proceedings. JBO 26, 050901 (2021).

7. S tubbs, V. C. et al. Intraoperative Imaging with Second Window Indocyanine Green for Head and Neck Lesions and Regional Metastasis.

Otolaryngol. Head Neck Surg. 161, 539–542 (2019).

Figure 2. Fluorescence-guided assessment of tumor boundaries. Representative intraoperative images of a head and neck squamous cell carcinoma of the tongue demonstrating in vivo ONM-100 fluorescence in the tumor without fluorescence of the surrounding normal parenchyma .

The head and neck are an area of highrisk real estate, containing vital structures that can be life-threatening if injured.

With its ability to enhance intraoperative tumor, nerve, and vascular visualization, optical imaging holds tremendous promise to revolutionize the landscape of otolaryngology, both by improving rates of tumor margin clearance, minimizing the need to remove normal tissue, and thus decreasing rates of iatrogenic neurovascular injury. However, larger scale clinical trials and more preclinical basic science studies dedicated to the investigation of additional fluorophore targets and development of new contrast agents are essential to the continued advancement of the field. Through the development of these emerging technologies, surgeons will be able to offer their patients better oncologic and surgical outcomes.

8. Teng, C. W. et al. Applications of indocyanine green in brain tumor surgery: review of clinical evidence and emerging technologies.

Neurosurg. Focus 50, E4 (2021).

References 1. van Keulen, S. et al. The Clinical Application of Fluorescence-Guided Surgery in Head and Neck Cancer. J. Nucl. Med. 60, 758–763 (2019).

9. Voskuil, F. J. et al. Exploiting metabolic acidosis in solid cancers using a tumoragnostic pH-activatable nanoprobe for fluorescence-guided surgery. Nat. Commun. 11, 3257 (2020).

2. Eldeeb, H., Macmillan, C., Elwell, C. & Hammod, A. The Effect of the Surgical Margins on the Outcome of Patients with Head and Neck Squamous Cell Carcinoma: Single Institution Experience.

Cancer Biol Med 9, 29–33 (2012).

3. Wu, C., Gleysteen, J., Teraphongphom, N. T., Li, Y. & Rosenthal, E. In-vivo optical imaging in head and neck oncology: basic principles, clinical applications and future directions. Int. J. Oral Sci. 10, 10 (2018).

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Tympanostomy Tubes for RAOM: What the Data Really Show Emily Savoca, MD Jeffrey P. Simons, MD, MMM Myringotomy with tympanostomy tube placement is one of the most common pediatric surgical procedures. The broad indications include chronic middle ear effusion with hearing concerns and recurrent acute otitis media (RAOM), defined as at least four episodes over a one-year period or three episodes over six months. [1] The widely held dogma that tympanostomy tubes decrease the incidence of acute otitis media is actually quite controversial in the literature and was again challenged in a New England Journal of Medicine publication earlier this year. [2] The study by Hoberman et al. has led to a wave of questions from parents, pediatricians, and otolaryngologists alike regarding the role for tympanostomy tubes. In light of these issues, it is timely to review the data behind tympanostomy tubes for RAOM and to take a deeper look into the Hoberman et al. study design and results.

Acute otitis media (AOM) is very common in young children due to Eustachian tube dysfunction and a high incidence of upper respiratory infections. It is one of the most common reasons for non-well-child visits to pediatricians, and the leading diagnosis prompting antibiotic prescriptions for children. [1] The approach to AOM has traditionally relied on a combination of tympanostomy tube placement, episodic antibiotic therapy, and prophylactic antibiotics, the latter of which has fallen out of favor due to lack of data supporting the risk-benefit ratio.

The benefits of tympanostomy tubes should be considered depending on indication for placement. Tubes for chronic otitis media with effusion (OME) treat the

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effusion and can lead to improvement in hearing. Conductive hearing loss from OME can range from minimal to moderate, with average loss around 28 dB.[3] Given concern for longstanding effects on speech and language development, tubes are recommended for chronic OME persistent beyond three months with hearing concerns or in children unlikely to spontaneously resolve the effusion. Furthermore, “at-risk” children are tympanostomy tube candidates for an even shorter duration chronic OME. The indications for tympanostomy tubes in patients with chronic OME are only briefly covered in this article, as the focus of the present discussion is on RAOM. In the management of RAOM, tympanostomy tubes provide a port of entry for ototopical medications and, controversially, may decrease the incidence of infections. The official guidelines per the American Academy of Otolaryngology-Head and Neck Surgery recommend tympanostomy tube consideration for patients with uncomplicated RAOM with the presence of middle ear effusion at the time of assessment. [1] The rationale for consideration of the middle ear status is that a cleared effusion is indicative of adequate Eustachian tube function.

Following an episode of AOM, effusion persists in 40% of children after one month and drops to 10% at three months. [4] The likelihood of resolution after three months is lower, tying back to hearing concerns. In practice, however, many children undergo tympanostomy tube placement despite falling short of these guideline criteria, which has prompted concern about overuse. [5] Indeed, the natural history of AOM may favor expectant management. The incidence of AOM peaks between the ages of six and 12 months. [6] In a systemic review of 15 trials, Rosenfeld et al. reported that children with RAOM averaging 5.5

episodes per year prior to study enrollment subsequently developed infections at a mean rate of only 2.8 episodes per year on placebo alone over the study period.

[4] This finding supports the concept that child growth and development is the main driver to reduce incidence of infections as opposed to medical intervention. Two other systematic reviews, both published in 2011, concluded that tympanostomy tubes either marginally reduced risk of AOM, or that data to support this benefit was inconclusive. [7,8] The marginal data, from Lous et al., demonstrated a numberneeded-to-treat of two to five children. In other words, a single prevented episode of AOM over a six-month period required tympanostomy tube placement in two to five children with RAOM. [8] In a large, matched cohort study using a national insurance claims database, Raol et al. reported that tympanostomy tubes did decrease infection rate and number of oral antibiotic prescriptions compared Continued on page 13

Tympanostomy Tubes for RAOM: What the Data Really Show Continued from page 12

to medical management over the first year after surgery. [9] That said, the absolute difference between groups was low (1.96 episodes per year in the tube group versus 2.18 episodes per year in the medical group). Because the sample population was over 13,000 patients, this difference did reach statistical significance. However, this small difference is unlikely to be of clinical significance. Of note, healthcare utilization was higher in the tube group based on number of visits to primary care or otolaryngology. Also of note, the benefit with tubes at one year study did not persist into the second year.

Similarly, the 2018 Cochrane review on tympanostomy tubes for RAOM found a benefit with tympanostomy tubes over active monitoring. The calculated number-needed-to-treat at six- and twelve-months post-tubes, respectively, was three and eight children, showing fatigue of the benefit with time. This review concluded that tubes were superior to active monitoring, but with the contingency that evidence in support of tubes was of low- to very-low quality. [10] In May of 2021, Hoberman et al. published their study on this topic in the New England Journal of Medicine. In a multicenter prospective trial, children between the ages of six and 35 months with a history of RAOM were enrolled and randomized to tympanostomy tube placement or medical management, meaning antibiotic treatment for AOM episodes. Based on the final intention-to-treat analysis of 250 children, the researchers concluded that tympanostomy tubes did not reduce the rate of AOM compared to expectant medical management. [2] To better interpret the results, a few salient study features deserve attention.

1. First of all, the criteria to define an episode of AOM differed between groups. For the medical group, an episode of AOM was defined by a score of two or higher on the AOM Severity of Symptom (AOM-SOS) scale with a middle ear effusion during event and either otalgia, tympanic membrane bulging, erythema, or purulent otorrhea.

In patients with tubes, AOM was defined by otorrhea with one or more positive items of the AOM-SOS scale.

This excluded symptoms immediately following surgery, which could be attributed to post-operative and postanesthesia effects. The AOM-SOS scale inquires about symptoms of increased ear tugging/rubbing, crying, irritability, difficulty sleeping, decreased activity/ appetite, and fevers over the preceding 12-hour period. While AOM does manifest differently in patients with and without tubes, differing diagnostic criteria between groups raises concern for discrepant rates of over- or underdiagnosis. For example, otorrhea is likely far less susceptible to diagnostic error than tympanic membrane erythema and middle ear effusion.

2. The study’s crossover rate was high and largely unilateral. Two hundred and fifty children were enrolled, with 129 assigned to tympanostomy tubes and 121 to medical management. Of the 129 children assigned to the tube group, 116 underwent tube placement.

In the medical group, 54 of 121 children (45%) also ultimately underwent tube placement. This crossover to receiving tympanostomy tubes was either for persistent AOM meeting initial enrollment criteria (35 children) or per parental request (19 children). These cases were defined as “treatment failures.”

3. R esults were reported based on an intention-to-treat analysis. This means that the 54 patients in the medical group that did undergo tubes were counted in the medical group. The intention-totreat analysis did not show a significant difference in incidence of AOM between group (1.48 vs 1.56 infections per child per year in the tube vs medical group, respectively, p= 0.66). There were also no significant differences between groups regarding percentage of severe AOM episodes, antimicrobialrelated diarrhea or diaper dermatitis, antimicrobial resistance, quality of life measures, and parent satisfaction.

Given the high rate of deviation for study protocol, a per-protocol analysis was also completed. This excluded the 13 tubegroup children that did not receive tubes and the 54 children in the medical group that did undergo tympanostomy tube insertion. The per-protocol results were reported for the primary outcome only, incidence of AOM, for which there was a significant difference between groups (tubes 1.47 vs medical 1.71, RR 0.82, 95% CI 0.69-0.97). Granted, the sample size was much smaller for this analysis. While not presented, the per-protocol analysis of secondary outcomes reportedly mirrored the intention-to-treat results.

The author’s decision to stay with the intention-to-treat analysis despite the high cross-over rate drew criticism. To the authors’ defense, per-protocol analyses do tend to overestimate treatment effects.

Furthermore, a per-protocol analysis in this study would be underpowered given loss of participants to crossover. In an editorial response, the authors also argued that the modest difference between groups in the per-protocol analysis suggested that any Continued on page 14

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Tympanostomy Tubes for RAOM: What the Data Really Show Continued from page 12

difference is likely clinically insignificant.

[11] Lastly, the either marginal or lack of difference between groups (depending on analysis) is in fact consistent with historic data, as reviewed above.

4. A final note on the Hoberman et al. study: there were a few underemphasized findings in favor of tympanostomy tubes. The days per year on systemic antibiotics was lower in the tube group (8.3 days/year vs 12.9 days/year in medical group), the time to first episode of AOM was longer, and the rate of treatment failure was lower. Per trial protocol, patients with AOM in the medical-management group were treated with Augmentin.

Those in the tube group were treated initially with twice daily ofloxacin, and only received systemic oral antibiotics when otorrhea lasted more than seven days.

A primary benefit of tympanostomy tubes for RAOM is access for direct topical delivery of antibiotics, thus decreasing the need for systemic antibiotics. Ototopical therapy allows for a higher concentration of drug delivery, which improves treatment response. [1] The Hoberman results do support this benefit. Interestingly, the results did not support any benefit from tubes in terms of decreasing the risks from systemic antibiotics, including diarrhea and antibiotic resistance.

It is also important to remember that the Hoberman et al. study specifically applied to tympanostomy tubes for RAOM. Patients referred for or undergoing tympanostomy tube placement for hearing concerns were excluded. Ultimately, the Hoberman et al. study confirmed what the data has historically suggested.

Tympanostomy tubes may slightly

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decrease the incidence of episodes in children with RAOM, but if so, the effect is likely small. Tympanostomy tubes do allow for more effective treatment using ototopical antibiotics, and fewer days per year on systemic antibiotics. Concerns for adverse and downstream effects from systemic antibiotics are warranted, though a causal effect is not well-established in the medical literature. With tubes, parents should expect occasional otorrhea, which can be a quality of life issue. Parents should also understand that the natural history of RAOM is favorable, and that time alone will coincide with disease resolution in most children. Based on this, younger children are more likely to benefit from tympanostomy tubes. Lastly, the possible benefits must always be weighed against the risks of surgery. For tympanostomy tubes specifically, the relevant risks include general anesthesia, tympanostomy tube dysfunction, and persistent tympanic membrane perforation. It is valuable to take a critical look at this recent study by Hoberman et al. in the context of other evidence regarding the potential benefits of tympanostomy tubes and to incorporate clinical judgment, clinical practice guidelines, and shared decision making with caregivers into the clinical care decisions for each patient.

1. Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical practice guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013 Jul;149(1 Suppl):S1-35. doi: 10.1177/0194599813487302. PMID: 23818543.

2. Hoberman A, Preciado D, Paradise JL, Chi DH, Haralam M, Block SL, Kearney DH, Bhatnagar S, Muñiz Pujalt GB, Shope TR, Martin JM, Felten DE, Kurs-Lasky M, Liu H, Yahner K, Jeong JH, Cohen NL, Czervionke B, Nagg JP, Dohar JE, Shaikh N. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media. N Engl J Med. 2021 May 13;384(19):1789-1799. doi: 10.1056/NEJMoa2027278. PMID: 33979487.

3. Fria TJ, Cantekin EI, Eichler JA. Hearing acuity of children with otitis media with effusion. Arch Otolaryngol. 1985 Jan;111(1):10-6. doi: 10.1001/ archotol.1985.00800030044003. PMID: 4038450.

4. Rosenfeld RM, Kay D. Natural history of untreated otitis media. Laryngoscope. 2003 Oct;113(10):1645-57. doi: 10.1097/00005537200310000-00004. PMID: 14520089.

5. The Joint Commission. Proceedings from the National Summit on Overuse. September 24, 2012. http://www.jointcommission.org/ assets/1/6/National_Summit_Overuse.pdf.

Accessed April 1, 2016.

6. Kaur R, Morris M, Pichichero ME. Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics. 2017 Sep;140(3):e20170181. doi: 10.1542/peds.20170181. Epub 2017 Aug 7. Erratum in: Pediatrics.

2018 Feb 28;: PMID: 28784702; PMCID: PMC5574724.

7. Hellström S, Groth A, Jörgensen F, Pettersson A, Ryding M, Uhlén I, Boström KB. Ventilation tube treatment: a systematic review of the literature. Otolaryngol Head Neck Surg. 2011 Sep;145(3):383-95. doi: 10.1177/0194599811409862. Epub 2011 Jun 1.

PMID: 21632976.

8. Lous J, Ryborg CT, Thomsen JL. A systematic review of the effect of tympanostomy tubes in children with recurrent acute otitis media. Int J Pediatr Otorhinolaryngol. 2011 Sep;75(9):1058-61. doi: 10.1016/j.ijporl.2011.05.009. Epub 2011 Jun 2.

PMID: 21636136.

9. Raol N, Sharma M, Boss EF, Jiang W, Scott JW, Learn P, Weissman JS. Tympanostomy Tube Placement vs Medical Management for Recurrent Acute Otitis Media in TRICAREInsured Children. Otolaryngol Head Neck Surg. 2017 Nov;157(5):867-873. doi: 10.1177/0194599817707718. Epub 2017 May 23. PMID: 28535362.

10. Venekamp RP, Mick P, Schilder AG, Nunez DA. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database Syst Rev. 2018 May 9;5(5):CD012017. doi: 10.1002/14651858.CD012017.pub2. PMID: 29741289; PMCID: PMC6494623.

11. Paradise JL, Hoberman A, Preciado D. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media. Reply. N Engl J Med. 2021 Aug 26;385(9):861-862. doi: 10.1056/NEJMc2109725. PMID: 34437793.

The Impact of Positive Margin on Survival in Oral Cavity Squamous Cell Carcinoma Vishaal Patel, MD; Thomas J. Galloway, MD; Jeffrey C. Liu, MD Oral cavity squamous cell carcinoma (OCSCC) is a common cancer globally with more than 200,000 cases per year.

The mainstay of therapy for early stage OCSCC is primarily surgical resection with positive margin rates varying from 2.7% to 15%. National Comprehensive Cancer Network (NCCN) guidelines recommend re-resection, radiation, or radiation with systemic therapy as possible options in the event of a positive margin, however radiation and systemic therapy are associated with severe toxicity making counseling and treatment decisions difficult. While many studies have shown that positive margins negatively impact survival by up to 8%, others have suggested that positive margins may have a limited impact. Other studies have shown that radiation can limit the impact of positive margins however they are generally smaller, single-institution patient cohorts.

To better examine the impact of positive margins OCSCC outcomes, we obtained data from the National Cancer Database, a national, multi-institution oncology dataset that captures treatment and

survival outcomes for more than 80% of head and neck cancers. The aim of our study was to measure the effect of positive margins on survival in early stage OCSCC and evaluate the relationship of co-factors, such as radiation, with survival following a positive margin.

We included a total of 26,049 patients with 2,093 positive margins and 3,642 patients receiving adjuvant radiation.

These patients were then separated into one of eight cohorts based on their history of positive or negative margin, positive or negative history of radiation, and positive or negative history of neck dissection.

By separating the analysis into specific cohorts, patients in whom upfront neck dissection was performed were only compared to other patients with neck dissection and non-dissected patients were only compared with non-dissected patients as a measure to control for neck dissection as a co-variate impacting survival.

When comparing non-irradiated negative margin patients with non-irradiated positive margin patients, overall survival fell by 11.4% and 12.8%, depending on history of neck dissection. Five year survival fell by 13.2% and 15.5%. After univariate analysis was performed, positive margins continued

to convey a hazard ratio of 1.47 and 1.62 (p<0.001) on multivariate analysis.

Other factors that correlated with survival in multivariate analysis were age, T-stage, and comorbidity index.

To determine if radiation improved survival, we compared survival outcomes in irradiated positive margin patients to nonirradiated positive margin patients. We found no significant difference in survival in these comparisons: overall survival varied by only 0.5 and 2.8% with 5-year survival varying by 0.9% and 1.6%, depending on history of neck dissection. Radiation did not correlate with survival outcomes on univariate analyses in these patient cohorts.

Using the NCDB database, we found that positive margins resulted in a 11-15% reduction in overall survival. We found no difference in survival in irradiated and non-irradiated positive margin patients.

This study adds a high powered analysis to the literature regarding management of positive margins in OCSCC and questions the utility of radiation alone in this setting.

Re-resection should be performed when possible and adjuvant treatment thereafter be discussed in a multi-disciplinary tumor board.

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BOG Update Fall 2021 Keith R. Conti MD1, Ronak Modi MD2, and Aaron Jaworek MD1,3,*

Karen A. Rizzo, MD, FACS Governor The 125th Annual Meeting of the AAO/HNS was recently held in Los Angeles. Dr. Ken Yanagisawa started his President's term and Dr. Carol Bradford completed hers. The meeting was attended by over 2000 physicians.

Both live presentations and on demand sessions were available. The Board of Governors also elected its new leadership. Dr. Karen Rizzo was elected Chair Elect and Dr. Christina Baldasarri was elected Secretary. Dr Troy Woodard is the new Chair. Dr Lance Manning is now past chair.

Dr Denneny discussed strategic goals of the academy to include a new Business of Medicine Program focusing on helping physicians maintain and promote practice viability and sustainability. A Private Practice Study Group has been formulated to study and evaluate various ways for the academy to utilize its resources to aid physicians in managing their practices to sustain growth and financial stability.

Promoting inclusivity and diversity encouraged.

From a legislative perspective, physicians are potentially facing a 9.75% Medicare reimbursement reduction on January 1, 2022. Representatives Ami Bera MD from California and Larry Bushon MD from Indiana through their letter are urging passage of legislation to avert these legislative cuts. By using the Academy's advocacy website, otolaryngologists are urged to contact their US representative to ask asking them to sign the Beri Bera-Bushon letter and support fair reimbursement for practicing otolaryngologists.

The AAO continues to lead efforts to oppose the audiology direct access legislation. It has sent several letters to House and Senate leadership expressing strong opposition to the Medicare Audiologist Access and Services Act

Save the Date!

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HR 1587. Over 110 national, state, and local organizations have expressed patient safety concerns for Medicare beneficiaries as well.

The Academy has demonstrated strong endorsement for HR 3173 which improves Seniors Timely Access to Care Act. This legislation which currently has 195 cosponsors would help protect Medicare patients from delays in care by streamlining and standardizing the use of prior authorization in the Medicare Advantage Program.

Toolkits are now available on the Board of Governors website to help physicians in the handling of reimbursement problems with insurers. Toolkits are also present to assist state societies with developing, organizing, and managing their society.

Slide sets are available for several clinical practice guidelines. Appeal letters and advocacy statements are available when payers deny claims. Using the BOG as a conduit for the sharing of information which impacts patient, practice, and legislative advocacy is recommended. Members are encouraged to visit the website to see the vast amount of information now available.

Karen A. Rizzo, MD FACS Chair Elect BOG/ PA Governor

Cochlear Implantation for Single Sided Deafness Abhinav R. Ettyreddy MD, Philip Perez MD, & Barry E. Hirsch MD, Andrew A. McCall MD Cochlear implantation (CI) remains the primary tool to restore auditory perception in patients with severeto-profound sensorineural hearing loss. Traditionally, CI was reserved for patients with bilateral profound hearing loss who failed an appropriate trial of hearing aid amplification. The benefits of CI in this population are well established including improvements in multiple quality-of-life metrics.1 Cochlear implantation CI candidacy criteria have expanded over time as advances in technology have resulted in improved outcomes and decreased surgical morbidity. Most recently, the U.S. Food and Drug Administration (FDA) approved the MED-EL Cochlear Implant System for individuals five years of age or older with single-sided deafness (SSD) or asymmetric hearing loss (AHL). The goal of the current article is to provide an overview of the benefits of binaural hearing that led to the expansion of CI candidacy criteria and to review the current guidelines for CI in SSD/AHL. Single-sided deafness is defined as a hearing loss with normal or nearly normal hearing in one ear and severe to profound hearing loss in the contralateral ear.2 The definition of AHL, on the other hand, is subject to some variability but generally accepted to be an interaural asymmetry of >20 dB hearing level (HL) in at least two contiguous frequencies.

3 Traditionally, patients with SSD or AHL were managed with contralateral routing of signal (CROS) hearing aids or bone conduction hearing devices which would route sound to the functional/ better hearing ear. Since these methods do not recreate binaural hearing, there have been limited benefits noted on subjective reports and on spatial hearing tests.4 The key advantages of binaural hearing include head shadow effects, binaural squelch, and binaural

summation. These binaural benefits are important for understanding speech in noise, especially in complex listening environments.4 In a cross-sectional study comparing adults with unilateral deafness to those with normal hearing, individuals with unilateral deafness demonstrated significant challenges in environments with background noise.5 Given the benefits of binaural hearing in complex listening environments, there has been increased interest in the role of CI in patients with SSD. Several studies have assessed the long-term audiologic outcomes after CI for SSD and demonstrated significant improvements in key metrics including sound localization, hearing in noise, and quality-of-life metrics.6 These benefits were rarely seen with the traditional CROS and bone conduction hearing systems.

In 2019, the FDA approved the MED-EL cochlear implant system for SSD/AHL to improve speech understanding in noise, sound localization, and self-perceived quality of hearing. On-label use indicates that the implanted ear has profound sensorineural hearing loss, which is defined as a pure tone average of 90 dB HL or greater at 500, 1000, 2000, and 4000 Hz. There are no defined restrictions on hearing level for the contralateral ear.

For sentence testing, patients must score <5% on consonant-nucleus-consonant (CNC) words in quiet under the best aided conditions when tested in the ear to be implanted. On-label use indicates that profound hearing loss should not be present for more than 10 years. Unlike traditional CI criteria, there is limited role for binaural sentence testing in this population. Finally, before implantation, individuals with SSD and AHL must complete a one-month trial with a CROS hearing aid system or similar device without subjective benefit.

undergo a surgical procedure or are poor surgical candidates. However, patients who find themselves in complex listening environments may be unsatisfied with the CROS hearing aid system and report minimal subjective improvements. In this population, CI is now a viable hearing rehabilitation strategy that can restore binaural hearing and provide significant benefit in multiple hearing domains.

References 1. Carlson ML. Cochlear implantation in adults. NEJM 2020; 382: 1531-1542.

2. Yu JW. Understanding patient perspectives on single-sided deafness.

JAMA Otolaryngol Head Neck Surg 2020; 146(10): 8875-886.

3. Durakovic N, Valente M, Goebel JA, & Wick CC. What defines asymmetric sensorineural hearing loss?

Laryngoscope 2018; 129(5): 10231024.

4. Thompson NJ, Dillon MT, Buss E, Rooth MA, King ER, Bucker AL, McCarthy SA, Deres EJ, O’Connell BP, Pillsbury JC, Brown KD. Subjective benefits of bimodal listening in cochlear implant recipients with asymmetric hearing loss.

Otolaryngol Head Neck Surg 2020; 162(6): 933-941.

5. Wie OB, Pripp AH, & Tvete O. Unilateral deafness in adults: effects on communication and social interaction.

Ann Otol Rhinol Laryngol 2010; 119(11): 772-781.

6. Sullivan CB, Al-Qurayshi Z, Zhu V, Liu A, Dunn C, Gantz BJ, & Hansen MR. Long-term audiologic outcomes after cochlear implantation for single-sided deafness. Laryngoscope 2020; 130(7): 1805-1811.

The management of patients with SSD/ AHL requires a thoughtful and nuanced approach. The traditional CROS hearing aid system remains the initial treatment option and may in fact be the ideal choice for patients who are hesitant to SOUNDINGS | Fall 2021

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Facing Image Disturbances Head-On in Cancer Patients Pallavi Kulkarni, BS; Jacqueline Tucker, BS; Jessyka G. Lighthall, MD FACS, Karen Y. Choi, MD Mental health disorders are surrounded by biases and stigma that can strongly impact patients’ quality of life. Head and neck cancer (HNC) patients are known to be at high risk for mental health disorders, such as anxiety and depression, in part due to the disfigurement of the disease and functional impact on daily activities such as eating, talking, and breathing.

HNC patients are treated with surgery, radiation, or chemotherapy, and often a combination of these modalities are employed. Often, for large and advanced HNCs, reconstructive surgery is required to restore function and image, and these surgical changes are often highly visible. While reconstructive measures aim to establish a “new normal” that allow patients to regain function, they often have lasting effects from surgery that impact their appearance, and cause them to be socially isolated, crippling their quality of life.

It is important to focus on patients' mental health and quality of life so they can holistically heal. This is an important and pertinent topic of research in HNC patients. The most common surveys used in the HNC population to assess quality of life include the Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module, the University of Washington Quality of Life Questionnaire, and the Functional Assessment of Cancer Therapy Head and Neck scale.[1] Often, these questionnaires group image disorders in with questions that assess quality of life, but it is important to note image disorders are a singular part of the bigger picture.

Body Image Disturbance (BID) is a complex and multidimensional mental health concern and includes selfperceptions, attitudes, and satisfaction

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of one’s physical appearance and ability to function. BID can be extremely common with HNC patients who undergo treatment. Patients often feel embarrassed or concerned about changes they have endured.[2] However, there is a lack of consensus on how best to evaluate body image perceptions. Most studies have used quantitative surveys, but these surveys vary in questions and focus. In fact, when conducting a systematic review, Kling et al. found more than 150 different body image measures had been used in recent years.

[3] As such, there is a need to improve cohesiveness in this field in order for studies to be comparable and improve our management of this issue.

Some popular survey studies for image disorders used in HNC research include the Body Image Scale (BIS) and the Body Image Quality of Life Inventory. [2,4,5] One study using the BIS found 13-20% of HNC patients were experiencing body image distress. Additionally, patients reported feelings of shame, feeling bad/ugly, depression, and negative reactions by individuals around them in the qualitative part of the same study.[2] Prior research has shown that patients with HNC undergoing a surgical procedure have a greater likelihood of having an issue with their appearance.

[5] Additionally, factors such as female sex, low level of education, smoking, and prior history of feelings of shame/ stigma and depression have been linked to increased risk of development of a body image disorder.[6,7] Understanding which patients are at increased risk for body image disturbances can help guide physicians’ expectant management.

When assessing how perceptions of body image change over time, Rhoten et al. found that while body image scores decrease from baseline to after treatment, by 12 weeks post-treatment there is significant body image improvement.

[5] Additionally, a systematic review found two longitudinal studies reporting improvement in body image disturbance over time as patients get further from treatment.[8] This could represent the

time needed for appropriate healing, and resolution of complications, or time for patients to adjust to their “new normal.” Since body image is a broad term that refers to the entire body, it may not adequately assess how patients feel specifically about the head and neck area that underwent treatment.

The face is the initial way people recognize us. It directly affects how we interact with our surroundings and helps form our identity to the world. Since HNC often affects facial appearance, it is important to specifically assess patient perceptions of the face. In patients undergoing microsurgery as part of their treatment for HNC, a body area satisfaction survey (BASS) showed lowest scores of satisfaction for the face.

[9] This data suggests that the face is an emotionally sensitive area for individuals that have undergone surgical intervention.

There have been very few patient-reported outcome measurement (PROM) studies in HNC, and no specific PROM surveys that focus on head and neck-specific measures of body image disturbance.[8] Recently, the Medical University of South Carolina developed and validated the first PROM for use in HNC.[10] The survey consists of items assessing patients’ perceptions of their bodies following HNC treatment.

However, this survey has not yet been widely distributed, and future studies should consider implementing this survey in different clinics and patient populations.

To aid in coping with and prevention of facial image disturbances, there is a critical need to understand the prevalence in HNC patients. As more data is gathered on head and neck specific image disturbance and head and neck specific measures become available, this will assist in early identification of changes in mental health that would benefit from further evaluation and treatment. An understanding of how post-treatment facial image disorders specifically impact patients’ mental health, outcomes, and satisfaction will allow for optimization of patient care and the patient experience.

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Facing Image Disturbances Head-On in Cancer Patients Continued from page 18

References: [1] O jo, B., Genden, E. M., Teng, M. S., Milbury, K., Misiukiewicz, K. J., & Badr, H. (2012). A systematic review of head and neck cancer quality of life assessment instruments. Oral oncology, 48(10), 923-937.

[2] M elissant, H. C., Jansen, F., Eerenstein, S. E., Cuijpers, P., Laan, E., Lissenberg-Witte, B. I., ... & Verdonck-de Leeuw, I. M. (2021).

Body image distress in head and neck cancer patients: what are we looking at? Supportive Care in Cancer, 29(4), 2161-2169.

[3] K ling, J., Kwakkenbos, L., Diedrichs, P. C., Rumsey, N., Frisen, A., Brandao, M. P., ... & Fitzgerald, A. (2019).

Systematic review of body image measures. Body Image, 30, 170-211.

[4] Hung, T. M., Lin, C. R., Chi, Y. C., Lin, C. Y., Chen, E. Y. C., Kang, C. J., ... & Chang, J. T. C. (2017). Body image in head and neck cancer patients treated with radiotherapy: the impact of surgical procedures. Health and Quality of Life Outcomes, 15 (1), 1-7 [5] Rhoten, B. A., Deng, J., Dietrich, M. S., Murphy, B., & Ridner, S. H. (2014).

Body image and depressive symptoms in patients with head and neck cancer: an important relationship. Supportive Care in Cancer, 22(11), 3053-3060 [6] Graboyes, E. M., Hill, E. G., Marsh, C. H., Maurer, S., Day, T. A., & Sterba, K. R. (2019). Body Image Disturbance in Surgically Treated Head and Neck Cancer Patients: A Prospective Cohort Pilot Study.

Otolaryngology–Head and Neck Surgery, 161(1), 105–110. https://doi. org/10.1177/0194599819835534

[7] Nogueira, T. E., Adorno, M., Mendonca, E., & Leles, C. (2018).

Factors associated with the quality of life of subjects with facial disfigurement due to surgical treatment of head and neck cancer. Medicina Oral Patología Oral y Cirugia Bucal. https://doi. org/10.4317/medoral.22072 [8] Ellis, M. A., Sterba, K. R., Brennan, E. A., Maurer, S., Hill, E. G., Day, T. A., & Graboyes, E. M. (2019). A systematic review of patient-reported outcome measures assessing body image disturbance in patients with head and neck cancer. Otolaryngology–Head and Neck Surgery, 160(6), 941-954.

[9] Liu, H.-E. (2008). Changes of satisfaction with appearance and working status for head and neck tumour patients. Journal of Clinical Nursing, 17(14), 1930–1938. https://doi.org/10.1111/j.13652702.2008.02291.x [10] Graboyes EM, Hand BN, Ellis MA, Huang AT, Nilsen ML, Pipkorn P, Marsh CH, Maurer S, Day TA, Sterba KR. Validation of a Novel, Multidomain Head and Neck Cancer Appearance- and FunctionDistress Patient-Reported Outcome Measure. Otolaryngol Head Neck Surg. 2020 Nov;163(5):979-985. doi: 10.1177/0194599820927364.

Epub 2020 Jun 2. PMID: 32482151.

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Radiofrequncy Ablation Of Benign Thyroid Nodules David Goldenberg MD, FACS Conservative estimates show that 100,000 to 150,000 thyroidectomies are performed in the United States annually. An estimated 53,000 patients will develop cancer in 2020, indicating that most thyroidectomies are for benign thyroid disease. Thyroid nodules are prevalent in the United States. The risk of developing a palpable thyroid nodule is about 10%; however, due to the use of high-resolution ultrasound, some 19-70% of randomly selected individuals will be shown to have a thyroid nodule. Nodular disease of the thyroid is common, but malignancy of the thyroid occurring in a nodule is not. The risk of malignancy in a solitary nodule is between 7–15 %. The incidence of thyroid nodules has increased rapidly in recent years. This increase is thought to be primarily driven by early detection and the increased use of highresolution imaging techniques. Benign thyroid nodules may represent various conditions, including colloid nodules, degenerative cysts, hyperplasia, thyroiditis, or benign neoplasms. The diagnostic workup of a thyroid nodule includes laboratory evaluation, utilizing a sensitive thyroid-stimulating hormone assay, which is used to screen for hyperthyroidism or hypothyroidism.

The routine initial diagnostic evaluation of a solitary thyroid nodule no longer includes nuclear imaging studies.

Because of technological advances, ultrasonography is highly sensitive in determining the size and number of thyroid nodules and may even hint towards a malignancy versus a benign nodule. By itself, ultrasonography cannot reliably be used to distinguish between a benign nodule or a malignant one. However, a combination of high-resolution sonography and fineneedle aspiration biopsy is both sensitive and specific. CT scanning or MRI is generally not cost-effective in the initial evaluation of a solitary thyroid nodule.

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Up until recently, the management of a solitary benign thyroid nodule included observation versus surgical excision.

Ultrasound-guided radio-frequency ablation (RFA) for thyroid lesions is a minimally invasive treatment modality that may be an alternative to surgery in patients with benign thyroid nodules which are symptomatic. It may also have an effective complementary role in the management of small or recurrent thyroid cancers. RFA is typically efficacious and safe in managing thyroid nodules that cause compressive symptoms or cosmetic problems. Radio-frequency ablation utilizes an electrode carrying a high-frequency alternating current to cause thermal injury in the nodule tissue.

This leads to cell death and shrinkage of the affected nodule. The procedure is performed under local anesthesia with the option of mild sedation if necessary.

After a local anesthetic is instilled, a thin needle is introduced into the thyroid nodule through the skin. This is done under continuous ultrasound visualization. The needle is connected to a generator that uses electricity to generate heat around the tip of the needle only. The needle is then moved back and forth inside the nodule, ablating it from the inside. Normal thyroid tissue is typically not affected since this is done under ultrasonic guidance with direct visualization of both the nodule and the surrounding thyroid. Thyroid ablation, using RFA, is effective and successful when the nodules are reduced by 50% or more. On average, a solid thyroid nodule will shrink by 80% and, in some cases, totally disappear. In most cases, this nonsurgical option results in an improvement in compressive symptoms and cosmetic concerns.

Complications of RFA are rare and may include hoarseness, which in most cases is temporary. Complications can be avoided by the physician using caution in the danger triangle towards the posterior portion of the thyroid gland near the recurrent laryngeal nerve. Skin burns have been reported, and nausea and vomiting may occur after the procedure. Rarely, a nodule may rupture.

RFA procedure costs vary depending on the state and location of the procedure.

As with any medical procedure conducted in the hospital setting, it may be costly.

However, the RFA treatment costs are significantly less than a thyroid lobectomy.

Pre-ablation assessment: All patients are to be evaluated clinically and undergo a neck ultrasound and a fine needle aspiration biopsy showing that the nodule in question is indeed benign. Patients who have metallic hardware or pacemakers, bleeding tendencies, pregnancy, or nodules that appear very suspicious on ultrasound, are not considered candidates for RFA. Informed consent should be obtained from the patient before performing the RFA.

Legislative Update Lobbyist Message: Are you ready to fall into a busy legislative season?

by Deborah Ann Shoemaker, PAO-HNS Lobbyist It is hard to believe that October is upon us. When I wrote my first article to our members this past spring, I expressed optimism that we could move past much of the political name calling and divisiveness.

Well, wishful thinking I guess in some respects.

The rest of the year will keep us busy, but in a good way.

Here is an update on grassroots advocacy activities that have occurred since our last newsletter article and a strategy moving ahead.

FALLING INTO ACTION: COVID-19 AND RELATED LEGISLATIVE ISSUES We are now into year two of the COVID-19 pandemic. Although Pennsylvania continues to experience more individuals either partially or fully vaccinated, we still have a long way to go. Debate continues as to if a booster shot is needed; if kids under the age of 11 should get vaccinated; and if a mandated mask mandate (especially in schools) is necessary or just a violation of personal freedoms. Regardless of your personal convictions on all the above topics, one thing is certain: access to care cannot be compromised for your patients- regardless of a pandemic.

On the federal level, the Biden Administration continues to extend the Public Health Emergency Declaration.

If it is in place, any federal rulemaking or policies that were relaxed or initiated during the pandemic remain in effect.

We will continue to advocate for those policies that have assisted in providing patient care (such as Medicare coverage of telemedicine) to continue throughout the duration of the declaration is over and/or beyond if applicable.

However, at the state level, there is much work to do in this regard. The state legislature enacted legislation that required a constitutional amendment change to limit any governor’s authority to declare a Public Health Emergency (PHE) to 21 daysregardless of the issue. All state regulatory and policy relaxations and/or changes would have to be vacated after the PHE. For sake of education, a Pennsylvania constitutional change must be voted on by voting citizens of the commonwealth prior to being enacted. This past spring, the referendum was on the state primary ballot and got a majority vote.

So, what does that mean for PAO-HNS? The end of our state’s PHE was September 30th. Prior to that deadline, I reviewed the significant impact of these changes to our members and provided an analysis. At that time, some of the biggest concerns involved the use of telemedicine, relaxed hospital practice privileges for those not on hospital staff, relaxed collaboration between CRNPs, PAs and other non-MD providers, and delayed state medical license renewals.

After much consumer/healthcare provider outrage and public pressure, House Republican leadership introduced House Bill 1861 to extend those policies initiated during COVID from September 30th for another 6 months. The governor signed the bill into law this week and its provisions immediately went into effect. NOTE: this victory buys us some time, but we will have to revisit this issue next year.

FALL INTO ACTION: PRIOR AUTHORIZATION House Bill 225 and Senate Bill 225 were introduced early this legislative session related to prior authorization. PAO-HNS sent out a solicitation in late June, targeting members residing and/or laboring in senatorial districts of Senate Banking and Insurance Committee members to request an affirmative vote in committee. As a result of medical specialty collective grassroots advocacy efforts, Senate Bill 225 was voted out of the committee on June 25th with significant amendments. For a copy of the amended version of the bill, feel free to ask me or get a copy on our website.

FALLING INTO ACTION: ASSISTING OUR COLLEAGUES WITHIN PAMED AND THEM WITH US! Our friends at PAMED have taken the lead on crucial legislative and regulatory initiatives, such as scope of practice expansion, medical malpractice, change of venue for liability actions, non-disclosure agreements, and payer relations.

Phillips Recall Issue- Our Collective Work: It was brought to our attention that Phillip Respironics device recall of 3-4 million devices (and their recommendation to cease using devices immediately) is impeding patient care and has the potential of adverse outcomes.

After invaluable input from PAO-HNS sleep member experts, we sent our draft letter to PAMED’s practice support department for input. PAO-HNS is finalizing our recipient list. After that is completed, we will forward our comment letter to the appropriate stakeholders for review and comment.

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Legislative Update Continued from page 15

House of Delegates:

Although we do not have a dedicated representative this year at HOD, our voice can still be heard. Our colleagues at the Pennsylvania Academy of Dermatology have introduced a House of Delegate Resolution on non-medical switching.

After careful review by Drs. Cognetti and McGinn, we wholeheartedly endorsed their resolution.

Prior to the virtual HOD later this month, I will review all HOD resolutions and provide a comprehensive overview.

Last, but not least, one of the best ways to get politically active is to educate our members about grassroots advocacy, our issues, and how to get engaged. I was excited to meet many of you (albeit in a virtual format) at our annual scientific

meeting in June. Although my virtual booth did not do justice to meeting you in person, it was an opportunity for our members to review legislation or be reminded to check out our website.

To tackle our aggressive grassroots advocacy efforts on the state and national level, we can use all your help. Please do not hesitate to reach out to me via email (dshoemaker@pamedsoc.org) if you have any questions, need more information, or want to get involved. A copy of our most recent legislative watch list and legislative update is enclosed for your review and can be viewed on our website.

Happy Fall!

Congratulations UPMC!

Congratulations to UPMC for their success winning the Resident Jeopardy Bowl

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Congratulations Everyday Hero!

Elliott Jody Bilofsky, DO, FAOCO, an otolaryngologist at UPMC Altoona Ear Nose & Throat and chief of UPMC Altoona ENT Service, has been named a Pennsylvania Medical Society (PAMED) Everyday Hero.

He received the award on July 28, 2021.

Dr. Bilofsky was nominated for this award by a colleague, who said that he is not only an outstanding otolaryngologist, but also a humanitarian and leader.

“Until last July, he was the solo otolaryngologist for UPMC Altoona,” said his nominator. “During the pandemic, Dr. Bilofsky has worked tirelessly to fight COVID-19. He has singlehandedly performed at least 70 tracheotomies in critically ill ICU COVID-19 patients. He has worked nights and weekends, even when not "on call,” to care for the sickest of sick COVID-19 patients.”

She went on to say,

“ We are lucky and blessed to have Doctor Bilofsky at UPMC Altoona; he is absolutely phenomenal!”

Colleagues and others share the accolades, describing Dr. Bilofsky as a physician who provides phenomenal care to patients and is all around amazing and a true leader of the profession. They call him a humanitarian at its finest, and refer to him as a modest and true physician who never stops and is ever giving of his expertise.

PAMED’s Everyday Hero Award program, launched in 2018, honors member physicians who go above and beyond in their profession and in providing patient care.

It’s designed to showcase exemplary physicians who probably don’t view themselves as heroes, but to patients and colleagues they are.

Patients and medical colleagues can nominate PAMED member physicians for this award at www.pamedsoc.org/EverydayHero.

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