Soundings PUBLISHED IN THE INTEREST OF OUR MEMBERS AND THEIR PATIENTS
President’s Message Ahmed M.S. Soliman, MD
It is hard to believe that my term as president of the PAO has started. It’s been nearly ten years since I have become actively involved with the organization. During this time, we have strengthened our relationship with PAMED through involvement in their Specialty Leadership Council, initiated a grassroots advocacy movement with our government relations firm, and increased our influence with the American Academy of OtolaryngologyHead & Neck Surgery by initiating the State Otolaryngology Society Roundtable meeting at the Spring Leadership Forum. Our Annual Meeting in Hershey was a great success with several pioneering sessions including talks on innovation and advocacy. The resident bowl was again a big hit with Penn State Hershey recapturing the “Conchal Bowl” for the third time! We were honored to have the Executive Vice President of the AAOHNS, James Denneny, MD, join us at our Annual Meeting in Hershey as a speaker. He reminisced on fond memories he had presenting some 30 years earlier at the PAO while a resident in Otolaryngology at the University of Pennsylvania. Rest assured though, the PAO will not just rest on its laurels! We will continue
to push forward, to advocate for Pennsylvania Otolaryngologists and for our patients. Just this summer, IBC implemented a new policy to reimburse an Evaluation and Management (E/M) service appended with modifier 25 at 50 percent when it is performed with a procedure having a 0-, or 10-day post-operative period. Immediately, we partnered with PAMED and sent a letter to IBC demanding the ill-advised policy not be implemented. We took part in an emergency meeting of the Specialty Leadership Council of PAMED to brainstorm and strategize regarding the matter. We similarly had an emergency meeting of the PAO Council and have sent a letter to IBC from the PAO urging the policy’s repeal. We have reached out to The American Academy of Otolaryngology-Head & Neck Surgery to sign on and are awaiting their response. The fight is ongoing.
We will continue to push forward, to advocate for Pennsylvania Otolaryngologists and for our patients. As your president, I will continue to advocate on behalf of Pennsylvania Otolaryngologists and their patients. I will continue the initiatives already in place and in addition focus on several new areas during my tenure: Value Based Medicine – This is the new reality. The PAO will help you negotiate this process with education and resources to help you transition over to these merit-based payment systems (MIPS) and Alternative payment models (APM’s).
Website Content – Under the leadership of Mike Ondik, MD, our website is already redesigned. Clinical content for patients will be added throughout this upcoming year and we look forward to a finished product by the June Meeting. Wellness – This is a very important issue affecting physicians in all specialties and in different stages of their career, including medical students. Otolaryngologists are not immune from burnout and career dissatisfaction. The PAO will take an active role in promoting wellness and work-life balance in our programs and in our meetings. Leadership Training – The PAO has served as leadership training for many of us who have served on its council. We want to provide a similar opportunity for all otolaryngologists. We will have sessions dedicated to leadership at our Annual Meeting. In collaboration with PAMED, leadership training programs will be available this year. Patient Safety – Primum non nocere, first do no harm, is the creed that we as physicians live by. At no time has this been more important. I have appointed PAO member Ellen Deutsch, MD, Medical Director at the Pennsylvania Patient Safety Authority, to lead an ad hoc committee on patient safety. Look for her Patient Safety Column to appear regularly in Soundings and for sessions at our annual meeting. I am honored to be your president and look forward to the next two years. Sincerely, Ahmed M.S. Soliman
BOARD OF GOVERNOR’S UPDATE
content Fall 2017
Karen Rizzo, MD, FACS, Board of Governor Representative, PAO-HNS
The AAO-HNS spearheaded opposition to the Audiology Physician Status Bill. A coalition of more than 120 physician organizations, led by the AAO-HNS, sent a letter to leaders in the U.S. House of Representatives expressing strong opposition to the Audiology Patient Choice Act (H.R.2276), which would provide audiologists with unlimited direct access to Medicare patients without a physician referral, as well as a limited license physician status under the Medicare program. The Pennsylvania Academy of Otolaryngology – Head and Neck Surgery also signed and supported opposition to this bill. The ENT PAC, the Academy’s political action committee, supported political events for U.S. Reps Bill Flores (R-TX); Linda Sanchez (D-CA); Michael Burgess, MD (R-TX); and David Scott (D-GA), who has been a strong champion for Truth in Advertising Legislation. Our
Legislative Advocacy staff continues to meet with lawmakers to secure additional sponsors for H.R. 1539, legislation to reauthorize the Early Detection and Intervention program. The AAO was successful in securing amendment language relating to labeling requirements and medically treatable causes of hearing loss. Once signed into law, the FDA will begin the regulatory process to create a category of OTC hearing aids. The AAO-HNS will monitor this process closely and provide comments during the rule making phase. Lastly, the FDA announced a major shift in tobacco policy by delaying the deadlines established for oversight of electronic cigarettes, cigars, and previously unregulated tobacco products for five years, while additional information and stakeholder feedback is collected. For more information on these topics contact govtaffairs@entnet.org.
3 Telemedicine in Otolaryngology 5 Persistent Obstructive Sleep Apnea after Adenotonsillectomy 7 Bone Anchored Hearing Devices 8 How The Pennsylvania Patient Safety Report System Improved Patient Safety 10 Legislative Update
PAO-HNS Past President Receives 2017-2018 Year-Round Leadership Academy Scholarship PAO WEBSITE TO PROVIDE UPDATED PATIENT INFORMATION Michael Ondik, MD Montgomery County ENT Institute
Dr. Jeffrey P. Simons has recently received a scholarship to participate in the 2017-2018 Year-Round Leadership Academy, provided by the Pennsylvania Medical Society. This year-long program provides physicians with broad, practical leadership training; facilitates networking and mentoring for participants; and helps them resolve challenges within their practice settings. Congratulations to Dr. Simons for this well-deserved recognition. 2
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We are pleased to announce that the patient information section of the PAO website is now under revision. We will be replacing the current patient information web pages with new articles written by our members that will cover the most common ENT conditions. The articles are being prepared in a uniform format and style that will be easily understood by patients. Our PAO Committee Chairs are leading this effort to create the new content and all PAO members are invited to help write. We will keep you posted on the status of this project.
President Ahmed M.S. Soliman, MD Temple Otorhinology Associates Kresge West Building 3440 N Broad St Fl 1 Philadelphia, PA 19140-5104 President-Elect Johnathan D. McGinn, MD Division of Otolaryngology – Head & Neck Surgery Penn State College of Medicine-Hershey 500 University Drive, MC H091 Hershey, PA 17033-2360 Secretary-Treasurer David M. Cognetti, MD FACS Otolaryngology-Head & Neck Surgery 925 Chestnut St Fl 6 Philadelphia PA 19107-4204 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 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.
Telemedicine in Otolaryngology Vanessa Christopher, BA; Ryan Rimmer, MD; Ailsa Falck, BS; David Cognetti, MD, Thomas Jefferson University Otolaryngology- Head and Neck Surgery
Telemedicine, sometimes referred to as “telehealth,” encompasses a broad array of applications that use telecommunications technology to remotely deliver care to patients.[1] The goals of telemedicine are to improve access to care while increasing efficiency for both the patient and provider. The practice of otolaryngology is particularly suited for telemedicine given that otolaryngologists are frequently located in urban centers without easy access for patients from more rural areas. Furthermore, many diagnoses within the field are based on objective data such as audiometry, endoscopy, lab work, and diagnostic imaging, which can be reviewed remotely.[2] The use of telemedicine within otolaryngology has been studied in the literature since the 1990’s.[3] It was initially used to link otolaryngologists with general practitioners in remote areas where specialist care was not readily available. This was achieved primarily via two methods: 1. synchronous, or 2. asynchronous. The synchronous method involves live teleconferencing, which is appealing due to its interactivity; however, it traditionally required considerable logistical coordination between all participants. Asynchronous methods are delayed and sometimes referred to as “store and forward”. With asynchronous methods, the initial provider collects all relevant patient data and then forwards this information to a specialist to be reviewed at a later time.[2] Thanks to significant technological advancement over the past twenty years,
the role of telemedicine has expanded.[4] Current applications allow for video-otoscopy, videoendoscopy, remote testing of cochlear implants, and overall improved ease and access of teleconferencing.[2] Additionally, telemedicine has been employed in a variety of clinical settings - from the initial patient encounter to preoperative and postoperative visits.[2,5] In the fall of 2015, the Department of Otolaryngology – Head and Neck Surgery at Thomas Jefferson University launched its telemedicine program allowing scheduled outpatient video visits with physicians. Telemedicine staff spent the initial weeks familiarizing themselves with the physicians and patients, introducing staff to the provider application, and registering patients for “JeffConnect” - the platform by which office visits would be scheduled. Initially, physicians were completing approximately four telemedicine visits per month. By March 2016, the Department grew to an average of 60 visits
per month. To date, the Department has completed over 1,000 telemedicine calls. The decision to participate in a telemedicine visit ultimately resides with the patient; however, many factors are taken into consideration including: type of appointment, comfort with technology, and distance from the clinic. The ability to perform a physical examination is the biggest limitation of telemedicine appointments,
comprised of patients with nonoperative complaints or follow-ups for recent results. Telemedicine was also used for long-term follow up of patients undergoing major head and neck surgery (e.g., thyroidectomy, parotidectomy, neck dissection), but not for the initial post-operative appointment in this subset. In a small minority of cases, telemedicine was used as the initial consultations for patients who could not
To date, the Department of Otolaryngology – Head and Neck Surgery at Thomas Jefferson University has completed over 1,000 telemedicine calls. and physicians must use judgement in selecting appropriate candidates. Within our Division of Head and Neck Surgery, most of the patients who participated in telemedicine appointments are postoperative encounters following sialoendoscopy or other minor head and neck surgery (e.g., lymph node biopsy or thyroglossal duct cyst excision). A similar proportion of visits was
attend an in-office visit due to travel concerns. In these patients, since physical examination could not be performed, subsequent inoffice appointments were scheduled before any plan of care was established. Careful selection of appropriate patients ensures that telemedicine remains an efficient and safe alternative to in-person visits. www.otopa.org | PAO-HNS
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In keeping with its goals, the advantages of telemedicine are numerous. It offers patients the ability to speak to their physician and receive medical updates, while reducing wait times and eliminating the need for transportation and parking fees. This benefit is magnified for institutions with large catchment areas where patients must travel long distances to their appointments. In a review of telemedicine patients within our Division of Head and Neck Surgery, the average commute avoided was 76 miles (~87 minutes). Visits typically last 5-20 minutes depending on the type of visit, and the average wait time was 10 minutes. Post-telemedicine surveys were always offered and, among respondents, 90% were satisfied with their visit.
...the most frequent obstacles to the telemedicine process are rooted in technological issues. As anticipated, the most frequent obstacles to the telemedicine process are rooted in technological issues. To successfully complete telemedicine appointments, patients must have either Apple or Android smart phones or tablets, or a computer with web-cam ability. Although the majority of patients have access to at least one of these options, there are occasionally individuals who lack such devices. The process also requires patients to have baseline knowledge of how to use such technology to download necessary applications and navigate through email. Finally, poor internet connection and malfunctions with downloading the necessary applications and computer software are periodic occurrences, particularly for patients in more remote locations. To mitigate these issues and support patients throughout the process, our telehealth department often performs test calls with patients prior to the scheduled telemedicine visit. As the field of otolaryngology continues to immerse itself in this new technology-based era of medicine, the future of telehealth is bright. In addition to scheduled outpatient telemedicine visits, our Department of Otolaryngology at Thomas Jefferson University has begun implementing “virtual rounds� on weekends. During these rounds, attending physicians remotely round with the oncall residents using Apple iPad videoconference technology. In collaboration with the residents, this allows attending physicians to virtually interact with patients and hospital staff, answer questions, and guide medical decision-making. This development is just another way in which telemedicine serves to enrich the patient experience. With appropriate patient selection and technological support, telemedicine can be an effective means of safely delivering patient care in multiple settings while maintaining high patient satisfaction. In our experience, this technology is particularly suited for otolaryngology and for institutions with large catchment areas to minimize patient travel time and improve efficiency. REFERENCES [1] Syms, M., & Syms III, C. (2001). The Regular Practice of Telemedicine: Telemedicine in Otolaryngology. Archives of Otolaryngology–Head & Neck Surgery, 127(3), 333-336. [2] Garritano, F. G., & Goldenberg, D. (2011). Successful telemedicine programs in otolaryngology. Otolaryngologic Clinics of North America,44(6), 1259-1274. [3] Sclafani, A., Heneghan, C., Ginsburg, J., Sabini, P., Stern, J., & Dolitsky, J. (1999). Teleconsultation in Otolaryngology. Otolaryngology- Head and Neck Surgery, 120(1), 62-72. [4] Olson CA, Thomas JF. Telehealth: No Longer an Idea for the Future. Adv Pediatr. 2017 Aug;64(1):347-370. [5] Beswick DM, et al. Consultation via telemedicine and access to operative care for patient with head and neck cancer in the Veterans Health Administration population. Head Neck. 2016 Jun;38(6):925-9.
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Persistent Obstructive Sleep Apnea after Adenotonsillectomy Christopher Azbell, MD and Allison Tobey, MD Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine
Multiple studies have demonstrated improvement or resolution of SDB (Sleep Disordered Breathing) as well as improvement in behavioral symptoms, school performance and quality of life metrics after surgery.
Sleep disordered breathing (SDB) in the pediatric population ranges from primary snoring to obstructive sleep apnea (OSA). The prevalence of OSA in children is up to 4%[1], however in children with craniofacial or neuromuscular disorders, it can be approach 100%. Moreover, habitual snoring with or without obstructive related arousals occurs in ~35% of children.[2] Symptoms include hyperactivity, anxiety, enuresis, emotional liability and depression and has also been associated with poor school performance and a decrease in quality of life.[3] Adenotonsillectomy has long been the first line of treatment in children with sleep disordered breathing. [4,5] Multiple studies have demonstrated improvement or resolution of SDB as well as improvement in behavioral symptoms, school performance and quality of life metrics after surgery.[3] An initial diagnosis of SDB is often made with a detailed history and physical exam alone without the need for further testing. Tonsillar and adenoid hypertrophy is the most common cause of SDB in children. Unfortunately, a significant number of children may have persistent SDB after adenotonsillectomy, with complete resolution in only 60% to 70% of patients.[6] Rates of resolution can be as low as 10% to 25% in obese children.[7] Children with craniofacial abnormalities, Down syndrome, cerebral palsy, or other comorbidities will also have a high likelihood of SDB after
adenotonsillectomy.[8] Postoperatively, if the patient’s symptoms, including snoring, apneas, behavioral issues, or school performance are improved or if post-operative apneas-hypopneas are <1, the SDB is often considered cured. However, when there are continuing symptoms there is likely persistent SDB that warrants further evaluation. Polysomnography (PSG) is an excellent tool to aid in work up and management of persistent sleep disturbances following adenotonsillectomy. PSG in children, especially those of younger ages, requires an overnight in-lab stay, as to date, home studies are not uniformly accepted as reliable secondary to the intricate nature of the setup, equipment needed and frequent need for technician adjustments throughout the night given movement and compliance.[9] Moreover, labs that specialize with working with children tend to yield better childspecific outcomes. Because of the need for pediatric specific sleep labs, PSGs are often expensive and time consuming for families. Nonetheless, PSGs provide useful information to quantify sleep disturbances and diagnosis other sleep related disorders such as periodic limb movement, seizures, narcolepsy, etc. Briefly, a PSG should quantify apneas, hypopneas, oxygen saturation, respiratory event related arousals (RERAs) and calculate apnea hypopnea index (AHI) and respiratory disturbance index (RDI). The RDI can often contribute
significantly to patients’ subjective sleep complaints as it incorporates all arousals related to respiratory disturbances (RERAs + hypopneas + apneas). Thus, a patient can have clinically significant symptoms even in the setting of an improved AHI. In the setting of persistent SDB, several medical and surgical options remain, including watchful waiting.[10] If symptoms are significant, an attempt to better localize the site(s) of obstruction can guide further medical or surgical management. Drug-induced sleep endoscopy (DISE) consists of flexible fiberoptic endoscopic examination during sedation mimicking “natural sleep” in order to study the dynamic upper airway anatomy. It was first described in the pediatric population in 2000 and has become the most frequent tool to assess persistent SDB after adenotonsillectomy.[8,11] Cine magnetic resonance imaging (MRI) can also provide detailed evaluation of upper airway collapse during sleep however is less readily used. Multiple classification schemes aimed towards identifying the anatomic site(s) of obstruction have been developed for both adults and children, but there is no universally accepted system for pediatric DISE. The VOTE classification is most widely utilized in the adult population, however, it lacks the ability to score all sites of obstruction pertinent to the pediatric population. A pediatric DISE grading system that describes all anatomic sites of possible www.otopa.org | PAO-HNS
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obstruction should include the nose, nasopharynx, retrovellum, oropharynx, retrolingual/tongue, epiglottis, arytenoids and some may argue glottis. Results from DISE and cine MRI in multiple studies have shown that most patients with persistent SDB after adenotonsillectomy have multilevel obstruction.[10] The most common site is tongue base obstruction. However, adenoid regrowth, supraglottic collapse, and inferior turbinate hypertrophy are also frequent locations of obstruction. Numerous surgical options are available to treat persistent OSA when the anatomic site is identified. Tongue base obstruction can be treated with lingual tonsillectomy using a variety of techniques. Radiofrequency ablation in combination with genioglossus advancement has been shown to be effective in some patients.[12] Osteogenic distractions of the mandible can be used to distract the tongue anteriorly. Hypoglossal nerve stimulation has been shown to be effective at treating in persistent OSA in adolescent patients with Downs syndrome, however, it is currently only available to adolescent patients with Downs.[13] Adenoid regrowth can be addressed with a revision adenoidectomy[10] and maxillary distractions or expansion techniques can create additional retrovellar and oral cavity space. Endoscopic inferior turbinate reduction with or without septoplasty can be effective in relieving nasal airway obstruction. Lastly, supraglottoplasty to address aryepiglottic folds, redundant arytenoid mucosa, or a posteriorly displaced epiglottis can relieve supraglottic obstruction. If no clear target for further surgical therapy is identified, or if parents wish to avoid further surgical interventions, a variety of non-surgical therapies are also available. Continuous positive airway pressure (CPAP), which is the mainstay of treatment of OSA in the adult population, can be tolerated in older children, but is not always practical for younger patients, due to poor compliance.[14] Centers have developed de-sensitization programs to help improve compliance, however it remains a limiting factor when treating SDB in children. Medical therapy targeted at relieving nasal obstruction as a contributor for SDB has been well studied. Nasal corticosteroids are the most studied. Randomized controlled trials in pediatric patients showed significant improvement 6
SOUNDINGS | Fall 2017
in AHI with fluticasone and budesonide sprays.[15,16] The drugs work to decrease lymphoid tissue size, and therefore may be useful in cases of adenoid regrowth, and to decrease mucous gland hypertrophy and therefore reduce
space for the tongue and increases the width of the nasal floor. Oral appliances aim to anterior displace the tongue, however require production costs and carry risks of poor compliance, jaw pain and changes to occlusion.
If symptoms are significant, an attempt to better localize the site(s) of obstruction can guide further medical or surgical management. turbinate size and secretion production. The decreased secretion production decreases turbulent airflow. Leukotriene receptor antagonists (LRAs) have also demonstrated effectiveness in decreasing AHI. LRAs decrease lymphoid tissue size and therefore may be useful for adenoid regrowth and lingual tonsillar hypertrophy. A recent blinded, controlled study showed reduction of AHI from 3.9 to 1.7 in a group of children age 2-10 who received 12 weeks of oral montelukast.[17] The combination of intranasal steroids and oral leukotriene antagonists has also shown to be effective in children with mild residual OSA after adenotonsillectomy.[18] In this study, children with an AHI of 1-5 on a PSG 10 to 14 weeks after adenotonsillectomy were treated with twelve weeks of intranasal budesonide and montelukast. Post-treatment PSG showed a mean decrease in AHI from 3.6 pre-treatment to 0.3 post-treatment. Rapid maxillary expansion (RME), oral appliances, oropharygneal exercises, positional therapy and weight loss have been shown to improve OSA/SDB in children but only in small sample studies.[19,20] RME increased the width of the palate and thus creates more
Oropharyngeal exercises strengthen upper airway dilators, but require active, ongoing participation. Non-surgical weight loss through lifestyle modification has also been shown to decrease AHI and improve oxygen saturation,[21] however, is difficult in non-structured, uncontrolled outpatient setting. The pediatric airway is a continuously changing system with multiple sites of obstruction that can improve or worsen with growth. Although adenotonsillectomy remains the primary surgical method of treatment, it will still fail in a significant proportion of patients. Patients and families must be appropriately counselled preoperatively that there is a chance of needing further workup and medical or surgical management. In certain patients, watchful waiting may even be an appropriate strategy, however, when obstructive sleep apnea persists after adenotonsillectomy, a wide range of diagnostic and therapeutic interventions are still available to the otolaryngologist. REFERENCES [1] Baugh RF, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144:S1-30.
[2] Li AM, Zhu Y, Au CT, et al. Natural history of primary snoring in school-aged children: a 4-year follow-up study. Chest. 2013;143:729-735 [3] Mitchell RB, Kelly J. Behavior, neurocognition and quality-of-life in children with sleep-disordered breathing. Int J Pediatr Otorhinolaryngol. 2006;70:395-406. [4] Brietzke SE, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg. 2006;134:979-984.
Bone Anchored Hearing Devices Barry E. Hirsch, MD and Andrew A. McCall, MD, University of Pittsburgh Medical Center
[5] Mitchell RB, Kelly J. Outcomes and quality of life following adenotonsillectomy for sleep-disordered breathing in children. ORL J Otorhinolaryngol Relat Spec. 2007;69:345-348. [6] Friedman M, Wilson M, Lin HC, et al. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head neck Surg. 2009;140:800-808. [7] Costa DJ, Mitchell R. Adenotonsillectomy for obstructive sleep apnea in obese children: a meta-analysis. Otolaryngol head Neck Surg. 2009;140:455-460 [8] Myatt HM, Beckenham EJ. The use of diagnostic sleep nasendoscopy in the management of children with complex upper airway obstruction. Clin Otolaryngol Allied Sci. 2000;25:200-208. [9] Scalzitti N, Hansen S, Maturo S, et al. Comparison of home sleep apnea testing versus laboratory polysomnography for the diagnosis of obstructive sleep apnea in children. Int J Ped Otolaryngol. 2017;100:44-51. [10] Manickam PV, Shott SR, Boss Ef, et al. Systematic review of site of obstruction identification and nonCPAP tratment options for children with persistent pediatric obstructive sleep apnea. Laryngoscope. 2006;126:491-500. [11] Durr ML, Meyer AK, Kezirian EJ, et al. Druginduced sleep endoscopy in persistent pediatric sleep-disordered breathing after adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 2012;138:638-643. [12] Wootten CT, Shott SR. Evolving therapies to treat retroglossal and base-of-tongue obstruction in children with sleep apnea. Arch Otolaryngol Head Neck Surg. 2010;136:983-987. [13] Diercks GR, Keamy D, Kinane TB, et al. Hypoglossal nerve stimulator implantation in an Adolescent with Downs Syndrome and sleep apnea. Pediatrics. 2016;137(5):e1-6. [14] Marcus CL, Ward SL, Mallory GB, et al. Use of nasal continuous positive airway pressure as treatment of childhood obstructive sleep apnea. Pediatr 1995;127:88-94. [15] Brouillette RT, Manoukian JJ, Ducharme FM, et al. Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. J Pediatr. 2001;138:838-44. [16] Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics. 2008;122:149-155. [17] Goldbart AD, Greenberg-Dotan S, Tal A. Montelukast for children with obstructive sleep apnea: a double-blind, placebo-controlled study. Pediatrics 2012;130:575-580. [18] Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. 2006;117:61-66. [19] Villa MP, Rizzoli A, Rabasco J, et al. Rapid maxillary expansion outcomes in treatment of obstructive sleep apnea in children. Sleep Med. 2015;16(6): 709-16 Guilleminault C, Huang YS, Sato R, et al. Critical role of myofascial reeducation in pediatric sleepdisordered breathing. Sleep Med. 2013; 14(6):518-25. [20] Verhulst SL, Franckx H, Van Gaal L, et al. The effect of weight loss on sleep-disordered breathing in obese teenagers. Obesity. 2009;17:1178-1183.
The normal physiologic means of hearing is the reception of sound waves that enter the ear canal, vibration of the tympanic membrane and ossicles, and transmission of the sound energy into the inner ear. These sound waves are then transformed into electrical signals through the organ of Corti. The inner ear can also be stimulated with sound vibration delivered directly to the cochlea through bone conduction. Via this mechanism, vibrations of the skull are transmitted to the inner ear and are similarly picked up by the basilar membrane and transduced by the hair cells in the organ of Corti into neural signals of the cochlear nerve. Hearing loss can be categorized as conductive, sensorineural, or mixed loss. Conductive loss can be alleviated through surgical correction or a hearing aid. Pathologic conditions may exist where sound energy cannot be delivered sufficiently or safely by sound amplification from a hearing aid. For example, diseases of the ear canal, such as skin intolerance, chronic otorrhea, or canal stenosis (particularly at the meatus), may prevent a patient from successfully using a hearing aid. Similarly, the sequelae of chronic otitis media, such as a large canal wall down cavity with drainage, or some congenital malformations of the middle or external ear may not be suitable for a hearing aid. This form of conductive loss can be helped with a bone anchored hearing system (BAHA). Single sided deafness cannot be rehabilitated with a hearing aid in the side of the loss. Patients can be helped by using a contralateral routing of signal (CROS) hearing device. The CROS aid system requires that the patient have two devices, one the receiver-transmitter in the poor ear and the other a receiver-amplifier in the better ear. Alternatively, BAHA can be used in patients with single sided deafness to provide transcranial stimulation from the anacoustic hear to the hearing ear. BAHA devices are surgical implanted into the posterior squamosa of the temporal bone. Sufficient space is needed behind the pinna to accommodate the sound processor. The two means of connection to the skull are via a transcutaneous (across the skin) or percutaneous (through the skin) attachment. There are specific audiometric criteria that should be present to justify when a BAHA can be offered. Patients with a conductive hearing loss of >30dB are candidates for a bone conduction system. The loss does not have to be strictly conductive. Patients with a mixed loss with bone (nerve) loss up to 65dB are also eligible for considering this hearing system. More powerful stimulating processors are available to provide sufficient stimulation in this setting. Patients with single sided deafness need to have sufficient cochlear reserved on the normal hearing side. Bone hearing threshold should be less than 20 dB. There are currently three manufacturers that provide products and support for bone anchored hearing devices: Oticon, Cochlear Corporation, and Sophono continues on page 9 www.otopa.org | PAO-HNS
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How The Pennsylvania Patient Safety Reporting System Improves Patient Safety Ellen S Deutsch, MD, MS, FACS, FAAP, Medical Director, Pennsylvania Patient Safety Authority
Do you know how the Pennsylvania Patient Safety Authority helps prevent patient harm and improve patient safety? Many physicians in Pennsylvania are not aware of the work we do or the resources we provide; I appreciate this opportunity to provide information. Our mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Our vision is safe healthcare for all patients. We work toward these goals in several ways, including analysis of incidents and serious events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS). Pennsylvania has one of the oldest and broadest state safety event reporting systems in the US. Many unique, important and insightful aspects of our reporting system make it exceptionally valuable. First, reporting of patient care events is based on unanticipated patient harm, rather than error. While error may contribute to some events of harm, there are circumstances in which harm occurs which are not the result of error. Second, reporting includes events in which harm could have occurred, but did not. These could be events which reached the patient, but did not cause harm; events in which chance or an active intervention prevented the 8
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event from reaching the patient; and even unsafe conditions, which could potentially impact many patients. This allows analysis of hazardous conditions or latent patient safety threats even before harm occurs. Finally, our state-wide perspective allows us to identify events and patterns of harm that are not necessarily apparent within single facilities or single healthcare systems. We analyze the incident and serious event reports submitted to the PA-PSRS and provide information and education in a variety of formats, including a peer-reviewed quarterly journal, the Pennsylvania Patient Safety Advisory, freely available online at http://patientsafety.pa.gov (select “Advisories and Events”). CME can be obtained for selected articles through PAMED. We also participate in collaboratives and provide in-person presentations, webinars, and online learning opportunities.
Here are examples of information obtained through analysis of PA-PSRS data: • O n average, one wrong site
operating room surgery event occurs every week in Pennsylvania. PA-PSRS contains reports of 717 wrong-site operating room surgery events that occurred
from July 2004 through September 2016. Wrong-site surgery events reported by ambulatory surgical facilities comprise almost a third of those reports. Errors include performing tonsillectomy instead of or in addition to adenoidectomy, when only adenoidectomy was intended (http://patientsafety. pa.gov/ADVISORIES/ Pages/201612_160.aspx). • T here were 70 reports of
surgical fires reported through PA-PSRS for the 7-year period ending in June 2011. 18 involved the head, five the neck, and one each the nasopharynx and trachea. Three involved the surgeon’s hand. An update is pending (http:// patientsafety.pa.gov/ADVISORIES/ Pages/201212_130.aspx). • F rom 2014 through 2015, 1
to 2 retained surgical items were reported per 100,000 patient procedures (http:// patientsafety.pa.gov/ADVISORIES/ Pages/201703_RSI.aspx). • M ore than a quarter of the
24,000 hospital acquired infections (HAIs) reported were surgical site infections,
for the 12-month period ending in March 2015. 19% of reported HAIs were caused by multidrug resistant organisms and 17% by C. difficile (http:// patientsafety.pa.gov/ADVISORIES/Pages/201512_149.aspx). •
here was a 66.4% decrease in the number T of reports of wrong-drug events involving opioids in 2014 compared with 2005 (http:// patientsafety.pa.gov/ADVISORIES/Pages/201603_29.aspx).
•
A-PSRS received 446 reports of patients P with delirium in the 10-year period ending in 2015. Injuries included falls resulting in fracture; intracranial bleeding; and death (http://patientsafety. pa.gov/ADVISORIES/Pages/201509_85.aspx).
Information is available about many other conditions and circumstances that may affect our patients, such as dementia, intoxication, weight-related medication errors, drug-drug interactions, simulation, antibiotic stewardship and much more. Advisory articles include data analysis along with evidence-based and expertise-based risk reduction strategies. In addition, the Advisory contains commentaries addressing patient safety concepts such as complex adaptive systems, work-as-imagined versus work-as-done, “data data everywhere,” and Safety-II (understanding what goes well in healthcare delivery). The MCARE Act (Act 13 of 2002) established the Authority as well as other reporting and patient safety requirements for facilities, including hospitals and ambulatory surgical facilities in Pennsylvania. Reports are confidential and nondiscoverable. Reporting by faculty and trainees can contribute to fulfilling the ACGME CLER requirements. The Authority estimates the combined efforts of Pennsylvania healthcare facilities, statewide quality improvement entities, and the Authority have contributed to saving more than 2,600 lives and more than $147 million dollars since the Authority was created by the MCARE Act. After healthcare providers submit reports within their internal reporting systems, Patient Safety Officers (or designees) in each facility assign harm scores and submit patient safety event reports through PA-PSRS. The Patient Safety Authority receives reports of incidents and serious events, which it analyzes to develop and disseminate aggregate information and education. Our function is distinct from the regulatory responsibilities of the Pennsylvania Department of Health, which receives reports of serious events, infrastructure failures, and a specific category of “other” but does not receive reports of incidents. In 2016, the Authority received more than 250,000 reports from acute healthcare facilities; 97% of these were incidents (rather than serious events), bringing the total number of reports received to 2.76 million since data collection began in June 2014. Each hospital and ambulatory care facility in Pennsylvania has a Patient Safety Officer, and the Authority has Patient Safety Liaisons (PSL) geographically distributed throughout the state. Your facility’s PSL, the Authority’s Patient Safety Analysts and I would be happy to respond to informational inquiries; provide presentations based on analysis derived from PA-PSRS or general concepts of safety to your facilities, your departments or your trainees; and discuss how we might collaborate on safety projects. Please send inquiries to https://www. surveymonkey.com/r/PSASpeakerRequest and reference this Soundings article.
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owned by Medtronic. Sophono’s unit is called Alpha-2. It is a transcutaneous system using an implant containing two magnets that are recessed into the skull giving a slim profile. It is recommended that three months be given for osseointegration before the external processor is connected. Similar to all devices, recipients must be older than five years of age to be eligible. The other transcutaneous device is the Cochlear Attract. A fixture screw is implanted into the post auricular bone and a disc magnet is attached and placed below a skin flap. After a period of one month of healing the external processor can be attached. Due to the polarity and fixation of the internal magnet, the device is considered MRI conditional (for up to 1.5T) though there will be considerable distortion of a wide area around the implant. This is an important consideration, particularly in patients that require periodic MRI scans to monitor pathology in the ipsilateral temporal bone or posterior fossa.
Along with more compact and sleek designs, there are now more powerful processors with enhanced technologic features. In contrast to the previous two devices, the Cochlear Connect and Oticon Ponto hearing devices have an abutment that comes through the skin. While the incidence of wound problems is higher in patients with a percutaneous abutment, these devices have the relative advantage of bypassing the attenuation of sound signal through the skin with transcutaneous devices. The incidence of wound problems must be accepted both by the patient and surgeon. Despite refinements in surgical technique, patients with a percutaneous device are potently subject to focal inflammation, drainage, keloid formation and skin over closure. This may require routine hygiene and vigilance on the part of the patient to minimize these complications. Patients with a percutaneous device should be monitored on a routine basis. If keloid or skin hooding should develop, topical steroid cream or intralesional steroid injections are helpful. It is strongly recommended that a trial of using these devices in the clinic, attached with a firm or soft headband (for Attract or Alpha-2) be given. Patients can express their level of satisfaction and if they wish to proceed. There have been significant advancements in the external sound processors. Along with more compact and sleek designs, there are now more powerful processors with enhanced technologic features. These include the availability of external wireless microphones and connectivity to other sound sources such as television and smart phones. In contrast to conventional hearing aids, this form of surgical intervention is usually covered by patients’ health insurance. In patients with an existing BAHA device, the external processor may be eligible for an upgrade supported by their health insurance. In summary, otolaryngologists should strongly consider using bone anchored hearing devices for hearing rehabilitation of patients with conductive, mixed, or sensorineural hearing loss (single sided deafness), particularly in patients who are not candidates for sound amplification through hearing aids.
www.otopa.org | PAO-HNS
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Legislative Update Milliron & Goodman, LLC
As this is being written, the Pennsylvania General Assembly is returning to voting session after the summer. When they return to vote, the primary focus will be on the Commonwealth’s outstanding budget requirements. The House, Senate, and Governor’s Office continue to try and resolve our state’s dire financial structure. In the meantime, the Academy of Otolaryngology continues to work legislatively to uphold quality medicine and patient safety. While there are numerous medical issues being considered by the General Assembly, we do our best to be PAO-HNS focused. On the flip side, we continue to defend our patients from unsafe practices and scope of practice encroachment. How we do this is through numerous channels, including good old fashioned advocacy from our member physicians. Our Academy’s strength has always been the willingness of the providers to participate. Be an advocate for your patients and profession. If you are reading this, you are already showing an interest in issues that have a direct impact. Make sure you are an advocate and spend time with your local House and Senate members. Make sure they know you well enough to call when they are making a policy decision in regard to healthcare.
balance, raising questions about whether the state can legally spend money.
LEGISLATION Milliron Goodman continues to work with the Academy’s leadership on legislation affecting your profession, your colleagues, and your patients. Some of the noteworthy bills we advocate on behalf of include smoking cessation, World voice, telemedicine, and online hearing aid sales.
2017 FALL LEGISLATIVE SESSION SCHEDULES SENATE FALL SESSION SCHEDULE September
18, 19, 20
October
16, 17, 18, 23, 24, 25
November
13, 14, 15
December
11, 12, 13, 18, 19, 20
HOUSE FALL SESSION SCHEDULE
BUDGET UPDATE
September
11, 12, 13, 25, 26, 27
The state House and state Senate have returned to Harrisburg for the fall legislative session. We are still in the midst of budget negotiations and lawmakers are focused on completing the 2017-18 state budget, which started July 1.
October
2, 3, 4, 16, 17, 18, 23, 24, 25
November
13, 14, 15, 20, 21, 22
December
4, 5, 6, 11, 12, 13, 18, 19, 20
Although Governor Tom Wolf let a nearly $32 billion budget bill become law without his signature, there is still much work to do. With the spending plan enacted, lawmakers must come up with $2.2 billion to balance the books and work on legislation necessary to enact the budget (i.e. the Code bills that direct how the dollars are spent). Also held up in the Legislature are measures to provide state funding to Penn State, Pitt, Temple, Lincoln, and Penn. Budget talks have been intense. New revenue options and how much in new, repeating revenues (i.e. taxes) is a major sticking point between the House and Senate chambers. Revenue options being discussed include borrowing against or selling a portion of future tobacco settlement payments, gambling expansion, tax credit reductions, taxing natural gas drillers, imposing new or additional taxes on consumers’ utility bills (telephone, electric and gas), and special fund transfers, including $200 million in reserves from the state-created medical malpractice insurer of last resort for doctors in the state. We are cautiously optimistic that an agreement will be worked out soon to avoid a repeat of the nine-month gridlock of the 2015-2016 session. However, the situation is still fluid. The state’s Constitution requires a balanced budget. Without a revenue package, the budget remains out of
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SOUNDINGS | Fall 2017
GRASSROOTS ADVOCACY At Milliron Goodman, we spend a lot of time emphasizing the importance of getting to know your legislators and more importantly, making sure they know you. We also will help you get engaged, if needed. By calling us or emailing, we can start the process of making you a profession advocate. Your involvement in the legislative process is crucial to the future success and stability of your profession and the care of your patients. If you have any questions regarding this legislative update or would like to get involved, please do not hesitate to contact us at 717.232.5322. We have an open-door policy.