Approaches and procedures are in flux almost constantly in medicine, and three experts at a panel session shared their approaches to three different areas of care: tonsillectomy, sialendoscopy, and cultivating trust with patients.
Explore This IssueMarch 2015
Hearing from colleagues can lead to a change in perspective and approach, said panel moderator Michael Friedman, MD, professor of otorhinolaryngology-head and neck surgery at Rush University in Chicago. “Doing procedures the way we did them when we were residents usually does not occur—there’s not a single procedure I do the same way I did a year ago,” he said. “I think one of the things that all of us look for is new ways to do the same thing.”
Sukgi Choi, MD, chair of pediatric otolaryngology at the Children’s Hospital of Pittsburgh, reviewed approaches to tonsillectomy, for which there are newly emerging options, each with pluses and minuses.
The cold tonsillectomy, the most conventional approach, is still commonly used, although Dr. Choi said she does not often use it. The advantages are that the tools used are very simple and it’s inexpensive. The downside is the blood loss. “The total blood loss is not very high but does obscure field of vision,” she said.
With Bovie electrocautery, another inexpensive option used by many surgeons, the goal is to minimize damage to underlying tissue. “The major criticism of this technique is that there is thermal injury to the underlying musculature, a significant amount of post-op pain and also increased post-op bleeding,” she said.
With coblation, which uses radiofrequency energy and ionized saline, an advantage is that there is relatively low heat generated—just 45° to 85° Celsius, compared with 400° Celsius for electrocautery. Plus, suction is attached, improving visibility. There are some concerns about bleeding, since the low temperature doesn’t help seal blood vessels, but Dr. Choi said those findings are still debatable. The procedure is also expensive, she added.
Microdebrider intracapsular tonsillectomy leaves residual tonsillar tissue but has a high level of effectiveness and less post-operative pain and bleeding than more traditional methods. But again, Dr. Choi said, it is an expensive approach.Ultimately, she said, “The surgeon’s experience and skill matter more than the tools.”
Arjun Joshi, MD, associate professor of head and neck surgery and microvascular reconstruction at George Washington University School of Medicine and Health Sciences in Washington, D.C., walked the audience through the steps of this procedure and said it is a tool that should be used more often in a diagnositc setting, and is especially useful in guiding management. “We don’t really have any good tool to study people who say that their gland is swelled,” he said. “And I think that diagnostic sialendoscopy is something that we should perform much more often because you’ll find so much more pathology than you were expecting.”
He performs most of his procedures in the office setting, while most others in the U.S. perform them in the operating room. During the procedure, the patient is awake and in a semi-sitting position, and the procedure is occasionally performed using loupes, with just one medical assistant or medical student needed. After the duct is topically anesthetized, Dr. Joshi looks for the papilla visually by finding the interdental impression on the buccal mucosa; the parotid papilla is almost always above that. The submandibular papilla is locted just next to the frenulum.
If you can’t find the duct, one option is to paint methylene blue over the mucosa and then use external pressure to force saliva through, giving a better idea of where the papilla is. Also, vitamin C or citric acid powder can cause saliva to flow freely, which will help with identifying the papilla. Injecting lidocaine with epinephrine under the papilla will create tension, which can also help with identification.
Finding and gaining access to the papilla is probably the biggest challenge with the procedure. “It definitely is a steep learning curve,” he said.
Once the papilla is found, it’s carefully probed with a lacrimal probe and dilated gently with a conical dilator. When using the scope, he uses his dominant hand to introduce it and to localize the pathology and stabilizes its position with his nondominant hand.
Indications for sialendoscopy include diagnosis, dilation, irrigation, and steroid instillation for stenosis or chronic sialadenitis, as well as removal of small stones up to 4 mm or 5 mm, depending on orientation and position. It can also be used as an adjunct to transoral sialolithotomy, in helping localize pathology in open techniques, and with ultrasound for localization.
“What I’ve noticed is that there is a trend now toward more treatment for stenosis and less for calculi because the stones that I get are usually too big for purely endoscopic treatment,” Dr. Joshi said. “There’s definitely a lot more room for advancement in this field in terms of studying patients with Sjogren’s syndrome, radioactive iodine sialadenitis, and juvenile recurrent parotitis.”
Earning Patient Trust
Mark Persky, MD, director of the head and neck center at New York University Langone Medical Center in New York City, said that developing trust with patients is all about “honesty, honesty, honesty”—honesty with patients, honesty with colleagues, and honesty with yourself.
Honesty with yourself, he said, is “probably the most difficult honesty to attain.” It’s important to realize when “money interferes with good medicine,” but sometimes that’s not easy to do, he said.
“There’s a very simple formula for success: Do unto others as you would have done unto yourself,” he said. “Just put yourself in the patient’s position. How would you like to be treated? How would you like to be talked to if you had the same problem that the patient presents to you with? It’s very simple, but it seems very difficult for most physicians to obtain.”
The initial impression is crucial in creating good rapport. This goal is facilitated when an actual person answers the phone and when that first contact asks the right questions in advance to make the first visit run smoothly. Also crucial are office cleanliness and staff who are respectful of patient needs and privacy. “The most important thing is the time you spend with the patient,” he said. “There’s no substitute for that.”
Physicians should aspire to be “professional, confident, polite, and sympathetic.” Dr. Persky said that rushing can lead to mistakes and miscommunication, and he advised that physicians who are running late should always apologize.
When discussing treatment options, he presents them and then gives his preference before asking the patients for theirs. “They’re there for your experience and expertise, so I tell them what my preference is after presenting all the options.”