In January 2021, the pediatric otolaryngologists at Nemours Children’s Hospital in Orlando, Fla., performed just 18 bilateral myringotomies and tube placements.
Before the COVID-19 pandemic, the team was regularly doing an average of 150 such surgeries each month. That number, of course, dropped to nearly zero last March, when state governments issued stay-at-home orders and elective surgeries were canceled. Nationwide, adult and pediatric otolaryngology clinic volumes decreased by about 30%; some practices reported decreases of almost 50%.
In recent months, volume has rebounded somewhat as states have relaxed COVID-19-related restrictions and vaccinations have decreased public concerns regarding disease transmission. However, appointments and surgical volumes have yet to return to pre-pandemic numbers. The pediatric otolaryngologists at Nemours Children’s Hospital performed 52 bilateral myringotomies and tube placements in February 2021—a nearly three-fold increase over the month previous. But in March, they performed only 53, or about one-third of the division’s usual volume.
Their experience isn’t isolated. According to Eric Gantwerker, MD, MMSc (MedEd), pediatric otolaryngologist at Cohen Children’s Medical Center at Northwell Health/Hofstra in Hempstead, N.Y., adult-oriented otolaryngology clinic and surgical volumes have rebounded to about 90% of their usual numbers. Pediatric cases, however, seem stalled at about 75% percent of pre-pandemic volume.
What do these decreased numbers mean for pediatric otolaryngologists and the families and communities they serve? Which pandemic-necessitated shifts in care delivery will persist? And how should pediatric laryngologists prepare for post-pandemic practice?
ENT Today asked physicians around the country to share their thoughts on the future of pediatric otolaryngology. Here are their predictions:
Healthcare Systems/Physician Practices Will Scramble to Make Up Lost Revenue
For decades, pediatric tympanostomy tube placements, tonsillectomies, and adenoidectomies have been the mainstay of otolaryngology practices. These relatively easy-to-perform, typically uncomplicated procedures can usually be completed in minutes—and net substantial income for hospitals, surgery centers, and physician practices. The nationwide pause on elective surgeries deeply affected the bottom line of hospitals, healthcare systems, and physicians.
“Because our U.S. healthcare system is a fee-for-service model, the decrease in pediatric ENT volume had a significant negative impact on children’s hospitals and practices, as well as community general otolaryngologists,” said Julie Wei, MD, division chief of otolaryngology at Nemours Children’s Hospital. “The financial impact isn’t just surgeon-related procedural fees, but anesthesia and facility fees, as well as all other associated procedural costs and revenues, such as audiology services.”
Of course, tympanostomy tube placements—and other common pediatric surgeries—had been trending downward even before the pandemic in response to clinical evidence showing that surgery isn’t necessary to manage many cases of recurrent otitis media and strep throat.
“Globally, over the last five years or so, while still a significant portion of our practice, we weren’t seeing as many kids coming in for ear tubes and tonsillectomies as we did around 15 years ago,” said Karen Zur, MD, chief of the division of otolaryngology at Children’s Hospital in Philadelphia (CHOP).
The sudden cessation of elective surgeries in early 2020 certainly accounts for much of the dramatic decline in surgical volumes from 2019 to the present. Physicians expect that numbers haven’t fully bounced back because many children remain home from school and daycare, and mask wearing, social distancing, and increased attention to hygiene have reduced children’s exposure to bacteria and viruses. Decreased exposure to germs means fewer cases of otitis media and strep throat, which may be one reason why tube placement and tonsillectomy numbers remain down nationwide.
Additionally, many parents and guardians who would once have brought their children in as soon as they noted fever or discomfort didn’t do so in 2020, as they were concerned about possible COVID-19 exposure in healthcare settings. Some of these adults learned that waiting two or three days may make the problem go away, Dr. Gantwerker said, noting that the so-called “worried well” typically accounted for a large majority of patients seen in urgent cares and pediatricians’ offices, and that some of these patients ended up being referred for ear tube placement or other procedures.
We were able to do multidisciplinary clinics through telemedicine with our aerodigestive team, with speech-language pathologists, pulmonary, gastroenterology, and otolaryngology all on a call at the same time. —Karen Zur, MD
So, on the one hand, the decrease in the number of children presenting for otolaryngologic surgery is positive. “We should celebrate children being healthier, and the effectiveness of social distancing and masking,” Dr. Wei said. “Yet, in our current health system, this achievement comes at significant cost and stress to surgeons and their employers, as it impacts income and revenue, with subsequent consequences leading, in some cases, to reductions in force or salary and the need to identify other ways to fill clinics with excess capacity.”
Pediatric otolaryngologists expect an increase in clinic volume in late summer or fall, after large numbers of children return to school and daycare and public mask wearing wanes. This uptick in volume may well lead to an uptick in surgical procedures, and in many cases, these surgeries will be warranted. However, some physicians are privately concerned that economic pressure could influence clinical decision making and patient care.
Telehealth Is Here to Stay, and May Expand Access to Specialized Services
Like so many other professionals, pediatric otolaryngologists turned to telemedicine to continue to care for patients throughout the pandemic. Some had been using the technology prior to 2020—a portion of the airway team at CHOP, for instance, was using telemedicine to connect with chronic tracheostomy patients—but it wasn’t a commonly used tool.
Though initially adopted as a temporary solution, nearly all physicians agree that telehealth is here to stay. Pediatric otolaryngologists and families have come to appreciate the convenience of virtual visits, and that many initial evaluations can be effectively conducted via video chat. Telehealth also allows healthcare professionals to provide specialized services to patients who may not otherwise be able to access those services.
“We were able to do multidisciplinary clinics through telemedicine with our aerodigestive team, with speech-language pathologists, pulmonary, gastroenterology, and otolaryngology all on a call at the same time,” Dr. Zur said. “I had a telemedicine patient in Hawaii who came here after the restrictions lifted a little, and we successfully performed surgery. He went back to Hawaii, and we followed up with telemedicine. It was great.” Families, she added, really appreciated the convenience of not having to travel with medically fragile children.
The pediatric otolaryngology team also learned that telemedicine can be effectively used to screen and triage patients with voice disorders. “Part of the triage is to listen to someone’s voice quality,” Dr. Zur said. “We can do evaluations through telemedicine and then bring in patients for otoscopies, endoscopies, and procedures as needed.” A voice therapist can also join the virtual visit, and if the therapist thinks the patient may benefit from voice therapy, those services can be provided via telehealth.
Pediatric voice therapy isn’t widely available; in fact, patients who live far from an academic medical center don’t usually have access to this specialized service. Telehealth has allowed CHOP patients convenient access to voice therapy “from someone who’s an expert in the field,” Dr. Zur said. Going forward, CHOP’s pediatric otolaryngology team plans to continue using telemedicine as an adjunct to follow children with certain pediatric voice, airway, and general pediatric otolaryngology disorders.
Telehealth may allow physicians to see patients from a distance, but the technology doesn’t allow for easy visual inspection of patients’ ears, so it can’t be used as a replacement for in-person care.
Pediatric Otolaryngologists May Focus on Complex Cases—or Not
Some physicians expect that the decline in clinic visits and surgical intervention for otitis media and pediatric sleep apnea will affect general otolaryngologists more than pediatric otolaryngologists working at tertiary medical centers. Many community-based generalists make much of their income performing relatively routine procedures; if numbers stay down, they’re more likely to be impacted than pediatric otolaryngologists who care for children with complex otolaryngologic disorders. And, if fewer children are presenting with relatively routine health complaints—otitis media, middle ear effusion, enlarged tonsils—specialists can concentrate their attention on complex cases.
“I wonder if we’ll start to see higher subspecialization of patients coming to our pediatric otolaryngologists, while general community otolaryngologists handle the more routine stuff,” Dr. Gantwerker said.
However, given that “routine stuff” is often the economic engine of community practices, it’s also possible that financial distress will cause some general otolaryngologists to close their practices. Practice closures, combined with a possible wave of early retirements due to COVID-19-related burnout, could result in physician shortages and increased caseloads for remaining physicians, as well as decreased access to care for patients and families.
Pediatric otolaryngologists may also be called upon to treat children with long-term COVID-19 symptoms. The United Kingdom’s Office for National Statistics estimates that around 13% to 15% of children who have COVID-19 experience symptoms for longer than five weeks, and Dr. Zur says her team has already seen some children with long-term COVID-19 symptoms. Commonly reported otolaryngologic symptoms include tinnitus and persistent loss or alteration of taste or smell. Some children haven’t regained their baseline functioning even months after infection.
Dr. Wei is a bit concerned because she has treated two children (one, aged 10 months; the other, aged 15 months) who developed “horrific sleep apnea and massive tonsils” a few months after COVID-19 infections. “Is that random, or is that because they had COVID?” she said. “No one knows.”
Systemic Inequities Need to Be Addressed
Families with reliable internet connections were able to consult physicians virtually throughout the pandemic. Some families even purchased digital otoscopes so they could upload photos of their children’s ears for physicians to review.
Other families lost income and health insurance. As a result, many children with hearing loss, sleep apnea, and other medical conditions didn’t receive treatment. And, because schools were closed, countless children who require speech therapy for autism, Down syndrome, or speech delays lost a year or more of therapy during critical windows of development. “We haven’t even begun to measure the impact of the disruption to therapy sources,” Dr. Wei said.
The ripple effects of delayed or deferred medical care will likely be seen over the years to come. Pediatric otolaryngologists must be prepared to address health conditions that worsened due to a lack of medical care and should advocate for funding and programs to address systemic inequities in access to care.
The COVID-19 pandemic upended healthcare and exposed complicated questions about access to and funding for pediatric otolaryngology services. These issues will likely linger long after COVID-19 vaccinations have curbed the spread of the novel coronavirus. The practice of pediatric otolaryngology may be forever changed.
Jennifer Fink is a freelance medical writer based in Wisconsin.