The Medical Side to ENT

[EChipouras]

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Hi,

I'm interested in ENT as a possible specialty. I like the idea of going into a field that has a good split between medical management and surgical management. I was wondering if you residents/attendings could describe some of the medical management that you do for patients in your office. Approx. how many medical cases do you do (compared to surgical cases)?

Also, to what extent does your practice overlap with that of an allergist (ie boarded in IM and then allergy)?

Thanks!

 

[resxn]

I think the American Academy of Oto/HNS says that 15-20% of the patients presenting to a general ENT become surgical cases. I believe that only means those that go to an OR, not those that get minor procedures in the clinic, which by CMS criteria are coded "surgical."

Referrals/Complaints which I treat far more often medically rather than surgically include:
Dizziness
Hoarseness (vast majority medically managed)
Globus (again far more medically managed than require surgery)
Facial Pain, esp Chronic
Otitis Externa
Tinnitus
SNHL
Cerumen
Cough
Rhinitis

Those that I treat medically slightly more often than surgically include
Chronic and Recurrent Acute Rhinosinusitis

Those that I often treat with minor procedures in the clinic rather than OR include
Snoring
Turbinate Hypertrophy
Skin lesions
Oral lesions
Epistaxis
Peritonsillar abscess
Nasal fractures

Those that I usually end up operating on include
Deep Neck Space Abscess
Thyroid nodules, esp if over 3cm
OME, RAOM
Recurrent Strep
OSA (not because surgery is best, it's not, but I usually see the CPAP failures)
Trauma
Airway issues (stridor in kids, prolonged intubation in adult ICU)
Severely deviated septums
Recalcitrant CRS or Recurrent ABRS (not responding to what I consider max medical therapy)
TM perforations
Conductive Hearing Losses
Mastoiditis (coalescent)
Non-infectious Neck Masses

My personal practice does not overlap with Allergists at all, but I'm the ONLY ENT of 8 in my area who does not do allergy. The reason is simple, because I'm the only one, all 4 allergists in my area refer to me exclusively when they need ENT because all the other ENT's are the allergists' competitors. Simply a business decision on my part. Has worked very well so far.

 

[TheThroat]

Agree with everything that resxn said. I do allergy, but allergic rhinitis is only one of many diseases that allergists treat. I have a great working relationship with the local allergy guys, as I still send my more difficult atopic cases to them and they send me surgical cases as well.

 

[medstylee]

i recently went to grand rounds and the talk was about how it's getting more and more difficult for residents to get adequate training in otology. it was really interesting and i was surprised at how few ear surgeries residents get to perform on average these days. anyway, i'm curious to know if that's had an impact on your training, career choices, what you feel comfortable doing in your practices, etc, for any of you guys.

 

[Dunce]

i recently went to grand rounds and the talk was about how it's getting more and more difficult for residents to get adequate training in otology. it was really interesting and i was surprised at how few ear surgeries residents get to perform on average these days. anyway, i'm curious to know if that's had an impact on your training, career choices, what you feel comfortable doing in your practices, etc, for any of you guys.

Was there any discussion on the reasons that quality otology training is getting more difficult and cases numbers are down?

 

[medstylee]

Was there any discussion on the reasons that quality otology training is getting more difficult and cases numbers are down?

i don't think he was necessarily saying that the quality of otologic training is on the decline. what i got out of the talk was that there are less and less surgeries being performed nationwide for things such as otosclerosis. and, as a result, residents are graduating with fewer of those procedures under their belts.

 

[resxn]

that wasn't true in my residency training, but that was almost 5 years ago now. Maybe it's changed.

 

[michaelrack]

Those that I often treat with minor procedures in the clinic rather than OR include
Snoring
Turbinate Hypertrophy
Skin lesions
Oral lesions
Epistaxis
Peritonsillar abscess
Nasal fractures
.

resxn,

what kind of sedation do you use for these procedures, particularly snoring/turbinate hypertrophy??

 

[resxn]

All of these can be done under local (I pretty much only use 2% lido w/ epi because it sets up so much faster) without sedation. In fact, I do not sedate for any one of these.

1 - snoring: pillar implants or RF palatal stiffening with about 3cc local. You can do LAUP's under local only as well. I tend to provide my Pillar pt's with cetacaine lollipops pre-injection since they're paying a wad for the procedure and I need to make them happy.
2 - turbs: I use Coblation for turbs and use topical followed by about 4cc local in each
3 - skin: local
4 - oral: local
5 - epistaxis: almost always topical. Sometimes inject the greater palatine with local
6 - PTA: local, occ I'll use topical before but I don't find it provides much benefit except maybe to decrease the gag reflex
7 - nasal fx: sometimes nothing at all, sometimes ice only, sometimes local. I find that the injections for local are as painful as the manipulation and sometimes worse if ice is used alone, so I give patients the choice on this. I get so many people that get vagal with nasal blocks, I try not to do them if I can get away with it. Fortunately the population that typically gets nasal fractures usually are not those that expect the highest level of catering.