What controversies have ENT talking? 3 expert insights

Three otolaryngologists told Becker's ASC Review about what they believe are the biggest controversies in the ENT field.

Note: Responses have been lightly edited for style and length.

Nicole Aaronson, MD, pediatric otolaryngologist at Alfred I. duPont Hospital (Wilmington, Del.): The controversial issues in ENT tend to be the ones where there is uncertainty about the optimal way to proceed. Sometimes, there is a paucity of scientific data. Other times, the evidence is contradictory. And sometimes, long-held practice patterns and beliefs simply conflict with the data.

When I think about controversies in pediatric otolaryngology, three main topics come to mind.

  • First is the topic of tongue tie and lip tie. The American Academy of Otolaryngology-Head and Neck Surgery came out with their Clinical Practice Guidelines on ankyloglossia and children in 2020, but there is still a wide variability in how different providers manage these patients. Many providers still disagree in their beliefs on whether tongue ties can affect speech, whether posterior tongue ties exist, and whether lip ties have functional significance.
  • Second is how to handle the shallowest of the laryngeal clefts, sometimes referred to as deep interarytenoid notches. Some providers believe that these are of no clinical significance, while others frequently intervene with treatments like augmentation injections.
  • Third is what is the optimal type of tonsillectomy. Some surgeons only offer the extracapsular tonsillectomy (variously called total or traditional). Others offer exclusively intracapsular tonsillectomies. A third group discusses the pros and cons of each option and tries to reach a shared decision with the family.

When I think about controversies in otolaryngology broadly, a couple of systemic issues come to mind. First is the issue of how we will use and incorporate telemedicine into our practices when the pandemic is over. There is still a lot of debate about what can or cannot be accomplished successfully via this modality and questions remain about the trade-off between access to care and quality of physical examination. Second is the issue of value-based care and how this can or should be incorporated into the practices of a surgical subspecialty.

Kenneth Altman, MD, PhD, chair of otolaryngology at Geisinger Health System (Danville, Pa.): In my opinion, the biggest controversies in otolaryngology fall under our important roles in team-based patient care and access based on the physician workforce. As science is evolving, our unique perspective on certain diseases may be different than those of our colleagues in other disciplines. This includes laryngopharyngeal reflux versus traditional GERD, the logic in our approach to allergy, comparative cost/effectiveness of new technologies, and the role of surgery with the new thyroid cancer guidelines. Fortunately, we've maintained an open conversation that respects clinical wisdom and science-based clinical practice guidelines.

But the bigger controversies today are common to all specialties that reflect complex issues determining the disposition of the patient and destiny of our profession:
Scope of practice (as recognized by CMS and state [departments of health]) for other healthcare providers, such as audiology, speech and language pathology, and advanced practitioners
Access to care based on patient insurance and unaffordable copays and deductibles
Concentration of the physician workforce in cities, sometimes limiting access to specialty care in rural communities
The trend toward more ambulatory-based (rather than hospital-based) practices, resulting in on-call shortages

Stacey Ishman, MD, otolaryngologist at Cincinnati Children's Hospital: For everyone in medicine today, I think the concerns about COVID's effects on patient care are primary. In otolaryngology, this manifests as questions about what procedures are really aerosolizing — for example, while flexible laryngoscopy may not be aerosolizing on its own, the response of crying or yelling by children may make it so — and what are the safest ways to handle this in the clinical setting. I have never thought about air handling questions much in the past, but the time to leave a room empty to allow for air exchange seems to be an issue in every clinical setting.

When we look beyond COVID, my specific concerns center around the best treatment options for children with obstructive sleep apnea, especially those who still have disease after adenotonsillectomy. The natural course of this disease is not well understood, [nor is] its impact on comorbidities and overall health into adulthood. Thus it is hard to understand if repeat sleep studies, positive airway pressure therapy or more invasive surgical therapy is best.

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