Published: October 23, 2013

Advances in Head and Neck Surgery

By M. Steele Brown, special assignment to Bulletin From preemptive strikes against pharyngeal cancers to advances in robotic surgery, Otolaryngology—Head and Neck Surgery is riding a wave of trends and technological discoveries toward significant breakthroughs. Jay O. Boyle, MD, chair of the Head and Neck Surgery section of the AAO—HNSF Centralized Otolaryngology Research Efforts (CORE) program, said one example of this is how the specialty is fighting head and neck squamous cell cancer on several fronts—and winning. “Our knowledge is expanding, and with that in mind, researchers are continually able to generate new and more exciting hypotheses,” Dr. Boyle said. “In addition to the research in the lab, technology is beginning to allow us to answer questions more completely and faster than previously possible, due to the continuing advances in molecular biology and the discovery of high-throughput ways in which we can analyze many tumors in a short period of time. In addition, the sequencing of the human genome—specifically the head and neck cancer genome, offers us quite a bit of insight into head and neck cancers, as well as a better understanding of other common issues, such as melanoma. We’ve also seen lots of good research in the area of salivary gland cancers.” Battling Cancer Many of the most important surgical breakthroughs occur before surgery is even necessary. Nowhere is this more true than in the realm of oncology. Head and neck cancer is the sixth-most common non-skin cancer in the world with more than half a million new cases each year. According to research from the National Cancer Institute (NCI), smokers, drinkers, and people infected with the human papillomavirus (HPV) have the highest risk of developing cancer in the oral cavity. Because of that, stopping these issues before they take root is an imperative. Dr. Boyle, also an associate attending physician in Head and Neck Surgery at Memorial Sloan-Kettering Cancer Center and associate professor of  otolaryngology, Weill Medical College of Cornell University in New York, said the increased understanding of tobacco addiction is one key to fighting cancer. “In addition, smoking cessation research is also advancing,” he said. “I think I speak for all head and neck surgeons when I say that I’m hoping that this research will help the effectiveness of the cessation programs that are out there right now. As awareness regarding the dangers of tobacco increases and smoking rates continue decreasing, this will have a positive influence on future head and neck cancer rates.” Marion E. Couch, MD, PhD, associate professor in the Department of Otolaryngology/Head and Neck Surgery at Fletcher Allen Health Care, said that on the public health front, the recent recommendation from the Centers for Disease Control and Prevention (CDC)—that boys and young men up to the age of 21 be vaccinated against HPV—is “huge for the field.” “From our point of view, this is a real victory because simply vaccinating young girls will not solve the problem,” Dr. Couch said. “We are leaving the other half of the population at risk. “While we are still looking for more and better data, there is evidence to suggest that HPV could be responsible for many cases of oral cancer—most of which occur in men. So I am greatly relieved that both boys and girls will now be vaccinated against HPV.” While the latest expansion of the indications for the HPV vaccine is not for head and neck cancer, Dr. Couch believes that evidence will inevitably come to light. “In the meantime, we will have to work to remove barriers in this regard,” she said. “But the news of the latest expansion is still welcome and will help us in our fight.” Dr. Boyle said he concurred with Dr. Couch regarding HPV’s connection to head and neck cancer, and added that while the evidence of the connection is anecdotal, he believes it is a real concern. “Some of the most important advances we have made are due to the fact that many of the cancers that we are finding in the pharynx now, we will find are caused by HPV,” he said. “The good thing about that is these particular cancers have a high cure rate—higher than 90 percent—and are amenable to cancer prevention, so from a curative standpoint, this is all new and exciting territory for head and neck surgeons.” Further Research In addition to the believed connection with HPV, Dr. Boyle said more encouraging advances exist in the realm of genomics. “As the field (of genomics) evolves during the next five to 10 years, we will be able to individualize therapy for cancer,” he said. “And as we learn more about the molecular biology of tumors and tumor-host interactions, as well as how cancers are inherited, we will be able to better tailor treatment to the specific biology that is going on with the particular cancer. It is a good bet that this promising advance in head and neck oncology will be available to us in the next five to 10 years.” As researchers make headway in understanding the process of carcinogenesis, Dr. Boyle  said they are also getting closer to identifying a way to reverse that process in the upper air tract using medications. “For example, I am involved in ongoing randomized trials with a cancer prevention drug used to treat precancerous lesions of the mouth,” he said. “That study is open in nine institutions in the United States and one in Italy. That is an example of bench-to-bedside research where a hypothesis from the lab, and the subsequent animal studies, may create a drug that is useful in preventing oral cancer by targeting leukoplakia.” Dr. Boyle was also quick to note that science should not be a substitute for cessation. “We are not here to make smoking safer,” he said. “We need to stay focused on cessation and cessation research, but those patients who do quit still remain at moderate risk, and they are the ones we need to help with these therapies. We need to be able to halt and reverse cancer formation in patients who are successful in quitting.” As the chair of CORE, Dr. Boyle said it is also important to note that new research is constantly coming to the attention of the Academy. “The number of head and neck oncology research proposals is increasing and the quality is improving as well,” he said. “There are lots of exciting ideas and they are coming to our attention in many different areas of cancer biology.” Educating on Robotic Surgery Headway is also being made as the number of otolaryngologic surgeons training in robotic procedures continues to grow, Dr. Couch said. “We could soon be looking at equivalent cure rates for robotic interventions and chemoradiation therapy,” he said. “That said, I think we are seeing the pendulum swing back to the surgical approach for many of these diseases, and our patients are demanding outcomes using these innovative techniques.” Dr. Boyle echoed that idea and said that transoral robotic surgery (TORS) has become a significant recent development. And while it is not yet proven to have the same cure rates as radiation therapy, it is likely to be proven in the next year or so. At this point, he said, the problem is with the number of trials. “There are not any direct head-to-head random trials because we cannot randomize surgical patients,” he said. “But the data we do have says the cure rates are good.” “So as TORS becomes more common in the coming five- to 10-year span, we can, and probably will, see a lowering in the intensity of radiation therapy necessary after surgery. That will be good for our patients.” Dennis H. Kraus, MD, the chair of Head and Neck Education for the Academy, added that robotic thyroidectomy is also helping head and neck surgeons advance the specialty. “With robotic thyroidectomy, we can avoid making incisions in the neck,” Dr. Kraus said. “It really seems to be catching on and it offers a lot of advantages, such as an approach under the arm and one behind the ear, for example. “I think there is a real focus on minimizing the effect of surgery on the patient right now. We are able to be just as effective, but in a way in which we do not hurt the patient, and that is an attractive path.” These developments, taken together, multiply the medical and surgical knowledge available exponentially, Dr. Couch said. “All of this has allowed us to embrace innovation, which is exciting for our field,” she said. “But it is also right in time because we are under pressure to treat patients who are getting younger because of HPV. Our patients used to be 60 to 80 years old, but now they are getting younger and are demanding excellent outcomes in terms of survival.”

By M. Steele Brown, special assignment to Bulletin

feature_From preemptive strikes against pharyngeal cancers to advances in robotic surgery, Otolaryngology—Head and Neck Surgery is riding a wave of trends and technological discoveries toward significant breakthroughs.

Jay O. Boyle, MD, chair of the Head and Neck Surgery section of the AAO—HNSF Centralized Otolaryngology Research Efforts (CORE) program, said one example of this is how the specialty is fighting head and neck squamous cell cancer on several fronts—and winning.

“Our knowledge is expanding, and with that in mind, researchers are continually able to generate new and more exciting hypotheses,” Dr. Boyle said. “In addition to the research in the lab, technology is beginning to allow us to answer questions more completely and faster than previously possible, due to the continuing advances in molecular biology and the discovery of high-throughput ways in which we can analyze many tumors in a short period of time.

In addition, the sequencing of the human genome—specifically the head and neck cancer genome, offers us quite a bit of insight into head and neck cancers, as well as a better understanding of other common issues, such as melanoma. We’ve also seen lots of good research in the area of salivary gland cancers.”

Battling Cancer
Many of the most important surgical breakthroughs occur before surgery is even necessary. Nowhere is this more true than in the realm of oncology.

Head and neck cancer is the sixth-most common non-skin cancer in the world with more than half a million new cases each year. According to research from the National Cancer Institute (NCI), smokers, drinkers, and people infected with the human papillomavirus (HPV) have the highest risk of developing cancer in the oral cavity. Because of that, stopping these issues before they take root is an imperative.

Dr. Boyle, also an associate attending physician in Head and Neck Surgery at Memorial Sloan-Kettering Cancer Center and associate professor of  otolaryngology, Weill Medical College of Cornell University in New York, said the increased understanding of tobacco addiction is one key to fighting cancer.

“In addition, smoking cessation research is also advancing,” he said. “I think I speak for all head and neck surgeons when I say that I’m hoping that this research will help the effectiveness of the cessation programs that are out there right now. As awareness regarding the dangers of tobacco increases and smoking rates continue decreasing, this will have a positive influence on future head and neck cancer rates.”

Marion E. Couch, MD, PhD, associate professor in the Department of Otolaryngology/Head and Neck Surgery at Fletcher Allen Health Care, said that on the public health front, the recent recommendation from the Centers for Disease Control and Prevention (CDC)—that boys and young men up to the age of 21 be vaccinated against HPV—is “huge for the field.”

“From our point of view, this is a real victory because simply vaccinating young girls will not solve the problem,” Dr. Couch said. “We are leaving the other half of the population at risk.

“While we are still looking for more and better data, there is evidence to suggest that HPV could be responsible for many cases of oral cancer—most of which occur in men. So I am greatly relieved that both boys and girls will now be vaccinated against HPV.”

While the latest expansion of the indications for the HPV vaccine is not for head and neck cancer, Dr. Couch believes that evidence will inevitably come to light.

“In the meantime, we will have to work to remove barriers in this regard,” she said. “But the news of the latest expansion is still welcome and will help us in our fight.”

Dr. Boyle said he concurred with Dr. Couch regarding HPV’s connection to head and neck cancer, and added that while the evidence of the connection is anecdotal, he believes it is a real concern.

“Some of the most important advances we have made are due to the fact that many of the cancers that we are finding in the pharynx now, we will find are caused by HPV,” he said. “The good thing about that is these particular cancers have a high cure rate—higher than 90 percent—and are amenable to cancer prevention, so from a curative standpoint, this is all new and exciting territory for head and neck surgeons.”

Further Research
In addition to the believed connection with HPV, Dr. Boyle said more encouraging advances exist in the realm of genomics.

“As the field (of genomics) evolves during the next five to 10 years, we will be able to individualize therapy for cancer,” he said. “And as we learn more about the molecular biology of tumors and tumor-host interactions, as well as how cancers are inherited, we will be able to better tailor treatment to the specific biology that is going on with the particular cancer. It is a good bet that this promising advance in head and neck oncology will be available to us in the next five to 10 years.”

As researchers make headway in understanding the process of carcinogenesis, Dr. Boyle  said they are also getting closer to identifying a way to reverse that process in the upper air tract using medications.

“For example, I am involved in ongoing randomized trials with a cancer prevention drug used to treat precancerous lesions of the mouth,” he said. “That study is open in nine institutions in the United States and one in Italy. That is an example of bench-to-bedside research where a hypothesis from the lab, and the subsequent animal studies, may create a drug that is useful in preventing oral cancer by targeting leukoplakia.”

Dr. Boyle was also quick to note that science should not be a substitute for cessation.

“We are not here to make smoking safer,” he said. “We need to stay focused on cessation and cessation research, but those patients who do quit still remain at moderate risk, and they are the ones we need to help with these therapies. We need to be able to halt and reverse cancer formation in patients who are successful in quitting.”

As the chair of CORE, Dr. Boyle said it is also important to note that new research is constantly coming to the attention of the Academy.

“The number of head and neck oncology research proposals is increasing and the quality is improving as well,” he said. “There are lots of exciting ideas and they are coming to our attention in many different areas of cancer biology.”

Operating room model set up for robotic surgery. © 2012 Intuitive Surgical, Inc.Operating room model set up for robotic surgery. © 2012 Intuitive Surgical, Inc.

Educating on Robotic Surgery
Headway is also being made as the number of otolaryngologic surgeons training in robotic procedures continues to grow, Dr. Couch said.

“We could soon be looking at equivalent cure rates for robotic interventions and chemoradiation therapy,” he said. “That said, I think we are seeing the pendulum swing back to the surgical approach for many of these diseases, and our patients are demanding outcomes using these innovative techniques.”

Dr. Boyle echoed that idea and said that transoral robotic surgery (TORS) has become a significant recent development. And while it is not yet proven to have the same cure rates as radiation therapy, it is likely to be proven in the next year or so. At this point, he said, the problem is with the number of trials.

“There are not any direct head-to-head random trials because we cannot randomize surgical patients,” he said. “But the data we do have says the cure rates are good.”

“So as TORS becomes more common in the coming five- to 10-year span, we can, and probably will, see a lowering in the intensity of radiation therapy necessary after surgery. That will be good for our patients.”

Dennis H. Kraus, MD, the chair of Head and Neck Education for the Academy, added that robotic thyroidectomy is also helping head and neck surgeons advance the specialty.

“With robotic thyroidectomy, we can avoid making incisions in the neck,” Dr. Kraus said. “It really seems to be catching on and it offers a lot of advantages, such as an approach under the arm and one behind the ear, for example.

“I think there is a real focus on minimizing the effect of surgery on the patient right now. We are able to be just as effective, but in a way in which we do not hurt the patient, and that is an attractive path.”

These developments, taken together, multiply the medical and surgical knowledge available exponentially, Dr. Couch said.

“All of this has allowed us to embrace innovation, which is exciting for our field,” she said. “But it is also right in time because we are under pressure to treat patients who are getting younger because of HPV. Our patients used to be 60 to 80 years old, but now they are getting younger and are demanding excellent outcomes in terms of survival.”

More from January 2012 - Vol. 31 No. 01
(left to right): Ciara with Bill Preston, president of M4M, responded slowly, but she soon lit up.
Medals 4 Mettle
Medals 4 Mettle (M4M) is a non-profit organization founded by Steven F. Isenberg, MD, a head and neck surgeon in Indianapolis and an active member of the AAO-HNSF. He founded the organization to help recognize the difficult battle adults and children endure when diagnosed with a life-threatening illness. Dr. Isenberg explained the impetus for M4M in The Indianapolis Star: “After I completed the Chicago Marathon in 2003, I came back to the hospital the morning after the race to see one of my colleagues, whom I had performed surgery on for cancer. I walked into his room, and it was dimly lit, very depressing. I had my medal in my briefcase. There wasn’t anything more I could do for him, so I just put it around his neck and said he deserved it more than me.  I did that several times for other patients. In 2005, I got the idea that other people might feel the same way, so I set up Medals for Mettle.”1  Since then Dr. Isenberg, and the staff and many M4M volunteers have awarded more than 20,000 medals to adults and children throughout the world. My experience with M4M began the morning of October 29, 2011, when I drove into Washington, DC, to the Georgetown University Hospital pediatric center to meet Dr. Isenberg and other M4M staff and volunteers. I entered the staff lounge to see two men conversing enthusiastically about the organization and their experience with M4M. I learned that, despite having worked to promote the mission of M4M for several years, this was the first time Dr. Isenberg and Joe Burns, coordinator of the Detroit, MI, chapter, had met in person. Bill Preston, president of M4M, and Sharan Kaur, national coordinator of M4M, were also present to help award medals to each child. Katie Foy, child life specialist for Georgetown Pediatrics, led us to the oncology and transplant units where we met 13 children. Although several were still sleeping, many of the kids were awake and happy to have visitors. We first met Laila. It was her 8th birthday, and her room was filled with balloons and decorations. She came to the door to greet us dressed from head to toe as the little mermaid. Behind her, taped to the door was a full-size poster that read “Happy Birthday!” with messages and birthday wishes from staff and visitors. Her smile ran from ear to ear when Dr. Isenberg placed the medal around her neck as she posed for pictures. We visited a 4-year-old girl named Ciara who was overwhelmed at first by everyone who entered the doorway, but slowly lit up when she realized the medal around her neck was hers to keep forever. We then met a little boy named DJ and his mother. The nurses warned us he didn’t like many things and probably wouldn’t be excited about the medal. No one could have predicted how elated DJ became when Joe placed the medal around his neck. He began moving around and shouting with excitement. You could see his mother was so pleased that something made her child so happy. Although we were there for only an hour, it was an experience I won’t soon forget. To finish a marathon is a reward in itself, but to share that triumph by donating a medal to those fighting to finish their own personal race makes the feeling of that last step over the finish line that much sweeter. If you would like to learn more about Medals 4 Mettle, how to volunteer your time, or to donate a medal, please visit: www.medals4mettle.org Reference: Rudavsky S. Marathon health battles are deserving of medals. The Indianaopolis Star. December 24, 2009: Features- Healthy Living.
Dr. Brackmann (middle) performed 38 surgeries in four days.
Mission to El Salvador
Derald E. Brackmann, MD, House Ear Clinic, Los Angeles, CA I recently had the opportunity to travel away from the House Ear Clinic in Los Angeles, CA, and accompany Richard Wagner, MD, of Global ENT Outreach (GEO), to the hospital ISSS-Instituto Salvadoreño, San Salvador, El Salvador. This was GEO’s 11th trip to El Salvador; it has an efficient system for visits well in place. Joni K. Doherty, MD, PhD, otologist from California, and Jason Gilde, a fourth-year medical student from USC School of Medicine, joined us for the trip. We operated on 38 patients in four days. Half of them were for otosclerosis, the others were for chronic otitis media with the exception of one glomus tumor and one encephalocele with spinal fluid leak. The ENT director at the hospital was cooperative and had all the patients prepared for their surgeries. The hospital and operating room staffs were supportive. Most of all, the patients were extremely appreciative. All in all, this was a very rewarding experience. I congratulate Dr. Wagner on all of his efforts. I look forward to doing this again. To learn more about Global ENT Outreach, contact geoutreach@yahoo.com or visit www.geoutreach.org.
Seoul, South Korea
AAO-HNSF Shares Guideline Development Work Internationally
The 8th Guidelines International Network (G-I-N) Conference took place August 28-31, 2011, at the Inchon Memorial Hall at Korea University in Seoul, South Korea. This year’s theme was “linking evidence, policy, and practice.” The scientific program committee was chaired by our own Richard M. Rosenfeld, MD, MPH. The G-I-N Conference brings together many colleagues from around the world to develop collaborations and facilitate the dissemination and discussion of every aspect of guidelines, including evidence synthesis, guideline development, quality improvement, and health policy to improve patient outcomes. It is the premier venue for worldwide sharing of knowledge and experience about guideline development, dissemination, and implementation. Presentations on guideline implementation made by Dave Davis, MD, were so thought-provoking for Dr. Rosenfeld and Stephanie Jones, director, Research and Quality Improvement, that they invited Dr. Davis to share his ideas and thoughts with the AAO-HNSF Guidelines Development Task Force at the October 31, 2011, meeting in Alexandria, VA. We are eager to learn from Dr. Davis’ experience with clinical practice guideline development, adaptation, and implementation. His (and colleagues’) 1995 JAMA systematic review of the effect of CME interventions is widely cited as a seminal study in this field. As the AAO-HNSF moves from developing guidelines to broader dissemination, implementation, and the development of educational tools, participation in G-I-N and networking with colleagues around the globe will be instrumental. We are thrilled to announce the launch of G-I-N North America (G-I-N NA), which will enable us to network more frequently with our colleagues closer to home. G-I-N NA is the first regional initiative of G-I-N and was founded by Dr. Rosenfeld, who is also chair of the steering group. Challenges faced by North American groups are not unique, but there are enough shared issues to justify a regional community. These include (a) heterogeneous guideline processes with minimal national oversight, (b) guideline development by diverse societies, groups, and organizations, (c) new standards from the Institute of Medicine that are likely to have broad implications for guideline processes, including possible accreditation, (d) common concerns about funding and support, and (e) a regional desire to communicate and share best practices. To address these challenges, G-I-N NA will launch a webinar series in January 2012, leading up to a two-day conference and workshop meeting in New York City, December 2012. Cochrane Colloquium The 19th Cochrane Colloquium took place October 19-22, 2011, in Madrid, Spain. The theme of this year’s program was “Scientific evidence for healthcare quality and patient safety.” Four AAO-HNSF Cochrane Scholars were provided with travel grants, sponsored by Sage, to attend the meeting in exchange for developing a systematic review over the coming year for publication in the journal, Otolaryngology—Head and Neck Surgery. This year’s scholars included: Peter H. Hwang, MD; Melissa A. Pynnonen, MD; Sujana S. Chandrasekhar, MD; and Seth M. Cohen, MD, MPH. In addition, the meeting was attended by the AAO-HNSF Guidelines Development Task Force chair and chair-elect, Richard M. Rosenfeld, MD, MPH, and Seth R. Schwartz, MD, MPH, respectively and AAO-HNSF Guidelines staff Stephanie Jones and Peter Robertson, MPA. The Cochrane Collaboration work is internationally recognized as the benchmark for high quality information about the effectiveness of healthcare and was recently recognized in the March 2011 report released by the Institute of Medicine titled Finding What Works in Healthcare: Standards for Systematic Reviews. The AAO-HNS has a strong relationship with the Cochrane Collaboration and is actively involved with the U.S. Cochrane Center and the Ear, Nose and Throat Disorders Group. During the years, Martin J. Burton, DM, FRCS, joint coordinating editor for the Ear, Nose and Throat Disorders Group, and Dr. Rosenfeld have provided educational programming at the AAO-HNSF Annual Meeting & OTO EXPO. The Cochrane ENT Information Specialist/Trials Search coordinator, Gemma Sandberg, has played an invaluable role in supporting the AAO-HNSF clinical practice guidelines. The call for applications for the 2012 Cochrane Scholars will be released soon. If you are interested in learning more, please contact Eileen Cavanagh  ecavanagh@entnet.org.
UHG’s Direct-to-Consumer Sale of Hearing Aids
On October 3, 2011, hi HealthInnovations, a UnitedHealth Group (UHG) subsidiary, announced the launch of an innovative and low-cost line of hearing aids available direct to consumer with a free, self-rendered online hearing test designed to work with most computers, tablets, or smartphones. The devices are priced from $749 to $949, compared to the cost of a traditional hearing aid, which ranges from $2,000 to $4,000. Although the Academy supports innovation and lower costs for hearing aids for patients, the online hearing test is not clinically validated. UHG has yet to release any immediate research or details regarding verification of the test. Similar to many other clinical studies, a time-based analysis will be important for determining the clinical credibility of the hearing test. Further, the new methodology appears to potentially eliminate otolaryngologists and hearing professionals from the evaluative process, greatly increases the risk of misdiagnosis, and could drive up overall costs of hearing healthcare in the long-run. Given the devices’ low price range, UHG anticipates that the line of devices will drive down immediate out-of-pocket costs of hearing aids for the consumer. While the Academy appreciates UHG’s intention to reduce costs, there are serious concerns regarding potential dangers, costs, and unforeseen consequences for patients with a self-rendered test. Furthermore, the Academy strongly believes that an online hearing test is, at best, only an initial screening tool, and could provide misleading and false results. Instead of saving consumers money with a low-cost hearing aid, the potential misdiagnosis that may arise from a self-rendered hearing test could lead to increased costs for patient health and healthcare over time. On October 6, the Academy was contacted by a reporter with American Medical News (AMN), a print and online news publication published by the American Medical Association, with questions regarding the Academy’s stance on UHG’s new initiative. The Health Policy team collaborated with the Physician Payment Policy (3P) workgroup, the chair of the Hearing Committee, AAO-HNS Communications, and Government Affairs staff to carefully construct responses to the reporter’s questions. The article quoted the Academy with the following statement: “Any changes in the paradigms by which hearing aids are evaluated and fitted must be shown to have equal or superior outcomes to those currently employed and not be based solely on cost.” The article can be found in AMN’s online October 24, 2011 issue. Subsequently, the Health Policy team worked with Government Affairs staff to research and analyze state and federal law related to the issue. On November 2, 2011, the Academy submitted comments and concerns about the program to the national medical director at United Healthcare (UHC), a subsidiary of UHG, to request a conference call to collaborate on appropriately treating hearing loss in patients. AAO-HNS directed the letter to United Healthcare’s national medical director after the Academy’s recent open dialogue and success in making positive changes to their rhinoplasty/septoplasty coverage guidelines. The Academy’s fundamental message to UHC focuses on patient safety/quality and physician oversight when diagnosing patients with hearing loss. The AAO-HNS received an immediate response from the medical director at UHC and is currently working toward scheduling a meeting to further discuss the Academy’s comments with UHC. Academy Health Policy senior staff have been involved in communications with the American Academy of Audiology (AAA), the American Speech-Language-Hearing Association (ASHA), the Academy of Doctors of Audiology (ADA), and the International Hearing Society (IHS) to discuss collaborating on the response strategy. All groups are currently submitting or have submitted individual letters and are sharing comments with one another. The Academy plans to communicate with each group on future collaborations and will continue to share any new information received from UHG. To view a copy of the Academy letter to UHC, go to http://www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm. Stay tuned for updates posted on the website and communicated via “The News.”
Update from the Physician Payment Policy Workgroup (3P)
Richard W. Waguespack, MD, Coordinator for Socioeconomic Affairs, and Michael Setzen, MD, Coordinator for Practice Affairs, Co-chairs of 3P; Jean Brereton, MBA, senior director, Research, Quality Improvement and Health Policy; Jenna Kappel, MPH, MA, Director, Health Policy; Joe Cody, MA, Health Policy analyst; and Harrison Peery, Health Policy analyst. The Physician Payment Policy Workgroup (3P), co-chaired by Richard W. Waguespack, MD, and Michael Setzen, MD, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding, or reimbursement, and practice services or management. 3P and the Health Policy staff were busy in 2011 with a continued high level of activity, constant e-mails and monthly calls, working tirelessly on behalf of all members. Below, we have highlighted some advocacy efforts (For the latest health policy updates, visit the “what’s new” page athttp://www.entnet.org/Practice/CMS-News.cfm). 3P’s Process for Private Payer Advocacy 3P developed a process for providing assistance to members dealing with private payers that may inappropriately deny or bundle a procedure or service you have furnished. The Academy cannot represent physician members individually on each issue with payers, so 3P recommends members contact their state otolaryngology society to resolve the issue at a state level. However, there are many resources available on the Academy’s website to assist members with individual issues, including appeal template letters, CPT for ENT articles, policy statements, and clinical indicators and guidelines. If the issue cannot be resolved at the state level, contact the Academy’s health policy department at healthpolicy@entnent.org and include all pertinent information including, a copy of the denial, the EOB (with HIPAA information redacted), setting of the procedure, or anything else that could help). 3P and staff will research the issue and decide whether to pursue advocacy with the payer. For more information, see http://www.entnet.org/Practice/Private-Payer-Resources.cfm. Examples of recent efforts to advocate on members’ behalf with private payers on a national level include: Discussing the balloon sinus ostial dilation reference medical policy with Blue Cross and Blue Shield Association’s (BCBSA) national medical director; and Commenting on United Health Group’s (UHG) direct-to-consumer hearing tests and aids and entering into dialogue with United Healthcare’s national medical director to discuss concerns. Look for updates in The News and on the website as 3P and Academy staff continue to work with United Healthcare on these concerns. (These issues are discussed in more detail in this issue on pages 33 for the BCBSA policy and 38 for UHG’s sale of hearing aids.) 3P would like to thank all of the committees and members who have provided input on these issues and others. We will continue to work on socioeconomic advocacy on behalf of the Academy and its members. Cahaba GBA Changes ‘Once in a Lifetime’ Policy  Cahaba Government Benefit Administrators®, LLC (Cahaba GBA) administers Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS). A major win for Academy members is Cahaba GBA removing procedures from their “once in a lifetime” procedure list. After learning about the inclusion of several procedures on the list, the Academy sent a letter to Cahaba GBA on September 30 explaining why they should be taken off the list. Shortly after receiving the letter, Cahaba removed the procedures from the list. Resources Available to You  from 3P 3P has developed a number of resources available to members. During the annual meeting, 3P sponsored several miniseminars and presentations to educate members on issues that directly affect them. They included courses and seminars on the transition from ICD-9 to ICD-10 and how it affects you; the CMS Carrier Advisor Committee (CAC) and the Recovery Audit Contractor (RAC) process; and Academy Advocacy for Physician Payment. The sessions were highly successful and 3P looks forward to presenting them again in 2012. Along with the resources available during Annual Meeting, 3P also developed a webinar for AcademyU®, providing instruction on how to fill out a RUC survey to coincide with recent resurvey of CPT code 31231 Diagnostic nasal endoscopy. For more on these and other resources, see http://www.entnet.org/Practice/regulatorySocioAdvocacy.cfm.
Event Reporting Web-based Portal
Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC The Academy, via the Patient Safety and Quality Improvement Committee, is eager to provide membership with quasi real-time reports on zones of risk within our specialty.  To approach this in a secure and appropriate manner, we considered forming a Patient Safety Organization. Designation of such an organization affords specific legal rights, but also places specific requirements on such an entity. Our intense research of this potential designation yielded great insight. Currently, it is not in the Academy’s best interest to pursue designation as a Patient Safety Organization. However, we do want to know what zones of risk exist for Academy members so they can ensure that the highest level of care is delivered to their patients. To this end, we can rely on articles published in peer-reviewed journals. However, it is difficult to have case reports on errors or sentinel events published in such journals. Furthermore, many ask if that is the appropriate forum for dissemination of such events. The study our group published in Laryngoscope in 2004 laid the foundation for many subsequent projects targeted at reducing harm and near-misses in our specialty. We hope that by collecting data we can address issues that affect our patients on a macro level that may not be identified in one-off reports or anecdotal vignettes. For example, if there is a device that has an issue at a frequency of 10-3, then that issue may never be evident to a single surgeon during a couple of decades. However, if 7,000 surgeons use the device, then infrequent issues could become rapidly apparent. The Food and Drug Administration has an excellent medication and device reporting system for adverse issues. However, when reviewing systemic defects with processes, some of these are not captured by such reporting mechanisms. An example of this would be the latent system defects in transitioning your office from a paper-based system to an electronic medical record process. This zone of risk (the potential for information technology to lead to adverse events) has only recently become evident in the patient safety and quality improvement world. However, a system that allows us to aggregate near-misses, adverse events, and errors would facilitate identification of this. The Patient Safety and Quality Improvement Committee is working diligently with Academy staff to create a web-based portal that members could access through the AAO-HNSF website. The portal would allow members to confidentially answer 10 brief questions on a near-miss, adverse event, or error. There would be no identifiable data, which is good and bad. The good we can all discern. The bad is that by having some potentially identifiable data, such as hospital characteristics, etc., we can learn more about the event and ways to minimize it. However, to ensure the confidentiality of the physician providing the report, it is absolutely imperative that only high-level information be obtained. We imagine you would submit a summary similar to this: “A 6-yo boy underwent a tonsillectomy and had a burn to the lip; I used xyz technique; I did the case, not a resident.” If we were to obtain a dozen similar reports, it would indicate that this is a potential zone of risk. We could then leverage our Academy resources to help prevent this condition. We are excited about the new web portal that will allow Academy members to input limited data about perceived or real safety issues; the end result would be an ability to see which issues affect Academy members and their patients and hopefully the most common sources of near misses, adverse events, and errors. We encourage members to write us with any topic of interest, and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
Update: BCBSA Balloon Sinus Ostial Dilation Reference Medical Policy
Since the beginning of 2011 members of the Physician Payment Policy (3P) workgroup and Academy staff have been in communication with staff from the Blue Cross Blue Shield Association (BCBSA) regarding its balloon sinus ostial dilation reference medical policy. (Catheter-based inflatable device is used as a synonymous term in the policy.) The Academy’s Rhinology and Paranasal Sinus Committee provided valuable input during the process. These communications included a letter from Academy Executive Vice President and CEO David R. Nielsen, MD, responding to the draft reference medical policy and a conference call with members from 3P and Academy staff on the final reference policy. In all of these communications, the Academy expressed disagreement with the classification of balloon sinus ostial dilation as “Investigational/ Not Medically Necessary” and provided evidence supporting the safety and effectiveness of the procedure. Despite these efforts, BCBSA decided to keep the “Investigational/ Not Medically Necessary” designation until future studies could meet the research criteria necessary for the policy to be changed. One study submitted by the Academy (Plaza G, et al. Balloon dilation of the frontal recess: a randomized clinical trial. Ann Otol Rhinol Laryngol. 2011;120(8):511-8) was acknowledged to be the type of literature needed to revise coverage determinations but was, unfortunately, deemed insufficiently powered by BCBSA to change its policy. Note that the BCBSA Reference Policies are available for use by each BCBS plan in making independent decisions about medical policy. Each plan may adopt the reference policy in whole or in part, may modify it, or may reject it. These reference policies are developed by BCBSA staff and then reviewed by a BCBSA Medical Policy Panel (MPP) comprised of senior medical plan directors. The Academy has been, and remains, ready to cooperate with appropriate industry and other groups to develop requested prospective studies that could evaluate the efficacy and safety of devices and raise the level of evidence. The BCBSA Medical Director stated that there was no reference policy on denying payment for an entire surgical session when one portion or element was considered “Investigational/ Not Medically Necessary.” The Academy will continue to work with BCBS plans, and any others with similar policies, to allow the balloon to be used as a tool to complement a procedure without the entire procedure being denied. The 3P workgroup strongly believes the use of a balloon as a tool in a standard approach to a sinus ostial dilation is acceptable. Members may use a template appeal letter to appeal the denial of an entire surgical session where a balloon is used for sinus ostial dilation as a component of that session. It is available at http://www.entnet.org/Practice/Appeal-Template-letters.cfm. If you receive this type of denial, forward information including an EOB/Explanation of Benefits (HIPAA information redacted), indicating whether the full session is being denied and in what setting the procedure is being denied to healthpolicy@entnet.org so we can continue to track these. Also let us know if your local BCBSA plan is covering and paying for balloon sinuplasty. Advocacy Efforts So Far January 1, 2011: CPT approved new CPT codes for balloon sinus ostial dilation  (31295-31297). February 11, 2011: AAO-HNS received request from WellPoint to provide input on draft reference medical policy for balloon sinus ostial dilation. Sends to Rhinology and Paranasal Sinus Committee (RPS) for review and comments, then sends to Academy’s 3P workgroup for final review with final approval from the AAO-HNS Board. May 17, 2011: AAO-HNS sent comments to WellPoint, which forwards them to BCBSA for review. May 2011: BCBSA reviewed the draft medical policy for balloon sinus ostial dilation at its Medical Policy Panel meeting, AAO-HNS received reviewed comments. July 29, 2011: BCBSA reported that draft policy was final after May 2011 BCBSA medical policy panel review. August 25, 2011: Via “The News,” sends request for members to inform the Academy of problems with third-party payer coverage of balloon sinus ostial dilation and opposition to outright denial of payment for any, including classic endoscopic sinus surgery, when balloons are used during a surgical session. The Academy’s interpretation of extant literature led it to a different conclusion, and the Academy strongly opposed this action. September 21, 2011: AAO-HNS conducted conference call with BCBSA Technical Evaluation Committee Medical Chairman, 3P, and Academy staff. BCBSA indicated classification remains investigational/not medically necessary due to current insufficient evidence of comparative effectiveness. 3P provides the Plaza, et al., study. The Medical Chairman notes on September 24, 2011, in a written response that BCBSA determined that the study does not present a sufficient quality level and has serious limitations. September 30, 2011: AAO-HNS sent BCBSA a follow-up letter requesting what further study/information is required to eliminate “investigational” designation for balloon sinus ostial dilation going forward. October 6, 2011: Received response from BCBSA providing more information on types of trials needed to provide sufficient evidence for coverage, noting that for a treatment such as balloon sinus ostial dilation, they would expect high-quality clinical trials that compare this modality to alternatives, including a trial of sufficient size, analysis of the most clinically important outcome measures, and avoidance of major bias. The improvement in the outcome measure(s) should be both statistically and clinically significant.
Fasten Your Seatbelts for Another Busy Year in Politics
2011 was another whirlwind year on Capitol Hill and in the statehouses. If you need a refresher, don’t miss the annual Legislative and Political Advocacy edition of the February Bulletin. Readers will learn more about: What to expect in the second session of the 112th Congress; Where Does Your State Rank? Find out which states won the inaugural ENT PAC State Fundraising and Membership Challenge and how to get your state ahead in 2012; 2011 ENT PAC Investors. See which of your peers is investing in their  future … today; AAO-HNS OTO Advocacy Summit, May 7-8, scheduled in conjunction with meetings of the Boards of Directors and Board of Governors (May 5-7). Advocacy activities will include Capitol Hill Meetings, advocacy training, and an exclusive ENT PAC event at the Masonic Temple in Alexandria, VA. AAO-HNS Election Central. 2012 is poised to be a crucial election year, and now is the time to become more involved. The AAO-HNS Government Affairs team looks forward to another action-packed year. Do you want to be the first to know what’s happening on Capitol Hill and in the states? Start the year off right by joining ENT Advocacy Network—a free AAO-HNS member benefit. Advocacy Network members receive the most timely updates straight to their email inboxes, including: “The ENT Advocate,” a bi-weekly email newsletter; legislative action alerts; and the latest news and updates regarding various ENT PAC programs. Join today by emailing govtaffairs@entnet.org.
ENT Advocacy: Raise Your Voice on Capitol Hill
Help increase otolaryngology’s visibility and influence on Capitol Hill by coming to Washington, DC, May 7-8. This year’s advocacy conference is planned in conjunction with the spring meetings of the AAO-HNS/F Boards of Directors and the Board of Governors in an effort to ease the burden on our members’ demanding schedules. The OTO Advocacy Summit provides AAO-HNS members the ideal opportunity to directly lobby Congress on behalf of the specialty. Attendees will participate in legislative training sessions and pre-scheduled meetings with Members of Congress and/or their staff. There also will be ample networking opportunities with your colleagues and an exclusive ENT PAC fundraising event at the historic George Washington Masonic Memorial in Alexandria, VA. Advocacy activities will include an in-depth briefing with “insider” knowledge on all of the Academy’s main legislative issues, including Medicare physician payment; truth in advertising; Medicare audiology direct access; graduate medical education (GME) funding; and comprehensive medical liability reform. AAO-HNS members also will be equipped with key talking points to fully brief Members of Congress and/or Congressional staff on important, specialty-related legislative issues. Key strategies and “The Dos and Don’ts of Capitol Hill” will prepare attendees on how to communicate effectively in their Capitol Hill meetings. Attendees also can expect to learn more about ENT PAC, the Academy’s political action committee. ENT PAC is one of the main advocacy resources available to Academy members to help increase the visibility of the specialty with federal legislators and candidates. AAO-HNS members will be briefed on several recent ENT PAC initiatives that have carried over from 2011, including the State Fundraising and Membership Challenge and our Leadership Club giving levels. Mark your calendar today, and don’t miss the opportunity to raise your voice on Capitol Hill for the specialty.  Top 10 Reasons to Attend the 2012 OTO Advocacy Summit Learn to communicate effectively with federal legislators during advocacy training sessions. Be informed of changes in the legislative landscape and political climate. Attend an “insider’s” briefing on key legislative priorities specific to otolaryngology. Meet with your federal legislators and/or their staff. Access numerous opportunities to network with your peers and other Academy leaders. Learn effective advocacy tools to use back home. Speak with a powerful, unified voice to Congress on key legislative issues. Learn about the activities of ENT PAC, the AAO-HNS political action committee. For 2012 ENT PAC Investors, attend an exclusive ENT PAC fundraising event. Protect the future of your practice and ensure continued access to quality care for your patients.
Applications Open for 2012 BOG Model Society Award, Practitioner Excellence Award
The Model Society Award recognizes outstanding local, state, and regional societies that exhibit effective leadership, institute Academy and Foundation programs, and further Academy goals through active participation in the Board of Governors. The award is based on activities from February 1, 2011 through January 31, 2012. Previous winners of the Model Society Award include: the Pennsylvania Academy of Otolaryngology-Head and Neck Surgery (2011), Massachusetts Society of Otolaryngology-Head and Neck Surgery (2008 and 2009). Please consider applying for this prestigious award and letting the Academy know what great programs you are running in your region or state to improve the quality of care of our patients. The Practitioner Excellence Award recognizes the prototypical clinical otolaryngologist one wishes to emulate. BOG representatives should nominate individuals who, within the past 10 years, have practiced medicine in an exemplary manner and are sought by other physicians because of their personal and effective care. The nominee must be an Academy member in good standing and should have, in addition to his or her clinical skills, one or more of the following attributes: Civic leadership Charitable activity Leadership involvement with local, state, or national medical organizations Community education Participation in local civic and/or community activities The applications deadline is March 19. Awards will be presented during the annual meeting in Washington, DC at the BOG General Assembly on Monday afternoon, September 10. Send questions to bog@entnet.org.
(Left to Right): Anurag Agarwal, MD; Tapan Padhya, MD; Ari I. Wirtschafter, MD (FSO-HNS Otolaryngologist of the Year); Michael Owens, MD; W. Mark Flintoff, Jr., MD; David R. Nielsen, MD; Todd Blum, MHA MBA CMPE; Michael S. Benninger, MD; Julie Wolfe, CFRE; and K. Paul Boyev, MD.
Academy in Action Previewed at FSO-HNS 2011
On November 11, Academy and Foundation staff had the privilege of attending the Florida Society of Otolaryngology—Head and Neck Surgery (FSO-HNS) 2011 Annual Fall Meeting outside of Orlando, FL. Throughout the weekend, staff had the opportunity to meet with the more than 75 otolaryngologists—head and neck surgeons attending the meeting and to discuss the most pressing issues for otolaryngologists in that area of the country. David R. Nielsen, MD, executive vice president and CEO of the AAO-HNS/F, gave an informative, timely, and inspiring talk about “Healthcare in Transition.” His discussion provided attendees with a greater understanding of how the Academy and Foundation continue to work for you in the areas of healthcare reform, quality initiatives, and medical education. Previewing the Your Academy in Action program, Foundation staff gave a presentation on becoming involved with the AAO-HNSF, focusing on how the Board of Governors (BOG) societies and the AAO-HNS/F can advance the specialty through individual society member involvement and advocacy efforts. From joining your local society and BOG, to participating in and joining the May OTO Advocacy Summit the ENT Advocacy Network or becoming a member of the Millennium Society, there is something for everyone willing to do more on behalf of the specialty. AAO-HNS/F also hosted a booth in the exhibit hall to have one-on-one conversations with members and attendees. From the exhibit booth, attendees became new members, current members pledged Millennium Society gifts, and important conversations were had with multiple groups about becoming more active through the AAO-HNS Partners for Progress program (a way for group practices to engage in our mission and provide vital annual funds to support it). The AAO-HNS/F’s presence at the FSO-HNS 2011 Annual Meeting was a success, and we hope to continue to be a part of BOG meetings throughout the country. All of this would not have been possible without the help and support of key individuals from the FSO-HNS. We would like to thank Tapan A. Padhya, MD, FSO-HNS president; Ari I. Wirtschafter, MD, FSO-HNS president-elect and program chair; Robin L. Wagner, FSO-HNS executive director; and Todd Blum, MHA, MBA, FSO-HNS ad hoc administrator; for their facilitation of the Academy’s and Foundation’s participation in this important event.
Charles E. Moore, MD with children after health education class. Dr. Moore is the 2011 Gold Foundation Award recipient for Humanism in Medicine. Photo courtesy of Jim and Tamie Lyles.
The HEALing Community Center: Reaching Out to the Underserved in the U.S.A.
Charles E. Moore, MD, for the Diversity Committee The health of many Americans has improved during the past few decades and tremendous scientific advancements have been made. However, the reality is that many homeless, uninsured, and low-income minorities are not benefitting from these advancements, nor are they receiving important health screenings and preventative primary medical care. A critical issue is that a lack of financial resources often plays an important role in access to care. African Americans are diagnosed with some form of cancer at 44 diagnoses per 100,000 individuals more than Caucasians. Additionally, the death rate is 33-percent higher for African Americans than it is for Caucasians. We know that for most disease processes early detection means a better chance of more effective treatment. We also know that early detection is less common among African Americans. In Fulton County, GA the increasing health disparity between Caucasians and African-Americans has cost 28,022 years of potential life lost due to premature death in African-Americans. This number is more than double the number of years lost in neighboring DeKalb County and is drastically higher than any of Georgia’s 159 other counties. When considering oral cavity and oropharyngeal cancers in particular, it is seen that it will destroy 14,000 to 15,000 lives annually (www.nccn.org, www.cancer.gov). Additionally, 50,000 people will develop head and neck cancer this year. Of those who develop cancer of the oral cavity, nearly 75 percent of the cases of squamous cell cancer of the oral cavity involve only 10 percent of the mucosal surfaces of the mouth. This is an area that can be easily identified and monitored by health professionals. Also, it can be easily taught to lay people to examine in the home or community setting for signs of abnormality. In my current practice in the Department of Otolaryngology at Emory University at Grady Health System, I saw numerous patients who sought medical care only after their cancer had progressed to the point where they had limited treatment options. When I continued to see such patients on an almost daily basis, I decided I could do more to increase awareness of head and neck cancers. I identified the three zip codes that represented the highest percentages of head and neck cancers that I saw in my clinic. All three of these zip codes were in medically underserved areas. I later focused my attention on creating a facility in the area that had the highest percentage of head and neck cancers identified with outreach to the other areas. Poverty, high crime rates, limited access to healthcare and joblessness make this area a real-life study in the social determinants of health. Accordingly, I decided to develop a strategic approach to care that encompasses not only design, but delivery. From a community needs assessment, it was determined that cancer education was of primary importance. I developed the concept for the HEALing Community Center (www.HEALingOurCommunities.org), a free medical facility that would provide health education and primary and specialty care in the zip codes that need them most. Through collaborations with multiple medical, faith-based, community, and academic organizations, the center provides direct services in a medically underserved inner-city area in Atlanta. The facility addresses the increasing health disparities among minorities and uninsured individuals in poverty. In July of 2009, the Healing Community Center began providing primary care, cancer screenings and mental health services in three small rooms at a community-based organization. On June 25, 2011 the construction was completed on an 8,000-square feet facility that focuses on health education while providing comprehensive, integrated care. Since then, the need has increased exponentially necessitating the expansion to a larger facility to accommodate the requests of the community and other potential collaborators. The creation of this new facility will allow the center to further expand its services to provide comprehensive, integrated care to address the social determinants of health faced by people in poverty. From the initial screenings, I saw firsthand the extent of medical issues that were not being addressed in the community. Education of the public is of paramount importance to empower our patients to address critical health issues. In this manner, together we can strive to decentralize the delivery of healthcare by providing critical information not only from bench to bedside, but from bench to bedside to curbside. Donations to the HEALing Community Center can be addressed to HEAL Inc, PO Box 7522, Atlanta, Ga 30357 or completed online at www.HEALingOurCommunities.org.
Your Academy in Action
The AAO-HNS embarks on a new initiative, Your Academy in Action, to engage with members and nonmembers alike by strategically identifying and participating in key state, local, and other society and specialty meetings. The goals of this initiative are to: Offer key staff experts as speakers/presenters on such topics as legislative advocacy, health policy, and public relations, to educate physicians on issues facing their practices, their patients, and the specialty, and provide insight into Academy policies and initiatives. Promote the value of Academy membership to members and nonmembers. Provide a venue for gathering feedback by initiating discussions with a wide variety of members and nonmembers on topics of mutual importance. We would like to incorporate interested Academy members into these presentations, as we consider you subject matter experts. If you are interested in participating in Your Academy in Action, or would like to suggest a meeting for the group to attend, contact: memberservices@entnet.org. We look forward to hearing from you.
Dates to Remember
Jan. 1 Bulletin Online available. Jan. 1 Otolaryngology–Head and Neck Surgery available online. Jan. 1 PR and media campaign member materials available online. Jan. 1 Join the 2012 Millennium Society. Jan. 16 CORE final application. Feb. 9 April Bulletin; features The Business of Medicine; content due to bulletin@entnet.org. Feb. 1 PR and media campaign member materials available online. Feb. 1 Nominations of Distinguished Humanitarian. Feb. 2 Committee member application due. Feb. 17-18 Coding Workshops, see www.entnet.org/conferencesandevents. Feb. 20 Close of AAO-HNSF 2012 Annual Meeting & OTO EXPO Call for Oral and Poster Papers. March 8 May Bulletin; features the AAO-HNSF Annual Meeting & OTO EXPO; content due to  bulletin@entnet.org. Visit www.entnet.org for more.
In Memoriam: AAO-HNS Acknowledges Member Deaths
Throughout the year, through family members and other sources, the Academy is notified of deaths of members. The list is updated as Member Services learns of members who have passed. The AAO-HNS acknowledges the following members for their years of service to the profession of otolaryngology—head and neck surgery. Our sympathies go out to their families. Richard P. Ariagno, MD;  Las Vegas; Fellow; McGaw Medical Center/Northwestern University, 1953. John J. Ballenger, MD; Natick, MA; Fellow; Massachusetts Eye and Ear Infirmary/Harvard Medical School, 1943. Col. William H. Gernon, MD; Lakewood, WA; Fellow; Walter Reed Army Medical Center, 1969. Helen F. Krause, MD; Gibsonia, PA; Fellow; University Health Center of Pittsburgh, 1962. Duane Sewell, MD; Baltimore, MD,  Fellow; University of Pennsylvania; 1994. Jose Smoler, MD; Mexico City, Mexico; Fellow, University of Illinois College of Medicine at Chicago, 1964.
Have You Visited Your Academy Benefits Package Lately?
Eve Humphreys AAO-HNS Sr. Director, Membership The AAO-HNS dues renewal campaign is in full swing, and we look forward to your continued involvement with the Academy in 2012. Each year, we (your Academy leadership and staff) take the opportunity to challenge the value we offer you, the member. During strategic planning, we review the value of Academy membership to make sure we are speaking to your needs as an otolaryngologist—head and neck surgeon; whether you practice in a community or an academic setting, you are a resident or a retired physician, practicing domestically or internationally. The AAO-HNS vision, as an organization, is to empower our members to provide the best patient care. Our organizational mission states we do this through physician and patient education, research, and advocacy. To that end, we encourage you to revisit your AAO-HNS member benefits package to ensure you are taking advantage of all opportunities. We all lead extraordinarily busy lives, and the Academy is here to help. There are many ways the Academy can help you serve your patients, run your practice, and enhance your professional development. We invite you to fully participate in your Academy to get the most out of membership. Engagement Opportunities The January Bulletin includes a brochure containing a comprehensive overview of ways members can become more involved in the Academy and Foundation. Opportunities are designed to meet all levels of participation for continued development as physicians and as leaders to further strengthen the specialty. Members can select opportunities based on schedules, interests, and priorities. Education and Lifelong Learning Maintenance of Certification (MOC)  The Foundation provides educational support for maintenance of licensure and certification. All education activities, including the AAO-HNSF Annual Meeting & OTO EXPO, are aligned with the specialty areas defined by the American Board of Otolaryngology, making it easy for you to customize your education. AAO-HNSF Annual Meeting & OTO EXPO The AAO-HNSF Annual Meeting & OTO EXPO is the world’s largest gathering of otolaryngologists, together with the world’s largest collection of products and services for the specialty. This four-day, premier educational program provides the latest in otolaryngology medicine through scientific oral and poster presentations, miniseminars, instruction courses, and more. AcademyU® We offer our members highly relevant educational opportunities to increase their knowledge, competence, and patient care. AcademyU®, the Foundation’s e-learning system, provides 24/7 access to hundreds of learning activities, one-stop access to your AAO-HNSF CME records, and tools to help you plan your future learning activities to prepare for licensure and re-certification. This member benefit, worth several hundred dollars, is available at no additional charge just by enrolling. Research Academy membership and participation supports the development of evidence-based guidance that is updated and refined based on feedback from current practice data.  We identify, promote, and address the key research questions and disseminate discoveries for advancement of our field and to fundamentally improve patient outcomes. Legislative  and Political Advocacy  Your membership and participation supports the Academy’s political and legislative advocacy efforts, strengthening the influence and visibility of the specialty on Capitol Hill and in state legislatures. The Academy’s Government Affairs team advocates on behalf of its members and the specialty, urging legislators to ensure fair payment, improve patient care and access, and prevent inappropriate scope-of-practice expansions by allied healthcare professionals. Health Policy  and Business of Medicine Academy membership allows otolaryngologists to gain access to coding and reimbursement resources including coding and reimbursement workshops, template letters, links to outside resources, and ENTCodingToday, our custom database designed to save members time and money when submitting services for reimbursement. Publications Otolaryngology–Head and Neck Surgery Ranked first** (Eigen Factor) among the journals in the specialty, it is packed with articles on scientific developments, cutting-edge research, guidelines, topical supplements, and systematic literature and evidence reviews. Members have access to the new AAO-HNSF online journal, Otolaryngology–Head and Neck Surgery (www.otojournal.com), with robust features and functionality. Editor’s Choice collections have been added to the electronic journal as well as popular monthly podcasts. Bulletin Our highly ranked and valued monthly magazine, the Bulletin, brings you timely, trusted insights on clinical developments, safety and socioeconomic issues, managing your practice, and translational research. Visit the Bulletin now online. The News  The News helps members stay informed with Academy news and other timely issues affecting the whole specialty. It is delivered weekly by email. Improve Your Practice and Stay Connected to Colleagues The Academy and its Foundation have gone far beyond traditional services for members to help build their practices, and further their careers. ENT Careers The AAO-HNS online career center, ENT Careers, includes all specialty areas within otolaryngology­—head and neck surgery. ENT Careers is a single-source solution for recruitment and career searches, and offers job candidates increased access and exposure to thousands of employers. For employers, job postings are advertised to millions of qualified job applicants. AAO-HNS Member Network  All members are automatically included in our online directory, “Find an ENT,” one of the most-visited features of our website. Do not miss having your name listed on this valuable referral tool. In addition, members receive an updated Membership Directory, a personal worldwide address and phone book for otolaryngology professionals. Members can use the Directory, and the companion online database, when making referrals out of their areas. Patient Information Members receive a discount when ordering our health information designed to educate patients on the diagnoses and treatments you provide most. Created and peer-reviewed by our member physicians, this information, in print or as content for a practice’s website, provides a basic overview of diagnoses and treatment conditions to help answer your patients’ questions. We are always looking to improve the value of membership. We are here to answer your questions, concerns, or suggestions at memberservices@entnet.org. Many questions can be answered on our website at www.entnet.org as well. Our success as an organization is directly related to your membership and participation. Thank you for your continued loyalty and dedication. **Eigenfactor™ Score (EF): A measure of the overall value provided by all of the articles published in a given journal in a year. Article Influence™ Score (AI): a measure of a journal’s prestige based on per article citations and comparable to Impact Factor
Joseph E. Hart, MD
Delivering the Best Care to Difficult Patients
Joseph E. Hart, MD, MS, Chair, Board of Governors Rules & Regulations Committee Waterloo, Iowa One of my favorite courses at the 2011 AAO-HNSF Annual Meeting & OTO EXPO was “The Difficult Patient,” which presented a project out of Henry Ford Health System, Detroit, MI. A young head and neck surgeon on staff, named Tamer Abdul-Hamlin Ghanem, MD, PhD, had some challenging patients in clinic. One young patient had kept his heavy drinking a secret from his immediate family, and denied the problem with the otolaryngology clinic staff. He had successful cancer surgery, yet had complications and an extended hospital stay due to delirium tremens treatment. Instead of having the departmental chair, Kathleen Yaremchuk, MD, and administrators chastise the patient, the care team approached the significant problem of identifying risk factors as an opportunity. They suggested a support staff position to share some of the immense burden of gleaning the real picture in their patients. Their attitude toward the problem was part of the solution. The otolaryngology team created a staff position for a psychologist, Michael Ryan, PhD, to meet with the patient and family to help determine the best plan of care. The psychologist routinely meets with the head and neck surgeon to discuss the possible treatment options, and then meets with the patient and family to evaluate their ability to partner with the plan of action. Being able to identify areas of support can be challenging for all of us, no matter how well connected we are. Surgeons know that patients and families may have issues that are not talked about or dealt with effectively. The sequelae can be far-reaching, if the issues are not identified and dealt with properly from the outset. Clinical impact can be a significant drain on patients, family members, physicians, staff, the hospital system, and community. Clarity and honesty can be lacking because patients may live in some degree of denial of their psychosocial challenges. Their day-to-day living situations may allow malcoping based on denial of the problem. This is where we surgeons can ask for, and get, some much needed help. As needed, the psychologist on staff at Henry Ford Hospital enters to perform straightforward evaluations of cognitive, emotional, and supportive environments. Several provided examples are eye-opening and relevant. One patient was estranged from his family and had to re-establish some support before surgery could be scheduled. Anger issues were identified and limits were set. All this is much easier to work out ahead of time, rather than after surgery. Another example was a patient who, due to some neurologic problems, was actually much lower functioning than his wife would allow anyone to see. The identification of that problem helped establish what the patient could tolerate for treatment. Without the psychologist’s evaluation, he may have been offered something more complex than he could emotionally and physically tolerate. A third example was a patient, spouse, and friend (advocate) who showed mistrust in all interactions with the physicians, nurses, and staff. The healthcare team dealt with it in an open way that did not deny the challenge but moved forward, with the patient always at the forefront. Identifying these concerns can help ease the burden on the surgeon and the whole team. At Henry Ford, it helped identify the problems at hand. It did not make things perfect, but did demonstrate where effective help could be offered to that patient, at that particular time. It raised the situation to something more clearly recognized as uplifting to all. What is further amazing to me was that this was taken on by a hospital system in a community that is suffering economically in ways I can only imagine. I had gotten to know some of the otolaryngology staff at Henry Ford through leadership in AAO-HNS. I had the privilege of going to their presentation, and I had the opportunity to meet them later. They were quite humble in their approach in dealing with the problems in their clinic. I felt their approach would help me in my practice. Likewise, I see many other otolaryngologists making headway on so many fronts. I wanted to point these people out. I welcome my colleagues to point out other positive stories, or their successes, to our Academy.
David R. Nielsen, MD, AAO-HNS/F EVP/CEO
Seasons of Renewal
David R. Nielsen, MD AAO-HNS/F EVP/CEO Frequently throughout our personal lives are seasons of renewal and introspection of our progress and growth. This phenomenon also occurs with institutions, and the AAO-HNS/F is no exception. In fact, it seems to have even more frequent formal milestones that suggest it’s time to raise the bar again. Our fiscal year begins July 1; our Annual Meeting & OTO EXPO in September/October; and of course, our calendar year January 1. Additionally, each of us who serves you here at AAO-HNS/F headquarters in Alexandria, VA, and in our Washington, DC, office participates in personal annual evaluations of our performance. Each of these events provides an opportunity to start fresh, to adjust our sights, and to raise our performance. Recently we strengthened the process of our staff’s personal evaluations to create greater integration and closer alignment with our annual AAO-HNS/F performance cycle. This ensures more synergy, accountability, and effectiveness on your behalf. The process that each staff member goes through with supervisors annually actually begins before the year starts to set SMART (Specific, Measurable, Attributable, Realistic, and Timely) goals. Monitoring progress is not a “report card” at the end of the year, but a dynamic activity that continues throughout the year. One of the improvement tools that we use to train all our staff we call the “Gradually, Then Suddenly” principle. It comes from Fierce Conversations by Susan Scott. This principle states that our efforts, our employment, our education, our relationships, and even our very lives succeed or fail gradually, then suddenly, one conversation, one action, or one day at a time. We are often surprised to suddenly find that something unexpected (often undesired) has evolved in our work, relationships, or our lives. But with careful consideration and scrutiny, we can often see in retrospect that what suddenly seemed to hit out of the blue was building up over time. If we are wise, we can learn to notice the change that is taking place in the gradually phase, when there is time to do something about it. When project milestones are not met, or when progress lags, or when dependent actions are not taken, we can assume that project failure is pending. As you read this column, our annual strategic planning process with our AAO-HNS/F and Boards of Directors will have already taken place. Now, our staff are working hard to update actions and deliverables, with the required budget proposals, which, when completed by the Boards, will define success this and next year. I ask you to join me in thanking the very many volunteers who sacrifice their time and energy to represent all of us in this critical process. In addition to our officers and Boards of Directors, we routinely invite specific board “guests” to provide essential expertise and perspective. These guests include leaders from our Residents and Fellows Section, Young Physicians Committee, Women in Otolaryngology Section, Diversity Committee, Nominating Committee, Research Advisory Board, Physician Payment Policy Workgroup, and AMA Delegation. When you add the skilled coordinators, at-large board members, and those expert representatives from our Board of Governors, Specialty Society Advisory Council, our journal, Otolaryngology–Head and Neck Surgery, and our professional staff, we have tremendous power and knowledge to address the challenges we face. In the next two years, you will be seeing more emphasis on agility in responding to challenges; more rapid delivery of education, research and quality, and member services products; a more useful and robust website; and more value from enhanced product and service integration. This will not only be demonstrated within AAO-HNS/F structure, but in our collegial relations with ABOto, SUO, OPDO, our dynamic specialty societies, and other entities of great importance to you. As you engage in your own personal and professional introspection and craft your goals and resolutions for 2012 and beyond, I thank you, along with our many leaders and volunteers. Further, I solicit your increased support and personal engagement in the AAO-HNS/F and its programs as we strengthen our position as the best resource for your career. Whether your interests are primarily educational, research oriented, health policy, legislation, or regulatory, or all the above, there are many ways for you to become and stay involved in the Academy. See the new Engagement Brochure along with this Bulletin to find many opportunities to make the “whole become greater than the sum of its parts.” I wish you all a happy and prosperous 2012!
Rodney P. Lusk, MD AAO-HNS/F President
Planning for 2012 and Beyond
Rodney P. Lusk, MD AAO-HNS/F President As the New Year begins, the AAO-HNS/F is getting ready for the challenges of 2012. The Boards, with “key leaders,” have just completed their yearly strategic planning with a focus on the viability and sustainability of our organizations. In early December, two days are set aside to focus on what priorities should guide us through the upcoming year and advance our stated Mission and Vision:  MISSION – We help our members achieve excellence and provide the best ear, nose, and throat care through professional and public education, research, and health policy advocacy. VISION – Empowering otolaryngologist-head and neck surgeons to deliver the best patient care. As many of you know, strategic plans are often developed with considerable effort and energy, then placed on the shelf and not referred to until the next year’s strategic plan. This is not the case with your Academy. We do not have unlimited resources and personnel; therefore our efforts have to be guided and targeted towards specific goals. The Boards’ function is to oversee the viability of the Academy by developing a vision for the future, identifying problems and framing the desired outcome or goal. The Boards then charge the Academy staff to work out the details of implementation and hold the Academy staff accountable for the outcome. The AAO-HNS/F leaders and staff have been working to structure these strategic planning sessions so that the problems and solutions have concrete measures to assess their effectiveness. This process involves the input of all Board members and guests through written comments and breakout discussions which further define the problems and desired results. It is understood that the visible outcome of our efforts will be a revised strategic document which guides the activities for 2012 and 2013. Hearing leaderships’ voice  The Boards and our specialty society leaders prepared for this year’s strategic planning meeting by responding to a questionnaire built upon a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis.  Each member provided  a written assessment of AAO-HNS/F’s Internal Strengths with an eye on our mission and vision, what are we doing well, what  should we keep doing and, are we meeting the needs of our members and patients? We were also assessing our Weaknesses. Where are we not meeting membership expectations, what areas need improvement, alternative approach, or complete change? We then assessed the AAO-HNS/F’s external and internal Opportunities. Looking at our strengths and weaknesses, where can we have our greatest impact, and how can we better serve the membership?  Where do we think we could add value?  How can we work together to strengthen our impact and value for our patients and members? We looked at both internal and external Threats.  What are the legislative or political trends that affect the Academy and its members? What competition and societal changes may affect our sustainability? The survey responses were organized into distinct categories and when we arrived in Alexandria on Thursday for the planning session, the Boards were briefed on the results of the SWOT analysis. To further prepare the Boards for this year’s planning, staff leaders gave presentations highlighting their business unit functions and how those linked to the strategic plan approved by last year’s Boards. The survey and staff presentations provided a good foundation for developing this year’s strategic plan.  Using the survey results, four areas of focus were identified for further discussion on how we: Enhance knowledge/data access for our patients and membership Strengthen the value of membership in the Academy Improve communication with our membership and other organizations Ensure sustainability of the Academy Along with key staff members, Board members and invited guests spent the day detailing and assessing what success would look like in these four areas. Working Forward As January begins, the staff will finalize plans to conform to the new strategic plan.  These plans will go to the Executive Committees and the Boards for approval. The approved plan will be shared in forthcoming issues of the Bulletin. No doubt, there will be unforeseen issues which will arise over the next year. Rest assured that your Boards, the Academy staff, and  I are working strategically to meet the challenges ahead.
Lisa A. Orloff, MD
Head and Neck’s Scope Include the Thyroid
Lisa A. Orloff, MD, Chair, Endocrine Surgery Committee, AAO-HNS Although September is Thyroid Cancer Awareness Month, the AAO-HNSF encourages all of its members and affiliates to support thyroid cancer education all year. Since otolaryngologist—head and neck surgeons are concerned for, and pre-eminently qualified in, the management and treatment of disorders and diseases of the thyroid, this collaboration is intended to enhance early detection and care based on expert standards and guidelines, and research to achieve cures for all types of thyroid cancer. Thyroid cancer is one of the few cancers continuing to increase in incidence, with a record high of more than 44,000 people newly diagnosed in the United States in 2010 and more than 200,000 people newly diagnosed worldwide. It is also a cancer that affects people of all ages, from young children to seniors. When detected early, most thyroid cancers are treatable. However, some thyroid cancers are aggressive and difficult to treat. These are some of the many reasons why the AAO-HNS is teaming up with ThyCa: Thyroid Cancer Survivors’ Association, Inc. to raise thyroid cancer awareness. Thyroid Cancer Awareness Month is a worldwide observance, sponsored and initiated by ThyCa: Thyroid Cancer Survivors’ Association, Inc. (http://www.thyca.org/september.htm). It began in 2000 as Thyroid Awareness Week, and in 2003, expanded to the entire month of September. People and organizations in at least 55 countries around the world now take part. Thyroid Cancer Awareness Month is listed in official health events calendars and directories, including the American Hospital Association’s Calendar of Health Observances & Recognition Days. ThyCa is a national nonprofit organization of thyroid cancer survivors, family members, and healthcare professionals dedicated to education, communication, support services, awareness for early detection, and thyroid cancer research fundraising and research grants. In addition to sponsoring Thyroid Cancer Awareness Month each September, ThyCa also sponsors free seminars, workshops, the annual International Thyroid Cancer Survivors’ Conference, plus other year-round awareness campaigns. It also provides free educational materials upon request. As partners, participating otolaryngologists are asked to help promote Thyroid Cancer Awareness Month, and to acknowledge ThyCa (www.thyca.org). Individual organizations will be recognized in ThyCa’s newsletters and on ThyCa’s website. Information about participants’ organizations will also be included at the next annual International Thyroid Cancer Survivors’ Conference, both on the resource tables and in the program booklet given to attendees. Large or small, local events are also a great opportunity to raise awareness of thyroid cancer and acknowledge the contributions of everyone involved. Partnering otolaryngologists and organizations are encouraged to let ThyCa know the details of any event hosted, to receive recognition, to benefit from promotion, and to offer guidance to others who may wish to develop a similar event. In addition to Thyroid Cancer Awareness Month, the AAO-HNSF is continually doing its part to raise awareness and expertise in the care of thyroid cancer and thyroid disorders, through resources that include: Online fact sheets such as: Thyroid disorders and surgery http://www.entnet.org/HealthInformation/Thyroid-Disorders.cfm Pediatric thyroid cancer http://www.entnet.org/HealthInformation/Pediatric-Thyroid-Cancer.cfm Fine needle aspiration biopsy http://www.entnet.org/HealthInformation/fineNeedleAspiration.cfm Numerous miniseminars and instruction courses at the upcoming Annual Meeting of the AAO-HNSF in Washington, DC September 9-12 Ongoing activities of the Endocrine Surgery Committee of the AAO-HNS, including: Public education campaigns about radiation exposure and health risks Professional campaigns including emphasizing the importance of baseline laryngoscopy in the evaluation of patients with thyroid disorders, and postoperative laryngoscopy in patients who undergo thyroid surgery Thyroid cancer research collaborations, database development, and outcomes studies Participation in humanitarian missions involving thyroid surgery in underserved parts of the world Review and endorsement of thyroid-related practice guidelines, most recently including the 2011 American Thyroid Association practice recommendations Radiation Safety in the Treatment of Patients with Thyroid Diseases by Radioiodine (131I) http://www.thyca.org/ataradiation.pdf. The AAO-HNSF and ThyCa invite everyone interested to help with thyroid cancer awareness efforts in their communities. For free materials from ThyCa and tips on how to raise awareness, as well as more information about thyroid cancer, email outreach@thyca.org, call 1-877-588-7904, fax to1-630-604-6078, write to PO Box 1545, New York, NY 10159-1545, or visit  www.thyca.org.
Robert A. Sofferman, MD
Ultrasound Course Summary
Robert A. Sofferman, MD,  Course Director, Ultrasound Course Director (Head and Neck) American College of Surgeons National Ultrasound Faculty In both Boston in 2010 and San Francisco in 2011 on the day before the AAO-HNSF Annual Meeting & OTO EXPO, an Exported American College of Surgeons (ACS) Credentialing Course on Thyroid and Parathyroid Ultrasound has been available for interested otolaryngologists. Although the course is defined by its title as emphasizing an endocrine orientation, it in fact allows the attendee to understand the application of ultrasound to virtually all areas of head and neck anatomy and disease. The course requires completing a preliminary online Basic Ultrasound CD ROM, attendance at the five didactic lectures, and a full afternoon hands-on skill session. This skill session allows the course attendee to perform ultrasound examinations on volunteer patients, many with relevant pathologic conditions, under the watchful eye of an experienced ultrasound faculty. The course culminates in a multiple choice examination and practicum and ensures that the individual has properly absorbed and understood the process. In each of the courses in Boston and San Francisco, 62 to 65 individuals have been credentialed, thanks the volunteer efforts of 14 unique faculty members. Each faculty member is an experienced endocrine surgeon with significant hands-on experience with ultrasound. This course is the beginning of a clinical immersion in ultrasound. Once this exciting application becomes a part of one’s clinical armamentarium, it will be impossible to practice general otolaryngology and neck surgery without it at arm’s length. Office-based ultrasound is convenient for the patient, the ideal means of understanding the condition under study at the time of presentation, and a means of obtaining appropriate, focused cytology and culture material when required. The natural progression of this tool from practice to education of residents in all training programs will place ultrasound in its proper clinical position. To learn more about upcoming ultrasound courses at the 2012 Annual Meeting & OTO EXPO, check the Academy website www.entnet.org or contact meetings@entnet.org.