Published: February 4, 2014

Clinical Practice Guideline: Acute Otitis Externa

Executive Summary Richard M. Rosenfeld, MD, MPH; Seth R. Schwartz, MD, MPH; C. Ron Cannon, MD; Peter S. Roland, MD; Geoffrey R. Simon, MD; Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP; William W. Huang, MD, MPH; Helen W. Haskell, MA; Peter J. Robertson, MPA. Corresponding author: Richard M. Rosenfeld, MD, MPH, Department of Otolaryngology, SUNY Downstate Medical Center and Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201-5514. Email: richrosenfeld@msn.com. This month, the AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) published its first clinical practice guideline update, “Acute Otitis Externa,” as a supplement to Otolaryngology–Head and Neck Surgery. Recommendations developed address appropriate diagnosis of acute otitis externa (AOE) and the use of oral and topical antimicrobials and highlight the need for adequate pain relief. The guideline was developed using the a priori protocol for guideline updates outlined in the AAO-HNS Clinical Practice Guideline Development Manual.1 The complete guideline is available at http://oto.sagepub.com. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. Recommendations in a guideline can be implemented only if they are clear and identifiable. This goal is best achieved by structuring the guideline around a series of key action statements, which are supported by amplifying text and action statement profiles. For ease of reference, only the statements and profiles are included in this brief summary. Please refer to the complete guideline for the important information in the amplifying text that further explains the supporting evidence and details of implementation for each key action statement. For more information about the AAO-HNSF’s other quality knowledge products (clinical practice guidelines and clinical consensus statements), our guideline development methodology, or to submit a topic for future guideline development, please visit http://www.entnet.org/guidelines. Differences from Prior Guideline This clinical practice guideline is an update and replacement for an earlier guideline published in 2006 by the AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation.1 Changes in content and methodology from the prior guideline include: Addition of a dermatologist and consumer advocate to the guideline development group Expanded action statement profiles to explicitly state confidence in the evidence, intentional vagueness, and differences of opinion Enhanced external review process to include public comment and journal peer review New evidence from 12 randomized, controlled trials and two systematic reviews Review and update of all supporting text Emphasis on patient education and counseling with new tables that list common questions with clear, simple answers and provide instructions for properly administering ear drops Introduction Acute otitis externa (AOE) as discussed in this guideline is defined as diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. A diagnosis of diffuse AOE requires rapid onset (generally within 48 hours) in the past three weeks of symptoms and signs of ear canal inflammation as detailed above in Table 1. A hallmark sign of diffuse AOE is tenderness of the tragus, pinna, or both that is often intense and disproportionate to what might be expected based on visual inspection. AOE is a cellulitis of the ear canal skin and subdermis, with acute inflammation and variable edema. Nearly all (98 percent) AOE in North America is bacterial.2 The most common pathogens are Pseudomonas aeruginosa (20-60 percent prevalence) and Staphylococcus aureus (10-70 percent prevalence), often occurring as a polymicrobial infection. Other pathogens are principally Gram negative organisms (other than P. aeruginosa), any one of which cause no more than 2-3 percent of cases in large clinical series.3-10 Fungal involvement is distinctly uncommon in primary AOE, but may be more common in chronic otitis externa or after treatment of AOE with topical, or less often systemic, antibiotics.11 The primary outcome considered in this guideline is clinical resolution of AOE, which implies resolution of all presenting signs and symptoms (e.g., pain, fever, otorrhea). Additional outcomes considered include minimizing the use of ineffective treatments; eradicating pathogens; minimizing recurrence, cost, complications, and adverse events; maximizing the health-related quality of life of individuals afflicted with AOE; increasing patient satisfaction;40 and permitting the continued use of necessary hearing aids. The relatively high incidence of AOE and the diversity of interventions in practice make AOE an important condition for the use of an up-to-date, evidence-based practice guideline. Purpose The primary purpose of the original guideline was to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief. An updated guideline is needed because of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group. The target patient is aged 2 years or older with diffuse AOE, defined as generalized inflammation of the external ear canal, with or without involvement of the pinna or tympanic membrane. This guideline does not apply to children younger than 2 years or to patients of any age with chronic or malignant (progressive necrotizing) otitis externa. AOE is uncommon before age 2 years, and very limited evidence exists regarding treatment or outcomes in this age group.41 Although the differential diagnosis of the “draining ear” will be discussed, recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. The following conditions will be briefly discussed, but not considered in detail: furunculosis (localized AOE), otomycosis, herpes zoster oticus (Ramsay Hunt syndrome), and contact dermatitis. The guideline is intended for primary care and specialist clinicians, including otolaryngologists-head and neck surgeons, pediatricians, family physicians, emergency physicians, internists, nurse-practitioners, and physician assistants. The guideline is applicable to any setting in which children, adolescents, or adults with diffuse AOE would be identified, monitored, or managed. Key Action Statements STATEMENT 1. DIFFERENTIAL DIAGNOSIS: Clinicians should distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the external ear canal. Recommendation based on observational studies with a preponderance of benefit over risk. Action Statement Profile Aggregate evidence quality: Grade C, observational studies and Grade D, reasoning from first principles Level of confidence in evidence: High Benefit: Improved diagnostic accuracy Risks, harms, costs: None in following the recommended action Benefits-harm assessment: Preponderance of benefit over harm Value judgments: Importance of accurate diagnosis Intentional vagueness: None Role of patient preferences: None, regarding the need for a proper diagnosis Exceptions: None Policy level: Recommendation Differences of opinion: None STATEMENT 2. MODIFYING FACTORS: Clinicians should assess the patient with diffuse AOE for factors that modify management (non-intact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy). Recommendation based on observational studies with a preponderance of benefit over risk. Action Statement Profile Aggregate evidence quality: Grade C, observational studies Level of confidence in evidence: High Benefit: Optimizing treatment of AOE through appropriate diagnosis and recognition of factors or co-morbid conditions that might alter management Risks, harms, costs: None from following the recommendation; additional expense of diagnostic tests or imaging studies to identify modifying factors Benefits-harm assessment: Preponderance of benefits over harm Value judgments: Avoiding complications that could potentially be prevented by modifying the management approach based on the specific factors identified Intentional vagueness: None Role of patient preferences: None Exceptions: None Policy level: Recommendation Differences of opinion: None STATEMENT 3. PAIN MANAGEMENT: The clinician should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain. Strong recommendation based on well-designed randomized trials with a preponderance of benefit over harm. Action Statement Profile Aggregate evidence quality: Grade B, one randomized controlled trial limited to AOE; consistent, well-designed randomized trials of analgesics for pain relief in general Level of confidence in evidence: High Benefit: Increase patient satisfaction, allow faster return to normal activities Risks, harms, costs: Adverse effects of analgesics; direct cost of medication Benefits-harms assessment: Preponderance of benefit over harm Value judgments: Consensus among guideline development group that the severity of pain associated with AOE is under-recognized; preeminent role of pain relief as an outcome when managing AOE Intentional vagueness: None Role of patient preferences: Moderate, choice of analgesic and degree of pain tolerance Exceptions: None Policy level: Strong recommendation Differences of opinion: None STATEMENT 4. SYSTEMIC ANTIMICROBIALS: Clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. Strong recommendation based on randomized controlled trials with minor limitations and a preponderance of benefit over harm. Action Statement Profile Aggregate evidence quality: Grade B, randomized controlled trials with minor limitations; no direct comparisons of topical vs. systemic therapy Level of confidence in evidence: High Benefit: Avoid side effects from ineffective therapy, reduce antibiotic resistance by avoiding systemic antibiotics Risks, harms, costs: None Benefits-harms assessment: Preponderance of benefit over harm Value judgments: Desire to decrease the use of ineffective treatments, societal benefit from avoiding the development of antibiotic resistance Intentional vagueness: None Role of patient preferences: None Exceptions: None Policy level: Strong recommendation Differences of opinion: None STATEMENT 5. TOPICAL THERAPY: Clinicians should prescribe topical preparations for initial therapy of diffuse, uncomplicated AOE. Recommendation based on randomized trials with some heterogeneity and a preponderance of benefit over harm. Action Statement Profile Aggregate evidence quality: Grade B, meta-analyses of randomized controlled trials with significant limitations and heterogeneity Level of confidence in evidence: High for the efficacy of topical therapy as initial management, but low regarding comparative benefits of different classes of drugs or combinations of ototopical drugs Benefit: Effective therapy, low incidence of adverse events Risks, harms, costs: Direct cost of medication (varies greatly depending on drug class and selection), risk of secondary fungal infection (otomycosis) with prolonged use of topical antibiotics Benefits-harms assessment: Preponderance of benefit over harm Value judgments: Randomized clinical trials results from largely specialty settings may not be generalizable to patients seen in primary care settings, where the ability to perform effective aural toilet may be limited Intentional vagueness: No specific recommendations regarding the choice of ototopical agent Role of patient preferences: Substantial role for patient preference in choice of topical therapeutic agent Exceptions: Patients with a non-intact tympanic membrane (see Statement No. 7, Non-intact tympanic membrane) Policy level: Recommendation Differences of opinion: None STATEMENT 6. DRUG DELIVERY: The clinician should enhance the delivery of topical drops by informing the patient how to administer topical drops and by performing aural toilet, placing a wick, or both, when the ear canal is obstructed. Recommendation based on observational studies with a preponderance of benefit over harm. Action Statement Profile Aggregate evidence quality: Grade C, observational studies and Grade D, first principles Level of confidence in evidence: High Benefit: Improved adherence to therapy and drug delivery Risks, harms, costs: Pain and local trauma caused by inappropriate aural toilet or wick insertion; direct cost of wick (inexpensive) Benefits-harms assessment: Preponderance of benefit over harm Value judgments: Despite an absence of RCTs demonstrating a benefit of aural toilet, the guideline development group agreed that cleaning was appropriate, when necessary, to improve penetration of the drops into the ear canal Intentional vagueness: None Role of patient preferences: Choice of self-administering drops vs. using assistant Exceptions: None Policy level: Recommendation Differences of opinion: None STATEMENT 7. NON-INTACT TYMPANIC MEMBRANE: When the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube, the clinician should prescribe a non-ototoxic topical preparation. Recommendation based on reasoning from first principles and on exceptional circumstances where validating studies cannot be performed with a preponderance of benefit over harm. Action Statement Profile Aggregate evidence quality: Grade D, reasoning from first principles, and Grade X, exceptional situations where validating studies cannot be performed Level of confidence in evidence: Moderate, because of extrapolation of data from animal studies and little direct evidence in patients with AOE Benefit: Reduce the possibility of hearing loss and balance disturbance Risk, harm, cost: Eardrops without ototoxicity may be more costly Benefits-harms assessment: Preponderance of benefit over harm Value judgments: Importance of avoiding iatrogenic hearing loss from a potentially ototoxic topical preparation when non-ototoxic alternatives are available; placing safety above direct cost Intentional vagueness: None Role of patient preferences: None Exceptions: None Policy level: Recommendation Differences of opinion: None STATEMENT 8. OUTCOME ASSESSMENT: The clinician should reassess the patient who fails to respond to the initial therapeutic option within 48-72 hours to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. Recommendation based on observational studies and a preponderance of benefit over harm. Action Statement Profile Aggregate evidence quality: Grade C, outcomes from individual treatment arms of randomized controlled trials of efficacy of topical therapy for AOE Level of confidence in evidence: Medium, because most randomized trials have been conducted in specialist settings and the generalizability to primary care settings is unknown Benefit: Identify misdiagnosis and potential complications from delayed management; reduce pain Risks, harms, costs: Cost of reevaluation by clinician Benefits-harms assessment: Preponderance of benefit over harm Value judgments: None Intentional vagueness: Time frame of 48 to 72 hours is specified since there are no data to substantiate a more precise estimate of time to improvement Role of patient preferences: None Exceptions: None Policy level: Recommendation Differences of opinion: None Disclaimer This clinical practice guideline is provided for information and education purposes only. It is not intended as a sole source of guidance in managing patients with acute otitis externa. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. This guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosis and management. As medical knowledge expands and technology advances, clinical indicators and guidelines are promoted as conditional and provisional proposals of what is recommended under specific conditions, but they are not absolute. Guidelines are not mandates; these do not and should not purport to be a legal standard of care. The responsible physician, in light of all the circumstances presented by the individual patient, must determine the appropriate treatment. Adherence to these guidelines will not ensure successful patient outcomes in every situation. The AAO-HNS, Inc. emphasizes that these clinical guidelines should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Acknowledgements We gratefully acknowledge the work of the original guideline development group: Lance Brown, MD, MPH; Rowena J. Dolor, MD, MHS; Theodore G. Ganiats, MD; S. Maureen Hannley, PhD; Phillip Kokemueller, MS, CAE; S. Michael Marcy, MD; Richard N. Shiffman, MD, MCIS; Sandra S. Stinnett, DrPH; David L. Witsell, MD, MHS Disclosures Competing interests: Kaparaboyna Ashok Kumar, consultant for SoutheastFetalAlcoholSpectrumDisordersTrainingCenter and faculty speaker for the National Procedures Institute Sponsorship: AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation Funding source: AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation References 1. Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. Apr 2006;134(4 Suppl):S4-23. 2. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. Jul 2002;112 (7 Pt 1):1166-1177. 3. Dibb WL. Microbial aetiology of otitis externa. J Infect. May 1991;22(3):233-239. 4. Agius AM, Pickles JM, Burch KL. A prospective study of otitis externa. Clin Otolaryngol Allied Sci. Apr 1992;17(2):150-154. 5.Cassisi N, Cohn A, Davidson T, Witten BR. Diffuse otitis externa: clinical and microbiologic findings in the course of a multicenter study on a new otic solution. Ann Otol Rhinol Laryngol Suppl. May-Jun 1977;86(3 Pt 3 Suppl 39):1-16. 6. Clark WB, Brook I, Bianki D, Thompson DH. Microbiology of otitis externa. Otolaryngol Head Neck Surg. Jan 1997;116(1):23-25. 7. Jones RN, Milazzo J, Seidlin M. Ofloxacin otic solution for treatment of otitis externa in children and adults. Arch Otolaryngol Head Neck Surg. Nov 1997;123 (11):1193-1200. 8. Pistorius B, Westburry K, Drehobl, et al. Prospective, randomized, comparative trial of ciprofloxacin otic drops, with or without hydrocortisone, vs. polymyxin B-neomycin-hydrocortisone otic suspension in the treatment of acute diffuse otitis externa. Infect Dis Clin Pract. 1999;8:387-395. 9. Arshad M, Khan NU, Ali N, AfridiNM. Sensitivity and spectrum of bacterial isolates in infectious otitis externa. J Coll Physicians Surg Pak. Mar 2004;14(3):146-149. 10. Manolidis S, Friedman R, Hannley M, et al. Comparative efficacy of aminoglycoside versus fluoroquinolone topical antibiotic drops. Otolaryngol Head Neck Surg. Mar 2004;130(3 Suppl):S83-88. 11. Martin TJ, Kerschner JE, FlanaryVA. Fungal causes of otitis externa and tympanostomy tube otorrhea. Int J Pediatr Otorhinolaryngol. Nov 2005;69(11):1503-1508. 12. Hajioff D. Otitis externa. Clin Evid. Dec 2004(12):755-763. 13. HalpernMT, Palmer CS, Seidlin M. Treatment patterns for otitis externa. J Am Board Fam Pract. Jan-Feb 1999;12(1):1-7. 14. McCoy SI, Zell ER, Besser RE. Antimicrobial prescribing for otitis externa in children. Pediatr Infect Dis J. Feb 2004;23(2):181-183. 15. Levy SB. The Antibiotic Paradox. How the Misuse of Antibiotics Destroys Their Curative Powers. 2nd ed. Cambridge, MA: Perseus Publishing; 2002. 16. McCormick AW, Whitney CG, Farley MM, et al. Geographic diversity and temporal trends of antimicrobial resistance in Streptococcus pneumoniae in the United States. Nat Med. Apr 2003;9(4):424-430. 17. Bassetti M, Merelli M, Temperoni C, Astilean A. New antibiotics for bad bugs: where are we? Ann Clin Microbiol Antimicrob. Aug 28 2013;12(1):22. 18. Nussinovitch M, Rimon A, Volovitz B, Raveh E, Prais D, Amir J. Cotton-tip applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol. Apr 2004;68(4):433-435. 19. Goffin FB. pH and otitis externa. Arch Otolaryngol. Apr 1963;77:363-364. 20. Martinez Devesa P, Willis CM, Capper JW. External auditory canal pH in chronic otitis externa. Clin Otolaryngol Allied Sci. Aug 2003;28(4):320-324. 21. Yelland M. Otitis externa in general practice. Med J Aust. Mar 2 1992;156(5):325-326, 330. 22. Blake P, Matthews R, Hornibrook J. When not to syringe an ear. N Z Med J. Nov 13 1998;111(1077):422-424. 23. Berry RG, CollymoreVA. Otitis externa and facial cellulitis from Oriental ear cleaners. West J Med. May 1993;158(5):536. 24. Brook I, Coolbaugh JC. Changes in the bacterial flora of the external ear canal from the wearing of occlusive equipment. Laryngoscope. Jul 1984;94(7):963-965. 25. Hirsch BE. Infections of the external ear. Am J Otolaryngol. May-Jun 1992;13(3):145-155. 26. Russell JD, Donnelly M, McShane DP, Alun-Jones T, Walsh M. What causes acute otitis externa? J Laryngol Otol. Oct 1993;107(10):898-901. 27. Hoadley AW, KnightDE. External otitis among swimmers and nonswimmers. Arch Environ Health. Sep 1975;30(9):445-448. 28. Calderon R, Mood EW. A epidemiological assessment of water quality and “swimmer’s ear.” Arch Environ Health. Sep-Oct 1982;37(5):300-305. 29. Hansen UD. Otitis externa among users of private swimming pools. Ugeskr Laeger. Jul 7 1997;159(28):4383-4388. 30. Moore JE, Heaney N, Millar BC, Crowe M, Elborn JS. Incidence of Pseudomonas aeruginosa in recreational and hydrotherapy pools. Commun Dis Public Health. Mar 2002;5(1):23-26. 31. Hajjartabar M. Poor-quality water in swimming pools associated with a substantial risk of otitis externa due to Pseudomonas aeruginosa. Water Sci Technol. 2004;50(1):63-67. 32. Stroman DW, Roland PS, Dohar J, Burt W. Microbiology of normal external auditory canal. Laryngoscope. Nov 2001;111(11 Pt 1):2054-2059. 33. Steuer MK, Hofstadter F, Probster L, Beuth J, Strutz J. Are ABH antigenic determinants on human outer ear canal epithelium responsible for Pseudomonas aeruginosa infections? ORL J Otorhinolaryngol Relat Spec. May-Jun 1995;57(3):148-152. 34. Sundstrom J, Jacobson K, Munck-Wikland E, Ringertz S. Pseudomonas aeruginosa in otitis externa. A particular variety of the bacteria? Arch Otolaryngol Head Neck Surg. Aug 1996;122(8):833-836. 35. Bojrab DI, Bruderly T, Abdulrazzak Y. Otitis externa. Otolaryngol Clin North Am. Oct 1996;29(5):761-782. 36. Nichols AW. Nonorthopaedic problems in the aquatic athlete. Clin Sports Med. Apr 1999;18(2):395-411, viii. 37. Raymond L, Spaur WH, Thalmann ED. Prevention of divers’ ear. Br Med J. Jan 7 1978;1(6104):48. 38. Sander R. Otitis externa: a practical guide to treatment and prevention. Am Fam Physician. Mar 1 2001;63(5):927-936, 941-922. 39. Hannley MT, Denneny JC, 3rd, Holzer SS. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg. Jun 2000;122(6):934-940. 40. Shikiar R, HalpernMT, McGann M, Palmer CS, Seidlin M. The relation of patient satisfaction with treatment of otitis externa to clinical outcomes: development of an instrument. Clin Ther. Jun 1999;21(6):1091-1104. 41. Alter SJ, Vidwan NK, Sobande PO, Omoloja A, Bennett JS. Common childhood bacterial infections. Curr Probl Pediatr Adolesc Health Care. Nov 2011;41(10):256-283.

Executive Summary

Richard M. Rosenfeld, MD, MPH; Seth R. Schwartz, MD, MPH; C. Ron Cannon, MD; Peter S. Roland, MD; Geoffrey R. Simon, MD; Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP; William W. Huang, MD, MPH; Helen W. Haskell, MA; Peter J. Robertson, MPA. Corresponding author: Richard M. Rosenfeld, MD, MPH, Department of Otolaryngology, SUNY Downstate Medical Center and Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201-5514. Email: richrosenfeld@msn.com.

table1This month, the AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) published its first clinical practice guideline update, “Acute Otitis Externa,” as a supplement to Otolaryngology–Head and Neck Surgery. Recommendations developed address appropriate diagnosis of acute otitis externa (AOE) and the use of oral and topical antimicrobials and highlight the need for adequate pain relief. The guideline was developed using the a priori protocol for guideline updates outlined in the AAO-HNS Clinical Practice Guideline Development Manual.1 The complete guideline is available at http://oto.sagepub.com.

To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. Recommendations in a guideline can be implemented only if they are clear and identifiable. This goal is best achieved by structuring the guideline around a series of key action statements, which are supported by amplifying text and action statement profiles. For ease of reference, only the statements and profiles are included in this brief summary. Please refer to the complete guideline for the important information in the amplifying text that further explains the supporting evidence and details of implementation for each key action statement.

For more information about the AAO-HNSF’s other quality knowledge products (clinical practice guidelines and clinical consensus statements), our guideline development methodology, or to submit a topic for future guideline development, please visit http://www.entnet.org/guidelines.

Differences from Prior Guideline

This clinical practice guideline is an update and replacement for an earlier guideline published in 2006 by the AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation.1 Changes in content and methodology from the prior guideline include:

  • Addition of a dermatologist and consumer advocate to the guideline development group
  • Expanded action statement profiles to explicitly state confidence in the evidence, intentional vagueness, and differences of opinion
  • Enhanced external review process to include public comment and journal peer review
  • New evidence from 12 randomized, controlled trials and two systematic reviews
  • Review and update of all supporting text
  • Emphasis on patient education and counseling with new tables that list common questions with clear, simple answers and provide instructions for properly administering ear drops

Introduction

table2Acute otitis externa (AOE) as discussed in this guideline is defined as diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. A diagnosis of diffuse AOE requires rapid onset (generally within 48 hours) in the past three weeks of symptoms and signs of ear canal inflammation as detailed above in Table 1. A hallmark sign of diffuse AOE is tenderness of the tragus, pinna, or both that is often intense and disproportionate to what might be expected based on visual inspection.

AOE is a cellulitis of the ear canal skin and subdermis, with acute inflammation and variable edema. Nearly all (98 percent) AOE in North America is bacterial.2 The most common pathogens are Pseudomonas aeruginosa (20-60 percent prevalence) and Staphylococcus aureus (10-70 percent prevalence), often occurring as a polymicrobial infection. Other pathogens are principally Gram negative organisms (other than P. aeruginosa), any one of which cause no more than 2-3 percent of cases in large clinical series.3-10 Fungal involvement is distinctly uncommon in primary AOE, but may be more common in chronic otitis externa or after treatment of AOE with topical, or less often systemic, antibiotics.11

The primary outcome considered in this guideline is clinical resolution of AOE, which implies resolution of all presenting signs and symptoms (e.g., pain, fever, otorrhea). Additional outcomes considered include minimizing the use of ineffective treatments; eradicating pathogens; minimizing recurrence, cost, complications, and adverse events; maximizing the health-related quality of life of individuals afflicted with AOE; increasing patient satisfaction;40 and permitting the continued use of necessary hearing aids. The relatively high incidence of AOE and the diversity of interventions in practice make AOE an important condition for the use of an up-to-date, evidence-based practice guideline.

Purpose

table3The primary purpose of the original guideline was to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief. An updated guideline is needed because of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group. The target patient is aged 2 years or older with diffuse AOE, defined as generalized inflammation of the external ear canal, with or without involvement of the pinna or tympanic membrane. This guideline does not apply to children younger than 2 years or to patients of any age with chronic or malignant (progressive necrotizing) otitis externa. AOE is uncommon before age 2 years, and very limited evidence exists regarding treatment or outcomes in this age group.41 Although the differential diagnosis of the “draining ear” will be discussed, recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. The following conditions will be briefly discussed, but not considered in detail: furunculosis (localized AOE), otomycosis, herpes zoster oticus (Ramsay Hunt syndrome), and contact dermatitis.

The guideline is intended for primary care and specialist clinicians, including otolaryngologists-head and neck surgeons, pediatricians, family physicians, emergency physicians, internists, nurse-practitioners, and physician assistants. The guideline is applicable to any setting in which children, adolescents, or adults with diffuse AOE would be identified, monitored, or managed.

Key Action Statementstable4


STATEMENT 1. DIFFERENTIAL DIAGNOSIS:

Clinicians should distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the external ear canal. Recommendation based on observational studies with a preponderance of benefit over risk.

Action Statement Profile

  • Aggregate evidence quality: Grade C, observational studies and Grade D, reasoning from first principles
  • Level of confidence in evidence: High
  • Benefit: Improved diagnostic accuracy
  • Risks, harms, costs: None in following the recommended action
  • Benefits-harm assessment: Preponderance of benefit over harm
  • Value judgments: Importance of accurate diagnosis
  • Intentional vagueness: None
  • Role of patient preferences: None, regarding the need for a proper diagnosis
  • Exceptions: None
  • Policy level: Recommendation
  • Differences of opinion: None

STATEMENT 2. MODIFYING FACTORS:

Clinicians should assess the patient with diffuse AOE for factors that modify management (non-intact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy). Recommendation based on observational studies with a preponderance of benefit over risk.

Action Statement Profile

  • Aggregate evidence quality: Grade C, observational studies
  • Level of confidence in evidence: High
  • Benefit: Optimizing treatment of AOE through appropriate diagnosis and recognition of factors or co-morbid conditions that might alter management
  • Risks, harms, costs: None from following the recommendation; additional expense of diagnostic tests or imaging studies to identify modifying factors
  • Benefits-harm assessment: Preponderance of benefits over harm
  • Value judgments: Avoiding complications that could potentially be prevented by modifying the management approach based on the specific factors identified
  • Intentional vagueness: None
  • Role of patient preferences: None
  • Exceptions: None
  • Policy level: Recommendation
  • Differences of opinion: None

STATEMENT 3. PAIN MANAGEMENT:

The clinician should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain. Strong recommendation based on well-designed randomized trials with a preponderance of benefit over harm.

Action Statement Profile

  • Aggregate evidence quality: Grade B, one randomized controlled trial limited to AOE; consistent, well-designed randomized trials of analgesics for pain relief in general
  • Level of confidence in evidence: High
  • Benefit: Increase patient satisfaction, allow faster return to normal activities
  • Risks, harms, costs: Adverse effects of analgesics; direct cost of medication
  • Benefits-harms assessment: Preponderance of benefit over harm
  • Value judgments: Consensus among guideline development group that the severity of pain associated with AOE is under-recognized; preeminent role of pain relief as an outcome when managing AOE
  • Intentional vagueness: None
  • Role of patient preferences: Moderate, choice of analgesic and degree of pain tolerance
  • Exceptions: None
  • Policy level: Strong recommendation
  • Differences of opinion: None

STATEMENT 4. SYSTEMIC ANTIMICROBIALS:

Clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. Strong recommendation based on randomized controlled trials with minor limitations and a preponderance of benefit over harm.

  • Action Statement Profile
    • Aggregate evidence quality: Grade B, randomized controlled trials with minor limitations; no direct comparisons of topical vs. systemic therapy
    • Level of confidence in evidence: High
    • Benefit: Avoid side effects from ineffective therapy, reduce antibiotic resistance by avoiding systemic antibiotics
    • Risks, harms, costs: None
    • Benefits-harms assessment: Preponderance of benefit over harm
    • Value judgments: Desire to decrease the use of ineffective treatments, societal benefit from avoiding the development of antibiotic resistance
    • Intentional vagueness: None
    • Role of patient preferences: None
    • Exceptions: None
    • Policy level: Strong recommendation
    • Differences of opinion: None

table5

STATEMENT 5. TOPICAL THERAPY:

Clinicians should prescribe topical preparations for initial therapy of diffuse, uncomplicated AOE. Recommendation based on randomized trials with some heterogeneity and a preponderance of benefit over harm.

Action Statement Profile

  • Aggregate evidence quality: Grade B, meta-analyses of randomized controlled trials with significant limitations and heterogeneity
  • Level of confidence in evidence: High for the efficacy of topical therapy as initial management, but low regarding comparative benefits of different classes of drugs or combinations of ototopical drugs
  • Benefit: Effective therapy, low incidence of adverse events
  • Risks, harms, costs: Direct cost of medication (varies greatly depending on drug class and selection), risk of secondary fungal infection (otomycosis) with prolonged use of topical antibiotics
  • Benefits-harms assessment: Preponderance of benefit over harm
  • Value judgments: Randomized clinical trials results from largely specialty settings may not be generalizable to patients seen in primary care settings, where the ability to perform effective aural toilet may be limited
  • Intentional vagueness: No specific recommendations regarding the choice of ototopical agent
  • Role of patient preferences: Substantial role for patient preference in choice of topical therapeutic agent
  • Exceptions: Patients with a non-intact tympanic membrane (see Statement No. 7, Non-intact tympanic membrane)
  • Policy level: Recommendation
  • Differences of opinion: None

STATEMENT 6. DRUG DELIVERY:

The clinician should enhance the delivery of topical drops by informing the patient how to administer topical drops and by performing aural toilet, placing a wick, or both, when the ear canal is obstructed. Recommendation based on observational studies with a preponderance of benefit over harm.

Action Statement Profile

  • Aggregate evidence quality: Grade C, observational studies and Grade D, first principles
  • Level of confidence in evidence: High
  • Benefit: Improved adherence to therapy and drug delivery
  • Risks, harms, costs: Pain and local trauma caused by inappropriate aural toilet or wick insertion; direct cost of wick (inexpensive)
  • Benefits-harms assessment: Preponderance of benefit over harm
  • Value judgments: Despite an absence of RCTs demonstrating a benefit of aural toilet, the guideline development group agreed that cleaning was appropriate, when necessary, to improve penetration of the drops into the ear canal
  • Intentional vagueness: None
  • Role of patient preferences: Choice of self-administering drops vs. using assistant
  • Exceptions: None
  • Policy level: Recommendation
  • Differences of opinion: None

STATEMENT 7. NON-INTACT TYMPANIC MEMBRANE:

When the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube, the clinician should prescribe a non-ototoxic topical preparation. Recommendation based on reasoning from first principles and on exceptional circumstances where validating studies cannot be performed with a preponderance of benefit over harm.

Action Statement Profile

  • Aggregate evidence quality: Grade D, reasoning from first principles, and Grade X, exceptional situations where validating studies cannot be performed
  • Level of confidence in evidence: Moderate, because of extrapolation of data from animal studies and little direct evidence in patients with AOE
  • Benefit: Reduce the possibility of hearing loss and balance disturbance
  • Risk, harm, cost: Eardrops without ototoxicity may be more costly
  • Benefits-harms assessment: Preponderance of benefit over harm
  • Value judgments: Importance of avoiding iatrogenic hearing loss from a potentially ototoxic topical preparation when non-ototoxic alternatives are available; placing safety above direct cost
  • Intentional vagueness: None
  • Role of patient preferences: None
  • Exceptions: None
  • Policy level: Recommendation
  • Differences of opinion: None

STATEMENT 8. OUTCOME ASSESSMENT:

The clinician should reassess the patient who fails to respond to the initial therapeutic option within 48-72 hours to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. Recommendation based on observational studies and a preponderance of benefit over harm.

Action Statement Profile

  • Aggregate evidence quality: Grade C, outcomes from individual treatment arms of randomized controlled trials of efficacy of topical therapy for AOE
  • Level of confidence in evidence: Medium, because most randomized trials have been conducted in specialist settings and the generalizability to primary care settings is unknown
  • Benefit: Identify misdiagnosis and potential complications from delayed management; reduce pain
  • Risks, harms, costs: Cost of reevaluation by clinician
  • Benefits-harms assessment: Preponderance of benefit over harm
  • Value judgments: None
  • Intentional vagueness: Time frame of 48 to 72 hours is specified since there are no data to substantiate a more precise estimate of time to improvement
  • Role of patient preferences: None
  • Exceptions: None
  • Policy level: Recommendation

Differences of opinion: None

Disclaimer

This clinical practice guideline is provided for information and education purposes only. It is not intended as a sole source of guidance in managing patients with acute otitis externa. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. This guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosis and management.

As medical knowledge expands and technology advances, clinical indicators and guidelines are promoted as conditional and provisional proposals of what is recommended under specific conditions, but they are not absolute. Guidelines are not mandates; these do not and should not purport to be a legal standard of care. The responsible physician, in light of all the circumstances presented by the individual patient, must determine the appropriate treatment. Adherence to these guidelines will not ensure successful patient outcomes in every situation. The AAO-HNS, Inc. emphasizes that these clinical guidelines should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.

Acknowledgements

We gratefully acknowledge the work of the original guideline development group: Lance Brown, MD, MPH; Rowena J. Dolor, MD, MHS; Theodore G. Ganiats, MD; S. Maureen Hannley, PhD; Phillip Kokemueller, MS, CAE; S. Michael Marcy, MD; Richard N. Shiffman, MD, MCIS; Sandra S. Stinnett, DrPH; David L. Witsell, MD, MHS

Disclosures

Competing interests: Kaparaboyna Ashok Kumar, consultant for SoutheastFetalAlcoholSpectrumDisordersTrainingCenter and faculty speaker for the National Procedures Institute

Sponsorship: AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation

Funding source: AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation

References

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29. Hansen UD. Otitis externa among users of private swimming pools. Ugeskr Laeger. Jul 7 1997;159(28):4383-4388.

30. Moore JE, Heaney N, Millar BC, Crowe M, Elborn JS. Incidence of Pseudomonas aeruginosa in recreational and hydrotherapy pools. Commun Dis Public Health. Mar 2002;5(1):23-26.

31. Hajjartabar M. Poor-quality water in swimming pools associated with a substantial risk of otitis externa due to Pseudomonas aeruginosa. Water Sci Technol. 2004;50(1):63-67.

32. Stroman DW, Roland PS, Dohar J, Burt W. Microbiology of normal external auditory canal. Laryngoscope. Nov 2001;111(11 Pt 1):2054-2059.

33. Steuer MK, Hofstadter F, Probster L, Beuth J, Strutz J. Are ABH antigenic determinants on human outer ear canal epithelium responsible for Pseudomonas aeruginosa infections? ORL J Otorhinolaryngol Relat Spec. May-Jun 1995;57(3):148-152.

34. Sundstrom J, Jacobson K, Munck-Wikland E, Ringertz S. Pseudomonas aeruginosa in otitis externa. A particular variety of the bacteria? Arch Otolaryngol Head Neck Surg. Aug 1996;122(8):833-836.

35. Bojrab DI, Bruderly T, Abdulrazzak Y. Otitis externa. Otolaryngol Clin North Am. Oct 1996;29(5):761-782.

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38. Sander R. Otitis externa: a practical guide to treatment and prevention. Am Fam Physician. Mar 1 2001;63(5):927-936, 941-922.

39. Hannley MT, Denneny JC, 3rd, Holzer SS. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg. Jun 2000;122(6):934-940.

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More from February 2014 – Vol. 33 No.02
08-before
Healing the Children—Santa Marta Smiles Again
Neha A. Patel, MD Third-year resident, otolaryngology-head and neck surgery The New York Eye & Ear Infirmary New York, NY In September 2013, I joined a team of 25 other volunteers from the U.S.-based Healing the Children organization. After months of planning and packing, we arrived at the Hospital Universitario Fernando Troconis in Santa Marta, Colombia. Excitement was in the air as the local volunteers of the Colombia-based UNIMA organization and enthusiastic Colombian medical students greeted us at the airport. The travel grant I was awarded by the Humanitarian Efforts Committee of the AmericanAcademy of Otolaryngology—Head and Neck Surgery gave me the opportunity to help give life-altering care to Colombian families. In Colombia, an ecologic paradise is juxtaposed with the extreme poverty of many indigenous children. We screened about 100 surgical candidates upon arrival. The patient population ranged from ages six-weeks to 38 years old. Many of these patients had waited years for their surgery and many families spent months to gather the funding to travel by bus and boat. We traveled with all our equipment from New York. This included the OR surgical masks and instruments, the anesthesia machines, the PACU pulse oximeters, and beverages for patients. We operated on 59 patients in five days. The majority of surgical patients were children who needed repair of cleft lip and palate. In addition, patients underwent tympanostomy tube placement, cleft rhinoplasty, and treatment for velopharyngeal insufficiency. Patients with disfiguring hemangiomas, burns, and microtias were also treated. The team was led by Andrew A. Jacono, MD, a New York Facial Plastic Surgeon, who has led several mission trips throughout the world. Other members of the American Academy of Otolaryngology—Head and Neck Surgery also included attending surgeons Joseph Rousso, MD, and Augustine L. Moscatello, MD, facial plastic and reconstructive fellow Benjamin Talei, MD, and otolaryngology residents including myself and fourth-year resident Michael Bassiri-Tehrani, MD. Additionally, an amazing team of anesthesiologists, nurse anesthetists, pediatricians, nurses, surgical technicians, administrators, and local Colombian volunteers contributed an enormous amount of time and effort to help these young patients receive excellent care. Every day would start with a team meeting to optimize the flow of cases and make sure all patients were treated optimally. The highlight of the week was seeing the tears of joy on the faces of the mothers when they saw the immediate difference surgery made on our patients. Day after day, I got the honor of helping treat children who no longer had to be ostracized by craniofacial malformations. Many children were able to get immediate improvement in their ability to eat, drink, and speak. I was blessed to share this amazing experience with the best team anyone could dream of. There are still many children who need our help and my week in Colombia helped me realize how lucky we are to have the ability to help make a difference in their lives.
Preoperative photo of a 72-year-old woman with a goiter for more than 30 years.
Kenya Relief at the Brase Clinic
Anya J. Miller, MD Humanitarian Grant Awardee, Resident, Henry Ford Hospital Royal Oak, MI Last September, I traveled with a team from Henry Ford Hospital and the University of Michigan to Migori, Kenya, with Kenya Relief. Under the supervision of Lamont R. Jones, MD, and Greg Basura, MD, PhD, we performed otologic surgery at the Brase Clinic. With the assistance of local nurses, scrub techs, and nurse practitioners, we were able to perform surgeries including hemithyroidectomies, tympanoplasties, cleft lips, and various lumps and bumps. Although we operated out of a clinic and not a hospital, our patients were able to stay overnight for observation due to the support of local nurses. Despite the occasional fly in the operating room, we enjoyed many amenities such as air conditioning, OR tables that moved up and down, operating microscopes, and Neptune suction machines, to name a few. In fact, after touring the local district hospital, our clinic appeared much better equipped thanks to many generous donations throughout the years. Supplementing with some supplies from home such as an ear tray and LED headlights, we were able to safely provide surgical care to the people. The majority of the surgical patients who arrived for ENT evaluation were women with goiters. While we were able to alleviate much of the compression and cosmetic deformity with a hemithyroidectomy, we were not able to provide them with a real long-term solution. For smaller goiters, we prescribed iodine drops and education on iodized salt. It was unfortunate that we had not brought with us any iodine drops to dispense to the patients, so how many people were actually able to get the medication is uncertain. While I do believe our team made a difference and patients were happy to have the surgery, multiple ENT teams arrive at the Brase Clinic each year and perform many surgeries for goiters. Despite this, the patients lined up with goiters are endless each time. It seems that the people in Kenya could benefit from ENT mission groups joining efforts with public health specialists. Given all the resources invested in taking a team to Kenya, a multidisciplinary approach to this issue could be both cost effective and provide a more substantial benefit to the local people. Without this or a similar effort, it seems inevitable that the lines of people waiting to have their goiters removed will continue to be lengthy. While we were there to serve the people of Kenya, from a resident’s perspective, there was much personal benefit derived from this experience as well. I was able to give my undivided attention to each surgical case without pagers going off, heading off to complete other clinical duties, or anything else that might draw my attention away from the case at hand. We also performed similar cases often, so I was able to learn from each case and improve on those skills without having days or weeks between cases to forget what I had learned. Having consistency in attendings also meant that I could reliably anticipate the next move, which also seemed to accelerate my learning. Medical missions are in general a huge undertaking for everyone involved, but patients are universally thankful and resident benefit is priceless. Because time and money committed to this endeavor is great, each mission group should look at the needs of the particular area and try to tailor their mission accordingly to maximize impact. Many thanks to the AAO-HNSF Humanitarian Efforts Committee for its grant that made my participation possible. Kenya Relief Brase Clinic P.O. Box 1078 Suna, Migori Kenya, Africa 40400 Contact: Dominic, Clinical Officer 011-254-724-777-048 Keptembwa@yahoo.com
www.entnet.org/AcademyU
Education: Awareness, Engagement, and Value
Always seeking to improve education for members, the AAO-HNS Foundation embarked on a year-long education needs assessment in 2013. The recent member-wide survey provided enlightening and actionable data regarding member’s perceptions of our education offerings. The five central themes that emerged were described in the January 2014 Bulletin: member awareness, engagement, and value; existing education products; technology and learning styles; collaboration; and ideal education platform. In the first of the series, this article presents findings from the survey regarding member awareness, engagement, and value in Foundation education and knowledge resources. Member Awareness Though a vast majority of members showed familiarity with the Annual Meeting & OTO EXPOSM and the Home Study Course, the familiarity did not extend to the 15-plus other knowledge products provided by the foundation. More than half of members are not aware that the Foundation offers free education resources such as online courses and lectures, COOL, COCLIA, and eBooks as a member benefit. More than one-third of the members were unable to distinguish between free education resources and those that are fee-based. Whether you are a long-time member or relatively new to the specialty, you may also be missing out on valuable resources. Take a look at the 2014 Educational Opportunities at www.entnet.org/EducationAndResearch/upload/2014_AcademyU_EduOpps_Final_Optimized.pdf or visit www.entnet.org/academyU to check your own knowledge of AAO-HNSF’s education and knowledge resources. Member Engagement The survey provided some positive news about member engagement in education, but also showed some opportunity for improvement—particularly for longer-term members. According to the survey, two-thirds of the respondent’s current continuing education needs are fulfilled by the Foundation. Half of those completing the survey plan to continue to or increase their engagement in education with the Foundation during the next three years. Newer members are particularly heavy users, indicating that they have accessed four or more education resources in the past three years. While this is all great news, we also learned that nearly one-third of long-term members have not used any Foundation education resources in the past three years. While one-third of members receive all of their education from the Foundation, many turn to other organizations as well. An additional one-third of respondents indicate that they rely on one other organization in addition to the AAO-HNSF for their education. Members list a variety of organizations they use for continuing education purposes with other otolaryngology specialty organizations making up the majority of other resources. Value The perceived value of the Foundation’s education content is high among long-time members, but newer members rate the value significantly lower. This decline in value between long-term and short-term members may indicate there are gaps in quality content, learning formats, delivery of information, or some combination of all three in the minds of the short-term members. In general, the Foundation has a positive reputation among its members in terms of education. More than half of members rate the value of education resources as very good and also indicate they are very likely to recommend them to others. However, both value and likelihood to recommend is lowest for younger members. The most common reasons the Foundation education resources offer better value than other organizations include: Education content is more relevant to area of practice  or interests Wider variety of topics covered Greater quantity of offerings / resources More advanced / in-depth content Accessibility / navigation / organization More online offerings Current / cutting edge The most common reasons the Foundation education resources offer worse value than other organizations include: Education content is less relevant to my area of practice or interests Expense of education products Content is too broad / too focused on generalists Fewer offerings available Poor accessibility Not as current or up-to-date Members do not see the Foundation as “providing one-stop-shopping” for all education needs.” Significant work will be required on the part of our education leadership to determine whether that goal is achievable, and if so, how to raise the bar to that level. The relationship between member awareness, engagement, and value of education and knowledge resources will be an overarching measure of success as we work to build a better education platform for members. Through improving the perceived value of its offerings, the Foundation will secure its spot as the primary source for otolaryngology education.
Academy Launches 2014 Socioeconomic Survey
Since 1997, the Academy, through its Health Policy Team, has disseminated a Socioeconomic Survey every three years to all members (excluding military, retirees, and those in training). The survey is an important tool for gathering information on members’ practice patterns, the healthcare environment, and future trends in otolaryngology-head and neck surgery. This data enables the Academy to provide members with useful benchmarking tools. The survey is the most recognized otolaryngology-specific member survey available and allows the Academy to identify key issues and policies affecting members, particularly as they relate to practice productivity, revenue, and operations. The Academy encourages all eligible members to get involved and lend their voice to this important survey. Members will be able to complete the online survey February 18-March 31 after receiving a unique link to their designated email address. Your participation is essential for strong, statistically meaningful results. The published aggregate results serve as an asset for members when measuring themselves against their peers. Aggregate results will be published by an independent research firm in the November Bulletin, and will be on display at the 2014 Annual Meeting in Orlando, Florida, September 21-24. For more information on the AAO-HNS Socioeconomic Survey, please email the Health Policy Team at healthpolicy@entnet.org.
160650307
Clarification of Position Statements: What Are They and How Can They be Used?
In an effort to provide clarification about the differences among the quality knowledge products the Academy provides, the Ad Hoc Payment Model Workgroup has summarized the products including the Clinical Practice Guidelines (CPG) and Clinical Consensus Statements (CCS)s as compared to other Academy documents such as Clinical Indicators (CI)s, and Position Statements (PS)s, providing members with descriptions of the documents and how to use them. These documents can be viewed at http://www.entnet.org/Practice/loader.cfm?csModule=security/getfile&pageID=175934. The Health Policy unit and the Physician Payment Policy (3P) Workgroup oversee the process for the development, review, and update of the position statements. Below are more details about the definition of a position statement, the process to create a position statement, and a summary of the recent review of all position statements. Position Statements Defined            A position statement (formerly known as “policy statement”) is used to designate a statement, policy, or declaration of the AmericanAcademy of Otolaryngology—Head and Neck Surgery, and Foundation (AAO-HNS/F) on a particular topic or topics. Statements are created to formalize the AAO-HNS/F position on a clinical procedure or medical service with third party payers, for use in state and federal regulatory or advocacy efforts, or to clarify the AAO-HNS/F approval or disapproval of certain practices in medicine. Creating a Position Statement Position statements are generated from within AAO-HNS/F committees. However, an individual member may request consideration of a topic for position statement development. If a member would like to propose the Academy consider developing a position statement on a particular topic, or revisions to an existing position statement, the details about the topic and concerns should be emailed to healthpolicy@entnet.org. The next steps in the process include: Academy staff will route the request to the Academy’s 3P workgroup for review and determination of which committee(s) should receive the draft position statement for consideration. The Chair of the committee(s) receives the request, examines the need for a statement, and works to draft the necessary position statement language. Academy staff will present it to 3P for review. If 3P has questions related to the draft position statements, they are relayed back to the committee(s) for further clarification, and then sent back to 3P for review. The position statement is then submitted to the Board of Directors (BOD) for review and approval. If the Executive Committee (EC) or BOD has any requests for clarification, they ask 3P, or related committee, to re-review and re-submit. Once the EC has approved, the request for a new or revised position statement is submitted to the Board of Directors during their biennial meetings for final approval. After that, the position statement is posted to the website. The same process is followed for any updates to the position statements.   2012–2013 Review Position Statements 3P and the Health Policy team are committed to ensuring the position statements are updated and useful for members. In August 2012, a process was initiated to review all of the position statements since they had not been reviewed for several years. At the commencement of the review process, there were 74 position statements. The position statement update process was reviewed and approved by the 3P. 3P initially divided the position statements into three tiers for three separate rounds of review during the course of a year (September 2012-September 2013) taking multiple factors into account for priority including how outdated each statement was, concurrent ongoing research and guideline development, and utilization of each. After prioritization, 3P assigned each of the statements to the clinical committee(s) of corresponding expertise for review and update. The committee(s) then made recommendations to reaffirm, revise, or delete assigned Position Statements. Round 3: In September 2013, after an extensive third-round review process by AAO-HNS committees, the EC, and Board of Directors, the Academy reaffirmed eight position statements and revised 10. The third-round updates can be found on the Academy website at www.bit.ly/PositionStatements.   Several existing and new position statements are undergoing further committee review in an effort to reach a consensus on suitable language prior to Board approval. The Academy currently reviews all position statements on a rolling four-year basis. The first round of review began in September 2012 and we continue to ensure that Position Statement content is up to date.
184744731
The Art of Balance
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC My hospital is making me see more patients and is going to penalize me financially for not achieving a patient satisfaction goal of more than 90 percent where patients rate me as “very good”! —AAO-HNS member The email I received from the Academy member above succinctly juxtaposes the competing demands that clinicians are currently facing: increasing volumes (in the face of declining reimbursement) and improving patient satisfaction. Many AAO-HNS members have implored me to write this month’s column to demonstrate that this dual aim is simply not possible. Since when did a monthly column dedicated to improving safety, quality, and outcomes for our patients start discussing the satisfaction of our patients? As you may have noticed, over the past five years, this column has tried to keep AAO-HNS members abreast of the latest trends in patient safety and quality improvement. We have discussed myriad topics such as zones of risk, pitfalls, strategies to ameliorate problems, reporting systems. Recently, probably in the last 18 months, we have started discussing the issue of patient satisfaction and how payers and others are using this as a pure quality measure and linking reimbursement and even at-risk compensation to ensure our patient’s experiences are the “top box.” The literature certainly supports that an optimized patient experience drives overall quality and is a surrogate for safety within an organization. However, operationalizing this is difficult. For example, I could guarantee that I would run/manage the safest and most efficient operating room in the world. It is easy to do this: I would simply operate on one patient a month. We would ensure that we spent millions of dollars and resources to keep that patient safe. If you ask me to do this for a thousand patients a month, it becomes difficult. Similarly, as the AAO-HNS member writes above, it is becoming difficult for physicians to increase their clinical volumes to achieve Relative Value Unit (RVU) targets while optimizing patient satisfaction. On many levels the paradox becomes apparent—the waiting room is swamped, your staff is exhausted, your phone line pick-up times are extended, etc. Elements Are Not Equal The problem is that external forces are driving hospitals to include the experience of care in their metrics and eventually will tie this to reimbursement. Organizational scorecards have started emphasizing and reporting on patient experience and satisfaction. The end result of such is that these organizational priorities have trickled down to the providers. The stress that organizations are feeling from external agencies is now being transferred to the providers and the competing demands emerge. I am secretly worried that piggybacking patient satisfaction to quality and safety will de facto erode the huge gains the industry has made in improving the overall outcomes of our patients. I have had the pleasure of hearing James Merlino, MD, the chief experience officer of the Cleveland Clinic, speak many times. One of his excellent analogies on these competing demands uses the airline industry as an example. He states that when we fly, our absolute priority is to not crash (safety), we really want to take-off and arrive on time (quality/ efficiency), and if the first two criteria are met, it would be great to have a nice experience (satisfaction). How does this relate to the hospital and how do we prioritize patient safety, quality, and satisfaction? We can use Dr. Merlino’s airline analogy to help us prioritize these demands in our realms of care. I wish I had an easy answer or a crystal ball to assuage our AAO-HNS members’ concerns. What I can guarantee is that for the short-term, there is no solution in sight and I eagerly look toward our exceptionally intelligent, passionate, and motivated membership for innovative solutions to this apparent paradox. We encourage members to write us with any topic of interest and we will try to research and discuss. Members’ names are published only after they have been contacted directly by Academy staff and have given consent. Please email the Academy at qualityimprovement@ entnet.org to engage us in a patient safety and quality discussion pertinent to your practice.
Physician Payment Policy (3P) Workgroup Update
James C. Denneny III, MD Coordinator for Socioeconomic Affairs Jane T. Dillon, MD Coordinator for Practice Affairs and Co-chairs of 3P The Physician Payment Policy Workgroup (3P), co-chaired by James C. Denneny III, MD, and Jane T. Dillon, 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 the last quarter of 2013 with a continued high level of activity, constant emails, and monthly calls, working diligently and tirelessly on behalf of all members. Key 3P Accomplishments Included: Face-to-Face Meeting with CMS/CMMI Representatives in November 2013 In early November, Academy leaders James C. Denneny, III, MD, Lisa E. Ishii, MD, MHS, (coordinator-elect for Research and Quality Improvement) and David Nielsen, MD, along with Health Policy and Research/Quality Improvement staff, Jean Brereton, MBA, senior director, Research, Quality and Health Policy, and Jenna Kappel, MPH, MA, director, Health Policy, met with Patrick Conway, MD, chief medical officer for Centers for Medicare & Medicaid Services and acting director for Center for Medicare & Medicaid Innovation (CMMI), along with other top officials at CMS to discuss payment reform efforts and the need for development of additional clinical quality measures to ensure successful participation in the PQRS and Value Based Modifier programs by otolaryngologists. The Academy representatives­ inquired as to why five of the nine sinusitis measures were not accepted within the 2014 proposed fee schedule, and outlined our continued concerns regarding CMS’ proposed Outpatient Prospective Payment System cap policy, which, if finalized in 2014, would reduce practice expense relative value units for 13 otolaryngology services when performed in the office setting. This meeting was yet another effort by the Academy to ensure CMS understands the critical role otolaryngologists play in the healthcare system and the influence these programs and policies have on our specialty. Direct Impact: Our meeting with Dr. Conway was instrumental in acceptance of four adult sinusitis measures for 2014 PQRS reporting. Continued dialogue also maintains the Academy’s high-level visibility with CMS. As a result of numerous advocacy efforts, including these face-to-face meetings, and comment letters, CMS decided not to move forward with the OPPS cap policy and finalized the four adult sinusitis measures for PQRS reporting in 2014. For more details on the Medicare Physician Fee Schedule final rule’s influence on otolaryngology, see page 31. Regulatory Issues: Academy Advocates on Behalf of Members Meaningful Use Stage 3 In November, the Academy submitted a comment letter to CMS regarding Proposed Clinical Quality Measures (CQMs) for Use in Stage 3 of the EHR Meaningful Use Incentive Program. Specifically, the proposed Stage 3 measure on Overuse of Diagnostic Imaging for Uncomplicated Headache. The letter also reiterated the Academy’s concerns regarding Stage 2 timing requirements and Stage 3 thresholds and penalties. Input was based on feedback from the Imaging Committee, PSQI, and 3P. Colorado Clean Claims Act The Academy has been active in providing comments to the Colorado Clean Claims Act Task Force, an effort to develop a standardized set of payment rules and claim edits to be used by payers and healthcare providers. This is being closely monitored as it could be used in many other parts of the nation. In the summer, we submitted a formal letter on the first round of rules released for comment. These comments were reviewed and vetted through the CPT team, Richard Waguespack, MD, Bradley F. Marple, MD, and Lawrence M. Simon, MD. During the second round of review, the task force liaison reached out to the Academy directly, seeking our input on a few of the rules, and we provided input on the multiple procedure payment rule and the modifier -50 draft rule. Finally, the task force liaison sent us an early preview of the third round proposed rule on multiple endoscopies, which the CPT team reviewed in October and submitted comment on. ICD-10 Also in November, the Academy submitted comments to the Centers for Disease Control and Prevention regarding the new ICD-10 Codes for Unilateral Hearing Loss in support of the Conductive and Sensorineural Hearing Loss proposal presented during the ICD-10-CM/PCS Coordination and Maintenance Committee Meeting on September 18, 2013. The comments oppose the removal of references of contra-laterality and instead state that the codes are unilateral and retain language referencing which ear the diagnosis relates to. This will facilitate the fact that different types of hearing loss conditions can exist in each ear. RUC and CPT Update The Academy is surveying new CPT code 4319X in preparation for the January 2014 AMA Relative Value Scale Update Committee (RUC) meeting. After only a week and a half, the Academy obtained an impressive 146 responses. The minimum requirement by AMA is 30 surveys so this response rate is excellent and is helpful to the Academy’s RUC team, who must base the recommendations for relative value units (RVUs) on the data received. The survey closed early December and was sent to our practicing members specializing in head and neck and laryngology/bronchoesophagology with the support/assistance of AHNS, ALA, and ABEA. Many thanks to the physician leadership of these subspecialties who made the large survey response possible. AMA CPT/RBVS Symposium At the AMA CPT/RBVS Symposium in Chicago, Dr. Waguespack presented on new, and modified, CPT codes for otolaryngology for 2014, including flexible and rigid transnasal esophagoscopy (otherwise known as TNE) and chemodenervation of the larynx for spasmodic dysphonia, which were RUC surveyed by the Academy. Jenna Minton, Esq, senior manager, Health Policy, also represented the Academy at this meeting. Academy Releases New CPT for ENT Coding Guidance You may have noticed that your 2014 CPT Code Books include several modifications and additions to CPT codes used to report otolaryngology services. To assist members in understanding these changes and achieving correct coding, the Academy has revised our CPT for ENT articles on CPT 69210 Removal Impacted Cerumen and CPT 64617 Chemodenervation of Larynx (formerly reported by CPT 64613). These articles can be found in our Coding Corner of the website at www.bit.ly/CPT4ENT. Academy Collaborates with UHC on Septoplasty Coverage Policy and Provides Feedback on Premier Designation Program In November, Academy physician leaders, Drs. James Denneny and Richard M. Rosenfeld, MD, MPH participated in a conference call with United Healthcare National Medical Director Richard Justman, MD, and other physician leaders at UHC, to discuss and provide feedback on United’s Premier Designation program. This program recognizes physicians who meet certain cost/quality parameters and highlights them with a “Premier” designation in the UHC physician networks. During the call, we were able to get confirmation from UHC leadership to work in partnership with otolaryngology to develop future models for reimbursement. The Academy has also been collaborating with UHC to provide comments regarding their Rhinoplasty, Septoplasty, Vestibular Stenosis policy and are working with them to address issues we’ve continued to hear from members related to receiving a septoplasty review that was approved prior to surgery, but denied coverage following surgery. UHC is working to correct these issues. Also, the Academy is providing UHC with recommendations about patient criteria for septoplasty for UHC to consider including in their coverage policy. New HP Team Member The Health Policy team welcomes Danielle Jarchow, Esq, to the staff as a health policy analyst. Danielle comes from a family of otolaryngology-head and neck surgeons with her father and sister, who practice in academic and private practice, members of the Academy. “HP Update” Archives Missed the last edition of the “HP Update”? Access the monthly newsletter: http://www.entnet.org/Practice/HP-Update.cfm. For questions on the above Health Policy issues, please send an email to HealthPolicy@entnet.org.
2013 ENT PAC Investors
Special thanks to our investors for their commitment to advancing the specialty! Chairman’s Club Investment of $1,000+ Annually Nikhil J. Bhatt, MD C. Y. Joseph Chang, MD Susan R. Cordes, MD Stephen P. Cragle, MD Agnes Czibulka, MD Scott A. Dempewolf, MD Lee D. Eisenberg, MD, MPH Wayne B. Eisman, MD Cameron D. Godfrey, MD Steven D. Horwitz, MD Paul M. Imber, DO Stacey L. Ishman, MD, MPH Alice L. Kuntz, MD Steven B. Levine, MD J. Scott Magnuson, MD Theodore P. Mason, MD Samantha Marie Mucha, MD Nathan E. Nachlas, MD David R. Nielsen, MD Robert Puchalski, MD R. Arturo Roa, MD Richard M. Rosenfeld, MD, MPH Michael D. Seidman, MD Gavin Setzen, MD Adam M. Shapiro, MD Paul F. Shea, MD Lawrence M. Simon, MD William H. Slattery III, MD Gangadhar Srikumar Sreepada, MD Oscar A. Tamez, MD John H. Taylor, MD Ken Yanagisawa, MD Kathleen Yaremchuk, MD, MSA Jay S. Youngerman, MD Resident Chairman’s Club Investment of $500+ Annually Nathan Deckard, MD Timothy O’Brien, MD Capitol Club Investment of $535+ Annually Peter J. Abramson, MD Michael A. Alexiou, MD Anna Aronzon, MD Jonathan E. Aviv, MD Dole P. Baker, Jr., MD Paul A. Bell, MD Drupad Bhatt, MD Bradley B. Block, MD Marcella R. Bothwell, MD Kevin Braat, MD Richard J. Brauer, MD Robin M. Brody, MD Henry Frederick Butehorn III, MD Mark E. Carney, MD John A. Cece, MD Sujana S. Chandrasekhar, MD Won-Taek Choe, MD Jason P. Cohen, MD Tahl Ya’ari Colen, MD Jeffrey N. Cousin, MD Jeffrey J. Cunningham, MD Robert J. Cusumano, MD Richard DeMaio, MD Elizabeth A. Dinces, MD Gary S. Fishman, MD Randy J. Folker, MD Jeffrey B. Ginsburg, MD David A. Godin, MD Steven M. Gold, MD Michael S. Goldrich, MD Michael A. Gordon, MD Robert P. Green, MD Karen L. Hermansen, MD Michael R. Holtel, MD John J. Huang, MD Madan N. Kandula, MD Matthew J. Kates, MD Natasha F. Keenan, MD Ronald H. Kirkland, MD, MBA Timothy D. Knudsen, MD Mitchell T. Kolker, MD Russell W. H. Kridel, MD Ronald B. Kuppersmith, MD, MBA Brian L. Lebovitz, MD Marc J. Levine, MD Guy Lin, MD Pei S. Lin, MD Scott B. Markowitz, MD Michael G. Mendelsohn, MD Charles Mixson, MD Alice H. Morgan, MD, PhD Eric A. Munzer, DO James L. Netterville, MD Timothy O’Brien, MD Rick Odland, MD, PhD Sheldon Palgon, MD Ira D. Papel, MD Rami N. Payman, MD Spencer C. Payne, MD George A. Pazos, MD David Poetker, MD, MA Liana Puscas, MD Jay S. Rechtweg, MD Andrew J. Reid, MD Edward B. Rhee, MD Eric Roffman, MD Steven H. Sacks, MD Zarina Sayeed, MD B. Todd Schaeffer, MD Daniel A. Scher, MD Scott R. Schoem, MD Jerry M. Schreibstein, MD Charles M. Schultz, MD Merry E. Sebelik, MD Elizabeth A. Shaw, MD Michael R. Shohet, MD Joseph R. Spiegel, MD J. Pablo Stolovitzky, MD Jerome O. Sugar, MD Gerald D. Suh, MD Jason B. Surow, MD Brian J. Szwarc, MD Raj Tandon, MD Michael B. Tom, MD Joy L. Trimmer, JD (staff) William Turner, MD Keith M. Ulnick, DO Richard W. Waguespack, MD Michael D. Weiss, MD Robert Weiss, MD Samuel B. Welch, MD, PhD Raymond Winicki, MD Karen A. Wirtshafter, MD Stanley Yankelowitz, MD Irene Yu, MD Todd A. Zachs, MD John J. Zappia, MD Warren H. Zelman, MD Resident Capitol Club Investment of $250+ Annually Scott Chaiet, MD Dollar-a-Day Club Investment of 365+ Annually Robert E. Adham, MD Mehmet C. Agabigum, MD Ravi P. Agarwal, MD Michael Agostino, MD J. Noble Anderson, Jr., MD Lauren C. Anderson de Moreno, MD Seilesh Babu, MD David A. Bianchi, MD David S. Boisoneau, MD Dennis I. Bojrab, MD William R. Bond, Jr., MD K. Paul Boyev, MD James T. Brawner, MD Steven H. Buck, MD Dennis Burachinsky, DO Scott L. Busch, DO Roy D. Carlson, MD Ryan C. Case, MD Ajay E. Chitkara, MD James Z. Cinberg, MD Anthony J. Cornetta, MD Kent W. Cox, MD Michael D’Anton, MD John M. DelGaudio, MD James C. Denneny III, MD Robert W. Dolan, MD John S. Donovan, MD Jeffrey S. Driben, MD David R. Edelstein, MD Moshe Ephrat, MD Michael D’Anton, MD John M. DelGaudio, MD James C. Denneny III, MD Robert W. Dolan, MD John S. Donovan, MD Jeffrey S. Driben, MD David R. Edelstein, MD Moshe Ephrat, MD Theodore W. Fetter, MD Stephen M. Froman, MD Michael J. Fucci, MD Krishna M. Ganti, MD Julie A. Goddard, MD Frederick A. Godley III, MD Debora W. Goebel, MD Stephen A. Goldstein, MD Steven I. Goldstein, MD Ramez Habib, MD Patrick Hall, MD Ronald D. Hanson, MD Stuart M. Hardy, MD Brenda Hargett, CPA (staff) Joseph E. Hart, MD, MS James M. Hartman, MD Sabine V. Hesse, MD Arlis W. Hibbard, MD Michael D’Anton, MD John M. DelGaudio, MD James C. Denneny III, MD Robert W. Dolan, MD John S. Donovan, MD Jeffrey S. Driben, MD David R. Edelstein, MD Moshe Ephrat, MD Michael D’Anton, MD John M. DelGaudio, MD James C. Denneny III, MD Robert W. Dolan, MD John S. Donovan, MD Jeffrey S. Driben, MD David R. Edelstein, MD Moshe Ephrat, MD Theodore W. Fetter, MD Stephen M. Froman, MD Michael J. Fucci, MD Krishna M. Ganti, MD Julie A. Goddard, MD Frederick A. Godley III, MD Debora W. Goebel, MD Stephen A. Goldstein, MD Steven I. Goldstein, MD Ramez Habib, MD Patrick Hall, MD Ronald D. Hanson, MD Stuart M. Hardy, MD Brenda Hargett, CPA (staff) Joseph E. Hart, MD, MS James M. Hartman, MD Sabine V. Hesse, MD Arlis W. Hibbard, MD John R. Houck, Jr., MD John W. House, MD Kenneth V. Hughes III, MD Ofer Jacobowitz, MD, PhD David M. Jakubowicz, MD Robert E. Johnson, MD Michael J. Kelleher, MD Jeffrey H. Kerner, MD Jay H. Klarsfeld, MD Steven T. Kmucha, MD, JD Michael J. Kortbus, MD Kevin C. Krebsbach, MD Greg Krempl, MD Jeffery J. Kuhn, MD Denis C. Lafreniere, MD Pierre Lavertu, MD David B. Lawrence, MD Amy D. Lazar, MD Joel F. Lehrer, MD Jonathan A. Lesserson, MD Sonya Malekzadeh, MD Megan Marcinko, MPS (staff) Jeffrey S. Masin, MD Marc D. Maslov, MD Phillip L. Massengill, MD William A. McClelland, MD Timothy M. McCulloch, MD Valentin F. Mersol, MD Abby C. Meyer, MD Donna J. Millay, MD David D. Morrissey, MD Iman Naseri, MD V. Rama Nathan, MD Paul R. Neis, MD James P. Oberman, MD Douglas A. O’Brien, MD J. David Osguthorpe, MD Gregory S. Parsons, MD Michael L. Patete, MD Lisa Perry-Gilkes, MD Kim E. Pershall, MD Guy J. Petruzzelli, MD, MBA, PhD Christopher P. Poje, MD Eileen M. Raynor, MD Michael J. Reilly, MD John S. Rhee, MD, MPH Grayson K. Rodgers, MD Jeffrey D. Roffman, MD Sarah L. Rohde, MD Philip T. Rowan, MD Phillip Rowan, MD Greg S. Rowin, DO Adam D. Rubin, MD Hyman Ryback, MD Daniel Santos, MD John Scheibelhoffer, MD Neil Schiff, MD David N. Schwartz, MD Rasesh P. Shah, MD Frank G. Shechtman, MD Katherine J. Shen, MD Abraham I. Sinnreich, MD Jonathan C. Smith, MD Gary M. Snyder, MD Christopher S. Song, MD Neil M. Sperling, MD Aaron T. Spingarn, MD F. Thomas Sporck, MD Robert J. Stachler, MD James A. Stankiewicz, MD Jayde M. Steckowych, MD Jamie Stern, MD Wendy B. Stern, MD Michael G. Stewart, MD, MPH Monica Tadros, MD Thomas G. Takoudes, MD Charles B. Tesar, MD J. Regan Thomas, MD Richard A. Tibbals, MD Paulus D. Tsai, MD Dale A. Tylor, MD Eugenia M. Vining, MD Hayes H. Wanamaker, MD Jared M. Wasserman, MD Daniel L. Wohl, MD Danny Wong, MD Arthur P. Wood, MD Gayle E. Woodson, MD Glen Y. Yoshida, MD K. John Yun, MD 2013 General Member David A. Abraham, MD Allan L. Abramson, MD Jason L. Acevedo, MD Olubunmi A. Ajose-Popoola, MD Mohammad M. Akbar, MD Raymond Aldridge, MD Keith J. Alexander, MD Art A. Ambrosio, MD Scott R. Anderson, MD Larry L. Bailey, MD John M. Barlow, MD Christian H. Barnes, MD Melynda A. Barnes, MD James P. Bartels, MD Richard Bauer, MD Russell N. Beckhardt, MD Mark G. Bell, MD Thomas J. Benda, Sr., MD Thomas J. Benda, Jr., MD David F. Bennhoff, MD Michael S. Benninger, MD Michael P. Bernstein, MD Shelley R. Berson, MD Jay M. Bhatt, MD Mahesh H. Bhaya, MD Christopher M. Bingcang, MD Mary Blome, MD Jacob O. Boeckmann, MD Peter C. Bondy, MD I. David Bough, Jr., MD Alexis C. Bouteneff, MD Phyllis B. Bouvier, MD Lawrence L. Braud, MD Maury B. Bray III, MD Michael J. Brenner, MD Jean Brereton, MBA (staff) Frank Allan Brettschneider, DO Jenna W. Briddell, MD David Brown, MD Laura D. Brown, MD Warren L. Buchalter, MD Lawrence P. A. Burgess, MD James E. Bush, MD Richard K. Caldwell, MD Rich Capparell (staff) John M. Carter, MD Margaret S. Carter, MD Louis Chanin, DO David R. Charnock, MD Hamad Chaudhary, MD Brian S. Chen, MD Bradford S. Chervin, MD Anthony E. Chin Loy, MD Sukgi S. Choi, MD Shawn C. Ciecko, MD William B. Clark, MD David S. Cohen, MD Candice C. Colby, MD Christian P. Conderman, MD Bryant T. Conger, Jr., MD Mary Pat Cornett (staff) Carolyn A. Coughlan, MD Thomas M. Crews, MD Roger L. Crumley, MD, MBA Lori L. Cudone, MD Brian D. D’Anza, MD Paul Davey, MD, PC Nichole R. Dean, DO Devang P. Desai, MD Joseph R. Di Bartolomeo, MD Karl W. Diehn, MD Jayme R. Dowdall, MD Thomas F. Dowling, MD Norman S. Druck, MD Carl Drucker, MD Peter T. Dziegielewski, MD Marc D. Eisen, MD, PhD Dale C. Ekbom, MD Michael S. Ellis, MD B. Kelly Ence, MD Jay B. Farrior, MD Berrylin J. Ferguson, MD Alberto T. Fernandez, MD William I. Forbes III, MD, PhD D. Scott Fortune, MD Allen Foulad, MD Mark L. Fox, MD Paul C. Frake, MD Marvin P. Fried, MD Ellen M. Friedman, MD Robert H. Furman, MD Judith E. Gallagher, MD Daniel Ganc, MD John Paul Giliberto, MD Aylon Y. Glaser, MD Sharon H. Gnagi, MD Lindsay I. Golden, MD Rebecca D. Golgert, MD Mariano E. Gonzalez-Diez, MD Steven J. Green, MD Nancy R. Griner, MD Samuel P. Gubbels, MD Yarah M. Haidar, MD Marc David Hamburger, MD Steven D. Handler, MD, MBE Charles J. Harkins, MD Michael S. Harris, MD A. Kristina E. Hart, MD Adrianna M. Hekiert, MD Webb S. Hersperger, MD Douglas M. Hildrew, MD David L. Hilton, MD Matthew L. Hinsley, MD Ronald H. Hirokawa, MD Barry Hirsch, MD Brian Ho, MD Paul T. Hoff, MD Thomas C. Huang, MD Robert J. Hughes, MD Charles G. Hurbis, MD Thomas M. Irwin Jr., MD Jeffrey Jablon, MD Neal Jackson, MD Gary W. Jones, PhD John W. Jones, MD Stephanie L. Jones (staff) Thomas C. Huang, MD Robert J. Hughes, MD Charles G. Hurbis, MD Thomas M. Irwin Jr., MD Jeffrey Jablon, MD Neal Jackson, MD Gary W. Jones, PhD John W. Jones, MD Stephanie L. Jones (staff) D. Scott Fortune, MD Allen Foulad, MD Mark L. Fox, MD Paul C. Frake, MD Marvin P. Fried, MD Ellen M. Friedman, MD Robert H. Furman, MD Judith E. Gallagher, MD Daniel Ganc, MD John Paul Giliberto, MD Aylon Y. Glaser, MD Sharon H. Gnagi, MD Lindsay I. Golden, MD Rebecca D. Golgert, MD Mariano E. Gonzalez-Diez, MD Steven J. Green, MD Nancy R. Griner, MD Samuel P. Gubbels, MD Yarah M. Haidar, MD Marc David Hamburger, MD Steven D. Handler, MD, MBE Charles J. Harkins, MD Michael S. Harris, MD A. Kristina E. Hart, MD Adrianna M. Hekiert, MD Webb S. Hersperger, MD Douglas M. Hildrew, MD David L. Hilton, MD Matthew L. Hinsley, MD Ronald H. Hirokawa, MD Barry Hirsch, MD Brian Ho, MD Paul T. Hoff, MD Thomas C. Huang, MD Robert J. Hughes, MD Charles G. Hurbis, MD Thomas M. Irwin Jr., MD Jeffrey Jablon, MD Neal Jackson, MD Gary W. Jones, PhD John W. Jones, MD Stephanie L. Jones (staff) Russel Kahmke, MD Lawrence Katin, MD Scott L. Kay, MD Kanwar S. Kelley, MD, JD Paul E. Kelly, MD Samuel C. Kerns, MD Anita Konka, MD Charles F. Koopmann, Jr., MD, MHSA Todd A. Kupferman, MD Steven L. Kutnick, MD Michael J. Latshaw, MD Dennis Lee, MD, MPH Gregory T. Lesnik, MD Thomas H. Lesnik, MD Douglas Leventhal, MD Katherine Lewis (staff) Carl M. Lieberman, MD Jennifer L. Lin, MD Jeffrey C. Liu, MD Brian C. Lobo, MD Mark B. Logan, MD Scott D. London, MD Lily Love, MD Rodney P. Lusk, MD Frank A. Luzzi, MD Bruce R. Maddern, MD James R. Magnussen, MD James A. Manning, MD Frances E. Marchant, MD Jonathan R. Mark, MD Frank I. Marlowe, MD Felipe J. Martinez, MD Nicholas Mastros, MD Bruce H. Matt, MD Clement J. McDonald III, MD Kathleen R. McDonald, MD Bryan R. McRae, MD Michael R. Menachof, MD Albert L. Merati, MD Ralph B. Metson, MD Elias Michaelides, MD Anya J. Miller, MD Ron Mitzner, MD Carl Moeller, MD David F. Moore, Jr., MD Willard B. Moran, Jr., MD Michael D. Morelock, MD Philip R. Morgan, MD Jesse Moss Jr., MD Kevin K. Motamedi, MD James J. Murdocco, MD James G. Murray, MD John P. Neis, MD Zephron G. Newmark, MD Carrie L. Nieman, MD, MPH Stephen Nogan, MD David C. Norcross, MD Raimundo L. Obregon, MD John V. O’Neill, MD Ryan K. Orosco, MD Ralph G. Owen, Jr., MD Othella T. Owens, MD Stephen E. Parey, MD Sanjay R. Parikh, MD Mariah B. Pate, MD Nilesh Patel, MD Andrew D. Pedersen, MD Ilya Perepelitsyn, MD Jennifer Ann Pesola, DO Linnea Peterson, MD Luke Philippsen, MD Brendan Pierce, MD Timothy F. Pingree, MD Colleen T. Plein, MD Joel E. Portnoy, MD William M. Portnoy, MD William S. Postal, MD William P. Potsic, MD Robert B. Prehn, MD Shannon P. Pryor, MD Michael D. Puricelli, MD Sanjeet Rangarajan, MD Nikhila P. Raol, MD David A. Reiersen, MD Yvonne L. Richardson, MD Anthony A. Rieder, MD Brianne B. Roby, MD Daniel Rocke, MD Inell C. Rosario, MD Eben L. Rosenthal, MD Mark I. Rubinstein, MD Ran Y. Rubinstein, MD Marisa A. Ryan, MD Stuart J. Sabol, MD Ron Sallerson (staff) Jordan Paul Sand, MD Eric W. Sargent, MD James E. Saunders, MD Mary J. Scaduto, MD Gordon F. Schaye, MD George Schein II, MD Michael Scherl, MD Jonathan L. Schmidt, MD Kristine Schulz, MPH Jerome Steven Schwartz, MD Curtis M. Seitz, MD Merritt J. Seshul, MD Michael Setzen, MD David G. Sexton, MD Priyanka Shah, MD David Shamouelian, MD Peter M. Shepard, MD William M. Sheppard, MD Michael J. Shinners, MD Abraham Shulman, MD Joseph D. Siefker, MD John G. Simmons, MD Michael J. Simmons, MD Ameet Singh, MD Lee P. Smith, MD Ray Soletic, MD Michael S. Srodes, MD C. Richard Stasney, MD Rebecca S. Stone, MD George B. Stoneman, MD Robert N. Strominger, MD Mariel Stroschein, MD Neelima Tammareddi, MD Christopher G. Tang, MD Rafael Tarnopolsky, MD Thomas B. Thomason, MD Prasad J. Thottam, DO Tjoson Tjoa, MD Jeremiah C. Tracy, MD Debara L. Tucci, MD John Martin Ulrich, DO Emilio R. Valdes, Jr., MD Zachary P. VandeGriend, MD Peter M. Vila, MD Valerie J. Vitale, MD Angela Vong, MD Matthew S. Voorman, MD Mark A. Voss, MD Kurtis A. Waters, MD Mark K. Wax, MD Roger E. Wehrs, MD Debra G. Weinberger, MD Adam S. Weisstuch, MD Josh Werber, MD Ralph F. Wetmore, MD James A. White III, MD Laura J. White, MD Lauren C. White, MD Peter F. White, MD Chad Whited, MD Neil P. Williams, MD Kevin F. Wilson, MD Meghan N. Wilson, MD Peak Woo, MD Kyle T. Yamamoto, MD Eiji Yanagisawa, MD C. Alan Yates, MD Yuk Yee Yau, MD Estelle S. Yoo, MD William Gregory Young, Jr., MD Lauren S. Zaretsky, MD Alice S. Zhao, MD Kevin L. Ziffra, MD Michael Zoller, MD 2013 Group Practice Contributions Advanced ENT & Allergy PLLC Cape Fear Otolaryngology Colden Seymour Ear, Nose, Throat & Allergy For more information about ENT PAC and its applicable programs, visit www.entpac.org (log-in with your AAO-HNS user ID and password). *Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the AmericanAcademy of Otolaryngology-Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year.
2014housecalendar
When Do I-GO?
With the release of the 2014 Congressional calendar, it is clear Members of Congress will have plenty of time at home to interact with their constituents and potential voters. Act now to schedule an in-district legislative meeting or host a lawmaker at your practice, and help make the AAO-HNS In-district Grassroots Outreach (I-GO) program a success in the New Year! For more information, email the AAO-HNS Government Affairs team at govtaffairs@entnet.org.
On the Frontlines: State Legislative Tracking
The 2014 state legislative sessions are in high gear, and a number of the specialty’s priorities are being debated by state lawmakers. AAO-HNS members are a key resource for tracking state legislation and communicating to policymakers its influence on the specialty, physician practices, and patients. Join the growing team of AAO-HNS state trackers by emailing govtaffairs@entnet.org to receive daily or weekly legislative tracking updates. If you identify legislation needing Academy action (e.g., letter, action alert, testimony), simply fill out the new online State Action Form at www.entnet.org/Advocacy.
Hot Topics and Slow (or No) Action: An Election Year Federal Legislative Update
The mid-term election year is upon us. So, what does that mean for our federal legislative priorities? Most election years promise to deliver a lighter-than-usual legislative schedule for lawmakers, and a general downtick in activity on the issues important to the specialty. While we already know the scheduling of fewer legislative days will remain true, the amount of activity and/or issue-specific dialogue for this year remains somewhat of a wildcard. Why, you ask? The bumpy rollout of Healthcare.gov during the last several months of 2013 has left a lasting spotlight on the ongoing implementation of the Affordable Care Act (ACA) and health-related issues in general. As a result, these issues are likely to remain prominent, if not the most critical issues discussed leading up to November’s mid-term elections. Read on for a brief overview of where our key legislative priorities may “register” in the ongoing dialogue. Medicare Physician Payment Repeal of the flawed Sustainable Growth Rate (SGR) formula used to determine payments to physicians in the Medicare system acted as a vacuum in 2013, dominating much of the legislative focus for the year. Despite these efforts, the fate of SGR-related legislation remained in flux as late as mid-December. However, hurried action by the Senate Finance and the House Ways & Means Committees resulted in the advancement of SGR repeal legislation prior to Congress adjourning for the holidays. In addition, language was included in the year-end budget agreement to temporarily (for three months) halt the scheduled SGR cuts and instead replace the payment reduction with a .5 percent increase. This payment “bridge” was largely put in place to provide additional time for lawmakers to further refine permanent SGR repeal/replacement legislation and identify the necessary offsets. Therefore, the SGR will remain a key policy issue this year. If Congress succeeds in repealing the SGR formula, the implementation of a new payment policy program will trigger a flurry of activity regarding the implementation of the new programs that many physicians—particularly surgeons—may have difficulty participating in. On the other hand, failure to repeal the SGR formula will “punt” a major—and costly—issue into an election year where fiscal policy will draw increased scrutiny. Audiology Direct Access Expect to hear a lot about “direct access” and general audiology-related issues this year. As reported in 2013, each of the respective audiology groups has been pursuing their own specific legislative initiatives. Based on current “intel,” it is highly likely that each group’s proposal will be introduced as legislation by early spring, at the latest. Notwithstanding the issue’s importance to our particular organization, we generally expect discussion regarding scope-of-practice issues to increase in the coming months/year. As more Americans obtain health insurance via the mandate in the ACA, some lawmakers view the expansion of services (by various non-physician providers) as a key means to mitigate assumed access-to-care issues. The AAO-HNS continues to support a physician-led, team-based approach to patient care. IPAB Repeal Repeal of the Independent Payment Advisory Board (IPAB) remains a top legislative priority for the AAO-HNS. In the last several months of 2013, Rep. Phil Roe, MD (R-TN), the lead sponsor of a bill to repeal the IPAB (H.R. 351), doubled efforts to obtain cosponsors on his legislation. As part of this push, various physician organizations, including the AAO-HNS, will be reaching out to past cosponsors and “newer” Members of Congress. The ultimate goal is to garner more than 218 cosponsors of H.R. 351, and to continue urging Congressional leaders to allow a “clean” vote on the legislation. Truth-in-Advertising While the “TIA” issue may not emerge as prominently as the SGR or scope-of-practice issues, the efforts of the AAO-HNS and others in the TIA coalition will increase this year to garner support for H.R. 1427, the “Truth in Healthcare Marketing Act of 2013.” Our goal is to further expand the cosponsor list and elevate the general awareness in Congress of this important legislation, as well as seek the introduction of a Senate “companion” bill. Medical Liability Reform The AAO-HNS continues to advocate for the implementation of substantive medical liability reforms. However, in the current hyper-partisan (and political) environment on Capitol Hill, it remains difficult to gain traction on broad liability legislation. However, the appetite for more targeted liability efforts may be increasing, and the potential cost-savings available through these efforts could be included in the election-year rhetoric. Funding for Graduate Medical Education The protection (and hoped for) increase in funding for GME remains a legislative quandary. Lawmakers tend to agree that the pipeline of physicians in training should be as robust as possible. However, that fact has not prevented cuts to existing GME funds from being regularly included in “offset” packages for various large legislative proposals. This year, it is possible that dialogue regarding the general funding mechanisms for GME will become woven into larger conversations about the overall healthcare delivery system. The bottom line is that while 2014 may not be a rich legislative year, it could become an action-packed discussion year, with many AAO-HNS priorities addressed and/or referenced in the context of broader healthcare-related election year dialogue. For more information regarding AAO-HNS federal legislative priorities, email legfederal@entnet.org.
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Otitis Media, Tympanostomy Tubes, and Clinical Practice Guidelines from 2013
Stephanie L. Jones Director, Research and Quality Improvement, AAO-HNSF David E. Tunkel, MD, Chair, AAO-HNS Pediatric Otolaryngology Committee Director of Pediatric Otolaryngology, Johns Hopkins Medical Institutions In 2013, both the American Academy of Pediatrics (AAP) and the AmericanAcademy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) published clinical practice guidelines (CPGs) that address the management of recurrent acute otitis media (AOM) and otitis media with effusion (OME), including treatment with tympanostomy tubes. In the table below we compare and contrast the different CPGs so clinicians can better understand the recommendations made by these two organizations.
Pediatric Patient Resources
Go to http://www.entnet.org/HealthInformation/pediatric.cfm to link to these topics. Children face many of the same health problems that adults do, however symptoms may show themselves differently and treatment methods that work well in adults may not be appropriate for children. This topic listing identifies common pediatric ENT, head, and neck ailments and what you may offer patients. Bell’s Palsy hildren’s Hearing Health Child’s Hearing Loss Choking Campaign El Humo del Tabaco Ambiental y los Niños Facial Sports Injuries Fact Sheet: Allergic Rhinitis (Hay Fever) Fact Sheet: Child Screening Fact Sheet: Children and Facial Trauma Fact Sheet: Cochlear-Meningitis Vaccination Fact Sheet: How Allergies Affect your Child’s Ears, Nose, and Throat Fact Sheet: Laryngopharyngeal Reflux and Children Fact Sheet: Noise-Induced Hearing Loss in Children Fact Sheet: Pediatric Food Allergies Fact Sheet: Pediatric GERD (Gastro-Esophageal Reflux Disease) Fact Sheet: Pediatric Obesity and Ear, Nose, and Throat Disorders Fact Sheet: Pediatric Sleep Disordered Breathing/Obstructive Sleep Apnea Fact Sheet: Pediatric Thyroid Cancer Fact Sheet: The Necessity of Early Intervention in Hearing Fact Sheet: When Your Child Has Tinnitus Hearing Loss and Ear Infection Pediatric Sinusitis Post-Tonsillectomy Analgesia Article Post-Tonsillectomy Analgesia, an Old Problem Revisited Reduced Choking Risks fact sheet Research Gaps-Pediatrics Second Hand Smoke and Children Spotlight on Patient Safety Social Network Get social for Kid’s ENT Month and help raise awareness! Visit www.entnet.org/facebook and www.entnet.org/twitter for special Kid’s ENT Month posts that you can share with your patients.
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Kids E.N.T. Health Month: Child Health Disparities
Emily F. Boss, MD, MPH Assistant Professor, Otolaryngology – Head and Neck Surgery Johns Hopkins University School of Medicine Introduction: Focus on Health Disparities A health disparity may be defined as “an inequitable difference between groups in health, healthcare, and developmental outcomes that are potentially systematic and avoidable.” Every year in the United States, thousands of children experience disparities in healthcare access and utilization resulting in worse overall health status and outcomes. While many factors contribute to these disparities, socioeconomic status, race, and ethnicity are key influential social determinants. Disparities related to socioeconomic status include factors such as parental education, health literacy, insurance status, household income, access to transportation, and availability of social/familial support structures such as childcare. Disparities related to race and ethnicity may arise from cultural beliefs about disease and doctors, language differences, and historical discrimination. Provider factors may create further barriers to care of children, including issues with qualifications and experience with the care of medically complex children, or non-acceptance of certain insurance programs such as Medicaid. In general, children from low-income families and racial or ethnic minorities experience increased morbidity and disability compared to children who are white or more affluent. Moreover, parents of children from lower income environments are more likely to report poor communication with health providers. Case Studies in Pediatric Otolaryngology: Sleep and Hearing Because ear, nose, and throat conditions are so common in children, it is no surprise that a number of disease-specific disparities have been demonstrated in the care of children with otolaryngologic disease. One key example considers variation related to diagnosis and treatment of sleep-disordered breathing (SDB) in children. SDB affects 5 percent to 20 percent of U.S. children and occurs even more frequently in children with co-morbid conditions such as Trisomy 21 and obesity. Race and ethnicity may influence the risk of SDB in children. Indeed, SDB has been found to be more common in African-American children and Hispanic children compared with white children. Likewise, children in families of low socioeconomic status appear to be at increased risk for SDB. Some proposed explanations for these differences include factors such as household crowding in low-income homes, dietary influences, increased prevalence of obesity among certain racial and ethnic subgroups, higher exposure to secondhand smoke, or increased risk of upper respiratory infections. Prompt diagnosis and treatment of SDB in vulnerable children is extremely important, particularly with the increased risk for minority children to suffer comorbid conditions such as obesity, neurocognitive delays, and behavioral problems such as Attention Deficit Hyperactivity Disorder. Although one might anticipate higher rates of adenotonsillectomy to treat SDB, which is often seen in at-risk or minority children, this trend has not been observed, perhaps because vulnerable subgroups of children may experience barriers to otolaryngic care, even with insurance coverage.   Moreover, the wide variation in tonsillectomy rates across U.S. geographic regions calls into question the effects of differences in healthcare delivery systems and insurance plans across the country. Efforts to reduce disparities related to evaluation and treatment of pediatric SDB may potentially include standardization of clinical protocols across regions, expanded coverage and access for children with public or no insurance, and application of shared decision-making to reduce unwarranted variation and promote appropriate use of adenotonsillectomy. Health disparities are also evident for children with hearing loss, where hearing services are limited for children from racial, ethnic, and socioeconomic minorities. For example, proportionately higher rates of cochlear implantation are observed in children who live in areas with high median income and in children who are white or Asian compared to other minority counterparts. Children from low socioeconomic strata display poorer speech and language outcomes following implantation. Families of hearing-impaired children live closer to the poverty level and more frequently are insured by Medicaid. Additionally, low socioeconomic status is a risk factor for otitis media with effusion. Multiple barriers may contribute to these health disparities experienced by children with hearing loss, including communication hurdles, medical costs for diagnosis, medical visits for audiologic evaluation, fitting of hearing aids, care of associated external and middle ear problems, and costs of assistive devices. Both monetary costs and time commitments related to special education services, speech and language pathologists, and interpreters may also augment health disparities related to hearing loss. The Role of Access The presence of health insurance is a key factor for promotion of improved health status and access to routine healthcare. Children of racial minorities and children from low socioeconomic strata are more likely to experience reduced healthcare coverage and access to care. In 2011, about 16.1 million (22 percent) of U.S. children younger than 17 years old lived in poverty, 39 percent of children were covered by public health insurance, and 7 million children were uninsured. Hispanic children were less likely to have health insurance (85 percent insured) compared to non-Hispanic white (93 percent insured) or black (90 percent insured) children. Even when children do have health insurance coverage, true access may limit referrals to otolaryngologic care. Research on access to specialty care found that in one community 31 percent of patients with public insurance were not offered otolaryngology appointments, and for clinics that accepted all insurance types, children with public insurance waited on average 53 days for an appointment compared with an average of six days for privately-insured children. In another community, less than 20 percent of otolaryngologists were willing to perform tonsillectomy on children with publicly funded insurance due to administrative and financial burdens placed on their practices. Although the Affordable Care Act will expand Medicaid coverage for children, it remains to be seen whether improved access to otolaryngologic and other specialty care will follow. Working to Reduce Disparities Although tracking and establishing the variations in healthcare access and utilization across child subgroups in otolaryngology is important, reducing these disparities in care and improving outcomes for vulnerable children is a separate challenge. The Department of Health and Human Services “Healthy People” program has made reducing disparities and achieving health equity a major goal during the past two decades. Our specialty is charged with studying the unique characteristics of our specific patient population, our specialty disease patterns and variation, and local practice/health system limitations in order to best design strategies to promote equitable otolaryngic healthcare for children of all backgrounds. Some potentially fruitful interventions may include construction of innovative educational programs targeting rural and inner city pediatricians, which focus on common conditions such as SDB and hearing loss; creation of policies which improve reimbursement to otolaryngologists serving areas where access for at-risk children is limited; development of outreach programs initiated by larger health organizations to provide greater regional otolaryngic care; design of health educational materials which are applicable to parents of all levels of health literacy; and conception of formalized programs educating otolaryngology providers on use of culturally-competent communication strategies with patients. References and Resources: Bisgaier J, Rhodes KV. Auditing Access to Specialty Care for Children with Public Insurance. N Engl J Med 2011; 265:2324-33. Federal Interagency Forum on Child and Family Statistics. America’s Children: Key National Indicators of Well-Being, 2013. Washington, DC: U.S. Government Printing Office. Cheng TL, Dreyer BP, Jenkins RR. Introduction: Child health disparities and health literacy. Pediatrics 2009;124 Suppl 3:S161-S162. National Institute for Health Care Management Foundation. Reducing Health Disparities Among Children: Strategies and Programs for Health Plans. 2007. Boss EF, Smith DF, Ishman SL. Racial/ethnic and socioeconomic disparities in the diagnosis and treatment of sleep-disordered breathing in children. Int J Pediatr Otorhinolaryngol 2011;75:299-307. Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med 1999;159:1527-1532. Spilsbury JC, Storfer-Isser A, Kirchner HL, Nelson L, Rosen CL, Drotar D, Redline S. Neighborhood disadvantage as a risk factor for pediatric obstructive sleep apnea. J Pediatr 2006;149:342-347. Boss EF, Marsteller JA, Simon AE. Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. J Pediatr 2012;160:814-819. Wang EC, Choe MC, Meara JG, Koempel JA. Inequality of access to surgical specialty health care: why children with government-funded insurance have less access than those with private insurance in Southern California. Pediatrics 2004;114:e584-e590. Stern RE, Yueh B, Lewis C, Norton S, Sie KC. Recent epidemiology of pediatric cochlear implantation in the United States: disparity among children of different ethnicity and socioeconomic status. Laryngoscope 2005;115:125-131. Kirkham E, Sacks C, Baroody F, Siddique J, Nevins ME, Woolley A, Suskind D. Health disparities in pediatric cochlear implantation: an audiologic perspective. Ear Hear 2009;30:515-525. Boss EF, Niparko JK, Gaskin DJ, Levinson KL. Socioeconomic disparities for hearing-impaired children in the United States. Laryngoscope 2011;121:860-866.
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David R. Nielsen, MD, Embarks on a Robust Final Year as EVP/CEO
David R. Nielsen, MD, will complete his tenure as Executive Vice President and CEO of the AmericanAcademy of Otolaryngology—Head and Neck Surgery and its Foundation, as planned, at the end of his contract in January 2015. “Even though I have remained in this position a little longer than I originally intended, I am continually impressed by the wealth of leadership within our membership that rises each year to the challenges of an evolving and often uncertain health care environment,” Dr. Nielsen said. “My goal is to ensure that we keep up the pace of improvement and leadership in the federation of medicine this year and to continue to help our members do what they care most about—providing the finest patient care possible.” Dr. Nielsen has served as the EVP and CEO for 12 years, completing two contract terms and agreeing in 2011 to a third and final three-year extension. “The vision David brought to AAO-HNS/F, early in his tenure shifting its culture to one more responsive to current challenges, now increasingly emphasizes research and quality improvement. This focus is preparing our organization for the critical challenges and opportunities that face us including healthcare reform, with its attendant quality-driven changes in physician payment, and the critical need for the integration of education and research,’’ said Richard W. Waguespack, MD, AAO-HNS/F president. “We are fortunate to have benefitted from his prescient leadership and look forward to working with him this year as we prepare for a transition in the EVP/CEO position.” The research and quality agenda over the past decade has focused on empowering physicians to provide the best patient care through the development of evidence-based guidance, identifying tools, services, and processes that contribute to the advancement of the field of otolaryngology-head and neck surgery and fundamentally to improved patient outcomes. “Our transition will be smooth and positive, and members and their patients will experience continued exceptional value,” Dr. Nielsen said. A search task force has been formed and an announcement of the search for a new Executive Vice President/CEO will be made in March 2014.
Acute Otitis Externa: Danger of Using Ototoxic Topical Drops
Adapted from Key Action Statement 7 of the CPG on Acute Otitis Externa Sujana S. Chandrasekhar, MD In the patient with acute otitis externa, if the tympanic membrane is known or suspected to be non-intact (including with the presence of a tympanostomy tube), topical drops that contain alcohol, have a low pH, or both should be AVOIDED because of pain and potential ototoxicity. Substances with ototoxic potential (e.g., aminoglycosides, alcohol) should NOT be utilized when the tympanic membrane is perforated and the middle ear space is open, because the risk of ototoxic injury outweighs the benefits compared to non-ototoxic antimicrobials with equal efficacy. The potential danger from administering an ototopical drop into the middle ear is the risk of its components reaching, and then crossing through, the round window membrane to affect the inner ear. Ototoxic antibiotics are used appropriately, for example, in Meniere’s disease, for their ability to cross the RWM and enter the cochlea and vestibule. The potential ototoxicity of such agents includes permanent SNHL and disequilibrium, and informed consent precedes that intervention. Clinical experience with topical ototoxic antibiotics in patients with tympanic membrane perforation suggests that hearing loss does not occur after a single short course of therapy; however, severe hearing loss has been observed after prolonged or repetitive administration of topical drops. There may be middle ear mucosal inflammation during the initial phase of AOE treatment in the case of the non-intact TM; as that swelling diminishes, the round window membrane actually becomes more accessible, and therefore the inner ear becomes potentially more susceptible to the deleterious effects of the ototoxic agents. Clinicians are advised to carefully evaluate the patient with AOE for presence of non-intact tympanic membrane by obtaining a thorough history and performing a comprehensive ear examination, including tympanometry as needed. Most tympanostomy tubes remain in the tympanic membrane for at least six to 12 months; therefore a patent tube should be assumed in that time frame, unless documented otherwise. Tubes may, of course, remain functional for three years or longer. Individuals who taste medicines placed into their ear, or who can expel air out of their ear canal by pinched nose blowing, can be assumed to have a perforation. The only topical antimicrobials approved by the FDA (December 2005) for middle ear use are quinolone drops. Additionally, there is an explicit warning by the manufacturer that neomycin/polymyxin B/hydrocortisone should NOT be used with a non-intact tympanic membrane, and that warning cites explicitly the risk of permanent SNHL with its use. It is reiterated, therefore: when treating a patient with acute otitis externa, obtain a focused history and perform an otological examination that will, in addition to defining the AOE, determine the status of the tympanic membrane. If you know or suspect that there is a TM perforation or PE tube, do NOT use ototoxic eardrops. The evidence supporting this is level D with a moderate level of confidence in the evidence.
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Impact of Chevalier Jackson and Gosta Dohlman on Endoscopic Surgical Therapy for Zenker’s Diverticulum
Alexander T. Hillel, MD Zenker’s diverticulum, or hypopharyngeal diverticulum, develops in a triangular area of weakness between the oblique muscle fibers of the inferior pharyngeal constrictor muscle and the horizontally oriented fibers of the cricopharyngeus muscle. Its location at the interface of the pharynx, neck, and mediastinum makes surgical access difficult and risks severe morbidity. The history of endoscopic treatment of Zenker’s diverticulum demonstrates the process of transition to new surgical therapies based on the sequential efforts of many pioneers. Two otolaryngologists of great renown, Chevalier Jackson and Gosta Dohlman, were critical in advancing the surgical technique and reducing morbidity in the endoscopic treatment of Zenker’s diverticulum. Jackson proposed an esophagoscope-assisted, one-stage, transcervical diverticulectomy with the aim of decreasing morbidity and improving recovery time as compared to the two-stage operation. Jackson’s use of contemporary endoscopic technology advanced the surgical treatment of Zenker’s diverticulum, lowering morbidity in a variety of ways. First, the esophagoscope emptied the diverticulum’s contents, which decreased the risk of aspiration pneumonia and mediastinitis. Second, its distal illumination facilitated identification of the diverticular sac, which in turn cut operative time. Jackson’s use of the esophagoscope represented a vital step in evolution of surgical treatment for Zenker’s diverticulum from an external diverticulectomy to the endoscopic esophagodiverticulostomy. Dohlman attributed cricopharyngeal spasm as the key cause of hypopharyngeal diverticulum, after comparing barium swallow studies of Zenker’s patients to those of controls. His utilization of the cricopharyngeal myotomy directly addressed this key component of disease pathogenesis. In 1960, Dohlman published his case series of 100 patients treated with the endoscopic esophagodiverticulostomy. He reported no cases of low morbidity and recurrence rate, along with much more rapid recovery times, supporting the role of cricopharyngeal myotomy as a key step in the evolution of endoscopic esophago-diverticulotomy. The great leap forward in the general acceptance of endolaryngeal repair of Zenker’s diverticulum can be attributed to the endoscopic stapler, introduced separately in 1993 by Martin-Hirsch et al. and Collard et al. The ability to simultaneously divide and staple the mucosal edges relieved concern about suture-less division of the esophagodiverticular wall. More importantly, the results achieved with the endoscopic stapler technique were more easily reproduced by other otolaryngologists, resulting in more patients treated endoscopically. Endoscopic stapler-assisted diverticulostomy now represents the first line surgical treatment for Zenker’s diverticulum, due to reduced morbidity and shortened operative and recovery times compared with external approaches. *Abridged from: Evolution of endoscopic surgical therapy for Zenker’s Diverticulum. Laryngoscope 2009; 119:39-44.)
Stacey L. Ishman, MD, MPHBOG Member-at-Large
The Otolaryngologist As Educator
When I became a physician, I did not realize I was signing on to a lifetime as an educator. While I knew I needed to remain up-to-date and participate in continuing medical education (CME), I did not realize I would spend a significant amount of my clinical time educating my patients and colleagues. As an academic physician, I understood I would be responsible for the training of medical students, residents, and fellows, and I have contributed to my fair share of book chapters and review lectures toward this endeavor. However, the more I learn, the more I realize I came unprepared for the job. In medical school, there was no instruction on curriculum development, skill assessment, or giving honest and constructive feedback, and yet I am expected to do all of these things. To address this gap in my knowledge, I have found courses, workshops, and articles (often in a piecemeal fashion) on giving feedback, curriculum development, and skill assessment to be the beginning of my educator education. Education Resources I am also assisted by an Academy that focuses many resources on education so I don’t have to do all the work myself. A quick look at Academy educational resources includes myriad educational formats that apply to learners at every level. Many are well-known such as the Home Study Course and Annual Meeting courses. However, there are a number of lesser-known products like the case-based Patient Management Perspectives (PMP) and AcademyQ™ App, which includes 400 study questions that are useful for exam preparation. There are also products geared to the residents like COCLIASM (Comprehensive Otolaryngologic Curriculum, Learning through Interactive Approach), products geared toward midlevel providers such as case-based COOLSM (Clinical Otolaryngology OnLine), and the ENT for the PA-C course, as well as resources for medical students (and future referrers) including the ENT Exam Video Series and PA-C Primary Care for Otolaryngology eBook. Kids E.N.T. Health Month In addition, the Academy assists us in our educational efforts through public education campaigns like the Kids E.N.T. Health Month being observed this month. This serves as an opportunity to educate our colleagues and patients about the appropriate diagnosis and management of pediatric ear, nose, and throat disorders. This is especially important as we reach out to our primary care partners, where more than 40 percent of their visits involve a pediatric ENT complaint. This campaign is also an opportunity to market our services and the Academy provides numerous resources (http://www.entnet.org/kidsent), including sample outreach letters to the media, fact sheets on common disorders, and links to pediatric otolaryngology organizations. While the Academy develops and promotes tools to treat and educate patients, none of them are effective unless they are used. Kids E.N.T. Health Month is an established occasion for us to promote both children’s health and our specialty, and the best part is, the Academy has really done most of the work. 2014 AAO-HNS/F Leadership Forum In addition to the Kids E.N.T. campaign, the Academy continues to provide education to members and our legislators on state and federal legislative issues. We accomplish this through our excellent legislative staff, ENT Advocacy Network, and the I-GO Program (designed to promote interactions with legislators in their home districts). In addition, the new AAO-HNS/F Leadership Forum (March 2-3 in Alexandria, VA) replaces the traditional advocacy day with a focus on both advocacy training for otolaryngologists and practice management education, which is offered with some free CME this year. This forum is designed to educate us on the topics such as clinical practice guidelines, current federal legislation, alternative payment models, and transition to ICD-10 coding. As in previous years, the candidates for AAO-HNS president-elect will be speaking at the candidates’ forum during the Board of Governors meeting that will occur during that event, giving us an opportunity to ask questions of the candidates directly. Unlike in previous years, we will not be visiting the Hill to meet our legislators and their staff, but will be equipped with the tools to conduct meetings in our home districts. (For more information see: www.entnet.org/LeadershipForum.) Whether you are in a private practice, a multispecialty group, or academic practice, each of us is an educator. I, for one, appreciate the plethora of educational opportunities and tools that are offered by the Academy and hope that you will join me to educate ourselves and our peers through the Kids E.N.T. campaign and the Academy’s Leadership Forum.
Newly Organized Regional BOG Groupings
Region 1—David Boisoneau, MD Boston—Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont Region 2—David R. Edelstein, MD New York—New Jersey, and New York Region 3—Soha N. Ghossaini, MD Philadelphia—Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia Region 4—Daniel L. Wohl, MD tlanta—Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee Region 5—Robert J. Stachler, MD Chicago—Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin Region 6—Larry M. Simon, MD Dallas—Arkansas, Louisiana, New Mexico, Oklahoma, and Texas Region 7—Joseph E. Hart, MD Kansas City—Iowa, Kansas, Missouri, and Nebraska Region 8—Phyllis B. Bouvier, MD Denver—Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming Region 9—Eric J. Kezirian, MD, MPH San Francisco—Arizona, California, Hawaii, Nevada Region 10—Sanjay R. Parikh, MD Seattle—Alaska, Idaho, Oregon, and Washington
Frogs have large protruding eyes, giving them almost 360° vision, allowing them to look without moving, and many are nocturnal, with good night vision. A mirror layer (tapetum lucidium) in the back of their eyes allows them to reflect light at night, giving them a search light for hunting.
Why a Frog?
Wendy B. Stern, MD, BOG Chair-Elect We want to jump out at you and catch your attention. The BOG Frog* and the Board of Governors are hoping that you will take a moment and think about how you can stay connected with the Academy, your local and regional ENT societies, and your fellow otolaryngologists. We want you to take the leap and become involved. The Board of Governors is the grassroots organization that represents your interests and concerns and serves as the conduit of information and action between you and the Academy. In order for us and for you to be successful, we need you to be involved. Everyone is welcomed to attend our 2014 AAO-HNS/F Leadership Forum, March 2-3 in Alexandria, VA: www.entnet.org/leadershipforum. Right now we need help finding you! If you represent or know a colleague who represents your local or state BOG society or if you work in an area that does not have a society and need help being represented please reach out to us and give us your contact information (bog@entnet.org). We look forward to hearing from you soon and seeing you in early March.
David R. Nielsen, MD AAO-HNS/F EVP/CEO
Developing Leadership
David R. Nielsen, MD AAO-HNS/F EVP/CEO Early in my undergraduate education, I was fortunate enough to take a course in business law taught by a judge who had previously been my father’s law partner. His class was particularly memorable for me not only because I knew him personally, but also because I knew he actually practiced law and conducted his personal life according to the principles he taught. He was not content to just teach the law as it applied to business conduct, but taught the principles of living with integrity. He demanded of his students that each of us conduct our businesses with high standards of personal behavior. He asserted that every business man or woman should set personal standards of conduct that were so high, that when we achieved them, we had already exceeded the legal and professional standards required of us. He repeatedly taught that this was the essence of leadership, and that no matter where we worked, or what our pay grade or job title was, leadership would be required of us. Throughout my life, whether in personal business ventures, managing finances, running my own solo medical practice, being employed in a large multi-specialty internationally renowned clinic, volunteering, or serving as the CEO of the Academy and Foundation, I have found this to be true. I require of our staff here in Alexandria, VA, and Washington, DC, that everyone from the newest hire to the most tenured of the leaders in the C-suites demonstrate leadership in standards of personal behavior and professional conduct. I am grateful for the positive way in which your Academy staff model leadership skills and professional development. It is our desire, as well, to ensure that we provide every possible opportunity for our membership to advance their leadership through teaching opportunities (Annual Meeting; Education Committees; journal submissions; etc.); research, quality, and patient safety initiatives; health policy work (RUC; CPT; and appropriations, etc.) content committee work; BOG and BOD involvement; local community service; and international and humanitarian engagement. As part of our offerings for you, our colleagues and members, to advance your leadership skills and involvement we have provided opportunities to learn about and engage in the necessary policy and political processes that influence the practice of medicine. We invite you to attend our Leadership Forum from February 28-March 3. Our programming combines many leadership activities, including the Boards of Directors (BODs) meetings and Strategic Planning sessions, Executive Committees, the Science and Education Committee, the Board of Governors sessions, related advocacy components, and more. We also offer special content designed for Residents and Young Physicians. You can access more information about this on our members-only web page at http://www.entnet.org/LeadershipForum. This meeting is one of many academy benefits; that is, registration is free, but you must register to attend. Participation allows members opportunities to network and engage with peers and Academy leaders, as well as political and professional experts in other fields. The Board of Governors and advocacy sessions are open to everyone and begin on Sunday morning, March 2, and continue through midday on Monday, March 3. New for this year, selected qualifying sessions will offer CME credit. This year’s program includes sessions addressing: Practice management Clinical Practice Guidelines Advocacy sessions Health Policy Academy 101 Model Society Forum with best practices Sunshine Act: What you need to know BOG General Assembly and Candidates Forum National leaders and guest speakers, including leadership from the Centers for Medicare and Medicaid Service (CMS) ENT PAC Reception (ENT PAC Leadership Club members only) As the healthcare delivery systems evolve, it is increasingly necessary for physicians to understand more of the formal language of leadership and business models to ensure that the clinical concerns of patients and their doctors remain the primary focus and do not take a secondary role to the “business of medicine.” Our professionalism and Hippocratic Oath require us to continually put the interests of patients and their health ahead of our own financial or personal interests. Only through our leadership and modeling of this focus, and engagement in policy processes, can we ensure that business and financial fiduciaries (employers, purchasers, insurers, health plans and systems, and government) do the same.
Richard W. Waguespack, MD AAO-HNS/F President
Reconnecting
Richard W. Waguespack, MD AAO-HNS/F President Sometimes we get stuck. We get lost in the process—the details—the sticking points and we forget to keep our sights on the end goal. We suddenly realize that we are involved in an issue so complex that it obfuscates passage, that we do not know where we are and cannot see the “markers” that may help us find our way. We all from time to time share this predicament, but our responses to it vary greatly. Do we continue on, doggedly convinced of the ideal, despite finding ourselves isolated and unsure? Or do we look for signs, blazes on the trees, so to speak, that lead us to other seekers who work together to find the way? When the sun shines along the way and the trails are clearly marked, we can sometimes be lucky enough to navigate alone. Often, however, this is not the case, and making progress becomes more time-consuming and frustrating. How we respond to our predicaments makes a difference. Our practice environments today provide ample opportunity for us as individuals in either a community-based or academic setting, to veer off course, and be overwhelmed. It is just such a time when the Academy can help us reconnect by drawing upon its resources. The Academy Board of Governors, for example, is well aware of the incredible challenges you, its members, face in finding your way through the ongoing requirements of change. Often local medical societies are the first to identify specific issues as they emerge in a community. To quote the AAO-HNS BOG Model Society Handbook, “…local societies have a significant advantage…because issues directly affect the local practitioner and the community. The result is a stronger desire for involvement.” The society is small and agile and built on personal relationships between the medical community and governing agents. These society-built relationships then become an asset to the Academy and you. When local societies work with the AAO-HNS Board of Governors network, such as those awarded each year as model societies, they coalesce their resources and function as a high-performing team for the overall good of the state society and the specialty. The BOG has a long history of leading our state societies to benefit the specialty at the national, regional, and state levels. They form an important legislative, socioeconomic, and public relations force for the specialty at large. At the national level the BOG accesses its collective power and reach to lead and find solutions that individuals and smaller societies cannot. I am reminded of our EVP and CEO David Nielsen’s BOG leadership in the late ‘90s for the hugely successful AAO-HNS Through with Chew campaign. In this effort, the Academy’s BOG developed a national message that received considerable attention. Many such successes have occurred since then marking the effectiveness of this pathway. Last year, the New York State Society of Otolaryngology-Head and Neck Surgery (NYSSO) was able to organize around legislative challenges and leverage relationships with other state organizations and individuals to be heard in its legislature. These resources help us all reconnect and find solutions together. Please click here for a listing of the newly organized regional BOG groupings that may help you make the right connection.