Podcasts about otolaryngology head neck surgery

The eustachian tube connects the middle ear to the nasopharynx (back of the nose). It helps aerate the middle ear as well as equalizing pressure such as when flying in an airplane. Sometimes the eustachian tube does not function as it is supposed to and sometimes this may be related to concurrent nasal and sinus issues. Learn more about what can go wrong and how to remedy it.Michael Yong, MD, MPH, MBA, is board certified in Otolaryngology – Head & Neck Surgery, and fellowship-trained in Neurorhinology – Advanced Sinus & Skull Base Surgery. At Pacific Neuroscience Institute®, Dr. Yong provides full-service general Otolaryngology care, with an expertise in sinonasal and skull base disorders. He specializes in using minimally invasive endoscopic techniques for the treatment of nasal obstruction, smell disorders, allergic and non-allergic rhinitis, facial pain, acute and chronic sinusitis, nasal polyps, and benign and malignant tumors of the sinonasal cavities, among others. In addition, he works closely with a multidisciplinary team including his Neurosurgery colleagues to perform endoscopic endonasal surgeries that address benign and malignant skull base disorders in a way that maximizes preservation of function and quality of life.

Do you suffer from nose bleeds? Dr. Wong helps patients who have recurrent nose bleeds whether they are a few spots on a tissue to ones that may last for 20-30 minutes on most days. Learn about the causes of nose bleeds and effective methods for dealing with them.Michael Yong, MD, MPH, MBA, is board certified in Otolaryngology – Head & Neck Surgery, and fellowship-trained in Neurorhinology – Advanced Sinus & Skull Base Surgery. At Pacific Neuroscience Institute®, Dr. Yong provides full-service general Otolaryngology care, with an expertise in sinonasal and skull base disorders. He specializes in using minimally invasive endoscopic techniques for the treatment of nasal obstruction, smell disorders, allergic and non-allergic rhinitis, facial pain, acute and chronic sinusitis, nasal polyps, and benign and malignant tumors of the sinonasal cavities, among others. In addition, he works closely with a multidisciplinary team including his Neurosurgery colleagues to perform endoscopic endonasal surgeries that address benign and malignant skull base disorders in a way that maximizes preservation of function and quality of life.

Allergic rhinitis is a chronic condition, characterized by inflammation of the nasal passages and is usually triggered by exposure to allergens such as pollen or pet dander. An incredibly common condition, allergic rhinitis affects about 1 in 5 people. Symptoms include sneezing, nasal congestion, a runny nose, and allergic conjunctivitis. Over-the-counter medications like antihistamines and nasal sprays are a common treatment to alleviating symptoms. Michael Yong, MD, MPH, MBA, is board certified in Otolaryngology – Head & Neck Surgery, and fellowship-trained in Neurorhinology – Advanced Sinus & Skull Base Surgery. At Pacific Neuroscience Institute®, Dr. Yong provides full-service general Otolaryngology care, with an expertise in sinonasal and skull base disorders. He specializes in using minimally invasive endoscopic techniques for the treatment of nasal obstruction, smell disorders, allergic and non-allergic rhinitis, facial pain, acute and chronic sinusitis, nasal polyps, and benign and malignant tumors of the sinonasal cavities, among others. In addition, he works closely with a multidisciplinary team including his Neurosurgery colleagues to perform endoscopic endonasal surgeries that address benign and malignant skull base disorders in a way that maximizes preservation of function and quality of life.

Michael Yong, MD, MPH, MBA, is board certified in Otolaryngology – Head & Neck Surgery, and fellowship-trained in Neurorhinology – Advanced Sinus & Skull Base Surgery. At Pacific Neuroscience Institute®, Dr. Yong provides full-service general Otolaryngology care, with an expertise in sinonasal and skull base disorders. He specializes in using minimally invasive endoscopic techniques for the treatment of nasal obstruction, smell disorders, allergic and non-allergic rhinitis, facial pain, acute and chronic sinusitis, nasal polyps, and benign and malignant tumors of the sinonasal cavities, among others. In addition, he works closely with a multidisciplinary team including his Neurosurgery colleagues to perform endoscopic endonasal surgeries that address benign and malignant skull base disorders in a way that maximizes preservation of function and quality of life.

Dr. De Wet Swanepoel joins Dr. D'Anne Rudden this month to discuss how audiologists can meet their patients in more accessible ways through teleaudiology. Dr. Swanepoel is Professor of Audiology at the University of Pretoria, South Africa, and an adjunct professor in Otolaryngology-Head & Neck Surgery at the University of Colorado School of Medicine. He is Editor-in-Chief of the International Journal of Audiology and founder of a digital health company called hearX group.

I'm Ellen Bernstein-Ellis, Program Specialist and Director Emeritus for the Aphasia Treatment Program at Cal State East Bay and a member of the Aphasia Access Podcast Working Group. Aphasia Access strives to provide members with information, inspiration, and ideas that support their aphasia care through a variety of educational materials and resources. I'm today's hosts for an episode that will feature Jocelen Hamilton and Theresa Yao from Stanford Healthcare. We will discuss how adapting the A-FROM to swallowing disorders can offer a person-centered approach to assessing and treating a person with dysphagia.   Guest Bios     Theresa Yao is a licensed speech language pathologist at Stanford healthcare and a lecturer at San Jose State University. Her clinical and research interests include head and neck cancer rehabilitation, voice disorders, dysphagia, and aphasia. She is passionate about serving people from diverse backgrounds with communication and swallowing disorders. She was a fellow for life of the Albert Schweitzer Fellowship program, and co-founded the Bay Area's Swallowing Support group. She has been actively volunteering in community groups for stroke survivors who need communication support. She has always been a strong advocate for her patients and profession. Jocelen Hamilton has practiced as a licensed speech language pathologist for 19 years. She specializes in management of communication and swallowing disorders in adults with head and neck cancer. She began her career at the University of Iowa Hospitals and Clinics, and then joined the Stanford Outpatient Head and Neck Clinic in 2020. She also previously served as a clinical assistant professor for the University of Iowa's Communication Sciences and Disorders department with a focus on supervising graduate students and helping individuals with strokes and brain injuries. Her current clinical interests center around the development of frameworks to facilitate whole person care for individuals with swallowing disorders.   Listener Take-aways Think creatively about how to apply the A-FROM to other communication disorders, like swallowing Learn how dysphagia can impact the participation, environment and personal domains Consider some PROs that help to capture the impact of dysphagia on quality of life of both the patient and the caregiver Explore some ways to adapt EMRs to incorporate A-FROM or Swal-FROM into your daily notes Show notes edited for conciseness and clarity Ellen Bernstein-Ellis So I'm excited to have both of you here today. Thank you and welcome, Theresa.   Theresa Yao  00:55 Thank you, Ellen. I'm glad to be here.   Ellen Bernstein-Ellis  00:57 And Jocelen you too.   Jocelen Hamilton  00:59 Yes. Thank you so much for having us.   Ellen Bernstein-Ellis (Interviewer)    Welcome both of you, again, to this podcast. And as our listeners get to know you, we like to open with a fun icebreaker question. I'm going to pose two different questions that you've selected for today. So, Theresa, let's start with you.   I guess for full disclosure, I want to admit that, I will share--I don't have to admit, I am sharing that I had the honor and pleasure of being your supervisor at Cal State East Bay in the Aphasia Treatment Program (ATP). So I know that may come up today. I just want to let our listeners know that we've known each other for a while. I have been really fortunate in that relationship and seeing you emerge and thrive as such a wonderful contributor to our field.   So Theresa, could you please share one experience or role that has been meaningful to you as an aphasia ambassador?   Theresa Yao  03:22 Thank you, Ellen. It was great experience when I was in the Aphasia Treatment Program at Cal State East Bay. So that's actually one of the experiences I wanted to share as an opening, because I was at the Aphasia Treatment Program as a co-director for the choir, Aphasia Tones. And that was one of the best memory in my life. And I remember one time, one of our members who had more of a severe expressive aphasia, and usually has minimum verbal output, and we all know him. But whenever he starts singing, Can't Help Falling in Love, this particular song, you can hear that those beautiful words just came out right out from his mouth, fluently, beautifully. He was always so happy every time that he heard the music, and he just enjoy singing along.   That was just a really amazing moment for me to realize that people with aphasia with minimum verbal output, they can still enjoy and participate in choir, and can still communicate that way. It's just showed me how powerful it was to use the Life Participation Approach to Aphasia. And in our choir at that time, we have all different levels of severity. All members join together, and then they all enjoy and engage in this choir experience. So that's really meaningful. Whenever I think of LPA, I think of him, I think of this song, and I think of Aphasia Tones.   Ellen Bernstein-Ellis  04:54 Thank you for sharing that. And Theresa, it was wonderful to have you as a co-director. And see you step up to the challenge of leading the choir. And you're right, we really have a strong motto of participation at every level. And you really worked hard to make sure that happened. So thank you for sharing that. And yes, that's one of my favorite topics, so I loved hearing about that.   And Jocelen, I'm also excited to ask you to share with the listeners something about one of your experiences. So would you like to share an Aphasia Access, favorite resource or moment? What comes to mind for you?   Jocelen Hamilton  05:28 Yes, well, this is really neat for me to be on this podcast, because it is this podcast that is a favorite of mine, and a major “aha” for me.   Ellen Bernstein-Ellis Well, thank you, just thank you.   Jocelen Hamilton I worked with patients with head neck cancer for about nine years. I then did a major shift and then worked in a graduate training clinic at the University of Iowa. And during that time, previously, when I was at the hospital with a very heavy caseload and working with individuals with dysphagia. And so then switching over and working with individuals with strokes and brain injuries, that was much more communication focused.   And I had this caseload I was taking over with the graduate students and learning about all the current treatment principles and treatment options and all the research that had been developed. It had been probably close to 10 years since I had worked regularly with individuals with neurogenic communication disorders.   I had knew nothing about LPAA. I knew nothing about Aphasia Access, the organization. And I was thinking about this recently, of how I even came across it. But I think probably I was searching one of these treatment modalities, and a podcast came up. So I listened to some of the other podcasts and I was like, oh my goodness, this totally resonated, LPAA. And the podcasts and other resources through the website, totally resonated with me, and helped me better understand what my frustration was within an impairment only based approach, which was in my training and my background, and things like that, to like see a whole different way. So I learned as much as I could. And I tried to share all of that with my students, we were all learning together of how to implement this. So it's really neat to now be a part of this podcast and participate.   Ellen Bernstein-Ellis  07:32 We're so glad you agreed. And I just want to thank you. If there was ever a wonderful plug for membership to Aphasia Access, I think you just gave it. Thank you so much. for that.   Well, let's dive in a little bit more to our topic of the day. We're going to be talking about how and why you both decided to adopt the A-FROM or the Framework for Outcome Measurement of Aphasia by Kagan and Simmons-Mackie to your work with head and neck cancer patients. So I know we usually focus on aphasia, but we're taking this really important tool and talking about how you adapt it. So many listeners are, of course already familiar with the A-FROM. But can you briefly describe the social model framework for our listeners?   Theresa Yao  08:16 I can start with just a brief introduction. I think everyone, if you're listening to this podcast, you are already very familiar with A-FROM, which is based on the World Health Organization's ICF model. They address a few health and social domains such as body structure, function, activities, participation and contextual factors like personal and environmental factors. And like Ellen mentioned before, Dr. Kagan and colleagues, adapted this ICF model to create a very user-friendly framework for the outcome measurement in aphasia. And this becomes the Living with Aphasia Framework Outcome Measures the A-FROM and it has the domain of aphasia severity, which is the body function or impairment level, and then also participation, environment, personal factor. So these are the core concepts of the LPA approach. Thats what we are based on using this A-FROM to adapt it to this Swallow-SWAL-FROM, we call it. The Living with Swallowing Difficulties framework of measures.   Ellen Bernstein-Ellis  09:22 So let's talk a little bit more about this. Jocelen, do you want to share your story as an SLP and how you came to introduce the A-FROM into your work at Stanford in the head and neck cancer clinic?   Jocelen Hamilton  09:37 Sure. So after about a year and a half of working with individuals with aphasia and applying LPAA and using the A-FROM with clients, I then changed gears back to working with people who had neck cancer and we moved to California and I joined the Stanford team and I was back into primarily working with individuals with dysphagia. I just kept thinking about how can I take this model the A-FROM and apply that to working with individuals with dysphagia.   How I would previously use the A-FROM is that Venn diagram. I would just draw it on a piece of paper and start writing my notes on that as I was maybe doing an intake or working with a client. I started doing some of that model just in my note taking and looking at these different domains that might be impacted. And this was just kind of over a series of months, and even a year, where I was thinking about how to apply this and shared it with my patients. Here are some of the things that I'm seeing and what you're sharing with me that shows your participation is being impacted.   Then I ended up talking with our director, Heather Starmer, about an idea of a project—like how can I move this ahead. Theresa had recently joined our team and Heather said, you might want to talk to Theresa about that. She might be interested in doing a presentation on this. And so it was great, because Theresa and I had not yet talked about our aphasia backgrounds together. It was really neat to then work together and begin to apply this with more of our patients. Initially, we kind of struggled with what the environmental domain look like for somebody with dysphagia. And it was neat to talk through different cases with each other to see how it could apply. And then that's where the Swal-FROM came from.   Ellen Bernstein-Ellis  11:39 Wow, that's wonderful that the two of you were at the right place at the right time. And I always feel that the expression “stronger together” seems really fitting in this situation. But Theresa, do you want to share how you brought a life participation perspective into your work at Stanford?   Theresa Yao  11:57 Yes, sure. Because I've always been a big fan of the ICF model. When I was a student clinician in Aphasia Treatment Program, I learned so much from this model, from LPAA, and from Ellen, you. And also, of course, our members in our Aphasia Treatment Program. And I just could see the huge benefit from the LPA approach in the client's life.   So that's why once I started working in real clinics, I always think about this model. And when I started in at Stanford, I started working with the head neck cancer patients. I just feel like so many patients, they live with long term dysphagia, or a sore throat because of the neck cancer treatment they had. And they sometimes just can't get rid of it. They have to live with it. It's just like aphasia. They live with aphasia. And then it just clicked.  I just think that it's pretty similar to the situation that you're living with aphasia, and it's that same impact on patients quality of life, on their participation.   Then I just started thinking, maybe we can do something with this model to help our patients. And then, of course, Jocelen was there, and then we were just talking about her experience with aphasia treatment and LPAA. And we just clicked. That's why we came up with this (ASHA) presentation, and this idea of how to adapt this A-FROM to our Swal-FROM. And then also, we're talking about this because I also started a support group because I feel like people wanted to get connected. They wanted to engage like aphasia group.  They wanted that community to be able to participate, to be able to share. So that's why I think this also helped me to try to initiate this project, this group, so that we can help more people so that they can, they can help each other.   Ellen Bernstein-Ellis  13:56 I really love that you saw the power of group therapy, and you then were able to bring it into a different treatment arena. I really don't remember hearing too much about separate support groups for people with swallowing disorders. I don't know how common they are. But it sounds wonderful that you started one, Theresa. So very exciting. What do we know about the incidence of dysphagia in stroke survivors, and then people in skilled nursing, and from there, head and neck cancer? The reason I ask because I think there's overlap. I mean, you're seeing the dysphagia in head and neck cancer, but we know that it occurs frequently. Do you have any numbers to share about the incidence in stroke survivors?   Jocelen Hamilton  14:39 Yes, so it's about 45% of individuals with strokes experience, some degree of dysphagia and there's been research that's shown 40 to 60% of older individuals in nursing homes have dysphagia. There's even some research out there that one in 25 adults will experience dysphagia. Then when we look at individuals with head and neck cancer, and this could be on the lower range, but one of the particular statistics is 45 to 50% of individuals with head and neck cancer experience dysphagia.   Ellen Bernstein-Ellis  15:11 The importance of considering the whole person (for dysphagia tx) is really going to affect a lot of people that we might be seeing as therapists. And the two of you saw that there was a strong impairment focus in dysphagia management.  Can you give an example?   Theresa Yao  15:27 I can talk a little bit about this. When I was in grad school, I know that most of the things we learned was how to identify the impairment of dysphagia. We learned all kinds of treatments and exercises for dysphagia. We learned like how to modify diet, how to look for aspiration, penetration. Almost everything we learned, and also what we've been practicing in our clinical practice are heavily focused on the deficit and impairments. That's basically how we trained to assess and treat the physiological changes or the deficit. It just, to me, sounds like it's really technical.   I recently just look up the ASHA NOMS, the National Outcomes Measurement System-- that's what we usually use as judgment of whether the patient is making progress or not. They use this particular functional communication measures to see there's like different levels. If you're really looking at this national measurement system, you can see that the wording and the definition of each level is pretty much impairment focus. They mention diet level, safety, efficiency of swallowing, compensatory strategies, or cues, etc. So these are really heavily focused on impairment, but you don't really see like things that relate to participation, quality of life, environment, and those factors. So the consequences that if all the clinicians are just looking at the impairments and not looking at other factors, then you are missing a lot, you're not treating the whole person.   Ellen Bernstein-Ellis  17:11 Well, that's perfect, because that leads me to my next question. Why is it important to go beyond the impairment level measurement with dysphagia?       Jocelen Hamilton  17:24 I would say, because dysphagia is more than a physical difficulty. That's our name for that physical impairment. But it influences more, just like we know, with aphasia, that it's not just how much they can say, what they understand in the different modalities, but how a change in this function in the body influences everything.   So one of the analogies that I can relate to, that I've heard before in terms of looking at accessibility, has to do with like, physical impairments. So if somebody is paralyzed, they can't move their legs, well, the physical therapists are going to look at their legs and see the range of motion, their strength and all of that. But they're also going to think about how are they going to get into their house? And how are they going to move around?   Well, sometimes what can happen with dysphagia, as Theresa already talked about, we're looking just at how does that epiglottis move? What is the airway invasion like? But then are we going to talk about well, what's going to happen? We just had the holiday with Thanksgiving and the holidays now. What are family meals going to look like? I think one of the things that sticks out to me is what would my day to day life and social life be like if I couldn't drink with ease and comfort, I couldn't eat with ease and comfort, if I needed to have special food and special liquids and special strategies? So this impacts so many things within a social realm, and personal realm as well. We'll get into that in more detail as we go. But it's not just about the change in a physical function. How does that influence the rest of our lives? And it really does. There's been research that shows about burden and quality of life and psychological health.   Ellen Bernstein-Ellis  19:08 Well, this really hits close to home for me. I'm going to share with our listeners a personal story, because I've always been very passionate about our field and an advocate for speech language pathologists, but being on the other side of the table, when my husband was diagnosed with terminal cancer, did nothing but increase my own respect and appreciation for the role we play in supporting our clients and their loved ones.   Through this process, specifically with dysphagia, and I want to give a shout out to my husband's speech pathologist at Stanford, Heather Starmer, (and another congratulations to her because she just was made a 2023 ASHA fellow), but I'll just always remember the day that we came in. I know that Heather was set with her treatment plan-- I could already guess what we needed to do for the day. And that plan went out the window because we both signaled, Steve and I, that he was just feeling an increasing burden of trying to manage all of the home tasks we were supposed to do for both PT and speech, and it was just really impacting how he was feeling. And so instead, Heather focused on the personal impact and the quality of life issues that we were bringing up. Steve wanted to be compliant. He wanted to be the best patient there was. But she really listened to him carefully. She brought her best counseling skills to the table that day, and helped us come up with a plan that we could manage in a way that would help us sustain his quality of life as best as possible.   So I really saw, personally, I mean, I saw day in and day out how his dysphagia from his head neck cancer really impacted, hugely impacted, his participation with our family, and his quality of life. I am grateful for this work that you're doing and the passion you feel for looking at the whole person as you assess and treat dysphagia. And thanks to you, I've been reading, since dysphagia is not usually in my wheelhouse as much these days, but thanks to preparing for this particular episode, I was able to read some articles by Rebecca Smith and her colleagues that showed me that there's some amazing work being done looking at this whole topic, so thank you for that. Okay, and taking a deep breath, because that's a story I've been thinking about for quite a bit.   Back into our next question. What is the speech pathologist's role in assessing and addressing health related quality of life and the associated mealtime quality of life? That seems to be talked about a lot in the literature right now. Jocelen, is that you again?   Jocelen Hamilton  21:57 I'm glad you mentioned Rebecca Smith's work. There are actually three papers, I think, that that group, she and colleagues, put out in 2022. And specifically, I'll share a few quotes from their paper The True Cost of Dysphagia and Quality of Life:  The Views of Adults with Swallowing Disability, but in a way, there's a call to action, and she's not the first to mention it. But for us to include social participation, and their overall well-being, as part of our dysphagia intervention. To make that routine, and then to also ask questions: How are you doing? How are the holidays? How are these social settings with eating? I like to ask patients and their family members, and ask them separately, not meaning like individually, within the same session: Are you participating in doing this, the same things that you did before your diagnosis? Or how is that looking? Are you going out to eat as much? What do you miss now that is different and you're experiencing changes in your swallowing.   And it's interesting, because sometimes the partner will say that they miss going out to eat, and they need to navigate feelings like, “Well, I don't feel comfortable eating this in front of my loved one who has difficulty swallowing. I feel conflicted about I get to eat ribs, and they don't.” Those kinds of things. The importance of eliciting these stories, so we can really see what are their challenges, because then we can, like LPAA teaches us, we can engage in this creative problem solving and how we can help navigate through some of these challenges. I think those are a couple of important things that we can look at to support people.   Ellen Bernstein-Ellis  23:45 Thank you. And I just wanted to let our listeners know that we're putting all these references into our show notes. I took some from your ASHA presentations that I attended. So those will all be cited in the show notes.   Well, to expand to the participation, environment, and personal domains, you started to think about using patient reported outcomes or PROs for assessment. Why don't we go through the domains and discuss potential tools and interventions to fill out this framework a little bit more. So what might it look like if you consider participation?   Jocelen Hamilton  24:24 When we're looking at participation, we're looking at these meaningful activities may or may not involve oral intake, but looking at their current levels of participation compared to their pre cancer status. So how often, and in what ways, is someone with swallowing challenges participating? I kind of already talked about that a little bit. And how are the family members doing?   Here's one of the interesting things that I've had patients share here. Sometimes, one of the swallowing strategies that a patient needs to complete is a purposeful throat clear, and a re-swallow, or some patients do naturally their throat clearing, or maybe they're coughing when they're eating and drinking. This is an area where it calls attention to them when they're doing this. And then during the pandemic, we were all super hyper aware is somebody clearing their throat? Is somebody coughing? I've had some patients where they really don't feel comfortable because it calls attention. And people ask, how are they doing?   And also, another challenge being that when swallowing is hard, talking and swallowing is extra hard. When swallowing is challenging, most people need to just do that, where we take for granted that meals are a very social time. So some of those issues can be really challenging. There's also some individuals where their difficulty with swallowing has to do with loss of the bolus coming out and so there's almost changes in appearance, where they may not feel it. Their lip, their chin might be numb, and they don't know that liquids are dripping out, or they have a piece of food sitting there. So, they might be hesitant to go out and participate in different social settings. Even sometimes we have patients where they don't feel comfortable eating with their own family members, where they will eat completely separate from their spouse.   Ellen Bernstein-Ellis  26:28 I am just really struck again about the overlap of some of the things in your head neck cancer patients with clients I see with aphasia. It's really striking. So should we take a moment and discuss how this might look if you consider the environment?   Jocelen Hamilton  26:44 I really didn't address a PRO at all.   Ellen Bernstein-Ellis  26:46 Oh, it's not too late. We can still do that.   Ellen Bernstein-Ellis  26:52 Why don't you go ahead?   Jocelen Hamilton  26:55 Sure. Okay. So we're looking in this interview, right, like gathering information, learning how these things are challenging for them. For patient reported outcomes, PROs, Theresa, and I both looked into different ones. And oh, this one has these questions. And this would fall within this domain. So I'll touch base on a few of them here. And then some of them, they have questions that actually apply to  all of the domains.   So for these, there's one the Swal-QOL, this is probably the most broad in terms of looking at all of the domains that are within this Swal-FROM. It has 10 different quality of life concepts that it has specific questions for. So for this one, there's one subset that's all about social functioning. Some of the questions, they're rating from either strongly agree five point scale to strongly disagree, One of the questions, for example, is “I do not go out to eat because of my swallowing problem.” That really tells you where they're at with that participation, or “Social gatherings like holidays or get togethers are not enjoyable because of my swallowing problem.” So that really hones in on that challenge.   Within our specific area of practice with individuals with head neck cancer, there's a scale called the Performance Status Scale Head Neck Cancer, PSS-HN. Now you might think, how might I use this? I encourage people to be open minded, even though this wasn't validated. And some of these are not validated on individuals who have dysphagia from a different cause other than head neck cancer. It doesn't mean that you can't use it as a way to gather information, engage, and perhaps re administer.   I'm also a big fan of, as people fill this out, having a conversation about their responses as they go to gather information. But with this, the Performance Status Scale, there's a specific rating scale about public eating. So zero means always eats alone. And 100 is no restriction of eating for any place food or company. So they would eat out at any opportunity. Where in-between might be one point on the scale, “eats only in the presence of selected persons and selected places”, or they would eat out but there would be another option,  “eat out, but be more selective about the diet textures and things they would consume in a social setting”, which is common. Some individuals will specifically choose different foods when they're when they're in a social setting.   There's also another PRO, the Dysphagia Handicap Index. So with this one, it's a 25 item questionnaire and it does specifically look at physical, functional and emotional aspects of dysphagia. And so a couple of questions from there that would fit with the participation domain include, “I'm embarrassed to eat in public” and “I don't socialize this much due to my swallowing problem”. Those could give some insight into these areas by selecting some of those questions.   Ellen Bernstein-Ellis  30:08 Well, I'm really glad you caught me. I think I was so struck about the overlap that, thank you for coming back and talking about those PRO's. Are we good? Can we transition to the environment next? What would this look like? What does the Swal-QOL look like if you consider the environment.   Theresa Yao  30:29 When you talk about the environment, it can be factors such as the availability of the appropriate food textures, and oral liquid consistencies across different social settings. For example, if you go out to the restaurant, are there any easier food texture that's available for people with dysphagia? And that's one of the environmental factors.   And then there's a new article from ASHA leader that just came out about dining with dysphagia. So that's actually a pilot program from University of Cincinnati that try to help restaurants to expand their menu options so that they have more choices for people with swallowing disorders.   Ellen Bernstein-Ellis That's amazing.   Theresa Yao Also, another factor that related to the environment is the attitude and level of acceptance or support the people with dysphagia can get from their family, their friends, or even just strangers in their eating situation. So just like Jocelen mentioned, if you're coughing or clearing the throat, what the reaction from other people will be like, -- if they're supportive, or if they're not so. Sometimes these factors can make a patient uncomfortable eating out because of those environmental factors. And then also, the attitude from people around usually can be impacted by culture. Which type of textures they prefer to consume, and how they consume. If you go to a different type of restaurant, they may have different types of food textures, that are specifically for that culture, so that's also another factor.   And then also, on the broader spectrum, is the attitude from the healthcare professionals or the public, because the attitude from healthcare professionals is basically, because dysphagia is invisible, and when you are in the hospital, not everyone can see it. If you have leg injury or arm injury, people can see it. But if you have dysphagia, you can't see it. And then when the health care provider is, prescribing your pills, and if you can't swallow, how can they take the pill? They probably are not aware of this, this type of disability, so they may not prescribe you the right pills.   These are the things that we can consider as environmental factors. And of course, even larger scale, there's health care policies, the service systems, that may impact the people with a dysphagia too, because insurance may not pay all the dysphagia services, or how often can people get dysphagia support or service? So those are all the environmental factors that we may consider.   Ellen Bernstein-Ellis  33:21 I think the importance of this framework is helping us as clinicians to continue to think just broader and more widely about what's impacting the person in front of us. I mean, wow, you are giving us a lot of factors, from the very personal to the broader social policy. And I want us to take a moment and also talk about personal factors, that whole domain.   Theresa Yao  33:41 Personal factors can also be very, very important. And  a lot of things can be involved. So we know that the person was dysphagia may not be the same person, have the same hobbies or same traits, as before their treatment. So that may cause anxiety, or they may feel embarrassed because of their eating habits, or the change of their eating habits. Because we know that eating and drinking is very individualized. Some people, if they're born as a slow eater, they probably are okay with their dysphagia diet or if we ask them to eat slowly and take smaller bites, that's totally fine. But if some people are born as a fast eater, they will have a huge challenge with, if you give them the strategy to eat slow, taking small bites, because that's just not them anymore. They just feel like they're a different person and then they feel disappointed or frustrated if they can't eat as fast as they used to.   And I always share this in my clinic. I  see two patients with similar procedures. One person can feel really happy with their diet. They feel okay because they're always eating soft foods or soups. And then another person just with a little bit of impairment of mouth opening, they feel like it's just really frustrating because they can't bite their sandwiches and burgers. And that just makes a huge difference. But if you're only looking at their swallow study, it's the same, they probably don't have any major impairment, but the impact on the quality of life on their participation, environment, and also personal factor. It's so different. So that's why I think considering a personal factor is really important.     Ellen Bernstein-Ellis  35:38 So you're giving us examples of the things we should be thinking about, you're giving us examples of some of the PROs that might help us measure. But if many of the EMRs, the electronic medical records are set up for impairment focused measures, how can you adapt the documentation to include these other domains? That's always a barrier, or can be maybe, not always, can be.   Jocelen Hamilton  36:00 I think sometimes it can be a barrier. If sometimes the entry is just you have to click certain things, there's not a lot of room for free text. With the EMR that we have, we can have a set template, but we can copy and paste anything in there. So what I did is I took the A-FROM--actually, in the same paper that put out the A-FROM, they put the FROM, Framework for Outcome Measurement, and actually suggest that you could use it for individuals with TBI and called it TBI-FROM.    I took that and put it into a template and have the citation for it there and then added a title. It gives a visual for other individuals reading the note of what I'm talking about. ‘Survivorship beyond body function domain: Dysphagia's impact on personal, participation, environmental domains', so I have that as a title. I have it as this set, we use epic, so I can do dot phrases (Smart Phrases). I can drop that into a note. And then as I go through and document, I have the subtitles of body function, participation, environment, personal factors in as I'm collecting this information. That's how I can organize my note.   I don't do it every single time with every single patient. Sometimes some of our sessions are more impairment focused, like we need to for safety reasons focus on this. Sometimes it's more a whole session all about how are they doing with their personal domain? I had a patient in the clinic today, and he is depressed, and we just had this quick talk of, “Okay, what do we need to do? Can you talk to your primary care doctor? This is common, many individuals with head neck cancer have depression.” But I'll organize my note, getting back to the notes, with those subtitles and putting the information in there. It also is a cue for me, because I keep needing cues and reminders to come back and broaden that focus, instead of always being in on the impairment and you monitor, document, and then monitor, as I'm reviewing back on their notes to see how they're doing across these different domains.   Ellen Bernstein-Ellis  38:19 That is a beautiful example of how you can adapt something. I'm sure a lot of our listeners really appreciate you describing it so carefully, and hopefully will inspire some of them to see what they can do to adapt their EMRs.   A little bit earlier, you mentioned the importance of getting perspective from both the client and the care partner. How does the caregiver or care partner experience fit into the Swal-FROM?   Theresa Yao  38:47 Caregiver or care partners, they play a really important role in this whole journey with individuals with dysphagia. And I'm sure Ellen, you probably were in that role before. Most of the time, it's the caregiver making the meals for the spouse. Making the meals for the patients with dysphagia can be very challenging. Because just the texture, you have to take care, and the taste. I have caregivers talking to me. They told me that they tried their best to make all the foods but the patient didn't eat at all or didn't like it at all. Then they feel super frustrated. These are all the challenges that the caregivers may face.   Dr. Samantha Shune and colleagues, they did a lot of work on this caregiver burden topic. Their study said increased caregiver burden has been associated with the degree of impact that dysphagia is having on mealtime logistics. Family members also report increased anxiety and fear and frustration, stress, embarrassment and social isolation. So these are very two critical things to consider when we're thinking about whole person care, because we can't just care for one person, the patient. But if the caregiver is also experiencing all the stress, all the anxieties, we also need to consider that factor.   Researchers in Australia, Professor Nund and colleagues, they also pointed out that this specific caregiver burden is third party disability. And it's the consequence of that person's impairment, which impacts the functioning and ability of their family members or significant others. That's why we want us to fit this caregiver experience into this Swal-FROM framework. Just adding the family caregiver in all the different domains to support patients with dysphagia. And caregiver can influence four domains. But at the same time, also, we need to take care of, examine, the four domains of the family member or the caregiver--going to check their participation, their environment, and their personal factors. Those are really important, because their health and well-being can be affected by being in the journey of taking care of people with dysphagia. So they're super tied closely. That's why we wanted to fit this framework as well.   Ellen Bernstein-Ellis  41:21 One of the clinical tools I've learned is available is a PRO measure called the CARES, developed by Shune and colleagues, and we'll again put the citation in our show notes. Theresa, could you describe that a little bit more?.   Theresa Yao  41:37 So this is a wonderful screening tool that developed by Dr. Shune and colleagues. It's full name is called Caregiver Analysis of Reported Experiences with Swallowing Disorders. It has 26 items in the questionnaire. And then there's two parts that explore a different aspect of dysphagia's impact on the caregiver. One is a checklist on the behavior and functional changes, and one is a checklist of the subjective caregiver stress. Basically, it's a simple yes/no questionnaire. You can give it to the caregiver and they can just circle yes or no. Then from that, you can figure out what area you may address as an SLP. Or you may want to refer them to a specific team or professionals to address that, because we have limited scope of practice, we can't do everything. But if we can help them to identify the issue and then point them in the right direction, to the right team. That may help a lot.   Ellen Bernstein-Ellis  42:43 In your ASHA presentation you also mentioned the Rome Foundation is a resource and another website that offers skill building around managing serious illness conversations. We're going to put both of those resources into the show notes for people, but we don't have time right now to go into them fully.   But Jocelen, can you address or share what benefits you've seen by adopting this framework? Does it help with goal setting? Does it help with acceptability of recommendations? What have you seen?   Jocelen Hamilton  43:12 I think it's helped me and I feel like it's helped patients and our families have a little more clarity about, okay, these are the areas that are challenging. And again, I'm a visual person, so if I write it out with them, and they're telling me things, and I'm explaining, I get excited about the diagram, and I'm like, you know, see, this seems like an area of challenge. Is there something that you're interested in doing in this area? Are you willing to talk with another person who's gone through this?   So I feel like it really can give clarity, I think, for myself, what you know that A-FROM does, and Swal-FROM now is to not, I professionally can get really hung up on the impairment. And I can't always change that, right? We can't always change it to the degree that we would like. Of course, we would like everybody to have complete resolution, right? And so there can be this frustration and powerlessness with that. And obviously the patients and our family members can be experiencing that also.   And with this broader view, we can say but here's what we can focus on what can we do to have you participate that would make you feel better? What can we do that would help you with your personal feelings? So I feel like it addresses things that matter and we can have more conversations about how is their day to day life being impacted? What are some small steps we can take in a direction that might help them and their families.   Ellen Bernstein-Ellis  44:43 That's beautiful. Thank you so much, Theresa and Jocelen. It has been a pleasure  and I've learned so much from both of you, listening to you apply this framework and look deeply and carefully at quality of life for people with dysphagia. I really appreciate it. Is there anything else you want to add?   Theresa Yao  45:03 I just wanted to add a little bit. So I think it's really important as clinicians to listen to our patients and caregivers, because we need to learn from their experiences, their perspective. And, like we mentioned dysphagia is invisible. I wanted to share one of the quotes from one of the dysphagia support members. He says,  “dysphagia is a label you carry with you inside.” And that's really just so true, because it's hidden. If you go outside, people see like you what you can walk, you can talk, but they don't know that this disability is hidden inside. And I think it's so important to address not just the impairment, but also listen to the patient's perspective. And then help them to address all the domains. I always think that you become a better clinician because what you learn from your patient. So that's all we need to do.   Ellen Bernstein-Ellis  46:08 I can't think of a better way to close this interview. Even though I could ask you several more questions, we could be here for another hour, I just want to thank you for bringing that patient's voice, a client's voice, into the discussion today, so beautifully. And let's end on that note of really learning from our patients' perspectives. So I want to thank you both. And I want to thank our listeners for listening today. And for the references and resources mentioned in today's show, please see our show notes. They're available on our website at www.aphasiaaccess.org. And there you can also become a member of our organization.   Jocelen Hamilton Yes, yes, Do it!   Ellen Bernstein-Ellis Thank you! Browse our growing library materials and find out about the Aphasia Access Academy. If you have an idea for a future podcast episode, email us at info@AphasiaAccess.org For Aphasia Access Conversations, I'm Ellen Bernstein-Ellis. And thanks again for your ongoing support Aphasia Access   Resources and References Ariadne Labs: Serious Illness Care Program https://www.ariadnelabs.org/serious-illness-care/serious-illness-care-program/ The Rome Foundation https://theromefoundation.org/   Chen, A. Y., Frankowski, R., Bishop-Leone, J., Hebert, T., Leyk, S., Lewin, J., & Goepfert, H. (2001). The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the MD Anderson dysphagia inventory. Archives of Otolaryngology–Head & Neck Surgery, 127(7), 870-876. Hamilton, J., Yao, T. J. (2023). Framework to Guide Whole-Person Care for Individuals with Dysphagia. 2023 ASHA Convention, Boston, MA. Hamilton, J., Yao, T. J. (2022). Shifting to Whole-Person Care for Head Neck Cancer Survivors Living with Dysphagia. 2022 ASHA Convention, New Orleans, LA. Hickey, E. and Douglas, N. (2021) Person-Centered Memory and Communication Interventions for Dementia: A Case Study Approach. Plural Publishing, Inc. Howells, S. R., Cornwell, P. L., Ward, E. C., & Kuipers, P. (2021). Client perspectives on living with dysphagia in the community. International Journal of Speech-Language Pathology, 23(2), 201-212. Kagan, A., Simmons‐Mackie, N., Rowland, A., Huijbregts, M., Shumway, E., McEwen, S., ... & Sharp, S. (2008). Counting what counts: A framework for capturing real‐life outcomes of aphasia intervention. Aphasiology, 22(3), 258-280. List, M. A., D'Antonio, L. L., Cella, D. F., Siston, A., Mumby, P., Haraf, D., & Vokes, E. (1996). The performance status scale for head and neck cancer patients and the functional assessment of cancer therapy‐head and neck scale: a study of utility and validity. Cancer: Interdisciplinary International Journal of the American Cancer Society, 77(11), 2294-2301. McGinnis, C. M., Homan, K., Solomon, M., Taylor, J., Staebell, K., Erger, D., & Raut, N. (2019). Dysphagia: interprofessional management, impact, and patient‐centered care. Nutrition in Clinical Practice, 34(1), 80-95. McHorney, C. A., Bricker, D. E., Kramer, A. E., Rosenbek, J. C., Robbins, J., Chignell, K. A., ... & Clarke, C. (2000). The SWAL-QOL outcomes tool for oropharyngeal dysphagia in adults: I. Conceptual foundation and item development. Dysphagia, 15, 115-121. Nund, R. L., Scarinci, N. A., Cartmill, B., Ward, E. C., Kuipers, P., & Porceddu, S. V. (2016). Third-party disability in carers of people with dysphagia following non-surgical management for head and neck cancer. Disability and rehabilitation, 38(5), 462–471. https://doi.org/10.3109/09638288.2015.1046563 Shune, S. Moving beyond the isolated swallow: Dysphagia in the context of the shared mealtime. https://dysphagiacafe.com/2015/03/19/moving-beyond-the-isolated-swallow-dysphagia-in-the-context-of-the-shared-mealtime/ Shune, S., Davis, C., & Namasivayam-MacDonald, A. (2021). Contributors to Dysphagia-Related Burden Among Spousal Caregivers of Stroke Survivors. Archives of Physical Medicine and Rehabilitation, 102(10), e65. Shune, S. E., & Namasivayam-MacDonald, A. (2020). Dysphagia-related caregiver burden: Moving beyond the physiological impairment. Perspectives of the ASHA Special Interest Groups, 5(5), 1282-1289. Silbergleit, A. K., Schultz, L., Jacobson, B. H., Beardsley, T., & Johnson, A. F. (2012). The dysphagia handicap index: development and validation. Dysphagia, 27, 46-52. Smith, R., Bryant, L., & Hemsley, B. (2023). The true cost of dysphagia on quality of life: The views of adults with swallowing disability. International Journal of Language & Communication Disorders, 58(2), 451-466. Smith, R., Bryant, L., & Hemsley, B. (2022). Dysphagia and quality of life, participation, and inclusion experiences and outcomes for adults and children with dysphagia: A scoping review. Perspectives of the ASHA Special Interest Groups, 7(1), 181-196.

MEDamorphosis Podcast Season 4 re-launches with this new episode from 2nd Yr UBC Medicine learner, Maya Naidu.New episodes of MEDamorphosis will be available the last Monday of each month.Maya speaks with Dr. Abhi Cherukupalli, a resident physician in Otolaryngology-Head & Neck Surgery (also known as ENT) at UBC. Dr. Cherukupalli walks us through his journey to his specialty and discusses finding his passions in medical innovation & global health along the way. Dr. Cherukupalli brings up the important topics of burnout and self-care in medical training, and shares his advice for medical students.Please rate, review, and subscribe to our podcast and explore the entire UBC Medicine Learning Network roster of podcasts on Spotify, Apple Podcasts, and where you find your podcasts.Follow the UBC Medicine Learning Network on all social media: @ubcmedvidGuest: Dr. Abhi CherukupalliHosted and Edited by: Maya NaiduMusic: Dr. Ian Downie(C) 2023 UBC Medicine Learning Network

Itchy eyes. Sinus pressure. Coughing and sneezing... Many people take antihistamines to get through an allergy episode, and that can be totally OK. But what about if you have to take them everyday? Are there potential long term side effects? Today's guest, Dr. Chris Thompson, is a Board Certified Otolaryngologist, Head & Neck Surgeon with over 25 years of experience practicing medicine in Texas. He earned his undergraduate degree in Biomedical Engineering from Texas A & M University in College Station and went on to receive his Doctorate of Medicine at the University of Texas Southwestern Medical Center in Dallas. Dr. Thompson completed his residency with the Department of Otolaryngology, Head & Neck Surgery at the University of Texas Medical Branch in Galveston.Dr. Thompson focuses solely on allergy, sinus and nasal treatment and is considered an expert in all three fields. He is one of a handful of doctors that played an integral role in the development of the cutting-edge sinus procedure, Balloon Sinuplasty. Dr. Thompson is also experienced with nasal reconstructive procedures and rhinoplasty. He is very excited for the future of allergy treatment through sublingual immunotherapy, as more patients choose and stay consistent with the treatment. He is also a member of the American Academy of Otolaryngology-Head & Neck Surgery, American Academy of Facial Plastic & Reconstructive Surgery, Texas Medical Association, and Travis County Medical Society. Join us as Dr. Thompson discusses all things relating to allergies, the side effects of long-term use of antihistamines, and other options that people can use or try to get off of those meds such as immunotherapy. Have you used antihistamines to calm down a severe allergic response? Have they helped, but you're ready to try something new? Let me know in the comments if you have questions! In this episode: Are antihistamines appropriate for daily use? Different types of antihistamines (what do they do?) How eczema, food allergies + asthma are related Antihistamines crossing the blood-brain barrier (YIKES) Non-pharmaceutical options to consider (and discuss with your doctor) Treatment options for different types of specific allergies Quotes “There are some studies that link long-term antihistamine use with things like dementia. There was one I read recently that showed an increase in glial tumors, which are typically brain tumors... There are links to depression. There are links to weight gain with these and all, but one of the antihistamines over-the-counter can cross the blood-brain barrier." [4:16] “One of the most surprising facts about allergy is that only 2% of the population of allergy patients seek allergy care. Imagine, if 3% of cancer patients or 2% of sleep apnea patients sought and received proper care for their medical ailment? It would just be unfathomable, but yet in the allergy world, again, we're not talking about a life threatening problem in most cases, but it really does get sidelined and poo-pooed by a lot of doctors." [25:20] Links Find Dr. Thompson online Follow Aspire Allergy on Instagram Healthy Skin Show ep. 248: Is Eczema Related To Histamine Intolerance?  Healthy Skin Show ep. 164: Mold Illness vs. Mold Allergy w/ Dr. Kasey Holland Healthy Skin Show ep. 037: Nickel Allergy And Eczema w/ Dr. Peter Lio

Tune in to an episode that discusses trending clinical topics that have been in the news recently: Monkeypox and Ramsay-Hunt Syndrome. We begin our conversation with Dr. Stan Deresinki who is a Clinical Professor of Medicine in the Division of Infectious Diseases and Travel Medicine at Stanford. We discuss the Monkeypox virus including the signs, symptoms, cause of the upward recent spread, transmission prevention and best practices to navigate the uncertainty of this virus. The next part of the episode will be a discussion about Ramsay Hunt syndrome (RHS) with Dr. Jon-Paul Pepper who is an Associate Professor of Otolaryngology – Head & Neck Surgery at Stanford. Listen to learn more about the causes, symptoms, differential diagnosis and treatment options for RHS. Transcript coming soon! CME Information: https://stanford.cloud-cme.com/medcastepisode44 Claim CE: https://stanford.cloud-cme.com/Form.aspx?FormID=1240

Standing on the podium to give a presentation can be a daunting task. Sharing your knowledge and research with a room of strangers is often not easy. Virtual audiences, while perhaps less fear-inspiring, can be even harder to engage. Dr. Glastonbury shared tips on how to conceive and prepare your next presentation and then present so that you can connect with your audience, share your expertise, and enjoy the experience. Learning Objectives: Upon completion of this activity, participants were able to: Understand the elements of a presentation that make it meaningful and memorable for an audience. Recognize basic slide techniques that ease the cognitive load of your audience. Develop a clear process & also inspiration, for planning their next presentation. Presenter: Christine M. Glastonbury, MBBS, is a Professor of Radiology & Biomedical Imaging, Otolaryngology-Head & Neck Surgery, and Radiation Oncology at the University of California, San Francisco. Dr. Glastonbury is a Neuroradiologist with a particular academic and clinical interest Head & Neck (HN) Imaging, and specifically HN cancer. She works closely with the Radiation Oncologists and HN surgeons on a weekly basis to optimize the care of HN cancer patients at UCSF. She has written and published multiple books, more than 130 articles and received multiple awards for teaching, mentoring and for education exhibits at scientific meetings. Dr. Glastonbury completed her medical degree and Radiology training at the University of Adelaide and the Royal Adelaide Hospital in South Australia before completing a fellowship at the Hammersmith Hospital in London. She then completed two years of Neuroradiology Fellowship and a year of Body Fellowship at the University of Utah, Salt Lake City before moving to San Francisco in 2001. At UCSF Dr. Glastonbury is the Vice-Chair for Academic Affairs and served as interim Chief of Neuroradiology for nearly 4 years until August 2021. She is the director of Mentoring in Radiology, a member of the Radiology Diversity Committee, and a co-founder and strong advocate for UCSF Women in Radiology. Dr. Glastonbury serves on the Executive Council of the American Roentgen Ray Society and on the Executive Committee for the American Society of Head and Neck Radiology where she is also the Treasurer. She is the Program President for the Symposium Neuroradiologicum XXII of the World Federation of Neuroradiological Sciences in May 2022. Click here for webinar.

In this “Giants of Plastic Surgery” episode of the PRS Global Open Deep Cuts Podcast, Peter Neligan FRCS(I), FRCSC, FACS joins us on the first day of his retirement to reflect on his glistening career, family life, illness, and how he achieved success in Plastic Surgery. Read a classic PRS Global Open article by Dr. Neligan and co-authors Guillermo Artero MD, Marina Ulla MD, and Claudio Angrigiani MD—"Bilateral Anatomic Variation of Anterolateral Thigh Flap in the Same Individual:” https://bit.ly/NeliganDeepCuts Dr Peter C. Neligan received his medical education at the University of Dublin, Trinity College, graduating MB, BCh, BAO in 1975. He obtained his FRCS in general surgery from the Royal College of Surgeons in Ireland in 1980 and subsequently trained in Plastic Surgery in Dublin. In 1983 he moved to Toronto for fellowship training at the University of Toronto, completing fellowships in surgical research, pediatric plastic surgery, microvascular surgery, and burn surgery. Having obtained his FRCS in Plastic Surgery, Dr. Neligan established practice in Sudbury, Ontario in 1987 before returning to the University of Toronto in 1991 to take up a position at the Wellesley Hospital as Director of the Ross Tilley Burn Unit. In 1993 he moved to Toronto General Hospital where he specialized in oncologic reconstruction and reconstructive microsurgery. Dr. Neligan served as Chief of Plastic Surgery at TGH from 1996 until 2007. In 1996 he was appointed Chair of the University Division of Plastic Surgery. In 1999 he was appointed the Wharton Chair in Reconstructive Plastic Surgery, the first endowed chair in Plastic Surgery in Canada. Dr. Neligan moved to Seattle, WA in July 2007 where he is now a Professor at the University of Washington in the Departments of Surgery and Otolaryngology/Head & Neck Surgery. He is active in numerous societies, and is past president of the Plastic Surgery Foundation, The American Society for Reconstructive Microsurgery and the North American Skull Base Society. Dr. Neligan currently serves on the Board of Directors for the American Society of Plastic Surgeons and is a past member of the Board of Directors for the American Head and Neck Society. He is the immediate past Chair of the Advisory Council for Plastic and Maxillofacial Surgery at the American College of Surgeons. Dr. Neligan has authored 7 books, over 70 book chapters, and over 170 peer-reviewed papers. He is the series editor of the third edition of the 6-volume set, Plastic Surgery, considered to be the bible of Plastic and Reconstructive Surgery. He has made over 200 peer-reviewed presentations at national and international meetings as well as delivering numerous invited lectures. He has served as Visiting Professor to numerous institutions nationally and internationally. He sits on the Editorial Board of five journals and is Editor-in-Chief of the Journal of Reconstructive Microsurgery. Your host, Dr. Vimal Gokani, is a senior Specialty Registrar in plastic surgery in London, England. This episode was produced & edited by Dr. George Adigbli, an academic Specialty Registrar in plastic surgery in Oxford & Aylesbury, England. #PRSGlobalOpen #DeepCutsPodcast #PlasticSurgery #GiantsPlasticSurgery

Burnout comes up a lot in the physician's space, and for a good reason. As women physicians, we are constantly exhausted from progressing our careers while doing everything society expects of women. The good news is that with a few mindset shifts and practices, you can get out of the box of burnout and start feeling like yourself again.   If You Want To Prevent Burnout, You Should: Get clear on what your passion is and create a plan to help you go after it Surround yourself with a supportive and inspiring community Ditch the all or nothing mentality and focus on taking small baby steps towards your goals   Preventing Burnout With Dr. Karen Hoffman Karen Hoffmann, MD, FAAOA, is board certified by the American Board of Otolaryngology-Head & Neck Surgery. Since joining Piedmont Ear, Nose, Throat, and Related Allergy in 2007, Dr. Hoffmann has specialized in the medical and surgical treatment of patients with Eustachian tube dysfunction, ear fullness, sinus, and allergy disorders, and hearing loss and chronic ear disease. She has successfully integrated compassionate and innovative care in private practice with clinical research and is passionate about helping others take care of themselves.   You Are In Control of Your Own Outcome Being a mother, wife, and physician, Dr. Hoffman got to a breaking point when she realized that her all-or-nothing mentality and internal dialogue were contributing to her burnout. By taking small baby steps to move away from this mentality and towards a long game strategy, she was able to change her thinking and change her life.  Now, Dr. Hoffman shows up to work every day excited, which reflects back onto her and onto her patients. By finding clients that push her out of her comfort zone and inspire her to approach medicine in a new way, she is pursuing her passion in an inspiring way.   Find Your Passion and Run With It One of the best ways to feel supported going forward in your journey is to find a community of other women and women physicians. If you don't have support, you will feel like you need to do it all. And while your imposter syndrome may be holding you back from finding a community, showing up authentically and making yourself a priority is the best way to overcome it.  The changes you will notice when you start to take care of yourself can be drastic. By getting clear and focusing on your passion, creating a plan to get there, and surrounding yourself with other women who continue to lift each other up, anything is possible.   Homework for Women Physicians Are you ready to prevent burnout by thinking outside of the box and prioritizing yourself? Share which ways you tackle burnout with me in the comments section of the episode page.   In This Episode  Why we experience burnout early on in our careers [3:30] How to use your thoughts and internal dialogue to determine your own outcome [6:49] Tips for creating a balance between family life and your career [13:30] Why being surrounded by a community of other women physicians is a gamechanger [15:28] Advice for women who believe they don't have the time to achieve their goals [19:20]   Quotes “You try to do everything, and I think it is almost like you are on a hamster wheel. You just keep going and going and going. It took me quite a while to figure out that wasn't really normal or sustainable.” [3:59] “I ultimately have the power to determine my outcome based on my thoughts. My internal dialogue and thoughts are much more important than my external circumstance and how I experience and interact with the world. So it ultimately gives me the power to determine my outcome.” [7:34] “There are really just so many hours in the day, and you can't be everything to everybody all at the same time.” [14:11] “Everyone has some imposter syndrome, I really think, unless they are a narcissist, and we just have to realize that everyone has that. And you just show up and do you, and you want to be your authentic self.” [18:25] “You have to figure out where you are going so that you can come up with a plan to actually get there.” [26:09]   Resources Mentioned Dr. Karen Hoffman Website Join G.O.A.L.S. Society Free for 30 Days  Join the Transform Waitlist Check out the full episode page here Find Life Coaching for Women Physicians Online Follow Dr. Ali Novitsky on Facebook | Instagram  Subscribe to Life Coaching for Women Physicians on Apple Podcasts Podcast production by the team at Counterweight Creative   Related Episodes Episode 64: Showing Up for Your Future Self Episode 59: Thinking Outside The Box with Dr. Tonya Caylor

Judith Lieu, MD, from the Department of Otolaryngology–Head & Neck Surgery at Washington University in St Louis, discusses the need for screening young children for hearing loss and the importance of treating hearing loss as early in life as is possible. Related Article: Hearing Loss in Children

    Casey Means is the Co-Founder of Levels Health, a digital health company focusing on maximizing human potential through optimized metabolic health, disease prevention & reversal + functional medicine. Before moving into digital health she was a Resident Physician of the Department of Otolaryngology Head & Neck Surgery with Oregon Health & Science University. She has been featured in many media publications including Forbes, Entrepreneur Magazine, and Business Insider and was listed  as one of this year's Top 10 Female Tech Leaders to Watch. Casey is passionate about preventative health care, identifying the immune system and how we treat it as the secret to a healthy and long life.   In today's episode Casey joins us to share her journey in the world of medicine, from resident Head and Neck Surgeon to co-founder of a digital health company that has just raised 12 million dollars from its first seed round. We discuss the team player tactics she and her co-founders used to gain feedback and information from all parts of the Levels company including their own investors. Casey explains how high-quality content in the Levels blog answered prospective customers questions thereby maximizing traffic to her company website. She reveals the shocking statistics of poor metabolic health in the U.S, and why eliminating preventable metabolic dysfunction in America is Levels' No 1 goal. Casey also shares her 4 foundations of health that she addresses in her own life to ensure optimum performance when running her business and personal life.   “Respect your network and ask for help and totally be in a growth/learn mindset every step of the way.” - Casey Means   This week on SocialFly's Entreprenista Podcast:   How Casey discovered the gap in the health service of the immune system How Levels has enabled Casey to reach more patients than she ever could as a surgeon Which platforms Casey recommends running your company remotely How Casey's company raised 12 million dollars from its first seed round Why you should seek feedback and advice from your investors Why your website should answer the customers questions Why only 12% of the U.S population have a healthy metabolic function Why we should be concerned by the behavior of our metabolism Caseys 4 point checklist for performing better in your day to day life       Our Favorite Quotes:   “You've got to put your ideas down and share them with your close network and put yourself out there for opportunities.” - Casey Means “If you're starting a company then you have to start figuring out Google and how to get people to your site organically.” - Casey Means “Being an Entrepenista means stepping back frequently throughout your life and taking stock of what you're doing and how you're spending your time. And really reflecting on what kind of impact you want to have on the world.” - Casey Means   Resources:   Book: The Obesity Code Book: The Diabetes Code Book: Why We Get Sick Notion Slack Superhuman Daily Harvest   Connect with Casey Means:   Levels Website Levels Blog Levels on Instagram Levels on Twitter Levels on Facebook Casey Means on Instagram Casey Means on Twitter Casey Means on LinkedIn   Say “Hello!” To DigiCards™   Are you ready to take your virtual team meetings to the next level? Are you tired of yelling “You're on mute!” at your computer screen and letting the important points you were trying to make get lost?   If you're tired of leading unproductive, distraction-filled team meetings, then it's time for you to say “Hello!” to DigiCards. Each pack of virtual meeting cards include 20 color-coded professional cards designed to streamline your meeting communications while allowing each meeting to create an opportunity for collaboration and fun.   Say “Goodbye!” to waving your arms, being ignored, and frantically typing in the chat.   Start your next virtual meeting with DigiCards - the virtual meeting cards for entreprenistas.   To grab your deck of DigiCards and bring fun, engagement, and collaboration back into your team meetings, visit www.hellodigicards.com. Use the coupon code: Entreprenista10 to receive 10% off your first order.   Become An Entreprenista!   Thanks for tuning into this week's episode of The Entreprenista Podcast - the most fun business meeting for female founders, by female founders. If you enjoyed this episode, please subscribe to the show and leave a review wherever you get your podcasts.   Apple Podcasts | TuneIn | Spotify | Stitcher | iHeartRadio | GooglePlay   Be sure to share your favorite episodes across social media to help us reach more amazing female founders, like you.   Don't forget to follow us on Facebook, Twitter, Instagram, and LinkedIn and for more exclusive content, tips, and insight, join the Entreprenistas Facebook group and visit the SocialFly website.  

James C. Denneny III, MD, AAO-HNS/F EVP/CEO; Eugene G. Brown III, MD, Partner at Charleston ENT & Allergy Associates, and Board, OASIS Clinically Integrated Network; Cecilia E. Schmalbach, MD, Professor & Chair, Department of Otolaryngology–Head & Neck Surgery at Temple University, Director, Temple Head & Neck Institute, and AAO-HNSF Coordinator for Research and Quality; Joel Selanikio, MD, physician, technologist, entrepreneur, emergency responder, TED speaker and medical futurist.

Please join us Wednesday, April 22, 2020 at 4:00 p.m. PST and 7:00 p.m. EST for a live show with host Denise Messenger.  Dr. Demetri Arnaoutakis is a Board Certified surgeon who specializes in facial plastic surgery, hair transplant procedures and injectables.  Dr. Demetri is a board certified by the American Board of Otolaryngology-Head & Neck Surgery and is an active member of the American Academy of Facial Plastic and Reconstructive Surgery. He frequently travels to attend national conferences to perpetually advance his education and present his research. To date he has authored over 30 peer-reviewed publications and book chapters. I

Lance A. Manning, MD, Chair of the AAO-HNS Practice Management Education Committee and Chair Elect of the BOG is joined by Douglas M. Hildrew, MD, Chair of the AAO-HNS Telemedicine Committee and Assistant Professor of Surgery at the Yale School of Medicine, Division of Otolaryngology–Head & Neck Surgery, and Lawrence M. Simon, MD, former AAO-HNS CPT Advisor, member of AMA’s CPT Editorial Panel, and Regional Medical Director for BCBS of Louisiana to discuss the rapid adaption of telemedicine during COVID-19.

Robert Wardlow is a graduating MD/PhD Candidate at JHUSOM. He will be matching into Otolaryngology - Head & Neck Surgery. He is originally from southern New Jersey and earned his B.S. in Biochemistry from the University of Maryland, Baltimore County (UMBC).

ADVENT President and Founder, Madan Kandula, MD, takes an iron fist in a velvet glove approach to combat the conventional constructs of a failed healthcare system. During his twenty years in clinical practice, Dr. Kandula has brought an entrepreneurial attitude to the practice of medicine. Dr. Kandula addresses each of his patient's problems and each obstacle in front of him with the mindset of, "What are the best tools or techniques to address this issue today (not yesterday and not tomorrow)." Board certified in Otolaryngology — Head & Neck Surgery, Dr. Kandula has been a pioneer in developing new techniques and treatments for his patients in Wisconsin with nose, sinus, snoring and sleep apnea complaints. His visionary approach is demonstrated by being the first surgeon to perform Balloon Sinuplasty in Wisconsin and developing a new model of care to evaluate The Breathing TriangletM. Long wait times, dismissal, and uncertainty define the healthcare experience in America, and Dr. Kandula knows that he can not only reinvent the experience for his own patients, but for patients all over the country.

Dr. John W. McGrath is Chairman & Program Director of the Department of Otolaryngology & Head & Neck Surgery at Philadelphia College of Osteopathic Medicine. We are talking about allergies and how to stop your suffering from them . --- Send in a voice message: https://anchor.fm/lisa-frattali/message

Statistics indicate that hearing loss is on the rise. In this interview, board certified otolaryngologist Dr. Ford D. Albritton IV describes the magnitude of the problem, as well as the research associated with key nutrients that can help reduce the risk of hearing loss. It's critical that all practitioners, not just hearing specialists, put this topic on their radar so they can help patients who already have hearing loss and those who are at risk.   About the Expert Ford D Albritton IV, MD, FACS, is the director of sinus surgery at the Sinus and Respiratory Disease Center at the Texas Institute for Surgery. He has served as chairman of the board of directors at the Texas Institute for Surgery and chairman of the Department of Otolaryngology-Head & Neck Surgery at the Texas Health Presbyterian Hospital of Dallas. Innovation and creative solutions to long standing problems in his field have been a focus of his practice since completing his training at the Emory University School of Medicine. He holds patents in the fields of nutritional compounds for targeting prevention of sensorineural hearing loss based on research initiated in the early 2000s. He also holds patents and expertise in the field of sinus disease and surgery with several publications to his credit. He remains active in clinical research and has been requested as a lecturer on the subject for surgeons domestically and internationally. Current interest exists in linking dietary methods of hearing preservation to cognitive function maintenance in patients with hearing disability, defining intervention strategy, and establishing modes of prevention. Transcript Karolyn Gazella: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today we have a fascinating topic. We'll be talking about how certain nutrients can help reduce the risk of developing hearing loss, and we have the perfect expert to help us with this topic. Dr. Ford Albritton, IV is a board certified otolaryngologist with the Sinus and Respiratory Disease Center at the Texas Institute. Dr. Albritton, thank you so much for joining me. Ford Albritton, IV: It's my pleasure, Karolyn. Thanks for having me. Gazella: Yeah. So, how common is hearing loss, and have we actually seen an increase over the past decade or so? Albritton: Hearing loss is incredibly common, and it's been pretty consistent if we look at the prevalence. The National Institutes of Health actually has its own group that looks at communication disorders, and they estimate the prevalence of about 15% of residents in the US having a diagnosis of hearing loss, and currently that puts us at about 38 to 40 million. And you asked the question has there been an increase, and it's sort of a tricky answer. Yes, there's been an increase, but so has the population increased. In 1971, that number was 13.2 million and basically one third the current number. So, why are we seeing such an increase? Well, it's a combination of population growth and the basic dynamics of our population age. If we look at aging as a criteria for hearing loss, we can compare people that are between the ages of 45 and 54. Only about 2% of those people are going to have a diagnosis of hearing loss, but if we go up to 75 years or older, almost one half to two thirds of the population will be having a hearing loss diagnosis depending on the studies you look at. And the World Health Organization has currently estimated hearing loss at about 466 million, but by 2050 they do predict that number should hit 900 million. So, there's certainly an increase, but it's tricky to say that that's because of something changing in the environment or our susceptibility is increasing, and their point of fact is a few years ago, pediatrics journals documented that adolescents were having an increased rate of hearing loss from comparing data between '94 and 2006. They reviewed that data again in 2010 and found that that was just simply a statistical error and that they had erroneously just compared two points of data instead of contiguous and that actually the rate of hearing loss has not increased in that age group. Gazella: Okay, that's interesting. So, what is considered a normal hearing range, and at what range does there begin to be a problem? Albritton: The way we measure hearing is using something called an audiogram or audiometry, and it measures sound intensity. The official measurement unit is called the decibel, which is a logarithmic measurement of sound intensity, and we define normal hearing as a threshold where a subject can recognize a presented tone at a specific frequency less than 20 decibels. So, if you're presented a tone at a low frequency or a high frequency and you can perceive it, recognize it at a sound energy level quieter or equal to 20 decibels, that's normal. Furthermore, we use some tricks of averaging and statistics to have some simple ways of measuring. Like we will average two tones or three tones or pitches on the hearing test and come up with a number of sound intensity, and we consider anything less than 20 normal, and anything above 25 we start to believe is abnormal and probably would benefit from some sort of intervention. Gazella: Okay, great. So, let's talk a little bit about risk factor. Who's at risk of developing hearing loss? Albritton: Probably a number one factor is family history. So, genetics play a larger role than we really can appreciate at this point in our mapping of the human genome, but family history is probably the most important question we ask patients into mapping their risk for hearing loss. The second one would be noise exposures, people with a high occupational noise exposure. OSHA measures that as greater than eight hours exposed at 90 decibels, so noise exposure at that rate can cause hearing loss. And then drugs; certain chemotherapy agents, some antibiotics are notorious for being toxic to the inner ear. Certain infections; one of the great benefits of immunizations and the reason we recommend immunizations is to prevent some of these preventable causes of hearing loss. Maternal infection of mumps, measles, rubella, for instance, can have devastating consequences on a fetal ear development and could have consequent hearing loss. And then finally, sort of our chronic illnesses, diabetes, hypertension, heart disease can compromise blood flow and health to the inner ear causing problems. Inflammatory conditions such as rheumatoid arthritis, certain inner ear inflammatory conditions can also cause problems. So, it's a pretty broad area of the things that can cause hearing loss, but the biggest risk, again, being family history. Gazella: So, when we think of hearing loss, it's understood that it obviously affects communication and how we communicate with each other, but does hearing loss have any physical impact on a patient's life? Albritton: That's an interesting question, and I think that 20 years ago we probably would not have directly thought so. It obviously does affect sense of wellbeing and ability to interact with others, but it can affect a lot of other things. An interesting study from last February demonstrated a correlation of hearing impairment severity and the incidence of fractures to the radial forearm, to the hip, to the spine, and it showed that patients with severe hearing impairment actually had an increased risk of fracture that was greater than the normal hearing group, and basically you had 1.4 to 1.6 greater risk of having one of those types of fracture from a fall if your hearing was severely affected. There's lots of further digging that needs to be explored such as severe hearing loss also contribute to injuries to the balance system. That's sort of outside the scope of the research at this time. But really the most newsworthy research in the past decade is focused on the correlation of hearing loss, severity of the hearing loss, with cognitive impairment and dementia. In 2013, a paper out of Johns Hopkins authored by Dr. Lin out of their department of otolaryngology and his colleagues demonstrated in just under 2000 patients that patients with a pure-tone average, that's that average we discussed earlier, of several frequencies of over 25 decibels, they had rates in decline in their cognitive function testing that was 30% to 40% greater than their normal hearing peers. And not only that, there was a linear relation between the hearing loss severity and the degree of decrease in their cognitive function test scores. So, that data really set off alarm bells, and health organizations throughout the world, the British health system, the French health system, Danes, Italians began looking at their population, and probably the most robust examination has been the English, many thousands of patients, have agreed with this information. They put a cognitive impairment risk of 1.6 times greater than normal hearing population with hearing impairment. Interestingly, some of these studies took the next step and tried to assess, well, if we do something for the hearing, such as a hearing aid or a Cochlear implant, something that will restore hearing, does that make a difference in the cognitive impairment testing? And it actually does. An Italian study was one of the preliminary studies to look at this, and they demonstrated that either a hearing aid or a Cochlear implant could actually reverse some of this cognitive impairment seen on the testing with improved scores. The French study was pretty astounding in terms of its result. Greater than 80% of their lowest scoring cognitive impairment patients tested, they showed improvement after the Cochlear implant, which was quite surprising. So, there's a question as to how hearing loss, how is this leading to dementia? And I don't think we fully understand that yet, though there are some hypotheses, and Dr. Lin laid out about four of these. First one being is there some common physiologic pathway that's contributing to both brain damage and inner ear damage? Something like blood pressure elevations where we see some chronic ischemic changes to the brain on MRIs or diabetes or something along those lines. The second theory is something called the cognitive load theory. Basically, it surmises that the effort of constantly trying to comprehend what is being heard takes memory resources, whether it be a neurotransmitter or other nutritive resources, and the chronicity and cumulative nature of this leads to issues and errors in ongoing brain function, the ability to maintain memories in an ongoing manner. A third theory is that hearing loss may affect brain structure. We do know that in brains of patients without stimulation, stroke patients, et cetera, that there's certain areas of the brain that shrink, and it isn't necessarily that we lose cells there, but there are some changes in the simple [inaudible 00:11:38] of those cells and that hearing loss patients do appear to show some of those similar findings on their MRIs. And then finally, social isolation. We know that social isolation happens with hearing loss, and we also know that social isolation is a known risk for cognitive impairment. One theory that a lot of fellow ENTs and otolaryngologists specializing in ear have known about since the '90s is that if we fit a patient with hearing aids earlier, they do better long term, and a large study in the VA looking at World War II veterans in the '90s established that patients that obtained hearing aids earlier did better with those hearing aids long term. They were able to accurately repeat words presented to them at a higher rate than their peers who had not obtained a hearing aid and had similar hearing test results. They would have basically the same level of hearing loss, but their ability to interpret speech was impaired, and the ability for the hearing aid to function with those patients was just suboptimal and were not able to get the same level of functionality from their hearing aid. And what the theory was is that the stimulation of certain areas of the cortical brain kept those areas healthy and functioning and that the old use it or lose it hypothesis, the patients who weren't using it did not maintain that brain and it therefore degenerated, never to really fully improve. This takes it to another level and seems to suggest that it's not just those areas of brain corresponding to speech recognition; it's rather the brain as a whole that is suffering from the lack of input. Gazella: Yeah. Early intervention is always best, so that makes a lot of sense. Now, you mentioned social isolation. Are there other areas that are affected with hearing loss that negatively impact the quality of the life of the patient? Albritton: Well, I'm sure that there are, and I'm sure that we're going to discover more, but I think the most obvious is isolation and its consequential potential for depression. People that can't hear, they eventually will isolate themselves in social situations because it just becomes too embarrassing or futile for them to continue trying to participate in a conversation they can't hear. And I think we all can appreciate what that feels like. If we've ever been to a noisy restaurant and we can't hear the conversation across the table or slightly away from us, we tend to withdraw. Imagine that for patients with significant hearing loss being a daily ongoing issue, and that ends up contributing to further self-isolation, but depression, and several studies have demonstrated that there is an increased incidence of associated depression with hearing loss. Gazella: Yeah, that makes a lot of sense. Now, you mentioned genetics. So, what is the difference between hereditary hearing loss and age-related hearing loss? Albritton: I would suggest that almost all forms of hearing loss that we attribute to age probably have some genetic component. As we look at just genetic programming for your resilience, your resilience of your skin, your eyes, your hair, your ears, all of those things are sort of pre-programmed, and most people accept multi-hit hypothesis to hearing loss. In other words, that it's not one thing; it's a multitude of things over time that lead to the cumulative and irreparable damage and that there are certain susceptibilities imparted by our genetics. So, we would guess that most age-related hearing loss does have some genetic, if not total genetic, predisposition, and the fact that it's not 100% of patients over the age of 75 with hearing loss, rather one half to two thirds, sort of backs that up. But in terms of congenital or hereditary hearing loss, there are certain conditions and syndromes which we know are hearing loss related, and we can diagnose those fairly young. It's the patients over the age of 40, 50, 60 that we're less able to determine. And there are some studies, though, that have looked at what we term age-related hearing loss and looked at their genetics and have identified some mutations that are fairly specific for a family group but not universally represented in other genomic studies, and they show up in certain areas of the gene pool where we know that genes dedicated to hearing messaging are present. So, there's probably a multitude of issues with mutations over our family histories that does lead to the age-related hearing loss, so I would look at them mostly in the same way. Gazella: Yeah. It'll be interesting to see how that research kind of plays out from an epigenetic standpoint. Now, there's early evidence showing that antioxidants, specifically beta-carotene, vitamins A, C, and E and magnesium can be protective. Tell us about that research. Albritton: Sure. I want to add one more little point to the last question as it'll tie into this. We do know that insulin-like growth factor 1 is something that's important in our homeostasis and our ability to fight off reactive oxygen species or free radicals, and some studies have demonstrated that this decreases with age, and some other studies have taken it a step further and looked at does this have a role in some of the age-related hearing loss, and it does appear to have some role in that. So, it's been a natural thing for antioxidants to have been targeted as a potential therapeutic arm against the aging of the ear. You mentioned vitamin A, C, E, magnesium, and I would caution drawing conclusions to these individual compounds at this time because the data is really all over the place. There are numerous studies in mice that have demonstrated some general improvements using a group of different antioxidants versus control groups. Some of those antioxidants include things like cysteine or acetylcarnitine. Longitudinal studies, though, looking at humans with vitamins A, E, C, B12, folate have showed different results. For instance, in men, they didn't find any difference with any of those vitamins used except in men over the age of 60 they did note that folate may have given some protective benefit. In women, they found that vitamin A and folate also helped not necessarily an age dependent result, but this is interesting; vitamin C, which has been shown to be helpful in some animal models, was actually harmful and actually worsened things in some women studies. We know that folate is an effective cofactor. We know that it helps balance out homocysteine levels, which can protect ischemic vascular damage, so that makes sense to us that it would work. The roles of vitamin C are just straight antioxidant properties, so that suggests that there's something more than just straight antioxidant benefits. One interesting study in Finland that was done about 10 years ago, and they call it the disco study, and it wasn't a very large study; about 20 people were given either an antioxidant vitamin or a placebo. They had their hearing tested before a night exposed to loud music and then they had their hearing tested short term and long term afterwards, and they definitively showed that the group with the antioxidants had less impact from the noise exposure than the control group. Gazella: That's interesting. I like they called it the disco study. That speaks to the era or the timing of that study, I think. So, when we're talking about studies, the research that I read I believe also included magnesium. What would be the connection with magnesium and why would magnesium help our ears? Am I correct? Was magnesium a part of that study? Albritton: Magnesium's a part in several of these studies, and magnesium and the metals probably have a bigger role in enzymatic cofactor, enzymes that can control either the release of certain natural antioxidants or enzymes that have some role in keeping a biochemical process in its favorable state as opposed to going to its unfavorable state. Those metals are essential to these enzymes functioning theoretically, and yes, in some military studies, the use of magnesium has been shown to be effective. Gazella: Now, you mentioned a lot of nutrients, A, C, E, just talked about magnesium. Is the combination of nutrients important and are there other nutrients that you wish researchers would be looking at? Albritton: Now, you're getting to what my interest is. I think yes. I think very much there is combination therapy that makes a difference. I think we're still trying to figure out what that precisely is. There are a host of readily available organic compounds that are something we may have picked up through ethnobotany or traditional Chinese medicine or just from the vitamin industry at large, but we have found that several of these compounds do appear to help in the protection of the inner ear, the heart, the kidney, et cetera. One of those is N-acetylcysteine in rat models, which has proven to be effective at protecting the outer hair cells of the inner ear, and one of the methods we think it works is just by scavenging the free radicals, but it does turn on the body's natural production of glutathione synthesis. So, it doesn't just target the free radicals with its own ability to neutralize them. It actually turns on the body's ability to keep producing those free radical fighters. But there's something else that goes on. It seems to regulate the nitric oxide in the inner ear, and one of the things that nitric oxide can do is, depending on its concentrations, it can trigger a cell to commit cell suicide. We call that apoptosis. In damage that may be sublethal, damage that shouldn't cause a cell to destroy itself, sometimes that misregulation allows the nitric oxide to get so high that it ends up allowing that cell to die. And as you may or may not know, these cells can't regenerate at this time, and so that regulation of the nitric oxide is one unexpected benefit of the N-acetylcysteine. And that's something we see in several other compounds. Some compounds, for instance ... I'm just going to give you a brief list. Resveratrol. We know resveratrol as a miracle compound that has some anti-aging properties in animals, turns on some anti-aging genes, but we found in several studies that it has a highly effective role in reducing inner ear damage in animal studies. It has not been studied in humans to date. We believe that's a real key chemical. CoQ10 has been also very effective in guinea pig models. We know that the mitochondria stabilization appears to be important, and CoQ10 is important in the function of our energy production in the mitochondria. Replacement does appear to have beneficial effects. One independent observation as I see patients in my office all the time with a balance disorder that we can attribute to a medication being used for their high cholesterol, and a class of medications HMG-CoA reductase inhibitors, such as the statin drugs, are notorious for depleting the body's natural production of CoQ10. So, replacement of that in patients has helped with balance preservation, and anything that helps balance preservation we can assume is also working in other areas of the inner ear as well. There are a number of elements and compounds that we discussed. We put together in 2006 a group of compounds we thought were going to be important that included the resveratrol, the N-acetylcysteine, N-acetyl-carnitine, alpha lipoic acid, green tea extracts, flavonoids from citrus, the CoQ10, B complex, and the trace minerals such as selenium, manganese, magnesium, and have found that to be effective in some pilot studies that we have performed on patients with their hearing loss showing some actual improvement in their hearing using the compound versus not using the compounds. We've not had the opportunity yet to complete a double blinded study at this time, but there is certain promise with this. I think the holy grail is a compound that would be able to be taken on a daily basis that would offer protective benefits to the whole body, not just the inner ear. Gazella: Right, and when you're talking about protection, you're even talking about protection in a patient that has some hearing loss; that it can also work in that patient population. Albritton: Yes. In fact, our pilot study really only targeted patients with hearing loss. We compared patients that had many years of hearing loss, and we had multiple hearing tests on them and then started therapy with them and measured several hearing tests on the medication, were able to compare their hearing test pre and post, and were able to make those comparisons based on a preexisting condition. And so we did see some improvements in patients with existing hearing loss. Gazella: What about reversal? Is that on the radar or is that a little bit too pie in the sky to actually reverse damage, to have a hearing be regained? Albritton: There's research being done in terms of hair cell regeneration. That's several decades away at best. That, if it does prove possible, would reverse it. Now, in terms of nutritional therapy, that's an unknown. We don't have the data yet to determine that. I think it is promising that we can see improvements in cognitive function with hearing aids and with Cochlear implants, but we can't know that by correcting some of the metabolic issues or protecting the interior from damage from its own physiologic stressors or noise exposures whether that's going to actually reverse the hearing loss that has occurred. I think that's probably pretty hopeful on our parts, but never rule anything out. Gazella: Yeah. Yeah, that's for sure. Now, given how common hearing loss is, it's likely that the readers of our journal have patients in their practice who are at risk. So, in addition to the nutrients that you mentioned, what else should doctors be recommending to their patients to help protect hearing? Albritton: I think first and foremost is recognize how common of a condition this is and screen for it. Ask patients, "Have you had any problems hearing? Has your spouse indicated that you may be having trouble hearing you?" It's interesting that spouses tend to be the ones that send patients for hearing tests more often than the patient seeks testing on their own. And it's a known fact that only one in five patients with hearing loss is going to seek help for it on their own typically. It can take 10 years or so before patients seek help for the symptoms. So, it can lay dormant, it can be hiding and be attributed to mumbling or volume not being turned up loud enough before a patient truly begins to embrace there may be a problem they need to evaluate. Refer patients for hearing tests if there is a presumed hearing loss or if there's a family history of hearing loss. Any patient that is on those medications, chemotherapy drugs, certain types of antibiotics, those patients should be monitored. One other thing that I think is very important and I think most practitioners are very good about doing, but let's remind them that noise exposure can be prevented. If you can't prevent the noise exposure, then protect yourself from it and that people that have hobbies or occupational risks should be wearing some degree of hearing protection, and just like smoking cessation's important for us to counsel, the use and adoption of protective devices should be something we continually discuss at our meetings with these patients. Gazella: Yeah, it's such a good point that you bring up that one in five seek help on their own and a lot just kind of let it go, let it go, and yet early detection, the earlier it's caught, the better off they'll be. So, I'm so glad that we're putting this on the radar of the doctors who are reading our journal. This has been very interesting, and I really appreciate you for joining me today. Albritton: Well, thank you. It's been a pleasure. Gazella: Have a great day. Albritton: You as well.

Beverly Hills Facial Plastic Surgeon Dr. Jason Diamond shares his expertise on celebrity facelifts. What is the trend for 2015? We also discuss the misconceptions of removing fat under the chin.  Plastic Surgery is main stream and many people are getting facelifts younger and younger. But not all facelifts are alike and not one technique works on all patients.  Patients have many misconceptions today about plastic surgery procedures, it is an easy sell. What's most important is that they have an understanding of the procedure what it can and cannot accomplish. Celebrities and models  earn a living with their looks, there is no room for error, yet we all have seen some disastrous plastic surgery results. Dr. Diamond talks about his different facelift techniques and what is the new 2015 lift.  We also discuss misconceptions about fat and some of the common problems people have after procedures such Kybella, Thermage and other skin tightening devices used in the neck area. Eliminating fat will make you have a facelift sooner, according to Dr Diamond. The area under the chin and neck is a misunderstood area.  A common problem he sees after liposuction,Thermage or Ulthera is that the patient's necks is more wrinkled and creppy.  Most people with aging faces do not have any excess fat. Consumers need to be very careful about these treatments.   Dr. Diamond is dual Board Certified by the Academy of Facial Plastic and Reconstructive Surgery and by the American Board of Otolaryngology – Head & Neck Surgery.  Dr. Diamond was recognized at the 2008 Aesthetics Show as “Best Facial Plastic Surgeon” and honored with “The Best Facial Plastic Surgeon Award” by his peers and colleagues. Dr. Diamond has been the featured facial plastic surgeon on E! Entertainment's “Dr. 90210” for the last seven consecutive years and is used as a plastic surgery resource for such media as the Discovery Health Channel and Entertainment Tonight and publications such as Harper's Bazaar Magazine, Life & Style Magazine, and People Magazine. www.jasonbdiamond.com * pls note this episode had some challenging technical problems, my apologies  in advance.