BackTable / ENT / Podcast / Transcript #21

Podcast Transcript: Airway Surgery: What's in Your Toolbox?

with Dr. Laura Matrka, Dr. Mark Gerber and Dr. Romaine Johnson

We talk with Laura Matrka MD and Mark Gerber MD about their approaches to airway surgery, including endoscopic vs open, tips on technique, and the importance of communication in the OR. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Journey to Airway Surgery

(2) Follow Up on Young Airway Surgery Patients

(3) Airway Surgery Tips for Young Fellows

(4) When to Pursue Surgery in the Adult Patient

(5) Airway Toolbox

(6) Suture Selection

(7) Otolaryngology Mentors

(8) Pearls for Pursuing an Open Airway Reconstruction

(9) Technology Improvements in Otolaryngology

(10) Effective Communication in the Operating Room

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Airway Surgery: What's in Your Toolbox? with Dr. Laura Matrka, Dr. Mark Gerber and Dr. Romaine Johnson on the BackTable ENT Podcast)
Ep 21 Airway Surgery: What's in Your Toolbox? with Dr. Laura Matrka, Dr. Mark Gerber and Dr. Romaine Johnson
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[Gopi Shah MD]
We have a very special podcast today on pediatric airway. What's in your toolbox? What's your philosophy? My co-host today is Dr. Romaine Johnson, associate professor and director of Pediatric Airway Program at UT Southwestern in Dallas. He truly is a renaissance man in our department when it comes to research, QI, just making things better and doing the right thing. You may remember him from Episode 5, Pediatric Tracheostomy: The Long Game, as well as Episode 14, Quality and Safety in Pediatric ENT Panel Discussion. Welcome to the show, Romaine.

[Romaine Johnson MD]
Thank you so much for having me. And let me just say, we're also going to talk about adult airways too.

[Gopi Shah MD]
Awesome. Which brings us to how excited we are for this all star panel. It's going to be a lot of fun and interesting because we have Dr. Laura Matrka, a laryngologist, and Dr. Mark Gerber, a pediatric otolaryngologist. Dr. Matrka is an associate professor in the Department of Otolaryngology-Head, Neck Surgery at The Ohio State University Medical Center in Columbus. She obtained her medical degree from the University of Cincinnati, College of Medicine. She completed her residency in otolaryngology at The Ohio State and she went on to do fellowship in laryngology under Dr. Blake Simpson at the University of Texas, San Antonio. Welcome to the show, Dr. Matrka.

[Laura Matrka MD]
Thank you. You made me sound great. I loved it.

[Gopi Shah MD]
All right. And then we have Dr. Mark Gerber. He's a pediatric otolaryngologist with more than 20 years of experience in the medical and surgical management of complex airway, voice and swallowing disorders in children. He obtained his medical degree from Loyola Chicago Stritch School of Medicine and completed his residency in otolaryngology at the University of Cincinnati and his fellowship in pediatric otolaryngology at Children's Hospital Medical Center in Cincinnati. Dr. Gerber is the chief of pediatric otolaryngology at Phoenix Children's Hospital in Arizona and a clinical professor at the University of Arizona College of Medicine, Phoenix and Creighton University. Prior to that, he was a division head of Otolaryngology-Head, Neck Surgery at NorthShore University HealthSystem and a clinical associate professor of surgery at the University of Chicago Pritzker School of Medicine. Welcome to the show, Dr. Gerber.

[Mark Gerber MD]
Thank you. It's great to be here.

[Gopi Shah MD]
All right. Well, I'm going to go ahead and hand over the mic to my co-host, Dr. Johnson, and let you lead the way.

[Romaine Johnson MD]
Thank you so much. Wow, an incredible resume for the two panelists. I know Dr. Matrka well. We are both on the outreach community for the American Broncho-Esophagological Association. We're also members of the American Laryngological Association. And of course, I do know Dr. Gerber very well. We are both Cincinnati fellows, what they commonly call Cottonoids. And so, I've known Mark since I was a fellow in 2004 to 2006. If I remember correctly, Dr. Gerber, didn't you graduate the same year as Dana?

[Mark Gerber MD]
No. Dana took my desk.

[Romaine Johnson MD]
Okay. So, very good and so great.

[Gopi Shah MD]
And Prashant Malhotra. We did residency together.

[Romaine Johnson MD]
It's a small world. And of course, everybody knows Dr. Blake Simpson, who is hilarious and such a great conversationalist and mentor.

[Gopi Shah MD]
Great mentor and great guy.

(1) Journey to Airway Surgery

[Romaine Johnson MD]
So, tell us a little bit about your stories. Maybe Dr. Matrka, we could start with you, how did you get to where you are? And then, maybe talk a little bit about what drew you to become an airway doctor?

[Laura Matrka MD]
Yeah. So, I got into ENT, I mean, it was almost pure chance, good, good chance, but then once I was an ENT resident, I think like so many people, I ended up in laryngology just because my mentor was a laryngologist. And really, I struggled between head and neck and laryngology, and so I guess, once I settled on laryngology, it probably made sense that with the pull toward head and neck, that airway attracted me. Really, Blake Simpson is probably who most made me just really excited about airway stuff, mostly endoscopic, and then as my career has gone on more and more open approaches and... Yeah, it's a nice balance I think. Sometimes, in laryngology, we feel like plastic surgeons of the voice, and it can feel a little fluffy. So, I love the airway side of my practice to balance it out. Yeah, very, very happy though with an airway practice and very doable, I think, despite what it might sound like.

[Romaine Johnson MD]
What about you, Mark?

[Mark Gerber MD]
So, I got lucky. I mean, I think every step through training, through life, doors open, doors close. After medical school in Chicago, I got lucky enough to land my residency in Cincinnati. What I didn't know as a young person is the breadth of the pediatric otolaryngology program in Cincinnati, and having the opportunity to be a young resident under Robin Cotton and his crew was just a phenomenal opportunity. Unlike Dr. Matrka, I had zero interest. I love to do surgeries for head and neck, but I just could not relate to the head and neck cancer patient, and I very easily drew myself into pediatrics. If those that know me, they know I am still just a big old child with gray hair. So, I easily slid into the idea of pediatric otolaryngology in the airway with the huge number of cases that I saw. I'm a slow learner. I was the last of the two years of general surgery along with my four years of ENT residency, so I was in Cincinnati for eight years. That and then the additional two years of the fellowship. By the time I left, I felt like a very comfortable airway surgeon. Unlike adult laryngology, the voice side of pediatric airway, we're still neophytes, we're still learning how to figure out how to manage the voice. So while I was training, it was all about airway, and the voice was secondary. Now, we're working on preserving voice at the same time as fixing the airways. We're thinking about it upfront, it's just a fascinating time to be a pediatric airway surgeon. I'm loving this.

(2) Follow Up on Young Airway Surgery Patients

[Romaine Johnson MD]
Very good. Let's talk about that voice pediatrics because obviously, I'm an airway physician too and do a lot of pediatric open reconstruction. And also, I have a voice clinic, so I see a lot of the consequences of long-standing voice problems in the former preemie. I'm curious with Dr. Matrka, do you see that 18 to 25-year-old who had surgery from Dr. Cotton and Dr. Gerber back in the 90s and the early 2000s and you're like, oh, yeah. Do you see those kind of patients? And what's your experience on the back end?

[Laura Matrka MD]
Yeah. No, you guys managed it all fine. We don't ever see them.

[Romaine Johnson MD]
Thank you.

[Laura Matrka MD]
Yeah, that's it.

[Romaine Johnson MD]
Especially the ones coming from Dallas.

[Mark Gerber MD]
I love those lines.

[Laura Matrka MD]
In truth, we actually don't see it that often though. And I think, some of it is that patients learn to adjust and live with it. And I've had a few patients like that who've come through, and it's interesting because just as often, they come through for something unrelated and you go, "Okay. Are we also going to be checking into your voice too?" And they'll say, "Oh, that's just me." We'll dig a little bit and they will say, "Yeah, I had surgery years ago and it's fine. Don't worry about that part." Or occasionally, they'll be here for that. You do make a good point though because those situations are tough. There's not always much we can offer someone who's had a problem. Whatever the problem is, the more years it's gone on without being addressed, our hope for improving it goes down a little bit. I've had a few really long-standing vocal fold paralysis patients come through like that, and they certainly still get benefit from medialization and things like that, but it's not quite the same. So, doing it well upfront really is important. But in all seriousness, I truly think that you guys do pay close attention to that. And because of it, I don't think we see as much as we would or did 10, 20 years ago.

(3) Airway Surgery Tips for Young Fellows

[Romaine Johnson MD]
What are some of the things, Dr. Gerber, that if you see a new fellow coming up, first year fellow, what are the things that you know today about airway reconstruction in the pediatric airway that you want that fellow to learn as fast as possible so they'll be a better surgeon, a better airway physician?

[Mark Gerber MD]
Oh, that's a great question without an easy answer, right? I think there's a lot of tidbits that come with time and experience. I think the most important thing is knowing when to operate and being flexible in your approach. There's many times that... Now, in a leadership role back in a pediatrics world, I have a lot of opportunity to guide and mentor, and I see a lot of cases that come up for discussion that really the best answer is more time, patience. And so, I think part of it is knowing when to operate. Don't get overzealous. You'll know when the time's right. And then being flexible, not being stuck with blinders in your approach. I think those are two very important things.

[Gopi Shah MD]
You make a good point, Mark. I was Johnson's fellow so I was, I guess, a Johnsonoid of the group. When we do airway, I do primarily sinus. I mean, I feel comfortable with endoscopic, NICU/PICU babies, but I am not the main open airway surgeon. And I remember, as a fellow, I'd be like, "So, how do you know?" And Dr. Johnson always say, "Oh, it's the Gestalt." And he has this way he does when he says that because there's a little dance to it and I'm like, "I don't have the Gestalt. What do you mean by the Gestalt?" I think it's time, experience, then knowing when to operate will come and being open and flexible as part of that. So, I get it.

[Romaine Johnson MD]
Yeah. And I'm still trying to figure out the Gestalt, age, weight, airway reactivity, overall health of the patient. I have seen more and more over the years, where if you have a 2-year-old who undergoes a double-stage LTR, it fails dramatically, and then you take that same patient at four, you do a same operation and there's a revision, and they heal beautifully. And you're like, "It's that same surgery. Why did it... " And I think sometimes, it iss the body's capacity to heal is what you're stressing, and it can be difficult to know when that moment comes. Do you have the same struggles? I'm sure you do, Dr. Matrka, but please, just humor us with how you make those decisions? How do you decide in the adult world?

(4) When to Pursue Surgery in the Adult Patient

[Laura Matrka MD]
Yeah, well, for me, I think one thing that I've found difficult is that most patients who need an open airway reconstruction, the reason they need it is because they're sick, they got a million comorbidities, and it's almost like the nature of the need is going to dictate a terrible background and make them a bad candidate right off the bat. So, I started to realize that every candidate was not a good candidate, and you got to just start doing them. And even really sick patients, if you prepare thoroughly, they'll do okay. I've almost come to fear the young healthy patient more because a lot of times, they're in their situation because of it and inherent propensity towards scar that is maybe even harder to deal with it. I want to go back if I can to, I think, a question that you were asking about what do you want trainees to learn first, and what can you teach an intern that only experience can teach, and then what can you really teach them. At least in our world, it's all about setup. I just want them to know what instruments to ask for, and then they can learn how to use them later, but I always say to patients or other consultants that you don't really want me so much as you want my tools. And I think that's where we can do right by our trainees is just in helping them understand how to prepare for an airway case, or even just on your way into the hospital for an emergent airway, and the experience will come. And then of course, then you really get into with choosing who you're gonna operate on.

(5) Airway Toolbox

[Romaine Johnson MD]
That's one of the things with the toolbox, right? The airway toolbox. What are the things that you need when you're going to do an airway case consistently? What are some of the things that you all feel like that's got to be on the back-table every airway case no matter what?

[Laura Matrka MD]
I mean, for me, I did my whole Triologic thesis at answering this question. For me, I try to use the same setup for every difficult airway even if I'm not going to need some of the things just for consistency's sake. A good scope, a good subglottic scope, in my case, I love the extended length or that is called the Garrett extension of the Ossoff-Pilling scope. That's just an absolute go-to for me. You can ventilate through it there. I love it. When I get the chance, I try to have a resident expose someone with maybe a different scope, and when they can't we then they try again with the [Garrett extension of the Ossoff-Pilling scope] and just see what a difference a good scope makes. And then, I could go on answering this question forever so I want to make sure everyone else gets a chance.

[Mark Gerber MD]
I'm listening to Dr. Matrka saying I need to do a better job at teaching that. I'm a little bit like, you give me a butter knife, I will take care of the problem. So, I am not as much of a planner. I think that is an incredible point that I've just learned something. I'm not too old to learn something new. It just reminds me. Yes, if I have a trainee in my room and we're getting set up for a case, I am talking about the instruments and what I want up there in front of me as I prepare for the individual case, and I'm sort of looking around the room. If it's open, I'm less worried. If it's a endoscopic case, I'm much more attentive to the instrumentation, the appropriate size laryngoscope, the appropriate size telescopes, depending on the size of the child, whether or not I'm going to need a bronchoscope or a tracheal scope at times where just the opening is only at the distal end. Those things I'm very attentive to in endoscopic, and open, I worry about it a little bit less. When it's open, am I going to be wanting a drill to take care of a thick posterior cricoid plate if I'm doing a cricotracheal resection? Little things like that, and suture, if I'm doing a slight tracheoplasty. Those things are important.

(6) Suture Selection

[Romaine Johnson MD]
What suture do you guys like for the airway? I always go back and forth. Do you do the Prolene? Do you do PDS? Do you like vicryl? Do you think it matters, particularly for anastomoses type work?

[Mark Gerber MD]
Well, for me, I trained with prolene, prolene, prolene, and prolene, right? That was all that Cotton used. I'm now an older cottonoid, but it took me a long time to start to transition to using PDS. So, those that were trained by Dr. Rutter and company thereafter, that PDS use was natural. For me, it was unnatural, but I've made that switch. I'm doing a lot of slides, even my CTRs end up as a modified slide. So, I'm using PDS. For grafts, I'm still using my prolene, but for slides, I'm using PDS and the double armed, and I'm usually running it for quite a bit of it.

[Laura Matrka MD]
Yeah. I mean, one little pearl, I guess, is that I like to use prolenes. I use vicryls when I'm sewing the posterior wall, but for traction or stay sutures, I use Maxons. And the color, they switched over our whole hospital, whatever our supplier is, and now the colors are more similar, and that silly detail has made it harder. Some of it is just stuff like that. There's a lot of good materials, and it probably doesn't matter as much as we think it does. Maybe mucosal versus submucosal, or luminal versus not is a bigger question, but yeah, I don't like... My greens and my blues need to look a lot different.

[Romaine Johnson MD]
Talk more about the mucosal versus submucosal. That's a new emerging concept.

[Laura Matrka MD]
Yeah. I first started thinking about it when I was assisting a thoracic surgeon years ago and he said, "Everyone overthinks that. Don't worry about it. It's okay if it passes mucosally." But I disagree. I mean, I try hard not to have it pass mucosally unless I'm just really struggling with a case or a redo or something and because, I mean, I found, when I can see a little bit of color endoscopically afterwards, they're just simply more likely to get granulation tissue there. And it's true that sometimes it's not clinically significant or it doesn't lead to swelling, but sometimes it does. So yeah, I really do like to stay submucosal.

[Romaine Johnson MD]
Yeah, I tend to stay submucosal as well. I use PDS. I switched to PDS primarily because it has less dehiscence, and so I just... Maybe you guys never have a dehiscence, but if a prolene dehisces, you got to go out and you got to get it out. Where from PDS dehiscence, it eventually goes away. So, I'd take my poison, but I do think prolene is less reactive, and I think you have less granulation tissue when you use prolene suture than PDS suture. I think PDS is much more reactive. And sometimes I wonder, do I see more prolonged inflammation after surgery because I switched to PDS compared to when I used prolene many years ago, but I've decided to just stick with it because I think the margin of harm, if you will, is relatively low. You mentioned earlier, both of you mentioned mentors. So you mentioned Dr. Cotton, you mentioned Dr. Simpson, who are some of your other mentors? Or tell me how those two individuals helped you along the way and gave you a better feel for what it meant to be a good airway physician, a good laryngologist, a good pediatric otolaryngologist.

(7) Otolaryngology Mentors

[Mark Gerber MD]
So, I'll back up to the suture question for two seconds and just say it. So, I've switched over to the PDS for all the grafts, but what I've also done with my slides is started a horizontal mattress so that I get better eversion. And that, I think is the single biggest thing that has cut down on granulation. I didn't come up with it, but I've definitely been a utilizer of it, and I think it's a phenomenal technique that takes away the figure-of-eight if you're doing a congenital slide. And even for a mid-tracheal slide in an older person, that horizontal mattress change really gives me a nicer version, so I'm not getting that buildup into the airway. In terms of mentors, I don't know why, but I was a very young resident and Dr. Cotton was staying in a duplex while his house was being redone literally down the block from me, and I was a second year in general surgery, but I was on the ENT service, and he walks into my room and asked me where I'm living. And I'm like, all right. Well, I told him, and then about 10 o'clock at night, a couple of nights later, he had three Schnauzers at that time, and he knocks on my door and just comes in, says, "Hi." Just we sat down and just chatted for about an hour. I was like, "Thank God I was dressed." But my relationship with him only got better from there and really, as a mentor, and you can include Dr. Meyer] and Dr. Schott and all the folks that were there just, it really... Each one has done a lot for me in terms of teaching me how to be a better person, a better otolaryngologist and an airway surgeon, let alone becoming a dad and raising my family. I think that's what this, in some ways, is all about, is the training and the mentorship, and it continues through the organizations that we're a part of as we age. And now, getting to be the old man and having a bunch of children of my own in the practice that we're in, it's a ton of fun.

[Laura Matrka MD]
Yeah, I feel like I could talk about mentors. We could do a whole podcast on it. And one thing in our field, I think, is just how many different mentors I've had. I mean, even people I met just in fellowship interviews ended up becoming mentors because of the day or two I spent during the interview. And we're really lucky in both of our fields in laryngology. There's just so many people and it's so tight of a community, where in ENT in general, we're very lucky but... So Blake Simpson, of course, is my fellowship director and just good friend. I mean, I can't overstate his influence. Rick Forrest actually was one of the early Vanderbilt fellows, and he's still with us at Ohio State and still practices a little bit, but he was a huge mentor for me. And maybe exactly why I was struggling between head, neck in laryngology because he did a laryngology fellowship, and he also did one of the first free flap fellowships. So, he taught most of our current head and neck attendings how to do free flaps, then he went and started up a laryngology division… Oh, I mean, I've just been so lucky the whole way through. Not to mention even my current partners our whole practice. I was resident under many of them, and now as partners, just seeing how they treat their patients, not the clinical management but just how to be a doctor, how to be a good doctor to people.

(8) Pearls for Pursuing an Open Airway Reconstruction

[Romaine Johnson MD]
It is interesting that you mentioned the Triological Society. I think, all three of us are members. And of course, Dr. Shah was just nominated this year. She's got to write her thesis. I think Triological Society has been a great organization to find mentoring. Obviously, Dr. Cotton and Dr. Willging and Dr. Schott and everyone you could think of along the pediatric side and as well as on the adult laryngology side belongs to that society. So, I'm just gonna give a shout out to the Triol Society for anyone listening. You can do it, you can write your thesis, you can become a member, start working on it today, it'll pay off dividends in ways I can't even tell you. Anyway, let's get back to talking about surgery. Let's talk about the open airway. When do you do it? I know you have choices. You can do endoscopic, you can do open. Open is still sort of the game, if you will. It's how you define yourself as a surgeon I think, but obviously, it has more risks. And so I'm curious, what are some of the pearls in your decision-making seeing a patient, saying this is a good open reconstructive case, this is not a good open reconstructive case?

[Mark Gerber MD]
I think for me, it's always easier if there's a trach. I can be patient and wait and bide my time. When you have a child who doesn't have a trach, and who has undergone attempts of endoscopic management that fail, how do you define failure? Is it two or three? I've seen kids who show up having had a dozen endoscopic attempts, and that's too much. Where is that dividing line? And again, there is a Gestalt there, right? Because sometimes, it may be better that you put a trach in and wait and do that later, and other times, you turn away right there and set up for your open reconstruction. But I like to be able to study my kids. So, for the pediatric population, I want to be able to do a flex scope to see what's happening with the supraglottic and glottic dynamics, what's their feeding history. I want to make sure I study that so I'm not presuming anything. So, either a FEES or a videofluoroscopic study, I want to be able to do my endoscopic assessment with the kids asleep and include a BAL so I'm getting cultures. And then, this is the one time that I'm also pretty anal about managing reflux. And it's not reflux disease, I'm managing reflux and how it can affect the outcome of airway reconstruction for a child. So, I want all of those kids to have an EGD with biopsy. I want to make sure I'm not dealing with EoE. And for the kids that I'm able to, I want to do a voice analysis. So, all of those things are my perfect setup, and if all the stars line up, then I'm ready. Sometimes, I can't wait for the stars to line up and you're forced, right? If I start an endoscopy, and when I'm done with an endoscopy, I'm pretty much hands off. I'm not using a sheath bronchoscope when I'm looking at an airway, so I'm just putting in telescopes most of the time. And if I come out with a telescope and I already see effacement of the ventricular space, that's not really an airway I want to manipulate yet, right? So, all those things play a role. And then, the severity, the stenosis, one if the... Obviously, grade three stenosis or worse, if you're talking about subglottis or tracheal, right? If you have a significant effacement and symptomatic in a child that doesn't have a trach, then I think those are the ones you have to go after and choosing to do it open versus putting in a temporary trach. Now, since I've been in Arizona, and I've seen the population which I know, Romaine, you came into in getting to Texas is the decision-making on putting in a trach for these families. I've been pushed many times already to do that reconstruction because I have a family that just can't handle a tracheotomy, and so I'm taking added risk to avoid. And sometimes I win, and sometimes I lose, but I've done my best. That also plays a role in the decision-making process.

[Laura Matrka MD]
So, I'm trying to think of concepts that will span across pediatric and adult airway, both, and I think this maybe is one, but one problem that I've had in my own practice, and maybe I'm going to raise more questions and answer, but we see a lot of idiopathic subglottic stenosis patients. And I find that considering open approaches for them is the very hardest decision I have to make because at least in my mind, they have so much more to lose. And so I think that if you have a patient who's otherwise pretty healthy and functional and you can temporize with endoscopic approaches, and I mean in our population, that temporize might mean a couple of years even, but then you follow them 10 years, and now you've operated on them eight times and you go, "Is this okay?" It's such a personal decision in the adult group. So, that's one area that I struggle with a little bit. I feel like I might continue longer with endoscopic approaches even if they're needing them every couple of years just because they do so well with them. It's an outpatient surgery, and the patients themselves are hesitant to take that risk. As far as patients with or without a trach, I mean, I'd rather not put a trach in just for surgical ease. I find it much easier to do the case if I can do it based only on where that stenosis is and not have to worry about the trach positioning. But it is true. If you have a patient who's already trach-dependent, you sure have a lot less to lose in doing that open reconstruction. And then, just as Dr. Gerber said, there's absolutely patients who you're just so fearful of them being out in the world with a trach. You know they don't really understand it, and they don't have any kind of... All the teaching and education you do just isn't landing, and those are patients who were, yeah. I've operated on some when they still weren't as healthy as I wanted them to be, and we got them through it. Boy, it's a nuanced decision. It's not easy.

[Romaine Johnson MD]
Dr. Gerber mentioned earlier protocols. He had mentioned in children, I want to do a voice analysis, I want to get a swallow study, I want to do an EGD. Do you do the same thing in the adult world? I haven't heard of that sort of thinking? Is that something that's also done with adult airway reconstruction?

[Laura Matrka MD]
Yeah, to a degree, not maybe in the same way. Actually, believe it or not, when I was at Cincinnati as a student, I did a project on whether clearing kids for EoE before open airway reconstruction was financially solvent or not. And there's another mentor, Ravi Elluru, when he was with you guys. And so, we're not looking for EoE. I'm not doing voice analysis in men. Now in women where I think they might need a CTR, yes, I think that's very important. And maybe it's not even the analysis that's important so much as the counseling because they will get a deeper voice. And even men, you need to tell them that. Sometimes, they're a little alarmed by it, by how manly they sound. They usually like it though. So, the recent change in my practice is that more and more often, I'm doing formal pH probes in my patients first, especially if they have that, you talked about the ventricular effacement, if we're seeing a lot of signs of inflammation. I've had a few patients in my practice who were requiring recurrent endoscopic attempts, and in preparation for open, we went ahead. They ended up getting a Nissen because they had such significant reflux, and they stopped needing anything. I dilated them at the beginning of the case. The general surgeon came in, did the Nissen and they flew. So, I'm relying more and more heavily on that, but they are good protocols in our world.

[Romaine Johnson MD]
Do you use PFTs?

[Laura Matrka MD]
I use them really heavily. It's sort of a thing, a research interest of mine. But again, I don't know that others are. I mean, we stopped peak flow devices in my clinic. Our airway patients get... We used to keep a box with everyone's peak flow, and we pull out the individual patients. Now, we just give a new one every time but yeah, personally, I love peak flows, full PFTs when I can get them and peak flows every visit.

[Romaine Johnson MD]
So, Dr. Gerber, besides just making sure you don't injure the recurrent laryngeal nerve, do you think there are things you can do in particular to reduce the incidence of post-airway reconstruction dysphonia?

[Mark Gerber MD]
I think it's really choosing the right operation in a way, right? So, part of it is don't try to do a third rib graft when there is no good solid cartilage to attach that to because you're only going to get more scarring and collapse, and that's going to affect the voice quality. Minimize manipulation of the supraglottic tissue. So, I try to stay away from that cricoarytenoid joint unless I have to be there. I worry a lot about the extended cricotracheal resection. I tend to actually try to do it separate. So, if I've got a combined posterior glottic issue along with a severe stenosis distally, there are times I'll do an endoscopic posterior graft. Knowing I've not fixed the child, but I've just fixed the posterior glottic aspect and then go in later, open and do my CTR, that separates it. I know it's two operations. I've not written about it yet, but to me, I think that I've had good outcomes with it because I'm not trying to get all that healing going at once and all those forces that I think collapsed inward. So, minimizing manipulation of mucosal surfaces, being very cognizant of that cricoarytenoid area when you're doing an open reconstruction, and of course, the anterior commissure as well, right? So, it really depends on what you're starting with, but nothing makes me more upset at myself if I've started with a good looking glottic aperture, and then I end up with something that's worse following reconstruction because of unrecognized difficulties with the healing process, whether it's infection or inflammatory. The things we don't quite yet understand in terms of how these children heal. If we can only predict how the kids are going to heal just like adults. I get frightened of that adult. I still think rib grafts would work well in adults. I have some experience in adult rib grafts, but I think adults are much more difficult to predict how they're going to heal than some of the kids.

(9) Technology Improvements in Otolaryngology

[Romaine Johnson MD]
I agree. One of the questions I wanted to ask you guys was about tech and we sort of talked about it earlier, pediatric otolaryngology in general, we use a lot of great technology. And Dr. Matrka, you've mentioned that special scopes that you like, and Dr. Gerber, you said, "Well, I just give you a butter knife, and I'll get at the air way." Is there any other tech that you really enjoy, that makes your job much easier as you do your airway reconstructions or endoscopic open whatever? And is there any tech that you use but man you wish it was better, or just something else, if you had this idea, this piece of tech, it would make things so much better?

[Laura Matrka MD]
I can start with the latter question. You can't tell this on this podcast, but I'm about five feet tall, and I don't know if this is because of that or because I'm a woman, but the TNE scope is a big thing in our field that it's just not made for a small hand. And frankly, I don't think it's made for most people's noses either. It's just a little bit bigger than it needs to be, and it's not easy to manipulate, and people are really excited about it, but I've just gotten farther and farther away from it as time goes on instead of embracing it. This is my plea for someone out there in Olympus or Pentax to fix that scope and the ergonomics of the handpiece.

[Mark Gerber MD]
I think in 2021 post-COVID, the expense of some of this technology, right? It's not going away, it's not going to get cheaper, but yet our ability to afford it is affected by what's going on. I mean, pediatric otolaryngology has been affected probably more than just about any other field in terms of our OR volumes for the simple things that we do. The difficult cases are still there, but it's the simple things that actually fund what we do. Airway surgery is not something that we do expecting remuneration, but I think the difficulty I have as a leader, that is being able to justify the distal chip scopes, the video endoscopes, which I think are crucial, but it's new. I got a very young Children's Hospital that has a lot of fiberoptic scopes, and changing those over to better technology is very expensive. And in a world today where it's very difficult to justify huge expenses, I find that very difficult. I mean, we have a patient population that needs that, and it's not easy to get it, especially when they are treating non-lumen scopes, like a scope with a lumen in terms of the cleaning needs when you're at a major Children's Hospital. So, all those forces together make it a very difficult time. So, that's my wish for technology is somehow make it less expensive so that we can bring that technology down to the kids that need it.

[Romaine Johnson MD]
That's an excellent point. Just to answer the question myself, the thing that... Maybe it was 10 years ago, 15 years ago, we were doing a surgery and there was a complication, and we got the patient through it, but I realized how difficult it is to see what the resident sees. And so for me, it's been a struggle. Some success, some failure to find a way to develop imaging. So, when the resident operates, I can see what they're seeing. And when they're scoping a patient in the ED or in the ICU that they able to give those images too. You not just describe but actually show me the images. There's tech, there's iPhone apps and things like that, but the images aren't great, but they're better, but that's one area where I hope to get really good, high fidelity, high def visualization of images that can be shared widely amongst a treating team so you can get rapid diagnosis like hey, I see this patient in the emergency room. Hey, let me look up and see what you saw. Like, no, no, no, that was clearly a papilloma, or the vocal cords aren't moving, but I don't know why we need to think about doing something else. So to me, that's the tech in terms of teaching and taking care of patients. Well, we're winding down a little bit. Do you guys have anything that you would like to just say?

(10) Effective Communication in the Operating Room

[Gopi Shah MD]
Can I just ask one last question? What's always stuck out to me about whether it's endoscopic or open airway is the importance of communication, and you both touched on that, whether it's discussing tracheostomy teaching to go set up this. I'll be in the hospital in five minutes. I know we have this airway foreign body. Please go, talk to the tech about getting the room set up. What do you guys think are effective ways to communicate as surgeons in the OR? I feel like the case starts with how we communicate. A part of our setup is how we communicate, what do you think are effective ways?

[Mark Gerber MD]
I think it's a great question. The barking that occurred 25 years ago just can't happen anymore, right? It's all has to be upfront, to the point. I'll be honest, and maybe I shouldn't be the one bringing it up as the white male, old man, I can say things differently than some of my younger colleagues that are not, and I find that incredibly frustrating as I counsel through when they get themselves in trouble with saying the exact same things I would have said. I think it is a huge challenge in today's world. And diversity and inclusion and growing that, and making people aware of what needs to happen to make a child safe, patient safe, that sometimes there's anxiety that gets into that conversation. So, being able to take your own pulse, to slow your breath and to effectively communicate is the best way to go about it even when you're stressed. One of the first things I try to teach is take your own pulse and breathe, and then communicate, and think about what you're going to say just for a sec even though it's hard to do that, and being proactive, right? The more you could think about it... Dr. Matrka, I can already tell you are thinking ahead, and that's a great thing. I will tell you that in my personality, I'm not as good at that, so I have to think about that when I have a trainee, right? So I have to stop myself, recognize I have a trainee with me because we don't have enough trainees where I'm at. It's always been a hit or miss so I have to stop and think, and then it's the communication also. As an airway surgeon, your anesthesiologist is your right arm. So, communicating upfront. And sometimes, when I have a friend, that's the anesthesiologist in the room with me, I may presume that they know what I'm thinking. And then it's like, "Oh, we were not on the same page." So backing up, thinking that through and communicating. And I think just stopping and breathing is a very important point, and I think that would get... A lot of the conversations I end up having probably wouldn't be needed if we just stopped and breathe. And we have a long, long way to go in terms of recognizing the roles of each of the people in the room and the importance of every single person in the room.

[Laura Matrka MD]
Yeah, I absolutely echo all of that. This is another area of interest. We published an airway communication protocol a few years ago that really speaks to the importance of finding your anesthesiologists before you go in the room and having an algorithm you go through with everyone there. And part of it is just especially, to address what you mentioned, one of my fellows told me that he used it, and I think it sort of proves my point, but part of it is that you need to be able to signal to everyone that you know what you're doing, and that you have a plan. And I think, when you go through some of these, use these protocols, I think what happens a lot of times is some of the heavy handed personalities in the room maybe go, "Oh gosh. I think she's thought about this whole lot more than I have. So maybe, I'll just step back a little bit." I've countered some of that myself, and I think it's helped so much to lay it all out there ahead of time and to know everyone's name so that if there is part of the protocol that I think is important is to say, to point to my scrub tech and say, "Hey Michelle, if we're not getting good chest rise, you're the one that needs to hand me that balloon dilator right away, and then I turn the circulator. And can you show me where it's sitting right now, where the balloon is sitting?" And that kind of thing is huge. I mean, I remember as a resident so many times, watching M&Ms, or I guess, as a medical student really, about codes that went poorly. And so many times, what it came down to was that the person running the code would ask for something. They identified the needs, but they wouldn't designate someone to do it. So, those little details end up being huge. You can do all the right things, make all the right decisions, stay calm. If you overlook some of those nuances in a really touchy airway situation, that can make or break it.

[Romaine Johnson MD]
That is a really good point about if you need help, you can't just say, "Somebody help me." You're more likely to get the help you need if you point to someone or designate someone, can you help me? That person is much more likely to help you. Anyway, that was an excellent comment, Dr. Shah. You could tell that she's a pro at this. And so anyway, we're winding down, and I just wanted to get to you all, last thoughts and pearls of wisdom as we round things up about the airway experience.

[Mark Gerber MD]
I don't know. This was a great experience for me. I hope that your listeners found it helpful. I take away something from all of these conversations. So, I appreciate and thank you for inviting me to join you.

[Romaine Johnson MD]
Thanks for coming.

[Laura Matrka MD]
Yeah. For me, I'm glad that Gopi ended it with the discussion about communication. I mean, that's probably my biggest pearl is. Preparing and thinking about positioning and using your paralytic and all those things are really important, but if you're working with an intern, you need to focus on what they can do well and expecting them to have the hands or to expose, not so much, but they can choose the right instruments to call for and to adjust it as you're getting more experienced residents and helping them to recognize who they really do need to worry about. I think one of the really important point to emphasize is Dr. Johnson, your point about being able to share technology and being better teachers, I don't think that can be overlooked. I used to work in a rural medicine setting, and I would use the kind of crappy fiberoptic scope they had there. And then sometimes, they had to come up to OSU and get strobe on my good tower, and I would change my own diagnosis. And it made me realize that we're expecting trainees to use this equipment when they don't even have the diagnostic skills, much less good equipment. And how on earth are they going to progress? How are they going to get any feedback if we're not looking at what they're looking at? I think that's a bigger issue and one that should be highlighted. And thank you again. This was great.

[Gopi Shah MD]
Dr. Johnson introduced an adapter to our iPhones that then go on the scopes, and that's been a game changer in terms of consults, whether it's our APPs to our resident, intern on call, for bedside laryngoscopy, bedside nasal endoscopy, for vocal cord evaluations after cardiac surgery to invasive fungal sinusitis in our immunocompromised patients, and that has been a huge game changer with us. I think, a simple modification for technology. So, it is a little case that you can put on the iPhone that has an adapter to your flexible scopes. And then, you can record it and then review it in slow mo, and it gives you a better idea in terms of do the chords work or not. I mean, I can't always tell, and I have to do the slow mo and I'm like, okay, I think that one side is weaker, whatnot. So, that's been definitely a great addition.

[Romaine Johnson MD]
So, one of the things I always talk about in my talks is about, when you're an otolaryngologist, the contributions you need to make or you should make, and one of the big contributions is community service. Dr. Gerber, Mark is part of the American Society of Pediatric Otolaryngology and the Quality and Safety committee. Laura is part of the ABEA's Community Outreach committee, and they're sharing their experiences with us. And for you and the audience, please consider joining these organizations, participating in these organizations so you can also make similar contributions. Thank you, Dr. Shah. I'm sorry.

[Gopi Shah MD]
No, thank you all for taking the time. It's great to meet everybody and learn from each other. Thank you to our listeners for tuning in. You can find us on Spotify, SoundCloud, Apple iHeartRadio. Please remember to rate, like and subscribe. You can find us on Instagram and Twitter at _backtableent. We love feedback, suggestions or if you want to come to the show. If you take anything from today's show, take a breath, check your pulse and make sure you know some names. Have a good day. It's a wrap.

Podcast Contributors

Dr. Laura Matrka discusses Airway Surgery: What's in Your Toolbox? on the BackTable 21 Podcast

Dr. Laura Matrka

Dr. Laura Matrka is an Assistant Professor of Otolaryngology at Ohio State University.

Dr. Mark Gerber discusses Airway Surgery: What's in Your Toolbox? on the BackTable 21 Podcast

Dr. Mark Gerber

Dr. Mark Gerber is Division Chief of Otolaryngology, Head and Neck Surgery at Phoenix Children's Hospital.

Dr. Romaine Johnson discusses Airway Surgery: What's in Your Toolbox? on the BackTable 21 Podcast

Dr. Romaine Johnson

Dr. Romaine Johnson is a practicing ENT and Associate Professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 27). Ep. 21 – Airway Surgery: What's in Your Toolbox? [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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