BackTable / ENT / Podcast / Episode #72
The Future of Otolaryngology is in the Office
with Dr. Madan Kandula
In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Mandan Kandula, founder of ADVENT, an ENT private medical practice, about embracing in-office procedures and building an efficient ENT private practice.
BackTable, LLC (Producer). (2022, October 4). Ep. 72 – The Future of Otolaryngology is in the Office [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Madan Kandula
Dr. Madan Kandula is a practicing ENT and the founder and CEO at ADVENT in Milwaukee, WIsconsin.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
First, Dr. Kandula talks about his journey to becoming a private practice ENT doctor. He became a proponent of office-based treatments when he opened up his solo private practice and has carried this approach into his expansion of ADVENT. Another approach he takes in his medical practice is simplifying all airway problems to identify the defect in the “breathing triangle”, a term he coined for the nose and throat. In order to identify the airway problem in patients, Dr. Kandula emphasizes the importance of defining a healthy airway, which he defines as normal anatomy and lining. Additionally, he notes that ENTs must assess the nose, throat, and sinuses together before choosing a treatment plan for the patient.
Another approach he takes in his medical practice is training nurse practitioners and physician assistants to deal with purely medical ENT matters, such as triage, intake, histories, and physicals. He even trains his NPs and PAs to perform scope examinations and to administer local anesthetic. Dr. Kandula prefers to free up time for his ENT surgeons to have extended conversations with patients and operate in the office or in the OR. However, he emphasizes the importance of having well-trained NPs and PAs. He also outsources sleep study reads to be more efficient.
The doctors then discuss treatments for obstructive sleep apnea. Dr. Kandula usually sees OSA patients who have already tried non-surgical options, such as nasal rinses and sprays. For OSA that is caused by an anatomical issue, he notes that turbinate hypertrophy is the most common cause. For these cases, he will perform a thorough turbinate reduction. He also obtains CT imaging to view the sinuses in order to assess if they are affecting airway patency.
Finally, Dr. Kandula speaks about challenges with insurance with regards to in-office procedures. His office usually takes the lead in dealing with insurance authorizations and repealing insurance denials. He explains that it is more difficult for academic ENTs to change to in-office procedures. Another challenge that doctors might face is the high cost of in-office equipment. He recommends working with industry and getting loans to help offset the financial burden of medical technology.
[Madan Kandula MD]
Well, the breathing triangle is a term that I had to coin for the nose and throat. I think most people know what an ENT is and you hear that terminology and obviously, we're in the field, so we know, even a layperson knows that. But when you break out the nose and throat as an isolated unit, nobody knows what you're talking about. The breathing triangle is the nose and throat. What does that mean? You have three passages that you can breathe through, and if those are working properly, your life is going to be as good as it can be; and if any of those areas are working improperly, your life will be impacted. That's the breathing triangle.
It’s a very, very simple concept. As a specific example, folks who have obstructive sleep apnea, they have a breathing triangle issue, meaning they have a throat issue 100% of the time. I'd venture to say probably 99.9% of the time, they never have an ENT that's in their care. That's not helping them. It doesn't help folks who have sleep apnea to have pulmonologists and neurologists and psychologists trying to manage the throat issue.
Basically, the breathing triangle is a concept that I felt like I needed to create as a category because nothing really existed, and those areas are absolutely intertwined. If somebody has sleep apnea, like I said, they've got a throat issue 100% of the time. They almost always have nose and sinus issues that are interrelated. They may not know about it. That may be something they've had their whole life. How are they supposed to know that it's not normal to have to breathe through your mouth when you're sleeping at night? That's not normal. Anyway, we do a lot of education for our patients in the community, just trying to let people know that you don't have to live a compromised life.
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