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Bill Prentice: 0:37
Hello, and welcome to the Advancing Surgical Care Podcast. My name is Bill Prentice, and I’m the CEO of the Ambulatory Surgery Center Association, or ASCA. On this episode of the ASC podcast, I’m pleased to welcome Dr. Jessica Lee, a surgical specialist in outpatient surgeries of the ear, nose and throat. Dr. Lee is a graduate of Mississippi State University and the University of Mississippi Medical School. She completed her internship and residency at the Medical University of South Carolina and received her board certification in otolaryngology, the study and treatment of diseases and ailments of the head and neck. Since many listeners may not be familiar with that precise medical term, otolaryngology, we might also say the Dr. Lee is an ear, nose and throat, or ENT, surgeon. Dr. Lee practices at the Surgery Center of Charleston in Charleston, South Carolina, and her special interests include lifestyle changes and integrative approaches to common chronic ENT issues. Dr. Lee, welcome to the ASC podcast.
Jessica Lee: 1:35
Thank you for having me. It’s a pleasure to be on with you.
Bill Prentice: 1:38
The pleasure is all ours, Jessica. If you don’t mind, it’d be helpful for some of our listeners to start by learning why a surgeon with your education and training needs to be a specialist in what are essentially three different and distinct parts of the head and neck.
Jessica Lee: 1:50
The three parts, of course, I believe you’re referring to being ear, nose and throat, and it’s actually a pretty interesting history. If you go back into really ancient history—Egyptian, Roman, Byzantine Empires—ENT complaints were always there, but it really wasn’t until through the Enlightenment when people learned more about things, we learned more about what these disease processes are. Really, otology was the first field to really develop. They were able to have procedures that were simple enough that they could do them without any really special instrumentation, and they were fairly effective for treatment of whatever ailments they were treating. In the late 19th century, otology, which was primarily a surgical specialty at that time, really started to merge with the field of laryngology, which would be the throat. And then those were mostly medical physicians who were doing treatments with their patients, usually, at that time, mostly sort of homeopathic things since, of course, antibiotics weren’t even around yet. So, otology and laryngology were really the first things to kind of fuse, and that was the mainstay of ENT at that time. The little bit that could be done in the nose was really pretty minimal. Rhinology, or the part around the nose, really didn’t develop until the mid-20th century, and a lot of that had to do with better understanding of our immune system, since we think of the nose and sinuses very closely linked to allergies and things like that. As a specialty, ENT formed its own society really around 1900, and I think that it’s an interesting story because actually it used to be ears, eyes, nose and throat, and it was like that until the 1970s when the ophthalmologists essentially broke off and made their own society. So, I still have older patients who remember when we were ears, eyes, nose and throat physicians. But these days, it’s just the ears, the nose and the throat that have seemed to merge to form this specialty.
Bill Prentice: 3:53
That’s fascinating—I didn’t realize that at one point eyes were part of the same kind of cohort. Well, as I mentioned in your introduction, you primarily practice in an outpatient surgery center setting. And I know that not very long ago, many of the surgeries and procedures involving the ears, nose and throat required a hospital stay, and of course some still do. That said, can you comment on the advances in surgical technique and anesthesia that have not only enabled outpatient ENT surgeries, but have also made it a preferential way for patients to get care?
Jessica Lee: 4:24
I’ll start with advances on the surgical side of things and, as we kind of have already mentioned, a lot of the advances in our field really did come in the 20th century, and it had a lot to do with advancements in technology. I mean, it’s easy for a physician to go in and visualize someone’s abdomen and percuss their abdomen and feel and listen with a stethoscope, and you can’t really do that well with the ears and the nose and the throat. And so traditionally, all we had was the head mirror. So you see old-timey representations of physicians and they had the band around their head with the circular mirror with a little tiny hole in the middle. And that was all we had to look in these orifices, if you will. Well, in the 1950s, we really saw this boom in technology; I think a lot of it was post-World War II manufacturing capabilities. And so we have the first binocular microscope, for instance, from Zeiss. Then you have development of fiber-optic light sources, which enable endoscopy. Prior to that, if someone wanted to look at their throat, you had to sedate the patient to be able to use the instruments that they had at that time to get a view of the vocal cords, for instance. And after the development of these types of technologies in the mid-1900s, now I can see a patient in-clinic and use a very tiny instrument to look at their vocal cords or look at their nasal passages or even look in their ear and be able to see a lot more, and so that translates into the surgical field as well. You know, you go from surgeries back in the 1800s that required major facial incisions and taking off of some of the anterior facial bones to be able to access a posterior sinus tumor, and nowadays it’s all done endoscopically. So no external incisions—I tell patients, you’re not even going to look like you had surgery. But you can basically go through the nose with these endoscopes and get access to these spaces that we didn’t have access to before. We see that also in some of the advances in laryngology, where we have use of endoscopes, microscopes and then laser technology. Again, there are a lot of specialists who are actually doing laryngology procedures in-clinic even, not even having to take patients to the operating room. So, we’ve seen a really dramatic change from inpatient surgery with large incisions, high morbidity, high mortality, now moving into more endoscopic, minimally invasive surgeries with the assistance of this technology. And of course, with that comes, for instance, outpatient settings, less morbidity, faster recovery.
Bill Prentice: 7:06
That’s great. I have some more questions to ask you, Jessica, but we’re going to take a brief pause here to hear a message from our podcast sponsor. We’ll be back in just a moment.
This episode of the Advancing Surgical Care Podcast is brought to you by Somnia Anesthesia, a national perioperative anesthesia management company, bringing advanced anesthesia and pain management techniques to surgery centers for 27 years. Somnia’s anesthesiologists and nurse anesthetists integrate fully with ASC clinical teams to deliver safe, high-quality care. Learn how they do it at somniainc.com.
Bill Prentice: 7:47
Before the break, we were talking about some of the medical advances that have enabled outpatient surgeries and allowed patients to recover in the comfort of their own home. Another important advancement that is of considerable interest to most patients is obviously postoperative pain management. Recognizing that different procedures will have different outcomes in terms of recovery, can you talk about how postoperative pain management has evolved in your field, and what most patients can expect following an outpatient ear, nose or throat procedure?
Jessica Lee: 8:16
Many of our surgeries don’t require a whole lot of postoperative pain medication. And I think that links back to what we talked about how a lot of these are endoscopic and they’re minimally invasive, so they’re just not as painful as they used to be. I think one of the big exceptions that people usually think of when they think of an ENT is tonsillectomy. And unfortunately, even the technologic advances from the instruments we use haven’t been able to really change that postoperative pain trajectory. I think the big thing that we’ve been focusing on is making sure that we are adequately managing pain without overmedicating patients. So, for instance, some of you may remember a couple of decades ago when codeine became really this hot topic, especially with kids. What was happening with that is a tonsillectomy is a painful surgery, and kids were getting Tylenol with codeine for their postoperative pain management. What wasn’t known at that time is that some children are what we consider ultra-metabolizers of codeine. Codeine is essentially an inactive form, and it has to be metabolized in your liver to morphine, which is the active analgesic. But unfortunately, in these kids, they were such rapid metabolizers that even with a normal weight-based dose that was appropriate for their age, their morphine levels would skyrocket very quickly. And of course, a side effect of that is sedation and respiratory depression. You combine that with a child who’s had a tonsillectomy where we also consider respiratory depression as a possible postoperative concern, and so now we’ve got two factors kind of playing into the same postoperative complication. And unfortunately, that combination was very serious and, in some cases, lethal. So, as probably most people know now, we don’t do Tylenol with codeine at all, and we really don’t do opioids at all anymore for young kids because of the same concerns. I think the other thing that we’ve done recently in our national society is catching up our prescribing practices with guidelines about opioid prescriptions. So again, always wanting to take into consideration that we are treating pain adequately but not overprescribing. And, for instance, in our surgery center, I just did a review of our standard postop medications and our entire group really agrees to decrease the amount of opioids we are giving out in order to try to help with some of the unintended side effects, whether it be excess opioid use or opioids that are being given to family members or friends who may have trouble with addiction or something like that. So, we really work hard to focus on our surgeries that are painful and control the pain as well as possible, without putting patients in a potentially dangerous or compromising position.
Bill Prentice: 11:12
That’s really interesting to hear because we obviously know over the last decade all we’ve learned about opioid addiction, and it’s fascinating to hear the things that you and your colleagues are doing to try and address that while still obviously making sure that patients get the care they need with as little discomfort as possible. Jessica, I’m also told that over the course of your career, you’ve been called on to extract some unusual objects from children’s ears and noses. Do you have a story or two you can share with us about that?
Jessica Lee: 11:37
Sure, there are always stories like this in our world. It’s kind of one of the fun parts to trade stories with colleagues. But I’d say the most memorable was in my residency. We had a young girl, she must have been five or six years old, who had presented with sinus infections and nosebleeds, and no one could really figure it out. And ultimately, before she was sent to us, someone had decided to do a scan. And when they did a scan of her head, there was a foreign body in her nose. And when we took her to the operating room, it was a safety pin. Problem was that safety pin had actually been in there for probably at least a year, if not longer.
Bill Prentice: 12:20
Oh, my goodness.
Jessica Lee: 12:20
And it had gotten very corroded. And it had opened somehow to where, if you can imagine an open safety pin, and the sharp edge was facing the nostril opening. So, you couldn’t just reach in and pull it out because it would just dig it deeper into the tissues. The second complication we ran into, or problem, is that in order to take it out, we were going to have to take it out in pieces, so we had to cut the wire. So, now we’re trying to find a wire cutter that’s strong enough to cut it, but small enough to fit in a five-year-old’s nostril. I remember there being a lot of trial and error. Let’s try that instrument. Nope, not strong enough. Let’s try this one. Nope, not big enough or small enough. So ultimately, we were able to cut it into a couple of pieces and take it out that way. But that was definitely the most memorable. In fact, if I remember right, I think one of those TV news stations, like Inside Edition or something, actually came and filmed it, like did a story on it.
Bill Prentice: 13:20
That makes me feel uncomfortable just hearing that. Well, we have time for one more question. As I mentioned in my introduction, you indicated to us that you have a special interest in promoting lifestyle changes and integrative approaches to common chronic ENT issues. Can you tell us a little bit about those?
Jessica Lee: 13:37
My interest in that area is really because there are still areas of our specialty that we unfortunately maybe haven’t made as much progress on as we’d like to. I mentioned before all of the major advances, really especially in the past 50 years or so. But things like degenerative changes with aging for otology, so sensory neural hearing loss and tinnitus in older patients, or inflammation and immune system dysregulation in the sinuses that we can’t get under control with pharmaceuticals or surgery. These are the kinds of things that I think are interesting because I think it’s going to be the next frontier for our specialty. I’ve done some additional training and lifestyle medicine, and when you really start to dig deep at nutrition, sleep, physical activity, avoidance of risky behaviors, like tobacco smoking or heavy alcohol use, it really is amazing the changes that you can see. I have a very anecdotal story of a patient who has had decades and multiple sinus surgeries and many issues with her sinuses. And by kind of coincidence, she started working with a bariatric program in town who basically put her on a carb-restricted diet. So, she cut out pretty much every simple sugar and really only had complex carbs through vegetables and fruits and things. And her sinuses—I had her signed up for surgery and she came in and she said, “I feel so much better, can we do a scan and check.” Her sinuses had completely cleared up simply by her drastically changing her diet. And she’s done well ever since; it’s been about a year and a half since she made that change. And that was just like a light bulb for me. So, I really, I hope to be able to continue to incorporate that when I’m seeing patients. I think it also has really interesting applications in the perioperative world because when you look at preoperative nutrition being important to prepare patients for the stress of surgery, or you look at same-day anxiety and how that may affect the body’s response to anesthesia, there are a lot of little ways we can intervene that can be very helpful. One of the things our surgery center has done in the past couple of years is we partner with a child life specialist who comes in especially with the kids and works with them and stays with them before surgery. And I think it’s not only helpful for the kids’ levels of anxiety, but the parents are much more calm. And that then also helps the kids when they see their parents are calm. And so, I think it’s a really cool way to use what I would think of as kind of an integrative approach and a multidisciplinary approach, even in that perioperative time, to try to improve patient experiences and outcomes.
Bill Prentice: 16:25
Well, that’s fascinating, and it’s so interesting to hear of a surgeon thinking about things in that kind of integrated way, as not just like, “oh, there’s a problem in front of me I have to fix” but that there are things that can be done to try and prevent that patient from having to end up in your OR. So, that’s really interesting. Well, Jessica, this has been a really interesting conversation and I very much appreciate you spending a few minutes with us, and I hope that we can have you on the podcast again sometime soon.
Jessica Lee: 16:53
Well, thank you so much. I enjoyed it and I appreciate it.
Bill Prentice: 16:56
Before closing this podcast, I would like again to acknowledge the support of our ASCA affiliate Somnia Anesthesia, a national anesthesia management company bringing advanced anesthesia and pain management techniques to surgery centers for over 27 years. Learn more at somniainc.com. So, until next time, thanks for listening and please continue to follow your local public health guidance.