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Wayne B. Eisman, M.D., F.A.C.S.

W e l c o m e t o e N t & A l l e r g y A s s o c i A t e s “ m e d i c i N e f o r t h e 2 1 s t c e N t u r y ” . . . 2 0 1 1 e d i t i o N

ENT & Allergy is designed and published by Custom Medical Design Group • 1.800.246.1637 • www.CustomMedicalMagazine.com. To advertise in an upcoming issue please contact Dave Lewcon at 508.278.6521 • This publication may not be reproduced in part or whole without the express written consent of Custom Medical Design Group.Medical

In the pages that follow, we hope to once again provide you with clinically useful information that you can use in your practice now…and perhaps entertain you a little bit along the way.

We recognize that as primary caregivers, your skill, training and insight are the keys to better outcomes for your patients. And we, at ENT and Allergy Associates LLP, are gratified that you have

chosen to send so many of them to us for specialized care. You have our commitment that we will always strive to deliver the highest quality medical care to each and every one of those patients…with compassion, expertise and respect.

This past year, many positive and productive events have taken place at ENTA, and I’d like to share those that most directly benefit your patients.

In 2011, ENT and Allergy Associates has:• Continued to roll out our own customized EMR (electronic medical records) system to a total of 26 (of our 37) offices.

And we plan on completing all 37 offices by first quarter 2012.• Added three new ENTA offices on the East End of Long Island.• Added 12 new physicians to our family…for a current total of 125.• Renovated and/or relocated our Garden City, Gramercy Park, Edison, Poughkeepsie, Newburgh, Park Slope and

Lake Success offices…to provide an even greater number of state-of-the-art exam rooms and other facilities for patients’ benefits.

• Added sleep labs to our Wayne, Garden City and Staten Island offices.• Expanded our relationship with the Mount Sinai Medical Center–as part of our unique affiliation between community and

academic medicine-for the screening and treatment of Esophageal Cancer and HPV–derived Head and Neck Cancer.• Enhanced our clinical offerings by expanding our sub-specialty divisions in the fields of:

� Voice and Swallowing� Vestibular Disorders� Facial Plastics

These advancements, in turn, will not only allow us to serve the needs of your patients, but will also serve as an effective tool as we continue to recruit the most highly trained otolaryngologists, sub-specialists and allergists.

Beyond these accomplishments, I am extremely proud to announce that ENT and Allergy was honored this year by the American Cancer Society at its 3rd annual Hope Lodge “Magic of Hope Luncheon,” an event and celebration that brings together concerned and caring community members to raise funds for this fabulous facility located in Mid-town NYC.

In addition, the Practice was just named winner of the 2011 HealthLeaders Media Award in the category of medical practices.

In the pages that follow, you will find clinically valuable articles—contributed by our physicians—on topics ranging from Cochlear Implants, Approach to Pediatric ENT Office Patients, TransOral Robotic Surgery, Voice Restoration and Balloon Sinus Surgery.

As always, we would like to thank our many sponsors, whose participation has made it possible for us to provide you with this educational publication.

And most importantly, we want to once again thank all of you, our valued colleagues, for your continued partnership as we strive to serve our mutual patients with the finest medical care possible. Please feel free to e-mail me at [email protected] with any comments, questions or suggestions you might have about the magazine.

Best,

Wayne B. Eisman, M.D. President, ENT & Allergy Associates, LLP

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Sinusitis is one of the top diagnosis for which individuals in the U.S. seek medical attention. An estimated 18-22 million office visits for sinusitis occur

in the U.S. each year, representing eight billion dollars of healthcare costs. A significant portion of the U.S. healthcare resources and dollars, therefore, are devoted to the management of this disease. The efficient diagnosis and management of this disease can limit a significant amount of patient suffering and lighten the burden on healthcare expense.

Disease of the nose and sinus have long been treated as either a medical problem, subject to orals, sprays and topical agents or as a surgical problem, pliable to cutting and reshaping of the nasal and sinus structure. This approach was guilded in an era before the modern understanding of the nature of sinus function and physiology had begun to unravel. The currently available treatment of sinusitis, recognizing the vast number of medical and surgical advances, is no longer as black or white.

The treatment of sinusitis complaints can be divided into those addressing acute symptoms versus chronic sinus symptoms. A vast majority of the acute episodes can be traced back to an acute viral or bacterial infectious etiology. For these uncomplicated cases, the therapy mainly consists of decongestants, nasal irrigation and therapeutics for symptomatic relief. When infections progress to a chronic condition, it is frequently a complex interplay of allergic, bacterial, fungal, autoimmune and obstructive components. The initial approach still remains a medical plan consisting of antibiotics, antifungals, anti-inflammatories and targeted irrigations, but a sinus intervention may be necessary to accelerate resolution.

When a maximum medical approach fails to resolve the disease course, the modification of the sinus mileua utilizing surgical procedures may be necessary. Surgical interventions for sinusitis historically began as a directed intervention to the acute complications of sinus disease. The early destructive techniques of externally opening the sinus slowly gave

t h e N e x t e v o l u t i o N i N t h e t r e A t m e N t o f s i N u s i t i s

D a n i e l R . G o l d , M . D .O t o l a r y n g o l o g y & H e a d a n d N e c k S u r g e r y

E N T a n d A l l e r g y A s s o c i a t e s , L L P

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way to the more directed and less invasive techniques of modern endoscopic sinus surgery. The use of endoscopes allowed direct visualization of the sinus drainage pathways and the lesions obstructing their proper drainage and health. This has now progressed to the development of even more selective sinus instruments such as the sinus tissue debrieder, sinus stents and most recently, sinus canulization and balloon dilation.

The ideal surgical intervention for sinus disease would selectively open the afflicted sinus ostium, clear out the inspisated mucus and restore function without injuring the fragile respiratory mucosa lining the sinus cavity. All of this must be accomplished with limited morbidity and inconvenience to the patient. The treatment of sinus disease with balloon sinus dilation currently offers the best fit for these goals. Under endoscopic guidance the location of the sinus ostium is identified. A flexible, soft-tipped guide wire is then passed into the sinus under direct visualization. The use of a lighted guidewire can afford transillumination of the face through the sinus wall verifying proper positioning of the canulla. An appropriate balloon catheter is then threaded over the guidewire into the sinus ostium. The balloon is inflated to high pressure within the ostium to dilate the openings. The balloon and wire are then removed. The technique produces a gentle stretching of the bone and overlying mucosa without damage to the mucosal integrity. The sinus lumen can then be irrigated via a catheter to rinse out any inspisated mucus leaving behind a clean sinus lumen. The dilated ostium can be later verified endoscopically in the OR or in the office.

As with any successful novel technique, there is a necessity to document the track record for balloon technology in the treatment of sinusitis. The long term results of the balloon sinus dilation have been demonstrated in a number of clinical studies over the last 10 years. The sinuses opened during the procedures have remained patent on exam through several years of follow-up. Patients received significant relief from their sinus symptoms when followed up years later. The benefits of the balloon sinus dilation over traditional sinus instrumentation have been documented many times. These include, shorter recovery time, less post-operative pain, and minimal bleeding.

The sinus balloon procedure can be performed under general anesthesia in the OR, and more recently under a local anesthesia in the office setting. The sinus balloon may be used in concert with the other surgical techniques providing a customized solution for each individual patient. Most significantly, the sinus disease should recur or continue to progress, the use

of balloon does not preclude the use of other sinus medical therapies or surgical techniques in the future.

The office based balloon dilation is currently reserved for patients with recurrent mild-moderate sinus disease who are not general anesthesia candidates or who wish to avoid a general anesthesia. The office procedure is well tolerated without significant post operative discomfort. Many patients require only a mild analgesics for the twenty-four hours after the procedure. The post-procedure goal is to return to work and full activity within twenty-four hours of the procedure. The treatment of sinusitis has undergone revolutionary changes over the last forty years. The use of antibiotics transitioned the treatment of sinusitis from dealing with complications to treating active infections and controlling complications. The addition of endoscopic techniques allowed the treatment of sinus disease to be a safer, less morbid and more tolerable treatment. Most recently, the treatment has leapt again with the addition of new endoscopic techniques including sinus balloon dilation. A new class of sinus treatment that straddles the border of medical therapy and surgical intervention has been born. There is now an option that allows the chronic sinus sufferer the benefits of selectively treating an affected, infected sinus without the morbidity traditionally associated with more invasive sinus surgery. The use of balloon dilation technology in sinusitis has been shown to be safe, effective and allow patients to return to normal, symptom-free life more quickly. Sinusitis is a chronic and debilitating disease and warrants continuous tweaking of our management approach and intervention techniques. Only by embracing these new techniques and devices, can we ameliorate the suffering and further enhance the lives of our patients suffering from chronic sinus diseases.

9e n t a n d a l l e r g y . c o m

An estimated 18-22 million office visits for sinusitis occur in the U.S. each year, representing eight billion dollars of healthcare costs.

In the modern age of communication, the voice is critical in projecting image and personality and establishing

credibility. Until very recently, voice has not received enough attention from the medical profession or from the general public. In fact, most people (doctors and the general public) do not realize anything can be done to improve a voice that is unsatisfactory or even one that is adequate but not optimal. Singers, actors, and public speakers have sought out “voice lessons” for centuries. However, recent techniques for voice improvement have expanded and improved, and they have become practical for a great many more people.

Vocal weakness, breathiness, insta-bility, impaired quality, and other characteristics commonly associated with aging can interfere with social and professional success. For most people, these vocal characteristics, which lead people to perceive a voice (and its owner) as “old” or “infirm”, can be improved or eliminated by a vocal habilitation or restoration program supervised by a laryngologist. Doing so is important not only for singers and other voice profession-als (teachers, radio announcers, politicians, clergy, salespeople, receptionists, etc.) but also really for almost everyone. This is especially true for older persons. It is ironic but true that, as we grow older, our voices get softer and weaker at the same time our spouses and friends start losing their hearing. This makes professional communication and social interaction difficult, es-pecially in noisy surroundings such as cars and restaurants.

When one has to work too hard to communicate, it is often related to vocal deficiencies. Therefore, it is not surprising that, when exercises and medications alone do not provide sufficient improvement, many patients elect voice surgery in an attempt to strengthen their vocal quality and endurance to improve their quality of life (so called “voice lift surgery”). Several different procedures can be used to strengthen weak or injured voices. The selection of the operation depends on the individual’s vocal condition as determined by a voice team evaluation, physical examination including strobovideolaryngoscopy, and consideration of what the person wants. Care must be taken to

ensure that the patient expectations are realistic.

In most cases, surgery is directed toward bringing the vocal folds closer together so that they close more firmly. This is done by inject-ing a material through the mouth or neck into the tissues adjacent to the vocal folds, to “bulk up” the vocal tissues and bring the vocal folds closer together. This is called injection laryngoplasty and is per-formed usually using fat, collagen, or other materials. It is sometimes performed in the operating room under general or local anesthesia and, in selected patients, in the office with only local anesthesia. Alterna-tively, the problem can be corrected by performing a thyroplasty. This operation involves making a small incision in the neck. The skeleton of the larynx is entered, and the laryn-geal tissues are slightly compressed using Gore-Tex, silastic implants, or other materials. All of these proce-

dures usually are performed on an outpatient basis. Recovery usually takes days to weeks. Rarely, the voice can be made worse. The most likely complications are that voice improvement is not quite sufficient or that it does not last over time. When these problems occur, they can be corrected by “fine tuning” through additional injections or surgical adjustment of the implant. However, satisfactory results are usually achieved the first time.

Voice rehabilitation through medical intervention and therapy/exercise training is appropriate for anyone unhappy with his or her vocal quality. It is suitable for almost anyone who does not have major, serious medical problems such as end- stage heart disease and is not on blood thinner medication that cannot be stopped safely for surgery, so long as that person has realistic vocal goals and expectations. As physicians and the general public become more aware of the options available, people will not only look young for their age, but sound so as well!

Material has been referenced and edited from:Sataloff, RT., Chowdhury, F., Joglekar, S., Hawkshaw, M. “Chapter 11 - Voice Cosmesis: The Voice Lift.” Atlas of Endoscopic Laryngeal Surgery. New Delhi, India: Jaypee Brothers, 2011.

v o i c e r e s t o r A t i o N - “ t h e v o i c e l i f t ”

F a r h a d C h o w d h u r y , D . O . O t o l a r y n g o l o g y & H e a d a n d N e c k S u r g e r y


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e N t & A l l e r g y p h y s i c i A N p r o f i l e s

John County, M.D., F.A.A.A.A.I.Allergy, Asthma and Immunology

Yorktown Heights and Sleepy Hollow

Jeffrey N. Cousin, M.D.Otolaryngology & Head and Neck Surgery

Yonkers and Tuckahoe

Michael A. D’Anton, M.D.Otolaryngology & Head and Neck Surgery

Wayne

Richard DeMaio, M.D.Otolaryngology & Head and Neck Surgery

Fishkill and Newburgh

Jay N. Dolitsky, M.D., F.A.A.P.Otolaryngology & Head and Neck Surgery

Gramercy Park and Garden City

Lee D. Eisenberg, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Englewood and Hackensack

Ricardo Arayata, M.D., F.A.C.A.A.I. Allergy, Asthma and Immunology

New Rochelle and Purchase

Michael Bergstein, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Yorktown Heights and Sleepy Hollow

I. David Bough, Jr, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Oradell and West Nyack

Anna Aronzon, M.D.Otolaryngology & Head and Neck Surgery

Wall Street

John Cece, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Wayne

Dorothy Chau, M.D.Allergy, Asthma and Immunology

Staten Island

Mark E. Carney, M.D. Otolaryngology & Head and Neck Surgery

Staten Island

Won-Taek Choe, M.D. Otolaryngology & Head and Neck Surgery

East Side and Englewood

Robin M. Brody, M.D. Otolaryngology & Head and Neck Surgery


Andrew L. Blank, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Bayside

Carol G. Baum, M.D., M.B.A., F.A.C.P., F.A.A.A.A.I.*

Allergy, Asthma and Immunology Bronx and West Side

Ryan Borress, M.D. Otolaryngology & Head and Neck Surgery

Poughkeepsie

Shawn C. Ciecko, M.D.Otolaryngology & Head and Neck Surgery

Staten Island

Jason P. Cohen, M.D. Otolaryngology & Head and Neck Surgery

Fishkill and Poughkeepsie


Jonathan Aviv, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

East Side and Sleepy Hollow

* Indicates New Doctors to the Practice

Tahl Colen, M.D. Otolaryngology & Head and Neck Surgery

Bay Ridge, Gramercy and Somerville

Farhad Chowdhury, D.O. Otolaryngology & Head and Neck Surgery

Edison and Old Bridge

Stephen Abrams, M.D., F.A.C.S.*Otolaryngology & Head and Neck Surgery

Wayne

Patrick M. Ambrosio, D.O.*Allergy, Asthma and Immunology


Paul A. Bell, M.D.Otolaryngology & Head and Neck Surgery

Garden City

Bradley Block, M.D. *Otolaryngology & Head and Neck Surgery

Garden City

Kevin Braat, M.D. *Otolaryngology & Head and Neck Surgery

East Hampton, Riverhead and Southampton

Robert Cusumano, M.D., F.A.C.S.*Otolaryngology & Head and Neck Surgery

Oradell

Paul Davey, M.D.*Otolaryngology & Head and Neck Surgery


Wayne Eisman, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

White Plains

Moshe Ephrat, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Lake Success

Gerald F. Fenster, M.D.Otolaryngology & Head and Neck Surgery

Somerville

Mark L. Fox, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Tuckahoe

Gary S. Fishman, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Carmel


David B. Lawrence, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Purchase

Cynthia Jerome, M.D., F.A.A.A.A.I., F.A.C.A.A.I.

Allergy, Asthma and ImmunologyWhite Plains

Nagalingam Jeyalingam, M.D.Otolaryngology & Head and Neck Surgery

Newburgh

John J. Huang, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Oradell and West Nyack

Michael Hugh, M.D.Allergy, Asthma and Immunology

Carmel, Poughkeepsie and Yorktown Heights

Jonathan A. Lesserson, M.D. Otolaryngology & Head and Neck Surgery

Hackensack and Oradell

Marc J. Levine, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

West Nyack

Jeffrey H. Jablon, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Purchase and New Rochelle

Scott R. Messenger, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Yorktown Heights

Dinesh C. Mehta, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Bronx

Debra S. Reich, M.D.Otolaryngology & Head and Neck Surgery

Yorktown Heights

Edward Rhee, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

West Nyack

Prashant Ponda, M.D.Allergy, Asthma and Immunology

Newburgh and Fishkill

Maria T. Quilop, M.D.Allergy, Asthma and Immunology

Bronx

George Pazos, M.D.Otolaryngology & Head and Neck Surgery

Carmel and Yorktown Heights

Amy D. Lazar, M.D.Otolaryngology & Head and Neck Surgery

Somerville

Brian L. Lebovitz, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Parsippany

Michael G. Mendelsohn, M.D.,F.A.C.S., F.A.A.P.

Otolaryngology & Head and Neck SurgeryGarden City

16

Steven M. Gold, M.D.Otolaryngology & Head and Neck Surgery

Englewood

Daniel R. Gold, M.D.Otolaryngology & Head and Neck Surgery

White Plains

David A. Godin, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Gramercy Park

Harrison J. Glassman, M.D. Otolaryngology & Head and Neck Surgery

Bronx

Adrianna M. Hekiert, M.D.Otolaryngology & Head and Neck Surgery

Somerville

Rami Payman, M.D.Otolaryngology & Head and Neck Surgery

Poughkeepsie

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Aylon Y. Glaser, M.D.Otolaryngology & Head and Neck Surgery

Hoboken

Vishvesh Mehta, M.D.Otolaryngology & Head and Neck Surgery


Debora Geller, M.D.Allergy, Asthma and Immunology


Jennifer Lee, M.D.*Allergy, Asthma and Immunology

Bay Ridge

Erin McGintee, M.D.* Allergy, Asthma and ImmunologyEast Hampton, Riverhead and

Southampton

Ron Mitzner, M.D.*Otolaryngology & Head and Neck Surgery

Lake Success

Robert P. Green, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

East Side

Lynelle C. Granady, M.D.Allergy, Asthma and Immunology

East Side and West Side

Natasha Keenan, M.D. Otolaryngology & Head and Neck Surgery

West Side

Mitchell T. Kolker, M.D.Otolaryngology & Head and Neck Surgery

Newburgh and Fishkill

Steven B. Kase, M.D. Otolaryngology & Head and Neck Surgery

White Plains

Daniel Grinberg, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

West Nyack

Steven I. Goldstein, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Bronx and Tuckahoe

Matthew J. Kates, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

New Rochelle

Scott B. Markowitz, M.D. Otolaryngology & Head and Neck Surgery

East Side

Peter LoGalbo, M.D., F.A.C.C.P., F.A.A.A.A.I.

Allergy, Asthma and ImmunologyOradell and West Nyack

Guy Lin, M.D.Otolaryngology & Head and Neck Surgery

East Side

Dan Moskowitz, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

White Plains

John T. Parrinello, M.D., F.A.A.A.A.I., F.A.C.A.A.I.

Allergy, Asthma and ImmunologyNewburgh

Michael A. Gordon, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Garden City

Kenneth N. Kunzman, M.D.Otolaryngology & Head and Neck Surgery

Somerville

Robert J. Marchlewski, M.D., F.A.A.P., F.A.C.A.A.I.

Allergy, Asthma and Immunology Garden City

Sheldon Palgon, M.D.Otolaryngology & Head and Neck Surgery

Wall Street and Bay Ridge


Smruti Parikh, M.D.Allergy, Asthma and Immunology

Parsippany and Somerville


Ramez Habib, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Bay Ridge West and Park Slope

Eric Roffman, M.D.Otolaryngology & Head and Neck Surgery

West Nyack and Oradell

Stephen Mattel, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Wayne

Paul E. Kelly, M.D.*Otolaryngology & Head and Neck Surgery


Edward McCoul, M.D.* Otolaryngology & Head and Neck Surgery

Tuckahoe and Yonkers

Eric Munzer, D.O.* Otolaryngology & Head and Neck Surgery

Fishkill and Newburgh

Krzysztof Nowak, M.D. *Allergy, Asthma and Immunology

Yonkers and Tuckahoe

Richard A. Rosenberg, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

White Plains

Hyman Ryback, M.D. F.R.C.S., F.A.C.S. Otolaryngology & Head and Neck Surgery

White Plains

Steven H. Sacks, M.D, F.A.C.S.Otolaryngology & Head and Neck Surgery

East Side

John Sadowski, M.D.Otolaryngology & Head and Neck Surgery

West Nyack

Brian Safier, M.D.Allergy, Asthma and Immunology

Bayside and Lake Success


Jill F. Zeitlin, M.D.Otolaryngology & Head and Neck Surgery

Sleepy Hollow

Richard T. Yung, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

White Plains

Irene Yu, M.D.Otolaryngology & Head and Neck Surgery

New Rochelle and Purchase

Jason Surow, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Oradell

Karen Wirtshafter, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Parsippany

Jared M. Wasserman, M.D. Otolaryngology & Head and Neck Surgery


Theresa Sohn, M.D.Allergy, Asthma and Immunology

Wayne

Derek Soohoo, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

New Rochelle and Yonkers

Gangadhar Sreepada, M.D.Otolaryngology & Head and Neck Surgery

Wayne

Gerald D. Suh, M.D.Otolaryngology & Head and Neck Surgery

Bayside and Yonkers

Michael B. Tom, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Yonkers

Stanley Yankelowitz, M.D., F.R.C.S.Otolaryngology & Head and Neck Surgery

Bronx

Hale Yarmohammadi, M.D., MPHAllergy, Asthma and Immunology Gramercy Park and Wall Street

Raj Tandon, M.D.Otolaryngology & Head and Neck Surgery

Hoboken

Warren H. Zelman, M.D., F.A.C.S., F.A.A.P.

Otolaryngology & Head and Neck Surgery Garden City

Jonathan C. Smith, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Bronx

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Christopher Song, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery


Milo Vassallo, M.D., Ph.D.Allergy, Asthma and Immunology


Tamekia Wakefield, M.D.Otolaryngology & Head and Neck Surgery

Bayside

Francisca Yao, M.D.Otolaryngology & Head and Neck Surgery


Justin M. Skripak, M.D.Allergy, Asthma and Immunology

Hoboken and Oradell

Michael Shohet, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

West Side

Abraham I. Sinnreich, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Staten Island

Zarina Sayeed, M.D.Otolaryngology & Head and Neck Surgery

Parsippany

B. Todd Schaeffer, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

Lake Success

John J. Scheibelhoffer, M.D., F.A.C.S. Otolaryngology & Head and Neck Surgery

Wayne

Daniel A. Scher, M.D.Otolaryngology & Head and Neck Surgery

Wayne

Charles M. Schultz, M.D.Otolaryngology & Head and Neck Surgery

Parsippany

Frank G. Shechtman, M.D., F.A.C.S.Otolaryngology & Head and Neck Surgery

White Plains

Eric Scarbrough, M.D.*Otolaryngology & Head and Neck Surgery

Riverhead


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Renee E. Angelo, Au.D.Yorktown Heights

Christine Atkins, M.A.Somerville

Sara Beckerman, Au.D.Gramercy Park

Susan Bloom, M.S.West Nyack

Beata Contri, Au.D.Staten Island

Marc D’Aprile, Sc.D.Bay Ridge West

Vincent D’Auria, Au.D.Gramercy Park

Cari Anne Degennaro-Zimny, M.A.White Plains

Nicole Ferguson, Au.D.Bay Ridge and Park Slope

Renee Freund, M.A.Oradell

Harriet Friedman-Wilson, Au.D.Staten Island

James Gahn, M.A.Fishkill and Newburgh

Gregg A. Goldhagen, M.S.East Side

Bonnie Kupchik, M.A.Bronx

Francesca DiNatale Lepsis, Au.D.Garden City

Rochelle Levine Port, M.A.Carmel

Linda Liebowitz, M.S.Hackensack

Anthony Macera, M.A.White Plains

Mary O’Sullivan, M.A.Yonkers

Lorianne K. Owen, M.A.Somerville

Kathleen Paoli, Au.D.Poughkeepsie and Yorktown Heights

Barbara M. Posen, M.S.White Plains

Patricia Reciniello, M.A.Garden City

Phyllis Schaffer-Cohen, Au.D.Director of Audiology

Jennifer Lohr-Seitz, M.S.Riverhead and Southampton

Barbara Tartaglia, Au.D.Yonkers

Marisa Thylstrup, Au.D.Tuckahoe, White Plains and

Yorktown Heights

Emily Ward, Au.D.East Hampton and Riverhead

Sue A. Weinstein, M.S.White Plains

Carol Wesemann, Au.D.Lake Success


Karen Bromberg, Au.D.Wall Street and Bay Ridge

Diane Butfilowski, M.S.West Nyack

Carmelina Cerrone, M.A.Fishkill

Jessica Comparetto, M.A.Sleep Hollow and White Plains

Maureen Connington, Ph.D.West Side

Dorothy Ditoro, Au.D.Bronx

Kimberly Emanuele, Au.D.Poughkeepsie

Emily Esca, Au.D.Bronx

Theresa Faughnan, M.A.Tuckahoe

Arielle Feiman, Au.D.Carmel and West Nyack

Catherine Hadeshian, M.A.Purchase

Marian Henniges, Au.D.New Rochelle

Michael Kaufer, Au.D.Bayside

Michelle Kraskin, Au.D.Bayside

Margaret Mass, Au.D.Fishkill

Laura McCrone, Au.D.Oradell

Laura McElhennon, M.A.West Nyack

Mala Rushabh Mehta, M.A.Hoboken and Wayne

Elizabeth Nemec, Au.D.Englewood

Angela M. Riemma, M.S.Purchase and Yorktown Heights

Alison Rooney, M.S.East Side

Robert Rosengarten, M.S.Edison and Old Bridge

Nicole Rubin, M.A.Garden City

Ilene Shapiro, M.A.White Plains

Richard Winter, Au.D.Bronx

Christopher Witzmann, Au.D.Parsippany

Lisa Zeitoun, Au.D.Bronx

Phyllis H. Zlotnick, M.A.Hackensack and Wayne

Kaitlyn Kelly, H.I.S.Riverhead

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A p p r o A c h t o p e d i A t r i c e N t o f f i c e p A t i e N t s

A n d r e w B l a n k , M . D .O t o l a r y n g o l o g y & H e a d a n d N e c k S u r g e r y


T here are two important issues that concern most parents when they bring their child to see an ENT doctor. First they want to know that the doctor they are visiting is knowledgeable about ENT problems

in children and second and just as importantly, they want to know that the doctor will make their child as comfortable as possible. This is an instinct for most parents or guardians. In my practice, the non-parent guardian is often a grandparent, aunt, uncle or even a sibling Every child who comes to my office arrives as at least two patients (the parent or guardian and the child) and frequently there are three or four. All of these individuals require care. The first patient is of course the child. However the parent (or parents) and very often other family member such as an aunt, sibling or grandparent are also taken care of by the physician. As we examine and treat a child we are in many ways treating the child’s family as well.

The tone of the people in the examination room often provides cues which the child can pick up including anxiety, fear, anger,

contentment, happiness or relief. As doctors taking care of children, we need to deliver care not only to the subject child but also the larger audience. A fearful child who senses an anxious parent or guardian will feel more anxiety. Conversely, a fearful child will often settle down and be more at ease when he senses that his guardian is calm. A gentle doctor, who relates to the child and shows levity, will often get this response from the parent. I employ many different approaches to create a reassuring and friendly environment for my pediatric patients. To start, although many approaches work, I believe in not using a white coat. The clothing I wear usually features a known cartoon character with which most children are familiar. In so doing, clothing becomes one less feature that separates me from the child and keeps us on the same team.

In order to create a less threatening environment, I often employ levity to diffuse the anxiety that is often palpable as I walk into a room. When appropriate, I address the child first, and then the parent or guardian. This makes the child feel important

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and part of the process. For a young new patient accompanied by his mother, I may start by addressing the child with, “Hello, how are you today? I see you brought your sister with you.” More often than not the child will respond with, “No that’s not my sister, that’s my mommy”. This often engenders a very quick laugh from both the parent and the child; not to mention a bit of transparent flattery to the mother. Furthermore, by getting the child to speak spontaneously early in our interview, I quickly accomplish one of my tasks as an ENT which is to assess the child’s speech and articulation as well as the nasality and any hoarseness of his voice. This action sets a gentle tone and also breaks the ice with many children and allows me to approach the child with a friendly demeanor while obtaining a great deal of information without being too serious. Sometimes, a silly action on my part that makes the parent laugh will change the entire atmosphere in my exam room. For example, when I need to perform an uncomfortable exam on a fearful child such as passing a fiberoptic scope through his nose, I often use humor to ease the situation. As an example, I will place a sticker on my own nose. This small action, showing both child and guardian that I am able to not take myself too seriously, often allows me to do so much more without a battle. If an instrument I am going to use may look a little scary then I will show the child on my arm and the parent’s arm that it does not hurt.

Having a medical assistant that relates well to children has also been very important. I will often use my assistant as my “Ed McMahon’’ and we have a few scripts that often work well. As I sit and talk to a parent, I never stop paying attention to the child. Even during a serious discussion about surgery, I will use the child’s head as an arm rest. My assistant will walk in the room and say, “Dr. Blank do you know that there is a kid under your arm?” The child often responds with, “I am not a table I am a kid!” Another obvious method that I employ is creating an inviting office setting that helps disarm both children and parents. My office has a fish tank, port holes in the walls and TVs in every exam room. I put portholes in the walls below the check out counter but above the desk on the other side. This allows small children or “low moving traffic” as I call them, to see the faces of the people on the other side of the counter. This is yet another form of personalizing the experience for the children and including them in the process; not to mention allowing the child to have a say in the very important process of selecting a sticker offered by the person on the other side of the wall, who now has a face. Another feature of my office to which adults and children relate is a wall in the hallway outside my exam room that is filled with pictures and notes from past pediatric patients. Kids and their parents relate to these testimonials from other children which feature pictures, notes and holiday cards of happy families. The wall represents a pictorial history of happy customers. One vital lesson I learned from one of the pediatric anesthesiologists with whom I work with often is that children are small and young but usually not oblivious to what we say. When talking about a pediatric patient, I don’t whisper around the child. Many know exactly who you are talking about and pick up on everything that is being said, even when we think that they are not listening. If I mention the word surgery, it is always attached to the phrase that nothing will hurt the child and that the parent will be there for them the whole time. All too often, children who are the subject of the visit are left out of the discussion phase of the appointment. Including or reassuring them helps when the pediatric patient remains at ease when each part of the visit. Lastly, I always keep in mind that if the kids are happy and well cared for, then so too will be their guardians.

As doctors taking care of children, we need to deliver care not only to the subject child but also the larger audience.

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The pituitary gland is pea-sized and is the master gland. It hangs down from the base of the brain.

It secretes nine hormones which control several bodily activities. It is strategically located between the carotid arteries and below the optic chiasm. The optic chiasm is where the optic (vision) nerves cross and meet behind the eyes. The pituitary gland sits behind the sphenoid sinus.

The sphenoid sinus is an air containing space whose upper back wall lies in front of the pituitary gland. Its sidewalls are where the carotid arteries (the major arteries that supply the brain) and optic nerves traverse. About 10% of brain tumors are pituitary tumors. Over 95% of pituitary tumors are benign and are called adenomas. About 85% of tumors involving the pituitary region are benign. Not all pituitary tumors need to be removed. A microadenoma (small tumor) commonly secrete excess hormones, which are detected by blood test. A prolactinoma can be treated with medicine. However, excess ACTH secreting tumors (Cushing’s Disease) which increase cortisol levels or Growth Hormone secreting tumors require surgery because if untreated they are fatal.

Pituitary tumors are either found on imaging tests such as MRI of the brain or by blood tests demonstrating excess hormones. An eye exam determines if the vision nerves are affected. Typically, peripheral vision is affected first with patients complaining of blurry vision. Double vision and blindness can also be caused by a pituitary tumors depending on size and location of the tumor. An eye exam and visual field test are typically required. Headache is the most

common symptom of a pituitary tumor and a MRI of the brain will detect it.

What to Expect: Pituitary surgery is performed endoscopically through the nose while the patient is asleep under general anesthesia. Image guidance (computer navigation) is frequently utilized. The surgery takes about three hours. The patient is transferred to the recovery room (PACU) and spends the evening there or is transferred to the neurosurgical ICU (NSICU) for 24 hours of observation. Monitoring of fluid intake and urine output during the first 24 hours is critical as the natural hormone to regulate fluid balance is located in pituitary and maybe temporarily functioning improperly. A typical hospital stay is

three days.

Check List of What to Do Prior to SurgeryMust be seen by eye doctor (visual field test), endocrinologist (blood test), neurosurgeon, sinus surgeon and medical doctor for clearance for surgery.

Nothing to eat or drink after midnight prior to surgery.

Go for CT scan with fiducials (“stickies” on forehead) either morning of or day before surgery.

Stop Aspirin, Advil, Motrin, Aleve, Plavix and any blood thinners 10-14 days prior to surgery as directed.

Why Should the Pituitary Tumor be Remov-ed and What are the Risks?It has been determined that the pituitary tumor (macroadenoma) is growing beyond the region of the pituitary gland (sella) and will potentially if not already affect your vision. It also causes headaches, which medicines are unable to treat or control. The tumor may also impair blood flow to the brain. Acromegaly (Growth Hormone

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MacroadenomaLarge tumor, usually non-secreting (hormone levels are normal), which cause headache or visual disturbance

MicroadenomaSmall tumor, usually secretes hormone, excess Growth Hormone (Acromegaly), excess ACTH (Cushing’s Disease) or excess Prolactin (Prolactinoma).

ApoplexySudden onset headache from bleeding into pituitary tumor with sudden visual disturbance. This requires emergency surgery.

The pituitary gland sits behind the sphenoid sinus, below the optic chiasm and between the carotid arteries at the base of the skull. The easiest and quickest way to access the gland is by using an endoscope in the nose, which is Dr. Schaeffer’s expertise. He does not use packing after surgery so the patient has an easier recovery.

p i t u i t A r y t u m o r se v e r y t h i N g y o u N e e d t o K N o W

B . T o d d S c h a e f f e r , M . D . , F . A . C . S .O t o l a r y n g o l o g y & H e a d a n d N e c k S u r g e r y


Endoscopic Skull Base Surgeons. Skull Base Surgeons. Above Dr. Schaeffer providing the approach to skull base tumors through the nose. To the right Neurosurgeon Dr. Mark Eisenberg and sinus surgeon Dr. Todd Schaeffer performing 3D Pituitary Surgery for the first time on Long Island, April 2010.


excess) and Cushing’s Disease (excess ACTH from the pituitary gland leading to excess cortisol) have no adequate medical treatment. If left untreated they will be fatal. Surgery is required to remove the entire tumor.

The major risks of any surgery are an-esthesia, bleeding or infection. Risks of pituitary surgery also include blurry vision, double vision, the remote possi-bility of blindness, revision surgery, leak-age of brain fluid (CSF leak), meningitis

and stoke. While these risks are low, it has been deemed these risks are outweighed by the benefits of the surgery. In other words, you have more risk by NOT performing surgery than removing the tumor. Having an ex-perienced skull base team decreases the risk.

Large pituitary tumor eroding into sphenoid sinus.

Why choose Dr. B. Todd Schaeffer as your endoscopic sinus and skull base surgeon?Dr. Schaeffer has been performing advanced endoscopic sinus surgery for twenty years. He has performed more endoscopic skull base surgery than any other sinus surgeon on Long Island. He commonly works with skull base neurosurgeon Dr. Mark Eisenberg. As a team, they have successfully treated pituitary tumor removal, closure of CSF leaks, removal of encephaloceles, chordomas, clival tumors, meningiomas, craniopharyngiomas, odontoidectomy, spinal cord, decompression, biopsies at the skull base and skull base reconstruction. The key to their success is collaboration together and the support staff of North Shore University Hospital and Long Island Jewish Medical Center. Experience and team collaboration counts.

Do’s and Don’ts After SurgeryHead of bed elevated on two pillows for three weeks

No nose blowing for three weeks

Use saline nasal spray several times a day for several months

No airplane flights for the first three weeks

No strenuous activities or heavy lifting for three weeks

Expect to be out of work for three weeks

Refrain from blood thinning agents, i.e. Aspirin, Advil, Motrin, Alleve for two weeks

Avoid steam/extremely hot showers for three weeks

Notify MD for excessive bleeding from the nose, headache, fever over 102 degrees or clear fluid from the nose

Notify MD for salty taste in the throat

Make appointment to see Dr. Schaeffer in his office after surgery at 3 weeks then monthly for the next three months.

Skull base team of Dr. Eisenberg and Schaeffer

What if you could stop cancer even before it started? The ability to detect cancer before it begins would be

a significant advantage in preventing the morbidity of an invading malignancy. This aspiration is now becoming a reality in the early detection and care of cancers in the oral cavity and upper aero digestive tract.

The prevalence of oral cavity cancer has been on the rise in the U.S. over the last several decades. There are believed to be many factors, but the at-risk individuals are becoming harder to recognize. Many of these affected individuals do not have the high-risk smoking and alcohol abuse history that was commonly a red-flag in these cancers. Lulled by low suspicion, these cancers are frequently detected only when they have grown large enough to become symptomatic. By this time, these lesions may be invasive and may require aggressive treatments to control and eradicate the disease. The key for treating these lesions would be to catch them before they become cancer.

Each year thousands of individuals are examined by their primary doctors, dentists and ENTs’ and noted to have small growths on their oral mucosa. The majority of oral cavity lesions will be benign mucosal changes that will resolve without treatment. Unfortunately, the difficulty is distinguishing those small red or white dysplastic plaques on the oral mucosa that will progress on to become cancer. They will frequently grow slowly for years unnoticed until they become painful or begin to bleed. If these lesions are discovered in the early “precancerous” state then they can be more effectively treated, with less morbidity and less risk to the individuals.

Until recently, there were limited tools available to screen a suspicious lesion for malignancy. The main stay of diagnosis

has been excisional (or incisional biopsy) of the lesion by an ENT or Oral surgery specialist. The gross tissue specimen is sent to a pathologist, appropriately stained and examined manually under the microscope for malignancy. Although direct biopsy is still the gold-standard, the aggressive nature of a “cold knife” biopsy may give a clinician hesitation when applied to a small minimally suspicious lesion. The biopsy area may require significant time to heal, the area may be painful and may require re-excision later.

The paradigm for the diagnosis of early oral cavity cancer has now begun to shift. A suspicious lesion now found on

routine oral exam can be painlessly and bloodlessly sampled utilizing a newly-developed minimally invasive brush biopsy technique. The lesion is then brush-ed to obtain a complete tissue sample of all epithelial layers. The brush specimen is then screened by trained pathologists for suspicious cells using advanced computer-assisted technology. If dysplastic cells are identified, the early lesion can then be efficiently and completely removed, well before it could progress to a more aggressive lesion.

Although the goal is to identify abnormal cellularity, the vast majority of sampled

lesions will not contain dysplastic cells and will not require further treatment. The clinician can then reassure the patient that the lesion is benign and will only require local treatment and adequate interval follow-up. The patient can continue on with the knowledge that the lesion in their mouth is not concerning.

Similar to its place in the diagnosis of oral cancer, the brush biopsy technique has also revolutionized the diagnosis and treatment of early esophageal and laryn-geal lesions. During examination with a flexible endoscope, a clinician can sample the cells of a suspicious lesion in a mini-mally invasive technique to determine whether dysplastic cells are present. This procedure can be easily performed in the ENT office, usually without the need for a systemic anesthesia. If a dysplastic le-sion is identified by the brush biopsy, the patient can then undergo the requisite removal of the lesion under sedation, if necessary. This technique has also proved helpful in the follow-up of patients with prior treatment for known laryngeal or esophageal malignancies. If a suspicious area is identified in the vicinity or distant from the original treated lesion, the new area can be rapidly screened and appro-priately treated if necessary.

In summary, accessible screening and early detection are currently the best tools available in our fight against cancer. The diagnosis and treatment of oral, esopha-geal and laryngeal cancers has been transformed by the ability to recognize the malignant potential of a lesion well before the lesion progresses to a cancer. The minimally invasive sampling of the surface cells utilizing a brush technique allows clinicians to detect and prevent the progression of dysplastic cells on mucosal surfaces. The lesions can then be identi-fied and destroyed before they become cancer. There is definitely no better way to treat a cancer than finding it before it has a chance to become a cancer.

t h e N e x t s t e p i N p r e v e N t i N g o r A l ,t h r o A t A N d e s o p h A g e A l c A N c e r

G a n g a d h a r S r e e p a d a , M . D .O t o l a r y n g o l o g y & H e a d a n d N e c k S u r g e r y


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A Simple Self Exam Could Save Your Life

A new ENTA awareness campaign encourages patients to check their mouths regularly for spots.

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Who is a candidate? A child or adult who does not sufficiently benefit from conventional hear-

ing aids.

Two examples:Case #1A newborn child is welcomed into the world by hearing parents. Thanks to uni-versal newborn hearing screening legis-lation, suspicion for a hearing deficit is identified prior to discharge home of the otherwise healthy child. Further workup with an auditory brainstem response, CT (or MRI) temporal bones and ge-netic testing reveal a bilateral profound sensorineural hearing loss secondary to Connexin 26 mutation, the most com-mon cause of non-syndromic, congeni-tal, autosomal recessive deafness. Prior to the advent of cochlear implantation, the child’s family would have been edu-cated about sign language as the primary mode of communication for the child. Speech might be possible, but would be at best a secondary means of communi-cating. Today, there is another option: early cochlear implantation (typically around the age of 1), followed by aggres-sive speech and auditory therapy, with the likely outcome of the child attending a regular school in a mainstream, non special-ed class, and achieving “normal” sounding, non-deaf speech.

Case #2Almost everyone has an elder fam-ily member with whom they have to raise their voice to communicate. Most of these people will do well with hear-ing aids. However, we are all familiar with the older patient who comes in and despite wearing two hearing aids can barely hear you. You find yourself yelling in order to be understood. This level of hearing loss has deep effects on a person’s life. They find themselves

isolated, even among loved ones. They are unable to estab-lish a relationship with their grandkids, who may not have the patience, knowledge or time to try to communi-cate with them. They find their spouses becoming frustrated with the in-evitable miscommunica-tions. They are fearful of going out alone and ne-gotiating simple errands. They likely have trouble us-ing the telephone and hear-ing a smoke alarm. Often, loneliness and depression re-sult. With a cochlear implant, this person can get a new lease on life. It will increase their ability to interact with loved ones and decrease loved one’s frustration with the patient. They will be able to hear a door-bell, a carbon monoxide alarm, or a nearby car in the street. Approximately 80% of these patient will be able to hear and converse on the tele-phone as well.

When to refer: Cochlear implants are for people with BILATERAL sensorineural hearing loss. Patients in the moderate to profound hearing loss levels may benefit, depending on associated speech discrimination level.

Those who may benefit include: congenital hearing loss, CMV-related hearing loss, progressive hearing loss in children or adults, sudden hearing loss with poor speech discrimination, noise induced hearing loss, ototoxicity, presbycusis.

****SPECIAL SITUATION: Deafness sec-ondary to meningitis should be evalu-ated for a cochlear implant urgently. Ossification of the cochlea can occur as

early as days to weeks after meningitis and postponing evaluation for CI may result in inability or reduced ability to benefit from an implant.********

Pre-implant evaluation: At a minimum, includes a complete head and neck exam by the cochlear implant surgeon, targeted imaging study (CT or MR), and cochlear implant audiology evaluation (special series of tests of speech discrimination with hearing aids on). In children especially, the evaluation may be more extensive, possibly involving neurology, psychology and speech evaluations. It is critical to set up a plan for post-implant therapy for the child at an appropriate school.

How the cochlear implant works: The implant has two components: an internal component that has electrodes that are inserted into the cochlea to bypass the


b y r e c o m m e N d i N g A c o c h l e A r i m p l A N t e v A l u A t i o N f o r y o u r p A t i e N t , y o u b e c o m e p A r t o f t h e h e A l t h c A r e t e A m t h A t W i l l c h A N g e s o m e o N e ’ s l i f e p r o f o u N d l y

T a h l C o l e n , M . D .O t o l a r y n g o l o g y & H e a d a n d N e c k S u r g e r y


Image provided by Cochlear

Image 1. Illustration of cochlear implant and how it works: http://products.cochlearamericas.com/cochlear-implants/how-nucleus-5-works. 1. External processor receives sound and converts it into a digital signal, which is then transmitted to the 2. Internal implant, which converts it to an electrical signal which is then transmitted through 3. The intracochlear electrode to 4. The auditory nerve.

t h e N e x t s t e p i N p r e v e N t i N g o r A l ,t h r o A t A N d e s o p h A g e A l c A N c e r

damaged inner hair cells and directly stimulate the auditory nerve. The external component looks like a conventional hearing aid, but has a wire coming off the top of it which ends in a magnet. The magnet aligns the internal and external transmitter/receiver to facilitate conversion of the external acoustic input into an electrical signal which then gets conveyed to the auditory nerve.

Surgery: Cochlear implant surgery can be done as an outpatient in the vast majority of cases, and takes 1-2 hours. The implant is placed through a small postauricular incision. Recovery is generally quite uneventful. Mild site pain is expected for several days. Dizziness may happen but is infrequent.

After surgery: After healing of surgi-cal incision for 2-4 weeks, the “initial stimulation” will take place with the audiologist. Patients will typically hear sounds initially, which will eventually be interpreted by the brain as speech.

This process of getting used to the new input can take days to months, and will require several visits with the audiologist over the first few months to update the programming as the brain and auditory nerve acclimate to the signal.

Outcomes: On average, adults with cochlear implants typically understand about 80% of what is spoken to them. Children who had hearing for several years prior to implantation or those who are implanted very young (around one year of age) typically keep up with their normal hearing peers academically, and have “normal” sounding speech.

Please help us identify cochlear implant candidates—YOU are the critical link in opening up the world of sound for your patients.

Dr. Colen’s subspecialty is Otology, Neurotology and Skull Base Surgery at the Bay Ridge, Gramercy and Somer-ville locations.

Image provided by Cochlear

Image 2. Appearance of patient wearing Cochlear’s Nucleus 5 external device

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On average, adults with cochlear implants typically understand about 80% of what is spoken to them.

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