Updates in Rhinology and Skull Base Surgery
Raj Sindwani, MD, Vice Chair and Section Head of Rhinology in our Head and Neck Institute, joins to discuss new research presented at the North American Skull Base Society annual meeting. Dr. Sindwani also shares how these newly published findings are innovating the approach of our skull base surgeons.
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Updates in Rhinology and Skull Base Surgery
Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic Podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology, head and neck surgery.
Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on Twitter @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology, Head and Neck Surgery by following @CleClinicHNI. That's C-L-E clinic HNI.
Today, I'm looking forward to speaking with Dr. Raj Sindwani, Vice Chairman and Section Head of Rhinology in our Head and Neck Institute. You can follow him on Twitter @mdsindwani. Dr. Sindwani, welcome to Head and Neck Innovations.
Raj Sindwani: Nice to be here. Thanks for having me, Paul.
Paul Bryson: Well, let's start. Can you give the listeners some background on yourself, where you're from, where you trained, and how you've come to Cleveland, and how your practice has evolved over the years?
Raj Sindwani: Sure, I'd be happy to, Paul. I've been at the Cleveland Clinic since 2010. I was recruited here back then to help build the Skull Base Program and to try to take their rhinology section to the next level. I'm Canadian, so I did my med school and residency in Canada, and then went to Boston to the Mass Gen part of the Harvard system to do my fellowship. My first job after fellowship was at St. Louis University where I was for five years bringing their Rhinology section into the contemporary future at that time as well.
Paul Bryson: Then as you've been here at Cleveland Clinic, we're going to dive into some of your surgical practice. What are some areas of expertise that you've refined and expanded here at the Head and Neck Institute?
Raj Sindwani: Probably the biggest splash that we've made is in our skull base world. I'm the co-director of the minimally invasive pituitary surgery and cranial-based surgery program along with Dr. Recinos from neurosurgery. Our brand of skull base surgery, which is practiced at a high level and high volume, that very few centers do across the country and really around the world, is to have the two-surgeon multi-handed approach doing skull base surgery through the nose. This takes exquisite advantage of the anatomy, our nose, nostrils, and sinuses are mostly air, and we can use that pathway as a conduit to get to the back of the nose where we of course meet the pituitary, the skull base, and so on. We can access a lot of different disease processes that are really intracranial pathology by going through the nose as a conduit.
We really have become a destination for patients with pituitary disorders, skull base tumors, meningioma, schwannoma, craniopharyngioma, and so on, as the place to go to get minimally invasive thorough treatment of these processes. Over the past five years, we've taken that two-surgeon multi-handed approach and actually expanded it to approach even other areas not traditionally felt to be within the realm of the skull base surgeon like the orbit. We actually are publishing the world's largest series of endoscopic endonasal intraconal orbital tumors taken up through the nose by our skull base team.
Paul Bryson: Yeah, that's great. As an observer, it seems like the program has only grown and grown. Things have only become more advanced, and I commend you on that. Beyond Dr. Recinos, she talked about some of the work, I mean the conus where the eye is. Do you also collaborate with some of our ophthalmologic surgeons?
Raj Sindwani: We do. I do a lot of DCR decompressions with Dr. Wong and Dr. Perry in oculoplastic. Dr. Arun Singh, who's their orbital tumor surgeon, actually has made this center with rhinology, neurosurgery, and then orbital tumor surgeons functioning as one team to try to access all areas of the deep spaces of the orbit. When tumors are more upfront, they're in their domain, Dr. Singh's domain. When they're way in the back near the chiasm or the optic nerve intracranially, well, we've been operating there with our neurosurgeons for the longest time. But when they're in between there sometimes it's a no-man's land. It's not right for the neurosurgeon. It's certainly not in our wheelhouse as a routine type of procedure, nor is it in the ophthalmologic surgeon's wheelhouse.
By bringing those three perspectives to bear, we can really come up with the best means to take out those tumors, which in many places are really just observed or radiated because it is this no man's land and there's no real option for surgical treatment, which is so fascinating and interesting because often the tumors that grow there are benign. If you were to take them out, you would achieve complete cure with gross tumor total reception. This is what some of the papers that we've more recently written have been about, highlighting the anatomy, coming up with nuanced approaches to it, and showing how having multiple hands and multiple perspectives in brains really can lead to superior outcomes for these patients.
Paul Bryson: Yeah, I mean it's really excellent. I think a lot of us are used to the idea of a head and neck tumor board, if you will, but it sounds like this is even a more multidisciplinary surgical tumor board for the anterior skull base.
Raj Sindwani: Yeah, it really is. It is partnering very closely with people who don't have a similar background as us, right, ophthalmologic surgeons, neurosurgeons, but because we're so used to working with them and have such a high volume of these cases, we end up doing this dance together very well. We spend a lot of time, unlike in head and neck surgery sometimes where you have two teams that operate serially, you respect, then you reconstruct, we're doing the resection, approach, and reconstruction together. It's a really deep level of commitment and partnership that we've really been able to enjoy. On the training side, that's also been the most rewarding part for me besides the patient care aspect is just training the next generation leaders. I think we're up to our 10th or 11th cycle now of fellowship applicants, and it's just been amazing to see where these trainings go and where they can push the field even beyond where it's at now.
Paul Bryson: Yeah, that's great. It's very exciting. It's always fun to hear about what's going on and what's new. It seems like the corridors for the approaches just continue to expand or they're refined in a way that maybe most people aren't aware is that it's even happening.
Raj Sindwani: Absolutely.
Paul Bryson: That's great. I know to kick off 2023, you've recently presented at several meetings including our Combined Otolaryngology Society Meetings and the North American Skull Base Society meetings. Can you give our listeners an update on some of the research you and the team here at Cleveland Clinic are planning to present or have presented?
Raj Sindwani: Sure. At the skull base meeting, we usually have a very good showing on the neurosurgery side as well as the rhinology side. I moderated a panel on reconstruction where we talked about the latest nuanced approaches of various techniques and endoscopic skull base reconstruction. One of the big barriers to doing more and more through the nose, say 15, 20 years ago, was anyone can make a big hole and take a tumor out, but you're limited by how you then reconstruct that hole that you created. That was a really fun panel to be a part of. I had some old fellows on that panel. Dr. Rosen from Jefferson was on it. We really were able to impart a lot of really amazing, nuanced knowledge to the audience there. The research that we've presented there, and that comes in multiple parts that will also be presenting at other meetings, really has to do with our recent focus of trying to better understand why patients may present to the emergency department after skull base surgery.
We all know that readmissions are a major healthcare expenditure and a key metric of hospital performance, and often these are proceeded of course by a trip to the emergency department. We look back over the past five years at all our endoscopic skull base patients that showed up in the emergency department within 30 days of their endoscopic skull base surgery. This actually was over 550 patients that we were able to dig deeply into. What we found is that 559, 61, or approximately 11 percent of them, actually presented to the emergency department following surgery within that 30 day window. The median post-operative day of presentation to the ED was about six days after surgery. Interestingly, one of the key findings of that study that blew us away a little bit was that 23 and of these patients missed their first postoperative appointment for a variety of different reasons. 62 and of the patients were then discharged from the emergency department when they did come in within those 30 days, usually on that fixed day, and only 40 and or a little bit less were actually readmitted.
The most common reasons that people presented that were eventually discharged were headache and epistaxis, and the ones that were admitted, the most common reasons were endocrine issues, adrenal insufficiency, hyponatremia, and so on. Interestingly, when we looked at those patients that were discharged home or that were admitted, the workup in the ED was very similar. A median of four tests as far as blood testing goes, a median of one imaging study, and at least one consult. There was still a lot of resource being expended even though the majority were then ultimately sent home. What we learned from that was really that while less common than readmission visits into the emergency department, even though many go home, still is an opportunity for improvement from the way that we utilize our healthcare resources. Patients may benefit obviously from early post-operative visits, so making sure that they're seen a few days or within a week after discharge, home after surgery, and also, we can afford better pre-operative counseling.
Many of these patients were just reassured that there was no CSF leak, or that their CT scan post-op looked okay and were counseled and then sent home. The other really interesting thing that's negative that jumped out to us as skull base surgeons is that it was very, very rare for them to present with a CSF leak after surgery. We had such a high-volume center, and our leak rate is so low that these patients almost never leak after surgery, and that was not the case probably 10 years ago when we started doing this. One of the other interesting follow-ups that we presented at the NASBS meeting was then also looking more deeply into who are the patients that are not receiving adequate education and counseling? We actually apply the ADI, or area deprivation index, to these patients who present to the emergency department.
For those listeners who aren't aware, this is a multi-dimensional index that really looks at a validated measure of social geographical disadvantage that's calculated from the United States census data, and it really drills down beyond even just the zip code of where patients live. This index has been used in a variety of different other healthcare measures looking at diabetes, MI risk, all these different types of things, and it's thought to be a very sophisticated index. Interestingly, when we apply the ADI to these patients that showed up in the emergency department, one other nuance that we learned is that less advantage patients as measured by the ADI were readmitted at a significantly lower rate from the ED following skull base surgery than more advantage patients were. The difference, we thought, or postulated may reflect higher ED utilization for minor postoperative concerns by patients with fewer resources and perhaps issues with healthcare literacy.
As we dig more deeply into these findings, I think making sure you have a good postoperative plan as far as signposts for calls, visits, endocrine follow up, and making sure that we appreciate the disparate healthcare literacy that patients may have really could be a key finding that we can act on going into the future.
Paul Bryson: Yeah, man, that's a great paper. That's exciting. It certainly allows for understanding and actionable impact, how you might change the structure before surgery and then how you might be able to try to arrange follow up clinically afterwards. It sets the expectation for the patients as well. That's great.
Raj Sindwani: Yeah. We start at the skull base level looking at this just because the impact can be so great. These patients are admitted for several days. It's a big procedure with a lot of follow up, but you might have some similar lessons learned even for some of the outpatient stuff that you and I also do, or other otolaryngologists do. I think that education peace and making sure we have thorough and thoughtful follow-up at the right time is going to be increasingly important to prevent these types of ED visits or even readmissions over the future.
Paul Bryson: Yeah, I mean, it sounds like at least in this population, some of the patterns for coming to the ED where stuff that you would expect you could talk about at that first post-op visit, they just got worried and didn't know where to turn or what have you.
Raj Sindwani: That's right.
Paul Bryson: I wanted to change gears. Again, you're going to be, or you currently are the editor-in-chief of the American Journal of Rhinology and Allergy, and I wanted to give you the opportunity to talk about your approach and the journal's approach to reviewing research and getting new information disseminated like the project you just described. I understand there's some changes at the Journal for the peer review process, and I wanted you to have an opportunity to highlight that.
Raj Sindwani: Yeah, great. Thank you for giving me the opportunity. This is a very big change at the AJRA, or American Journal of Rhinology and Allergy effective January 2023, so hot off the presses. I think we're all aware that the peer review process of how journals and societies arbitrate or decide whether something is suitable for publication dates back many centuries, adopted by learned societies back in the 17th, 18th centuries. It's really the accepted way of how we decide whether something could get published or not. The goals of this process simply really are to ensure that the work that's being submitted meets reasonable standards. Then also secondarily, it gives the journal and its representatives, our colleagues, the opportunity to identify any flaws in methodology and really to suggest improvements, even papers that maybe don't get accepted.
There are really two streams of thought on how we can best do that. There's the open peer review process where the person who submits the article, the author and the reviewer know each other, know each other's identity. The review may even be published with an author of the review of the paper. That's not very common, but there has been some thought that maybe that could be something we migrate to. Far more common, however, is the closed review process, which is the large proportion of all medical journals. This can be single blind or double blinded, and we use the term anonymized rather than blinded. Most journals in the medical field use a single blind process. What I mean by that, Paul, is that you're the submitting author. You submit your paper. You may get a review or two back, and you'll never know the reviewer's identity, but the reviewer knew who you were as an author. Okay?
The thought here, by keeping the reviewer's identity blinded, the main idea is that it allows a reviewer to comment freely on the work without fear of retribution or favor, and they can really just give their anonymous thoughts. One thing that has been brought up more recently, however, and there's been growing evidence and some literature on this as well, that suggests that having the reviewer's identity blinded to the author now may increase the chances of biases entering into the picture of the reviewer, against, you can imagine, underrepresented minority, women in science and medicine, smaller, less known institutions, and maybe even papers coming from other countries. Some of these biases are conscious and some may be unconscious, but the thought was if you could implement a double anonymized review process where the author doesn't know the reviewer and the reviewer in turn does not know the author or where this paper is coming from, would we get a pure scientific reading of the caliber and merit of this work? That's what we've implemented.
There has been a lot of operational change that's been necessary, but I canvas many other editors in chiefs in a variety of different disciplines, and our editorial board near unanimously agreed to lead in this space and to implement this double anonymized review process. Interestingly, we will be the only US rhinology journal that does this. There's only one other US otolaryngology journal that does it, so it'll be the second one there. Even across the world when you look, there's very, very few journals that are adopting this and leading in this space. Currently under the SAGE umbrella, and my journal, the AJRA falls under Sage Publishing, 90 percents of the humanities journal now offer double blinded or double anonymized reviews, and 30 percents of science and medical journals offer it. I think it's a trend that we're going to continue to see. I think it makes sense from a lot of different perspectives. I think it's meeting us and the world where it is right now in our time in history, place and history, and I think it's just the right thing to do.
Paul Bryson: Congratulations on bringing about that sort of change with the journal. It certainly will be exciting to see how that plays through and compare it to processes in the past. Yeah, it should be very exciting, so congrats on that. Well, we've reached a point where it might be time to wrap up. I just wanted to ask for our listeners that might want to refer patients to our rhinology or to our complex multidisciplinary skull base program, what can the patient or the referring physician expect, and how are these appointments made, and how are they structured?
Raj Sindwani: Sure. I mean, we have many points of entry. We have a really big team on the neurosurgery side and on the rhinology side. Speaking of skull base first, we have care coordinators, different types of folks that can help guide you through the journey start to finish. What the patient can expect is to be handheld the whole way through. One number to contact. If there's ever an issue reaching out to my office, we'll implement a cascade of people who are there to service you and make sure that you have a pleasant experience through this very daunting and scary time in one's life. It's multidisciplinary. It's seamless for the patient. We have the neurosurgery side and the ENT side, or rhinology side, working hand in glove to make sure that we get the best outcomes and that every patient that we meet indeed experiences world class care.
We're able to provide that because of the Cleveland Clinic infrastructure, because of our partnership that we alluded to before, and because we are on the cutting edge of what is possible surgically and otherwise for the management of these types of problems. That speaks to the research and the training that we offer here in our program. On the rhinology side, the other thing that we really offer and boast about is you can be seen where you're at. We have sites on the west side, sites on the east side. There are four fellowship trained rhinologists in our section who are all amazing, well trained, thoughtful, compassionate, and very personable people that will give you the best quality of care, I would argue that you can find anywhere on the planet.
Paul Bryson: Well, Raj, I really appreciate your time today. It's been great having you on the podcast.
Raj Sindwani: It's been my pleasure. Thank you so much for the opportunity to share some of the amazing work that me and my colleagues are up to.
Paul Bryson: For more information on Cleveland Clinic section of Rhinology, sinus and skull base surgery, please visit clevelandclinic.org/rhinology. That's clevelandclinic.org/rhinology. To speak with a specialist or submit a referral, please call 216.444.8500. That's 216.444.8500. Thanks for joining Head and Neck Innovations.
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