Contemporary Management of Hereditary Hemorrhagic Telangiectasia

Podcast Transcript

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 on Twitter, that's CleClinicHNI. And new this year, find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today, I'm honored to be joined by my colleague and friend, Dr. Troy Woodard, a Rhinologist and skull-base surgeon in our Head and Neck Institute. Dr. Woodard is also a professor of Otolaryngology Head and Neck Surgery, rhinology, sinus and Skull-based Surgery at the Cleveland Clinic Lerner College of Medicine at Case Western University. He's also the director of our Rhinology and Skull-based fellowship program, and you can follow him on both Twitter @troywoodardMD and Instagram @doctroywoodard. Dr. Woodard, welcome to Head and Neck Innovations.

Troy Woodard: Thanks, Dr. Bryson. I really appreciate the opportunity to speak with you today.

Paul Bryson: Well, let's start by having you share some background on yourself for our listeners and where you're from, where you trained, how you came to Cleveland Clinic, and maybe just some of the evolution of your career.

Troy Woodard: Okay.

Paul Bryson: You've been here a minute.

Troy Woodard: All right. So, I'm originally from Nashville, Tennessee, and from there, Nashville was a pretty small town. All right. It was back in the late '90s, and I wanted to go to a large city, ended up in Chicago at DePaul University. From there, I went out east to Baltimore and trained at Johns Hopkins. Then I had fond memories of Chicago, so I wanted to go back and finish my training. Did residency at Loyola University, and then I did a rhinology, sinus skull-based fellowship at the Medical College of Georgia. So, I ended up here. Basically, I'm out of fellowship looking for jobs, and what I realized when I walked into this campus was that this was just an amazing place for the colleagues, the camaraderie, even the beauty of the facility. All of that really made me decide to make this my place of employment. And I would say you and I are pretty unique in that we have stayed at one facility or one institution our whole career. So, I've been at the Cleveland Clinic about 14 years now.

Paul Bryson: Yeah, I mean, it's amazing, right? You get the sense of momentum and opportunity, and certainly just as an observer of your academic career, it's been amazing to see you bring your expertise clinically and surgically, but then also really be just a pivotal member of the skull-based surgery team, and to see that practice... There's always been a lot of that work here, but to see it really grow and expand over the last decade with you here has been really cool and just great for patients.

Troy Woodard: You're absolutely correct. Prior to the implementation of the skull-based team, which is combined of the neurosurgeons, endoscopic neurosurgeons, and myself and my partner, Dr. Sindwani, many of those patients had to have larger surgeries, external cuts from ear to ear to remove whatever pathology or tumor. But now with the implementation of the endoscopic skull-based program, we actually save a lot of our patients... Well, I want to say we make their experience better. How so? Well, we go through the nose as opposed to making large external incisions. A lot of those patients are able to get out of the hospital quicker and ultimately have better results.

Paul Bryson: Yeah, I mean, it's a real innovation and to see the care and the team in action is really cool. For any listeners that are thinking of visiting or spending time with the team, it's certainly worth your while to see how they work together. I mean, just the finesse and skill of the group. I also, on my list of agenda items for us today, you have some expertise in a range of different things that affect rhinology and the skull base, but one of the specifics is hereditary hemorrhagic telangiectasia, otherwise known as HHT. Can you give the listener some background? What is it, how is it connected to your work, and how did you come to find yourself taking care of patients with this condition?

Troy Woodard: Yeah, sure, no problem. So HHT is a genetic disorder in which the blood vessels within our bodies, if you have this disorder, they're pretty thin-walled, and they rupture fairly quickly. Usually patients that have this disorder, they primarily present with severe nose bleeds, and when I say severe, I mean sometimes they can happen multiple times a day, every day, lasting up to a couple of hours. These are pretty bad. In addition, patients also have family members with similar types of issues. They may have lesions in their internal organs, like your lungs, brain, liver, and finally, a lot of these patients present with small little red vascular lesions in their mouth, on their lips, on their hands. And so, I would say I started seeing my first couple of patients probably around the second year of my working here. And what I noticed; these patients really had a very poor quality of life.

Many of the patients couldn't really leave the house because they were afraid that they were going to bleed out in public. I've had some patients who had this disorder, and it really made their work difficult. For example, imagine being a chef and trying to cook food, and then you start bleeding into the food, or imagine being a lawyer and you have all these papers that get drenched with blood. It's pretty miserable. And so, what I found by treating these patients is that even ultimately, small procedures can really have drastic and huge improvements in their quality of life.

Paul Bryson: Yeah, I mean, it's amazing when problems are so severe. Can you elaborate a little bit on what are some of the innovative ways that you manage this condition? How did you approach it, and what have you learned over the years?

Troy Woodard: Right.

Paul Bryson: I'm sure things have changed.

Troy Woodard: Yes, they have. So, when I first started treating patients with this disorder, we utilized laser and cautery to just zap the little lesions, if you will. That would help, but it was very short-lived, and oftentimes, the patients would present to our emergency room. Our residents would have to go down, take care of the patients, pack them. It was miserable for the patient and the physician taking care of them because there was no way to really improve the situation. Over the years, I've been partnering with several colleagues here in the pulmonology department, the GI department. And what we've really developed here, I would say, is a pretty unique way of treating these patients. We're a team, and as a matter of fact, we're an HHT Center of Excellence, which means that you have multiple providers providing comprehensive care of these patients, and so you're able to take care of all their needs.

And so over time, we began using other methods to try to control the nose bleeds, for instance, topical therapies. Studies have shown that some topical medicines can reduce the growth of these vascular lesions. We've even started to use systemic therapies as well. And so, when I see a patient in my clinic, one, I assess how bad their nose bleeds are, two, if they've tried any of the other less invasive approaches to treat their lesions, and three, if all else fails, then we will proceed to surgery. My method of surgical intervention has changed. I remember, initially I was using laser and cautery, but now I use something called sclerotherapy. That's a procedure that you might be familiar with it. Oftentimes, people who have varicose veins would get those veins injected. What does it do? Well, it actually hardens the vessel so that it's less prone to rupture.

Paul Bryson: Yeah, I mean, it's amazing. It's an amazing way to repurpose things, and for the listener, if you haven't seen this, it's not just one little vessel that bleeds, it's like almost a field effect, right, along the mucosa. So, it requires strategic injection of the sclerotherapy agent, right?

Troy Woodard: Yes. Yes, you're absolutely correct. There is multiple, sometimes hundreds of lesions within the nasal cavity, and so yes, you have to strategically map out your plan of attack, and so you inject each lesion. And what we have found, we've done some research and compared. We followed our patients for two years, and we compared their outcomes to those patients who had laser and cautery, and we were pleasantly surprised. On an average over a two-year time period, our patients who receive sclerotherapy only required two treatments, whereas those that had the laser and cautery required up to eight treatments to get them to the same level of mild nose bleeds.

Paul Bryson: Yeah, I mean, pretty amazing when you think about them, and it's not just the number of nose bleeds, it's the severity of the nosebleed.

Troy Woodard: Right. In addition, you have to also think about how much time it takes the patient to come to our office, take off of work, maybe they have to get a family member or friend to drive them to the Cleveland Clinic. That's a lot of resources that are spent on this, and I think if we're able to help reduce those resources, help improve their quality of life, and I think this is a win-win for everyone.

Paul Bryson: Yeah. No, I mean, great work and great team effort and great, it's always fun to see how you're an expert in the area and how you can refine things just as you spend time with a hard problem, really.

Troy Woodard: Right, yes.

Paul Bryson: Yes.

Troy Woodard: And it's very interesting. Last year, we were at our annual academy meeting, and I was walking with one of our residents, and someone came up to me and said, "Oh, yeah, I heard you take care of patients with HHT," and I said, "Yes, I do." He says, "Oh, it's so hard. I really don't like that disease," and blah, blah, blah, blah, blah. And so, I explained to that person my technique and how it's really revolutionized how I even treat these patients. And so, when we were leaving, my resident was like, "What is he talking about? They're pretty easy to take care of." And I say, "That's because we have a great system, and we utilize sclerotherapy."

Paul Bryson: Right.

Troy Woodard: Yes.

Paul Bryson: And he's coming here. She's coming into this after several years of you refining the technique.

Troy Woodard: Right. And so, what's interesting, that provider was used to, again, treating these patients, having them show up unexpectedly multiple times in the emergency room, come into the clinic with massive bleeding, actively bleeding, and after I started doing or performing sclerotherapy, we don't have that. And so, what tends to happen is we will first see the patient in our office very careful not to disrupt any blood vessels, so they won't bleed, develop a treatment plan where there's topical therapy or surgical therapy. And then we can see them virtually if they start to have bad nose bleeds subsequent to their surgical procedure.

Usually, patients begin to contact me around month nine or month 10 after the procedure, and so we don't wait till they're extremely bad. Once they start to worsen, then we plan the surgical procedure again, and that way, they're comfortable. They're not experiencing these massive nose bleeds. We are not experiencing the treatment of these massive nose bleeds in the clinic or over-utilizing some resources in the emergency room. So, I think, again, it's very beneficial.

Paul Bryson: Yeah. No, that's great. And the way that you've employed virtual visits and telehealth to take something that is non-elective and kind of make it elective, it really empowers the patient and the healthcare team, right?

Troy Woodard: Right, right. Exactly.

Paul Bryson: Yeah. Well, I really appreciate your time today. As we wrap up, any final take home messages for our listeners?

Troy Woodard: Well, if you know someone who has HHT, please feel free to refer them to the Cleveland Clinic. In addition, besides treating HHT in tumors, we also treat inflammatory disorders like chronic sinusitis and nasal polyps, even septal deviations, which could cause nasal congestion. We'll be happy to treat you. We have four fellowship trained rhinologists in our department. Thank you.

Paul Bryson: Yeah, no, I appreciate it. For more information on the Cleveland Clinic section of rhinology, sinus and skull-base surgery, please visit clevelandclinic.org/rhinology. That's clevelandclinic.org/rhinology. And to speak with a specialist or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr. Woodard, thanks for joining Head and Neck Innovations.

Troy Woodard: Thanks for having me.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access real-time updates from Cleveland Clinic experts in otolaryngology - head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.