January 23, 2018

New Procedure for Obstructive Sleep Apnea

I am excited to announce a new option for patients suffering from obstructive sleep apnea, the Inspire.

Check back for updates over the next few weeks to learn more about sleep apnea and this exciting new procedure.


You can also check out the Inspire website for more details.

How to Pick Your Thyroid Surgeon: How many thyroidectomies does your surgeon perform each year?

This study was published recently in the Annals of Surgery.   We have known for a number of years that “high-volume” thyroid surgeons tend to get overall better results and lower complication rates than “low-volume” thyroid surgeons.   The term ‘high-volume’ or ‘low-volume’ simply refers to how many thyroid surgeries a surgeon does in a year.   This study tries to put a specific number on what constitutes a ‘high-volume’ surgeon, or in other words, what is the minimum number of thyroid surgeries your surgeon should be doing per year, in order to acheive the best results?   The answer is more than 25 thyroid surgeries per year.    So if you are needing thyroid or parathyroid surgery, go ahead and ask your surgeon how many of these surgeries they do a year.  If the answer is less than 25 / year you might want to consider finding a higher volume surgeon.   If the answer is < 5 per year, you should definitely look for a higher volume surgeon.

Is There a Minimum Number of Thyroidectomies a Surgeon Should Perform to Optimize Patient Outcomes?

Mohamed Abdelgadir Adam, MD; Samantha Thomas, MS; Linda Youngwirth, MD; Terry Hyslop, PhD; Shelby D. Reed, PhD; Randall P. Scheri, MD; Sanziana A. Roman, MD; Julie A. Sosa, MD, MA

Annals of Surgery. 2017;265(2):402-407.


Objective: To determine the number of total thyroidectomies per surgeon per year associated with the lowest risk of complications.

Background: The surgeon volume–outcome association has been established for thyroidectomy; however, a threshold number of cases defining a “high-volume” surgeon remains unclear.

Methods: Adults undergoing total thyroidectomy were identified from the Health Care Utilization Project-National Inpatient Sample (1998–2009). Multivariate logistic regression with restricted cubic splines was utilized to examine the association between the number of annual total thyroidectomies per surgeon and risk of complications.

Results: Among 16,954 patients undergoing total thyroidectomy, 47% had thyroid cancer and 53% benign disease. Median annual surgeon volume was 7 cases; 51% of surgeons performed 1 case/y. Overall, 6% of the patients experienced complications. After adjustment, the likelihood of experiencing a complication decreased with increasing surgeon volume up to 26 cases/y (P < 0.01). Among all patients, 81% had surgery by low-volume surgeons (≤25 cases/y). With adjustment, patients undergoing surgery by low-volume surgeons were more likely to experience complications (odds ratio 1.51, P = 0.002) and longer hospital stays (+12%, P = 0.006). Patients had an 87% increase in the odds of having a complication if the surgeon performed 1 case/y, 68% for 2 to 5 cases/y, 42% for 6 to 10 cases/y, 22% for 11 to 15 cases/y, 10% for 16 to 20 cases/y, and 3% for 21 to 25 cases/y.

Conclusions: This is the first study to identify a surgeon volume threshold (>25 total thyroidectomies/y) that is associated with improved patient outcomes. Identifying a threshold number of cases defining a high-volume thyroid surgeon is important, as it has implications for quality improvement, criteria for referral and reimbursement, and surgical education.

Nose Sprays for nasal congestion (Flonase, Nasacort)


Over the past year two prescription nose sprays became available to the consumer over-the-counter.  You no longer need to go see a doctor, and get a prescription.  You can just stop by your local pharmacy and pick up the medication on your own, and start using it.

These nose sprays are classified as “topical corticosteroid” sprays.   We know that they have effective anti-inflammatory properties.  The effect of this is to decrease the degree of swelling and congestion in the nasal tissues, and decrease the degree of “runny nose”.    You may find relief of these symptoms:  nasal congestion, runny nose, itching of the nose / eyes, sneezing.

These medications are useful in treating nasal allergy symptoms, but also in treatment of non-allergic nasal symptoms, and sinusitis.

Go ahead and try them.   You should give it a 2-3 week trial to see how well it works for you.  Some people prefer Flonase and some people prefer Nasacort – you’ll have to try for yourself.

Sinus surgery for mucocele

I recently treated a patient with a frontal sinus mucocele.  This condition is much different than the more common “mucus retention cyst” that many patients have in their sinuses.  A “mucocele” slowly enlarges and expands over time, and can result in problems if it erodes into the orbit (eye) or the cranial cavity (brain).  For this reason, surgery is usually necessary to treat sinus mucoceles, but mucus retention cysts can often be observed.

These images show the mucocele in the frontal sinus which is about 4.0 cm wide (1.6 inches).  Fortunately for this patient, the mucocele had not yet expanded into the orbit or cranial cavity.  It was treated with an endoscopic surgery approach through the nostrils, with no external incision or scar.


Frontal sinus mucocele

Frontal Sinus Mucocele (coronal view)


Frontal Sinus Mucocele (axial view)

Frontal Sinus Mucocele (axial view)






Parotid surgery

The past few months I have seen in increase in parotid tumors (about 5 patients).  Parotid tumors are growths in the parotid gland.  The parotid gland is one of the “major” salivary glands.  It is located in the cheek and jaw area (below the ear).

Here is a diagram of the parotid gland (From: Blausen.com staff. “Blausen gallery 2014“. Wikiversity Journal of Medicine.)



Patients usually don’t have pain, but just notice a lump or mass in the cheek, or below the ear.  The tumor or mass can be either benign or cancerous.  Fortunately most are benign.  Evaluation of the parotid mass includes a physical exam at my office, and often includes a fine-needle biopsy and a CT scan.

Surgery is recommended for many patients with parotid tumors.  Surgery is helpful even for the benign tumors because they will just continue to get larger and larger, and potentially put pressure on nearby nerves/vessels.  Some benign tumors will even degrade into a cancer if left alone for many years.

The surgery is a meticulous one – taking a couple of hours.  The surgeon must find the facial nerve and trace out its branches – which travel right through the parotid gland.  The recovery from surgery is usually well-tolerated by patients.  Pain is minimal and the scar is typically not very noticeable.


Mini CAT CT scanner

One critical tool for diagnosing and treating chronic sinus problems is a CT scan (x-ray) of the face and sinuses.  Just as recently as 8-10 years ago we had to send patients over to the hospital to get this done, then see them back in our office, requiring two extra visits, and a couple of weeks time.  The Mini CAT was developed as an in-office CT scanner, saving you (the patient) a lot of time traveling between hospitals and clinics.  Now this can usually all be done on the same day – just one visit.








It is very “patient-friendly”.  As you can see in the photo above, the scan is obtained sitting in a chair.   This tends to be much more comfortable than having to lie down flat on a table.   The actual scan is done in less than a minute.  The amount of radiation exposure is much lower with this kind of CT scanner compared to the traditional CT scanners.  In fact there is 90% less radiation exposure using this compared to conventional CT scanners.

My office (Peak Ear, Nose, & Throat) in Provo was one of the first clinics in Utah to have this great addition to our medical practice.  We have been using it with great patient satisfaction since about 2006.   We are an IAC accredited facility for performing sinus CT scans in our office.


It’s allergy season in Utah!

Here is a nice write-up in the Deseret News newspaper about allergies, and includes quotes from two of my allergy patients that are treated here at our Peak ENT Allergy department.


Click here for article


Video clip of how to do saline sinus rinse (nasal rinse)

I have written a previous post about the benefits of nasal saline irrigations.  Here is a video clip showing how to do it with the NeilMed rinse kit.  Click on the link below:


Video of Sinus Rinse



Sinusitis vs. Rhinitis – what is the difference?

As medical professionals we tend to come up with a lot of medical terminology that people may find confusing.   When you have sinus problems you might call this a “sinus infection” or a “sinus headache.”   As doctors we tend to use words like “rhinitis” and “sinusitis” and then we combine the two words for “rhinosinusitis.”   There is a lot of overlap between symptoms of rhinitis and sinusitis, such as nasal congestion and nasal discharge.


“Rhinitis” – means inflammation of the nose.  (Think rhinoceros –  NOSE).     This term usually refers to the nasal cavity proper- which means the air passages and tissues just beyond the nostrils.   It does not necessarily involve any sinuses which are adjacent to the nasal cavity.  A frequent cause of rhinitis is allergies.


“Sinusitis” – means inflammation of the sinuses.   The sinuses are spaces separate from, and lying right next to the nasal cavity.  When the sinus tissues become swollen, and infected this is called “sinusitis”.

See diagram of sinuses.


“Rhinosinusitis” is a term suggesting inflammation of both the nasal cavity and the sinuses.  This is probably the most accurate description of what is going on in patients with chronic sinus problems.

During the office visit, I will spend time reviewing your history and symptoms to conclude exactly what type of problem you have and how to best treat it.

When is thyroid surgery needed?

Most people never want to have surgery.  But there are times when it’s necessary.  There are three main reasons that we do thyroidectomy (thyroid surgery, or removing the thyroid gland).

The first reason is to remove a thyroid mass/nodule that is a cancer, or has suspicious characteristics.  By “suspicious” we mean it has the potential to be a cancer.  Things that might make it suspicious include the results of a needle biopsy, a family history of thyroid cancer, or the sheer size of the mass. _2

Another reason for thyroid surgery is to remove a gland that has become so large (even though it is non-cancerous) that it causes trouble swallowing, or breathing, or compresses other structures in your neck.   An enlarged thyroid gland like this is called a “goiter”.  Thyroid goiter - neck

A third reason for thyroid surgery is to remove a hyperactive gland which is secreting too much hormone.  These hyperactive glands are sometimes treated with medications, or with radioactive medicine, but surgery is also a good option.


Thyroid surgery is typically done under general anesthesia, and it is common to spend one night in the hospital.  Sometimes you might be able to go home the same day.