Course Director: Scott Graham, MD (scott-graham@uiowa.edu)

Contact person for the rotation: Julie Kobliska (julie-kobliska@uiowa.edu)

Return to: Medical Student Instruction

Structure of the Rotation

The Otolaryngology sub-I for elective students is a 4-week rotation that is split between three inpatient services: Otology, Pediatrics, and Head & Neck. General Otolaryngology and Facial Plastic Surgery patients are divided amongst these teams.

The Otolaryngology Department is unique in how the teams are structured. Students attend morning rounds with their assigned team but have the freedom to move around to different clinics and OR cases during the day. For example, if you are a student assigned to the pediatric team, you will round with your team each morning, but could choose a different clinic or OR case during the day. In other words, you are not restricted to just Pediatric clinics or OR cases when you are on the Peds team.

The advanced rotation clinic and OR experience is flexible, so students can pick their own schedule and help where needed, as long as you are productive each day. Having this flexibility is favorable especially when there are multiple Sub-I's on the rotation. 

Students are assigned 2 weeks in Head & Neck, and 1 week each in Pediatrics and Otology. Teams are pre-assigned prior to the start of the rotation so you know where to begin your week(s). You’ll receive the daily OR and weekly clinic schedule, so as you plan for the days and week ahead, communicate with the other students (if any) so that there isn’t any overlap in any one particular clinic or OR.

We want students to get the most out of their time here, so we encourage you to spend time in each of the clinics. Engage with our faculty & residents and ask questions. Not only does this leave a good impression, but also helps lay the foundation for success in your medical career.

General Tips

Rounding Expectations:

• Student will round with their assigned team each morning before clinic/OR. The exact time and place changes from day to day. Students will receive a rounding email each evening with meeting time/location and are assigned one to two patients to pre-round on and present.
• Pre-rounding on the Pediatrics team consists of getting numbers and touching base with the nurse to ask about any overnight events. We do NOT ask students to see kids on their own before rounds - we try to let them sleep, then wake them up together as a team.
• It is generally helpful to write progress notes on the patients you were assigned to for rounds. You will share the note, then the junior resident also assigned to that patient will sign it. Assist with any floor work including suture removal, removal of drains, advancing penroses, trach changes, etc. Anticipate floor work and have supplies ready for rounds in the morning or pre-rounding. (Discuss with resident ahead of time to avoid pulling drains or removing dressings too early).
• Help prepare discharge summaries - can be done in the days prior to the day of discharge so resident can addend as necessary.
• Follow-up on labs, consults, radiology, pathology and discuss with resident any necessary orders.
• Think about the meaning of pathology: determine if radiation oncology or hematology oncology consults are necessary.
• Think about what is keeping the patient in the hospital. The goal is to discharge the patient to home or an appropriate facility.

After your clinic/OR responsibilities during the day, it’s recommended to touch base with a member of the team to ensure there are no other tasks to take care of before heading home. We round on most of our patients each afternoon, but the time is variable and depends on when members of the team are available. If you're around to join us, great; if you're still busy in clinic or the OR, it's no problem at all.

Clinics

• Resident assignments are made on a weekly basis for each clinic.
• Introduce yourself to the staff at the beginning of clinic.
• Ask the staff their preference for which patients they would like you to see (new patients vs return patients).
• There is a Clinic Note template in Epic used for all clinics. Indicate the staff as the co-signer and sign the note when it is completed so the staff may sign.
• All patients need to have a diagnosis and a problem list. If you do not know how to do this, ask the resident in clinic for help.
• You should not attempt to clean patient's ears in clinic- this should be done by staff, resident, or fellow.
• Many patients will be scoped during clinic. Patients should be sprayed prior to staffing so they are ready for scoping. If you are unsure if they will need to be scoped, ask the resident or the staff prior to applying the topical anesthetic.
• The quickest place to grab a bite if you get a chance is the Melrose cafeteria (5th floor above the clinic) or coffee is 1st floor of Pomerantz (below the cancer center)

Other Notes

• Students are expected to attend didactics, Grand Rounds and Tumor Boards. You will receive calendar invites each week.
• By the 3rd week of the rotation, please provide a copy of your institution's evaluation form along with a list of faculty & residents you have worked with the most to Julie Kobliska. She will have forms completed and returned back to your academic advisor.

Team-specific Tips

Hints for Head & Neck:

• Suture removal ~ 1 week postop unless history of radiation then 2 weeks.
• Drains:
  • JP drain outputs are reported in 8 hour shifts for a total of 24 hours. Drains are removed when output less than 30 cc/24 hour
  • Penrose drains: Usually advance 1-2 cm per day once start advancing. Penrose drains have to be stitched in place. Put a loop in the skin and then stitch the loop to the drain. Trim the penrose so around 1.5 cm is sticking out from the skin.
• Trach: cuff down POD 1 (or once off ventilator), change POD 3-5, if free flap then sutured in place (NO STRAPS)
• Pain management: typically lortab or oxycodone, morphine for breakthrough. Palliative consult if difficulties with pain control.
• All patient should be on bowel regimen: typically colace, may add senna, milk of magnesia, miralax, dulcolax suppository
• Antibiotics:
  • If need home antibiotics: IV unasyn switched to PO augmentin, IV ancef switched to PO keflex, IV clindamycin switched to PO clindamycin
  • Thyroids and parathyroids clean cases, do not require antibiotics.
  • If nasal packing in place, need to go home on antibiotics (staph coverage).
• Total laryngectomies:
  • Tube feeds- start clear diet POD 7-10
  • Fever or WBC POD 5+ may be sign of fistula formation
  • Often leave medial drain over pharyngeal closure as last drain to be pulled to monitor for fistula
  • Often have bivona stent in stoma to help prevent stenosis or prevent soft tissue collapse
  • All patients need speech path consult while in hospital for temporary electrolarynx
• Free flaps: You will likely see a number of flaps while on service. This information may be useful to refer to when preparing for rounds.
  • Common flaps: radial forearm free flap (RFFF), fibula, latissimus, pectoralis
  • Flap checks: doppler, palpate, appearance (white: arterial occlusion, dusky: venous congestion)
  • Anticoagulation regimen varies by staff:
    • Dr Chang: Aspirin 325 mg daily, heparin 5000 units subQ BID
    • Dr Pagedar: Heparin 5000 units subQ TID
    • Dr Bayon: toradol (15-30 mg) Q6H (unless renal dysfunction) x 5 days, heparin 5000 units subQ BID
  • Radial Forearm:
    • Dr Chang: splint off POD 5, wound vac/bolster off POD 7
    • Dr Pagedar: cast and bolster off POD 7
    • Dr Bayon: cast and wound vac off POD 7
  • Fibula Flap:
    • Dr Chang: non-weight bearing until POD 4, toe touch POD 4-7; cast off POD 5; wound vac off POD 7
    • Dr Pagedar: toe touch until POD 4 then may walk; cast off POD 5 (replace ace wrap over soft roll); dressing on until POD 7
    • Dr Bayon: non-weight bearing until POD 4, toe touch POD 4-7; cast and wound vac off POD 7
  • Skin graft donor site:
    • Dr Chang: tegaderm off POD 7
    • Dr Pagedar: allevyn pad off POD 10
    • Dr Bayon: tegaderm/xeroform off POD 7 

Hints for Otology:

• Mastoid dressing changes daily for Dr Gantz patients, every other day for Dr Hansen patients.
• All patients should be on stool softeners with pain medication to avoid straining.
• Suture removal 7-10 days postop for Dr Gantz patients, 10-14 days for Dr Hansen patients.
• Patients with strip gauze in the ear return in 1 week for packing removal, home on PO antibiotics.
• Patients with gelfoam in the ear use drops until the time of follow-up (usually 1 month)
• MCF (middle cranial fossa) and translab:
  • Admit to SICU postop then transfer to floor on POD 1.
  • 48 hours Ancef
  • 48 hours decadron (patient on PPI and sliding scale insulin while on decadron)
  • Tylenol 3 or codeine for pain
  • No valium or ativan for vertigo
  • Usually discharge POD 3-5
  • F/u in 1 months with MRI (+audio if MCF)
• Canal wall reconstruction: 
  • 48 hours admit for IV zosyn and cipro, f/u 1 week for packing removal, drops to ear until 1 month f/u
• Stapedectomy: 
  • 23 hour admission, start drops at discharge, f/u 1 month
• Cochlear implant: 
  • 23 hour admission, keflex x 1 week, suture removal 1 week, f/u 3-4 weeks for activation
• Hybrid cochlear implant: 
  • 23 hour admission, keflex x 1 week, steroids for 1 week postop and for 1 week starting day before activation, f/u 3-4 weeks for activation