Robert Lebovics, MD, has a famous observation in his practice: “It is amazing what you can see when you just take a look.” As an ear, nose, and throat physician who has specialized in treating autoimmune disorders that impact the airway for more than three decades, he likes to think of himself as the eyes and ears of his patients and other medical specialties—looking at places inside the nose, mouth, and windpipe where they cannot see.

Robert S. Lebovics, MD, FACS, Site Chair of Otolaryngology-Head and Neck Surgery and Co-Director of the Airway Center at Mount Sinai West

Autoimmune disorders occur when the body’s immune system mistakenly attacks healthy tissue and can cause significant damage to the upper airway.

Disorders like Sjogren’s syndrome, Systemic Lupus Erythematosus, and asthma, as well as rare conditions like granulomatosis with polyangiitis (GPA or Wegener’s granulomatosis), eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), relapsing polychondritis, and sarcoidosis, can cause inflammation to develop within the airway that restricts both blood and air flow. Patients may experience symptoms like coughing, voice changes, facial pain, loss of smell, and difficulty breathing, swallowing, or hearing.

“The airway is ultimately a pipe system,” says Robert Lebovics, MD, Site Chair of Otolaryngology-Head and Neck Surgery and Co-Director of the Airway Center at Mount Sinai West. “If a pipe in your house is blocked it can’t drain or supply water. In the case of autoimmune disease, inflammation forms in the inner lining of these tissues and may cause it to swell, scar, or bleed. The ability of air to move is diminished.”

Typically, patients are diagnosed with an autoimmune disorder by a rheumatologist or immunologist. If the disease is known to affect the airway, they are often referred to an ear, nose, and throat physician. In general, autoimmune diseases are more common in women than men.

Dr. Lebovics uses specialized instruments like a bronchoscope — a thin tube with a camera that is inserted through the mouth and down the throat—to visualize the airway, voice box, windpipe, upper bronchi, and related structures. Even if patients are not experiencing symptoms like difficulty breathing or painful swallowing, it is vital to get a baseline breathing evaluation.

“The best way to deal with a problem is to prevent it,” says Dr. Lebovics. “I do a lot of surveillance. Sometimes patients do not have any damage yet, and other times they come to me and I see they have been breathing through a three millimeter airway that is significantly scarred from Wegener’s or relapsing polychondritis.”

Treatment for Autoimmune and Airway Disorders

Autoimmune and airway diseases are rarely curable and require lifelong monitoring and management. Many of these conditions have a high incidence of relapse and may be life-threatening if left untreated.

Fortunately, there are many therapies that can help. Depending on the severity of disease, patients may need medications like steroids and immunosuppressants, pulmonary rehabilitation, or surgical interventions. Dr. Lebovics works closely with rheumatologists and pulmonologists to develop a personalized treatment plan for every patient. For example, many individuals with granulomatosis with polyangiitis or Wegener’s have associated ear conditions. “These conditions can be multisystem disorders,” says Dr. Lebovics. “It is critical for physicians to work together and create long-term monitoring relationships with their patients.”

COVID-19 Impact on the Airway

Now, more than ever, it is important for anyone experiencing a breathing problem in the nose, mouth, or chest to seek medical attention. If someone becomes infected with COVID-19, it may cause damage to the lungs and lining of the airway. When someone is gasping for air, they often call 911 or visit the closest emergency room. But those who experience slower changes, like finding it progressively harder to climb the stairs or making noises when they breathe, often do not seek treatment fast enough.

“On a simple level, breathing is not underrated, and your physicians need to help you move air,” says Dr. Lebovics. “At Mount Sinai, we have a niche practice that specializes in treating rare disorders of the airway and autoimmune system, and a track record of success in partnering with patients living with chronic disease to improve their quality of life.”

Approximately 15 percent of adults in the United States experience debilitating symptoms of chronic rhinosinusitis (CRS), which include congestion, runny nose, and headache. Far fewer, however, seek the advice of a physician. Satish Govindaraj, MD, Chief of Rhinology and Sinus Surgery, at the Mount Sinai Health System, discusses a variety of innovative treatments that have significantly improved the quality of life for tens of thousands of patients each year.

Satish Govindaraj, MD, Chief of Rhinology and Skull Base Surgery at the Mount Sinai Health System

What is chronic rhinosinusitis?

Most of us have had a runny or stuffy nose at some point in our lifetime. When these symptoms last for a few days or even weeks you may be diagnosed with a condition known as acute sinusitis. Chronic rhinosinusitis (CRS), however, occurs when the sinuses passages—four pairs of hollow cavities in the nose and head—swell and are unable to properly drain for a period of three months or longer.

What are the symptoms?

Patients with CRS typically experience persistent nasal drainage, congestion that impacts their ability to breathe, headache, facial pain or pressure, fatigue, and difficulty smelling or tasting. These symptoms can have a tremendous impact on your ability to work and enjoy leisure time.

What treatments are available?

When the sinus passages swell and are unable to drain, mucus gets stuck and can become infected. The key to treating CRS is to reduce this inflammation. The first line of defense is always medical management, including nasal saline irrigations that flush out the nasal passageways, topical steroids sprayed into the nose to reduce swelling, and oral antibiotics which treat infection. If medical management fails, numerous surgical options are also available. Mount Sinai’s ear, nose, and throat specialists (otolaryngologists) are highly trained in a variety of minimally invasive procedures that can be performed in the office setting without making an incision.

Am I a candidate for balloon sinuplasty?

We partner with patients to develop an individualized treatment plan based on their unique anatomy, symptoms, procedure tolerance, and medical history. Patients with CRS are typically eligible for balloon sinuplasty if their symptoms have not improved with medical management and they have had four or more sinus infections in one year.

How does balloon sinuplasty work?

Balloon sinuplasty opens up the nasal passageways. During this in-office procedure, a thin wire or probe with an attached balloon is guided through the nose into the swollen sinus cavity. When the balloon is in the correct spot, it is inflated and dilates the blocked passageway—similar to the way a stent is used to open up a clogged artery. The sinus cavity is then irrigated or flushed with salt water to allow the trapped mucus to drain out.

What distinguishes Mount Sinai with balloon sinuplasty treatment?

Many of our ear, nose, and throat physicians are fellowship trained in sinus surgery and receive additional education in performing the balloon sinuplasty procedure. Mount Sinai surgeons also specialize in using image-guided CT scans to precisely navigate tiny instruments through the nasal passageways. As a large, tertiary medical center reputable for managing complex cases, patients can feel safe knowing there is a multidisciplinary team at every surgeon’s fingertips. We have multiple locations throughout New York City, making it easy to find care close to home.

What are the benefits of balloon sinuplasty?

Research shows numerous advantages to having a balloon sinuplasty, compared to traditional sinus surgery. These include:

• Faster recovery time — patients report fewer missed days of work or school
• Use of local sedation rather than general anesthesia — the procedure is performed in a doctor’s office rather than an operating room using numbing agents and IV sedation when necessary
• Shorter operating time — depending on how many sinus cavities are affected, the procedure typically takes one hour
• Comparable outcomes to more invasive sinus surgeries in patients with mild to moderate chronic sinusitis
• Fewer side effects, including pain, soreness, and congestion — the surgery does not require an incision or any tissue or bone to be removed
• Minimal follow-up care — there is no nasal packing after the operation

What is the follow-up treatment? Will my CRS return?

A balloon sinuplasty procedure causes minimal disruption to daily life—most patients return to work the next day. In an abundance of caution, individuals who have sinus surgery should not exert themselves physically for a few days. Follow-up appointments are typically made in one to two weeks. The overwhelming majority of patients who have balloon sinuplasty notice a significant improvement in their symptoms. The length of time individuals experience benefit depends on the severity of their disease and whether or not they have other compromising disorders such as allergies or immune system conditions. To ensure success, it is important that patients continue to take their medication regularly after surgery and properly irrigate their sinuses with nasal rinses.

Physicians are taught to make recommendations based on research and experience. But Marita Teng, MD, Professor of Otolaryngology – Head and Neck Surgery at Mount Sinai, often finds herself telling patients that decisions in thyroid cancer surgery are becoming as much personal as medical. The ‘right’ decision regarding whether to biopsy a thyroid nodule, or how much surgery to have, she explains, is different for every patient.

Marita Teng, MD, Professor of Otolaryngology – Head and Neck Surgery at Mount Sinai

This is particularly true in the field of thyroid cancer, where so much of the thinking and approach has changed in the last five years. The American Thyroid Association (ATA) published more than 100 new recommendations for the treatment of thyroid cancer in 2015. One of the most remarkable changes, and difficult decisions for patients, is determining what type of surgery to have.

“We are living in an age of information being at people’s fingertips and a culture where shared decision-making is more prevalent,” explains Dr. Teng. “Many times, there is not simply one right treatment path. Clinical outcomes are important, but decisions also depend on what feels right to the patient.”

Choosing between Total Thyroidectomy and Hemithyroidectomy

For decades, total thyroidectomy—a surgical procedure which removes the entire thyroid gland—was considered the gold standard treatment for most thyroid cancers. However, the latest ATA guidelines advocate that removing half of the thyroid gland, a procedure known as hemithyroidectomy, is as beneficial as having a total thyroidectomy in patients with well-differentiated cancerous growths measuring up to four centimeters.

“Some individuals who have thyroid cancer want the entire organ out of their body, so they do not have to worry about having problems with the other side. Other patients want to have as little surgery as possible. After I give these options to my patients, they frequently know exactly which one resonates with them,” explains Dr. Teng.

The Consideration of Thyroid-Stimulating Hormone Post Surgery

There are pros and cons to both hemi- and total thyroidectomy. One of the most important differences is the need for thyroid-stimulating hormone after surgery. The thyroid produces hormones that help regulate important body functions such as the heart rate and metabolism. When the entire thyroid is surgically removed, patients must take synthetic thyroid hormone for the rest of their lives. When half of the thyroid remains intact, close to 90 percent of patients can maintain normal thyroid function without medication.

“Some people shrug it off when I tell them they have to take medicine every day; others absolutely do not want to take a pill,” Dr. Teng says. “I also explain that some patients can be more difficult to regulate with medication than others. It really depends on how much that inconvenience strikes them.”

What Are the Risks of Thyroid Surgery?

The surgical risks of any thyroid procedure are small. But the likelihood of the rare complication, such as injury to the nerve that controls the voice, is cut in half with hemithyroidectomy because the procedure involves only one side as opposed to both. The recovery for both operations is about the same.

One potential downside to hemithyroidectomy, however, is that the remaining side will require monitoring and may potentially need to be removed later. In a small number of patients, a later biopsy finds cancer in the side that was thought to be unaffected.

“We can predict a fair amount before we operate. When I counsel patients, I try not to give them a recommendation that could bring them back to the operating room again,” explains Dr. Teng. “But by taking out the entire gland you never have to worry about that small chance you may need another thyroid operation.”

Dr. Teng says it is important that patients are informed, because implementing new guidelines into widespread practice can be a challenge. In fact, it takes an average of 17 years for an established medical guideline to become common practice. That means it could be be 2032 by the time these 2015 ATA guidelines are consistently followed throughout the country. Patients who were told total thyroidectomy was their only option often see her for a second opinion.

Mount Sinai Provides Patients with a Personalized Approach

“At Mount Sinai, we provide a personalized approach to every case and are up to date on current practice guidelines. We have a multidisciplinary team; for complex cases, our recommendations are evaluated carefully as a group of surgeons, endocrinologists, nuclear medicine specialists, and sometimes even medical and radiation oncologists.  We are thankful to be able to engage our patients in this collaborative decision-making process,” says Dr. Teng.