Multidisciplinary Team Work is Necessary for the Optimization of Clinical Effectiveness in Otorhinolaryngology: Implications from a Case Paradigm

Dear Sir,

The hospital either as an asclepeion, a monastery, or even a modern university institution has always been the place where every socioeconomic group has sought healthcare (1). However, the modern orientation toward a patient-centered healthcare necessitated the maximization of clinical effectiveness through multidisciplinary team (MDT) work. MDT comprises a group of healthcare professionals of varied disciplines and roles but complimentary experience, qualifications, and skills who work together toward the common goal of providing optimal care for a patient (2). Hence, there can be little doubt that MDT work represents the main mechanism to truly ensure holistic care and a seamless service for patients throughout their disease trajectory (3).

Before the early 1990s, only a relatively small proportion of Ear Nose and Throat (ENT) patients, namely those with cancer, benefited from their care being managed by MDT work. Although such teams may have had existed for decades in some hospitals, especially in the UK, MDT work was the exception and not the rule pertaining to ENT. As a result, some factors relevant to decision-making were being missed, and in some challenging cases, ENT patients were not receiving optimal treatment.

Although MDT work has currently been accepted as the standard of care for patients with head and neck cancer, it seems prudent to extend this care model to most, if not all, ENT subspecialties. The disease paradigm, which is presented, involves a 22-year-old male patient with typical Cogan’s syndrome, who presented to the ENT Accident and Emergency Department with a sudden onset of hearing loss, vertigo, and instability. The patient was subsequently diagnosed with bilateral interstitial keratitis by an ophthalmologist, but his profound sensorineural hearing loss did not improve despite treatment with high doses of intravenous steroids. After systemic autoimmune disease had been excluded and following an MDT meeting with ENT, ophthalmology, and rheumatology input, a decision was reached to start the patient on infliximab, a chimeric monoclonal antibody typically used in the treatment of various autoimmune conditions (rheumatoid arthritis, psoriasis, etc.) and off-label in Behçet’s disease. The patient underwent four monthly cycles of infliximab without substantial improvement and a trial of azathioprine with limited benefit. He is now wearing bilateral hearing aids, pending approval for cochlear implantation.

Multidisciplinary team work implies the willingness to share and indeed give up exclusive physician claims to specialist knowledge and authority if the patients’ needs can be more effectively met (4). In this context, ENT MDTs should not only be established with regard to head and neck cancer but also replace the occasional osmosis of knowledge between medical and/or surgical specialties by being extended to most, if not all, ENT subspecialties. Despite the rather disappointing disease outcome in the presented patient, which, however, was closely related to the physical history of Cogan’s syndrome (5), creating MDTs with cohesive structure across the entire ENT spectrum is likely to help ENT surgeons to overcome the challenges associated with perplexing cases as clinical decision-making is increasingly shifting toward patient informed consent at the turning of the second decade of the 21st century.