Check Up with Samer Fakhri

by MainGate Staff
Spring/Summer 2020

Dr. Fakhri is professor and the chair of Department of Otorhinolaryngology and Head and Neck Surgery at AUBMC.

Can you describe your area of specialty?

My field is otorhinolaryngology—head and neck surgery—commonly referred to as ear, nose, and throat (ENT). “Oto” means ear, “rhino” means nose, and “layrngo” refers to the throat. Within this specialty, there are subspecialties. Mine is focused on the “rhino” part, so that’s everything that has to do with the nose and sinuses.

What are the most common issues you see patients for?

I exclusively treat patients that have complaints related to their nose and sinuses, and tumors of the base of the skull. The most common complaint for patients visiting my clinic is nasal obstruction, that is, they can’t breathe through their nose. This could be due to a number of causes such as allergies, chronic sinus infections, or nasal polyps (a painless benign growth on the lining of the nose or sinuses). A very small percentage are referred for tumors inside their nose and sinuses.

What are some of the procedures you perform?

The most common procedures I perform are endoscopic sinus surgeries (ESS), as well as surgery on the nasal septum (when necessary) to improve nasal breathing. I also do endoscopic skull-based surgery on tumors at the base of the skull, the base of the brain. This is performed in conjunction with a neurosurgeon. Instead of cutting the skull from the outside and lifting the brain to get to the tumors out, we now insert a small camera and instruments into the nose to reach the area of the tumor and deal with it in a minimally invasive fashion.

Does insurance in Lebanon typically cover these procedures? What do they cost out of pocket? How much is covered?

In general, these procedures are fully covered by private and government insurance. Most of the conditions I deal with are quality-of-life issues and chronic conditions, not cosmetic procedures. Typically, we do a full evaluation of patients in our state-of-the-art clinic. For patients with nasal obstruction and sinus issues, the initial treatment is medical therapy, such as anti-allergy medication and nasal sprays and sometimes antibiotics. If they don’t respond to medical therapy, then surgery might be the appropriate next step.

 How do patients come to see you? Is the process by which they arrive at your office different in Lebanon than in the United States?

In Lebanon, the referral patterns are different than those in the US. Here, people come to the super specialist right away—even with, say, a cold, they’ll go right to the ENT doctor. Ideally, the common cold and other basic problems should be seen first by a general practitioner, and only referred to the specialist or super specialist if the issue is complicated or treatment resistant. Otherwise, the resources will be strained and the cost of care delivery will increase. The only system that relies on referrals in Lebanon is AUB’s Health Insurance Plan, which covers AUB employees. It is analogous to an HMO (health maintenance organization) in the US.

Given the current political debate in the United States and elsewhere concerning healthcare systems, could you comment on your preferred system?

I participated in three different healthcare systems: the Canadian, the American (which is almost financially and philosophically opposite to the Canadian system), and the Lebanese, which is somewhat similar to the US, but much more disorganized.

I think there are merits to each of these systems, but the mushrooming costs of the US healthcare systems show that it’s unsustainable. Healthcare costs make up almost 20 percent of GDP in the United States, whereas in Canada, it’s about 11 percent. One upside to the US system is its overall responsiveness and quality of service delivered to individuals even for elective treatments. In addition, acquisition of newer technology is easier, but that contributes to rising costs.

Canada has better overall health service performance and better life expectancy. The problem is that if you have an elective problem in Canada, you’re going to wait a long time, sometimes over a year to see a doctor or to have surgery. If you have a serious or life-threatening issue such as cancer or a cardiac issue, you’ll get quick access to high-quality care. Philosophically, in the US, healthcare is a commodity to be bought and sold for profit; in Canada, it’s considered a human right.

I guess the best model is somewhere in the middle, a two-tiered system, like you have in some parts of Europe and the far east. I support the principle of universal access to care as long as it is efficient and cost sensitive. I had a patient in the United States die of cancer because she couldn’t afford the care. It’s not only shocking but unconscionable to have patients fall through the cracks and die in any society because they can’t get treatment.

Do you see more or less of a certain kind of issue or condition in Lebanon as compared to in the United States?

Since access is open in Lebanon, I see a larger volume of basic conditions. In Houston, I used to see a larger volume of more advanced sinus and skull base cases, mostly referred by colleagues in general ENT. Here you do not get as many referrals from other ENTs.

There are high rates of rhinoplasty in Lebanon. Can that cause sinus issues?

Yes, that’s right—it can cause nasal and sometimes sinus problems. A high percentage of the population gets rhinoplasty. I do see a lot of patients who have had rhinoplasty come to see me because of breathing issues following surgery. Their breathing may have worsened as a direct result of the surgery. A high proportion of these rhinoplasties are done by surgeons who focus on cosmetic improvements, while neglecting the functional breathing aspects.

What are some of the advances in rhinology that you’re excited about?

The way we view chronic rhinosinusitis (CRS) has changed over the years. It used to be viewed as an infection and treated with antibiotics. We now realize it is a very complex condition with different causes and mechanisms. One exciting trend is to “profile” each patient based on individual mechanisms of disease. This is called endotyping. We now look at the cells, molecules, and pathways involved in inflammation based on individual patient nasal tissue or blood analysis. We look at key receptors and focus on developing treatments that target these specific cells, molecules, or receptors. These novel drug treatments are referred to as “biologics.” Instead of using blanket treatments, we practice precision medicine and individualize treatment decisions based on the patient’s profile or endotype.

Any tips you can give our readers when it comes to sinus care and nose care?

Avoid smoking. There is a strong link between smoking and sinus related issues. Don’t overuse antibiotics, which can backfire on the sinuses by wiping out microbiomes (the healthy bacterial mix in the nose). Educate yourself and know when to seek medical attention.