Cost analysis of office-based transnasal esophagoscopy

Training for Awake, Office-Based Laryngeal Procedures-The Laryngology Fellow's Perspective

OBJECTIVE

The aim was to explore recent laryngology graduates' perspectives on their experience, competency, and challenges learning office-based procedures during fellowship training in the United States and Canada.

METHODS

Anonymous 22-item questionnaire survey was distributed electronically to fellowship-trained laryngologists having completed fellowship within past 5 years.

RESULTS

Ninety fellowship-trained laryngologists between 2018 and 2022 were surveyed. Response rate was 48.9% (n = 44), 1 declined participation, with 20 different fellowship programs represented. Fellows were frequently provided the opportunity to act as primary surgeon for most procedures, except for laryngeal botulinum toxin injection, diagnostic laryngeal electromyography, trans-nasal esophagoscopy, secondary tracheoesophageal puncture, and high-resolution pharyngeal manometry. A majority reported high (n = 27, 62.8%) or moderate (n = 12, 27.9%) confidence with vocal fold injection augmentation. Various techniques were taught: transoral (74.4%), cricothyroid (74.4%), thyrohyoid (69.8%), transcartilagenous (14.0%), and catheter-needle (25.6%). Numerous statistically significant associations with independent procedure involvement and competence were identified. Laryngeal botulinum toxin injection was a procedure performed with high frequency but low volume of independent fellow involvement, and the procedure with which fellows reported wanting more practice learning. Most common training barriers included patient being awake, patient consenting to trainee performing the procedure, and the technical challenge/complexity of the procedure. Teaching methods/tools largely focused on informal debriefing (97.3%) and case by case troubleshooting (81.1%).

CONCLUSIONS

Laryngology fellows are well trained with favorable perceived levels of competence for numerous office-based procedures, particularly vocal fold injection augmentation. Procedures for which fellows reported a low level of independent participation trended towards lower perceived competency.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:873-881, 2024.

Equipping your facial plastic clinic for office-based procedures

Office-based procedures can be a fulfilling part of the facial plastic practice with the right tools, personnel, and preparation. Equipping the clinic for office-based procedures has several unique considerations that ultimately impact its success. It is important to strategize preemptively regarding what treatments will be offered and the respective equipment that will allow the safe, cost-effective, and high-quality delivery of those treatments. Most procedures in the office-based setting are cosmetic in nature and there are often overlapping treatment modalities that target similar outcomes. Patient selection and counseling is a crucial step in preparing for office-based procedures in the effort to maximize patient satisfaction. Nearly all the most common facial plastic procedures can be delivered in the office-based based setting under local anesthesia and moderate sedation, depending on the expertise of the surgeon. To enable these and other categories of treatments, there are certain expensive pieces of technology that one might consider for their office-based practice and other fundamental supplies that are necessary for almost all practices. Though the initial investment in equipment can be costly, this article also discusses more affordable alternatives or third-party sales of devices and equipment. The field of facial plastic surgery is very dynamic and having both peer and mentorship networks is invaluable in navigating some of the financial decisions discussed herein. This article also briefly covers personnel, training, and accreditation considerations.

A systematic review: impact of in-office biopsy on safety and waiting times in head and neck cancer

Objective

This study aimed to assess the current literature on the safety and impact of in-office biopsy on cancer waiting times as well as review evidence regarding cost-efficacy and patient satisfaction.

Method

A search of Cinahl, Cochrane Library, Embase, Medline, Prospero, PubMed and Web of Science was conducted for papers relevant to this study. Included articles were quality assessed and critically appraised.

Results

Of 19 741 identified studies, 22 articles were included. Lower costs were consistently reported for in-office biopsy compared with operating room biopsy. Four complications requiring intervention were documented. In-office biopsy is highly tolerated, with a procedure abandonment rate of less than 1 per cent. When compared with operating room biopsy, it is associated with significantly reduced time-to-diagnosis and time-to-treatment initiation. It is linked to improved overall three-year survival.

Conclusion

In-office biopsy is a safe procedure that may help certain patients avoid general anaesthetic. It was shown to significantly reduce time-to-diagnosis and time-to-treatment initiation when compared with operating room biopsy. This may have important implications for oncological outcomes. In-office biopsy requires fewer resources and is likely to be cost-saving five-years following introduction. With high rates of sensitivity and specificity, in-office biopsy should be considered as the first-line procedure to achieve tissue diagnosis.

The assessment and management of globus pharyngeus

Globus is the sensation of a foreign body in the throat. Investigation and management of patients with globus is widely variable. Most investigations yield negative results yet incur varying patient morbidity and healthcare costs, while malignancy is vanishingly rare in the absence of red flag symptoms and ear, nose and throat examination findings. History taking is key and can help to identify possible causative pathology, directing further investigations and management if necessary. Treatment of globus mainly centres on patient reassurance and counselling, and may include reflux management, neuromodulation, or speech therapy in selected cases, and treatment of any identified cause.

Feasibility and Safety of Office-Based Transnasal Balloon Dilation for Neopharyngeal and Proximal Esophageal Strictures in Patients with a History of Head and Neck Carcinoma

The aim of this study was to assess feasibility and safety of office-based transnasal balloon dilation of neopharyngeal and proximal esophageal strictures in patients with a history of head and neck carcinoma. The secondary objective was to explore its effectiveness. This prospective case series included patients previously treated for head and neck carcinoma with neopharyngeal or proximal esophageal strictures who underwent transnasal balloon dilation under topical anesthesia. The target dilation diameter was 15 mm; if necessary dilation procedures were repeated every 2–4 weeks until this target was reached. Completion rates, adverse events, and patient experiences measured by VAS scores (0 = no complaints – 10 = unbearable complaints), dysphagia scores based on food consistency (0 = no dysphagia – 5 = unable to swallow liquids/saliva), and self-reported changes in swallowing symptoms were recorded. Follow-up was 2 months. Twenty-six procedures were performed in 12 patients, with a completion rate of 92%. One minor complication occurred, i.e. an infection of the dilation site. Tolerance of the procedure was good (median VAS = 2). The dysphagia score improved after a mean of 2.2 procedures per patient, however not significantly. Eight patients reported improvement in dysphagia, of whom 3 had recurrence of dysphagia within 1 month post-treatment. Office-based transnasal balloon dilation is a feasible and safe in-office procedure which is well-tolerated by patients. The dilations can improve dysphagia, although effects might be transient.

Development of the outer tube through transnasal endoscopy to reduce nasal pain and epistaxis

BackgroundRecently, transnasal endoscopy has become common in Japan. While transnasal endoscopy has many advantages, nasal pain and epistaxis are typical complaints. Consequently, we developed a new tube sheath system for transnasal endoscopy to reduce nasal pain and epistaxis. This new tube sheath system (outer sheath and inner tube) has been named Nasal Slider® and is produced by TOP Corporation, Japan.MethodsA tube sheath longer than the nasal concha is inserted to reduce pain along the nasal turbinate. Since the sheath is left in place, tubes can be passed through the nose multiple times without causing additional pain.A total of 34 consecutive patients (mean age 68.1 years, 22 males and 12 females) who had experienced transnasal endoscopy in the past, would undergo transnasal endoscopy with Nasal Slider® again. After the transnasal endoscopy was completed, patients who gave consent for use of the nasal slider® were interviewed using 3 questionnaires about nasal discomfort, nasal pain and epistaxis.ResultsSince the transnasal endoscope passes inside the sheath, epistaxis can be prevented. Thirty patients for whom trans nasal endoscopy using Nasal Slider® could be carried out. Twenty-seven and 28 patients of all patients used Nasal Slider® expressed feeling less nasal discomfort and pain compared to an examination without Nasal Slider®. No epistaxis was detected in all patients using Nasal Slider®.ConclusionsTo reduce nasal pain and epistaxis, Nasal Slider® for transnasal endoscopy was considerably available. It is currently in use at many hospitals in Japan.

Extended role of transnasal oesophagoscopy: a review of the literature

BACKGROUND

Advances in endoscopic technology have allowed transnasal oesophagoscopy to be used for a variety of diagnostic and therapeutic procedures.

METHOD

A review of the literature was carried out to look into the extended role of transnasal oesophagoscopy within otolaryngology, using the Embase, Cinahl and Medline databases.

RESULTS

There were 16 studies showing that transnasal oesophagoscopy is safe and cost effective and can be used for removal of foreign bodies, tracheoesophageal puncture, laser laryngeal surgery and balloon dilatation.

CONCLUSION

This study presents a summary of the literature showing that transnasal oesophagoscopy can be used as a safe and cost-effective alternative or adjunct to traditional rigid endoscopes for therapeutic procedures.

Office-based CO2 laser surgery for benign and premalignant laryngeal lesions

Objective

Patients with laryngeal pathology are often treated with CO₂ laser surgery, usually in the operating room under general anesthesia. Although office‐based laser surgery using several other laser types has been investigated, prospective studies on office‐based CO₂ laser surgery are scarce. Our goal was to investigate the feasibility of office‐based CO₂ laser surgery for benign and premalignant laryngeal pathology by analyzing completion rate, safety, effect on voice quality, and success rate (i.e., no residual or recurrent disease).

Methods

A prospective cohort study was performed of 30 consecutive procedures. Inclusion started in June 2016 and was completed in August 2018. Adult patients with clinically benign or premalignant laryngeal lesions who could not undergo transoral laser microsurgery in the operating room under general anesthesia were included. Reasons were either contraindications for general anesthesia, previously failed therapeutic laryngoscopy under general anesthesia, and preference of a procedure under topical anesthesia by the patient. The mean follow‐up was 9 months.

Results

Thirty procedures were performed in 27 patients (24 males) with an average age of 62 years. Twenty‐nine (97%) procedures were fully completed without complications. The mean preoperative Voice Handicap Index (VHI) score (VHI 44) significantly decreased 2 months (VHI 28, P = 0.032) and 6 months (VHI 14, P < 0.001) after the procedure. Almost two‐thirds of patients showed no residual or recurrent disease at their follow‐up visits.

Conclusion

Office‐based CO₂ laser surgery is a feasible and safe procedure that results in significant voice‐quality improvement. Almost two‐thirds of patients did not require further treatment.

Level of Evidence

2 Laryngoscope, 130:1503–1507, 2020

Office-based vs. operating room-performed laryngopharyngeal surgery: a review of cost differences

Purpose

Office-based transnasal flexible endoscopic surgery under topical anesthesia has recently been developed as an alternative for transoral laryngopharyngeal surgery under general anesthesia. The aim of this study was to evaluate differences in health care costs between the two surgical settings.

Methods

PubMed, EMBASE and Cochrane Library were searched for studies reporting on costs of laryngopharyngeal procedures that could either be performed in the office or operating room (i.e., laser surgery, biopsies, vocal fold injection, or hypopharyngeal or esophageal dilation). Quality assessment of the included references was performed.

Results

Of 2953 identified studies, 13 were included. Quality assessment revealed that methodology differed significantly among the included studies. All studies reported lower costs for procedures performed in the office compared to those performed in the operating room. The variation within reported hospital and physician charges was substantial.

Conclusion

Office-based laryngopharyngeal procedures under topical anesthesia result in lower costs compared to similar procedures performed under general anesthesia.

Electronic supplementary material

The online version of this article (10.1007/s00405-019-05617-z) contains supplementary material, which is available to authorized users.