Complications and Functional Voice Limitations Following Gender-Affirming Laryngeal Surgery (GALS)

OBJECTIVE

Gender-affirming laryngeal surgery (GALS) procedures are effective, with high rates of patient satisfaction following endoscopic vocal fold shortening (glottoplasty) or chondrolaryngoplasty. Despite this, complications and functional limitations in voice use following GALS are not well described. The current study aims to visually characterize the clinical and laryngoscopic features of complications following GALS.

METHODS

Patients who presented with complications or subjective dysphonia following glottoplasty or chondrolaryngoplasty across three tertiary care centers were included. Medical charts were reviewed for demographics, surgical history, the primary outcomes of short- and long-term surgical complications, and the secondary outcome of subjective difficulty in daily voice use unrelated to pitch or gender congruence. Postoperative videostroboscopy exams were reviewed for correlating features.

RESULTS

Eighteen patients with complications after glottoplasty, chondrolaryngoplasty, or both were identified. Complications after chondrolaryngoplasty occurred in three patients and included skin tethering, late-stage infection with fistula, and voice change. Short-term complications following glottoplasty occurred in four patients and included persistent granulation at the neocommissure (n = 3) and suture dehiscence (n = 1). Persistent dysphonia or voice limitations greater than 6 months following glottoplasty were described by eight patients; associated stroboscopy findings included excessive web formation of greater than 50% (n = 4), incomplete web formation with opening anterior to the neocommissure (n = 2), and scarring of the remaining membranous vocal fold (n = 5). Dysphonia complaints were consistent with observed glottic insufficiency in seven of eight of these patients, with incomplete membranous vocal fold closure posterior to the neocommissure or anterior air escape.

CONCLUSION

While chondrolaryngoplasty and glottoplasty have high success rates, complications related to healing, granulation, and web length are not uncommon. Long-term dysphonia appears to be related to postprocedural glottic insufficiency. These data should be used to counsel patients preoperatively about the risks and benefits of GALS.

Otolaryngologist Performance in the Merit-Based Incentive Payment System in 2018

In 2017, the Centers for Medicare and Medicaid Services transitioned clinicians to the Merit-Based Incentive Payment System (MIPS), the largest mandatory pay-for-performance program in health care history. The first full MIPS program year was 2018, during which the Centers for Medicare and Medicaid Services raised participation requirements and performance thresholds. Using publicly available Medicare data, we conducted a retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS in 2017 and 2018. In 2018, otolaryngologists reporting as individuals were less likely (P < .001) to earn positive payment adjustments (n = 1076/1584, 67.9%) than those participating as groups (n = 2802/2804, 99.9%) or in alternative payment models (n = 1705/1705, 100.0%). Approximately one-third (n = 1286/4472, 28.8%) of otolaryngologists changed reporting affiliations between 2017 and 2018. Otolaryngologists who transitioned from reporting as individuals to participating in alternative payment models (n = 137, 3.1%) achieved the greatest performance score improvements (median change, +23.4 points; interquartile range, 12.0-65.5). These findings have important implications for solo and independent otolaryngology practices in the era of value-based care.

Compensation Rates for Otolaryngologic Procedures Under the Medicare Physician Fee Schedule in 2018

OBJECTIVE/HYPOTHESIS

Medicare reimbursement for physician work depends on the estimated time and intensity - which encompasses technical skill, cognitive load, and stress - required to perform services. The Centers for Medicare and Medicaid Services (CMS) quantitatively expresses intensity estimates as compensation rates per unit time. This study aimed to characterize compensation rates under the Medicare Physician Fee Schedule (PFS) for operative procedures commonly performed by otolaryngologists.

STUDY DESIGN

This study was a retrospective, cross-sectional analysis.

METHODS

This study was a retrospective, cross-sectional analysis of fiscal year 2018 PFS specifications and publicly available Medicare Part B utilization data for the top 100 highest-volume procedures furnished by otolaryngologists to Medicare beneficiaries in inpatient and ambulatory surgical center (ASC) settings between January 1, 2018, and December 31, 2018. Co-primary outcomes were the estimated 1) total compensation rate ($/min) and 2) intraservice (i.e., "skin-to-skin" time) compensation rate ($/min) for each included procedure.

RESULTS

The analytic sample included 147 unique procedure types (settings non-mutually exclusive): 82 inpatient procedure types (n = 33,907 procedures) and 95 ASC procedure types (n = 34,765 procedures). In the inpatient setting, median total compensation rate and intraservice compensation rates were $1.50/min (interquartile range [IQR]: $1.19/min-$1.65/min) and $2.27/min (IQR: $1.69/min-$2.68/min), respectively. In the ASC setting, median total compensation rate and intraservice compensation rates were $1.48/min (interquartile range [IQR]: $1.27/min-$1.77/min) and $2.39/min (IQR: $1.82/min-$2.91/min), respectively. At the service line level, volume-weighted total (inpatient: $1.91/min, ASC: $1.90/min) and intraservice (inpatient: $3.84/min, ASC: $3.37/min) compensation rates were highest for rhinologic procedures.

CONCLUSIONS

Compensation rates under the Medicare PFS varied widely for operative procedures commonly performed by otolaryngologists.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E1785-E1791, 2021.

Review of Audiovestibular Symptoms Following Exposure to Acoustic and Electromagnetic Energy Outside Conventional Human Hearing

Objective: We aim to examine the existing literature on, and identify knowledge gaps in, the study of adverse animal and human audiovestibular effects from exposure to acoustic or electromagnetic waves that are outside of conventional human hearing. Design/Setting/Participants: A review was performed, which included searches of relevant MeSH terms using PubMed, Embase, and Scopus. Primary outcomes included documented auditory and/or vestibular signs or symptoms in animals or humans exposed to infrasound, ultrasound, radiofrequency, and magnetic resonance imaging. The references of these articles were then reviewed in order to identify primary sources and literature not captured by electronic search databases. Results: Infrasound and ultrasound acoustic waves have been described in the literature to result in audiovestibular symptomology following exposure. Technology emitting infrasound such as wind turbines and rocket engines have produced isolated reports of vestibular symptoms, including dizziness and nausea and auditory complaints, such as tinnitus following exposure. Occupational exposure to both low frequency and high frequency ultrasound has resulted in reports of wide-ranging audiovestibular symptoms, with less robust evidence of symptomology following modern-day exposure via new technology such as remote controls, automated door openers, and wireless phone chargers. Radiofrequency exposure has been linked to both auditory and vestibular dysfunction in animal models, with additional historical evidence of human audiovestibular disturbance following unquantifiable exposure. While several theories, such as the cavitation theory, have been postulated as a cause for symptomology, there is extremely limited knowledge of the pathophysiology behind the adverse effects that particular exposure frequencies, intensities, and durations have on animals and humans. This has created a knowledge gap in which much of our understanding is derived from retrospective examination of patients who develop symptoms after postulated exposures. Conclusion and Relevance: Evidence for adverse human audiovestibular symptomology following exposure to acoustic waves and electromagnetic energy outside the spectrum of human hearing is largely rooted in case series or small cohort studies. Further research on the pathogenesis of audiovestibular dysfunction following acoustic exposure to these frequencies is critical to understand reported symptoms.

Analysis of Potential Conflicts of Interest among Otolaryngologic Patient Advocacy Organizations in 2016

Patient advocacy organizations (PAOs) are nonprofits dedicated to benefiting patients and their families through activities such as education/counseling and research funding. Although medical drug/device companies may serve as important partners, industry donations may bias the efforts of PAOs. We conducted a retrospective cross-sectional analysis of the Kaiser Health News nonprofit database to identify and characterize otolaryngologic PAOs (n = 32) active in 2016. Among these PAOs, half (n = 16, 50.0%) focused on otologic diseases, and mean total annual revenue was $3.1 million. Among the 15 PAOs (46.9%) with publicly available donor lists, 10 (66.7%) received donations from industry. Few PAOs publicly reported the total amount donated by industry (n = 3, 9.4%) or published policies for mitigating potential financial conflicts of interest with donors (n = 3, 9.4%). Requiring drug and device companies to publicly report donations to PAOs may help patients, providers, and policy makers to better understand advocacy by these influential stakeholders.