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Finding a Better Venue for Upper Airway Procedures

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From OR to Office
 
MADISON - Patients in need of upper airway care are exchanging their surgical gowns for street clothes as lasers and injectables are finding their way from the operating room to the provider's office.

A number of forces are helping to spur this migration. The aging population, an increased awareness of the risk of general anesthesia and advances in the field of upper airway procedures have combined with cost-efficiency to make the office a more ideal location. But to UW Health otolaryngologist Seth Dailey, MD, the most important reason to consider in-office ENT procedures comes down to safety and comfort.

"We can reduce the possibility of complications by using local instead of general anesthesia, which not only improves the procedure's safety, but also improves the patient's level of comfort," he says. "They feel better in their provider's office, and we feel it is safer. It's a win-win."
 
Otolaryngologists have long performed visualization procedures in-office, but with the availability of endoscopes, lasers and vocal cord injectables, safe interventions to the upper airway are more possible than ever. Dr. Dailey points to several benefits to performing such procedures as vocal cord injections, pulsed dye laser treatments, transnasal esophagoscopies (TNE) or throat biopsies in a clinical office over a hospital operating room.

"When performed in the office, most of these procedures can be done with minimal amounts of local anesthetic, eliminating the need for general anesthesia," he says. "That means fewer complications, quicker recovery and less time lost at work or home."

Office-Based Upper Airway Procedures Address Many Needs
 
Office-based upper airway procedures address a variety of medical needs. In addition to safely and comfortably performing biopsies of the laryngopharynx and esophagus without sedation or general anesthesia, TNE can be used to evaluate dysphagia and odynophagia. Patients with hoarseness secondary to vocal cord paralysis, atrophy or other forms of dysphonia are safely and comfortably treated in the office with vocal cord injections. Otolaryngologists now ablate some obstructive tissue and vascular abnormalities in the larynx and upper aerodigestive tract with the use of flexible lasers and local anesthetics.

Reducing the need for general anesthesia is particularly relevant as the US population ages - the Census Bureau projects a nearly 50 percent increase in the number of residents aged 65 or older over the next 12 years. The possibility of a negative reaction to general anesthesia rises with age, potentially making the anesthesia a bigger risk than the procedure itself.

Even though they are receiving less anesthetic, patients who have upper airway procedures done in office rather than in the operating room tend to have low pain ratings as measured on the F.A.C.E.S. scale. Dr. Dailey says his experience has shown in-office procedures have success rates similar to, or sometimes better than, those performed in the OR.

"We have performed close to 450 upper airway procedures in office over the past two years," Dr. Dailey says. "Only two have had complications that required hospital admission. We've never had problems with bleeding, even with our patients on blood thinners."

The medical community can reap benefits, as many upper airway procedures can be performed less expensively in office. For example, the overall cost of performing an in-office injection for vocal cord paralysis is about a fifth of the cost of doing so in an operating room.

Dr. Dailey says he recognizes there are challenges to moving upper airway procedures out of the OR and into the office, especially in acquiring equipment and expertise. Working with local anesthesia creates a limited time window, which means that providers need to be able to work quickly and confidently.

"I spend much more time preparing for a procedure than performing it," he says. "A two-minute TNE will take at least 10 or 15 minutes of preparation. And before that, we'll spend time explaining the procedure to patients, since they will be awake for it. We not only let them know what to expect, but we also make sure to listen to their feedback and concerns. I call it 'verbal anesthesia,' and it makes us much more effective."

Leading-Edge Otolaryngology Research
 
The leading-edge in-office procedure resources at UW Health have contributed to the otolaryngology department's strong tradition of forward thinking research as well. The UW currently receives more NIH funding for voice-related research than any other program in the country, including further study in such areas as vocal cord tissue engineering and laser treatments.

"With the exception of advanced airway reconstructions or cancer cases, almost all upper airway procedures can now be performed in-office," Dr. Dailey says. "There are numerous opportunities to improve hoarseness, swallowing, breathing with less risk and greater patient comfort."

For more information about office-based upper airway procedures, call (608) 263-6190.
 
Date published: 4/28/2008