A Medicare Physician Fee Schedule Analysis of Reimbursement Trends in Laryngology from 2000 to 2021.

OBJECTIVE: The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades. METHODS: This analysis used CMS' Physician Fee Schedule (PFS) Look-Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office-based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non-facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization. RESULTS: Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office-based procedures was -2.0%, for airway procedures was -2.2%, for voice disorders procedures was -1.4%, and for dysphagia procedures was -1.7%. In non-facilities, the weighted average CAGR for office-based procedures was -0.9%. The procedures in the other procedure groups did not have a corresponding non-facility reimbursement rate. CONCLUSION: Like other otolaryngology subspecialties, inflation-adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care. LEVEL OF EVIDENCE: NA Laryngoscope, 134:247-256, 2024.

Practice Consolidation in Otolaryngology: The Decline of the Single-Provider Practice.

OBJECTIVE: To observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021. STUDY DESIGN: Retrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services. SETTING: United States. METHODS: Annual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed "otolaryngology" as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021. RESULTS: Over the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%. CONCLUSION: The otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

Airway Management in a Patient With Tracheal Disruption due to Penetrating Neck Trauma With Hollow Point Ammunition: A Case Report.

Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.

Hunsaker Mon-Jet tube ventilation: a 15-year experience.

OBJECTIVE/HYPOTHESIS: The Hunsaker Mon-Jet tube (HMJT) (Xomed, Jacksonville, FL) has been used effectively for subglottic ventilation. We previously reported a series of 552 patients over a 10-year period with no major complications. This is a continuation of that series with an additional 5 years of cases. STUDY DESIGN: Retrospective consecutive case series. METHODS: Patients who were ventilated with the HMJT for microlaryngeal surgery at the University of Washington Medical Center over a 15-year period (1995-2010) were identified from the Voice Disorders database. Charts were reviewed for demographic data, laryngeal diagnosis, and anesthetic parameters. Main outcome measure was the rate of complications. RESULTS: Fifty-seven complications occurred in 49 cases out of 839 cases (5.8% complication rate). In descending order, the complications were hypoxia (SpO(2) <90%, n = 30, 3.6%), hypercarbia (end tidal CO(2) of >60 mm Hg, n = 17, 2.0%), airway obstruction (n = 4, 0.5%), barotrauma (n = 2, 0.2%), seeding of blood into trachea (n = 2, 0.2%), submucosal injection of air (n = 1, 0.1%), and mucosal damage (n = 1, 0.1%). Factors associated with complications included high body mass index (P = .04), American Society of Anesthesiology class III or IV (P = .01), history of heart disease (P = .02), history of previous laryngeal surgery (P = .02), longer duration of case (P = .006), and laser use (P = .005). CONCLUSIONS: Although subglottic ventilation via an HMJT is a safe alternative to traditional endotracheal intubation in an appropriately selected population, practitioners should remain vigilant about the known complications.

A multi-institutional analysis of tracheotomy complications.

OBJECTIVES/HYPOTHESIS: To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence. STUDY DESIGN: Multi-institution historical cohort. METHODS: Data regarding tracheotomy tube complications from consecutive surgeries performed across eight participating institutions between January 1, 2008 and December 31, 2009 were retrospectively collected. Patient demographics, comorbidities, physician specialty, and surgical technique were recorded and statistically analyzed to identify the incidence of surgical complications following tracheotomy and associated RFs. RESULTS: The charts of 1,175 tracheotomy procedures were reviewed from eight academic institutions. Otolaryngologists performed 66.2% of the tracheotomies. Intraoperative, early (<1 week), and late complication rates were 1.4%, 5.6%, and 7.1%, respectively. Postoperative bleeding was identified as the most common early complication (2.6%), whereas airway stenosis was the most common late complication (1.7%). The use of outer flange security sutures to anchor the tracheostomy tube was negatively associated with the incidence of early complication (P<.0001). The use of large endotracheal tubes (size>7.5) and obesity were associated with the development of airway stenosis (P<.05).Twenty-two percent of patients undergoing tracheotomy died during hospitalization. CONCLUSIONS: Perioperative tracheotomy complications are rare; however, the rate of death for all causes is high (22%) in this population. Obesity and the use of endotracheal tubes over 7.5 in size are major risk factors for the development of airway stenosis. Although percutaneous tracheotomy resulted in a significantly higher rate of postoperative bleeding (6.6%) than the open method (1.9%) (P<.05), the use of outer flange tracheostomy tube sutures may reduce this complication.

The Hunsaker Mon-Jet tube with jet ventilation is effective for microlaryngeal surgery.

PURPOSE: Microlaryngeal surgery involves a delicate balance between airway control and appropriate visualization of laryngeal anatomy. When the self-centering, laser-safe Hunsaker Mon-Jet tube (Xomed, Jacksonville, FL) was introduced in 1994, to provide subglottic ventilation, the needs of both anesthesiologist and surgeon appeared to have been adequately met. However, limited data exists regarding the efficacy of this device in a large patient series. The aim of this cohort study was to explore the spectrum of patients and procedures for which this technique could be used. METHODS: We report a retrospective study of 552 patients who had undergone microlaryngeal surgery between January 1995 and June 2005, utilizing the Hunsaker Mon-Jet tube and automated jet ventilator to provide subglottic ventilation. In addition to patient demographics, overall success of ventilation and several perioperative outcomes were evaluated, including the incidence of complications. RESULTS: In combination with an automatic jet ventilator, the Hunsaker Mon-Jet tube was successfully utilized in more than 98% of the 552 patients, including those with severe co-morbidities, obesity and difficult airway access, providing optimal visualization of the vocal cords and excellent surgical access for a wide range of laryngeal disorders, including laser treatment. In less than 2% of patients, hypoxia, hypercarbia, or both, necessitated exchange of the Hunsaker Mon-Jet tube for a standard or laser-safe endotracheal tube with rapid resolution of the precipitating cause. CONCLUSIONS: Subglottic ventilation via the Hunsaker Mon-Jet tube with an automated jet ventilator may be considered an effective, safe and versatile technique for the anesthetic management of microlaryngeal surgery.

The voice and laryngeal dysfunction in stroke: a report from the Neurolaryngology Subcommittee of the American Academy of Otolaryngology-Head and Neck Surgery.

OBJECTIVE: Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature. STUDY DESIGN: Consensus report and retrospective literature review. RESULTS: Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented. CONCLUSION: There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient. SIGNIFICANCE: Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.

The psychosocial consequences of BOTOX injections for spasmodic dysphonia: a qualitative study of patients' experiences.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to examine the psychosocial consequences of BOTOX (Allergan, Inc. Irvine, CA) treatment for spasmodic dysphonia (SD). This article also explores how patients judge the success of treatment and make decisions about future treatment based on psychosocial issues relevant to them. STUDY DESIGN: This study follows the phenomenological tradition of qualitative inquiry in which the objective is to explore the lived experiences of a group of persons who share a common phenomenon, in this case receiving BOTOX injections for SD. METHODS: Six adults with SD who had been receiving BOTOX injections on a long-term basis participated in face-to-face interviews. The interviews were recorded, transcribed, and analyzed according to phenomenological guidelines to identify consistent themes as well as differences among participants' experiences. RESULTS: The results are summarized in three primary themes that suggest (1) participants' experiences vary over time based on changes in factors such as lifestyle and personal priorities; (2) BOTOX has multidimensional psychosocial implications in physical, personal, and social domains; and (3) participants individualize their treatment regimens, taking into consideration the burden of treatment, scheduling priorities, and other strategies to maximize the benefits of BOTOX. CONCLUSIONS: Based on this study, suggestions are provided for future research into a psychosocial outcome measurement, including longitudinal evaluations that accommodate changing patient priorities over time; multidimensional evaluations that incorporate physical, personal, and social issues; evaluations that include a measure of the burden of treatment; and evaluations that support a shared decision-making model with the voice clinicians.

A new electromyographic definition of laryngeal synkinesis.

Laryngeal synkinesis involves the misdirected reinnervation of an injured recurrent laryngeal nerve to vocal fold abductor and adductor musculature. The resultant laryngeal dyscoordination can cause vocal fold immobility and airway compromise. Although this entity is sometimes considered in the differential diagnosis, it is only demonstrable with laryngeal electromyography (EMG). We propose a new EMG definition of synkinesis to assist in its identification during workup of vocal fold immobility. A retrospective chart review from 1992 to 1997 in the Voice Disorders Clinic identified 10 patients with laryngeal synkinesis. Five patients had bilateral immobility, and 5 had unilateral immobility. Monopolar EMG was performed on all patients. Fine-wire EMG was performed when monopolar EMG did not elucidate the cause of the immobility. The EMG studies revealed synkinetic reinnervation in all subjects. On the basis of the EMG results, 7 of the 10 patients were treated with botulinum toxin to weaken the undesired reinnervation. Three of the 7 patients had benefit from this therapy. Laryngeal synkinesis should be considered as part of the differential diagnosis of vocal fold immobility. Awake laryngeal EMG is the only method to demonstrate synkinesis of the larynx. The diagnosis of synkinesis is clinically significant in cases of immobility to identify patients who might benefit from botulinum toxin therapy. Additionally, the presence of synkinesis in cases of unilateral immobility may be a contraindication to laryngeal reinnervation procedures. The benefit of botulinum toxin therapy is likely greater in the treatment of bilateral as opposed to unilateral immobility.

Findings of multiple muscle involvement in a study of 214 patients with laryngeal dystonia using fine-wire electromyography.

Although perceptual and stroboscopic data help in diagnosing and classifying laryngeal dystonia, these measures do not aid the voice clinician in targeting which specific muscles to treat with botulinum toxin. Most patients achieve smoother, less effortful voicing with standard injection regimens. However, there is a notable failure rate. We performed fine-wire electromyography on 214 consecutive patients with laryngeal dystonia. We correlated voice ratings, stroboscopy data, and fine-wire electromyography data. Videostroboscopy was successful in visually demonstrating most of the audible findings in isolated vocal tremor, but it was much less successful in identifying breaks alone or a combination of breaks and tremor. Fine-wire electromyography revealed that the thyroarytenoid muscle was significantly more likely than the lateral cricoarytenoid muscle to be the predominant muscle associated with adductor spasmodic dysphonia, and that the thyroarytenoid and lateral cricoarytenoid muscles were equally likely to be predominantly involved in tremor spasmodic dysphonia. In addition, several patients in both the adductor spasmodic dysphonia and the tremor spasmodic dysphonia groups presented with interarytenoid muscle predominance. All of the intrinsic laryngeal muscles are capable of being the predominant muscle in laryngeal dystonia, and there are patterns of muscle abnormalities that differ between adductor spasmodic dysphonia and tremor spasmodic dysphonia. Some of the failures in treating adductor spasmodic dysphonia with botulinum toxin, and the greater difficulty with success in treating patients with tremor spasmodic dysphonia, are due to failure to deliver toxin to the appropriate muscles.

Treatment of the interarytenoid muscle with botulinum toxin for laryngeal dystonia.

The treatment of laryngeal dystonia with botulinum toxin has provided various degrees of relief to the majority of patients with adductor dysphonia; however, a significant number of patients have limited or no improvement with this type of therapy. It remains unclear why some patients respond to the routine administration of toxin to the thyroarytenoid muscles whereas others do not. Injections into the lateral cricoarytenoid muscles have provided an improved voice in some patients who were unresponsive to injections into the thyroarytenoid muscles. Fine-wire electromyography can demonstrate the particular dystonic activity of these muscles to help determine which muscle is predominantly involved. It can also demonstrate dramatic dystonic activity in the interarytenoid (IA) muscle in many patients. We present the results of 23 patients treated with injections to the IA muscle after demonstration of dystonic IA activity. Ten have benefited from IA therapy. Five of these 10 patients did not have a good result from botulinum toxin until IA injections were added to the treatment plan. In 8 patients, IA therapy provided no improvement, and 5 patients were lost to adequate follow-up. According to fine-wire electromyography and clinical response, the IA muscle is an active dystonic muscle in some patients with laryngeal dystonia and should be treated with botulinum toxin in selected patients.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle.

Tremor laryngeal dystonia is a clinical entity distinct from adductor laryngeal dystonia, according to perceptual, stroboscopic, and fine-wire electromyographic findings. Treatment with botulinum toxin has proven more difficult for tremor laryngeal dystonia than for adductor laryngeal dystonia, yet no treatment variations have been considered that might produce improved clinical results. We present 81 patients with a clinical presentation of tremor laryngeal dystonia who were treated with a variety of approaches with botulinum toxin. On the basis of both fine-wire electromyographic findings and clinical response, currently 44 of those patients are being followed up after at least 3 injections. Twenty-one patients (48%) are maintained on lateral cricoarytenoid injections, and 23 (52%) are maintained on thyroarytenoid muscle injections. The electromyographic findings of this group are presented along with their clinical outcome. According to our findings, the majority of patients with tremor laryngeal dystonia can be successfully treated with botulinum toxin if the practitioner includes injections to the lateral cricoarytenoid muscle as a treatment option.

Paraneoplastic movement disorder in a patient with non-Hodgkin's lymphoma and CRMP-5 autoantibody.

The paraneoplastic autoantibody, collapsin response-mediator protein (CRMP)-5 immunoglobulin G (IgG), is specific for neuronal cytoplasmic CRMP-5, and is usually associated with small-cell lung carcinoma or thymoma. We report on details of a movement disorder that followed anti-B-cell therapy in a patient with lymphoma, and was accompanied by CRMP-5 IgG.

Transcriptional expression profiles of oral squamous cell carcinomas.

BACKGROUND: Currently, the classification of oral squamous cell carcinoma (OSCC) depends heavily on the clinical and pathologic examination of tissue. This system can lead to the classification of potentially heterogeneous tumors into single groups when they may have different degrees of aggressiveness. No system to date has incorporated genetic changes as a factor by which to classify OSCC tumors. METHODS: To test the hypothesis that OSCC has a genome-wide genetic expression profile that differs from normal oral tissue and that transcriptional expression profiling can be used to characterize the heterogeneity among tumors, the authors examined the genetic expression profiles of 26 invasive squamous cell carcinomas of the oral cavity and oropharynx, 2 premalignant lesions, and 18 normal oral tissue samples using oligonucleotide arrays that contained probes representing approximately 7000 full-length human genes. RESULTS: Using hierarchical clustering analysis, the data show that oral carcinomas are distinguishable from normal oral tissue based on genome-wide transcriptional expression patterns. However, there is genetic expression profile heterogeneity among tumors of a particular histopathologic grade and stage. In addition, using a statistical approach that integrated normalization and regression analysis, the authors found 314 genes that were expressed differentially in the OSCC samples with statistical significance (P