The implementation of a multidisciplinary, electronic health record embedded care pathway to improve structured data recording and decrease electronic health record burden.

INTRODUCTION: Theoretically, the added value of electronic health records (EHRs) is extensive. Reusable data capture in EHRs could lead to major improvements in quality measurement, scientific research, and decision support. To achieve these goals, structured and standardized recording of healthcare data is a prerequisite. However, time spent on EHRs by physicians is already high. This study evaluated the effect of implementing an EHR embedded care pathway with structured data recording on the EHR burden of physicians. MATERIALS AND METHODS: Before and six months after implementation, consultations were recorded and analyzed with video-analytic software. Main outcome measures were time spent on specific tasks within the EHR, total consultation duration, and usability indicators such as required mouse clicks and keystrokes. Additionally, a validated questionnaire was completed twice to evaluate changes in physician perception of EHR system factors and documentation process factors. RESULTS: Total EHR time in initial oncology consultations was significantly reduced by 3.7 min, a 27 % decrease. In contrast, although a decrease of 13 % in consultation duration was observed, no significant effect on EHR time was found in follow-up consultations. Additionally, perceptions of physicians regarding the EHR and documentation improved significantly. DISCUSSION: Our results have shown that it is possible to achieve structured data capture while simultaneously reducing the EHR burden, which is a decisive factor in end-user acceptance of documentation systems. Proper alignment of structured documentation with workflows is critical for success. CONCLUSION: Implementing an EHR embedded care pathway with structured documentation led to decreased EHR burden.

Is ultraviolet light disinfection fit to be the future standard for the disinfection of flexible endoscopes without a working channel?

OBJECTIVE: To investigate colony-forming unit (CFU) reduction on contaminated flexible endoscopes (FEs) without a working channel after UV-C light disinfection, compared to the current disinfection method with the endoscope washer disinfector (EWD). DESIGN, SETTING AND PARTICIPANTS: After pharyngolaryngoscopy, a manual pre-cleaning with tap water was performed. A culture was then collected by rolling the distal 8-10 cm of the FE over an Agar plate. The FE was disinfected using the D60 (60-s disinfection process with UV-C light) or the EWD (gold standard reprocessing process with water and chemicals). Another culture was then taken. After incubation, a CFU count was performed. RESULTS: A total of 200 FEs without a working channel were divided equally between the two disinfection groups. After clinical use and manual pre-cleaning, 84 of the 100 (84.0%) (UV-C light group) and 79 of the 100 (79.0%) (EWD) FEs were contaminated with at least 1 CFU. FEs that showed no contamination after use were excluded from further analysis. After disinfection with UV-C light, 72 (85.7%) FEs showed no contamination (i.e., 0 CFUs) versus 66 (83.5%) FEs after reprocessing with the EWD. CONCLUSION: There is no difference in CFUs reduction on contaminated FEs without a working channel between UV-C light disinfection and the current gold standard, the EWD.

Development and validation of automated electronic health record data reuse for a multidisciplinary quality dashboard.

Objective: To describe the development and validation of automated electronic health record data reuse for a multidisciplinary quality dashboard. Materials and methods: Comparative study analyzing a manually extracted and an automatically extracted dataset with 262 patients treated for HNC cancer in a tertiary oncology center in the Netherlands in 2020. The primary outcome measures were the percentage of agreement on data elements required for calculating quality indicators and the difference between indicators results calculated using manually collected and indicators that used automatically extracted data. Results: The results of this study demonstrate high agreement between manual and automatically collected variables, reaching up to 99.0% agreement. However, some variables demonstrate lower levels of agreement, with one variable showing only a 20.0% agreement rate. The indicator results obtained through manual collection and automatic extraction show high agreement in most cases, with discrepancy rates ranging from 0.3% to 3.5%. One indicator is identified as a negative outlier, with a discrepancy rate of nearly 25%. Conclusions: This study shows that it is possible to use routinely collected structured data to reliably measure the quality of care in real-time, which could render manual data collection for quality measurement obsolete. To achieve reliable data reuse, it is important that relevant data is recorded as structured data during the care process. Furthermore, the results also imply that data validation is conditional to development of a reliable dashboard.

Evaluation of a remote monitoring app in head and neck cancer follow-up care.

BACKGROUND: A remote monitoring app was developed for head and neck cancer (HNC) follow-up during the SARS-CoV-2 pandemic. This mixed-methods study provides insight in the usability and patients' experiences with the app to develop recommendations for future use. METHODS: Patients were invited to participate if they were treated for HNC, used the app at least once and were in clinical follow-up. A subset was selected for semi-structured interviews through purposive sampling considering gender and age. This study was conducted between September 2021-May 2022 at a Dutch university medical center. RESULTS: 135 of the 216 invited patients completed the questionnaire, resulting in a total mHealth usability score of 4.72 (± 1.13) out of 7. Thirteen semi-structured interviews revealed 12 barriers and 11 facilitators. Most of them occurred at the level of the app itself. For example, patients received no feedback when all their answers were normal. The app made patients feel more responsible over their follow-up, but could not fulfill the need for personal contact with the attending physician. Patients felt that the app could replace some of the outpatient follow-up visits. CONCLUSIONS: Our app is user-friendly, makes patients feel more in control and remote monitoring can reduce the frequency of outpatient follow-up visits. The barriers that emerged must be resolved before the app can be used in regular HNC follow-up. Future studies should investigate the appropriate ratio of remote monitoring to outpatient follow-up visits and the cost-effectiveness of remote monitoring in oncology care on a larger scale.

Detection of laryngeal carcinoma during endoscopy using artificial intelligence.

BACKGROUND: The objective of this study was to assess the performance and application of a self-developed deep learning (DL) algorithm for the real-time localization and classification of both vocal cord carcinoma and benign vocal cord lesions. METHODS: The algorithm was trained and validated upon a dataset of videos and photos collected from our own department, as well as an open-access dataset named "Laryngoscope8". RESULTS: The algorithm correctly localizes and classifies vocal cord carcinoma on still images with a sensitivity between 71% and 78% and benign vocal cord lesions with a sensitivity between 70% and 82%. Furthermore, the best algorithm had an average frame per second rate of 63, thus making it suitable to use in an outpatient clinic setting for real-time detection of laryngeal pathology. CONCLUSION: We have demonstrated that our developed DL algorithm is able to localize and classify benign and malignant laryngeal pathology during endoscopy.

Sentinel node identification in laryngeal and pharyngeal carcinoma after flexible endoscopy-guided tracer injection under topical anesthesia: A feasibility study.

BACKGROUND: The aim of this study was to investigate the feasibility of flexible endoscopy-guided tracer injection for sentinel lymph node (SLN) identification in patients with laryngeal and pharyngeal carcinoma. METHODS: Sixteen cT1-4N0-2M0 patients with laryngeal or pharyngeal carcinoma underwent intra- and peritumoral [99m Tc]Tc-nanocolloid injections after topical anesthesia under endoscopic guidance. SPECT-CT scans were performed at two time points. RESULTS: Tracer injection and visualization of SLNs was successful in 15/16 (94%) patients. Median number of tracer injections was 1 intratumoral and 3 peritumoral. The median duration of the endoscopic procedure including tracer injection after biopsy taking was 7 min (range 4-16 min). A total of 28 SLNs were identified which were all visualized on the early and late SPECT-CT. Most SLNs were visualized in neck levels II and III. CONCLUSIONS: Flexible endoscopy-guided tracer injection for SLN identification is a feasible and fast procedure in laryngeal and pharyngeal carcinoma patients.

Individualised follow-up for head and neck cancer-design of a prospective cohort study to assess its feasibility.

INTRODUCTION: It is a common practice for many cancer types to monitor patients after treatment to detect new disease manifestations early. For head and neck cancer (HNC), however, long-term routine follow-up is up for debate for several reasons. The benefits of prolonged routine follow-up on survival have not been proven. Also, cancer follow-up is putting increasing pressure on healthcare resources due to rising incidence and survival rates. Therefore, this study investigates a novel follow-up approach among HNC patients, giving them the opportunity to choose their own follow-up programme. METHODS AND ANALYSIS: HNC patients are offered a decision-aided choice between standardised or individualised follow-up after 1.5 years of uncomplicated guideline-prescribed follow-up. Standardised follow-up entails continuing the 5-year guideline-prescribed schedule. Individualised follow-up means the patient only attends the outpatient clinic on their own initiative in case of physical symptoms or supportive care needs. Patients are educated on self-examination and when a control visit is necessary. The primary outcome measure is the feasibility of offering patients this choice. Secondary outcome measures are quality of life, costs, productivity loss and detection of new disease. ETHICS AND DISSEMINATION: We believe that it is essential to let patients determine their follow-up programme based on their own values and preferences. If this choice is feasible, it can be implemented and investigated in other HNC care centres. TRIAL REGISTRATION NUMBER: NCT05386225.

Quantifying the Electronic Health Record Burden in Head and Neck Cancer Care.

BACKGROUND: Although the main task of health care providers is to provide patient care, studies show that increasing amounts of time are spent on documentation. OBJECTIVE: To quantify the time and effort spent on the electronic health record (EHR) in head and neck cancer care. METHODS: Cross-sectional time-motion study. Primary outcomes were the percentages of time spent on the EHR and the three main tasks (chart review, input, placing orders), number of mouse events, and keystrokes per consultation. Secondary outcome measures were perceptions of health care providers regarding EHR documentation and satisfaction. RESULTS: In total, 44.0% of initial oncological consultation (IOC) duration and 30.7% of follow-up consultation (FUC) duration are spent on EHR tasks. During 80.0% of an IOC and 67.9% of a FUC, the patient and provider were actively communicating. Providers required 593 mouse events and 1,664 keystrokes per IOC and 140 mouse events and 597 keystrokes per FUC, indicating almost 13 mouse clicks and close to 40 keystrokes for every minute of consultation time. Less than a quarter of providers indicated that there is enough time for documentation. CONCLUSION: This study quantifies the widespread concern of high documentation burden for health care providers in oncology, which has been related to burnout and a decrease of patient-clinician interaction. Despite excessive time and effort spent on the EHR, health care providers still felt this was insufficient for proper documentation. However, the need for accurate and complete documentation is high, as reuse of information becomes increasingly important. The challenge is to decrease the documentation burden while increasing the quality of EHR data.

The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.

The reuse of healthcare data for various purposes will become increasingly important in the future. To enable the reuse of clinical data, structured and standardized documentation is conditional. However, the primary purpose of clinical documentation is to support high-quality patient care. Therefore, this study investigated the effect of increased structured and standardized documentation on the quality of notes in the Electronic Health Record. A multicenter, retrospective design was used to assess the difference in note quality between 144 unstructured and 144 structured notes. Independent reviewers measured note quality by scoring the notes with the Qnote instrument. This instrument rates all note elements independently using and results in a grand mean score on a 0-100 scale. The mean quality score for unstructured notes was 64.35 (95% CI 61.30-67.35). Structured and standardized documentation improved the Qnote quality score to 77.2 (95% CI 74.18-80.21), a 12.8 point difference (p < 0.001). Furthermore, results showed that structured notes were significantly longer than unstructured notes. Nevertheless, structured notes were more clear and concise. Structured documentation led to a significant increase in note quality. Moreover, considering the benefits of structured data recording in terms of data reuse, implementing structured and standardized documentation into the EHR is recommended.

Thermal Effects of CO2, KTP, and Blue Lasers with a Flexible Fiber Delivery System on Vocal Folds.

OBJECTIVE: To determine the differences in thermal effects on vocal folds between four fiber-routed lasers. METHODS: In this experimental laboratory study the thermal effects of an AcuPulse Duo CO2 (CO2 AP), UltraPulse Duo CO2 (CO2 UP), KTP, and Blue laser were analyzed using a Schlieren technique on a human tissue mimicking gel model. Power, laser duration, laser fiber distance to tissue and mode (continuous wave [CW] vs pulsed [P] modes) were evaluated in varying combinations in order to compare the effects of the tested lasers and to explore the individual effect on thermal expansion and incision depth of each setting. The model was validated by comparing the results from the Schlieren model with histology of ex vivo fresh human vocal folds after laser irradiation using a selection of the same laser settings, and calculating the intraclass correlation coefficient (ICC). RESULTS: One thousand ninety-eight Schlieren experiments and 56 vocal cord experiments were conducted. In comparison with CW mode, less thermal expansion occurred in P mode in all lasers, while incisions were deeper in the CO2 and more superficial in the KTP and Blue lasers. The mean thermal expansion was found to be minimally smaller, whereas incision depth was pronouncedly smaller in the KTP and Blue compared to the CO2 lasers. Duration of laser irradiation was the most important factor of influence on thermal expansion and incision depth for all lasers in both CW and P modes. The ICC for consistency between the results of the Schlieren model and the vocal cord histology was classified from fair to excellent, except for the thermal expansion of the Blue laser, which was classified as poor. CONCLUSION: This study demonstrates important differences in thermal effects between CO2, KTP, and Blue lasers which can be explained by the different physical characteristics of the P modes and divergence of the fiber delivery system. The Schlieren imaging model is a good predictor of the relative thermal effects in vocal fold tissue. Our results can be used as a guidance for ENT surgeons using fiber-routed lasers, in order to achieve effective treatment of vocal fold lesions and prevention of functional impairment of vocal folds.

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.

Flexible Endoscopic Biopsy: Identifying Factors to Increase Accuracy in Diagnosing Benign and Malignant Laryngopharyngeal Pathology.

OBJECTIVES: To assess the influence that several factors, such as the amount of obtained biopsies, difficult procedures, biopsy site and the experience of the attending physician, have on accuracy of flexible endoscopic biopsy (FEB). MATERIALS AND METHODS: 203 FEB procedures for benign or malignant laryngopharyngeal lesions were prospectively included. During the procedure, three representative biopsies (macroscopically containing vital tumor tissue and not only necrosis or healthy tissue) were obtained. The accuracy of each biopsy was separately analyzed. Difficulties during the procedures leading to failure of acquiring three representative biopsies were recorded and classified into tumor, patient and procedural factors. Histological results of FEB were defined correct when consistent with clinical context, additional biopsies or Positron emission tomography-computed tomography (PET-CT) revealed equivalent pathology, or the lesion was stable or resolved in >6 months follow-up. RESULTS: The first representative biopsy yielded a correct diagnosis in 65% of the cases. After the second representative biopsy, 78% was correctly diagnosed. The contribution of the third and fourth representative biopsies to accuracy was 3%. The overall accuracy of FEB was 85%. Difficult procedures were more likely to result in misdiagnosis, whereas biopsy site or experience of the attending physician did not influence results. CONCLUSIONS: FEB was accurate in diagnosing laryngopharyngeal lesions when at least two representative biopsies were obtained. Accuracy of FEB could be further improved by limiting possible constraints during the procedures, for example by selecting, informing, and anesthetizing patients carefully.

Voice Characteristics in Patients with Acromegaly during Treatment.

BACKGROUND: Active acromegaly is characterized by Growth Hormone and Insulin-like Growth Factor (IGF)-1 excess. Voice complaints are common in active acromegaly and are suggested to be caused by effects of Growth Hormone or IGF-1 on vocal folds and the surrounding soft tissues. Prospective studies on the course of voice characteristics in acromegaly patients are scarce and results are conflicting. This study investigates objective changes in voice parameters, self-reported perception of voice and laryngostroboscopic features during the first 2.5 years of acromegaly treatment. MATERIAL AND METHOD: In this prospective study, acoustic voice analysis (and videolaryngostroboscopic examination were performed in 27 consecutive treatment-naive acromegaly patients at diagnosis (T0), after 1 year (T1) and after 2.5 years (T2) of treatment. The voice handicap index (VHI-30) questionnaire was taken. RESULTS: During acromegaly treatment, VHI scores decreased, and mucosal edema & hypertrophy diminished. No significant changes in objective voice parameters were detected. The within-subject change in serum IGF-1 levels (97.3 (40.6-208) to 22.4 (10.2-34.1) nmol/L (P < 0.001)) during follow-up correlated positively with the changes in VHI questionnaire scores (R 0.32-0.45; P = 0.002-0.03). CONCLUSIONS: At diagnosis and during acromegaly treatment, mean VHI scores were in the normal range, although they decreased during follow-up. Mucosal edema and hypertrophy largely resolved during treatment. No significant changes in objective voice parameters were observed. Voice characteristics are in the normal range in patients with acromegaly, but may change during treatment. However, voice complaints are important to discuss, since they may influence quality of life.

Impact of optimizing diagnostic workup and reducing the time to treatment in head and neck cancer.

BACKGROUND: Timely and efficient diagnostic workup of patients with head and neck cancer (HNC) is challenging. This observational study describes the implementation of an optimized multidisciplinary oncological diagnostic workup for patients with HNC and its impact on diagnostic and treatment intervals, survival, costs, and patient satisfaction. METHODS: All patients with newly diagnosed HNC who underwent staging and treatment at the Radboud University Medical Center were included. Conventional workup (CW) in 2009 was compared with the fast-track, multidisciplinary, integrated care program, that is, optimized workup (OW), as implemented in 2014. RESULTS: The study included 486 patients with HNC (218 with CW and 268 with OW). The time-to-treatment interval was significantly lower in the OW cohort than the CW cohort (21 vs 34 days; P < .0001). The 3-year overall survival rate was 12% higher after OW (72% in the CW cohort vs 84% in the OW cohort; P = .002). After correction for confounders, the 3-year risk of death remained significantly lower in the OW cohort (hazard ratio, 1.73; 95% confidence interval, 1.14-2.63; P = .010). Total diagnostic costs were comparable in the 2 cohorts. The general satisfaction score, as measured with the Consumer Quality Index for Oncological Care, was significantly better in a matched OW group than the CW group (9.1 vs 8.5; P = .007). CONCLUSIONS: After the implementation of a fast-track, multidisciplinary, integrated care program, the time-to-treatment interval was significantly reduced. Overall survival and patient satisfaction increased significantly, whereas costs did not change. This demonstrates the impact and improved quality of care achieved by efficiently organizing the diagnostic phase of HNC management.

Impact of Time to Diagnosis and Treatment in Head and Neck Cancer: A Systematic Review.

OBJECTIVE: An increased interval between symptomatic disease and treatment may negatively influence oncologic and/or functional outcomes in head and neck cancer (HNC). This systematic review aims to provide insight into the effects of time to treatment intervals on oncologic and functional outcomes in oral cavity, pharyngeal, and laryngeal cancer. DATA SOURCES: PubMed, EMBASE, and Cochrane library were searched. REVIEW METHODS: All studies on delay or time to diagnosis or treatment in oral, pharyngeal, and laryngeal cancer were included. Quality assessment was performed with an adjusted version of the Newcastle-Ottawa scale. Outcomes of interest were tumor volume, stage, recurrence, survival, patient-reported outcome measures (PROMs), toxicity, and functionality after treatment. RESULTS: A total of 51 studies were included. Current literature on the influence of delay in HNC is inconsistent but indicates higher stage and worse survival with longer delay. The effects on PROMs, toxicity, and functional outcome after treatment have not been investigated. The inconsistencies in outcomes were most likely caused by factors such as heterogeneity in study design, differences in the definitions of delay, bias of results, and incomplete adjustment for confounding factors in the included studies. CONCLUSION: Irrespective of the level of evidence, the unfavorable effects of delay on oncologic, functional, and psychosocial outcomes are undisputed. Timely treatment while maintaining high-quality diagnostic procedures and decision making reflects good clinical practice in our opinion. This review will pose practical and logistic challenges that will have to be overcome.

Optimizing Settings for Office-Based Endoscopic CO2 Laser Surgery Using an Experimental Vocal Cord Model.

OBJECTIVES/HYPOTHESIS: To provide insight in the thermal effects of individual laser settings in target tissues to optimize flexible endoscopic CO2 laser surgery treatment. STUDY DESIGN: Experimental laboratory study. METHODS: Thermal effects of the CO2 laser using a fiber delivery system were visualized using the color Schlieren technique in combination with a polyacrylamide gel tissue model. Variable settings were used for emission mode, power, laser fiber distance, and laser duration, which were evaluated in every possible combination. Collateral thermal expansion and incision depth were measured. To validate the model, the results were compared to histology after CO2 laser irradiation of ex vivo human vocal cords, and the intraclass correlation coefficient was calculated. Thermal damage and incision depth were measured by a blinded pathologist. RESULTS: Of all parameters studied, duration of laser irradiation had the greatest effect on thermal expansion. Increased distance between laser tip and target tissue resulted in significantly reduced incision depth and increased thermal expansion. Pulsed emission modes led to increased incision depths. The intraclass correlation coefficient for consistency between the model setup and the ex vivo human vocal cords was classified as "fair." CONCLUSIONS: By using high-intensity pulsed lasers at minimal distance to the target tissue, exposure times and subsequent damage to surrounding tissue can be reduced. If an evaporation technique is used, lower power in continuous wave at a larger distance to the target tissue will lead to superficial but broader thermal effects. The model setup used in this study is a valid model to investigate laser-induced thermal effects in vocal cord tissue. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E680-E685, 2020.

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.

Cost analysis of office-based transnasal esophagoscopy.

PURPOSE: Although office-based transnasal esophagoscopy has been investigated extensively, a cost analysis is still lacking. We performed a cost analysis combined with feasibility study for two diagnostic processes: patients with globus pharyngeus and/or dysphagia, and hypopharyngeal carcinoma. METHODS: Prospective cohort study. RESULTS: Forty-one procedures were performed, of which 35 were fully completed. The procedure was well tolerated with mild complaints such as nasal or pharyngeal pain and burping. Four complications occurred: two minor epistaxis and two vasovagal reactions. In patients with globus pharyngeus and/or dysphagia, transnasal esophagoscopy resulted in a cost saving of €94.43 (p 0.026) per procedure, compared to our regular diagnostic process. In patients with suspicion of hypopharyngeal carcinoma, cost savings were €831.41 (p 0.000) per case. CONCLUSIONS: Cost analysis showed that office-based transnasal esophagoscopy can provide significant cost savings for the current standard of care. Furthermore, this procedure resulted in good patient acceptability and few complications.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract.

OBJECTIVE: Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications. MATERIAL AND METHODS: A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed. RESULTS: Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare. CONCLUSIONS: By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.