Resident - Jason Showmaker MD Faculty –James Denneny MD 9/3/14

Resident - Jason Showmaker MD
Faculty – James Denneny MD
9/3/14
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Laryngeal Biopsy
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>100 yrs ago office laryngeal surgery for
infectious obstruction
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*Insert Chevalier Jackson tidbit here*
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Advances favoring OR – better outcomes
 General anesthesia
 Endotracheal intubation
 Surgical microscopes
 Surgical lasers
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1855 – Manuel Garcia – first mirror laryngoscopy
1857 – Ludwig Turck – mirror on cadavers
 Poor illumination made mirror laryngoscopy unusable
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Meanwhile, at about the same time…
 Johann Cermak – added artificial light
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1897 Kiersten – First in office direct laryngoscopy
using electric light.
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1927 Baird described light transmission down
a glass fiber through internal refraction
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1959 Harold Hopkins develops rod-lens
 High quality rod-shaped lenses placed in series
 Prisms of varying angles could be placed at end
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1960’s – flexible fiberoptic scope designed in
Japan
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Miniature camera at the tip of the scope
acquires image
 transmitted electronically through the scope.
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Improved image quality (no fiberoptic
degradation)
Increased illumination (narrow wire)
Narrower scope diameter (wire vs bundle)
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Sitting upright
Able to monitor voice quality throughout
Reduced costs
Increased safety
GI or Pulm endoscopy suites may be better
option than a true “office”
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Laryngeal Biopsy
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Must be excellent.
Steep learning curve, choose ideal candidates
 Minimal or no gag reflex
 High pain tolerance
 Low anxiety
 Still and cooperate 20-30 min
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Anticoagulants
Overly anxious patient
 Can give 2-5mg diazepam 30 min prior but this
negates many of the benefits of office based
treatment (monitoring and driver)
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Simpson et al 2004
 Nasal spray oxymetazoline/tetracaine 2%
 Cetacaine spray to palate/oropharynx
 Lidocaine 4% drip on tongue base and larynx with
flex laryngoscope guidance.
Technique
• 3cc syringe with 4% lidocaine
• 1 cc drip on tongue base
• 2-4 cc dripped in 0.5-1cc increments over larynx during
phonation producing a “laryngeal gargle”
If they have a tracheostomy
-squirt it through the tube then put finger over tube during
cough.
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Flexible scope administration
 Lidocaine instilled through working channel
▪ Catheter allows controlled release
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Nebulized lidocaine
 3-4cc lidocaine 4%
 Supplement with drip lidocaine
Rarely required
Palpate greater cornu of hyoid.
Hyoid is then displaced towards
the side that is to be blocked.
Identify hyoid with needle and
walk inferiorly.
Aspirate to confirm no air, then
inject.
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Lidocaine works in 90 seconds, lasts 60
minutes, but pts start gagging after 20 min.
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Toxicity
 4% lidocaine – 8cc safe in 70kg adult
 Cetacaine – 2 seconds of spray safe
 Tessalon Perles (100mg) – 2 tabs safe
▪ Socrative Questions
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Laryngeal Biopsy
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Topical anesthesia allows safe evaluation
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Cricoarytenoid Joint Fixation
Subglottic and tracheal stenosis
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Once anesthetized the patient grasps their
tongue.
Rigid 70 degree endoscope placed by
physician
Transoral placement of curved laryngeal
forceps or the Abraham cannula
Gentle lateral pressure applied.
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After topical anesthesia a standard fiberoptic
scope may be passed to the carina safely in
clinic.
If inflamed then do not perform.
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Balloon dilitation
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 Flexible endoscopy, guidewire placed across segment,
guidewire left in place as scope withdrawn and
replaced flanking the wire.
 http://www.youtube.com/watch?v=TwVAmsWiLFQ
 1, 2 min
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Laryngeal Biopsy
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The ideal laser
 Superficial penetration
 Little collateral thermal injury
 Adjustable to allow for coag and precision cut
 Have a flexible delivery system
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Carbon dioxide
Potassium titanyl phosphate
Thulium
Pulse dye laser
Used for epithelial lesions
 Laryngeal papilloma
 Granuloma
 Leukoplakia
 Dysplasia
 Reinke’s edema
 Vocal fold polyps
Not used for subepithelial lesions
 Intracordal cysts
 Rheumatoid nodules
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Wavelength 10,600 nm
Chromophore is water
 Therefore energy is dissipated rapidly in
superficial lamina priopria without deep
penetration.
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Is excellent for cutting scar and ablating
epithelial lesions such as granuloma and
papilloma.
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A flexible fiber based transmission system
Very expensive to manufacture
Endoscopic, handheld, or robotic use
No aiming beam, cannot diffuse for coag/cut
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Wavelength 2013 nm
Chromophore is water
Similar cutting abilities as CO2, better coag
Small aparatus
Thin glass fiber (much cheaper to
manufacture)
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Wavelength 585 nm
Chromophore oxyhemoglobin
Mechanism: destroying blood supply to
lesion, leading to involution (Zietels et al)
Is also efficacious for non vascular lesions
http://www.youtube.com/watch?v=HU7qmCJ
3QOM
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Wavelength 532 nm
Chromophore oxyhemoglobin
Excellent coagulation abilities but not very
good at cutting.
Reinkes edema, etc
0.9 % incidence of minor
complications
87% stated they prefer it
to OR
Pain minimal
• Avg costs and reimbursements for OR vs Clinic (50 cases in each arm)
• Office based procedures save third party payers $5000 per case
• OR reimbursement $6453
• minus OR costs
- $2000
• Hospital Profit
>$3000
• Clinic reimbursement $643
• minus clinic costs
- $1388
• Clinic Loss
>$500 lost per case
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Laryngeal Biopsy
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The most common and useful in-office
laryngeal procedure
Easy to get started, just by the injectable (no
laser, sheeth, etc.)
0.5 mL typical
Anesthetize skin overlying cricothyroid
membrane and the thyroid ala.
3-5mm from lower border
Younger patients
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If thyroid cartilage ossified
then slowly walk needle to
inferior border of thyroid
and medial 3-4 mm.
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Orient needle nearly straight
up. Bend 45 at 1cm.
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http://www.youtube.com/w
atch?v=YLxe9Ksb9G8
1:30
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Anesthetize
thyrohyoid
membrane
Extend neck
25 g needle with 4%
lido pierces just
above thyroid notch
directed downward,
entering airway
through the petiole.
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http://www.youtube.com/watch?v=Y8x5BFg5
7E8
Pittsburgh
• 108 patients in OR vs 50 patients in clinic
• Avg reimbursement $2505 for OR
• Avg reimbursement $496 for clinic (just barely covers laser fiber
cost)
Projection: If clinic reimbursement increased by $1000 to help defray
costs to surgeon/clinic…
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Would still save third party payers $40 million per year.
Highlights the benefits of moving procedures to clinic
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Transnasal Esophagoscopy
Laryngeal Biopsy
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Topical and nasal anesthetic
Working channel flexible esophagoscope
passed.
Head flexed to chest
Scope advanced into esophagus and rapidly
passed to stomach.
Slow withdrawal/air/suction
http://www.youtube.com/watch?v=qQh480R
Y7wM
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History
Understanding Technology of Scopes
Topical Anesthesia
Procedures offered
Laser Surgery
Injection Laryngoplasty
Laryngeal Biopsy
Forceps can be deliverable through working
channel endosheath on a standard fiberoptic
scope.
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In office laryngeal procedures are safe and
efficacious.
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Major barriers to widespread use is cost due to
poor reimbursement.
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Requires patience and increased patient
interaction time.
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May benefit from utilizing a hospital endoscopy
suite.