As for personnel, he said the safety net of a hospital or surgical center is reassuring, but many practices are in office buildings, not hospitals. That hurdle can be overcome, he said, by performing procedures in a procedure room or endoscopy suite at the hospital or surgical center, an option that can also be easier and more cost effective.
Explore This IssueNovember 2015
It’s important to establish a critical volume, in part because some of the procedures can be difficult. “If you’re doing it just sporadically, it can be difficult to develop the skill set and there’s much potential for torture, not just for the patient but for you,” Dr. Rubin said. “It is more difficult if you’re not predominantly doing a laryngology-type practice.”
Seth Dailey, MD, chief of laryngology and voice surgery at the University of Wisconsin School of Medicine and Public Health in Madison, said that it’s not surprising that laryngeal procedures can be challenging, because gagging, laryngeal closure, and cough are measures the body takes to protect itself. “If you try to rush these, it won’t go well,” he said. He added that it’s important that patients’ reactions to a procedure not be so strong that it creates a “memorable event,” a phenomenon involving a spike in circulating catecholamines, which may result in post-traumatic stress disorder. “If you traumatize them, it’s not going to be a good relationship,” he said.
Dr. Dailey added that the reaction can be more favorable with proper positioning: Ask patients to sniff with their chin up and leaning forward, breathing slowly and deeply. One way to get them to relax is to suggest that they “let their muscles go,” rather than to just command them to “relax.” Also, asking them to stare at a fixed point is helpful, as is reducing uncertainty using steps such as introducing them to staff, taking them through the informed consent process, and carefully explaining all the steps.
Dr. McHugh said that physicians need to be aware of the possibility of complications. Some complications are related to patient tolerance and vagal reactions—including side effects of lidocaine such as secretions, shortness of breath, and dysphagia. There are also anatomic issues, he said. “I’ve run into a few patients where you’re not going to be able to get the larger flexible scope … through their nose,” he said. “Seeing that ahead of time makes a difference, obviously, before you’re struggling inside the patient’s nose.”