Explore This IssueMay 2013
ORLANDO—Having procedures and tests performed right in the office is an attractive prospect for both doctors and patients, and it’s becoming more and more common. A panel of experts here touched on laser ablation of laryngeal pathologies, rhinology imaging, neck ultrasounds and aesthetic lasers—all in the office setting—and offered guidance for those considering trying to provide more services directly at the point of care. The experts were gathered April 12 at the 116th Annual Meeting of the Triological Society, held as part of the Combined Otolaryngology Spring Meetings.
Gaelyn Garrett, MD, medical director at the Vanderbilt Voice Center in Nashville, Tenn., said that lasers are just “an instrument” when it comes to treating laryngeal pathologies. “Laser technology is an option,” she said. “It’s a way to accomplish an end result. But it’s usually not the only way to accomplish an end result. So the laser itself is not a treatment, it’s how you get to the treatment outcome.”
She added that “not all lasers are equal,” and there are options for wavelength choice, method of delivery and the pulse structure. Users should keep in mind what their target chromophore is, whether it’s water, melanin or hemoglobin. They should have at least a basic understanding of how laser-tissue interaction works and should have a good grip on the nature of the pathology, particularly whether it’s stable.
A big consideration is whether a patient is capable of handling an awake flexible laryngoscopy, which can be “a little stressful.” A dose of the cough suppressant benzonatate in the morning of the day of the procedure, plus another dose an hour before, can help, Dr. Garrett said. “I did not [use benzonatate] when I first started doing these procedures, and it has made a big difference I think, probably in the majority of my patients,” she said.
The office option doesn’t necessarily mean a procedure shouldn’t be done in the operating room, she added. “Most of these can be done either in the O.R. or the office,” she said. “Sometimes for precision you’re probably better off going to the O.R. if you’ve got a patient who doesn’t have any anesthetic risk.”
Point-of-service imaging in rhinology is done either by cone beam CT, which uses a lower radiation dose, with an upright, compact design; or the more conventional standard multi-slice CT in a miniaturized form, said Brent Senior, MD, chief of the division of rhinology, allergy and endoscopic skull base surgery at the University of North Carolina School of Medicine in Chapel Hill.
“There are a lot of arguments in favor of point-of-care imaging,” from earlier diagnosis, to convenience, to avoiding delays in scheduling, and earlier diagnosis means patients can avoid taking antibiotics or steroids during that period, Dr. Senior said.
The American Academy of Otolaryngology-Head and Neck Surgery, he pointed out, came out solidly in favor of in-office CT imaging in 2010 with a physician statement. But, the American College of Radiology has raised concerns about self-referral; a report several years ago found that during a five-year period at the beginning of the last decade, the CT volume in private offices owned by radiologists increased by 85 percent—but rose 263 percent for non-radiologists. Further, the former director of the White House Office of Management and Budget, Peter Orszag, said in 2009 that 20 to 50 percent of CT, MR and PET procedures were unnecessary.
Dr. Senior said concerns about increasing exposure to radiation are warranted. FDA data he presented shows that it would take from two days to more than two years of natural exposure to absorb the amount of radiation from CT procedures, depending on the procedure type. He suggested the use of thyroid collars, which he said can reduce the effective dose by 40 percent.
David Steward, MD, professor and director of thyroid/parathyroid disorders at the University of Cincinnati, said ultrasound is best for imaging of thyroid nodules. “Ultrasound has become the workhorse of thyroid patients,” he said. “It’s very convenient for the patient to come into the office … see the physician and get the imaging and diagnostic or therapeutic procedure done at the same time. And that does help with your practice building.”
It is useful for parathyroid, salivary gland, lymph node and neck mass imaging, Dr. Steward said. Ultrasound equipment is “maybe an order of magnitude less” than CT scanners but is “not inexpensive” at about $35,000 but “one can usually recoup that cost over a one- to three-year period depending on the volume,” he said. Dr. Steward noted that although it does add time to the office visit, a thyroid ultrasound is fairly quick and straightforward, taking less than five minutes.
Ivan Wayne, MD, assistant professor of facial plastic and reconstructive surgery at the University of Oklahoma in Oklahoma City, said that when considering adding aesthetic laser equipment to your office practice, it’s best to rent it first. “Make sure that it’s something you like to do or your staff likes to do, and that you can actually make money at it,” he said. Physicians should also be aware of who can run the equipment. Oklahoma regulations allow anyone to run it, under his supervision, but rules vary from state to state.
Dr. Wayne gave most of his attention to fractional ablation, so named because only some of the tissue is treated, rather than 100-percent ablation as seen with more traditional machines. “The idea is that you vaporize a portion of the tissue, and then you have healing from the sides,” he said. The typical patient wants a tighter face but without getting a facelift.
He said it’s a procedure with significantly reduced morbidity, faster healing, less risk of hypo- or hyperpigmentation and less skin redness. He said it will make the skin look better but couldn’t say definitively how long the results last. “I don’t tell patients this is permanent,” he said. “I tell them that, ‘You can’t stop the aging clock. This definitely will help make your skin look better. You may need to get additional treatments in the future.’ And it’s kind of the underselling/over-delivery we like to do in our practice.”
He added, “It’s an interesting area. Studies of long-term results are lacking, and the public wants these new technologies.”