Out of Committee: Patient Safety and Quality Improvement – Safety of Office-based Laryngology Procedures

March 2020 – Vol. 39, No. 2

VyVy N. Young, MD

Within medicine, otolaryngology-head and neck surgery is often recognized for its balance of surgical procedures and clinical care of patients. Throughout the field of otolaryngology, there has been a shift over time to move an increasing number of our surgical procedures into the office setting.1-3 Increased efficiency, enhanced cost-effectiveness, and high procedural tolerance coupled with low complication rates have led to both patient and surgeon preference for office-based procedures when appropriate.4-11

In laryngology especially, this trend has been quite pronounced. Laryngology procedures now commonly performed in the office setting include laryngoscopy, bronchoscopy, transnasal esophagoscopy, biopsy, vocal fold injection (e.g., augmentation, steroid, or botulinum toxin), laser treatment of laryngeal pathology, esophageal dilation, and even some airway surgery (e.g., laser, dilation, or steroid injection).6,10-19 For reference, the American Academy of Otolaryngology–Head and Neck Surgery and its Foundation (AAO-HNS/F) outlined a Position Statement with supporting evidence related to in-office photoangiolytic laser treatment of laryngeal pathology.20

Multiple techniques to perform these procedures, either through the use of the working channel of an endoscope versus a percutaneous or transoral approach, have been described. Some methods may be performed with a single surgeon while others require an assistant.2,10,13-16,18,21-24 Often these are unsedated procedures, performed under local anesthesia. The local anesthetic may be administered to the laryngopharynx indirectly via nebulizer treatment, percutaneously via transtracheal approach, or directly through an instrument (e.g., Abraham cannula) or the working channel of an endoscope.2,25 Otolaryngologists performing these procedures should be familiar with multiple techniques, both for administration of local anesthesia and for the procedure itself, to enhance patient safety and likelihood of procedure success.

Office-based laryngology procedures are generally considered safe, related to a low-reported complication rate.5,6,10,14-18,26 Complications are minor (including patient anxiety/intolerance of the procedure, epistaxis, vasovagal response, coughing, or gagging), tend to be mild in nature, and often spontaneously resolve.5,12 More serious complications are even more rare but may include laryngospasm, airway compromise, significant bleeding/hematoma, or a cardiac event.12 It is imperative that the otolaryngologist be aware of the potential for complications and have a safety plan in place to address any issues that arise.

Proper identification of appropriate candidates for these types of procedures is fundamental. Multiple studies have reported hemodynamic changes during awake laryngology procedures, including a 20mm Hg increase in blood pressure (BP).27-29 Therefore, monitoring of vital signs (at a minimum, BP and heart rate) at least before and after the procedure is recommended to verify that the patient remains within a safe range from a cardiovascular standpoint. A multi-institutional study described a screening protocol identifying patients in need of further cardiovascular evaluation prior to pursuing an office-based procedure (e.g., those patients with systolic BP >160, diastolic BP >100, and/or HR >110 beats/minute).30 Risk factors identifying potentially poor candidates for office-based otolaryngology procedures have been nicely summarized by Schmalbach.3 Otolaryngologists performing office-based procedures should have ready access to all the equipment necessary to perform the procedure, as well as any other supplies that may be needed to address potential complications. In this regard, checklists may be particularly helpful—especially for resuscitation equipment, which is thankfully only rarely utilized.3,31

In summary, although it is a procedurally based surgical subspecialty, otolaryngology covers the spectrum from operative to ambulatory practice. Advances in laryngology in particular have allowed an increasing number of procedures to be performed in the office setting. Reports of safety have been favorable to date. Pre-procedure screening (e.g., vital signs and American Society of Anesthesiologist [ASA] level) and suitable patient selection lies at the heart of office-based laryngeal procedure safety. Continued vigilance and monitoring are vital as we move forward, especially for those practitioners newly adding office-based procedures to their clinical practice.

References

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