Nasolaryngoscopy in A Family Medicine Clinic: Indications, Findings, and Economics
Nasolaryngoscopy in A Family Medicine Clinic: Indications, Findings, and Economics
Nasolaryngoscopy in A Family Medicine Clinic: Indications, Findings, and Economics
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Nasolaryngoscopy in a Family Medicine Clinic:
Indications, Findings, and Economics
Thad Wilkins, MD, Ralph A. Gillies, PhD, April Getz, MD,
Dave Zimmerman, MD, MBA, and Larry Kang, MD
Background: Nasopharyngeal complaints are common among patients who present to primary care.
Patients with these complaints are often referred for nasolaryngoscopy evaluation to exclude serious
conditions such as laryngeal cancer.
Methods: This study is a retrospective case series in which 276 charts of adult outpatients who were
referred for nasolaryngoscopy were reviewed. We examined patient demographics, procedure indica-
tions and findings, complications, and changes in clinical management.
Results: Nasolaryngoscopy was completed in 273 (98.9%) patients (mean age, 51.3 ⴞ 14.6 years;
71.4% were women). The most common indications for nasolaryngoscopy were hoarseness (51.3%),
globus sensation (32.0%), and chronic cough (17.1%); the most common findings included laryngopha-
ryngeal reflux (42.5%), chronic rhinitis (32.2%), and vocal cord lesions (13.2%). Three patients (1.1%)
were diagnosed with laryngeal cancer and this diagnosis was significantly associated with a history of
smoking (P ⴝ .03). No major complications occurred.
Conclusions: We found that nasolaryngoscopy was a safe procedure in the primary care setting, and
no major complications occurred in our series. Patients who have ever smoked and complain of hoarse-
ness are at higher risk for laryngeal cancer. An alarming 1% of patients in our series were diagnosed
with laryngeal cancer. This is the first study to define the rates of laryngopharyngeal reflux, vocal cord
lesions, and laryngeal cancer among primary care patients. (J Am Board Fam Med 2010;23:591–597.)
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Keywords: Laryngoscopy, Laryngeal Neoplasms, Laryngopharyngeal Reflux, Primary Health Care
In the United States in 2008, 12,250 new cases of creasing survival from laryngeal cancer. Currently,
laryngeal cancer were diagnosed, and an estimated there are no screening guidelines for laryngeal cancer.
3,670 deaths occurred from laryngeal cancer.1 The Although a primary care series of adult smokers aged
death rates from laryngeal cancer did not significantly 40 years and older found a 3% prevalence of laryngeal
change from 1990 (2.97 per 100,000) to 2004 (2.24 cancer,2 the prevalence of nasopharyngeal symptoms
per 100,000). The 5-year survival rates decreased in primary care is largely unknown.
minimally, from 67% in 1975 to 64% in 2003.1 Early Family physicians commonly evaluate patients
diagnosis and definitive treatment is the key to in- with nasopharyngeal complaints, eg, hoarseness, dys-
phagia, chronic cough, throat clearing, globus sensa-
tion, or chronic sore throat, and some of these pa-
This article was externally peer reviewed. tients may have serious conditions such as laryngeal
Submitted 29 July 2009; revised 2 March 2010; accepted 8 cancer. In a primary care practice research network,
March 2010.
From the Department of Family Medicine, Medical Col- the prevalence of dysphagia was 23%.3 In another
lege of Georgia, Augusta (TW, RAG, AG, DZ); and Eisen- primary care series, the prevalence of hoarseness was
hower Army Medical Center, Fort Gordon, GA (LK).
Funding: none. 11%. The association between gastroesophageal re-
Conflict of interest: none declared. flux disease (GERD) and laryngopharyngeal reflux
Corresponding author: Thad Wilkins, MD, Department
of Family Medicine, 1120 15th Street, HB-4032, Medical (LPR) is well established, and extra-esophageal symp-
College of Georgia, Augusta, GA 30912 (E-mail: toms, eg, hoarseness and globus sensation, improve
twilkins@mcg.edu).
with acid suppression.4 A systematic review found an
increased risk of chronic cough in patients with
GERD (odds ratio, 1.7; 95% CI, 1.4 –2.1),5 and a
See Related Commentary on national cross-sectional postal survey in Scotland
Page 564. found a 31% prevalence of sore throat.6
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The primary analyses for the study included de-
scriptive statistics of the indications and findings
for nasolaryngoscopy. Subsequent 2 analyses ex-
Methods amined the influence of the following independent
This retrospective chart review examined the med-
factors on indications and findings: age, sex, eth-
ical records of 276 adult, English-speaking, non-
nicity, and alcohol and tobacco use. SPSS software
emergent, consecutive outpatients older than 18
version 11 (SPSS, Inc., Chicago, IL) was used for
years of age who had a nasolaryngoscopy per-
all analyses.
formed in a university-based family medicine clinic.
Our family medicine clinic has approximately
30,000 patient visits per year, 47% of whom are Results
African American and 66% are women. Nasolaryn- Two hundred seventy-six patients were included in
goscopy was deemed necessary by the patient’s pri- this case series. The mean age of the patients was
mary care physician based on nasopharyngeal com- 51.3 years (⫾14.6); 71.4% were women, 48.1%
plaints and was performed as part of a medical were white, and 46.9% were black. Table 1 pre-
evaluation of these complaints. All patients referred sents the demographics of patients in this series.
for this procedure were scheduled without exclu- The most common indications for the nasolaryn-
sion criteria. We did not track data about the per- goscopy were hoarseness (51.3%), globus sensation
cent of patients who missed or canceled their ap- (32.0%), chronic cough (17.1%), chronic rhinitis
pointment for this procedure. After they provided (13.5%), and sore throat (10.9%). Table 2 lists the
informed consent, patients were anesthetized using common indications for nasolaryngoscopy as well
a method we have described previously.9 The pro- as how each indication varied across demographic
cedures in this study were performed by or super- groups. Chronic rhinitis and chronic sinusitis were
vised by the lead author (TW) between February more common in patients ⬍50 years of age com-
2002 and April 2008 using either XEF-140Y1 gas- pared with patients ⬎50 years old (P ⫽ .007 and
trointestinal videoscope or ENF-P3 laryngoscope P ⫽ .02, respectively). Dysphagia was more com-
(Olympus America, Inc., Melville, NY). The XEF- mon among patients who drank alcohol (12.8%)
.004
.72
.57
.26
.91
.20
.16
.69
.08
.64
.17
P
Nasolaryngoscopy (n ⴝ 276)
Factor
Tobacco Use
17 (16.3)
31 (29.8)
58 (55.8)
6 (5.8)
8 (7.7)
10 (9.6)
3 (4.3)
10 (9.6)
6 (5.8)
0 (0.0)
7 (6.7)
Ever
Age (mean years ⫾ SD) 51.3 ⫾ 14.6
Female sex 197 (71.4)
30 (18.1)
55 (33.1)
81 (48.8)
21 (12.7)
26 (15.7)
Race
9 (5.4)
11 (5.5)
7 (4.2)
12 (7.2)
3 (1.8)
1 (0.6)
None
Black 121 (46.9)
White 124 (48.1)
Values provided as n (%). Note that denominator numbers may vary slightly from numbers listed in Table 1 because of missing data for that particular analysis.
Other 13 (4.7)
0.003
0.32
0.24
0.94
0.93
0.16
0.31
0.58
0.18
0.23
0.83
P
Alcohol use
Current (yes) 66 (24.7)
Past (yes) 83 (31.1)
Alcohol Use
12 (14.0)
32 (37.2)
44 (51.2)
6 (20.7)
9 (10.5)
11 (12.8)
5 (5.8)
3 (3.5)
8 (9.3)
0 (0.0)
2 (2.3)
Ever
Tobacco use
Current 70 (25.8)
Ever 104 (38.4)
34 (18.9)
54 (30.0)
93 (51.7)
23 (12.8)
27 (15.0)
10 (5.6)
9 (5.0)
6 (3.3)
9 (5.0)
3 (1.7)
5 (2.8)
None
Values provided as n (%) unless otherwise indicated.
.56
.08
.91
.09
.74
.30
.36
.49
.75
.15
.63
P
.003). Vocal cord lesions were more common
among smokers (6.7%) versus nonsmokers (0.6%;
22 (17.7)
47 (37.9)
62 (51.7)
12 (10.0)
14 (11.3)
White
4 (3.2)
5 (4.0)
10 (8.1)
8 (6.5)
0 (0.0)
2 (1.6)
P ⫽ .004).
Race
14 (11.3)
19 (15.8)
10 (4.1)
8 (6.7)
7 (5.8)
9 (7.5)
2 (1.7)
3 (2.5)
Black
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curred in 3 procedures (1.1%): 2 patients experi-
enced pain but the procedure was completed and 1
.11
.52
.50
.18
.26
.35
.86
.24
.66
.86
.58
P
13 (16.5)
4 (5.1)
7 (8.9)
6 (7.6)
1 (1.3)
3 (3.8)
Male
24 (12.2)
24 (12.2)
13 (6.6)
11 (5.6)
10 (5.1)
12 (6.1)
2 (1.0)
5 (2.6)
Female
.22
.60
.46
.73
.15
.02
.08
.38
.43
.07
9 (6.0)
13 (8.6)
13 (8.6)
4 (2.6)
13 (8.6)
10 (6.6)
1 (0.7)
7 (4.6)
ⱖ50
17 (14.2)
24 (20.0)
6 (5.0)
11 (9.2)
4 (3.3)
5 (4.2)
2 (1.7)
1 (0.8)
⬍50
Chronic sinusitis
Chronic rhinitis
Hemoptysis
Sore throat
Hoarseness
the nasolaryngoscopy.
Dysphagia
Epistaxis
Symptoms
Diagnoses
Reflux
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LPR during subsequent testing, for a total of 134
(48.5%). Table 5 provides referral outcomes. Discussion
2 analysis was used to determine which factors In our case series, 276 patients underwent nasolaryn-
were significantly associated with referral out- goscopy for various nasopharyngeal symptoms, in-
cluding hoarseness, globus sensation, chronic cough,
chronic rhinitis, sore throat, epistaxis, dysphagia, and
Table 4. Management Changes After Nasolaryngoscopy
reflux. Laryngeal cancer should be excluded in pa-
(n ⴝ 276)
tients with persistent or chronic nasopharyngeal
Management n (%)* symptoms, especially in those patients who have
Medication changes risk factors for developing cancer, which include
Added 140 (50.7) tobacco and alcohol use, GERD, and occupational
Deleted 9 (3.3) exposure. The prevalence of laryngeal cancer in our
Referrals series was an alarming 1%. This finding is of par-
Otolaryngology 72 (26.1) ticular importance for patients who present with
Gastroenterology 8 (2.9) nasopharyngeal complaints like hoarseness, but this
Other diagnostic tests finding may not be generalizable. We were inter-
CAT scan 18 (6.5) ested in determining the rate of tobacco use among
Barium swallow 14 (5.1)
the patients in our series. Nationally, 24% of indi-
Esophagogastroduodenoscopy 12 (4.3)
viduals self-report tobacco use10 compared with
Repeat nasolaryngoscopy 5 (1.8)
26% in our study; however, self-report of tobacco
Other† 16 (5.8)
No changes to therapeutic plan 56 (20.3)
use has been shown to be an underestimation of the
true smoking prevalence.11
*Percentages do not sum to 100% because patients may have The overall prevalence of LPR was 48.5%. LPR
had more than one change.
†
is a condition in which gastric contents flow in a
“Other” includes sleep study, allergy/immunology consult, ma-
nometry, pillcam, and transnasoesophagoscopy. retrograde fashion and contact the tissues of the
CAT, computed axial tomography. upper aerodigestive tract. LPR is associated with
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for $2,000 per year, which yields a total fixed potential advantage for patients and physicians is that
startup cost for the first year of $10,675 to $12,850, this is a brief in-office procedure (⬍5 minutes).
Table 6. Estimated Breakeven Points Assuming Various Ratios of Payor Sources and Current Procedural
Technology (CPT) Billing Codes
Relative Payor Ratio (Medicare/Private Insurance)
Relative CPT Billing Code Ratio* 0%/100% 20%/80% 40%/60% 60%/40% 80%/20% 100%/0%
0% 92511
56 66 78 97 129 190
100% 31575
20% 92511
66 76 90 110 141 199
80% 31575
40% 92511
79 90 105 125 156 208
60% 31575
60% 92511
98 111 126 147 175 218
40% 31575
80% 92511
131 143 158 176 199 229
40% 31575
100% 92511
197 205 213 222 231 242
0% 31575
Data are presented as Q values at different payor mix and CPT code ratios. Q equals the no. of procedures required to breakeven at
the end of the first year, calculated as:
Q ⫽ T/(N关(M*53.28) ⫹ (P*65.37)兴 ⫹ L关(M*67.75) ⫹ (P*230)兴)
where N equals the percentage of procedures performed coded as nasopharyngoscopy; L equals the percentage of procedures
performed coded as laryngoscopy; M equals the percentage of procedures covered by Medicare insurance; P equals the percentage of
procedures covered by private insurance; and T equals the total estimated startup costs for the first year ($12,850).
*CPT code 92511: Nasopharyngoscopy with endoscope; CPT code 31575: Laryngoscopy, flexible fiber optic.
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formed in the primary care setting. In our experi-
likely explanation is that it reflects the higher per- ence with training family medicine residents in
centage of women (66%) seen in our clinic. Other nasolaryngoscopy, technical expertise is rapidly ac-
possible reasons for more women in our series are quired in as few as 10 supervised procedures. Al-
that more women discuss nasopharyngeal com- though the procedure is technically easy to learn,
plaints with their physicians or more women agree confidence in accurately making a diagnosis and
to nasolaryngoscopy compared with men. We did ruling out cancer can be more challenging. With
not record the time of the procedure. No informa- only 6% of family physicians performing naso-
tion was reported about the total patient population laryngoscopy, this procedure is an important but
that was initially referred for nasolaryngoscopy ver- underutilized procedure in family medicine. Given
sus those who were seen and had a procedure. our findings and potential revenue, can family phy-
Patient tolerance of the procedure, pain, and level sicians afford not to offer nasolaryngoscopy?
of anxiety and the patient’s willingness to undergo
a repeat nasolaryngoscopy were not evaluated in
References
our study. In addition, the effectiveness and accu-
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics,
racy of nasolaryngoscopy performed by primary 2008. CA Cancer J Clin 2008;58:71–96.
care physicians versus specialists has not been eval- 2. Prout MN, Sidari JN, Witzburg RA, Grillone GA,
uated. Training of family medicine residents in Vaughan CW. Head and neck cancer screening
nasolaryngoscopy is not standardized and varies by among 4611 tobacco users older than forty years.
residency program. Our residency training pro- Otolaryngol Head Neck Surg 1997;116:201– 8.
gram requires a minimum of 10 procedures, eval- 3. Wilkins T, Gillies RA, Thomas AM, Wagner PJ.
uation of technical skills by an attending physician, The prevalence of dysphagia in primary care pa-
tients: a HamesNet Research Network study. J Am
and a written examination.
Board Fam Med 2007;20:144 –50.
Future studies should assess training variation
4. Qua CS, Wong CH, Gopala K, Goh KL. Gastro-
among family medicine residency programs and oesophageal reflux disease in chronic laryngitis:
competency of graduates to perform nasolaryngos- prevalence and response to acid-suppressive therapy.
copy. Additional studies might address the diag- Aliment Pharmacol Ther 2007;25:287–95.
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