Nasolaryngoscopy in A Family Medicine Clinic: Indications, Findings, and Economics

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J Am Board Fam Med: first published as 10.3122/jabfm.2010.05.090186 on 7 September 2010. Downloaded from http://www.jabfm.org/ on 21 August 2019 by guest.

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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

doi: 10.3122/jabfm.2010.05.090186 Nasolaryngoscopy in a Family Medicine Clinic 591


J Am Board Fam Med: first published as 10.3122/jabfm.2010.05.090186 on 7 September 2010. Downloaded from http://www.jabfm.org/ on 21 August 2019 by guest. Protected by
Nasolaryngoscopy is often used to exclude seri- 140Y1 has an outer diameter of 4.0 mm at the
ous medical conditions, eg, laryngeal cancer, in insertion tube, a working length of 600 mm, a
patients with nasopharyngeal complaints, but this bending section that can be maneuvered upward
procedure is only performed by 6% of family phy- 180 degrees and downward 90 degrees (with no
sicians in the United States.7 Nasolaryngoscopy is right or left deflection), and a field of view of 120
performed in the office setting with topical anes- degrees. The ENF-P3 has an outer diameter of 3.7
thesia and nasal decongestants. In 1998 an initial mm at the insertion tube, a working length of 300
study of nasolaryngoscopies performed by family mm, a bending section that can be maneuvered
physicians (n ⫽ 66) reported a mean examination upward 130 degrees and downward 130 degrees
time of 4.6 minutes, and the procedure was well (with no right or left deflection), and a field of view
tolerated by patients.8 In a subsequent study, 210 of 85 degrees. The study was approved by the
patients were evaluated by nasolaryngoscopies per- Medical College of Georgia’s institutional review
formed by family physicians; 90% of these cases board.
resulted in changes in diagnosis or management A list of patients was obtained by a clinical query
after the procedure; however, both of these case of our electronic medical record using “nasolaryn-
series were published 20 years ago. In this article goscopy” as a search term and by reviewing an
and in our study we define “nasolaryngoscopy” to established list of procedures that is maintained by
mean a nasopharyngoscopy (endoscopy of the nose the procedure nurse in the family medicine clinic.
and nasopharynx) or a nasolaryngoscopy (endos- We reviewed the chart records for demographic
copy of the nose, nasopharynx, and larynx). The data, indications, findings, and need for further
purpose of this study was to determine the common consultation or evaluation. Complications were
indications, findings, the rate of laryngeal cancer, also noted.
and quantify the economics of nasolaryngoscopy in
an urban, university-based family medicine clinic in
Data Analysis
the Southeastern United States.

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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%)

592 JABFM September–October 2010 Vol. 23 No. 5 http://www.jabfm.org


J Am Board Fam Med: first published as 10.3122/jabfm.2010.05.090186 on 7 September 2010. Downloaded from http://www.jabfm.org/ on 21 August 2019 by guest. Protected by
Table 1. Demographics of Patients Referred for

.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.

compared with those that did not drink (3.3%; P ⫽

.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

Nasolaryngoscopy was completed in 273 (98.9%)


of the patients. Three patients could not tolerate the 18 (15.0)
33 (27.5)
65 (52.4)

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

procedure because of pain. Minor complications oc-

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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

patient experienced mild epistaxis that was con-


trolled with pressure. Most of the procedures were
9 (11.4)
23 (29.1)
38 (48.1)

13 (16.5)

performed nasally (98.6%), with 3 procedures per-


2 (2.5)
6 (7.6)

4 (5.1)
7 (8.9)
6 (7.6)
1 (1.3)
3 (3.8)
Male

formed orally (1.1%) and one procedure completed


Sex

via both routes (0.3%). Although we did not record


procedure times, in our experience procedure times
38 (19.4)
65 (33.2)
103 (52.6)

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

are generally ⱕ5 minutes. A resident assisted with


154 procedures (55.8%). In our clinic, 80% of pro-
Table 2. Indications for Nasolaryngoscopy (n ⴝ 276)

cedures were nasolaryngoscopy and 20% of proce-


.007
P*

.22
.60
.46
.73
.15

.02
.08
.38
.43
.07

dures were nasopharyngoscopy.


Nasolaryngoscopy was normal in 35 patients
(12.8%). The most common findings from the na-
30 (19.9)
47 (31.1)
81 (53.6)
Age (years)

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

solaryngoscopy were LPR (42.5%); chronic rhinitis


(32.2%); and vocal cord lesions, eg, granuloma or
*␹2 analyses for other demographics.

polyp (13.2%). Table 3 lists the common findings.


17 (14.2)
41 (34.2)
59 (49.2)

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

A new medication, eg, proton pump inhibitor, an-


tihistamine, or intranasal steroid, was added for 140
patients (50.7%) and in 9 patients (3.3%) a medi-
History of vocal cord polyp

cation was discontinued (eg, H2-blocker). Seventy-


two patients received a referral to otolaryngology
Globus sensation

Chronic sinusitis
Chronic rhinitis

(26.1%). Table 4 shows management changes after


Chronic cough

Hemoptysis
Sore throat
Hoarseness

the nasolaryngoscopy.
Dysphagia
Epistaxis
Symptoms

Diagnoses
Reflux

Of the 72 patients who were referred to otolar-


yngology, 3 patients (1.1%) were diagnosed with

doi: 10.3122/jabfm.2010.05.090186 Nasolaryngoscopy in a Family Medicine Clinic 593


J Am Board Fam Med: first published as 10.3122/jabfm.2010.05.090186 on 7 September 2010. Downloaded from http://www.jabfm.org/ on 21 August 2019 by guest. Protected by
Table 3. Findings from Completed Nasolaryngoscopy Table 5. Referral Outcomes*
(n ⴝ 273)* Referred patients†
Findings n (%) † (n ⫽ 127) Overall
(n 关%兴) (n ⫽ 276) (%)
Laryngopharyngeal reflux 116 (42.5)
Referral Outcome
Chronic rhinitis 88 (32.2)
Laryngeal cancer 3 (2.4) (1.1)
Other‡ 84 (30.8) (confirmed by biopsy)
Vocal cord lesion 36 (13.2) Vocal cord lesion 9 (7.1) (3.3)
Nasal polyps 10 (3.7) Laryngopharyngeal reflux 25 (19.7) (9.1)
Other pharyngeal lesion 8 (2.9) Other‡ 40 (31.5) (14.5)
Precancerous lesion 5 (1.8)
Laryngeal mass 2 (0.7) *Patient may have more than one outcome.

Normal findings 35 (12.8) One hundred twenty-seven patients were referred for fol-
low-up assessment by otolaryngology or gastroenterology or for
other diagnostic tests.
*Three of the 276 patients did not complete the entire naso- ‡
laryngoscopy procedure. “Other outcome” includes vocal cord granuloma, sinonasal
† disease, nodules, vocal cord polyp, esophageal cancer with me-
Percentages do not sum to 100% because patients may have
tastasis, parotid adenoma, small cell lung cancer, enlarged thy-
had more than one finding.
‡ roid, esophagitis, and gastritis.
“Other” includes tissue hypertrophy, acute inflammation, aspi-
ration, eustachian tube dysfunction, candidal infection, septal
perforation, bony spur, aphthous ulcer, vocal cord dysfunction,
prominent vessel, and hemangioma. comes. Laryngeal cancer was associated with pre-
vious or current tobacco use (P ⫽ .03). Vocal cord
lesions were associated with hoarseness (P ⫽ .003)
laryngeal cancer and 9 (3.3%) were diagnosed with
and previous or current tobacco use (P ⬍ .0001).
vocal cord lesions. One hundred sixteen patients
LPR was associated with hoarseness (P ⫽ .009) and
were diagnosed with LPR using nasolaryngoscopy,
sore throat (P ⫽ .03).
and an additional 18 patients were classified with

copyright.
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

594 JABFM September–October 2010 Vol. 23 No. 5 http://www.jabfm.org


J Am Board Fam Med: first published as 10.3122/jabfm.2010.05.090186 on 7 September 2010. Downloaded from http://www.jabfm.org/ on 21 August 2019 by guest. Protected by
hoarseness, cough, globus sensation, refractory assuming a cash purchase. In our clinic, 80% of
asthma, laryngeal ulcers and granulomas, subglottic procedures billed are laryngoscopy flexible fiber
stenosis, and laryngeal cancer. Physiologic barriers optic (31575), and with our payor distribution mix
protect the oropharyngeal tract from reflux injury; (80% private insurance and 20% Medicare), it
however, the epithelium of the respiratory tract is would take approximately 76 procedures to break
sensitive to damage when these mechanisms fail. A even during the first year. Although we did not
recent Cochrane review found insufficient evidence calculate the break-even point for subsequent years,
to support acid suppression for the treatment of it would be substantially less (including maintenance
hoarseness12; however, acid suppression with pro- and cleaning costs of equipment). Table 6 outlines an
ton pump inhibitors is effective for decreasing the estimation of breakeven points, assuming various
symptoms of LPR and possibly decreasing the risk mixtures of payor sources and ratios of CPT billing
of complications from LPR. codes. This rudimentary cost model assumes labor
Common Current Procedural Technology to be a sunk cost and no variable costs (such as
(CPT) billing codes for nasolaryngoscopy in- cleaning costs and supplies such as lidocaine and
clude 31575 (laryngoscopy, flexible fiber optic) afrin). Further, opportunity costs are considered to
and 92511 (nasopharyngoscopy with endoscope). be zero.
Typical Medicare and private insurance reim- Nasolaryngoscopy is often done with local an-
bursement rates are $67.75 and $230.00, respec- esthesia and nasal decongestants, without the need
tively, for CPT code 31575 and $53.28 and for sedation. It is a brief procedure with short
$65.37, respectively, for CPT code 92511. The recovery time, and patients are able to return to
fixed equipment necessary to perform nasolaryn- their usual activity, including working and driving,
goscopy in primary care include a nasolaryngo- immediately after the procedure. Another inherent
scope, light source, guide cable, and rigid eyepiece advantage of nasolaryngoscopy is that results are im-
for viewing, and startup costs are estimated at mediately available, and the endoscopist can review
$8,675 to $10,850. A service contract can be added results with the patient after the procedure. Another

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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.

doi: 10.3122/jabfm.2010.05.090186 Nasolaryngoscopy in a Family Medicine Clinic 595


J Am Board Fam Med: first published as 10.3122/jabfm.2010.05.090186 on 7 September 2010. Downloaded from http://www.jabfm.org/ on 21 August 2019 by guest. Protected by
Nearly 75% of patients in this study had rhinitis nostic accuracy of nasolarynoscopy performed by
or LPR, which can be managed by family physi- family physicians compared with a gold standard.
cians without the need for specialty referral. Un- Another interesting study might examine the cost
dergoing the procedure in the primary physician’s effectiveness of managing patients with nasopha-
office has a number of other potential advantages. ryngeal complaints in primary care versus specialty
It allows the primary care physician to be directly care. Lastly, a future study should address the nat-
involved with patient care, eliminates the wait time ural history of patients with nasopharyngeal com-
for the patient to be evaluated by another physi- plaints in primary care and those that progress to
cian, may decrease cost by decreasing evaluation by laryngeal cancer.
specialists, improves convenience for the patient
with fewer office visits, decreases anxiety awaiting Conclusion
procedure and results, and improves compliance In our series there was a 1% prevalence of laryngeal
with completing the procedure. The apparent dis- cancer among patients who were referred for naso-
advantages of nasolaryngoscopy include the some- laryngoscopy. Although there is no screening rec-
what narrow field of view, less maneuverability ommendation for laryngeal cancer, those patients
than other endoscopes with up/down and left/right at high risk, eg, smokers with chronic hoarseness or
controls, lack of biopsy or suction capability, and throat pain, should be considered for nasolaryngos-
missed diagnosis (eg, missed laryngeal cancer). copy. LPR was a common diagnosis among pa-
Our study was done at an academic university- tients in our case series. This is an important diag-
based medical center, which may not represent the nosis because of the risk of complications (vocal
typical primary care practices from a racial (primar- cord granuloma, laryngeal ulcer, etc), and these
ily white and black patients), social (alcohol and patients see improvement of their symptoms with
tobacco use), or economic (insurance and payer aggressive acid suppression. We also found that
mix) point of view. There was an over representa- nasolaryngoscopy is a safe procedure when per-
tion of women in our case series (71.4%); the most

copyright.
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
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doi: 10.3122/jabfm.2010.05.090186 Nasolaryngoscopy in a Family Medicine Clinic 597

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