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

Methods

This retrospective chart review examined the medical records of 276 adult, English-speaking, nonemergent, consecutive outpatients older than 18 years of age who had a nasolaryngoscopy performed in a university-based family medicine clinic. Our family medicine clinic has approximately 30,000 patient visits per year, 47% of whom are African American and 66% are women. Nasolaryngoscopy was deemed necessary by the patient's primary care physician based on nasopharyngeal complaints and was performed as part of a medical evaluation of these complaints. All patients referred for this procedure were scheduled without exclusion criteria. We did not track data about the percent of patients who missed or canceled their appointment for this procedure. After they provided informed consent, patients were anesthetized using a method we have described previously.⁹ The procedures in this study were performed by or supervised by the lead author (TW) between February 2002 and April 2008 using either XEF-140Y1 gastrointestinal videoscope or ENF-P3 laryngoscope (Olympus America, Inc., Melville, NY). The XEF-140Y1 has an outer diameter of 4.0 mm at the insertion tube, a working length of 600 mm, a bending section that can be maneuvered upward 180 degrees and downward 90 degrees (with no right or left deflection), and a field of view of 120 degrees. The ENF-P3 has an outer diameter of 3.7 mm at the insertion tube, a working length of 300 mm, a bending section that can be maneuvered upward 130 degrees and downward 130 degrees (with no right or left deflection), and a field of view of 85 degrees. The study was approved by the Medical College of Georgia's institutional review board.

A list of patients was obtained by a clinical query of our electronic medical record using “nasolaryngoscopy” as a search term and by reviewing an established list of procedures that is maintained by the procedure nurse in the family medicine clinic. We reviewed the chart records for demographic data, indications, findings, and need for further consultation or evaluation. Complications were also noted.

Results

Two hundred seventy-six patients were included in this case series. The mean age of the patients was 51.3 years (±14.6); 71.4% were women, 48.1% were white, and 46.9% were black. Table 1 presents the demographics of patients in this series. The most common indications for the nasolaryngoscopy were hoarseness (51.3%), globus sensation (32.0%), chronic cough (17.1%), chronic rhinitis (13.5%), and sore throat (10.9%). Table 2 lists the common indications for nasolaryngoscopy as well as how each indication varied across demographic groups. Chronic rhinitis and chronic sinusitis were more common in patients <50 years of age compared with patients >50 years old (P = .007 and P = .02, respectively). Dysphagia was more common among patients who drank alcohol (12.8%) compared with those that did not drink (3.3%; P = .003). Vocal cord lesions were more common among smokers (6.7%) versus nonsmokers (0.6%; P = .004).

Nasolaryngoscopy was completed in 273 (98.9%) of the patients. Three patients could not tolerate the procedure because of pain. Minor complications occurred in 3 procedures (1.1%): 2 patients experienced pain but the procedure was completed and 1 patient experienced mild epistaxis that was controlled with pressure. Most of the procedures were performed nasally (98.6%), with 3 procedures performed orally (1.1%) and one procedure completed via both routes (0.3%). Although we did not record procedure times, in our experience procedure times are generally ≤5 minutes. A resident assisted with 154 procedures (55.8%). In our clinic, 80% of procedures were nasolaryngoscopy and 20% of procedures were nasopharyngoscopy.

Nasolaryngoscopy was normal in 35 patients (12.8%). The most common findings from the nasolaryngoscopy were LPR (42.5%); chronic rhinitis (32.2%); and vocal cord lesions, eg, granuloma or polyp (13.2%). Table 3 lists the common findings. A new medication, eg, proton pump inhibitor, antihistamine, or intranasal steroid, was added for 140 patients (50.7%) and in 9 patients (3.3%) a medication was discontinued (eg, H₂-blocker). Seventy-two patients received a referral to otolaryngology (26.1%). Table 4 shows management changes after the nasolaryngoscopy.

Of the 72 patients who were referred to otolaryngology, 3 patients (1.1%) were diagnosed with laryngeal cancer and 9 (3.3%) were diagnosed with vocal cord lesions. One hundred sixteen patients were diagnosed with LPR using nasolaryngoscopy, and an additional 18 patients were classified with LPR during subsequent testing, for a total of 134 (48.5%). Table 5 provides referral outcomes.

χ² analysis was used to determine which factors were significantly associated with referral outcomes. Laryngeal cancer was associated with previous or current tobacco use (P = .03). Vocal cord lesions were associated with hoarseness (P = .003) and previous or current tobacco use (P < .0001). LPR was associated with hoarseness (P = .009) and sore throat (P = .03).

Discussion

In our case series, 276 patients underwent nasolaryngoscopy for various nasopharyngeal symptoms, including hoarseness, globus sensation, chronic cough, chronic rhinitis, sore throat, epistaxis, dysphagia, and reflux. Laryngeal cancer should be excluded in patients with persistent or chronic nasopharyngeal symptoms, especially in those patients who have risk factors for developing cancer, which include tobacco and alcohol use, GERD, and occupational exposure. The prevalence of laryngeal cancer in our series was an alarming 1%. This finding is of particular importance for patients who present with nasopharyngeal complaints like hoarseness, but this finding may not be generalizable. We were interested in determining the rate of tobacco use among the patients in our series. Nationally, 24% of individuals self-report tobacco use¹⁰ compared with 26% in our study; however, self-report of tobacco use has been shown to be an underestimation of the true smoking prevalence.¹¹

The overall prevalence of LPR was 48.5%. LPR is a condition in which gastric contents flow in a retrograde fashion and contact the tissues of the upper aerodigestive tract. LPR is associated with hoarseness, cough, globus sensation, refractory asthma, laryngeal ulcers and granulomas, subglottic stenosis, and laryngeal cancer. Physiologic barriers protect the oropharyngeal tract from reflux injury; however, the epithelium of the respiratory tract is sensitive to damage when these mechanisms fail. A recent Cochrane review found insufficient evidence to support acid suppression for the treatment of hoarseness¹²; however, acid suppression with proton pump inhibitors is effective for decreasing the symptoms of LPR and possibly decreasing the risk of complications from LPR.

Common Current Procedural Technology (CPT) billing codes for nasolaryngoscopy include 31575 (laryngoscopy, flexible fiber optic) and 92511 (nasopharyngoscopy with endoscope). Typical Medicare and private insurance reimbursement rates are $67.75 and $230.00, respectively, for CPT code 31575 and $53.28 and $65.37, respectively, for CPT code 92511. The fixed equipment necessary to perform nasolaryngoscopy in primary care include a nasolaryngoscope, light source, guide cable, and rigid eyepiece for viewing, and startup costs are estimated at $8,675 to $10,850. A service contract can be added for $2,000 per year, which yields a total fixed startup cost for the first year of $10,675 to $12,850, assuming a cash purchase. In our clinic, 80% of procedures billed are laryngoscopy flexible fiber optic (31575), and with our payor distribution mix (80% private insurance and 20% Medicare), it would take approximately 76 procedures to break even during the first year. Although we did not calculate the break-even point for subsequent years, it would be substantially less (including maintenance and cleaning costs of equipment). Table 6 outlines an estimation of breakeven points, assuming various mixtures of payor sources and ratios of CPT billing codes. This rudimentary cost model assumes labor to be a sunk cost and no variable costs (such as cleaning costs and supplies such as lidocaine and afrin). Further, opportunity costs are considered to be zero.

Nasolaryngoscopy is often done with local anesthesia and nasal decongestants, without the need for sedation. It is a brief procedure with short recovery time, and patients are able to return to their usual activity, including working and driving, immediately after the procedure. Another inherent advantage of nasolaryngoscopy is that results are immediately available, and the endoscopist can review results with the patient after the procedure. Another potential advantage for patients and physicians is that this is a brief in-office procedure (<5 minutes).

Nearly 75% of patients in this study had rhinitis or LPR, which can be managed by family physicians without the need for specialty referral. Undergoing the procedure in the primary physician's office has a number of other potential advantages. It allows the primary care physician to be directly involved with patient care, eliminates the wait time for the patient to be evaluated by another physician, may decrease cost by decreasing evaluation by specialists, improves convenience for the patient with fewer office visits, decreases anxiety awaiting procedure and results, and improves compliance with completing the procedure. The apparent disadvantages of nasolaryngoscopy include the somewhat narrow field of view, less maneuverability than other endoscopes with up/down and left/right controls, lack of biopsy or suction capability, and missed diagnosis (eg, missed laryngeal cancer).

Our study was done at an academic university-based medical center, which may not represent the typical primary care practices from a racial (primarily white and black patients), social (alcohol and tobacco use), or economic (insurance and payer mix) point of view. There was an over representation of women in our case series (71.4%); the most likely explanation is that it reflects the higher percentage of women (66%) seen in our clinic. Other possible reasons for more women in our series are that more women discuss nasopharyngeal complaints with their physicians or more women agree to nasolaryngoscopy compared with men. We did not record the time of the procedure. No information was reported about the total patient population that was initially referred for nasolaryngoscopy versus those who were seen and had a procedure. Patient tolerance of the procedure, pain, and level of anxiety and the patient's willingness to undergo a repeat nasolaryngoscopy were not evaluated in our study. In addition, the effectiveness and accuracy of nasolaryngoscopy performed by primary care physicians versus specialists has not been evaluated. Training of family medicine residents in nasolaryngoscopy is not standardized and varies by residency program. Our residency training program requires a minimum of 10 procedures, evaluation of technical skills by an attending physician, and a written examination.

Future studies should assess training variation among family medicine residency programs and competency of graduates to perform nasolaryngoscopy. Additional studies might address the diagnostic accuracy of nasolarynoscopy performed by family physicians compared with a gold standard. Another interesting study might examine the cost effectiveness of managing patients with nasopharyngeal complaints in primary care versus specialty care. Lastly, a future study should address the natural history of patients with nasopharyngeal complaints in primary care and those that progress to laryngeal cancer.

Conclusion

In our series there was a 1% prevalence of laryngeal cancer among patients who were referred for nasolaryngoscopy. Although there is no screening recommendation for laryngeal cancer, those patients at high risk, eg, smokers with chronic hoarseness or throat pain, should be considered for nasolaryngoscopy. LPR was a common diagnosis among patients in our case series. This is an important diagnosis because of the risk of complications (vocal cord granuloma, laryngeal ulcer, etc), and these patients see improvement of their symptoms with aggressive acid suppression. We also found that nasolaryngoscopy is a safe procedure when performed in the primary care setting. In our experience with training family medicine residents in nasolaryngoscopy, technical expertise is rapidly acquired in as few as 10 supervised procedures. Although the procedure is technically easy to learn, confidence in accurately making a diagnosis and ruling out cancer can be more challenging. With only 6% of family physicians performing nasolaryngoscopy, this procedure is an important but underutilized procedure in family medicine. Given our findings and potential revenue, can family physicians afford not to offer nasolaryngoscopy?