Otolaryngology in ASCs: A Growing Frontier for Technology

Otolaryngology in ASCs: A Growing Frontier for Technology

By Kris Ellis

Otolaryngologists, or ear, nose, and throat (ENT) physicians, specialize in the medical and surgical management of head and neck disorders, including surgery for cancer; the ears, sinuses, and throat; nasal surgery; and reconstructive and plastic surgery. As the tools, techniques, and knowledge around this specialty have improved and evolved, opportunities for successfully and efficiently performing these types of procedures in the outpatient setting have increased dramatically, providing ambulatory surgery centers with a wealth of ENT options to incorporate into their practices.

“Very few things that we do other than the larger cases actually require an inpatient stay,” says Stephanie Cordes, MD, of Tomball, Texas-based Spring Creek Surgery Center. “We see mostly tonsil and adenoid, myringotomy and tubes in the ears, sinus surgery — things like that are most commonly done in an outpatient setting.”

Terence M. Davidson, MD, FACS, professor of surgery in the Division of Otolaryngology — Head and Neck Surgery, associate dean for continuing medical education at the University of California, San Diego School of Medicine, and section chief of head and neck surgery at the VA San Diego Healthcare System has seen the vast majority of his surgeries move to the outpatient setting over the years. “I run a busy general ENT practice with interest in sleep apnea, smell and taste, and sinusitis,” he says. “My practice is somewhat heavily weighted in that direction, but I also do general things with trauma, tumors, etc.

I operate almost exclusively in our same-day surgery center, so virtually everything I do, from endoscopic sinus surgery to sleep apnea surgery to smaller tumors, is done in same-day surgery. If you look at how the world has changed over the 30 years that I’ve practiced, the anesthetic agents are much cleaner, so people walk into the operating room (OR) and have their surgery and when they’re finished they wake up and go to a recovery room. Two hours later they’re in a car being driven home.

That’s compared to 36 hours of lying around absolutely drugged [in the past]. In addition, surgery which in the old days was ‘open surgery’ — you made a large incision and looked at whatever it was you wanted to operate on — today we do through endoscopes and small incisions. We do better than we used to do in terms of making people feel better, with a lot less pain and suffering.”

Technology has been a significant component of this success, with things like endoscopes, image-guided systems, and lasers leading the way. The future also holds great promise for advances in this respect, according to Davidson. “I think the big change to come will be the introduction of robotic systems,” he says. “In a certain sense, the image-guided technology is a first step in the ENT world because, for example, if I do some intranasal surgery now with a rotating cutter, it’s something that takes off a 2-3 mm bite every time it rolls around, and I can actually track that on the image-guided system and it will tell me within 1-2 mm exactly where inside the patient’s nose the tip of the machine lies. So even if there’s a little bit of oozing or if the anatomy is a little bit obscure, I can actually do the operation watching the image-guided system. I can compare it, if you will, to the aviation industry where I’m ‘flying’ by instruments rather than visual. And once you switch — you never fly both — you can look back and forth obviously, but with the image-guided system we can ‘fly IFR (instrument flight rules).’ “They have robotic systems for abdominal endoscopic or laparoscopic surgery, and it won’t be long before somebody hooks up one of the robotic systems to the sinus instruments,” Davidson continues. “Then instead of using my hands, we’ll have steel clamps, springs, and servos that will do the surgery exactly, obviously with me watching it, first by visual and later by IFR, by my watching the Xray machines, and as we develop that, if you can do the operation sitting 10 feet away, you can do it 10,000 miles away, so with robotics comes the ability to do some of these things by tele-surgery.”

Image-guided surgery (IGS), which incorporates medical imaging, sensor technology, and computers, gives ENT surgeons a tool for safely and effectively treating a number of head and neck diseases and conditions. Children in particular may benefit from this technology, according to information from the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS). Pediatric tumors such as juvenile nasopharyngeal angiofibromas and rhabdomyosarcomas usually involve operations that have the potential to disfigure patients. Surgery for deep neck abscesses in children commonly results in scars on the neck. Traditional surgery for congenital abnormalities such as choanal atresia (bone blocking the back of the nose causing breathing difficulties) may be technically difficult due to unfamiliar surgical landmarks. IGS promotes “keyhole” surgery in all these cases by minimizing endoscopic dissection, facilitating full excision of tumors, and reducing the need for facial or neck incisions.¹

Another technology that has application in the ENT world is Coblation® for tonsillec-tomies, Cordes says. “We’ve been using this for probably the last year and a half to two years. It tends to have less pain associated with it and patients can return to a normal diet a bit faster, and you get a little faster healing, so comfortwise it seems to be better for the patient.”

Coblation technology (bipolar radiofrequency ablation), from ArthoCare Corporation, is a controlled, non-heat driven process that uses radiofrequency energy to “excite” electrolytes in a conductive medium, such as saline solution, thus creating a focused plasma. The plasma’s energized particles then have enough energy to break molecular bonds within tissue, which causes the tissue to dissolve at relatively low temperatures (typically 40 degrees Celsius to 70 degrees Celsius). As a result, volumetric removal of target tissue with minimal damage to surrounding tissue is possible. Many coblation devices also are designed to stop blood and coagulate or seal bleeding vessels. Since radiofrequency current does not pass directly through tissue during the /oblation process, tissue heating is minimal. Most of the heat is consumed in the plasma layer, or in other words, by the ionization process. These ions then bombard tissue in their path, causing molecular bonds to break apart and tissue to dissolve. The process is designed to effect gentle removal of target tissue and have minimal effect on surrounding tissue.²

In a randomized, controlled trial of coblation vs. electrocautery tonsillectomy, children with obstructive sleep apnea who underwent tonsillectomy and adenoidectomy using coblation were shown to experience significantly better postoperative recovery.³ Another study found that children who received coblation for total tonsillectomy were less likely to contact the physician regarding postoperative complications.⁴ Additionally, these children tended to discontinue prescription narcotics one day earlier than electrosurgery patients and took one half as many daily doses. Also, more parents of coblation patients rated the postoperative experience as “better than expected” than the parents of electrosurgery patients.

In the past, children undergoing tonsillectomy and/or adenoidectomy often stayed in the hospital for a week or so after the procedure. More and more evidence, however, suggests that these procedures are safe and effective in an outpatient setting. One study followed 1,419 children who underwent tonsillectomy and/or adenoidectomy at a single outpatient facility. For a month-long postoperative period, any emergency room visits or hospital admissions were reviewed for these patients, and complications such as upper airway obstruction, stridor, nausea, vomiting, oxygen desaturation, or decreased oral intake or inability to take oral medications were tracked. The study concluded that an outpatient approach for these procedures is beneficial for all children, although children younger than three years of age undergoing tonsillectomy are significantly more likely to experience complications.⁵

Cordes points out that when dealing with pediatric patient populations such as those most often encountered with procedures such as tonsillectomy and tubes in the ears, fear and anxiety on the part of the child and the parents can sometimes be problematic. “You tend to explain things to the parents, and I usually ask the parents to explain the process of what’s going to happen that day to their children,” she says. “We talk about the anesthetic — whether they’re going to get an IV before or an IV after they’ve had some medication and kind of have the parent talk to the child about that before the day of surgery. If they’re still very anxious [on the day of surgery], we can give them premeds like Versed or Tylenol.”

Davidson notes that factors such as stress and psychological health also contribute to patients’ disease processes more than ever before. “I think that the world has become a crowded place and the pace of change has increased and I think that patients are stressed; I think we’re all stressed,” he offers. “Stress is a major factor in one’s perception of one’s physical being, and so increasingly people come with a substantially important psychological component to their health, and medicine has not dealt with this well. My practice has changed in that I have to be even more of a psychiatrist or a mental health practitioner — patients are screaming for the good old-fashioned physician who would just sit and talk to them. I see more psychologically induced disorder than I’ve ever seen and I have to be smart about sorting those out. If you take somebody with a sinus complaint and you do a nasal surgery on them, number one, you won’t make them any better, and number two, you may in fact hurt them. I see a lot of people who have been inadvertently, unintentionally damaged.”

Surgery to enlarge the openings that drain the sinuses is sometimes an option for patients with recurrent sinus infections that don’t respond well to medications such as antibiotics, decongestants, antihistamines, and nasal steroids, or other treatments for acute sinusitis such as flushing the sinuses. Functional endoscopic sinus surgery (FESS), which was first developed in the 1950s, involves the insertion of a fiber-optic endoscope into the nose to view the opening into the sinuses directly. Any obstructive tissues can then be removed. This kind of treatment usually results in only minor swelling and discomfort for patients.

Image-guided endoscopic surgery is also an option, particularly for patients who have undergone sinus surgery previously or who have very unusual sinus anatomy, thus making typical sinus surgery difficult. This type of surgery uses compute tomography (CT) and infrared signals to provide the surgeon with a precise, near-three-dimensional map of the sinus passages during surgery.

The Caldwell-Luc operation treats chronic sinusitis by creating a “window” to connect the maxillary sinus with the nose, improving drainage of the sinuses. This procedure was once quite popular, although endoscopic treatment has cut down on its use. The Caldwell-Luc procedure is now used most often when a malignancy is present in the sinus cavity.⁶

Sleep apnea is another major condition that is successfully treated by otolaryngologists on a regular basis, according to Davidson. “It’s a major condition, and a full third of the patients present to the ENT physicians, so we are now doing sleep testing in the office with home sleep tests,” he says. “We do that efficiently, inexpensively, and effectively. We put people with sleep apnea on CPAP (continuous positive airway pressure) and change their lives. That’s thirty percent of my practice today, and for many generalists it has become a substantial part of their business and a place where ENT surgery is making major improvements in the health of the world.”

1. http://www.newswise.com/articles/view/20605/ 

2. http://www.arthrocare.com/our_technology/ot_coblation_explained.htm 

3. Chang KW. “Randomized controlled trial of Coblation versus electrocautery tonsillectomy.” Otolaryngol Head Neck Surg. 2005 Feb;132(2):273-80.

4. Stoker KE, et al. “Pediatric total tonsillectomy using coblation compared to conventional electrosurgery: a prospective, controlled single-blind study.” Otolaryngol Head Neck Surg. 2004 Jun;130(6):666-75.

5. http://www.newswise.com/articles/view/25775/ 

6. http://www.entnet.org/healthinfo/sinus/sinus_surgery.cfm