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Abstract
Background: Routine preoperative vocal cord (VC) assessment with laryngoscopy in patients undergoing thyroidectomy allows clear documentation of baseline VC function, aids in surgical planning in patients with palsies, and facilitates interpretation of intraoperative neuromonitoring (IONM) findings. We aimed to determine the incidence of preoperative vocal cord palsy (VCP); to evaluate the associated risk factors for preoperative VCP; and to calculate the cost-savings potential of implementing a selective approach. Methods: Patients with a pre-thyroidectomy VC assessment by fiberoptic laryngoscopy were retrospectively recruited from the Monash University Endocrine Surgery Unit database from 2000 to 2018. Cases with preoperative VCP were reviewed for potential contributing factors and compared with a non-palsy cohort. Results: Of the 5987 patients who had preoperative laryngoscopy, VCP was documented in 41 (0.68%) patients. Four clinical parameters were found to be potential indicators of VCP, including: age (p < 0.001), nodule ≥3.5 cm recorded on ultrasound imaging (p = 0.01), presence of voice symptoms (p < 0.001), and previous neck surgery (p < 0.001). Malignant cytology (p = 0.5) and exposure to head and neck irradiation were not different between the groups. Utilizing these risk factors, 2354 (39%) patients had at least one feature that may raise suspicion for preoperative VCP. By performing preoperative laryngoscopy only on this subset of patients, the potential cost savings exceeds 400 Australian Dollars per patient. Conclusions: Using this large dataset, we have established that a VCP is rare in the absence of a large nodule, hoarseness, or previous neck surgery. Therefore, in the era of IONM, we support a selective approach to preoperative laryngoscopy by using the aforementioned criteria.
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Affiliation(s)
- Dominic I Maher
- Department of General Surgery, Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Stephanie Goare
- Department of General Surgery, Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Edward Forrest
- Department of General Surgery, Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
| | - Simon Grodski
- Department of General Surgery, Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Jonathan W Serpell
- Department of General Surgery, Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - James C Lee
- Department of General Surgery, Monash University Endocrine Surgery Unit, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
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Kerris EJ, Patregnani JT, Sharron M, Sochet AA. Use of the pediatric intensive care unit for post-procedural monitoring in young children following microlaryngobronchoscopy: Impact on resource utilization and hospital cost. Int J Pediatr Otorhinolaryngol 2018; 115:1-5. [PMID: 30368366 DOI: 10.1016/j.ijporl.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/01/2018] [Accepted: 09/12/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the frequency of post-procedural complications, medical interventions, and hospital costs associated with microlaryngobronchoscopy (MLB) in children prophylactically admitted for pediatric intensive care unit (PICU) monitoring for age ≤ 2 years. METHODS We performed a single-center, retrospective, descriptive study within a 44-bed PICU in a stand-alone, tertiary, pediatric referral center. Inclusion criteria were age ≤2 years and pre-procedural selection of prophylactic PICU monitoring after MLB between January 2010 and December 2015. Children were excluded for existing tracheostomy, if undergoing concurrent non-otolaryngeal procedures, or if intubated at the time of PICU admission. Primary outcomes were the development of major and minor procedural complications and medical rescue interventions. Secondary outcomes were hospital cost and length of stay (LOS). RESULTS One hundred and eight subjects met inclusion criteria with a median age of 5.3 (IQR: 2.6-10.9) months. A majority (86%) underwent therapeutic instrumentation in addition to diagnostic MLB. There were no observed major complications or rescue interventions. Minor complications were noted within 5 h of monitoring and included isolated stridor (24%), desaturation <90% (10%), and nausea/emesis (8%). Minor interventions included supplemental oxygen via regular nasal cannula (39%), single-dose inhaled racemic epinephrine (19%), single-dose systemic corticosteroids (19%), or high flow nasal cannula (HFNC) therapy (4%). Save for two cases of HFNC, interventions were completed or discontinued within 5 h. Median PICU LOS was 1.1 days and median cost was $9650 (IQR: $8235- $14,861) per encounter. Estimated cost of same day observation in our post anesthesia care unit (PACU) following MLB without PICU admission is $1921 per encounter. CONCLUSIONS In children ≤ 2 years of age prophylactically admitted for PICU observation, we did not observe severe complications or major interventions after MLB. Minor interventions and complications were noted early during post-procedural monitoring. PICU monitoring was substantially more expensive than same-day PACU observation. Young age as the sole criteria for prophylactic PICU monitoring after diagnostic or therapeutic MLB may be unjustified when comparable, cost-conscious care can be achieved in a PACU setting. Prior to pre-procedural selection of PICU monitoring, we recommend a broad contextual risk assessment including a review of comorbidities, operative plan, and intended anesthetic exposure.
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Affiliation(s)
- Elizabeth J Kerris
- Pediatric Critical Care Medicine, Department of Medicine, Division of Critical Care Medicine, Children's National Health System, 111 Michigan Ave NW, Suite M4811, Washington, DC, 20010, USA.
| | - Jason T Patregnani
- Pediatric Cardiac Intensive Care Medicine, Department of Medicine Division of Cardiac Intensive Care Medicine, Children's National Health System, 111 Michigan Ave NW, Suite M4811, Washington, DC, 20010, USA.
| | - Matthew Sharron
- Pediatric Critical Care Medicine, Department of Medicine, Division of Critical Care Medicine, Children's National Health System, 111 Michigan Ave NW, Suite M4811, Washington, DC, 20010, USA.
| | - Anthony A Sochet
- Anesthesiology and Critical Care Medicine, Department of Medicine, Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, 501 6th Street South, OCC Suite 702, Room 709, St. Petersburg, FL, 33701, USA.
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Yuan YJ, Xue FS, Wang Q, Liu JH, Xiong J, Liao X. Comparison of the tracheal intubation using Macintosh laryngoscope and GlideScope® videolaryngoscope by advanced cardiac life support providers in a manikin study. Minerva Anestesiol 2011; 77:558-561. [PMID: 21540813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 2008; 111:407-11. [PMID: 18829091 DOI: 10.1016/j.ygyno.2008.08.022] [Citation(s) in RCA: 302] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Revised: 08/20/2008] [Accepted: 08/24/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Maria C Bell
- Department of Obstetrics and Gynecology, Sanford Women's Health, Sanford Clinic, Sioux Falls, SD 57105, USA.
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5
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Abstract
OBJECTIVES To compare the cost effectiveness of plain film radiography, computed tomography (CT), and endoscopy as initial diagnostic modalities in adult patients complaining of retained ingested foreign bodies. DESIGN A systematic literature review was conducted to determine key statistics for the analysis, such as prevalence of disease, prevalence of complications, and the sensitivity and specificity of each diagnostic modality. Costs were estimated using 2006 Medicare reimbursement for hospital and professional fees. A deterministic cost-effectiveness analysis was then conducted using decision analysis software and a decision tree model to evaluate the various diagnostic strategies. After identifying initial results, we also performed sensitivity and threshold analysis to assess the strength of the recommendations. RESULTS We reviewed 316 abstracts, identified 16 pertinent studies that included a total of 7,088 patients with possible foreign bodies, and extracted key statistics from those papers. Decision analysis showed that CT scanning as an initial diagnostic strategy proved more cost effective than plain film or operative endoscopy. The incremental cost of immediate endoscopy for every additional correctly diagnosed patient was $5,238. Plain radiography was more costly and less effective, even with the addition of confirmatory CT scanning after a negative plain film. Sensitivity and threshold analyses demonstrated that these results are robust. CONCLUSIONS Patients presenting with a complaint of a retained ingested foreign body are most cost-effectively managed with CT scan, after history and physical. Immediate endoscopy may be considered if CT is not available, although it adds significant cost. Plain films are dominated by these two diagnostic strategies.
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Affiliation(s)
- Mark G Shrime
- Department of Otorhinolaryngology/Head and Neck Surgery, University of Toronto Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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6
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Andrade Filho PA, Carrau RL, Buckmire RA. Safety and cost-effectiveness of intra-office flexible videolaryngoscopy with transoral vocal fold injection in dysphagic patients. Am J Otolaryngol 2006; 27:319-22. [PMID: 16935175 DOI: 10.1016/j.amjoto.2006.01.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Indexed: 10/24/2022]
Abstract
SETTING A tertiary care referral-based otolaryngology practice. OBJECTIVES To evaluate the safety of office-based transoral oral vocal fold injection in an ambulatory dysphagic population and to evaluate cost-effectiveness in comparison with traditional injection laryngoplasty done under general anesthesia in the operating room. Dysphagia is a nonspecific and common symptom of many head and neck and systemic disease processes. In patients with glottal incompetence, the presenting complaint of dysphagia generally portends to more global oropharyngeal dysfunction than dysphonia alone. Although many authors have reported on and advocated the use of office injection technique in the management of dysphonia caused by glottal insufficiency, there is a paucity of literature regarding the use of this technique in a more medically compromised dysphagic patient population (Ann Otol Rhinol Laryngol 1997;106:778-83). We describe our experience with vocal fold injection in the office setting using a transoral technique under flexible videolaryngoscopy for the treatment of glottal insufficiency in dysphagic patients. The safety and cost-effectiveness of this approach are highlighted.
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Affiliation(s)
- Pedro A Andrade Filho
- Department of Otolaryngology, Eye and Ear Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Ubell ML, Ettema SL, Toohill RJ, Simpson CB, Merati AL. Mitomycin-c Application in Airway Stenosis Surgery: Analysis of Safety and Costs. Otolaryngol Head Neck Surg 2006; 134:403-6. [PMID: 16500435 DOI: 10.1016/j.otohns.2005.10.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 10/24/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study describes a large series of patients receiving topical mitomycin-c (MMC) during airway surgery, including complications, and carries out a cost analysis for its use in laryngotracheal stenosis. STUDY DESIGN AND SETTING Retrospective review, tertiary center. Airway patients receiving MMC are reviewed for demographics, stenosis characteristics, and MMC usage. A basic cost analysis is carried out. RESULTS Fifty patients underwent 93 MMC applications (mean = 50.8 years, 25 male, 25 female). In 89 of 93 applications (96%), the concentration of MMC was 0.4 mg/ml. One major complication occurred (1.1%). The expense for MMC is $455; the mean cost for airway surgery is $7,840. It is estimated that if 1 of 17 MMC treated patients requires one less operation, the cost ratio is favorable. CONCLUSIONS This large series contributes to literature that MMC is a safe adjunct to laryngotracheal surgery. The marginal cost for MMC application is favorable based on our basic cost analysis and existing efficacy data. SIGNIFICANCE Mitomycin-c seems to be safe and cost-effective in endoscopic airway surgery. EBM RATING C-4.
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Affiliation(s)
- Matthew L Ubell
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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8
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LeGrand M. CPT coding for upper airway endoscopies. ORL Head Neck Nurs 2006; 24:17-8. [PMID: 16841808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The Spring issue (Rudy, 2005) of ORL-Head and Neck Nursing presented a broad review of endoscopic procedures for evaluation and management of upper airway problems. Zarnitz (2005) briefly addressed billing for the most commonly performed upper airway endoscopies in that issue. This paper presents, in detail, the coding for a wider range of upper airway endoscopies performed in the office setting, along with how to report them to third-party payors.
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Abstract
CONCLUSION The new technique of ILM-guided vocal cord biopsy and APC is safe, cost-effective and non-invasive. It provides excellent airway control, adequate exposure of the vocal cords and effective treatment of laryngeal bleeding. OBJECTIVE Suspension microlaryngoscopy is a standard diagnostic procedure for vocal cord biopsy. In experienced hands failure of the procedure is extremely rare and may indicate a need for more invasive techniques. The aim of this study was to present a new technique of laryngoscopy/vocal cord biopsy and to review the relevant literature. MATERIAL AND METHODS After induction of general anesthesia and preoxygenation an intubation laryngeal mask (ILM) was inserted. A flexible bronchoscope was passed through the ILM and an anterior lesion was identified at the vocal cord. Biopsies were taken with forceps inserted through the instrument's working channel. The procedure was performed using video-endoscopic guidance. Bleeding from the wound surface was adequately treated with argon-plasma coagulation (APC). RESULTS Identification of the vocal cords was readily accomplished using the ILM. Only four literature reports matched our search criteria; all used the standard laryngeal mask or other instruments such as a laser or did not use the procedure for definitive therapy.
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Affiliation(s)
- J P Windfuhr
- Department of Otorhinolaryngology--Head & Neck Surgery, St Anna Hospital, Duisburg, Germany.
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10
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Rudman DT, Elmaraghy CA, Shiels WE, Wiet GJ. The role of airway fluoroscopy in the evaluation of stridor in children. Arch Otolaryngol Head Neck Surg 2003; 129:305-9. [PMID: 12622539 DOI: 10.1001/archotol.129.3.305] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine the role of airway fluoroscopy in comparison with other diagnostic modalities in diagnosing the site of partial airway obstruction in children with stridor. DESIGN Prospective study comparing direct laryngoscopy and bronchoscopy with nasopharyngoscopy, airway fluoroscopy, and plain films. Children with stridor or partial airway obstruction were evaluated by the Department of Otolaryngology at Columbus Children's Hospital, Columbus, Ohio. A history review and physical examination, including flexible fiberoptic laryngoscopy, plain films, airway fluoroscopy, and direct laryngoscopy and bronchoscopy, were performed for all children. SETTING Tertiary care children's hospital. PATIENTS From November 1996 to September 1999, 64 children aged 1 week to 12 years, with a mean age of 1.8 years and male-female ratio of 3:2, were evaluated for stridor. MAIN OUTCOME MEASURES The sensitivity and specificity of airway fluoroscopy in diagnosing the site of partial airway obstruction in comparison with nasopharyngoscopy and plain films. RESULTS Airway fluoroscopy had a sensitivity of 80% for subglottic, 73% for tracheal, and 80% for bronchial sites of obstruction. It was less sensitive for supraglottic and glottic sites-33% and 14%, respectively. Nasopharyngoscopy was more sensitive for supraglottic and glottic sites of obstruction. Overall, airway fluoroscopy was far more sensitive than plain films for diagnosing site of obstruction. CONCLUSIONS Airway fluoroscopy is a quick, noninvasive, and dynamic study of the entire airway that provides important additional information to the history review and physical examination and is a valuable adjunct to flexible fiberoptic laryngoscopy. It was far superior to plain films and may serve as a cost-effective screening tool in the evaluation of stridor in children, especially for lesions of the lower airway.
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Affiliation(s)
- David T Rudman
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Columbus Children's Hospital, The Ohio State University College of Medicine and Public Health, USA
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11
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Abstract
This study presents a cost analysis of and comparison between laser cordotomy and external beam irradiation for the treatment of early glottic carcinoma. It compares the curative results of the two modalities from data of a retrospective study at my institution and a literature review of published cure rates. It also reviews the results of objective voice assessments in cases representing both treatments. The findings of this study indicate that the cure rates are equivalent and that voice quality obtained after laser cordotomy is comparable to that obtained after irradiation, yet the total cost of external beam radiotherapy is significantly higher than that of laser surgery. Hence, the findings of this study provide strong support for initially treating early glottic tumors with laser surgery.
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Affiliation(s)
- J H Brandenburg
- Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin Hospital, Madison 53792-3236, USA
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Hogikyan ND, Pynnonen M. Indirect laryngeal surgery in the clinical voice laboratory: the renewal of a lost art. Ear Nose Throat J 2000; 79:350, 354, 357-8, passim. [PMID: 10832200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Since the advent of precision instruments and safe techniques for direct laryngoscopic surgery under general anesthesia, indirect laryngeal surgery has become very uncommon. A review of the recent literature finds that few authors advocate indirect surgery under topical anesthesia, and many otolaryngologists dismiss this technique as being either of only historical interest or an idiosyncratic method practiced only by a handful of clinicians. The societal mandate for cost-effective healthcare and the availability of relatively low-cost, high-quality endoscopes and video equipment warrant a renewed and broader interest in this type of surgery. In this article, we review a series of 27 indirect surgical procedures performed under topical anesthesia in the clinical voice laboratory. We discuss the indications, outcomes, advantages, and disadvantages of this surgery, and we present a brief analysis of its cost-effectiveness. We conclude that indirect laryngeal surgery in the clinical voice laboratory is an effective, safe, efficient, and less costly alternative to some procedures routinely performed under general anesthesia.
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Affiliation(s)
- N D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor 48109-0312, USA.
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Puura AI, Rorarius MG, Manninen P, Hoppu S, Hopput S, Baer GA. The costs of intense neuromuscular block for anesthesia during endolaryngeal procedures due to waiting time. Anesth Analg 1999; 88:1335-9. [PMID: 10357341 DOI: 10.1097/00000539-199906000-00026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED The goal of this double-blinded, prospective study was to compare the costs incurred by waiting time of intense neuromuscular block while posttetanic count (PTC) was maintained at 0-2 during jet ventilation. Fifty patients were randomized into five groups to receive atracurium (ATR), mivacurium (MIV), rocuronium (ROC), vecuronium (VEC), and succinylcholine (SUCC). PTC < or =2 was maintained until completion of laryngomicroscopy by administering additional doses of relaxants or by adjusting the speed of the infusion of SUCC. We compared waiting time, i.e., onset time and recovery time, and costs of intense neuromuscular block. The expenses due to waiting time were calculated based on the average costs in the otorhinolaryngological operating room in Tampere University Hospital: FIM 40 (approximately $8) per minute in 1997. MIV and SUCC differ favorably from ATR, ROC, and VEC when waiting time and costs are concerned. The recovery times with MIV and SUCC were considerably shorter than those with ATR, ROC, and VEC (P < 0.001 in all pairwise comparisons). Using the muscle relaxant with the longest waiting time instead of that with the shortest waiting time (difference 21.8 min) cost more than FIM 800 (approximately $160) extra per patient. IMPLICATIONS In this randomized, double-blinded, prospective study, we evaluated the costs of intense neuromuscular block due to waiting time. Succinylcholine and mivacurium are the most economical muscle relaxants to use when intense neuromuscular block is mandatory. Using intermediate-acting muscle relaxants results in unduly prolonged recovery time and extra costs.
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Affiliation(s)
- A I Puura
- Department of Anaesthesia, Municipal Hospital of Valkeakoski, Finland.
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Maroldi R, Battaglia G, Maculotti P, Cabassa P, Chiesa A. Computed tomography scanning of supraglottic neoplasms: its cost-effective use in preoperative staging. Acad Radiol 1996; 3 Suppl 1:S57-9. [PMID: 8796515 DOI: 10.1016/s1076-6332(96)80485-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- R Maroldi
- Department of Radiology, University of Brescia, Italy
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Affiliation(s)
- W C Taylor
- Beth Israel Hospital, Harvard Medical School, Boston, Mass
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Bjoraker DG. The Bullard intubating laryngoscopes. Anesthesiol Rev 1990; 17:64-70. [PMID: 10149051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- D G Bjoraker
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville
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Thawley SE, Ogura JH. Health care costs of laryngeal surgery. Laryngoscope 1979; 89:595-600. [PMID: 431259 DOI: 10.1288/00005537-197904000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The total costs of various laryngeal surgeries were considered from initial visit through one year postoperatively. For the four most widely used procedures, average costs were: laryngoscopy with biopsy, $1,000.00; hemilaryngectomy, $5,035.00; total laryngectomy $6,010.00; and supraglottic laryngectomy and neck dissection, $12,096.00. Most ancillary service charges decrease as length of hospitalization increases except for pharmacy and respiratory therapy. Physicians whose decisions affect health care should also take cognizance of health care costs.
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