University Place Wednesday Nite @ the Lab Seth Dailey, "Office-Based Procedures of the Upper Airway" 7/28/2010  UP 462   cc >> Thank you to joining me tonight for Wednesday Nite at the Lab at the UW Madison Biotech Center. Tonight, we welcome Dr. Seth Dailey of the Department of Surgery. Dr. Dailey is a board certified otolaryngologist, a head and neck surgeon with a subspecialization in laryngology, disorders of the voice, swallowing, and airway. Dr. Dailey completed his undergrad at Columbia University, medical school at NYU in New York City, and a residency at Albert Einstein college in the Bronx. He completed a laryngology fellowship at Harvard and was on the faculty at Harvard for a few years before joining the staff here at UW about seven years ago. He is an associate professor in the Department of Surgery and does research, teaches, and sees patients. He also sang with the metropolitan and city operas in New York City as a kid, and so he has a special interest in voice restoration. Please join me in welcoming Dr. Dailey this evening. (applause) >> Dailey: Thank you, very much. Shall I get started? Okay. 

So thanks everyone for coming. I know there's Concert on the Square tonight, and so you have many options and coming here, I'm glad that you did. I was last here about two years ago and had a really good time so I thought it would be time, sort of, for an update of the discussion we had a couple of years ago. This evening we're going to talk about awake unsedated procedures for voice, swallowing, and airway disorders, technological advances for an aging population. This is what I hope not to do to all of you this evening, to put you to sleep. (laughter) This is a wood cut of early experiments with ether, actually. And actually the sleep theme is particularly dear to me because all of my insomniac patients saw the talk from two years ago late at night on Wisconsin Public Television so I have confirmation that, in fact, the previous one was viewed by human beings who were awake. So what are our goals today? Of note, any questions that you have, if it's very burning, go ahead and ask it during the talk, and if not, maybe just jot it down and we'll answer questions during the Q&A session at the end. Can everyone hear me all right? Very good. So we're going to talk about the logic of unsedated procedures in the office, review some basic laryngotracheal anatomy, discover what's possible nowadays using some video demonstrations, and then I'm going to review some of my experience at the university along with that of my colleagues, maybe some pearls and pitfalls, things for consumption and discussion. 

So if there's anything important, this is a slide from the US Census Bureau website depicting on the X axis time and on the Y axis millions of people in increments of 10. As you can see here, I think you can see my arrow, perfect. Currently we're here in about 2010, and over the next 20 years we're going to have a substantial increase in the US population in the number of individuals over 65 from around 35 to around 70 million people. So basically it's going to double. So we in otolaryngology and in many other associated fields need to be aware of that and to try to anticipate those needs. So just to give you some basic numbers about why all of what I'm talking about makes sense. Again, the number of people over 65 is going to double in the next 20 years. There is one study that looked at a hundred individuals over 65 and found that 30% of them had a voice concern. So this is not an inconsequential problem. Furthermore, amongst those who are not necessarily over 65, about 7.5 million Americans at any given time have a voice problem. 

And just considering teachers, there's an estimate of about $2.5 billion lost to work time when they're not at work because of voice disorders. These are some other fun facts related to the aging population. One, just bear with me, I know there's a lot of text here, is that the rate of growth in the workforce in those over 55 is projected to grow at a rate five times that of the rest of the workforce over the next 10 years. Furthermore, the percentage of those in the workforce over 55 will grow from 13% to 20% in the next 10 years and will be maintained at that 20% mark until 2050. Of those 65 or over, these are all US Census Bureau numbers off the website, of those who are working who are 65 and older, 65.2% work in sales or office jobs, management, professional and related duties with dependence on vocal activities. So if you look historically, we've gone from an agrarian society to an industrial society, now largely to a communication-based society. So perhaps never more in human history has the power of the voice been more substantial, not just in terms of social interactivity, but in terms of financial importance. Another key thing to keep in mind is that of anesthetic risk of general anesthesia. So again traditionally with our profession for disorders of the voice and airway and swallowing, we have subjected patients to general anesthesia in order to inspect the area and in order to perform some sort of intervention. So this is a chart looking at, again on the X axis age and on the Y axis the probability of any major complication from general anesthesia in the attended surgery which somebody might be undergoing. 

These ASA scores relate to the preoperative risk. And, as you can see, if you have a low risk profile when you start, let's say you're age 70, your risk of a major complication is here, somewhere around 4.5%. As you go up, if you're preoperative risk status is that of a four, which is the worst kind, and you're still 70 years old, then your risk is going to be closer to 10%. So the short version of this is that if you can avoid general anesthesia and you're over 65, that probably is something that makes sense. So why would we do procedures in the office? So as I mentioned, there's lower patient morbidity because you're not subjecting patients to general anesthesia. There's limited pain that people undergo. You can return to work the same day, the same morning even. There's similar efficacy to procedures performed under general anesthesia. Many patients, once they've had an office-based procedure and they've had also a general anesthetic, will prefer the office-based procedure. And then as I mentioned the key element of the aging demographic. 

What about the counterargument? Why would you not do procedures in the office? Well first of all, a lot of the equipment costs money so it's expensive. There are reimbursement problems because a lot of what we do doesn't even have codes. There's no standard code to which we can apply many of our procedures, and that can create problems in getting paid for the services. It requires some extra staff, staff training. There are technical challenges to it. It's not something that you just pick up and do like there's a ball on the ground and you pick it up, it's not like that. There's definitely a learning curve associated with it. The learning curve, I would say primarily is related to anesthetic management because what we're doing with office-based procedures is somehow circumventing all of the protective mechanisms of the upper airway, gag, laryngospasm, and cough, which are very powerful protective mechanisms. And so we're having to quiet many of those responses in order to try to achieve access to the area which we're trying to examine or intervene upon. Furthermore, it probably makes sense from an overall financial perspective. 

So there was a retrospective study looking at the use of this particular laser called the PDL, or pulsed dye laser, in the OR versus in the office. And there was about a cost savings of $5,000 per case. So reimbursement, depending on where you are, can be substantially lower than that, and so in order for us to assure that patients can receive this, we need to work with the insurance companies and have some updates. For other financial considerations relate to vocal cord injections which we do a great deal of. There was a retrospective study looking at, again, costs in the operating room versus the office, and here there's about a $2,000 savings per case. And in the predictive model in which this article was published, they estimated about a $40 million savings to the overall healthcare system per year. So I wanted to just go over some of the basic laryngeal anatomy so we're all talking the same language. These are some drawings, again you can all see the arrow here, depicting the muscles and some of the superstructure of the upper airway. The larynx, the voice box, begins at this crown-shaped bone called the hyoid bone, sometimes called the tongue bone, from which the tongue emanates and extends into the oral cavity. Probably the most easily prominent feature from the outside is the thyroid cartilage, and the front of which is the Adam's apple or laryngeal prominence right there. 

The bottom part of the larynx which attaches to the trachea, your airway, sits here and is the only circumferential ring of the airway and can be narrow in children and in adults alike and can create airway problems. Behind the trachea is the esophagus, and behind the larynx is the pharynx or throat. Of interest, emergency airway procedures are done through this membrane, the cricothyroid membrane in cases of someone not being able to be intubated. So that's sort of a favorite spot for medical students to know what that is. These are some other schematics and drawings. Here is the thyroid cartilage viewed from the interior, this is where the vocal folds or vocal cords, either one, insert. This is the head of a serpent-shaped epiglottis, which sits here just above the vocal cords. The vocal cords themselves, which are muscle and this specially designed membrane which I'll talk about in a minute, attach to mobile cartilages back here called the arytenoids which in turn sit on the cricoid cartilage. So if you put it all together and remove muscles and mucosa, this is what it would look like from a posterior or back view. Here's your cricoid cartilage, your little arytenoids that move back and forth. 

Here's your epiglottis and your thyroid cartilage. If you were an anesthesiologist and you were going to put a breathing tube in someone, this is what you would view. These are the vocal cords themselves. This is the epiglottis which is somewhat curvaceous. Here is the top of the arytenoids, and down there through the vocal cords is your trachea. So how does all this work? There are three major functions for the larynx. It opens so that you can breathe, and then it closes for the other four major functions, two of which are noted here. Swallowing, so that you don't have Spotted Cow and brats go down into your trachea. Voice, so that when the vocal folds close air passes by and sets them into motion. The other ones which I did not mention here include cough, to eject things from your lungs that aren't supposed to be there. 

And then of course the Valsalva Maneuver or bearing down so that women can give birth and we can lift heavy objects and things like that. So how do we make voice? Well, you can break it down conceptually into three major areas. There's the generator, which is air that passes from your lungs, through your trachea and past your larynx. The vibrator, which is your vocal cords. And then the resonator, which is everything from the vocal cords to the tip of your lips and nose. That's why I sound like me and you sound like you and you sound like you, etc. That's our signature horn. So just taking that as a different example. The generator and the vibrator are the exact same for a trumpet and a tuba, but the reason trumpets and tubas sound different is because of the horn. Sorry I missed one. 

So there are three components for high quality voicing. The vocal folds have to close or nearly close. They have to be supple and have proper viscoelastic properties so that they can vibrate. And then they need to be alike. They need to be one looking just like the other in contour, symmetry, tension, bulk, etc. So here is a schematic of a vocal cord cut in cross section. So if my vocals cords are like this, this would be a section like that. This is the surface epithelium which is only six to 12 cell layers thick. You could read a newspaper through it if you so desired. The components of the lamina propria are beneath this. 

This is a very organized, very specialized area with glycoproteins that helps again to have a vibratory source. And then here beneath that is the muscle which allows you to apply tension and change the pressure gradient across the glottis. So what does a normal exam look like? A stroboscopy is an examination which slows down fast things. So if I do this... (hums) That's about a hundred cycles or so of the vocal cord. So we can't see that with our naked eye so we need a special contraption called a stroboscope to slow that down and make sort of a composite movie which we can then examine, and this is what it would look like. (video humming) I don't know if that can be turned up. Or I can turn it up. (video humming) Let me try that again. Better. 

(video humming) So here you can see the vocal folds. They're white because of the collagen within them. Those are the arytenoids back there. I'm going to turn my mic volume down just a touch, I hit the wrong button, and I'll play it one more time. (video humming) The trachea is through there. This is your epiglottis. Those are your arytenoids back there. Okay, nice symmetric motion. Looks fabulously healthy. So what new technologies are we talking about? Why is this a revolutionary time in what we do? First is something called the distal chip endoscope. 

It used to be back in the late 1960s, early 1970s and even up to 10 years ago, that the primary scope that we used was a flexible little thing, goes through the nose. It's been used for bronchoscopy, and it's individual fibers of fiber optic cables wrapped in parallel with a plastic sheath. So the images are good but not great. And now we have something called the distal chip endoscope which actually has a camera at the end and allows much better resolution in terms of color and clarity. We can photo document so we can record everything and share with other providers and also share with a patient. We have plenty of things to inject into the vocal cords, Botox, steroids, and a whole bunch of fillers designed to move the vocal cords together because, as I mentioned before, if the vocal cords can't close, you're going to have a breathy dysfunctional voice. And I'll show a couple of examples of some of those. And we also have a whole host of lasers, including ones that target water and target blood vessels. And that's particularly applicable in terms of small tumors that grow and anything that has a vibrant blood supply. So I'll show you some video examples of things that we do every week, almost every day, including vocal cord injections, some biopsies of patients while they're awake, which is particularly handy for those who want a rapid diagnosis of cancer or other disorders. 

Some laser procedures looking through the nose into the esophagus called transnasal esophagoscopy. And then airway examinations which we affectionately call TNT or transnasal tracheoscopy. Sounds better as TNT. So why would we do a vocal cord injection on someone? There are a number of reasons and these are the ways that we access. And you can go through the mouth, you can go even through the nose with a special needle through the endoscope, and then oftentimes we go through the skin, through the front here via three different routes, that cricoid thyroid membrane that I mentioned before for emergency airway procedures, from above through that higher membrane called the thyroid hyoid membrane, and then also right through the cartilage into the vocal cord. So here is a, this is a plastic model of the larynx which depicts some of these routes. Here is a curved needle going through the mouth down towards the larynx. Here is the needle going through the cricoid thyroid membrane, or the top of it rather, into the larynx. So just to give you kind of an idea. We need, as I mentioned, quite a bit of expensive equipment. 

Here is otolaryngology examination chair. Here is a video tower so we can have immediate video feedback. This is actually attached to our radiology system. So anything that we record goes immediately into the radiology system just like it would a CAT scan or an x-ray or anything. So it makes for good sharing of information, again, with other providers. And these are two different lasers which we use regularly. And here is one called the pulsed dye laser, and here is one called the RevoLix which is about the size of a large briefcase. You have to have people who know what they're doing. These are a couple of the nurses in the otolaryngology room who've helped us build this program to something that's pretty functional now. This is a video of the application of some Lidocaine. 

So the patient will be sitting in a chair through the mouth and with my left hand I will hold the camera that projects the image up on the screen and my right hand delivers some Lidocaine through a curved needle. And you can even see on the video monitor here those are the vocal cords. This patient is obviously awake. Lidocaine is being dripped down on the larynx. It bounces around, anesthetizes the interior of the larynx, and then the patient will breathe in and that anesthetizes the trachea. This is a close up view of kind of what you just saw. There's no sound on this one. So as I mentioned, when you say E your vocal folds vibrate and that in turn bounces the Lidocaine around and provides fabulous anesthesia for the interior of the larynx and then down into the trachea when it drops in. So who benefits from vocal cord injections? Why bother doing these things? You can do it for vocal cord paralysis, so when you have one side that's moving and one side that's not. That happens when often the nerve supply to one half of the larynx is compromised. 

That can happen from lung surgery, heart surgery, thyroid surgery, carotid neck, and it can happen all by itself from a virus. That's one of the main indications is vocal cord paralysis. Other indications might be vocal cord scar, aging from atrophy of the muscles when you develop a gap between the vocal cords that you're trying to correct. We also use pharmaceuticals like Botox for spasmodic dysphonia and even vocal tremor to try to reduce the effect of that on voice production. We use steroids for singer's nodules as well as for granulomas which are sort of nonspecific inflammatory disorders of the back of the larynx. So here's a video, again all of these videos are with people awake sitting in the otolaryngology chair. There's no sound to this one either so I'll narrate. This person has some nodules in the midsection of their vocal cord which is classically where they happen. And I'm using a very tiny needle through the mouth to inject that superficial compartment called the lamina propria that's so specialized with a steroid to reduce swelling and hopefully assist voice therapy so that people can have a return to more normal function. And you can see the patient's breathing, moving their vocal cords, and that's the way it works. 

This is a collagen injection for someone with vocal fold atrophy and they end up kind of with a breathier voice. Many individuals will recognize the 65- to 75- to 85-year-old voice depending on who you are. It's usually breathy, strained, and in men higher-pitched. (speaking in a breathy voice) "Hey, come here, I want to tell you something." It's sort of a higher pitched voice, and it's breathy and strained because the vocal folds simply cannot meet and so there's air escape. It's a leaky valve. It's a gap. So collagen is delivered into the muscle to recontour the vocal folds, move that striking surface closer together to assist with less effortful, less problematic voicing. So you have to push the false vocal cord out of the way with a needle, as you can see there. Then the needle is delivered into the muscle, and collagen paste is delivered into that compartment to, again, help recontour, as you can see. It went from sort of convex, excuse me concave to convex, and then the exact same procedure is performed on the other side. 

So this is, again, a nice solution, albeit temporary, for patients with vocal fold gaps. We have since moved to more, well, to different injectables. There's one which is FDA approved called --. There are a number of others which we use off-label because we feel they have beneficial properties. This is a Botox injection for a young lady with spasmodic dysphonia. This is a different approach. This is through that cricoid thyroid membrane, that emergency airway membrane, and you can see here that the needle can be viewed with this endoscope and is then passed directly into the vocal cord into the muscular compartment so that the muscle can be temporarily weakened and therefore reduce the symptoms of that patient's spasmodic dysphonia. The only reason I did not go through the mouth with this person is because they had a very powerful gag reflex, and that can happen sometimes. This is sort of a video or a still image of how that procedure works. There an assistant who holds the endoscope to provide the image projected up on the video screen, which I can then watch and then deliver the needle through that cricoid thyroid membrane to the desired area. 

This is an alternate approach where you go right through the thyroid cartilage. And if you notice here there's sort of a bouncing of the needle on the, you can see the needle sort of pushing on the structures there so I know I'm in the right place. This is more blind because you don't have direct visualization of the needle but you have a pretty darn good idea where it is and it's safe and easily applicable. So what other things can we do? How about biopsies? You can either go, again, through the nose or through the mouth. Patients with suspected carcinoma, with cancer where they want to get a quick diagnosis and speed their time to treatment, this is very useful. And then leukoplakia, is just a Greek term and it means white plaque, is often seen on the vocal cord, can be seen on the oral cavity as well, and basically tells us that the surface, the epithelium, which is where cancer comes from, has changed. And so we often suspect that that person may have, if not cancer, precancerous changes which we can then diagnose and follow appropriately. This is a transoral biopsy being performed. This is an individual who had a laser resection of a carcinoma and had some suspicious tissue at that front part of the vocal cord, and we wanted to make sure that it wasn't still cancer. I'll play that again. 

This is a specialized curved instrument through the mouth which grasps a little bit of tissue. You can see that there's minimal bleeding, and we were able to get an immediate diagnosis. That turned out not to be cancer and just healing tissue which was nice. So other things that we do include laser therapy. I mentioned the 585 nanometer, I forgot nanometer in there, pulsed dye laser. There's a 532 nanometer wave length pulsed KTP, or potassium-titanyl-phosphate, laser. Both of those target blood vessels and are very useful and indeed somewhat revolutionary for the treatment of upper airway disorders. And then a holmium laser which delivers a hotter, more thermally-based approach since it targets water and literally will blow up tissue since most of our cells happen to be water. So who benefits from this? RRP stands for recurrent respiratory papillomatosis. We did a little story on NBC15 the other day on a young man who has had 35 surgeries for this, and that's pretty standard if you have the juvenile type because it comes back and it comes back and it comes back. 

So the beauty of this type of laser, these angiolytic lasers like the KTP and the pulsed dye lasers, is that they have much more limited thermal effect on the vocal cords. So we want to treat the tissue that's abnormal but leave the tissue that's normal. So it tends to have a very limited effect in terms of scarring and that's a beautiful thing. Leukoplakia, again as I mentioned, can be treated with the laser as a solitary treatment option. Reinke's edema is the voice that middle-aged female smokers, principally, will get. So for those of you familiar with the Simpsons, it's Marge's sisters who have this very rough voice. Sort of like almost like a stereotypical truck driver voice and some women are mistaken for men on the telephone and it's very irritating for them and I can show you video of that in a moment. And then granulomas which are these small scab-like attachments to the back of the vocal cord, often seen in reflux and in patients with a very active vocal schedule. So here is a video of the pulsed dye laser being applied. It does have, you can see the flashes. 

This is a pulse because it's a pulsed dye laser. There's a tiny amount of blood coming out from small blood vessels that have been burst. This superficial area of the papilloma is being treated. There is a marginal thermal effect which is why you can see it turning to white which means that the proteins have been denatured. But also what we're achieving here is choking off the blood supply to the papilloma by turning a flowing river of blood within each of those -- into a frozen river. So then the papilloma will no longer have a blood supply and will fall off. This is an example of the 585 nanometer pulsed dye laser on Reinke's edema. That is a very large vocal cord. Particularly on the patient's right side. The left side on the screen. 

So what we're doing here, this is sort of a different, less well understood mechanism of the laser where it basically sets into motion a biological cascade by which the vocal fold will shrink and even probably become more organized. So the pulsed dye laser, just as an example, has been used in dermatology for many years. It will turn hypertrophic thick scar into something that's more normal sized and organized. It will also turn atrophic skin, which is thin, into thicker, more normal, more organized skin. So it has biological effects. It's not like a laser where you're blowing it up. It's really sort of a, it's almost like a medicine. So it's almost like photo medicine to a certain extent. The pulsed KTP has very similar methods of action. This has a faster firing rate and allows us to get a little bit more done. 

This is a patient with papilloma towards the back part of the vocal cord in the so-called interarytenoid region which we're treating, again, in the office. All these patients are awake. They come and go in half an hour. And you can see some of those same effects with the superficial thermal effect and the angiolysis. This is the RevoLix laser which we have had for, I don't know, five years or so. This is the tip of the laser. These are very large granulomas which are obviously impeding this patient's ability to voice. And they also produce a lot of discomfort in the throat with various functions such as swallowing and voicing. So here you can see this is a very different laser. It is applying a lot of thermal energy to a very specific area. 

And you may be saying to yourself, wait a minute, if you have such a hot thermal laser, how is it that this patient is able to tolerate this? And the answer is it that granulomas don't have a nerve supply. They don't have their own nervous supply, and so you can do pretty much whatever you want to a granuloma and the patient's not going to feel it at all. This is an example of this patient after surgery. I'm going to try and pause it at just the right moment. I may have to play it again, it's a little tricky. I'm sorry about that. >> A gentle breath. >> There. So this is what that left-sided granuloma looked like after one treatment. It's probably about 20% of its original volume. 

And after that we often apply medicine systemically for reflux treatment and voice therapy, and that should be enough to carry the day for these individuals. So what about the airway? Classically, when you're going to examine someone's air passage, you would take them to the operating room, put them under general anesthesia, use your eyes or some sort of lighting instrument to be able to look inside. So borrowing from the bronchoscopic literature, pulmonary and then just sort of innovating a little bit, we've been using airway exams, one of which I did today, to examine people while they're in their natural state. So they're sitting in a chair, they breathe in Lidocaine, we apply a little bit more Lidocaine, they have an anesthetized larynx. So here you can see that this patient has a paralyzed right vocal cord, but that's not really what I'm interested in. I want to know what's beneath there. So once you pass through the vocal folds, you can see that this patient has considerable narrowing at about three to four rings down the trachea. This is an individual who had undergone a tracheotomy and had had collapse and scarring of the area after the tracheotomy tube, which was in the trachea, had been removed. So this is not an uncommon occurrence, and so anybody who comes in after their trach is removed and they're having trouble breathing and making airway noise, this is the sort of information we want to have. So now that we have this information we can plan for surgery, we can have really definitive planning to know what to do rather than subjecting them to a second anesthetic. 

So that's a nice feature. So when do we do this? Who benefits from this? So stridor, stridor without known cause, stridor is upper airway noise. (takes a ragged breath) That's so-called stridor. It can be on the way in, on the way out, or both. And when we want to assess that in the office this is an awfully handy tool. We can also make sure that someone doesn't have a mass lesion like papilloma or carcinoma sitting in their airway. As I mentioned, postextubation airway restriction with exertion, what does that mean? So after someone has had a breathing tube removed and they have trouble moving air, airway restriction, when we exercise, so exertion, that tells us that they might have an anatomic problem related to their airway that we want to examine. And vocal cord dysfunction is an interesting disorder where patients, instead of separating their vocal cords during breathing, will actually approximate them. So this is not particularly well understood but is thought to be due to in part reflux, sometimes stress exacerbates it. It can be seen in oftentimes athletes of a young age. 

So to make sure they don't have something else such as subglottic stenosis or some other disorder, we will perform an office-based airway exam. So the nice part about this, you may be saying that's nice, you can see up to this area but what about past? What about the rest of the trachea, aren't you going to miss something? And so we're able actually because of the dense anesthesia that we're able to achieve with topical anesthesia, you can actually pass this endoscope through the area of the stenosis and go all the way down to the so-called carina which is down there. That's where the trachea separates into left and main stem bronchi. So this is really a definitive exam. So I know very well what I'm dealing with prior to counseling the patient afterwards. TNE again stands for transnasal esophagoscopy. This is an example. So this is about a six millimeter scope which is passed through the nose after decongestion and topical anesthesia, into the esophagus all the way down to the junction of the esophagus in the stomach. We will then look in the stomach and even look up back at ourselves at the under surface of the stomach-esophagus junction. So why would we do something like this? So we often perform this as a screening exam with refractory GERD, or gastroesophageal reflux disease, symptoms. 

Heart burn, chest pain, dyspepsia. You can find ulcers in the esophagus, you can find infection, you can find all sorts of things. And most importantly, you can find Barrett's esophagus which is a precursor to adenocarcinoma of the esophagus which is one of the fastest growing carcinomas in the United States. So this is a 20- to 30-minute procedure which allows patients a lot of confidence in knowing they don't have an incipient carcinoma. Refractory globus, globus is a sensation of feeling like something is stuck in your throat. This can actually be from the esophagus because the spatial resolution from the nervous system perspective of the upper airway stinks. So I can have pain, I can have some sort of noxious stimulus to my throat and feel it in my ear. I can have some sort of noxious stimulus in my esophagus and feel it as a lump in my throat. The resolution of the upper airway is poor so we often have to rely on objective data such as imaging or other testing to tell us what the heck is going on. You can find stricture, which is a narrowing from scarring, and we often perform TNE for chronic cough. 

So cough can be caused also by ulceration or Barrett's or esophageal reflux disease. So these are all very useful features. So the pain scale, what is this all about? So particularly when we were gaining preliminary experience in these procedures, we wanted to ask patients where they had the most discomfort and what was their discomfort level. So on the bottom here are the so-called FACES, capital F-A-C-E-S, it's an acronym for children, but we also began to use it for adults. More often than not we'll use the zero to 10 for adults since they don't really need a happy face to point at. My personal experience over the last five years or so, which is joined by that of my partners, is about 1500 procedures in over five years. These are for the larynx, the trachea, and the esophagus. We've had two hospital admissions during that time. One for a reaction to an injectable which we no longer use for the vocal folds, and one for laser to the subglottis. This was in a patient where I was doing my best to keep her out of trouble. 

She was in her first trimester of pregnancy, and I didn't want to subject her to surgery. We had to admit her for some systemic steroids to prevent her from getting worse. We've never had a bleeding problem even for individuals on blood thinners. This is particularly applicable for the patient population who are 65 and older who are oftentimes on aspirin, Plavix, or Coumadin, more often than not from heart problems. In our recent review of injections not including Botox injections, we had a 98% completion rate in the office. So we had to take three or four patients to the operating room simply because they couldn't tolerate it. So that's awfully handy. We have about 166 laser procedures that we've performed successfully. One thing that's been fascinating to me is that sometimes during these procedures, particularly looking at the esophagus, patients will feel a little light-headed. We've had patients rest for a couple of minutes with the scope still in. 

They recover and feel fine. We finish the exam and are done. So what we can get away with in the office is pretty substantial. And in general, patients report a zero to two out of five mostly for the injections. Sometimes for the nose, especially with the TNE scope, that can be a little bit higher because the nose is a very sensitive place. So I've left a little bit of time for questions, but basically this represents a real revolution in my practice and in that of everybody nationally who does what I do. There's been a substantial shift back into the office away from the operating room, which saves people the morbidity of general anesthesia and potentially serious complications, heart attack, stroke, etc. As we move along, reimbursement, time and familiarity will dictate use in otolaryngology. So as general otolaryngologists become familiar with this, as the cost of the equipment comes down, as the reimbursements rise, this will become standard practice X period of time from now. These are very safe procedures, and that's one of the fabulous features we can really rely upon because we don't want to have a lot of problems in the office. 

They're very effective and the beautiful part is that this, as a general notion, really anticipates the needs of the US population over the next 15 to 20 years. So I imagine this approach, both in otolaryngology and even in other allied fields, will start to become more common. So with that, I will stop for question and answer, and I thank you for your time and attention. (applause)