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June 30, 2012

New Medical Device to Cure Excessive Sweating

Everybody sweats, but some sweat more than others to the point where even constant anti-perspirant usage is insufficient.

Beyond botox which is painful and lasts only a few months, options have been few until now...

A new medical device called Miradry destroys sweat glands by heating up the junction between the second and third layer of the skin using microwave after sucking up secretions. Before the procedure, numbing injections are required.

A company study shows patients who used Miradry experienced an 82 percent reduction in sweat over 18 months. Patients may require the procedure to be repeated for ultimate sweat control.

So far, it is available ONLY for underarm treatment.

However, for those with excessive facial sweating, botox injections or robinul medication is still the only treatment, but who knows... perhaps Miradry will soon be available for the face/neck area at some point.

Clinical Evaluation of a Microwave Device for Treating Axillary Hyperhidrosis H. Chih-Ho Hong, MD, Mark Lupin, MD et al; Dermatologic Surgery 2012; 38:728-735

A Randomized, Blinded Clinical Evaluation of a Novel Microwave Device for Treating Axillary Hyperhidrosis: The Dermatologic Reduction in Underarm Perspiration Study Dee Anna Glaser, MD et al; Dermatologic Surgery 2012; 38:185-191

Microwave thermolysis of sweat glands Jessi Johnson, PhD et al; Lasers in Surgery and Medicine 2012; 44:20-25

American Girl Doll Gets Hearing Aids

The American Girl doll company now offers hearing aids for their 18 inch doll models only through their Doll Hospital. Thanks to Tampa Bay ENT who shared this information.

Unlike humans who are able to obtain many different styles of hearing aids, only BTE (behind-the-ear) style is available for American Girl dolls.

Interesting, the medical services offered through the Doll Hospital is MUCH more impressive than what can be offered for humans. Services beyond hearing aids include new heads, new bodies, eye replacements, and limb replacements.

Though we do not offer hearing aids for American Girl dolls, we do offer the full array of hearing aids (selling, repairing, adjusting) for humans from Oticon, Phonak, and Widex.

June 29, 2012

New Oral Appliance for OSA (Only Needs Heat to Fit)

A new sleep apnea oral appliance can be fitted and used at home without going to a dentist called ApneaRx!

Oral appliances to treat obstructive sleep apnea (OSA) have an upper and lower component that fit into the upper and lower jaws. A mechanism within the device than allows for the lower jaw to be thrust forward to some degree which pulls the tongue and anterior airway forward thereby enlarging the airway and preventing obstructive apneas during sleep. It can also help with snoring.

Typically, such OSA oral appliances must be fit by a dentist and cost upwards of $300 or more.

Most patients or loathe to spend that kind of money if they are not sure if:

1) It will actually help
2) It will be something they can actually tolerate or use

That's where this new OSA oral appliance called ApneaRx comes in which is considered a "transition" device to try and see if oral appliances will work for a given patient before going with an expensive dentist-fit customized oral appliance.

In essence, the device is heated and bitten into for fitting. The device can than be adjusted in 1mm increments by squeezing from the sides.

If this device "works" for a patient, they can either continue to use this device, or now take the time and expense of getting a customized device from a dentist.

However, please be aware that there's only one size currently available which may be too large for 20% of patients, especially women. There will soon be a smaller version for those with a smaller mouth by the end of 2012.

Read brochure.

June 25, 2012

R&B Singer Maxwell with Vocal Cord Hemorrhage

At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

June 22, 2012

Oral Mass Excised From Fetus Still in the Womb!

In a world's first, surgeons removed a 4 cm oral mass (teratoma) in a 4 month old fetus while still in the womb. This was performed at the University of Miami Hospital.

A cannula was inserted through the mother's belly and into the womb where it was directed to the mass under ultrasound and endoscopic guidance. Via this cannula, a laser was used to lop the mass off free.

A healthy baby was born 5 months later and is now a healthy, normal 20 month old child.

A more common variation of this procedure is what is known as an "exit procedure". In an exit procedure, a cesarean section is performed and while the newborn is still connected via umbilical cord, all necessary procedures are performed before the cord is cut and the newborn fully delivered.

Needless to say, performing surgery while still in the womb is an amazing feat of medical science and technology.

Kudos to the surgery team and the mother!!!

Successful in utero treatment of an oral teratoma via operative fetoscopy: case report and review of the literature. American Journal of Obstetrics & Gynecology Volume 207, Issue 1 , Pages e12-e15, July 2012

June 21, 2012

Scientists Publish Research on Breakthrough Treatment for Tonsil Stones

Title sounds very exciting... even more so when I realized it was talking about the research paper that I co-authored with fellow ENT colleague Dr. Richard Thrasher on a new way of addressing tonsil stones.

I never really considered myself a "scientist,"but glad to hear that at least somebody considers me one!

This article apparently came out on MedicalXpress, a medical news website. It has also been picked up in a few other channels as listed under sources.

Scientists Publish Research on Breakthrough Treatment for Tonsil Stones. MedicalXpress 6/20/12

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang. Fauquier ENT Blog. 6/14/20

Ear, Nose & Throat Journal publishes research on breakthrough treatment for tonsil stones. EurekaAlert 6/20/12

Coblation cryptolysis to treat tonsil stones: A retrospective case series. Ear Nose Throat J. 2012 Jun;91(6):238-54.

June 14, 2012

New Minimally Invasive Technique to Treat Tonsil Stones Developed by Dr. Chang

Dr. Chang developed an innovative minimally invasive technique to treat tonsil stones using coblation technology. His findings have been published in this month's ENT Journal. In fact, his research made the front cover of the journal! Dr. Richard Thrasher of ENT Centers of Texas was a co-author in the study.

This technique called coblation tonsil cryptolysis is unique in that it can be performed in adult patients without sedation using only local anesthesia, much like laser tonsil cryptolysis. As with laser cryptolysis, pain is significant for only a few days and most adults can resume normal diet and activity within 1 week. In contrast, tonsillectomy entails significant morbidity for several weeks. However, coblation avoids the significant disadvantages of laser use, including the potential for airway fire, retinal damage from reflected scatter, dealing with plume from vaporized tissues, oral/facial burns, and the high cost of purchasing and maintaining laser equipment. After a single session of coblation tonsil cryptolysis, a significant decrease and even elimination of tonsil stones can potentially be achieved.

Read more about this mode of treatment here.

Read the research article here.

June 12, 2012

Smartphone Otoscope for the Masses

The geniuses at UC Berkley (Cellscope) have developed an otoscope that can attach to a smartphone allowing visualization of the eardrum on the phone's screen.

Possible applications include allowing parents to take pictures of their child's ear on the smartphone and emailing to their physician rather than a clinic visit for diagnosis of an ear infection, fluid behind the eardrum, or eardrum perforation.

Not for sale yet... as far as I know...

Here is their original research paper describing this idea which extends not just to eardrum visualization, but any application where magnification is required.

Mobile Phone Based Clinical Microscopy for Global Health Applications. PLoS ONE 4(7): e6320. doi:10.1371/journal.pone.0006320

Saliva Test for Laryngopharyngeal Reflux (LPR)

Various groups have been developing a fast, cheap, non-invasive saliva swab test to determine whether laryngopharyngeal reflux (LPR) is present or not. LPR may cause symptoms of:
When you compare a spit test to the current way of how reflux is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state "yes" or "no" whether LPR is present or not. Keep in mind that this test does NOT inform what type of reflux is present whether acid reflux or non-acid reflux, nor does it reliably inform how severe the reflux is.  Only the 24 hour ph/impedance testing can provide such information.

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is rdbiomed using their Peptest kit.

Unfortunately, such testing is not offered in most labs except in Europe. (This test is currently not FDA approved and as such, is not even available for purchase yet in the United States. However, FDA approval is expected in 2014.)

However, we do offer this test in our office for current patients of ours. Click here for more info.

However, you can order this test yourself as an individual. It is recommended you take the standard 3 sample peptest. Click here for more information.

Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

June 11, 2012

12 Years Old Girl Dies After Tonsillectomy

Tampa Bay Times reported on June 10, 2012 a 12 years old girl died after a tonsillectomy performed on Aug 13, 2010 for chronic tonsillitis. From the details provided from the news report, it seems that several independent issues all contributed together that lead to this child's unfortunate and tragic death.

This case was also complicated by subsequent non-medically related actions taken by medical personnel which will not be discussed here.

Strictly medically speaking...

Local Anesthetic With Epinephrine

It is unclear exactly when the local anesthetic bupivacaine (Marcaine) with epinephrine was injected into the tonsil region which may help with post-tonsillectomy pain control in the pediatric population. Also unclear is what concentration and how much got injected.

However, it is far from common practice (though not rare) and it is not something I personally inject in the pediatric population for a few reasons in spite of its well-known suspicion to minimize a sore throat after surgery. (There are plenty of papers that report such injection offers NO additional pain control in children. See references below.)

1) The risk of bupivacaine is toxicity to the heart leading to arrhythmias that may ultimately lead to a heart attack.
2) Epinephrine can result in hypertension as well as further exacerbate cardiac problems

Given report of "bloody froth" in the endotracheal tube along with acute onset of tachycardia and hypertension, I suspect the child suffered from pulmonary edema, most likely secondary to accidental intra-vascular injection of the local anesthetic (causing cardiac failure) and epinephrine (causing tachycardia and hypertension).

Given these risks and fact that kids are so much smaller and more susceptible to medication risks, I personally never inject this medication during/after tonsillectomy. Even in adults, I never inject routinely, though I do offer to adults undergoing tonsillectomy (but than I use bupivacaine alone without epinephrine).

The hypertension itself led to problem #2...

Congenital Cerebellar Vascular Anomaly

The child had a congenital cerebellar vascular anomaly that ruptured leading to a life-threatening bleed in the brain.

In and of itself, this anomaly would not have been a problem, but given the reported sudden hypertension, the rupture is akin to inflating a tire with too much air causing it to pop.

Most likely, if the child's cardiovascular compromise never occurred, this bleed never would have happened in the first place.

It's also entirely possible if the local anesthetic was never used, this death would not have happened as well.

Lawsuit claims doctors' mistakes caused Palm Harbor girl to die after tonsillectomy. Tampa Bay Times 6/10/12.

Comparison of clonidine, local anesthetics, and placebo for pain reduction in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg. 2011 Jun;137(6):591-7. Epub 2011 Mar 21.

Preincisional bupivacaine in posttonsillectomy pain relief: a randomized prospective study. Arch Otolaryngol Head Neck Surg. 2002 Feb;128(2):145-9.

Control of early postoperative pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J. 1993 Aug;72(8):560-3.

June 10, 2012

The Rationing of High Cost Healthcare

I would like to start this blog article with an extreme hypothetical situation...
Imagine a pharmaceutical company comes out with a pill... a WONDERFUL pill "Xyz" that is GUARANTEED to extend life by 1 month with no side-effects that works on kids as well as adults. For every 1 of the these pills that are taken, 1 month is added to your life expectancy guaranteed. Doesn't matter if you have cancer, in a coma, suffering from a horrible infection, stroke, or you are completely healthy. One month added to your life expectancy for every 1 pill you take.
Catch is, this pill is very expensive. For ONE person, it is $5,000 per pill or $150,0000 per month or $1.8 million per year.
In this hypothetical situation, should patients pay out-of-pocket for this treatment? Than only the rich will be able to afford such expensive treatment.

Should insurance pay for this treatment? Well, given the high cost, the insurance companies will raise premiums in order to afford to pay for this treatment... otherwise go into bankruptcy. With increase in premiums, more and more people as well as companies will not be able to afford health insurance.

In response, in order to make health insurance more affordable, insurance companies have increased deductibles as well as included riders that exclude the Xyz pill coverage.

• Increase in premiums
• Inability to pay for health insurance premiums
• Increase in deductibles
• Exclusion riders

All as a response to an increased cost of providing healthcare (via this wonderful "Xyz" pill).

Should the government pay for this treatment? The population in the United States is 312 million currently. The cost to government will be $562 million per year to provide treatment for every individual for one year. Given everybody theoretically could live forever while taking Xyz pill... nobody will die which means the population will increase. With population increase, the United States will eventually go into bankruptcy it it continues to provide treatment for everybody.

As such to prevent government bankruptcy, Congress passes a variety of laws that include cutting medicare/medicaid benefits, raising the United States debt ceiling, cutting back on education/military spending, increasing taxes, etc.

This story sound familiar?

That's because it is... though not because of the existence of the Xyz pill. But "expensive" healthcare exists due to new pills, new tests, new surgeries that keep coming out which are more expensive than prior healthcare interventions.

The insurance and government's responses are the same in real life as to the fictional response to the hypothetical Xyz pill.

So what's the answer???

I don't have one that will make everybody happy... Read more about the healthcare dilemma.

June 08, 2012

100% Patient Satisfaction Scores

What if I told you this 100% patient satisfaction score was due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.


Whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that WILL happen one way or another.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.

June 07, 2012

ENT as Comic Book Hero (or Villain)

I had no idea that ENTs with our head mirrors are relatively common in the comic book world alternately portrayed as heroes or villains. (Most of us have upgraded to a headlight powered by battery, but some of us ENTs still use a head mirror.)

There is a Family Practice physician who has compiled all the situations where ENTs were portrayed in comic book settings in his blog Polite Dissent.

The full list can be found here.

I have reproduced a few of my favorites below:

June 06, 2012

Head CT Scans Increase Risk of Cancer in Kids

By how much?

Brain tumor/cancer risk was 3X greater than the general population in children who received two to three CT scans of the head.

And the chance of developing leukemia was three times as great for children who received five to 10 CT scans of the head.

In the study published in Lancet, the researchers examined 176,587 children who had received a CT scan before age 22 and looked at their medical history for an average of 10 years afterward.

Though the risk sounds "high," the overall risk is still relatively small and CT scans should still be performed if medically warranted.

Phrased another way, the risk corresponds to one additional case of leukemia in the 10 years after the first scan for every 10,000 patients younger than 10 who were scanned or an extra case of brain cancer for every 30,000 children scanned.

Even so, the study does illustrate that CT scans should not be ordered unless there's a very good reason to do so, especially in children given they are more radiosensitive compared to adults.

In the ENT world, the most common reason to order a CT scan is to evaluate for sinusitis.

My own personal preference is to obtain one in children if and only if all other sinusitis interventions have already been performed.

Such "sinusitis" interventions include:

Allergy intervention (steroid and/or anti-histamine nasal sprays)
• Failure to respond to antibiotics
Adenoidectomy (if large adenoids present which can be determined on endoscopy)
Turbinate Reduction (if turbinates are enlarged)
• Check for cystic fibrosis and primary ciliary dyskinesia

If above interventions have been performed, only than would I consider a CT scan of the sinuses.

Some (other ENTs) may argue that CT scan of the sinuses should be performed early as a more directed intervention can than be performed.

My argument against that is, EVEN if the CT sinus comes back abnormal, I STILL would perform the above interventions first because often the above interventions will clear up and sinus abnormality seen on a CT scan.

Only when everything else has been tried would I consider sinus surgery in a child and only than would a CT sinus be justified in my mind.

However, there are certain other situations I may consider getting a CT scan relatively quickly...

• If I find a sino-nasal mass on exam concerning for tumor or nasal polyps
Congenital hearing loss
• Cholesteatoma (tumor of the ear)
• "Significant" Facial Trauma (ie, not just for a simple broken nose)

Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 7 June 2012. doi:10.1016/S0140-6736(12)60815-0

Children's CT Scans Pose Cancer Risk. Wall Street Journal 6/6/12

daVinci Surgical Robot Makes Paper Airplane... Yawn!

A blog reader of mine informed me about this YouTube video of a surgeon, Dr. James Porter, making a paper airplane using a daVinci surgical robot.

For those unawares, the daVinci robot is used to assist the surgeon in "difficult-to-reach" procedures. It is used in the fields of urology, ENT, gynecology, and general surgery.

There is much debate whether the daVinci robot really is worth it.

This paper airplane video is a perfect example of why it is NOT worth the $1.3 million price tag.


Because I can make a paper airplane with my own two hands that is just as good as the one made by the robot, even if it is smaller than a penny... and I can do it faster and WAY more cheaply.

I should also point out that the paper airplane made by the robot couldn't even fly...

NOW... what would have been a much more impressive video and would highlight specifically what the daVinci robot can do that a human would not have been able to do is to make a paper airplane INSIDE of a wine bottle.

Sheryl Crow With Benign Brain Tumor

It was announced yesterday that Sheryl Crow has a benign brain tumor known as a meningioma.

The Grammy award winning singer did not disclose what her symptoms were that led to the discovery of this tumor which often is made by an MRI scan of the head.

From an ENT perspective, such a tumor can be confused with an acoustic neuroma if found in an area of the brain called the cerebellopontine angle (CPA) and patients will often initially present to an ENT with symptoms of:

• Ringing of the ear on just one side (tinnitus)
• Sense of ear fullness on one side that does not go away
Hearing loss worse on one side (asymmetric sensorineural hearing loss)
• More rarely, balance problems

After a basic exam of the ear, a hearing test is performed. If the hearing test shows a significant asymmetry in NERVE hearing (as opposed to conductive hearing loss which is hearing loss NOT due to a nerve problem), an MRI scan of the head with gadolinium is often ordered.

The tumor can be seen very easily on this type of scan.

Other testing that might be performed include:

ABR (Auditory Brainstem Response)
OAE (Otoacoustic Emission)

Depending on the location of the meningioma, the patient may see either a neurosurgeon or a neuro-otologic surgeon (sub-specialized ENT surgeon). Typical options depending on symptoms, location, and size include:

• Monitor
• Surgical excision
• Radiation ("gamma" or "cyber"-knife)

It is unclear what course of treatment she has elected to pursue.

Sheryl Crow Assures Fans Her Brain Tumor Is Non-Cancerous. People 6/6/12.

June 05, 2012

Costs of Surgery... How Is This Calculated?

So I have blogged about this topic a few times in the past, but there still seems to be confusion regarding the costs of surgery.

As mentioned in the past, the cost of surgery is broken down into basically 3 separate charges:

• Surgeon's charge
• Anesthesia's charge
• Hospital's charge

So... after surgery, a patient typically will get 3 bills; one each from surgeon, anesthesia, and hospital.

At least in the United States, the three charges are completely separate from each other to the point that anesthesia will have no idea what the charges for the surgeon as well as hospital will be.

Same goes for the surgeon... the surgeon will know his charges, but will have no idea what the charges will be for anesthesia and the hospital.

Even if the surgeon demands to know what anesthesia and the hospital will charge for a surgical procedure (s)he will perform, a specific charge will not (can not) be provided in the United States typically.

Why is that?

If I am going to perform for example, a tonsillectomy, why can't anesthesia give even me the surgeon a specific dollar amount of what anesthesia will charge? Why can't the hospital administration provide me the hospital charges?

Here's why... or at least part of the reason why in the United States...

Surgeon's Charge

The surgeon's charge is set. For a given surgeon, his/her charge will remain the same regardless of time or difficulty of the surgery. It may be different between different surgeons... but for a given individual surgeon, it will always be the same for a given procedure.

For example, if the surgeon's tonsillectomy charge is $250. It will remain $250 whether it takes 15 minutes or 3 hours. It will remain $250 if the surgery was technically difficult or a piece of cake.

So, the surgeon's charge is easy. It is what it is.

The harder question to answer is what the anesthesia and hospital charges will be...

Anesthesia Charges

Anesthesia charges on a per time basis (in increments of 15 minutes) on top of a "base" charge that depends on the surgical procedure.

For example, let's say a given anesthesia group has a base charge of $500 for tonsillectomy.

Let's also assume this particular anesthesiology group charges $500 per 15 minutes of anesthesia.

SO... if the surgeon performs a tonsillectomy and it takes the surgeon 30 minutes to perform the procedure, the anesthesia charge will be $500 base charge PLUS $1000 for the time ($500 per 15 minutes) for a total anesthesia charge of $1500.

If it so happens that the surgery takes only 15 minutes... than the anesthesia charge will be $1000 ($500 base charge plus $500 for the 15 minutes surgical time).

In other words, for the SAME exact surgical procedure, the anesthesia charges may be different for different patients depending on how long the surgery takes.

Hospital Charges

Different hospitals calculate their charges differently... but in essence, the hospital will charge whatever it cost them to allow the surgery to happen in their facility plus a nebulous "profit" factor.

SO, a given hospital charge will include the:
  • Salary of all the personnel used in the surgery (surgical tech, registered nurse, circulating nurse, anesthesia tech, secretary, etc)
  • Equipment used during the surgery (IV lines, needles, anesthesia tubing, masks, endotracheal tube, surgical equipment, etc)
  • Medications used during the surgery (gases, IV drugs, etc)
  • Facility costs expended during the surgery (electricity, water, oxygen, medical waste disposal, etc)
To take the example of tonsillectomy, the hospital charges will include all the equipment, medications, personnel, and facility costs utilized during the tonsillectomy surgery.

In Summary, the Cost of Surgery is... It Depends

Given anesthesia charges vary based on the time duration of surgery regardless of WHAT the surgery is as well as hospital charges which may vary based on how much was "expended" during the surgery regardless of WHAT the surgery is, the anesthesia and hospital charges are moving targets which roughly correlate with how long the surgery takes.

The surgeon can certainly state what their charges will be up-front because this charge is fixed, but anesthesia and hospital charges are NOT fixed and depend on a certain time factor regardless of WHAT surgical procedure is being performed.

Because of this time dependence, that's why anesthesia and hospital charges can not typically be obtained prior to surgery in most places.

That's also why most places can't (won't) post the total cost of surgery up-front.

Of course, if a given surgeon is very consistent and always takes 15 minutes to perform surgery and always uses the same exact equipment, than anesthesia and the hospital may be able to provide an "averaged" charge up-front.

It is also not uncommon that additional "discounts" may be offered based on a patient's income.

Some places like the Surgery Center of Oklahoma somehow persuaded the anesthesiologist, surgeon, and facility administrators to sit around a table and force an agreement on a fixed TOTAL charge for different surgical procedures. Once an agreement is made on a fixed charge for each, an up-front cost can be publicized... but this can never happen as long as anesthesia and hospital refuses to agree to a fixed charge and rather stick with a time-based framework to determine their charges.

Vice-President Biden's Daughter Marries an ENT Doctor

On June 2, 2012, Vice-President's daughter Ashley married Dr. Howard Krein in Delaware.

Though this news is not really all that interesting in itself, the neat thing is that Dr. Howard Krein is an ENT!

He received his medical degree from Jefferson Medical College in 2000 (same year as me!)...

He obtained his otolaryngology training at Thomas Jefferson University Hospital and completed a facial plastics fellowship at the Medical College of Virginia in Richmond, VA.

After fellowship completion, he later joined the faculty at Thomas Jefferson University Hospital as a facial plastic and reconstructive surgeon.

He is also active in social media... Chief Medical Officer of Organized Wisdom and goes by the twitter handle @howardkrein as well as @kreinmd.

Congratulations to the happy couple!

VP Biden's daughter Ashley marries a doctor in Delaware. USA Today. 6/2/12

June 03, 2012

Surgery Center Posts Prices of Procedures

Given the uproar over the lack of transparency of surgery prices, it was only a matter of time before an operating facility in the United States (oversea facilities have already done so) takes the step of posting the cost of surgery... a set cost that is exactly what a patient pays. Complete cost transparency.

The Surgery Center of Oklahoma is an AAAHC accredited facility since 1998 and has over 40 participating surgeons. And they are the first that I'm aware of that has taken the step of posting the cost of surgery on their website. The caveat being the cost shown ONLY applies to those who do not have health insurance.

On their website, they state:
"Transparent, direct, package pricing means the patient knows exactly what the cost of the service will be upfront. Fees for the surgeon, anesthesiologist and facility are all included in one low price. There are no hidden costs, charges or surprises."
Keep in mind that this cost is NOT just the surgeon's fee, but also includes the anesthesia charges as well as facility charges. Read more about such charges here.

So what are the charges? They have it all posted on their website!

But below is a list of charges for ENT procedures as of 6/3/12 (surgeon, anesthesia, and facility charges all bundled into a single charge). The webpage also includes prices for general surgery, orthopedics, urology, ophthalmology, etc.

I wonder if other facilities in the United States will start following suit???

Thyroidectomy$ 6,160.00
Lymph Node Excision / Biopsy$ 2,255.00
Myringoplasty$ 2,400.00
Bilateral Myringotomy with tubes$ 1,700.00
Tympanoplasty$ 5,060.00
Tympanoplasty - Mastoidectomy$ 7,050.00
Mastoidectomy$ 6,640.00
Inner Ear - Stapedectomy$ 5,390.00
Ossiculoplasty$ 5,060.00
Cochlear Implant$ 8,800.00
Foreign Body Removal$ 1,500.00
Bilateral SMR Turb$ 2,700.00
Sinus / Turbinates 1 side$ 3,795.00
complex$ 4,950.00
Sinus / Turbinates both sides$ 4,510.00
complex$ 5,885.00
Septoplasty$ 3,550.00
Septoplasty and Sinus/Turbinates$ 5,060.00
Nasal Fracture Simple Closed$ 1,900.00
Nasal Frature Complex Open$ 4,015.00
Tonsillectomy$ 3,050.00
Adenoidectomy$ 2,695.00
Tonsillectomy and Adenoidectomy$ 3,695.00
Adenoidectomy and BMT$ 3,300.00
Tonsillectomy and Adenoidectomy and BMT$ 4,400.00
Frenulectomy$ 1,600.00
Uvulopalatopharyngoplasty$ 5,445.00
Diagnostic Laryngoscopy with biopsy$ 2,970.00

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