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PDF Hosted at the Radboud Repository of the Radboud University Nijmegen PDF hosted at the Radboud Repository of the Radboud University Nijmegen The following full text is a publisher's version. For additional information about this publication click this link. https://hdl.handle.net/2066/226629 Please be advised that this information was generated on 2021-09-26 and may be subject to change. OFFICE-BASED ENDOSCOPIC SURGERY IN LARYNGOLOGY AND HEAD AND NECK ONCOLOGY NECK AND HEAD AND LARYNGOLOGY IN SURGERY ENDOSCOPIC OFFICE-BASED OFFICE-BASED ENDOSCOPIC SURGERY IN LARYNGOLOGY AND HEAD AND NECK ONCOLOGY IMPROVING QUALITY OF CARE AND EFFICIENCY THROUGH INNOVATIVE TECHNIQUES DAVID WELLENSTEIN J. DAVID DAVID J. WELLENSTEIN OFFICE-BASED ENDOSCOPIC SURGERY IN LARYNGOLOGY AND HEAD AND NECK ONCOLOGY NECK AND HEAD AND LARYNGOLOGY IN SURGERY ENDOSCOPIC OFFICE-BASED OFFICE-BASED ENDOSCOPIC SURGERY IN LARYNGOLOGY AND HEAD AND NECK ONCOLOGY IMPROVING QUALITY OF CARE AND EFFICIENCY THROUGH INNOVATIVE TECHNIQUES DAVID WELLENSTEIN J. DAVID DAVID J. WELLENSTEIN OFFICE-BASED ENDOSCOPIC SURGERY IN LARYNGOLOGY AND HEAD AND NECK ONCOLOGY IMPROVING QUALITY OF CARE AND EFFICIENCY THROUGH INNOVATIVE TECHNIQUES David J. Wellenstein 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 1 Office-based endoscopic surgery in laryngology and head and neck oncology Improving quality of care and efficiency through innovative techniques David Jonathan Wellenstein ISBN XXXX Copyright © David J. Wellenstein, 2020 Design by Bregje Jaspers, ProefschriftOntwerp.nl Printed by Ipskamp drukkers Printing of this thesis was financially supported by: Pentax Medical, Soluvos Medical, Lumenis, Medical Disposables Store, Laservision, Mylan, Atos Medical, ALK and Radboud university medical center/Radboud University Nijmegen 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 2 OFFICE-BASED ENDOSCOPIC SURGERY IN LARYNGOLOGY AND HEAD AND NECK ONCOLOGY IMPROVING QUALITY OF CARE AND EFFICIENCY THROUGH INNOVATIVE TECHNIQUES Proefschrift ter verkrijging van de graad van doctor aan de Radboud Universiteit Nijmegen op gezag van de rector magnificus prof. dr. J.H.J.M. van Krieken, volgens besluit van het college van decanen in het openbaar te verdedigen op 11 december 2020 om 12:30 uur precies door David Jonathan Wellenstein geboren op 26 juni 1988 te Leidschendam 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 3 Promoteren: Prof. dr. H.A.M. Marres Prof. dr. R.P. Takes Copromotor: Dr. G.B. van den Broek Manuscriptcommissie Prof. dr. P.D. Siersema Prof. dr. R.J. Baatenburg de Jong (Erasmus MC) Dr. H.F.M. van der Heijden 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 4 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 5 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 6 TABLE OF CONTENTS Chapter 1 General introduction 9 Chapter 2 Office-based procedures for the diagnosis and treatment of 21 laryngeal pathology Chapter 3 Office-based procedures for the diagnosis and treatment of 51 esophageal pathology Chapter 4 Topical anesthesia for endoscopic office-based procedures of 75 the upper aerodigestive tract Chapter 5 Safety of flexible endoscopic biopsy of the pharynx and larynx 101 under topical anesthesia Chapter 6 Office-based CO2 laser surgery for benign and premalignant 115 laryngeal lesions Chapter 7 Cost analysis of office-based transnasal esophagoscopy 129 Chapter 8 General discussion 145 Chapter 9 Appendix 1 and 2 155 Chapter 10 Summary 167 Chapter 11 Summary in Dutch 175 Chapter 12 Acknowledgements 183 Chapter 13 Curriculum Vitae 189 Chapter 14 List of publications 193 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 7 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 8 CHAPTER 1 General introduction 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 9 Chapter 1 10 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 10 General introduction The fi rst published data about diagnostic and therapeutic offi ce-based procedures in 1 laryngology and head and neck oncology dates back to over more than 120 years(1). During the 20th and 21st century, there have been many changes in health care perspective and necessities. The improvement of endoscopic and digital techniques are in line with these changes, and allow for innovative, less invasive, and cost reducing surgical procedures for patients with laryngeal and head and neck (oncological) lesions. But which of these offi ce- based endoscopic procedures can be useful to incorporate in clinical practice? And how can they contribute to these needed changes in health care? OFFICE-BASED PROCEDURES Offi ce-based procedures are diagnostic or therapeutic surgical procedures performed under topical anesthesia, usually in the outpatient clinic, instead of the operating room under general anesthesia. Although the theory of offi ce-based procedures in laryngology and head and neck oncology is known for more than a century, the practice in its current form (i.e. via digital fl exible transnasal endoscopy, usually with working channel) has just been reported on during the last two decades(2, 3). Before this digital revolution, detection of lesions in the pharynx and larynx was usually performed in the outpatient clinic with a fi beroptic fl exible laryngoscope (see Appendix for a more detailed description). Image quality was poor, and the capacity to store images was lacking. Furthermore, it was not possible to perform endoscopic diagnostic and therapeutic procedures in the outpatient clinic, thus procedures under general anesthesia were the only option. Figure 1. Transnasal laryngoscope 11 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 11 Chapter 1 With the introduction of digital endoscopy, image quality significantly improved, and linking of digital images to the electronic patient file became possible. Images of lesions can be stored in the electronic patient file, and objectively followed over time or discussed with other clinicians. Figure 2. Digital flexible transnasal laryngoscope (VNL 1070STK, Pentax Medical, https://www. pentaxmedical.com/pentax/nl/107/1/Video-Naso-Pharyngo-Laryngoscope-VNL-1070STK) With the introduction of digital flexible transnasal endoscopes with a working channel, diagnostic and therapeutic endoscopic procedures became possible to perform in the office instead of the operating room, leading to numerous advantages for patients, clinicians and the healthcare system. Figure 3. Digital flexible transnasal laryngoscope with working channel (VNL 1075STK, Pentax Medical, https://www.pentaxmedical.com/pentax/nl/107/1/Video-Naso-Pharyngo-Laryngoscope-VNL-1570STK) For laryngeal pathology, a digital flexible transnasal laryngoscope or esophagoscope can be used. Alternative endoscopes are a fiberoptic flexible transnasal or digital rigid transoral laryngoscope, but we do not focus on these procedures in this thesis. A digital flexible 12 549724-L-sub01-bw-Wellenstein Processed on: 21-10-2020 PDF page: 12 General introduction transnasal laryngoscope is available with (distal diameter 4.8 mm) or without (distal diameter 1 3.0 – 3.5 mm) working channel(4), and both have different advantages and indications. Since a laryngoscope with working channel is shorter (working length 300 vs. 600 mm) and has a less wide diameter (distal diameter 4.9 vs. 5.1 mm) compared to a transnasal esophagoscope(4), this endoscope is easier to handle for clinicians and presumably less uncomfortable for the patient. When a working channel is incorporated in the laryngoscope, it is possible to perform suction in order to increase visualization on a tumor (e.g. in case of abundant saliva or tumor necrosis). Furthermore, diagnostic and therapeutic instrumentation such as flexible biopsy forceps, laser fiber or injection needle can be passed through the working channel. The transnasal esophagoscope is always equipped with a working channel and has the advantage of being able to inflate and perform suction, although not at the same time. The possibility of inflation gives an advantage when inspecting the hypopharynx, and is essential for the esophagus since peristalsis causes the esophagus to collapse. A VIEW ON THE CURRENT HEALTH CARE SYSTEM Although it is not possible to summarize the developments in health care during the last decades in a single paragraph, some important factors which can be related to office- based procedures are outlined in this paragraph. Historically, (academic) hospitals pursue several goals, such as patient care, education, and research. Recently, improving value for patients is an additional intention in healthcare(5). Value-based healthcare is developed to improve patient centered care, and simultaneously reduce the unsustainable rising costs in healthcare (e.g. due to an aging population and rise in available medical technology). The current vision that health care should be organized around the patient and his or her pathway, and patient related outcomes should be measured instead of former outcome measures, is well adapted(5). With increasing expenses, reaching almost €100 billion in The Netherlands in 2017, the quest for cost saving procedures is ongoing(6). New technologies such as office-based endoscopic procedures have the possibility to considerably change common practice, and can also play a role in patient’s needs. These needs can be different for an individual or patient category, and are usually determined by the patient related variables such as medical condition(5). Anatomical location of a suspected lesion (e.g. anterior
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