What to Do and Care After Vocal Cord Surgery

When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.

The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.

When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.


As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.

I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.

Strict Voice Rest! 

This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.

The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Strict voice rest typically lasts for 1-2 weeks after surgery.

No Coughing or Throat-Clearing

Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.

Take Reflux Medications

Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.

Voice Therapy

Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!

The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.

Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!

Restricted Voice Rest

Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.

Restricted voice rest is a fairly broad phrase, but essentially means to:

• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)

This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!

Read More

Why Patients Travel a Long Distance for Care

The decision for a patient to travel hours away for their medical care is a highly personal decision or a matter of necessity, especially if the care is unavailable locally.

Assuming care IS available locally, based on my own personal observations, the reason to travel for medical care ultimately is due to level of anxiety... either the patient or the surgeon.

Patient A:

I recently saw a patient with a small parotid tumor... about 1.5cm in size that was confirmed on needle biopsy to be a pleomorphic adenoma. Ultimately, the decision for surgery was pursued... but the patient wanted to go elsewhere to have the surgery done even though the patient understood I was perfectly competent to perform the resection.

Why? Because of the high anxiety and concern for the risk of facial paralysis associated with the surgery. The patient perceived her risk of this complication would be smaller if she went elsewhere.

Such patients, like Patient A, typically have certain characteristics:

• Type A personality
• Young (20-40s)
• Never had surgery before
• Surgery has a significant risk associated with it

Patient B:

In another patient who I saw a few months prior to patient A, same scenario, but the parotid tumor was 4cm in size and located in the deep lobe. Decision for surgery was also pursued, but this time, I as the surgeon recommended the patient to go elsewhere to have the surgery done.

Why? Because of the high anxiety and concern for the risk of facial paralysis associated with the surgery. I perceived the risk of this complication would be smaller if he went elsewhere where this type of surgery is frequently performed. This particular patient desperately asked and ultimately begged that I perform the surgery. He really did not want to travel to get the surgery done. However, I explained to the patient that based on size and location, the risk for facial paralysis was quite significant. If it was smaller, like in Patient A, I would have felt perfectly comfortable in performing the surgery.

Patient B ultimately did go elsewhere to have the surgery done... and did, unfortunately, suffer from facial paralysis afterwards.

However, I was happy to provide routine post-op follow-up care given it was more geographically convenient for the patient.


Such patients, like Patient B, typically have certain characteristics:

• Older (50+)
• Has had surgery before

Issues With Long-Distance Care

Regardless of innate patient characteristics, having surgery done a long-distance away is a pain for the patient. Think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.

Even in the hands of the BEST surgeon, problems can arise after surgery. Is the surgical wound becoming infected? Where is that fever coming from? There's a little drainage occurring... is that normal? Why is the skin red? There's a lot of pain and his medications aren't working.

To complicate things further, narcotic pain killers can NOT be called in by federal rules. A hardcopy prescription is required. Now, wouldn't that be mighty inconvenient if a patient (who mind you is in pain), needs to drive hours to the surgeon's office just to pick up a hardcopy narcotic prescription.

The logistical difficulties of dealing with post-operative care after patient discharge is tremendous for both the surgeon as well as the patient if the distance between the two is large.

How to Make Long-Distance Care Easier for the Patient

DO see your most appropriate local doctor and discuss your medical case with him/her. If decision to pursue surgery a long-distance away is made, DO keep your local doctor in the loop.

Routine post-operative care can all be provided locally. Suture removal can be done locally. Infection evaluation can be done locally.

The decision to have surgery a long-distance away was due to concern of risks inherent to the surgery itself... not the care afterwards and as such, such post-operative care can all be provided locally by a competent physician.

Of course, if there's significant concern, the patient can always travel back to the original surgeon, but most often, this travel is unnecessary.

Read More

After Surgery, Do Patients Have Out-of-Pocket Costs for Follow-Up Visits?

Assuming a patient has insurance, the answer is generally no for a certain period of time...

For a period of time after surgery, insurance specifies that a surgeon provides any and all routine post-operative care for "free" without any patient out-of-pocket charges.

This period after surgery is called "global period" and is based on the assumption that the insurance has already paid for not only the surgery, but all the post-operative care that goes along with the surgery.

BUT... there are certain situations where global period does not apply... such as if a problem arises that is separate from the surgery like seeing the surgeon for a sinus infection after having a skin wart removed.

The sinus infection is a separate problem from the skin wart removal procedure and out-of-pocket copays will apply.

Also, global period does not apply if you decide to see a different surgeon in a different office for any post-operative care. It only applies to the surgeon who actually performed the procedure.

The next question is how long the global period is for post-operative care?

For most surgical procedures, it is 90 days after which any subsequent care is NOT "free".

However, especially for ENT-type procedures, there are a significant number of procedures where the global period is substantially shorter... even zero days.

Here's a sampling of common ENT-type procedures and the global period number of days.

90 Days Global Period
Tonsillectomy +/- Adenoidectomy
Uvulopalatopharyngoplasty
Parotidectomy
Thyroidectomy
Septoplasty

10 Days Global Period
Ear Tube Placement
Coblation Turbinate Reduction
Closed Nasal Reduction for Nasal Fracture

0 Day Global Period
Sinus Surgery
Vocal Cord Surgery
Nosebleed Control

For procedures that have a short global period, depending on circumstances, the surgeon may elect to not charge if a patient is seen past the specified number of days.

Read More

Financial Issues with Emergency Room Specialist Care

Imagine this scenario... A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the emergency room and the emergency room doctor offers to suture up the child's face.

The next question a parent will probably ask (or demand) is the desire for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that's when the financial nightmare begins...

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does NOT participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child's family.

Here is a New York Times article describing this situation.

Outrageous?

Unfortunately, it is not unusual... and there are lawsuits now pending among insurance companies, specialist physicians, as well as even against patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.

Background

If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient's insurance is found. However, if the patient decides to see a physician who does NOT participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care IS covered by insurance... because it is an "emergency," but services performed ONLY by the emergency room staff applies. NOT services by outside specialists called in.

What to Do?

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite... ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist MUST be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100-$200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only ONE doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Bottom Line

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That's just how the medical system is set up currently.

Read More

Greater Patient Satisfaction At Expense of Better Care?

Much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage
• INCREASED RISK OF DEATH!

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths. They can also cause side effects that may require additional healthcare intervention.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Also, the more testing and treatment that is performed, the higher the risk of downstream adverse effects. For example, a patient may desire a CT scan of the chest to rule out lung cancer even though the chest x-ray is normal. Unfortunately, the CT scan picks up a small liver nodule. Needle biopsies are performed which unfortunately resulted in excessive bleeding requiring surgical correction and several days in the hospital. In the end, it was just a benign cyst that never required any treatment.

These examples may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

Reference:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Media:
Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13.

Read More