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How Can We Save $65 Million? Look in the Patient's Mouth

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Our American Academy of Otolaryngology-Head and Neck Surgery has many educational opportunities. The pinnacle event is our yearly meeting, where up to 12,000 people gather from around the world to learn, share knowledge, discuss best practices, and catch up with one another (or, for the past two years, sadly virtually).

I am blessed to not only be an active member of our society but also to be elected to chair our board of governors and also an elected member of our board of directors. It has been quite a privilege to be part of the team that guides the direction of our academy to provide the best otolaryngologic care for our patients, to navigate the world of insurance company challenges, to advocate, to produce top guidelines, and to facilitate continuing education for our members.

I have had the opportunity to present our research and techniques over the past 30 years — where the resident or the medical student would share our work. I am interested in otologic and neurotologic disorders. When I left Henry Ford Health System after nearly 30 years to join Advent Health Medical group in 2016, I was surprised to see that patients with possible peritonsillar abscesses (PTA) all ended up with CT scans (to rule out a PTA). I think the best way to decide if a patient has pharyngitis, peritonsillar cellulitis, or a PTA is to look in the oral cavity. 

There are telling symptoms like otalgia on the involved side, trismus, odynophagia, and dysphagia. During an exam, the uvula is often pushed away to the opposite side; i.e., if it is a left PTA, the uvula may deviate rightward. There is often fullness or edema of the soft palate. If someone has infectious mononucleosis and has bilateral 4+/4+ tonsils, as long as it is symmetric, there is not likely a PTA. The tough call comes when there may be a PTA versus peritonsillar cellulitis. This is important because a surgeon can often hasten recovery with procedural intervention for larger PTAs. Cellulitis, phlegmon, or small PTAs only require treatment with antibiotics and/or steroids. One issue with CT scanning is that the reading radiologist cannot differentiate between phlegmon and abscess, which compels the EM clinician to contact the Oto-HNS on call. If everyone could recognize the difference between pharyngitis, peritonsillar cellulitis, and PTA (therefore eliminating the need for CT scans), we could save nearly $65 million per year and protect patients from radiation exposure. We based this $65 million number on the fact that there are nearly 45,000 patients treated in the US for PTA each year, the cost of managing these PTAs is approximately $150 million per year, and approximately 90% of these patients had CTs ordered.

Mitch Eliason, MD, Andy Wang, MD, (a third-year student at the University of Central Florida when we started this project), Jihoon Lim (a second-year medical student), and I reviewed nearly 6,500 charts, and hundreds of CT scans to come up with our recommendations. We also put together a 10–15 minute training opportunity for the ED to teach everyone how to recognize the difference between pharyngitis, peritonsillar cellulitis, and PTA. Additionally, given the use of teleconferencing, it is easy to have the EM clinician record the exam and send it to the Oto-HNS for their opinion before considering a CT or having the Oto-HNS come to the ER or perhaps placing the patient in their office schedule the following morning. We think this is an important process improvement opportunity, cost-saving opportunity, and best practices opportunity for our patients. The presentation was given by Dr. Andy Wang on Tuesday, Oct. 5, 2021, in Los Angeles, during our academy meeting. The paper is being submitted for peer review and will hopefully be published in 2021 or 2022.

Dr. Seidman has received grants from the NIH.

Image by everything bagel / Shutterstock

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