Key Messages

1. Biopsies under local anaesthetic can be undertaken in an outpatient setting, as an alternative to inpatient or day case biopsy procedures which require theatre time and a hospital bed.
2. Biopsies under local anaesthetic are effective in identifying people who do not require further follow up. This means that patients can have their biopsy taken under local anaesthetic at the time of initial outpatient investigation and avoid needing a confirmatory biopsy under general anaesthetic in an operating theatre.
3. Undertaking biopsies in an outpatient setting provides an opportunity to ease hospital resource pressures and reduce waiting times to diagnosis and treatment. A reduction in the number of patients requiring inpatient biopsy procedures will lead to substantial resource savings for NHSScotland.
4. In circumstances where the use of reusable biopsy equipment is not feasible (for example, during the COVID-19 pandemic) disposable biopsy equipment provides an alternative means to perform biopsies. It should be noted that:

• no evidence is currently available to determine whether disposable biopsy equipment is as effective as reusable biopsy equipment
• the use of disposable biopsy equipment is more costly than the use of reusable equipment
• over the lifecycle, reusable equipment produces fewer carbon emissions compared with disposable equipment.

What were we asked to look at

The Scottish Health Technologies Group (SHTG) was asked by Ear, Nose and Throat (ENT) clinicians in NHS Greater Glasgow and Clyde (GGC) to assess the evidence on the clinical and cost effectiveness of outpatient local anaesthetic biopsies of suspicious laryngeal and pharyngeal lesions. As part of our assessment, we were asked to consider the evidence surrounding disposable (that is, single use) rhino laryngoscopes.

Why is this important

The incidence of head and neck cancer in the Scottish population is increasing. The Scottish Government has set targets for waiting times to diagnosis and treatment that are becoming increasingly challenging to deliver given current service pressures. Undertaking biopsies in an outpatient setting instead of an inpatient setting may help to lessen resource pressure.

Patients who are referred to ENT or head and neck outpatient clinics, based on their symptoms, commonly undergo transnasal endoscopy to visualise the larynx, pharynx and tongue base. When suspected malignant lesions are identified, the ‘gold standard’ investigation is direct laryngoscopy under general anaesthetic in the operating theatre. This requires scheduled theatre time, an overnight or day case hospital bed, and pre-procedure assessment. Developments in the technology for transnasal endoscopy include the incorporation of an instrument channel through which biopsy forceps may be used. This means that, for some patients, a biopsy can be taken under local anaesthetic at the time of initial outpatient investigation.

Referred by

Consultant ENT Surgeon, NHS Greater Glasgow & Clyde