Office Based Rhinology

with Dr. Scott Fortune

Dr. Scott Fortune talks with us about how he built an Office Based Rhinology practice (now a Center of Excellence), including a how-to on safely performing procedures in the office. You can read the full transcript here or listen to this episode on BackTable.com.

Office Based Rhinology

Table of Contents

(1) Dr. Scott Fortune’s Journey into Office-Based Rhinology

(2) Office-Based Rhinology Candidacy, Workup, and Procedures

(3) Important Anesthetic Considerations in Office-Based Rhinologic Procedures

(4) Anesthetic Dosing, Technique, and Pre-Procedure Safety

(5) Equipment and Room Setup for Office-Based Rhinologic Procedures

(6) Maximizing Time Efficiency for the Patients and the Practice

(7) Peer-to-Peer Training Sessions in Office-Based Rhinology

(8) Pearls on Incorporating Office-Based Rhinologic Procedures into a Practice

(9) It’s Never Too Late to Start

Introduction

[Ashley Agan MD]
This week on the BackTable Podcast.

[Scott Fortune MD]
A key point especially for chronic rhinitis treatment is a good sphenopalatine injection. That's especially important for cryotherapy because the one pitfall in this procedure is the ice cream headache and I've had a couple of them and they can be pretty bad. You really want to try to head that off. A good way to prevent that ice cream headache is to make sure you get a good sphenopalatine injection. We talked about that reinforced anesthesia needle. That's a key tool to provide a good sphenopalatine block. The one little modification for cryotherapy is I will provide that block before I do the procedure, and then as soon as I get that cryo wand out of the nose, I'll apply a little bit more of the local in that area and that seems to blunt the ice cream headache quite nicely.

[Ashley Agan MD]
All right. Hey, everybody, welcome to the show. This is the BackTable ENT Podcast. Here we bring you conversations with the best and brightest minds in otolaryngology with the hope that you can take this information and apply it to your own practice. I'm Ashley Agan and I'm a general otolaryngologist, practicing in an academic setting in Dallas, Texas.

[Gopi Shah MD]
I'm Gopi Shah and I'm a pediatric otolaryngologist at Children's Medical Center in Dallas. We're your host and we're so glad that you stopped by to check out our podcast today, Market Declines, Unemployment: The COVID-19 Pandemic. Don't let headlines derail your long-term financial strategy. This BackTable episode is brought to you by Yaphet Tadesse, Edward Jones financial advisor in Dallas, Texas. He'll work with you to help you understand the impact of short-term events and how to prepare for the long term. Learn how he can help you reach your financial goals. Visit edwardjones.com/yaphet, Y-A-P-H-E-T, -tadesse, T-A-D-E-S-S-E or backtable.com/401k for more information. Edward Jones Member SIPC.

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[Ashley Agan MD]
We've got a great show today. How are you feeling, Gopi?

[Gopi Shah MD]
I'm actually feeling very fortunate because we have a guest, Dr. Scott Fortune on our show today.

[Ashley Agan MD]
Nice.

[Gopi Shah MD]
That's right. I do feel fortunate.

[Ashley Agan MD]
He was born in Kentucky and raised in Tennessee. He went to medical school and residency at Vanderbilt. In 1999, he joined Allergy and ENT Associates, a private practice in Nashville and is still with this group today. He is board certified by the American Board of Otolaryngology and is a fellow of the American Academy of Otolaryngic Allergy. He is a center of excellence trainer for Stryker ENT and he has hosted peer-to-peer training sessions for visiting physicians to teach them the latest techniques of minimally invasive office-based sinus procedures. Today, he's going to talk to us about office-based rhinology. Welcome to the show, Scott. Welcome to the show.

[Scott Fortune MD]
Great to be here, a longtime fan and I've finally made my way onto the stage, so I'm really thrilled to join you guys today and talk about one of my passions.

(1) Dr. Scott Fortune’s Journey into Office-Based Rhinology

[Ashley Agan MD]
Well, thank you for all the support you've given us. We truly appreciate it and for giving us the chance to have you on today. We'd love for you to first just tell us about yourself and tell us about your practice.

[Scott Fortune MD]
As you mentioned, I was born in a small town in Kentucky near the Tennessee border and then I was raised in East Tennessee in Knoxville. I had the opportunity to go away to college in Atlanta and then found myself in Nashville and arrived here in 1989 and I've never left. That's been one of the great decisions, although I've spent a lot of time in the Southeast and I finally realized that I needed to broaden my horizons a little bit, and along with performing one of these DNA tests that we all do nowadays, I found my roots in Ireland and England and discovered another passion which is travel. We usually enjoy taking trips there to find out where we came from. In my off time, I enjoy travel and historical fiction, especially as it relates to the UK or Ireland.

[Gopi Shah MD]
That's great. Very nice. That's fun. You're talking to us today about office-based rhinology. Tell us, what does that mean? What does that entail? How did you find yourself specializing in this?

[Scott Fortune MD]
I'm going to go back to the beginning a little bit. In my training, Vanderbilt was known as a strong program in laryngology and head neck surgery. We had a single rhinologist and we had three residents a year. That meant that sometimes residents didn't all get the same experience. I was a little bit on the short end of rhinology. I'll take responsibility for my part in that, but when I entered training, that was not a great skill. By the way, when I finished training, many of us barely had cell phones. We were still completely on paper. I've seen a lot of change in healthcare in my day.

We have over these years from 1999 to now become digital. We're one practice in two locations. We have three advanced practice providers. We've got four audiologists, five otolaryngologists. The numbers make my head spin, but the journey to being an office-based rhinologist started about five or six years into my career. I had done some sinus surgery and I'd just gotten my allergy fellowship certification and I found myself in the OR one day doing what I thought was a routine endoscopic sinus case and had the dreaded complication of a cerebral spinal fluid leak.

You might imagine the impact that has on a young practitioner and it had an outsized impact on me. I became a very timid sinus surgeon, and really, I quit doing any sinus procedures other than anything really straightforward, maybe a septoplasty, some turbinate reductions, barely any maxillary cases. Fast forward a few years to around 2010 and my partner, Dr. Lee Bryant, who's also a trainer, wanted to begin an office surgery program. He began with some terminated reductions in the office. This evolved over a couple of years until one day he came to me in 2014 and said, "I need you to partner with me to take this to the next level. I have some ideas of what I want to do with this, but I'm going to need someone to help me cover the cost of this equipment. This equipment is expensive and I need more of it to do what I want to do and I need you to get on board."

I very quickly realized that I needed some education. I needed to add some skills. My skill set was not where I wanted it to be to partner with him to provide this service. One of the great lessons and one of the take-home points for me from our talk today is that your education doesn't end when you walk out the door of your residency. In fact, in many ways, it's just beginning. I've learned that in 2014 in droves. I found myself at the Western States rhinology course. I was at The Academy and every training booth I could get into. I went to area labs. Any company that was offering some kind of training, I've availed myself of that.

It took a couple of years, but eventually I got to the point where I could do these things and I felt comfortable with it. That's when it really began for me. It all has to do with a patient providing an experience that's patient centered and one of the main benefits, if you will, of office-based rhinology is minimum downtime. Compared to the recovery from an operating room case, the things we do in the office take a day, two, three at the most to recover from. We'll often do these on Friday and send the patient back to work on Monday. We'll do them on Friday and let them use their CPAP again Sunday or Monday night.

These are some important things about rhinology. It really was a fortitude, this thing. I was at a point in my career ... I wasn't burned out, but I was at a point that a lot of us reach where nothing was new. I was doing the same old things I'd done since the day I left Vanderbilt, and then all of a sudden, all these things dropped into my lap at once, turbinate reductions and little septoplasties, polypectomies, biopsies, epistaxis and the list goes on and on and we will cover the list, but it was a breath of fresh air. It was, I'll call it a career renaissance. It came at just the right time when I needed a boost.

We all find ourselves in that place and hopefully something comes along for each one of you that came along for me and that really improved my practice satisfaction. It makes my days easier. It makes the hassles we all deal with administrative or insurance or whatever, it may make those all much more tolerable. Our administrator remarked that the physicians' mood was significantly different once we started offering this. There's so many benefits of it. Like I said, if you just place the patient at the center, everything will fall into place for you. That's a long answer, but that's an important part of the story.

(2) Office-Based Rhinology Candidacy, Workup, and Procedures

[Ashley Agan MD]
That's awesome. I think it's wonderful. I love that it is a career renaissance. How amazing is that? What procedures do you offer in the office that you've historically have done in the OR. When the patient comes to you or if anybody comes and says, "Hey, what kind of things in-practice, in-office procedures are all doing for rhinology?" What is the list?

[Scott Fortune MD]
I think what most of us consider operating room rhinology is septoplasty, turbinate reductions, endoscopic sinus surgery. I think that's a pretty standard list, but if you want to talk about office-based rhinology, a good way to think about this is to break it down into what we call the four disease states. Those are chronic rhinosinusitis, chronic rhinitis, lateral wall or nasal valve insufficiency and Eustachian tube dysfunction. Then I'll throw in a couple of bonuses and you could lump them under one of these other categories if you like, but two other ones are nosebleeds and then minor neoplasms. We'll go through those in just a moment.

My answer to this question would have been a lot different before the pandemic than it is after the pandemic. We all know what's happened with that. There's now a need for PPE, air scrubbers. There's got to be room downtime. You got to do terminal sanitizations, you got to have air exchanges, the list goes on and on. These things add time and costs to everything that we're doing. Before the pandemic, the procedures we offer to our patients included limited septoplasty, inferior turbinate submucous resection. Of course, balloon sinus dilation is a primary procedure that most will offer in an office rhinology program.

We did some limited endoscopic sinus surgery, some anterior ethmoidectomy, occasional sphenoidotomy. Most of our frontal sinus stuff had to do with balloon dilation, but we also did some polypectomies. We started to treat epistaxis. We ended up getting an image-guided system to allow us to do a little more complex procedures. Then we did some simple biopsies. We started doing Eustachian dilation. Then over the course of a couple of years, we added the polymer implants for lateral wall insufficiency, then the cryoablation unit and the radiofrequency devices came along.

After a while, we had some cases that were what I call multi-agenda. There were a lot of things on the list. A patient could have a septoplasty, turbinates, a cryo. You could add several things there. The important thing to know about that is if you've got a lot on your agenda, it takes a lot of time. That's a good segue into what are we doing now that the pandemic has fallen upon us. We've had to change our ways pretty significantly. It's basically what we've eliminated is septoplasty and any procedure that's going to take over 30 to 40 minutes. All those multi-agenda cases are now done back in the OR.

The reason for the 30 to 40-minute window is it takes time to clean the room and for the air scrubbers to have time to recirculate the air. There's lots of data out there. I know this is a nuts and bolts talk, and even though we're private practitioners, we read the literature too and then we follow best practices. There's a lot out there from Stanford and Harvard and the other groups studying this and you can go to that literature and find out how to clean the air in your procedure room and to calculate how long it takes for that air to turn around. For us, for a procedure room of our size, the air exchange between the HVAC system and the HEPA filtration system that we installed takes about 18 minutes.

If your procedure takes 30 minutes, it takes the nursing staff about 15 minutes to clean and then you have about 18 minutes to let that air clean. That's pretty much your hour. It's had a significant impact on what we do. I just brought some things back to the ambulatory surgery center or the main hospital operating room that we used to try to tackle in the office.

[Gopi Shah MD]
That makes sense. When you're thinking about patients who come in and may have any of these conditions that you mentioned, how do you get a sense of whether a patient is going to be a good candidate for an in-office procedure? What does that look like?

[Scott Fortune MD]
If you want to do office-based rhinology, you have to go back to the beginning a little bit. First of all, it requires a little bit of a change of mindset. You have to start looking for things that maybe you weren't looking for previously. A great example of that is nasal valve. I could probably count on one hand the times I recognized a nasal valve issue before we really started to focus on treating lateral wall insufficiency in our office. It took me getting into my head that before I walk in that patient's room, I've got to at least be thinking about this as soon as I read the history. A corollary to that is to help focus the physician. We got the nursing staff to add symptom scores every triage.

As soon as a patient complains about anything in their nose or their ear, out comes the symptom score. We use our SNOT Score, we use the NOSE score, we use the total nasal symptom scores, we use the ETD Q70. These are all clinically validated tools that are objective assessments of the patient's symptoms. The eye doesn't see what the mind doesn't know. If you aren't thinking about it before you walk in the room, then you'll miss it. I had to change how I do my exam. I had to add a modified Cottle maneuver to every exam so that I didn't miss that lateral wall insufficiency. That's but one example. You have to change your way of thinking.

Then one other frameshift or mindset change, if you will, is when you're evaluating a patient, maybe your first question becomes, "Can I do this procedure in my office?" If not, well then you're going to have a different discussion with them, then if the answer is yes and so those are the first things to think about for evaluating a patient for an office procedure. They don't say the next set of criteria is what we all know. They need to have maximum medical therapy. The first thing you're going to do for a patient is not operating on them for whatever symptom they walk in with. You're going to want to make sure they've tried whatever your definition or your peers' definition of maximum medical therapy is first.

Then you also want to make sure their workup is complete. If you're considering balloon dilation for sinuses, you definitely want to have some imaging on hand. You want to know if there's any complicated anatomy, anything you might anticipate during that procedure that can make things difficult. For the Eustachian tube patient, you want to make sure that you've done a nasopharyngoscopy and you have some tympanometry and you've met all the criteria. Another thing to know, especially in RA and I'm sure it's true around other parts of the country is insurers have varying criteria that they use to determine whether a patient is approved for these procedures or not. You have to get that in your head.

It's nearly mind boggling in Tennessee. I can't keep it all in my head. I have charts everywhere that tell me what the Cigna criteria are and the Blue Cross criteria are and UnitedHealthcare seems to change all the time. It's very difficult to keep up with all this. You need a reference to that somewhere or you're going to be frustrated. You're going to spend a lot of time not getting approval for what you want to do. That's important to anticipate ahead of time. Now once you've got those things in mind, I would say the next thing is what's the level of disease and for most office-based rhinology, we're going to be treating mild-to-moderate disease.

You're not really going to be able to do too much for the patient who walks in your office and there are polyps peeking out the end of their nose. That's not an office-based procedure. That's still going to be handled best in the operating room. I'll give you one example that's maybe a little contrary to that in just a minute, but generally, we're going to deal with mild-to-moderate disease. However that's defined, it can be based on the symptom scores, the patient's history, if you do CT scan grading like Lund-Mackay score, that's fine to use too, polyp grades, whatever it is. You're going to be treating mild-to-moderate disease.

Once we've settled on that and it looks like this patient is a good candidate for something in the office, I've got three pretty simple tests that we put the patient through to determine if they're a good candidate. The first is how do they handle having a telescope in their nose? We've all seen the patients that you come at them with a telescope and they're immediately backing away from you or some fall out of the chair. Those are not your office procedure candidates. Another good one is to ask them how they've done with invasive dental work. If they can handle these deep cleanings and fillings and crowns and things that dentists do to people in their office, chances are they are going to be able to handle what you might put them through in your office-based rhinology procedure.

Then the third one, and sometimes this is the one that trips people up, is you got to tell them. When we're doing things in their nose, they're going to hear it. It pops and it crackles and there's sounds of the devices inflating and so forth. Sometimes that's the one where the patient's eyes are rolling back and you're like, "Okay, well, we're going to be doing this within the OR then." Those are three simple tests you can use to sort out on the frontend who might be an office candidate or not. I will say it's a pretty good set, but it's not foolproof. Some get through those three and-

[Gopi Shah MD]
I was going to ask you, what percent do you feel like you have to abort?

[Scott Fortune MD]
I haven't had to abort too often. I'll have one flight attendant who needed balloon sinus dilation and Eustachian tube dilation because she was just miserable every time the plane took off and landed. Her face was hurting and her ears were excruciating and she made it through all three of those tests, but the first time we did anything in her nose, she sat straight up in the chair and vomited all over the procedure chair and we weren't quite ready for that. Things can happen. In just a minute when we get to anesthesia, I'm going to touch on this again, but one thing you've got to be ready for in an office-based procedure is what if things don't go just quiet right. You have to be ready to handle that because things come up.

You'll have good anesthesia, and yet, the patient may squirm a little bit and you got to know how to handle that. A good thing to keep in mind is the awake patient is a completely different animal than the one in the operating room. In the operating room, everything's pretty much controlled. If it's not, you can ask your anesthesia colleagues to fix that, but in the office, it all falls to you to troubleshoot that. You need to anticipate that before you do any office procedures. Then I would say the final thing to know who's a good candidate. We touched on it a little bit before, but you need to know the criteria because they're going to come when you got to fight the fight.

I've had it happen plenty of times that I met all of Blue Cross criteria and they still denied the procedure. If you really want this for your patient, you've got to be an advocate. You got to be willing to request a peer to peer or to take it to a higher level wherever you need to. Those are the things to run through before you offer the service and to know who's a good candidate for the procedures you might consider.

[Gopi Shah MD]
What's the youngest age had ... I mean, any adolescents or teenagers that you all have done or is 18 the standard? I don't know what the age range of what the practice sees or what you see, Dr. Fortune?

[Scott Fortune MD]
The first thing I would say is make sure you're aware of what your state regulations are. It may vary from state to state. This is true for age or anesthesia, or any of these things. In Tennessee, generally 18 is a good number to hang your hat on. I will say that my partner a lot of times has late teenagers, 18 and 19. My actually youngest patient was that flight attendant. She was 21. I've not had a lot of teenagers that needed an office-based procedure, number one, but number two, that age group can go either way. Some are pretty tough, some just the talk of it. You can tell by the look in their eyes that they're not going to be doing anything in your office other than talking to you. It depends on the patient, but I would say they need to be at least 18 or 19 before you'd consider it.

(3) Important Anesthetic Considerations in Office-Based Rhinologic Procedures

[Ashley Agan MD]
Well, let's get into the anesthesia protocol because I think that's the part that I think about the most and worry about the most. When I do any in-office procedure, the handful that I've done, I feel like that's the part where you really need to take the most time and make sure all of that is good and goes well because then the success of the procedure all stems from that setup in my mind. I don't know. Can you talk about that?

[Scott Fortune MD]
Yes, you're exactly right. For office-based rhinology, the anesthesia is the whole procedure. Another good saying is the longer the anesthetic, the shorter the case. In other words, the better you have the patient anesthetized, the smoother things are going to go for you. The anesthesia has three needs. The first need is the patient. The patient's got to be comfortable because the last thing you want is for the patient to walk out and say, "Wow, that doctor really hurt me because a patient is pleased. He's going to tell five of their friends, but a patient that has a bad experience are going to tell 10 or 20 people. Things can go wrong right out of the gate if you don't have a good anesthesia plan in place.

The other need is for the staff. If the staff senses that the patient's uncomfortable, the staff gets distracted and your procedure will not go smoothly. Then the anesthesia protocol is important for you too. I mentioned that the otolaryngologist is the captain of the team here, and if you're not comfortable, then everyone else takes their cue from you. That includes the patient. The patients, even with little sedation, know what's going on. They can see if you're sweaty, you're uncomfortable, if your staff. The anesthesia has got to be good for everybody. It's got to be good for the patient, good for the staff and good for the surgeon.

The next consideration about that is to consider the anesthesia before the procedure. How we handle that is we have a debriefing the day before our office procedures are scheduled and we go through the patients and we say, "We have Patient X tomorrow and their list of medical problems include some sleep apnea or some whatever and their medications are these." These are important things to consider before you get in the room with the patient. Part of the anesthesia, I would say, is having some monitoring on hand. If you got to give any little bit of sedation, you need at least a pulse ox and a pulse monitor.

We have evolved into having a little Welch Allyn unit. It's not very large and it was pretty inexpensive, but it will cycle blood pressure, pulse. It has a little plethysmography part which will capture the respiratory rate. It does a continuous saturation and the nice thing is, at the end, it will give you a little printout and you can scan that into your chart as a record that you monitored the patient which is helpful too. Most otolaryngologists already have this no matter what setting they're practicing in, but you need to make sure you got a crash guard. If your patient has to be sedated and you need some airway equipment, the time to find out that you don't have that is not when you're standing there with a patient who needs that. Before you do this, you need to give some thought to your rescue equipment, make sure that's set and that's all part of your anesthesia protocol.

Once we've run through that debriefing, we set a plan for the next day and so our anesthesia includes three phases. Once again, make sure you know your state laws and what we're doing in Tennessee is considered level one anesthesia. It's really a procedure under local with just a little added sedative. We don't require any extra certification from the state or anything like that to provide this, but in some states you may, so make sure you know your state rules on this, but our pre meds, we call them, our oral medications that we give to the patients on the day of the procedure and they're administered about an hour ahead of time, we found that's the optimum time to get these medicines in and to have their effect.

First we give acetaminophen. That's 500 mgs. That's your analgesic. We use promethazine. We use 12.5 mgs. We like that because it gives a little bit of sedation, but promethazine has two really important other side benefits. One, it's a cough suppressant, right? Think about your cough syrups, Phenergan with codeine, right? It prevents that coughing thing that office-based patients can get going and the second thing it does is it's an antiemetic. It prevents them from getting nauseated. If you've ever done anything in your office that people become vasovagal, they get the vapors and the promethazine we find just smooths all that problem out.

Then the other sedative that we use and it's an anxiolytic, it's triazolam. It's a very short-acting benzodiazepine which is important because you can control it. When we first started doing these, we used diazepam. That's Valium. It's a long-acting benzo and we found that there was just too much variability. Some people would be falling out on the side of the wheelchair when we rolled them over the procedure room and others would be nothing happened and everywhere in between and it was just too variable. We didn't get a reliable effect of that sedative. We switched after a site visit to using triazolam and we're much more satisfied with the anxiolytic effects and just a little bit of sedation that that supplied. That works on that-

[Ashley Agan MD]
What's the dosing on that?

[Scott Fortune MD]
I'm sorry, the dose of the triazolam that we use is 0.125. Just a little safety tip, we have the patients fill the prescriptions, but bring them to our office and we administer the medicines. The reason I bring this up is we've had it happen twice that a patient showed up to our office with triazolam 0.25 mgs, twice the dose that we prescribed. You definitely want to be aware of something like that. Pharmacists sometimes will fill ... If you write for two tablets of 0.125, they'll just give you one tablet of 0.25 if they don't have the dose you prescribed, at least in our state.

We always check the medications, make sure they're the right dose. We administer them in the office. We have a nurse and either a second nurse or one of our mid-levels who verify the medicines, check the patient's vital signs before we administer any medication and give the medications an hour before the procedure begins.

[Gopi Shah MD]
Who are the patients that maybe can't ... Are there patients who can't do this three-medication cocktail? Are there any patients that you worry about, "Hey, I don't know if I want to do the anxiolytic and the promethazine"? Ever have patients like that or is this protocol pretty standard for most, 95% of the time, this is what it is? Did you have to veer off I guess?

[Scott Fortune MD]
Yeah, we have patients that either choose not to do it or that we advise against it. It's usually the ones that are having less done. If they're just having cryoablation or radiofrequency and nothing else, that's one situation or another situation that comes up sometimes is that they don't have family or friends or anyone that can drive them to and from the office. As soon as they get a sedative, they have to have a driver. It's even a little risky I would say to rely on a medical taxi to take that patient home because the taxi drivers really aren't qualified to do any sort of assessment if something happens in the car on the way home, but yes, there are times when we don't use that oral protocol. We will still give them the acetaminophen, but if they're not having much done or they're uncomfortable with a little bit of sedation or they don't have a driver, we'll skip that part of the anesthesia protocol.

(4) Anesthetic Dosing, Technique, and Pre-Procedure Safety

[Ashley Agan MD]
Another question I had for you Scott is what about those patients that are obese or severe OSA? Are those better to then just do in the OR or do they also do okay with this protocol in your office, or, "Hey, we just do the Tylenol and we still get them in the office because even general anesthesia can be complex, riskier for these patients as well"?

[Scott Fortune MD]
These are all important points. That's the reason we do the debriefing the day before is to go over things like this and the one for sure that you want to be anticipating a problem with is a sleep apnea patient. Typically, what we'll do with those is, let's say they're on some other medicines that concern us like a lot of people in Tennessee are on gabapentin or Lyrica or other sedative-type medicines. What we'll do for that patient is instead of giving them a whole tablet of the 0.125, we might just give them a half. In our crash cart, we do have a benzodiazepine-reversing agent. We have the flumazenil and I've never had to use it, but I feel comfortable that it's there in case I find myself in a situation where someone's too sedated, I can use that medication to reverse that effect.

That is exactly why we don't use narcotics. Our anesthesiology colleagues tell us that mishaps with medications more often than not involve narcotics. There's much more of a safety margin with the benzodiazepines, especially if you're using a short-acting one and a low dose. That's another reason we like triazolam, those two reasons. I wouldn't definitely not recommend using diazepam in a sleep apnea patient. Now, because if nothing happens in your office, the effect of that medication is going to last for hours after you release that patient home. That's where things can happen once they leave your office. The triazolam is short enough acting that by the time they've had the medication on board an hour before the procedure and have gotten through there 30 minutes of the procedure and then we observe them for another 20 or 30 minutes afterwards, most of the medication effect is gone by then. It's that short acting. The triazolam gives you a good margin of safety.

Another one that a lot of people use is lorazepam. That's Ativan. It's a little bit longer acting. If you're going to use that, I would definitely recommend you go with the lower end of 0.25 or 0.5 of that one. I would not use 1 mg. I think that's too much and it will last too long, but you bring up a good point, so yeah.

[Gopi Shah MD]
The patients come in and you've given the medicines and now take us through the ... I assume there's some topical anesthesia preparation. What do you do for that?

[Scott Fortune MD]
Yeah, so the first phase was the oral sedation, which we've covered pretty well, but the second phase is the topical anesthesia. The first step of that is just what you normally use for any scope procedure in your office. We had to change that a little bit too for the pandemic. It used to be sprayed. Now it's all about cotton. Our topical gets applied by the nurse on some cotton fibers in their nose in the holding room before we move over to the procedure room. The topical begins about 15 minutes before the scheduled time, so about 15 minutes before we want to start.

Let's say our first procedure of the day is going to be 7:30. About 7:15, we're going to go into the pre-procedure room and we're going to apply the cotton. For us, the topical that we use for scopes is 1% lidocaine with 1:15,000 epi and that's a mixture we started with a long time ago and we just stuck with it. It's pretty good for basic endoscopy. That alone would not be enough to do any of these office based rhinology procedures. The second part of the topical starts when the patient gets in the procedure room. That's when the physician enters and we'll start placing pledges.

What we use is a 1:1 mixture of 4% lidocaine light again, and 1:1,000 epinephrine. That is a potent epinephrine which is another reason you want to have that monitor handy, that pulse ox or that little Welch Allyn unit that I was referring to earlier. Most are going to tolerate this pretty well because you've pre-decongested them with your regular topical solution. We actually have the patient bring some Afrin too. Right when they go into the procedure room, we'll squirt their nose with Afrin and that's another way to get some decongestion which prevents the systemic absorption of the epinephrine.

Once we have the second round of the topical in the nose, we'll wait about 10 minutes and then we'll start the third phase of the anesthesia which is the injections. Our injection is 1% lidocaine with 1:200,000 epinephrine and we like that because it gives good vasoconstriction and it gives excellent anesthesia, but it doesn't give palpitations. The epi is just a little bit more dilute in that injection and so the patient doesn't feel as if their heart's racing. If I've seen one thing that patients complain of depending on your local, it's the palpitations. They definitely feel the 1:100,000 I've never seen pulse rates get above 90 or 100 once I inject, but the patient's definitely noticed it. When we changed to 1:200,000, all that went away.

[Ashley Agan MD]
I guess you're debriefing the day before along with the OSA and the sedation, your cardiac patients, so like hypertension, coronary artery disease may play a role and any changes of your topical injections or whether or not you decide to keep them in the office versus go to the OR, would you say?

[Scott Fortune MD]
Yes, that's true. Those with cardiac history, we're going to stay on the low end of injection. Typically, for what I'm doing, I don't need more than anywhere from 4 to 6 mLs of injection total. That includes both sides. That usually keeps you below a threshold where any cardiac events might happen, but if you've got a patient with a pretty serious cardiac history and then they're a risk for general anesthesia and you want to do this in your office. I might recommend you have that monitor unit because at least the Welch Allyn thing at least you have one lead of ECG tracing on that. The sedative protocol we talked about is not so much that the patients are completely out. If they're failing something, they can tell you.

[Ashley Agan MD]
The one thing because I do a lot of kids, so the volume matters in terms of weight-based dosing. I like using the 1 cc TB syringes, not the needle, but the syringes and it helps me inject nice and slow and I can get where I need to go just with that one route of the turbinate, little turbinate. It's a nice slow diffuse without me feeling like I'm putting in 1.5, 2 cc at one site? Do you use certain size syringes or is it just a 10 or a 5? Does that matter to you at all?

[Scott Fortune MD]
It does matter. You hit two really important points. One is low volume. You don't need a lot, but the second really important point that you said is slow diffusion. If he infiltrates slowly, you don't need as much volume. If you infiltrate slowly, you don't get all that back blow onto your scope or that extravasation out into the nasal cavity and into the nasopharynx which doesn't matter that much in the operating room, but it doesn't matter in the office. You don't want that stuff running down the patient's throat, because as soon as it does, their throat gets numb and then they start the, "Ah, ah, ah," or the, "Doctor can't swallow," thing and you definitely want to avoid that.

A low volume slow infiltration is really important. I've evolved to where ... I don't have an office in an OR protocol anymore. I just have a protocol. I do these the same no matter which side of service I'm in and the one piece of equipment that's really helped us with this is the reinforced anesthesia needle. If you're not familiar with this, just ask your Stryker rep to bring one by some time. It's a really great device and it's low cost. It's a modification of a spinal needle. I found two things with a spinal needle, either it was so big and the needle was so sharp that all my local was just running out of the place I was injecting it and going everywhere I wanted it to you but the site I was infiltrating or if I use a smaller spinal, it was so floppy. I never could control where it was going in the nose.

Then the RAN, the reinforced anesthesia needle, takes care of both of those issues. It has a 21-gauge shell, but it's got a 27-gauge tip. It's at the end of the needle. It's got about 3 or 4 mm to allow you to get in that submucosal plane, but it won't allow you to go any deeper. What this does is it allows you to do that slow infiltration and it prevents all the extravasation, so you're not getting blowback onto your scope, you're not getting a leak of the anesthetic solution that's going to run down the nasopharynx and anesthetize the hypopharynx and it gets you in the right plane to do that slow, smooth, low-volume infiltration that you mentioned.

That device has really been a game changer for our office procedures, and if you're not using this device, I would really highly recommend you take a serious look at it.

(5) Equipment and Room Setup for Office-Based Rhinologic Procedures

[Gopi Shah MD]
While we're on the topic of equipment, can you talk to us about some other tools that you have that you feel are important to you the success of being able to do these in-office procedures?

[Scott Fortune MD]
Always start with the basics. The first basic for this is good visualization. You need some good telescopes. If you can, you need at least 4k resolution. We were lucky one of our surgery centers was changing endoscopy equipment and they were just going to throw away a 4k monitor. We were like, "Hey, we'll take that off your hands." We purchase it from them at a fantastic used price and that's been our workhorse ever since. We've had that piece of equipment now for about four or five years. If you could do something like that, it really puts you on the right path. Having good visualization is so important. You got to be able to see what you're doing to do it well.

[Gopi Shah MD]
In terms of scope size, do you find that you do most of these with a 4 mm or 2.7 since they're awake and you don't want them to feel as much, but it's smaller and so things get blurry faster?

[Scott Fortune MD]
The scopes we use are more pediatric size. It gives us a little more room to maneuver around in the nose. Nowadays, I think from most scope providers, you can get a wide field view. Even if you're using a 3 mm telescope or a 2.7, as you mentioned, you can still get a view that's equivalent to a 4 mm. Once you get a 4 mm scope in there, it's surprising. Even with a patient decongested, it really limits your degree of freedom. If you can use the lower profile scopes, I'd really recommend that. My go-to scopes are the 0 and the 30, but I do occasionally pull out a 45 if I really need to visualize the maxillary natural ostium really well, I find that 45 to be important for that.

Once you have your scopes, then there's a decision point, a fork in the road, if you will. If you don't have a lot of equipment, you can ask your rep of whatever company you prefer to bring you what you need. That's one pathway. You can do what we did, which is start small and then remodel often. We started with a couple of scopes and a microdebrider. Those were our first equipment purchases. Then what we would do is set aside a little bit of revenue from some procedures, save that up and then purchase the next round of equipment, whatever we needed. That's what I call the small acquisition model.

Then the other thing you can do these days, if you have the capital or you're a large organization, you can just go to a company and say, "I need everything," and you can get everything from scopes to the balloon devices. You can get a MiniFESS instrument tray. You can get image guidance if you want that. Those are three different ways you can go. You can borrow it, you can start small and add on or you can just get the whole package. Just to summarize, you'll need good endoscopes. You'll need some sinus instruments. You'll need some small Blakesley Thru-Cut Forceps. You'll need a Bayonet, but if you can get an alligator, either an otologic alligator or we were lucky to find an alligator forceps that's about 8 cm long and this is really useful for placing those small pledges far back in the nose.

Especially if you're going to do anything around the sphenoid or the Eustachian tube, you need to be able to get a small cotton pledget back there. A longer alligator of some sort really helps you with that. A microdebrider, possibly image guidance. You can get as fancy as having a wireless camera if you want. We don't have that. We just use the wires and struggle with spaghetti occasionally, but all those things are available. I'd say that's a basic setup of equipment that you would need for these office-based rhinology procedures.

[Gopi Shah MD]
This is a small detail, but in terms of pledget size, when you say the small ones, what size do you tend to? Is it-

[Scott Fortune MD]
We use two kinds of pledgets. We use 0.5 x 3s. Those are the ones we place on the first round, and there, we just put them as far back in the nose as the patient can tolerate to start with, but once we start the second round of topical after we've injected, we use 0.5 x 1s or 0.5 by 2s, so the smallest size you can get and that's important because you need a small profile to tuck in lateral to the middle turbinate, medial to the middle turbinate, especially you need a small one to tuck into the torus if you want to do some Eustachian tube work or if you want to get a pledget in sphenoethmoidal recess or around the superior turbinate, you need a small one. We found that 0.5 x 1s or 0.5 x 2s are most useful for that.

[Gopi Shah MD]
Do you cut the strings off or do you have the ones with the strings?

[Scott Fortune MD]
We use the ones with the strings. I don't cut the strings off for two reasons. One, you have a slightly sedated patient and if that falls down their throat, they may not notice it. The other is that sometimes patients will swallow and the act of swallowing, even if their throat is not anesthetized will start to pull the cotton down their throat. To me, you need a rescue line there to keep that from happening. You don't want your cotton pledgets becoming a foreign body that you've got to deal with outside your office.

[Ashley Agan MD]
We had our endoscopic ear surgery talk recently and we were just talking about cutting the strings, holding on to the ... Anyways.

[Scott Fortune MD]
It's the great debate. I feel like a rhinologist fall into one or two camps, they keep the strings or they cut them off, but I would recommend that you keep …

[Ashley Agan MD]
I keep mine on too.

[Gopi Shah MD]
Anything else as far as set up and available equipment? Did we miss anything from that standpoint?

[Scott Fortune MD]
A couple of things, we have two rooms that we've dedicated to this. If you have that capability, I'd recommend it. It's a little harder to transition back and forth between an exam room and a procedure room. Sometimes you have to, depending on the size and footprint of your office, but if you can dedicate a room or two to this, I would recommend that. Then we talked a little bit about staff earlier under anesthesia, but just to touch on that again, you need the right staff. You need nursing help that can tolerate the procedures too. Some nurses don't like the popping and crackling sounds or the little bit of blood that comes out the nose. You don't want your assistant becoming faint during a procedure.

Knowing that ahead of time is important and cross training. More than one person needs to know how to do this. You don't want to find yourself on that procedure day and your nursing help is out because they have childcare issues or they're ill or they've had a death in the family or all the things that come up in our lives and you don't want to be there by yourself. You need to make sure that you've got a couple of people cross trained who can fill in, backfill, if you will, in case your primary assistant is not available. I would put that under extra needs for the procedure. Some important things to consider before you do this.

(6) Maximizing Time Efficiency for the Patients and the Practice

[Gopi Shah MD]
I wanted to get into some specific procedures, but before we get there, do you have a separate recovery room for your patients? We talked about how after the procedure is done, you need time for the air scrubber and turnover. Is the patient in the same room during this time or do they go somewhere else?

[Scott Fortune MD]
That's a great question. What we do with that is we just use a regular exam room for a pre-procedure room and then we put the patient in a wheelchair from the procedure room and roll them to just another exam room that we just use as a post-procedure or if you want to call it a recovery room. We usually like to put that somewhere close to the nursing station, so that the nursing staff can go in frequently and check vital signs and just do the routine follow ups. Usually my routine is once I'm done with the procedure, I will go straight to the electronic record and get a few key details in there. While I'm doing that, the nurses are transferring the patient by wheelchair from the procedure room to the post-procedure room and then they'll run and grab the family.

By the time they've done that, I'll go back in to the post-procedure room and meet with the family and give them all the go-home instructions and let them know how things went and anything special that they need to know for the aftercare, when can they use their CPAP, when they can go back to work, if there were some medicines we stopped, some anticoagulants or whatever specific instructions about that. Then another couple of checks by the nursing staff after that usually runs 30 to 40 minutes of post-procedure observation. Once that triazolam has pretty much worn off, that's when we'll roll them down to their car in a wheelchair.

Once we've sedated them, we don't really let them up. They might be wobbly. They could be vasovagal or just enough sedated from the medications. You don't want to take the chance of them falling and injuring themselves in your office. Once I get those medications, we pretty much transport them wherever they're going to go.

[Ashley Agan MD]
Then one other question in terms of the process, do you basically then just have like one half day or one day where you schedule these procedures? For somebody starting out that maybe doesn't have the volume yet or maybe you have colleagues, do you ever have clinic at the same time that you're doing these procedures?

[Scott Fortune MD]
I don't. I either dedicate a day to doing clinic or I dedicate a day to doing procedures. Now I will say, here's what I recommend for starting out or what I do sometimes if my schedule is not full. If you're just starting out, what I would recommend is do the procedure first thing in the morning and then leave a little bit of time after the procedure. Then if you want to see a couple of patients after that, I think that's fine. I would not fill every single slot on either side of that procedure when you're starting out. Don't recommend that at all.

Even though I'm a little bit seasoned in this, on days that I don't have a full schedule, I will only scatter in just a few patients. I either like to allocate my time to doing procedures and focusing just on that or to clinic and I don't like to mix the two. For me it's just a little too disruptive to switch gears back and forth. It just helps me focus more on what I'm doing, but if I just have one thing that I'm doing that day, either procedures or clinic.

(7) Peer-to-Peer Training Sessions in Office-Based Rhinology

[Gopi Shah MD]
I totally agree. I tend to be like that as well. You're a trainer. You host physicians to do these peer-to-peer training sessions. What is that event like? Can you tell us more about that?

[Scott Fortune MD]
The event starts when a field rep identifies a physician client who's interested in doing these procedures and wants to learn more. All this happens behind the scenes away from me, but there's a matching process for what level that person who wants to come for the visit is at and then they match with a trainer across the country. A lot of the folks that come to see us are ones that are just starting out or have done a little of it and just want to get a little more comfortable or see what the next level is. Our practice is geared nicely to that level. We're not a Sinus Center. All of us that do these are just comprehensive otolaryngologists. We do everything else. We do tubes and tonsils and sleep apnea and tons of allergy and I do want to circle back to the allergy point later.

Once the client is matched with a program, then a date is set for the visit. We usually like to do these on a Friday to minimize the disruption to that visiting surgeon's schedule and family activities and this sort of thing. It's a three or four-step event. They will usually come in Thursday evening, so that way they can work most of Thursday and not miss time that day. Thursday evening is what we call hospitality. We usually like to get together just over an informal dinner and usually the discussions are, "Where are you? What is it you're trying to get out of this visit? Here's what's on our agenda tomorrow. How can we tailor this to what you want to get out of the visit?"

We spend a lot of time sorting that out. Then the next step in the visit is the actual day of the procedures. Different COE sites, Center of Excellence sites, will do this differently, but the way we handle it is we have set up a little slideshow. As soon as the physician comes, they meet in our breakroom and we have a video set up in there and a little bit of a slideshow about the equipment, the anesthesia technique, all these different things we've talked about so far. We run through that. The next thing we'll do is pull up the list of procedures and I'll usually just go through with them the patient's history, what workup we've done, we'll look at the imaging together, all those normal steps that you would do yourself leading up to a procedure.

Then they will come in with us during the procedure and we have ... Our main room that we do this in is arranged, so that they can stand in one corner and see everything. We have the room set up around the opposite corner where all the video monitoring is and we actually have another screen that will display the video. If we have image guidance going, they can see that easily, they can get their eyes on the equipment. We have the assistant situated in the room so that they can see what's happening there. Some physicians will bring their nurse with them. Some will also bring their administrator and there's an experience we provide for them too.

The nurses meet with our nursing staff and run through that. While we're doing the procedures with the physician, the administrator will meet with our administrative team and learn about billing and coding and all those things. We try to touch on everything that's needed to set this up. Then there's two more steps after this is done. After we're done with our procedure day and our teaching and so forth, we like to have another hospitality thing. We try to go to lunch and just debrief, "What questions do you have? You've seen a lot. Does this apply to you? How might you start this? Where do I begin to get this equipment?" all that and we leave them with a packet that answers all these questions.

It has our anesthesia protocol. It has the equipment master list. We just try to go through everything with them again. Then the fourth phase actually happens after the visit. Once the physician is back at their practice a few weeks later, we try to get them to get back in touch with us with a phone call or email or text or whatever to say, "Hey, how's it going? What can we do to address your concerns? How can we help you take the next step?" That's pretty much how we handle a peer-to-peer visit. There's a lot of different types of learning and they're all valuable, but I'll tell you what, I learned just as much from these visits as the visiting physicians do. I'll learn what challenges they have and how they handle them. It's helped me more times than I can count in my practice.

Just peer-to-peer exchange and networking I found to be so valuable. That's my favorite part of this whole thing. I know you guys are academicians and you might take this for granted, but one of the definitions of doctor is teacher. While I don't teach residents, I do teach my patients every day and I do teach my nursing staff, but I was missing one little piece of the puzzle and that was teaching physicians and that has really brought my career to a level that I've never anticipated and it's been extremely satisfying to be able to impart what I do and then have physicians see me somewhere down the road and say, "Hey, we took back what you taught us and we've done this and we've made it better in this way," and that's a really important part of this peer-to-peer teaching, I think.

[Ashley Agan MD]
That's awesome. I would totally agree. Teaching is my passion for sure. It's just one of the most rewarding things because I think basically what you're doing is being carried forward and then exponentially passing it down and that's pretty powerful to think about.

[Scott Fortune MD]
We stand tall on the shoulders of those that came before us and we have been lots of places and visited lots of practices. We've modeled ourselves after what we thought was the best from here and there and then that's spread out around the country. It's a big family. That's what I tell people. Once you've been to visit us, you're part of the family, you can always get back in touch and tell me what's good, what's bad, what do I need to do better, when someone comes to see me the next time or what did I do well the last time, that's all an important part of it.

(8) Pearls on Incorporating Office-Based Rhinologic Procedures into a Practice

[Ashley Agan MD]
There's a lot of growth for sure. Dr. Fortune, what is a procedure that's a good one to start with for somebody trying to incorporate office-based rhinology in their practice?

[Scott Fortune MD]
I would recommend considering your first step is treating those patients with chronic rhinitis. We all have the patient that walks into our office with the drippy nose that doesn't seem to respond to any medications and it's socially embarrassing. Their nose runs when they sit down to eat. They've always got the handkerchief. You know the type I'm talking about, I'm certain. There's a little relief you can provide for those folks with nasal sprays, especially ipratropium petroleum seems to be helpful. It's actually predictive of who might respond to treatment for chronic rhinitis.

If the patient has a positive response to the ipratropium and doesn't want to use medication for a long period of time, that they're probably a good candidate for treatment of chronic rhinitis. You've basically got two options there. They're the opposites of one another. You can cool it down or you can heat it up. You can offer cryotherapy or you can offer radiofrequency ablation. Both of those have been shown in studies to be safe and effective. The percentage responses in those studies are typically above 70%. A good rule of thumb for procedures for chronic rhinitis is that about four out of five are going to improve and improve, for some, means they don't need the nasal spray, but it's important to set a good expectation for patients.

Some will still need the nasal spray even though they don't need it as much and that's a nice subtle distinction to make for your patient, but let's just assume that you've done the workup, you've provided that prescription. They've come back and they've said, "Yeah, I improved a little bit on the ipratropium, but I don't want to use this medication for the next months, years, my life, whatever." Then you might offer to them a procedure to try to minimize that. Chronic rhinitis is a good starting point because there's not a lot of equipment needs and the procedures are fairly straightforward.

I find that either the cryotherapy wand or the radiofrequency device is low enough in profile that you can often maneuver some septal deviations and things like this and not have to address that also. That's an important point, but for the cryotherapy or radiofrequency patient, I will offer them the option of having the pre-medications or not. We talked about this a little bit earlier. This is a patient where a lot of them want to drive themselves to and from the procedure because there's essentially no recovery time. They can have it and go back to work the same day if they wanted. This is one situation where I often find myself not giving them the oral sedation medications. It's quite possible to get them comfortable with the anesthetic protocols we described earlier for this.

Let's assume that they want to do that and they're going to do it without the pre-meds. The process is still the same. They're set up on a procedure day. They will come and they'll still get their acetaminophen an hour ahead of time, and then 15 minutes ahead, they'll get their first round of pledgets. Shortly after that, they'll get their Afrin spray, then they're moved over to the procedure room and then they get their first set of the long pledgets that we discussed with the lidocaine and epi mixture. I've altered my technique just a little bit and I want to tell you why.

What I used to do at first was to take the pledgets out, inject the left side, put the pledges back, take the pledgets out of the right, inject the right side and put the pledgets back. Not so much for chronic rhinitis, but for some of the other procedures. What I found in doing that was by the time I got back to the right side to finish things up, the anesthetic was wearing off. Now what I will do is take the pledgets out of the left, inject, put the pledgets back, wait about three, four or five minutes and you got to figure out what you're going to do with those few minutes because when you're not doing anything, they're the longest three, four or five minutes of your life and then I will take the pledgets out and do the procedure on the left side and then repack that and then go and inject the right and do the procedure on the right. Doing that, I've found that I avoid that anesthetic wearing off problem.

A key point especially for chronic rhinitis treatment is a good sphenopalatine injection. That's especially important for cryotherapy because the one pitfall in this procedure is the ice cream headache. I've had a couple of them and they can be pretty bad. You really want to try to head that off. A good way to prevent that ice cream headache is to make sure you get a good sphenopalatine injection. We talked about that reinforced anesthesia needle. That's a key tool to provide a good sphenopalatine block. The one little modification for cryotherapy is I will provide that block before I do the procedure, and then as soon as I get that cryo wand out of the nose, I'll apply a little bit more of the local in that area. That seems to blunt the ice cream headache quite nicely.

If you do get one, just have some hot liquids on hand. That's another good way to manage an ice cream headache is to give the patient some hot coffee or some hot tea. Basically the reason it happens is you're applying cold treatment to a branch of the trigeminal nerve and we all know from anatomy how big the trigeminal nerve is and we know how much substance P and other toxic things it can release and start the whole headache process. You've seen this with your migraineurs and so forth and just knowing that and respecting that and providing a good block before and after will keep you out of trouble with that ice cream headache, but that's one pitfall to know about and to anticipate and to try to avoid in cryotherapy.

The ice cream headache is not such an issue with radiofrequency. The trigeminal nerve is not so sensitive to heat that it seems to create that same headache issue, but once you've chosen your technique, you can maneuver the device back into the sphenopalatine area. For either one, the cryotherapy balloon, which is you can get from Stryker or the RhinAer wand, which you can get from Aerin medical, the device goes back right over the sphenopalatine area and then you apply the treatment, and with the cryo wand, your treatment time is 30 seconds. Then you need to let the wand sit where it is for 45 seconds because if you pull it straight out, you're going to pull out a large piece of mucosa with it.

The cryo wand cools off to such a temperature that the balloon device freezes to the tissue for a moment. To allow that to release, you need to give about 45 seconds. You'll know when you can take the wand out because all of the frost will be gone from both the balloon and from the mucosa. Then what I'll do at that point is just give the balloon a slight little wiggle. If it's not stuck at all in the mucosa, you can take it out. The radiofrequency device treatment time is 12 seconds. Once the wand has gone through a full cycle of treatment and cooling which lasts 12 seconds, you can take it straight off of the mucosa. That's another slight subtle difference between the two procedures.

A final difference is the radiofrequency wand can be used to touch the posterior aspect of the inferior turbinate a little bit. It does have one advantage over the cryo wand and that you can treat some nasal congestion at the same time by using it to apply a little bit of that radiofrequency energy to the mulberry tip or the posterior part of the inferior turbinate and the patients get nice relief of congestion from that. I would say with the cryo wand, a lot of my patients come back telling me they can breathe better. I have a suspicion that the cryotherapy ablates a little bit of tissue around the middle turbinate. If you go back to your nasal physiology, which we all want to forget, but about a third of the airflow goes through that middle meatus right over the middle turbinate.

If there's a little less tissue there, the patient sensed a little easier airflow. Even my cryotherapy patients often will come back and say, "I breathe a little better since you did this for me." That's a benefit that you can look for. I don't tell my cryotherapy patients too much about that on the frontend in case they don't get that result, but I do often see it, and if they bring it up afterwards, I'll tell them some about it. Those are some differences with those two procedures. That's a nice starting point. I would say that all that together, once the surgeon gets in the room, it's about a 15 or 20-minute process. Most of that time again is the anesthesia.

The actual treatment times for those, as I mentioned, are pretty short. The active working part is pretty limited, but you want to be patient with that anesthetic. Make sure your patient is comfortable. Do all those things that we talked about to avoid the ice cream headache. What I will do from there is to have them both ... I'll have them just use a lot of saline. If I did quite a bit of radiofrequency, sometimes they will crust, whereas the cryo patients don't crust very much. For radiofrequency, I'll have them use a little bit of mupirocin ointment in their nose, especially at nighttime, maybe one other time a day.

For both, I'll see them back in about five weeks. The reason for that is the physiology of the procedure is that the sphenopalatine nerves are injured by either cold or heat and it takes time for the degeneration of that nerve to go back to the first order ganglion and that process takes about four weeks on average. If you wait about five weeks to see them back, you're going to have a pretty good idea of what result you're going to wind up with. What we will do is have them come back. We'll have them tell us their history. We'll examine their nose and we will do that symptom score because sometimes the patients don't realize what difference there has been in their preop and postop symptoms. That symptom score is a nice way to say, "Well, you had this before the procedure and now you're down to this level. That's a good objective measure of your response to the treatment."

[Gopi Shah MD]
All right, lots and lots of good advice. Thank you so much. Any parting words for our listeners?

(9) It’s Never Too Late to Start

[Scott Fortune MD]
A couple of things. One has to do with all we've talked about today and the other has to do with my academy roles. The first is you're never too old or too far in practice to learn these techniques we've talked about today. You can be fresh out of training. I've trained those at The Academy meeting. We will typically be in one of the equipment provider booths to train people hands on, but I've had physicians who were within a year or two of retirement and wanted to learn this, come visit also. I mentioned to you that your training doesn't end the day you walk out of residency. It continues throughout your practice and, and even at the end of your career, you can still learn about these things. Even if you're not going to do them, you'll know who to refer them to. That's an important thing to know.

The second is we're at an important time for the specialty and your academy is doing all sorts of things for you with education and advocacy. One of my committee's responsibilities is education for rhinology and allergy. We are providing all types of education for every type of learner. If you haven't taken a look at it, I would recommend that you take a look at the FLEX. For those who really liked the home study course, there's still a set of articles to read and review and answer questions on to get your CME credit, but for other types of learners, there are podcasts, there are surgical videos, there are Patient of the Week questions. It's a really rich model of education. There's something there for everyone. I've just submitted my first round of questions for that, so you can look for those sometime in the future. Rely on The Academy for your ongoing education.

The second is we've had an election and a turnover in administration and there's lots of moving parts in healthcare right now. I'm on the Legislative Affairs Committee and we do monitor what's happening with healthcare legislation as it relates to otolaryngology. Our specialty is in need of some financial support. I would encourage you to take a look at the ENT Pack and to try to support that. What that allows us to do is to identify legislators that are favorable to issues that face otolaryngology as a specialty and for us to engage with them. It's just the nature of the beast in 2021 that you have to have some funds to be able to sit at the table with these folks and the ENT Pack needs your support for that.

To maintain the good position our specialty is in now and to position us for the future. I really would appreciate you supporting the ENT Pack to keep us headed in the right direction.

[Gopi Shah MD]
Well, thank you so much, Dr. Fortune. Thank you for taking the time. I learned a ton today. I'm really excited for our listeners to hear this one and for their feedback. Thank you to our listeners for tuning in. You can find us @_backtableent. Our podcasts are on SoundCloud, Spotify, iHeart Radio, Apple. What else am I missing?

[Scott Fortune MD]
On Audible now, too.

[Gopi Shah MD]
Oh, on Audible. Thanks. What else am I missing, Ash or Dr. Fortune?

[Ashley Agan MD]
Scott, for our listeners who want to reach out and connect with you, what social media platforms are you on? I know we've connected via Twitter. Is that your main place?

[Scott Fortune MD]
Yeah, you can find me easily on Twitter and I do respond there. Feel free to send me a direct message. My Twitter handle is @DrScottFortune, and on that Twitter account, I do highlight some of what we do with office-based rhinology and we've got a couple of hashtags if you want to follow that along. One is #minimallyinvasiverhinology and the second is #officebasedrhinology. There's a practice website. It's not quite as robust as the Twitter feed, but it does have some good information. Our practice website is www.myallergyent.com. That's M-Y, allergyent.com, but I'll also give you my email and feel free to reach out to me. I've done the same for some of your previous guests. I've had some great conversations with some of the recent folks you've had on the podcast. My email is sfentallergy@yahoo.com. Scott Fortune, entallergy@yahoo.com.

[Ashley Agan MD]
Awesome, thank you. Reach out to Scott. Let him know how this podcast landed for you. Reach out to Gopi and I and let us know what you thought and what other material you might want to hear. Thank you for stopping by the podcast today. Please subscribe, rate and share us with your friends. Until next time, it's a wrap. Bye-bye, everybody. Thanks.

Podcast Participants

Dr. Scott Fortune

Dr. Scott Fortune is a practicing physician with Allergy & ENT Associates in Nashville, Tennesee.

Dr. Gopi Shah

Host Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan

Co-host Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

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Medical Disclaimer

The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable ENT Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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