In-Office Sinus Surgery for Nasal Obstruction

[Gopi Shah MD]
So I wanted to talk specifically about, in-clinic or in-office procedures specific for nasal obstruction. What are the different procedures that kind of fit that group? What are the procedures that are in-clinic done for nasal obstruction that you do?

[Ashley Sikand MD]
Maybe I'll start with one of the more common causes of nasal obstruction that I've been interested in working with and treating in the office. And that's a deviated nasal septum. So, a lot of people did septoplasties under local anesthesia back in the 1950s and sixties. And Dr. Weeks, his father may have remembered those days in his training as well. And I think that's encountering resurgence now, with better local anesthesia techniques and minimal sedation techniques. We can do it in the office. I became interested in that because a lot of my patients may have had sinus disease, but they also had nasal obstruction, frequently from a deviated nasal septum. So, I found that interesting at times challenging, but the focus has always been providing a proficient procedure with the patient having not only a good outcome, but a good experience, so not encountering the discomfort.

And as that relates to our meticulous anesthesia technique that we owe a debt of gratitude actually to our colleagues in oral surgery and dentistry. I read the early papers there about blocks and the type of anesthesia that's used, sphenopalatine blocks and their early pioneers in ENT. And essentially, I use that almost on every patient that I do in the office. And then an evolving science of minimal sedation or not true conscious sedation, but sort of anxiolysis with some pain management that I think is continuing to evolve. So the septoplasty, I think is a very, in many cases, is very amenable to the office. Not all cases. And severely deviated septums where you can't even get close to doing a sphenopalatine block, I don't recommend it, but we've been able to do a large series and that we'll be reporting on shortly. So that's one thing I definitely would encourage people that have had some experience with an office to consider a septoplasty as well.

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[Gopi Shah MD]
And so, I want to get into the anesthesia portion, as well, but before we get to there, we've talked about, deviated nasal septum, nasal valve. And I would imagine probably a lot of turbinate obstruction, in terms of nasal obstrution. What else am I missing? Because when I think of nasal obstruction, those are kind of the three that I think of, but I'm sure there's other things I should be thinking of.

[Brian Weeks MD]
Yeah, I think I can just add, and Ash, if you have anything else. But you know, obviously with things like nasal polyps, nasal obstruction, and then even things like just the effects of chronic rhinitis conditions, things like that. I mean, we have the ability to effectively treat all of those diseases in the office. And I think specifically with polyps, I think most ENT doctors that have an office-based platform have a microdebrider in the office and we use our microdebrider every single day in the office. And it's not uncommon to remove large burden of polyps in the office. Interestingly, I was just having a conversation at the course here in Scottsdale. And, it's actually far easier to remove nasal polyps in the office than in the OR because there's really no bleeding in the office. And I know that sounds crazy, but the patients aren't vasodilated and there's no lability in the blood pressure. And these are essentially avascular procedures. And Ash, you’ve done a ton of ethmoidectomy and nasal polypectomies as well in the office. I mean, I'll let you speak to that, but would you agree?


[Ashley Sikand MD]
Absolutely. And I started getting very interested in office-based procedures because I got a lot of referrals from pulmonologists whose patients have COPD and other chronic conditions that make it difficult for them to undergo general anesthesia, but they can't breathe through the nose because of, in many cases, nasal polyps or hypertrophied turbinates, very large or expanding and concha bullosa that becomes infected. So these conditions are all amenable to being treated in the office and with significantly less risk or morbidity than doing them under general anesthesia. So agree a hundred percent, with you Brian on that.

So I think, we've sort of dealt with the panoply of nasal obstruction etiology there, by adding the polyps and then the concha bullosa, turbinate hypertrophy, chronic rhinitis, all of these are challenges and very common conditions that we deal with. And I also agree with the fact that the advent of newer technologies actually make us more aware of some of these problems and a simple example is the development of nasal endoscopy to be able to refine our evaluation of the nasal airway and perhaps emerging technologies that allows to scan the nasal airway, determine sites of obstruction and become a much more precise in developing a treatment paradigm for managing those conditions.

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[Gopi Shah MD]
Okay. Just cause I'm not as familiar with those. So LATERA is the nasal valve, the nasal valve device. And I apologize. I don't know what the ClariFix is.

[Brian Weeks MD]
No, it's no problem. So I'll tell you exactly. So LATERA is the lateral nasal wall implant, and that is the stabilizing implant, that stabilizes the internal nasal valve. And it's made specifically for dynamic nasal valve collapse. So it prevents that or improves that. And then ClariFix is posterior nasal nerve or postganglionic branches of the sphenopalatine cryoablation.
So it's a freezing and there's other technologies too. There's a competitive technology called RhinAer. And then LATERA’s kind of competitive technology is something called Vivear and that's more, in my opinion, ideal for a static nasal valve hypertrophy, as opposed to dynamic nasal valve collapse.

[Gopi Shah MD]
If somebody wants to start doing these procedures, what would you definitely need to have?

[Ashley Sikand MD]
First of all, I think you have to put some thought into what the room set up is going to be obviously. The first thing you're going to need is a good endoscopic system. A tower that actually provides a great transillumination, great visualization technology, companies that have these and whatever you're comfortable with, whatever works for you, but that is a mainstay of workhorse of what you're going to need. You're going to also need an appropriate camera to do the procedure, and then, instrument trays. So over time, I guess I started with, the basics through cut forceps up and down, giraffe forceps, and also a microdebrider. Because you’ll encounter sometimes as we do in the operating room as well, a CT scan doesn't appear to have polyps, but then there are some polyps there. And although you can use through cuts, I found that a microdebrider just is able to take care of it so efficiently and effectively and very rapidly, which is important. And when you're in the office, you want to get the case done fairly quickly. So I think those are very important parts of the equation. Obviously disposables like a balloon dilation system for working with that.

Then it depends on whatever else you're going to do. So if you're going to do revision cases, cases that involve ethmoid work or more challenging cases, image guidance becomes important. And we added that on fairly early. And then, of course, like in my case I have a septoplasty tray, similar to what we'd have in the operating room. We have different treatment options for turbinates, radiofrequency, energy, as well as microdebrider for turbinates. So that's kind of the equipment that I've developed over time. And I think you start with the basic workhorse, endoscopy, camera, and some basic equipment tray. And it allows you to accomplish, cases that are– if you're embarking on this for the first time, it may be just be single balloon dilation, and then, progressing it after that.

[Brian Weeks MD]
I would say a couple other things that maybe seem obvious or maybe not even somebody mentioned, but having a very comfortable exam chair that can recline, is really, really important. One that's adjustable because really your comfort and the patient comfort are tantamount. Having a high-quality suction, making sure that your SMR carts are really suctioning. You need effective suction when you have an awake patient who's asleep and those are simple, obvious things, but amazingly they'll let you down and you'll regret it.

And then remember a couple of other things for a new adopter, who's just trying to get started or maybe somebody fresh out of training who doesn't have the luxury of a robust profit and loss and a lot of money coming in. You know, this is where you leverage your industry partners. You literally say to them, listen, I want to get started. I need your help. I need you to bring in a demo for me, for my first five cases. And I need you to let me try a couple of cases with your balloon to make sure that this is something. So you get a couple cases, and that's part of trialing the balloon, right? You get a couple of free cases to check it out, decide which technology you want to use. They'll bring in a camera for you to demo. They'll bring in a tower. I mean they'll bring in the mini FESS set for three or four cases. Highly recommend doing that. It'll generate some income, it'll generate some confidence, and then it'll allow you to really fine-tune what you like, what you dislike, what you're looking for, kind of for a more permanent fix.