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In-Office Sinus Surgery for Nasal Obstruction
Taylor Spurgeon-Hess • May 12, 2022 • 156 hits
In-office sinus surgery is being adopted by a growing population of otolaryngologists. With the proper tools and scheduling considerations, office-based procedures allow an increase in both efficiency and patient comfort without compromising the quality of care. In this article, we survey the various procedures which can be performed for nasal obstruction, the patient selection considerations, and the basic equipment requirements for a physician to get started with in-office sinus surgery.
Dr. Sikand and Dr. Weeks comment on their experience with office-based surgery and share their insights for those looking to start. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Common in-office procedures include septoplasties, nasal polyp removal, and the use of ENT devices such as the LATERA nasal implant and ClariFix cryotherapy treatment.
• Patients with high procedure anxiety, those who have had issues with local anesthesia in the past, or candidates who metabolize anesthesia quickly may be better suited to undergo surgery in the operating room, as opposed to in the office.
• Elderly patients generally benefit from undergoing in-office sinus surgery as they face greater risks with the use of general anesthesia in the OR and often present with less anxiety about procedures than other groups.
• Key equipment required by any physician looking to branch into office-based surgery includes a comfortable and adjustable exam chair, a stellar endoscopic tower, instrument trays, a camera, and a microdebrider.
Table of Contents
(1) Common In-Office Procedures for Nasal Obstruction
(2) Patient Selection for In-Office Nasal Obstruction Surgery
(3) Equipment Considerations for In-Office Sinus Surgery
Common In-Office Procedures for Nasal Obstruction
Nasal obstruction often involves a deviated nasal septum, the presence of nasal polyps, or turbinate obstruction. To address these concerns, some otolaryngologists have found great success in performing septoplasties and nasal polyp removal in-office. Nasal polyp removal is reported as far easier in the office versus in the operating room; patients are not vasodilated and there is no lability in blood pressure, so therefore, there is no bleeding to worry about. Some individuals with nasal obstruction may be referred for an office-based procedure by a pulmonologist, as the patient’s chronic conditions, such as COPD, may make undergoing general anesthesia difficult.
The advent of modern ENT devices has allowed for an even wider range of in-office treatment for various conditions. ClariFix, a cryotherapy treatment, can be easily utilized in-office to relieve the pain and inflammation associated with chronic rhinosinusitis. Another commonly used device, the LATERA nasal implant, helps to treat obstruction by stabilizing the internal nasal valve and is also suitable for in-office use.
[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.
[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.
[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.
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Patient Selection for In-Office Nasal Obstruction Surgery
While most patients with nasal obstruction would likely qualify for in-office sinus surgery, a few subgroups should be avoided. From the psychological standpoint, patients with high levels of anxiety or people who often feel uncomfortable during dental procedures or their initial nasal endoscopic evaluation may be more comfortable in an OR setting. On the other hand, elderly patients often experience less anxiety in procedural settings, and this notion, coupled with the increased risks to these patients while under general anesthesia, often makes them ideal candidates for office-based care. The other consideration for patient selection relies on physician confidence and experience. Generally, if patients are undergoing multiple procedures at once, such as polyp removal, an ethmoidectomy, and a balloon sinus dilation, the procedure may run too long and would be better suited for the OR. However, this guideline is often based on the operating physician’s preferences and comfort. The operating room might also be more suitable for patients that quickly metabolize anesthesia or have a history of issues with local anesthesia.
[Gopi Shah MD]
In terms of patient selection, I guess the question is what are the red flags or who are the patients that you just can't do this or when is the disease so bad that you just are like, “Nah, we should do this in the OR.”
[Ashley Sikand MD]
Right. So I think you've, in your question, you touched on the two, sort of the bifurcation of, patient assessment or patient selection, right? So one is the focusing on the patient's sort of psychology, a personality inventory, if you will. The patient who just has a tremendous amount of anxiety, doesn't do well at all on any kind of dental procedures, or cannot do that. And, is very, very apprehensive during even your nasal endoscopic exam. So that is a subgroup of patients that may not be appropriate for this kind of situation. I've found that our older patients do extremely well in the office and that's fortunate because they also may have more problems with general anesthesia, right? So they do very well. And some younger high anxiety individuals are a little bit more problematic.
Then on the other side, the type of case, there are two considerations there. One is definitely, the number of procedures that are going to be performed. So if you're going to fix the deviated septum, but you also have to take out a reasonable number of polyps, an ethmoidectomy, and a balloon sinus dilation, the procedure might be a little too long for an office-based case. So, those are the kinds of considerations, and I think a lot of it has to do also with you experience and your confidence that builds over time.
[Brian Weeks MD]
Yeah, I would second pretty much the same thing. Definitely, if a patient tells you, I don't do well with local anesthesia. Listen, do yourself a favor, just take that patient to the operating room. If they're literally flashing the red lights in your face, “Doctor I have a horrible time at the dentist. I don't do well with local anesthesia.” The other one is, “I metabolize the anesthesia really fast. I'm kind of resistant.” Yeah. Don't even bother, just take the patient to the operating room. I think certain disease states, I mean, I allergic fungal sinusitis is not an office procedure most of the time. And patients who have disruption to the biome, chronic biofilms that need high volume irrigation and hydrobridement, have definite fluid management issues in the office when you get over 50 CCS of irrigant. If you're using one of the high-pressure irrigation vacuums that the technology partners make, you can do a fair bit of irrigating and suctioning effectively, but like when you're talking about four liters of irrigation to blast out, there's no way. So those patients all need to be appropriate site of service. And then lastly, I would, I would just second, there's a group of adolescent patients. You know, it's frequently that the adolescent macho man or the adolescent females that tend to have some difficulty. And the older patients usually fall asleep and they're the cutest sweetest people. They wake up, usually you're waking up Mrs. Jones. When you're finished, after she's been snoring for 30 minutes, you're like Mrs. Jones, you're done. And she's like, I'm done. What do you mean I'm done? I didn't even know you started. And that's exactly how we want it. You know, it's really a pleasure. And they're such sweet people.
Equipment Considerations for In-Office Sinus Surgery
For physicians looking to introduce in-office surgeries to their practice, Dr. Weeks and Dr. Sikand offer a number of equipment recommendations which have aided in their success. Essentials include a good endoscopic system that provides exceptional visualization and transillumination technology, as well as instrument trays, a microdebrider, and an appropriate camera. For patient comfort, utilizing a comfortable exam with sufficient recline and adjustability is also key. New adopters can work with industry partners who will often bring in equipment for physicians to demo when they’re just starting out.
[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.
Dr. Brian Weeks
Dr. Brian Weeks is a private practice otolaryngologist with SENTA Clinic in San Diego, California.
Dr. Ashley Sikand
Dr. Ashley Sikand is a private practice otolaryngologist with Nevada Sinus Relief in Las Vegas, Nevada.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, March 22). Ep. 54 – Keeping up with Technology for In-Office Sinus Procedures [Audio podcast]. Retrieved from https://www.backtable.com
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