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BackTable / ENT / Article
Treating Nasal Valve Obstruction: The VivAer Procedure Explained
Taylor Spurgeon-Hess • Sep 22, 2022 • 1.5k hits
To address the various causes of nasal valve obstruction, otolaryngologists often start with the conservative route and treat patients with a combination of modalities including nasal steroid spray, topical antihistamines, decongestants, and nasal strips or nose cones. If these non-invasive options fail, patients can turn to surgery, but may prefer an in-office treatment such as the VivAer. The VivAer procedure works by remodeling the nasal airway and takes only a few minutes. For qualified patients, this procedure offers lasting relief and requires minimal time for recovery.
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
• The VivAer device applies radiofrequency energy to the nasal valve which stiffens and retracts the tissue allowing easier breathing for patients.
• No incisions are required and the whole procedure can be completed in the office in under twenty minutes. People can carry on with their day directly after the visit concludes.
• While the procedure does not work well on external valve collapse, it works especially well for internal valve collapse, as well as patients who previously had a septoplasty or turbinate reduction, or those looking for something that helps them to avoid surgery and offers minimal recovery.
• Patients can expect some scabbing inside the nose and may notice tenseness in the tip of their nose, but these symptoms resolve within a few weeks post-procedure. The treatment finalizes within six to eight weeks, and complications are rare.
Table of Contents
(1) The VivAer Procedure Explained
(2) Patient Selection Considerations for the VivAer
(3) VivAer Post-Op Care and Recovery
The VivAer Procedure Explained
The VivAer nasal valve remodeling procedure works by utilizing temperature-controlled radiofrequency energy. The VivAer device has a paddle that, when applied to the nasal valve, can remodel by shrinking the tissue to stiffen and retract the area. In layman’s terms, the radiofrequency energy does not burn the area, but rather, helps to heat up the tissue by vibrating the structures causing them to change their shape. Everything can be performed in-office and may only require relaxing anxiolytic medication beforehand, or some local anesthesia to numb the area. The procedure does not require any incisions, making recovery easier for patients than surgical approaches.
[Mary Ashmead MD]
All right. So, for those patients who do respond well to the modified Cottle in the office, and so you can kind of mimic the types of results you can get with a radiofrequency procedure. Like VivAer we talk about it. And I show them videos of what we can expect. This is what to go through. And sometimes we will kind of piggyback this with turbinates as well, if we have other problems. But if they respond well to that modified Cottle in the office, we have really good data to say that they will respond to the VivAer procedure. And it's data that lasts out to four years now. That we get lasting relief from this office procedure that we can offer our patients who don't want surgery, and they don't want to change the outside of their nose and they are having trouble breathing through their nose. And so then we start to go through exactly what it is and how it works and, uh, whether or not this would be a good option.
[Ashley Agan MD]
And for listeners who don't know what it is, can you kind of do your spiel about [the VivAer]. What is it?
[Mary Ashmead MD]
Yeah. So, VivAer is a disposable handpiece or stylist that delivers bipolar radiofrequency energy. So it's a little paddle that we can use to shrink down this tissue and to help, to stiffen and retract and change and remodel that internal nasal valve. And so there's a video, an animation on their website that I will show them say, this is what we're trying to accomplish. And then they usually ask, well, what's radiofrequency energy, you know, how does this work? And I tell them that it causes tissue vibration that causes things to heat up. And so if you put this against a grape, it makes that grape kind of slowly implode because they immediately think burning, right? Like, oh, you're going to go burn my nose. No, that's not what we're doing. This is it's temperature controlled. It does not overheat this little paddle that delivers this energy in a way that will remodel and reshape that small area that's most important. And so we talk a little bit about the nasal valve and how, this is the area that's the smallest and the nose. And we talk a little, very small amount about physics, which is always a good time. But there's no incisions. And in the end, you can do this in the office and, we can give you some relaxing medication beforehand, or you can, we can numb everything up, and you can drive yourself home and go straight back. And recovery is minimal. And so we talk about this, this procedure and go through the details. So the short answer is that this is a remodeling we're trying to remodel the inside of your nose so you can breathe better.
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Patient Selection Considerations for the VivAer
While the VivAer procedure can benefit patients with a variety of nasal conditions, it does not work well for patients with external valve collapse, but does aid those with internal valve collapse. Upon physical exam, patients that respond well to the modified Cottle maneuver have been shown to also respond well to the VivAer. If a past septoplasty or turbinate reduction fail to fully relieve symptoms, radiofrequency ablation may offer extended relief. Patient preferences also play a large role in candidacy for the VivAer treatment; the best fit patients are those who are looking to breathe better but not seeking perfection, and would like to prioritize minimal recovery and avoiding surgery.
[Ashley Agan MD]
Awesome. Any other pitfalls or things to, to note as far as you know, doing the procedure or, complications or other things to know?
[Mary Ashmead MD]
I think the main thing is to know that it doesn't work great for external valve collapse. Right. And so talking to patients about it and really kind of going through exams and how much of this is internal versus external valve. And when you're doing that modified Cottle to really make sure you're only moving that internal valve, that would be the main thing.
[Gopi Shah MD]
I was going to say, in terms of, it sounds like for patient selection. So, the modified Cottles have a very important physical exam correlation, for patients where it's a bigger external valve problem. Are there any other pearls for patient selection? Perhaps there was a history of septorhinoplasty or any medical conditions that you look for? I know what patients can tolerate in the office or not, but just for the, uh, radio-frequency technique, itself.
[Mary Ashmead MD]
Right. So, the post-septo-turb patient who’s still unhappy, and there's actually a pretty high level of this. This has been looked at that there's more than we would think going back. You know, a decade and patients who had a septoplasty and turbinate reduction that still have symptomatic nasal obstruction. Those are prime people to be looking at their nasal valve. Those are our prime people. It's great. If we can find them ahead of time and you can treat them all together. Sometimes it's hard. Sometimes you don't find that valve collapse until you've straightened out that septum and now they have more airflow and now things are collapsing more. So it's a tricky thing to say treat everybody upfront then may not need that. But those patients who've had surgery before who have had a turbinate reduction and you look in their nose and you get in the nasal speculum and you look and it looks perfect and their septum looks great. And they're like, oh, if I still can't breathe. Great. Yes, those are, those are great patients to look at. But also the, the dynamic valve collapse patients. The, I have trouble when I'm exercising or I have trouble when I sniff in hard and the harder I'm breathing. The more I'm collapsing and they have really thin skin. And so you don't want to change the outside and they are not looking to make external changes. These patients are great. Great to consider a radiofrequency procedure because you're really just going to gain a little bit of space on the inside without changing anything else that they're happy with
Other patients are patients who have had a rhinoplasty, not just a septoplasty, but had a rhinoplasty. You know, we're trying to make the nose smaller. And, and that can really narrow that valve. You can get a lot of extra cartilage there. Sometimes it can really narrow that internal valve. It looks perfect. They're so happy with their external results, but internally they have trouble.
Another group are the snorers, the people who are, you know, “Oh, I'm just snoring. I wanna fix this. And I use this breathe right strip and it's great.” those aren't great people to look for. The tricky part that I've found is that it doesn't always work. You sometimes have to overlook the septum. If they respond to the Cottle, it's hard. So going back to before, when you see this thing, you want to fix it, but we know that our outcomes don't always correlate to what we see. And so, hey, I'm responding to this thing. Okay your septum is bad. Well, we may just be looking for better. I'm trying to fix my snoring so I can breathe fine. It doesn't need to be perfect. I don't want something big. I don't want to go to the operating room. I don't have time for a big recovery. I just want to breathe better. Great patients to look at radiofrequency ablation.
VivAer Post-Op Care and Recovery
As a quick and easy procedure with minimal complications, the VivAer appeals to many otolaryngologists and patients alike. Full recovery and finalization takes roughly six to eight weeks, and patients can expect some scabbing inside their nose where the device was applied. The full results cannot be appreciated until the scab heals. The tip of the nose may also feel tense or tight for a few days, similar to the sensation of a sunburn, but cosmetically, it often goes unnoticed by others. If the feeling bothers the patient, they may take a steroid, such as prednisone, once a day for five days, or as needed. Most patients can get by with over-the-counter painkillers but may be prescribed a short course of Tramadol.
[Gopi Shah MD]
Is there any sort of rebound intra-nasal swelling for any of these locations that you have to tell them about or, is there any, and I know we, so it didn't affect the way the appearance of the noise, but do you ever have any temporary, external swelling or anything?
[Mary Ashmead MD]
Yes. So we talk about all of those things. So like any radiofrequency procedure, really it's six to eight weeks before it's really completely finalized. Right? So just like when you use coblation technology or anything else in, within the nose or turbinates. It does take some time for that to completely finalize. The other thing that you do get, you get a crust and this is the most annoying part for the patient. And I tell them this, like, you know, the procedure is very easy and recovery is very easy, but you're going to get this little scab on the inside of your nose, where we do this, this little nasal valve procedure. And that can stick around for several weeks. I do have them, use ointments. I have them use ointments twice a day until that scab goes away. I will sometimes switch them over after a couple of weeks to just something like saline gel or something that is not petroleum based. But we talk about that scab and like, it's going to be better sooner, but it will be even better when the scab.
You do also tend to get some tenseness on the tip of the nose. So what I tell patients and with their family members there, you know, “tomorrow, you may look at the tip of your nose and think, oh, that looks a little swollen, or it feels tense or tight. Like when you've had a sunburn and your skin feels tight, it's not going to look different to someone who doesn't know you”. I've had patients go straight to the grocery store after the procedure. So you don't look different, but it does feel a little bit tense, or feel a little bit tight for a few days. I give my patients an optional little pulse dose of prednisone. I just do, I do 40 milligrams once a day for five days. And I tell them that this is optional. Steroids have side effects. And we go through those. But I want you to have this on hand, my procedure days on Fridays. And so I want you to have this so that if it feels tense or it feels uncomfortable, you can take this. If you're doing great, you don't have to in the long run. This is not going to make any difference with healing, but in the short term, it can make it a little bit more comfortable. And this is an option for you that I want you to have.
[Ashley Agan MD]
Anything else that you counsel to look out for? Does the nose look red and swollen or anything, or is that the worst? It gets just a little bit of tip tenseness.
[Mary Ashmead MD]
Yeah. A little bit of tip tenseness. And then that scab that's really it. I have had no other problems. It's a little sore, like it's bruised on the outside. So if you manipulate the nose and that can stick around for a few weeks it doesn't hurt at baseline. But if you hit it like, oh yeah, it's a little bit sore. Not really a risk for infection or anything else because of the nature of the process of the handpiece itself.
[Ashley Agan MD]
And so patients probably can just get by with Tylenol Motrin. So I'm like probably aren't requiring narcotics?
[Mary Ashmead MD]
I usually give them a couple of Tramadol. For my patients that I premedicate, for my nervous people. We talk, we go through all of this kind of extensively. We could talk about anesthesia protocols for a couple hours. So I'll give them a couple of Tramadol to take ahead of time. And then there's a couple extra there in case they need it. I've never had anybody ask me for more than that though.
Podcast Contributors
Dr. Mary Ashmead
Dr. Mary Ashmead is a practicing rhinologist with ENT Southlake in Texas.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
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, August 23). Ep. 68 – In-Office Procedures for Nasal Valve Obstruction [Audio podcast]. Retrieved from https://www.backtable.com
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 Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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