BackTable / ENT / Podcast / Transcript #158

Podcast Transcript: Nasal Airway Management: Evolving Practices in Diagnosis and Treatment

with Dr. Nora Perkins

In this episode, Dr. Nora Perkins (Albany ENT & Allergy Services), discusses in-office procedural management of nasal airway obstruction with hosts Dr. Ashley Agan and Dr. Gopi Shah. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Benefits of In-Office Procedures

(2) Patient Presentation of Nasal Obstruction

(3) Assessing Success: Using Patient-Recorded Outcome Measurements

(4) Medical Management of Nasal Congestion

(5) Using Physical Exam Findings to Guide Management Decisions

(6) Treating Turbinate Hypertrophy with the VivAer Device

(7) Tackling Challenging Anatomy: When to Refer to a Facial Plastic Surgeon

(8) Anesthesia Protocol for In-Office Turbinate Reduction

(9) How Dr. Perkins Relieves Nasal Obstruction Using VivAer

(10) Building Your Procedural Skill Set

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[Dr. Gopi Shah]
This week on the BackTable Podcast.

[Dr. Nora Perkins]
The first thing that I would recommend is reaching out to your rep. They have a wealth of resources and information to help you. They have seen hundreds of cases. They are trained in this device and this procedure, in the pathology. The other thing I would say is if you're thinking about doing these type of procedures, adding the no score routinely is very, very helpful.

The last thing I would say is if you want to start doing office procedures, set aside a block in your schedule to do them. If you give yourself time and your staff time and the patients time, it's going to be a wonderful experience. Everyone's going to do really well. You're going to say, "Wow, I really like these. This patient's happy. I'm happy. It's fun. The staff liked it, and the patient did well afterward."

[Dr. Gopi Shah]
Hello, everyone, and welcome to the BackTable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice.

Now, a quick word from our sponsor. Aerin Medical provides ENTs with advanced treatment options that provide lasting relief for patients with chronic nasal conditions. Fitting seamlessly into the office or OR setting, Aerin Medical's portfolio of non-invasive temperature-controlled radio frequency products include VivAer for addressing nasal airway obstruction and RhinAer for chronic rhinitis. Learn more at aerinmedical.com. Now back to the show.

Hello, everybody, and welcome to the BackTable ENT Podcast. My name is Gopi Shah. I'm one of your hosts today. I'm a pediatric ENT and I have my co-host, Dr. Ashley Agan here with me today. How are you, Ash?

[Dr. Ashley Agan]
Hey, Gopi. Good morning. Always happy to be across the mic from you. How's it going?

[Dr. Gopi Shah]
I'm doing well. I'm doing well. Excited for our episode and our guest today.

[Dr. Ashley Agan]
Yes. Let's talk about nasal airway obstruction. We have the fantastic Dr. Nora Perkins. She's an otolaryngologist practicing with Albany ENT and Allergy Services. Dr. Perkins has a clinical focus in minimally invasive office-based sinus and nasal procedures, as well as expertise in voice and laryngology evaluation and treatments. She's here today to talk to us about office technology for nasal airway obstruction. Welcome to the show, Nora.

[Dr. Nora Perkins]
Thank you so much for having me. I'm excited to speak with you ladies today about nasal airway obstruction and all things general ENT and in-office procedures.

[Dr. Gopi Shah]
Nora, can you first tell us a little bit about yourself and your practice?

[Dr. Nora Perkins]
Yes, sure. I'm a general ENT. I'm in a single specialty private practice ENT group in Albany, New York. We have nine docs. We have a slightly interesting situation where we have 18 physician assistants who we work with and nine audiologists, a really large allergy department. We have a CT scanner in the office. It's really a full-service, mid-size ENT practice.

[Dr. Gopi Shah]
That's cool. How long have you been there?

[Dr. Nora Perkins]
I have been there for 13 years.

[Dr. Gopi Shah]
Oh, wow.

(1) Benefits of In-Office Procedures

[Dr. Nora Perkins]
I know, it's kind of funny because trying to look back about when things started and when you started to do things, it's really hard to look back at your own career and say, "Hey, I did this X number of years ago." Yes, 13 years here, really great group. They've done an amazing job of allowing physicians who are interested in in-office procedures to really grow that part of the practice. I wouldn't say we're necessarily high volume by any means, but it is a large part of our practice and I think it's a really nice offering for patients.

[Dr. Ashley Agan]
Yes, me too. I think being able to offer an office procedure versus having to go to the OR and do the whole thing and be NPO and get checked, arrive two hours early, and all that, as opposed to the office procedure is, I think patients do really appreciate that.

[Dr. Nora Perkins]
Yes. Ashley, I think you're really hitting on something too. Not only is it inconvenient for patients, I think it's really intimidating, especially if you're in a hospital setting. You may be in pre-op with really sick patients next to you, see some things that the average person is not used to seeing. It can be incredibly unnerving, right? An office procedure, you've been to this office many times, presumably you're used to this type of thing. You've had breakfast, you've maybe had a little relaxation medicine. It's a much nicer, more relaxing experience.

There isn't that barrier that sometimes exists with patients who are just anxious about the idea of having surgery or going to the operating room or having general anesthesia. I think that's another thing that we don't necessarily always appreciate can be a really big barrier for patients.

[Dr. Gopi Shah]
Nora, how did you get into office-based procedures? Is this something that you started doing when you first got out of your training or how did you roll it into your skill set?

[Dr. Nora Perkins]
When I finished my training, I was fortunate in that balloons were a part of my training. I was familiar with that as a tool for sinus procedures, but we were doing them exclusively in the operating room. When I started in practice, it was probably around, I think it was in 2010, 2011, around the time in-office procedures were sort of new, but becoming a bit more popular. My balloon rep at the time really was pushing, "You'll be great at this. In-office procedures are the way of the future. This is something you should really incorporate."

I liked the idea of it for all the reasons we just mentioned. I was very comfortable with the technology. I started to do some in the office and I will tell you, it was not great. It was not great for me. It was not great for my patients. It was a really stressful, uncomfortable situation. The reason being, especially now looking back, I didn't have a good anesthesia protocol. I was looking for the unicorn patient who only needed a maxillary balloon dilation and didn't have any other pathology, didn't need a turbinate.

I had a limited number of people and I didn't really have a good protocol to make sure that they were comfortable. That's unpleasant for everyone. It didn't make me want to continue doing more of those cases. Really, the big change was getting a good anesthesia protocol. I did that by visiting other physicians who were doing in-office procedures. The medical device reps are incredibly knowledgeable. They have a lot of experience.

As physicians, we're a little hesitant to take their guidance, especially when it comes to medication regimens. Not to be offensive, but you're not a physician. If you're telling me-- especially if you're telling me to start to mix a little benzodiazepine with maybe some type of narcotic, I start to get really nervous about that. I was happy to go visit another office, see another physician doing in-office procedures, and learn their anesthetic regimen. Then once I had a really good anesthetic regimen, that was a game-changer because then my patients were comfortable.

I had a really uniform patient, just meaning I knew what they were going to be. Then I could just do the procedures that I needed to do. That was the biggest difference as far as transitioning from the OR, where we don't really worry about anesthesia at all, to the office and making sure it's successful, comfortable for you, comfortable for your patients, and that you can actually complete the procedures that you are trying to.

[Dr. Ashley Agan]
Yes, I agree. Once you have that one game-changing experience where you're like, "Whoa, are you awake?" The patients where you have that amazing, straightforward case, then it gives you that confidence of like, "Okay, I got this. This is going to be great."

[Dr. Nora Perkins]
I think having that confidence, that's critical because you're going to direct your patient either to go to the operating room or to go to the office for the procedure or to not have a procedure by how you present those options. If you're not confident that you can make them comfortable in the office or that you can successfully complete the procedure, most patients are going to pick up on that. They're going to sort of either say, "You know what? Let's hold off on the procedure," or, "Let's just go to the OR and I'll be asleep." You may not know that you're influencing your patients, but if you're not confident, you definitely will.

(2) Patient Presentation of Nasal Obstruction

[Dr. Gopi Shah]
Getting into our clinical topic today, tell us a little bit how patients with nasal obstruction present to you.

[Dr. Nora Perkins]
I'm going to group them as two large groups of patients. There's the patients who self-select. They come in because they cannot breathe through their nose. Sometimes they've actually done the research and they say, "Hey, I read about this and I want this procedure." For nasal airway obstruction, I would say they might have hit on the right thing. You can kind of have some self-selection, especially if they've tried Breathe Right strips, they've tried sinus cones, they've been on nasal sprays in the past.

They've sort of done all of the initial steps. That group of patients is nice because they've done some of the work. They have an idea of what they want. They know what their goals are. You're at least halfway down the road.

The other patients who come in might have other complaints. They may have ear pressure or congestion. They might have swallowing symptoms or throat symptoms or sleep symptoms. They have these non-nasal symptoms, but during the evaluation, it becomes apparent that the nose is part of this problem. That's usually a little bit of a longer path because obviously, we have to rule out the throat or address if they have reflux or address if they have post-nasal drainage or whatever their issues are.

I do think if you stay with those patients, if you listen to them, and if you're willing to consider the nose as part of what could be causing some of those symptoms, you can definitely identify those patients. They're very receptive to the idea of the nose, especially once you've gone through that whole process of evaluating the larynx and the ears and whatnot. They're excited that somebody is giving them a potential treatment option because I'm sure you have all seen patients who've seen other ear, nose, and throat doctors, primary doctors, and said, "There's nothing wrong with you."

I find that just a really frustrating response. I think it's actually a little lazy on our part. There's one thing to be reassuring when you have an anxious patient who says, "I'm just nervous that I have a tumor or something." Reassuring them that they don't have that is great. For the patient who says, "My ear just feels funny. It is plugged. It is congested," and you can identify they have a septal deviation. They have huge turbinates. They have some things that might actually contribute to some of that symptomatology.

I think patients appreciate you evaluating it, considering it, not diminishing their symptoms or telling them that they don't have these symptoms. Then if you can actually do something to help the symptom, that's-- even if you can't, but if you listen and don't make them feel like they're being crazy, I know that's a silly thing to say, but it happens so often and being dismissive is just not something that I want.

[Dr. Gopi Shah]
Yes. That's very true. For patients that have the non-typical presentation, are you finding that those patients have nasal obstruction and some other symptom and that they respond well to treating the nasal obstruction and maybe this other symptom will get better? Is that how you think about that?

[Dr. Nora Perkins]
I usually think about-- let's say there's somebody who has some sort of throat symptom, I don't know, globus or something like that. You've scoped them, you've maybe treated them for reflux or diet, or done an esophagram, or done a CT of the neck, you've done your thorough examination and you've treated, and maybe they're noticing 30% improvement. They're pleased, they believe you, you've done things to be thorough, but now you're trying to figure out why they still have some of these persistent symptoms.

I think occasionally, I've gone through that whole process and then I'm like, "Oh, wait, maybe it's also because of your nose because you do have these anatomic findings that I see."

I hope that I'm better now at sort of evaluating that earlier on. I may not necessarily change-- I might still do all that other stuff first, but then think if none of these things work, then we may need to consider addressing this.

The other thing I will say is occasionally I have somebody who has nasal airway obstructive symptoms, and then they also have other symptoms. If we address the nasal airway, they say, "Hey, my throat feels so much better. I've noticed I can swallow more easily. I'm not having burping after swallowing," because if they're congested, swallowing is really hard and it gives you very weird laryngeal symptoms. Addressing the nose, you might just actually unexpectedly improve some other symptoms as well.

[Dr. Ashley Agan]
It's interesting how interrelated some of these symptoms are. Because the anatomy we think is separate in these different boxes, it's hard to say, "Oh, okay, how it all fits together. If I help one, helping them breathe out their nose better, then it might help that globus for those reasons, or it might help that reflux for those reasons." Do you use symptom surveys or anything, those tools to help you tease some of this apart? Because you bring up some of the different symptoms patients can have, but I also think it's hard to tease out even just chronic sinus patients from straight-up nasal airway obstruction patients.

(3) Assessing Success: Using Patient-Recorded Outcome Measurements

[Dr. Nora Perkins]
Definitely. We do use NOSE scores and TNSS on patients who are coming in with nasal complaints. That's something that we've gotten much better about in the past few years. I still haven't gotten to the point where I'm giving every patient those surveys. If you're coming in with ear pressure, you may not necessarily be getting those surveys, but certainly, if we do your ear exam and your pressures are normal and everything is pretty unremarkable, the next visit we may bring those surveys into place.

For chronic sinus patients, I do think it can be difficult because obviously, those patients can have nasal airway obstruction. We have a huge allergy practice, and I really feel strongly about treating allergy. I think treating allergy makes us look like better ear, nose, and throat doctors because a lot of things get better if we treat allergy. Again, ear symptoms, throat symptoms, nasal symptoms, and our best surgery will not necessarily be successful if we're not addressing their allergy.

For chronic sinus patients, I'm doing, if appropriate, allergy testing, allergy treatment, medications with irrigations, and whatnot. Nasal endoscopy, I would say, is pretty routine for anybody with any nose, ear-- I'll use a flexible or rigid scope. Looking at the larynx is just really an extension of that.

I have a pretty low threshold for imaging as well. I wouldn't say if somebody came in like that first group of patients we were referring to where they've done nasal sprays, they don't have sinus infections, their symptom is, "I can't breathe when I'm running or when I'm doing my workout class. I've been using Breathe Right strips and they work really well," and you scope them and don't find anything abnormal, that patient doesn't necessarily, in my opinion, need allergy testing. They probably don't need sinus imaging.

I think that would be reasonable. For the person who's a little less specific, they have sinus, "I always have sinus infections." "Oh, really? Do you get antibiotics?" "No." "Okay. Do you have sinus infections or do you have chronic sinusitis? Who knows?" Those patients I think deserve a more thorough exam and evaluation.

(4) Medical Management of Nasal Congestion

[Dr. Ashley Agan]
Yes. This can be tricky for sure. For your patients who you do want to go down that medical management pathway, do you have a particular regimen that you prescribe in the beginning as far as what you like to start with?

[Dr. Nora Perkins]
I love sinus irrigations. I feel like I should have some sort of stock in them. I don't, but I'm a pretty big proponent of sinus irrigations. I like adding budesonide to them, especially for patients who may have tried nasal sprays over the counter and maybe didn't necessarily have success. I think the administration of the medication is just much more thorough and sometimes patients do a lot better with an irrigated steroid.

Nasal antihistamines certainly would be reasonable if they have other allergy symptoms, allergy testing, but that tends to be where I'll go for medical management. One thing that I think I have personally changed in my practice, I like to start conservative and take a stepwise approach, but I definitely like the patient to also weigh in on that.

If I have somebody with allergy and they're doing medications, they're using their saline rinses, their steroids, whatnot, if they're thinking of starting allergy immunotherapy as part of their treatment, but they also have some nasal airway obstructive symptoms, I will tend to offer them intervention earlier because immunotherapy is incredibly successful, but it's like getting braces. It's going to be a few years. We're going to have this relationship for a while and I'm optimistic that you're going to find significant benefit, but it's going to take a little bit of time.

If we can also give you some immediate symptom relief, I think that's something that in my practice, I'm trying to offer a little earlier rather than, "I'll see you in a year. Let's see how these weekly shots have gone," because that's a really big time investment for patients. It's asking them to do a lot and maybe not see dramatic symptom changes for a number of months.

[Dr. Gopi Shah]
Do you try Breathe Right strips or cones? What are your thoughts on that for the patients that haven't tried them?

[Dr. Nora Perkins]
I think they're a really great option to identify patients with lateral nasal wall, either dynamic collapse or fixed obstruction there. I think it's funny when patients are hesitant to use them. Because you can use them at night, use them at home. I'm not asking you to walk to the grocery store or to go to school events or anything like that, but just try them because if those give you some benefit, I think that's a very good predictor that you will do well with a nasal valve procedure.

[Dr. Gopi Shah]
For your budesonide irrigations, that's even in the non-polyp population, right?

[Dr. Nora Perkins]
Yes. In allergic rhinitis patients or congestion patients, yes, but not necessarily a polyp patient. Again, typically if somebody hasn't had success with a nasal steroid spray, those are the ones where I'm going to jump to the budesonide irrigation. Also, realistically, if we're adding four steps, if I'm like, "I want you to rinse and then I want you to use your nasal steroid spray, and then I want you to use your nasal antihistamines, then do all the other stuff you have to do in your life," it just becomes real difficult. Combining some of them for efficiency is also helpful.

[Dr. Ashley Agan]
Yes. How do you have them mix their budesonide rinses?

[Dr. Nora Perkins]
I like the rinse bottle. That's my preference. I find a neti pot. I've tried to use a neti pot and I found it so difficult, which I think is silly. Unless somebody's already using it successfully, I'll usually have them use the rinse bottle and just the distilled water, usually warm, with a salt packet and budesonide.

[Dr. Ashley Agan]
The whole bottle or do you have them use half the bottle and then put the budesonide in the last half?

[Dr. Nora Perkins]
I have them use the whole bottle.

[Dr. Ashley Agan]
Okay. The whole bottle. I do the same thing because I'm like, "Less steps. I just need you to be consistent and use it." I'm not going to remember to rinse half and then pour it in and do the other half. Just let's go because it's consistency, right? They do it once correctly. It's not going to make a difference. I also think about my own routine where I'm like, "Oh, my gosh, I have to add one more step to this. It can be a real barrier."

[Dr. Gopi Shah]
It's like, "Well, dang, did I use it? Is there half left? Oh, gosh, I used it all. There's only a third left. Am I going to be able to hit both sides?" It's silly after a while. Totally.

[Dr. Nora Perkins]
To your guys' point, simple, right? Let's keep it simple. The idea of even overcoming the fear of using saline irrigation, that's the first step. Then having them actually apply some medication. Patients can get there, but it's scary for patients. Also, they'll maybe read about some sort of complication of sinus irrigation. Then they didn't use it and they come back to see you and they haven't really done anything that you've asked them to. It's a challenge.

(5) Using Physical Exam Findings to Guide Management Decisions

[Dr. Gopi Shah]
Moving on to what's in your nasal obstruction toolbox? What kind of options or interventions are you thinking about when these patients are at that point where it's like, "Okay, let's do something more definitive."?

[Dr. Nora Perkins]
Yes. I think it depends a little bit. From an exam standpoint, I'm going to just look at their nose. I usually ask people to sort of tilt their head back a little bit and just look at essentially the nostril, the external nasal valve. If it's an incredibly narrow external valve and they take a sniff and the whole nostril collapses, I'm not sure that I'm the best person to address that. They probably need to see a facial plastic surgeon and have a little bit of a more extensive rhinoplasty procedure, which I don't do rhinoplasty, but if their external nasal valve is pretty reasonable, I'll start to examine the internal nasal valve.

Is there just a compromise there? Is it just incredibly narrow or is there a dynamic collapse with normal breathing or deep inspiration? Once we've sort of addressed, is it the turbinates? Do they have a huge septal deviation? My personal treatment options for an in-office procedure, I think the radiofrequency treatments of the nasal valve are very simple and very effective for patients with either fixed or dynamic internal nasal valve collapse.

They're simple in that you're directly treating the areas collapsing. It isn't something where you have to try to imagine, how is this going to support that area? Is it placed in the actual area that I want it to be placed to offer that support? You directly see it. Under your endoscopic visualization or using a headlight and nasal speculum, you can see where you're treating and you do get some immediate visual response to what you've done. You can see that you've treated that area and you can adjust your treatment as needed to allow for some improvement.

That's one option. I use radiofrequency to treat the inferior turbinates for turbinate hypertrophy. I am a believer/treater of the septal swell bodies. I think that was something that we had all seen where you see the superior deviation on both sides and wonder how is that possible that they have this deviation on both sides or you get the CAT scan that shows it and you're like, "How am I going to address this?" Because it causes a lot of obstruction and it's in an area that otherwise would be hard to meet and a septoplasty probably isn't really going to do anything for it.

I will treat that area with radiofrequency. I also will use a microdebrider for submucous reduction of the inferior turbinates. I will out-fracture inferior turbinates in the office. as far as the in-office offerings for obstruction, that's where I stay. I will do excision of septal spurs. Less commonly will I actually do septoplasty, and that tends to be not so much about patient comfort because with an anesthetic protocol, patients can be incredibly comfortable for septal work. You can do a full hemi-transfixion incision. You can raise flaps. You can use osteotomes because they're sharp and they don't because really a lot of torque on the patient, but the time is the challenge.

If something's going to be longer than 45 minutes of procedure time for me, I'm probably not going to do that in the office just because I think that's hard to ask somebody to just lay here awake, slightly relaxed for that long.

[Dr. Ashley Agan]
Back to your exam before we move on, you mentioned looking externally at any collapse for when they're breathing. Are you using any Cottle maneuver, modified Cottle maneuver? Are you decongesting to look at anything else in your exam?

[Dr. Nora Perkins]
Yes. Initially, I don't decongest. New York, shockingly, has lots of particular rules about who can apply medications, so our medical assistants can’t actually apply medication anyway. That sort of helps me not rush this, so I'll look initially without decongestion in place. When I'm looking at the nasal valve, I don't tend to do a Cottle maneuver because I feel like everyone feels great with a Cottle maneuver. It is such a dramatic opening of the nose. I don't necessarily think I have a lot of nasal obstruction, but if I do that, it feels pretty good.

Same thing with the speculum. You can just create this huge opening that feels great. I tend to use a modified caudal. I will use a little wax curette or just something to just gently support the internal nasal valve. Or if I see an area that's a fixed obstruction there, I will displace it a little bit super laterally just to try to give a subtle change because again, I think if you make a really big opening, everybody feels great. If you try to mimic what you realistically think you can do with the device, as in preventing the dynamic collapse or just creating a little bit more space, then that gives patients a good idea of whether or not they have improvement.

We'll do it with regular breathing and then more deep nasal inspiration. Then I try to compress the septal swell with that same curette before decongesting because the septal swell can decongest a little bit. Sometimes I forget to do it. Honestly, I just do the modified Cottle, look in the nose, and then I spray them for the scope. I think doing a modified Cottle before and after decongestion will help you know if addressing the turbinate would be useful because obviously the turbinate typically responds really well to the decongestion.

Also, it just gives patients an idea of, this is what we could achieve because we're not doing anything to your septal deviation. I would say the majority of patients have some degree of septal deviation. In my practice, one big change that I made when I started doing more cases in the office is I started to be really conservative with septoplasty, meaning I realized a lot of people do well with a submucous reduction of the inferior turbinates or treating the nasal valve, and I didn't necessarily have to do a septoplasty.

Because we're doing it in the office, worst case scenario, if we have to go back and do a septoplasty, we can. I think when you're taking somebody to the OR, at least for me personally, I felt like I wanted to do everything that I might possibly need to do for this person while they're under anesthesia. In the office, I don't feel that same pressure. I'm much more comfortable, especially if the patient is comfortable with the idea of taking a very stepwise approach, trying the most conservative things first, and then seeing how they respond and if it's enough to alleviate their symptom.

(6) Treating Turbinate Hypertrophy with the VivAer Device

[Dr. Ashley Agan]
That's a great point. I wanted to talk to you a little bit about device-specific. For radiofrequency ablation, there's the VivAer device, which we wanted to get into a little bit more today. Can you tell us a little bit about that technology and how that device works?

[Dr. Nora Perkins]
Yes. As I mentioned, I've been doing in-office procedures for a long time, but I'm a relatively newer adopter of the radiofrequency treatments of the nasal valve. Part of it was I was just a little bit skeptical. The idea of heat energy that potentially could create a burn or create some type of skin change externally, honestly, I was nervous about it. Once I learned a little bit more, the temperature control nature of the device made it much more comfortable for me to consider.

The fact that it's really going-- the hottest it's getting is 140 degrees, which it's hot, but it's not something where I'm worried that it's going to overheat the tissues. The fact that it's a disposable device that can be done in the office is nice from my staff standpoint. When we do the turbinate reductions with the microdebrider, we have the reusable blades, which are great. They're wonderful, but it does require a lot of staff turnover, whereas this being disposable, it's much easier for staff.

Then looking at the data, the fact that the patients are continuing to get four-year benefit is pretty remarkable. I do think for patients, again, having the discussion that we have data that suggest significant improvement, 95% of patients are going to notice improvement, they're going to have a significant reduction in their NOSE score, so their obstruction is going to be dramatically reduced. Also, it's going to last for four years.

If we had to do this procedure again in the office, because patients will always ask us or frequently ask this, it's no big deal. We could do something like this again in the office if we had to, particularly the turbinate tissues, maybe the septal swell. Again, for allergic patients, if they're not treating their allergy, I do worry that the turbinate hypertrophy could return. I have less concerns that the nasal valve would all of a sudden lose some of its newfound structural support, but the turbinate hypertrophy, for sure, is something that I think could return, particularly in an allergy patient who's not necessarily treating their allergy.

[Dr. Ashley Agan]
With the VivAer, the same stylet or wand, it's all three of those sites, meaning the internal nasal valve, the inferior turbinate, and the swell body, the septal swell bodies can be treated at the same time.

[Dr. Nora Perkins]
Yes, you can use the same device for the nasal valve, for the inferior turbinate, and the septal swell. The soft tissue sites, the septal swell, and the turbinate, it's a very short treatment with no cooling. You really have-- I don't want to say as many treatment sites as you want to with the device, but you have a number of treatment sites. I feel like I can adequately treat the turbinate.

Depending on patient's anatomy, if they have a really significant septal deviation, I may have trouble getting very far posterior on the inferior turbinate. For most patients, I can pretty much treat the entire turbinate with a device, which I love because I feel like they're getting a really thorough turbinate treatment. Then I can still address the nasal valve as well.

[Dr. Ashley Agan]
How do you counsel patients about expectations afterwards?

[Dr. Nora Perkins]
I think that's an incredibly important part of the conversation. What are your goals? What are your expectations? What's your recovery going to be like? If patients find benefit from the modified caudal, the decongestant, and they say, "This feels good. My symptoms feel better like that," I say, "Great. I think there's a very good chance that with this really simple in-office procedure, we'll be able to achieve these results."

Recovery from a procedure like this is very minimal. Essentially, I allow patients to start to resume normal activities the day after if they've had a little oral sedation or the day of if they haven't had anything. They can drive themselves if they haven't taken any pre-medications. As far as what to expect, I always counsel patients that they're going to have crusting. They're going to have crusting in the nasal valves and sometimes the turbinates as well and sometimes on the septum.

I will typically ask them to use Mupirocin ointment two or three times a day to try to reduce the crusting. I'll ask them to use nasal saline sprays. If they normally use irrigations, they can resume use of irrigations. I don't generally expect them to have any external swelling, redness, anything like that. I don't routinely treat with any oral antibiotics or any oral steroids, but I do let them know that their nose may feel tender if they touch it. If they're wiggling, it may feel tight or tender, but that's very temporary.

The crusting will generally be gone. I see patients back three weeks after the procedure, and by then, there usually is very minimal crusting. I have seen a few patients probably where I was more aggressive with my treatment sites. I try not to overlap treatment sites just to reduce the risk of that sort of deeper tissue change and more significant crusting, but I have seen patients where I presume it's my technique and I may have slightly overlapped in order to address an area that was causing some persistent obstruction. After three weeks, they heal. Their crusting is gone just like everybody else's. It just may be a little bit longer if you do accidentally overlap a bit.

[Dr. Ashley Agan]
The only thing they need to do for the crusting is just put Mupirocin ointment on it. Don't pick at it. It'll go away.

[Dr. Nora Perkins]
Correct. Keep it moist. Keep it lubricated. In New York right now, it is incredibly dry. The air is so dry. I tell everybody, pretty much every patient who's having any surgery in the winter, to get a humidifier, put a humidifier by the bedside. For these patients in particular, anything that's a lubricant, lanolin, saline gels, anything that will just add a little moisture will be helpful.

(7) Tackling Challenging Anatomy: When to Refer to a Facial Plastic Surgeon

[Dr. Gopi Shah]
Any anatomical variations that might prohibit you from doing this in office? I think of the-- maybe not necessarily the septal spur, you mentioned that you can take those down. What on your exam or in your initial evaluation makes you think, "Wait a second, nah, this is something we should do in the OR."?

[Dr. Nora Perkins]
I think the biggest thing for me would be that external nasal valve. If they just have an incredibly narrow nostril, I don't think anything I'm going to do is going to help. I'm going to recommend that they see a facial plastics person. For me, there are not a lot of anatomic considerations that make people not an office candidate because if you have a good anesthetic protocol, even a severe septal deviation can be-- you can work around it.

Now, without addressing the septum, if somebody has completely obstructed left nasal cavity, I don't know that anything you're going to do over there is going to help them. If you treated the right side in the office, like during your pre-procedure examination and they said, "Wow, that feels amazing," you could just treat the right side or you could do a septoplasty on them as well in the office.

[Dr. Ashley Agan]
Do you have a VivAer in the OR for the patient who's just like, "No way, I don't want to be awake, put me out."?

[Dr. Nora Perkins]
I have never done a VivAer in the OR. I don't. I was thinking about that earlier. Again, I think it's probably my preference, but from a patient standpoint, even your most anxious patient, if you pre-treat them with some anxiety medications, you can make them very numb. I reassure patients, you're not going to be anxious because we're going to treat that, and you're not going to have pain because we're going to make sure that you're totally numb.

I don't want to say I don't offer that option. For a procedure like this, I just feel really strongly like doing it in the office is the right place to do it. Putting them through anesthesia for this is more than they need. Now, if you're doing it combined with a septoplasty or you're combining it with other procedures and you know it's going to be an hour and a half long, then that's fine. Take them to the operating room to do it. Again, I tend to do more of a stepwise approach and not necessarily do everything at once. I haven't done that.

[Dr. Gopi Shah]
Have you combined any of this with like a sinus surgery, combining your nasal airway obstruction procedures with some of your chronic rhinosinusitis procedures?

[Dr. Nora Perkins]
Yes. I think if a patient has both disease processes, then it's very reasonable and simple to combine them. You can end up with some insurance challenges because if you're doing a maxillary antrostomy or something that doesn't really require a disposable device, then I think that's less of a problem. If you're using something like a balloon, so you have that disposable device cost, and then you have another disposable device, I think that can be a limitation, but they can definitely be done together. There's no contraindication to the procedures being done together. I'm going to defer to my billing people.

[Dr. Ashley Agan]
Like the billers and coders who you ask ahead of time, "Hey, can I actually do these two things together?"

(8) Anesthesia Protocol for In-Office Turbinate Reduction

[Dr. Gopi Shah]
Can we move on to anesthetic protocol?

[Dr. Nora Perkins]
For sure. As I mentioned, I started out with a very poor anesthetic protocol. Again, that was just because I didn't know. I didn't know, and I wasn't super comfortable. At the time, I don't think even my rep really knew at the time what we should be doing. I tried five milligrams of Valium, and that was on my first in-office procedure. It was not for a VivAer, it was for a balloon case, and it went horribly. Since then, had a few different changes, but now for something like a VivAer, a turbinate, any sort of anterior nasal procedure, I will pretty routinely do this. It's actually not terribly different even for the sinus cases.

I have patients ahead of time use Afrin at home, typically starting about an hour or so before they're supposed to come into the office. They apply Afrin a few times. They're already very decongested when they come to the office. I generally will have patients use an oral anxiolytic regimen. I would say 70% of my patients use this. I think VivAer is one of the procedures where it is the least necessary.

If patients have any hesitation about taking it, they want to drive themselves, I'm fine with them not taking the pre-medications or oral anxiolytics. For more posterior treatments, if you're doing the treatment of the posterior nasal nerve, if you're doing a Eustachian tube balloon, if you're doing sphenoid balloons, in those situations, I push the pre-medications more because then I get a very consistent patient. I know how they're going to be. I know we're going to be able to successfully do this.

An hour before the procedure, I will typically have patients take 50 milligrams of tramadol, 0.125 milligrams of triazolam, and then 25 milligrams of Phenergan or promethazine. They take that little combo ahead of time. They do have to have a driver. Their consents and everything are done ahead of that time. They're done really when they sign up for the procedure. In the office, if somebody is still just incredibly anxious, which again is not real common for the VivAer procedures, but if somebody has-- they're just tapping their toes, feeling anxious, then I will give them more triazolam in the office. They bring their meds with them in case they need more.

Then I move to topical medications. I like to do just Afrin, regular Afrin with 4% lidocaine pledgets to start with. Then I put a little bit of cetacaine underneath the lips in the canine fossa because I do an infraorbital injection for any anterior nasal, like lateral nasal wall procedure. I call it “walrus-ing.” I take those long Q-tips, the wooden Q-tips, put a little cetacaine on it. Yes, exactly. They look like a walrus for a few minutes.

Those stay in for typically about seven minutes or so. I take those out. I will then do the infraorbital injection and it's not really a true infraorbital block. I'm just going into the canine fossa and fanning out about half of a milliliter of lidocaine. With supply issues, it's either 1% or 2%. I do use with epinephrine, but I use 1:200,000 epinephrine. Patients don't typically notice any kind of tachycardia. If they do, I will mention that they might, you may notice a little bit of an increase in your heart rate. I just want you to know you're not getting anxious. It's just the medication. It goes right away.

I should mention that we also do routinely put a pulse ox on the patients. We're monitoring heart rate. We're monitoring oxygen. Nothing I'm really giving them besides the epinephrine is going to affect that. I think it's probably more for my comfort and well-being. Even just being able to see, "Hey, your heart rate went from 65 to 85. Fine. Oh, it's already coming back down," just giving the patient feedback so that they know what to expect and also know that you're aware of it and you're monitoring it, I think just reassures people quite a bit.

After the infra-orbital injection, I will usually place another pledget inside the nose with 4% lidocaine and then typically epi, 1:1,000. Again, they're so decongested by that time that really there's no change in their heart rate with that topical administration. I'll let those sit for a few more minutes and then I'll come back and do injections with 1% or 2% lidocaine, 1:200,000 along the area of treatment in the nasal valve, the turbinate, the septum, so whatever areas I'm going to treat.

I think the alar injections or that valve injection can be incredibly painful. We were actually involved in one of the initial studies for the lateral nasal wall implant. We were doing some of those injections without doing the infra-orbital block. It was very, very painful. When we reduced, we started doing the infra-orbital blocks, that pain and discomfort reduced dramatically. I make it a pretty routine part of my anesthetic protocol. The injection there is minimally uncomfortable or has minimal discomfort, but the injection of the ala can be very uncomfortable. The infra-orbital injection makes it a zero, a one, so really minimally uncomfortable.

[Dr. Gopi Shah]
For your injections, do you have a specific size syringe or needle so that as it goes in, it's not like a big weld-up area, it diffuses at the rate at which you want it to diffuse?

[Dr. Nora Perkins]
Yes, I typically will use a 3cc syringe and a 27 gauge needle. I'm trying-- at the nasal valve area in particular, trying not to over-inject. I'll typically inject maybe 0.5 milliliters there, maybe even a little bit less. I use an endoscope during this case. I have patients completely supine. I do try to make it a comfortable spa-like experience. We turn the room lights down, we have this classical pop music station on that's like instrumental versions of pop songs. It's very nice. I would recommend it highly.

Patients like it, they can identify the songs. I do cover the eyes because the endoscope obviously can be really bright. We have them completely supine. Typically, we'll put a pillow under the knee. We're just trying to do anything to make the patient relaxed and comfortable for the procedure. With the actual injection of the local anesthetic, the one thing I will say is you can definitely end up with a little bit of drip.

I want to try to avoid having that lidocaine drip down into the throat. I don't spray before these procedures because I don't really want their throat to be numb. Sometimes I'll put a pledget a little farther, posteriorly in the nasal cavity against the turbinate, and then do those more anterior injections, so it just catches any drip.

(9) How Dr. Perkins Relieves Nasal Obstruction Using VivAer

[Dr. Gopi Shah]
It's a good idea. Then moving on to your specifics of the procedure itself.

[Dr. Nora Perkins]
Yes, for the procedure itself, typically I'll start with the turbinate. I start anteriorly on the turbinate. I will progressively work myself, maybe the superior aspect of the anterior inferior turbinate, and then go right below that, and then stepwise work more posteriorly. Like I said, I will often treat the entire turbinate. I will often take a freer and out-fracture the turbinate as well because that is giving everyone a little bit more space, and with the local anesthetic, patients tolerate that really, really well.

Then I will treat the septal swell, and that definitely with the amount of decongestion can be a little challenge. You want to have your treatment area in mind at the beginning before you really get started. After it's been anesthetized, that area is very easy to treat and you do see some pretty immediate treatment response in that area.

You see it on the turbinates as well, but I think the septal swell is even more pronounced where you can see that tissue really retract. Then I go to the nasal valve last and typically I'm treating three sites. I usually start in the middle of the nasal valves and I'll treat that area and then I'll move more superiorly toward the apex and then I'll move more inferiorly. If somebody still has some collapse or if they just have a larger space, I may do a fourth treatment site. Trying not to overlap.

[Dr. Gopi Shah]
For the nasal valve, the device has a full cycle where it's heating and then you hold it while you're cooling. For the soft tissue, how long are your cycles for that because you don't need that cooling cycle, right?

[Dr. Nora Perkins]
Exactly. Yes. Typically, I'm holding it in place for about 18 seconds there. We're leaving it and then removing it. I know that people have mentioned this before, but it does make a funny little beep when you take it off before the cycle has ended. Just reassuring patients that that's just the noise the machine makes. That's generally what I would recommend.

Because these patients are awake, I think it's really important. If there's anything that may feel weird, sound weird, I pretty much talk to the patient through the case. Now they may be snoozy and maybe I'm just talking and they're not really listening, but I think it's helpful for people to just hear you say, "You're going to feel pressure here. You're going to hear a little crackly noise," especially when you out-fracture the turbinate, that can be really loud. Letting them know, "Hey that's a great sound." Very positive reinforcement. "That means we're creating more space in your nose, we're going to give you more room to breathe."

I think just constantly letting patients know what to expect and that everything is going as expected as you want it to go can really be helpful in an awake patient, especially if they are a little bit nervous even with the anxiolytic because sometimes patients are still fighting the anxiolytic if you will, or still just a little nervous. Generally, talking them through can really overcome that.

Patients afterward are pleasantly surprised with how simple the procedure was, how comfortable it was. They often are like, "Wow, that was it? I shouldn't have been worried about that. That was not anything like what I was expecting." Even though we've had a pretty extensive discussion about what to expect, I think they know patients who have had FESS, they know patients who have had septoplasty. They may know patients who had their entire nose packed. Even though that has nothing to do with what we're doing for that patient, a nasal surgery is a nasal surgery. They may be worried about some of those things.

[Dr. Gopi Shah]
For this technique, any complications I would need to worry about during the procedure or anything immediate post-op that you found?

[Dr. Nora Perkins]
I warn every patient that with any nasal procedure, nosebleed is always a potential complication. Fortunately, I have not seen nosebleed afterward. I think the only time patients really notice it is if they have crusting and if they pick at their crusting, which is true of any nosebleed. From a complication standpoint, there are not any serious adverse events that have been reported. I have not seen that. I can't even really describe this as a complication, but again, maybe some delayed crusting on areas that I potentially overlapped or treated aggressively in the nasal valve, but the ointment continues to allow those areas to heal. I really haven't seen any other complications.

[Dr. Gopi Shah]
Patients when they're following up, you see them three weeks later, do we expect that they are feeling better at that point? How quickly do they see their results?

[Dr. Nora Perkins]
I counsel everyone that they're typically not going to see full results for about six to eight weeks afterward, but typically at three weeks they notice improvement. They're generally feeling like they can breathe better through the nose. The one exception would be if they do have a lot of crusting, those patients still feel a little congested, a little obstructed.

I try to not remove the crust, although sometimes, as you guys know, any debridement, it's really hard when you see that and you know that they'll feel better if you took that crust off. You have to play it by ear. If it's really loose and barely hanging on by a thread. Fine, I'll take it off. Otherwise, I just reassure them this is going to continue to get better, these crusts are going to go away.

[Dr. Gopi Shah]
Do they feel worse? In the beginning, right after the procedure, I usually tell patients like, "Things are going to swell up. You might feel like you have a cold." Do you see that too?

[Dr. Nora Perkins]
Yes, I would agree with that. I think initially that day they feel pretty good, and then the first week, they start to get congested. Part of it's the crusting and part of it I think, to your point, is a little bit of swelling and an edema, but just reassurance. Selfishly that's part of the reason I see them back at three weeks. It's like seeing a post-tonsil patient, I don't really want to see you Week 1 because you're probably not going to be happy. You're going to have a lot of symptoms. I know you're okay, but it's not going to be a great visit.

At three weeks, you're going to say, "Hey, that first week I was a little congested, I felt a little sore, I felt a little crusty, but now I feel pretty good." That's generally why I would recommend doing that. I also don't think there's any medical reason to see them back sooner.

[Dr. Gopi Shah]
Nora, can you tell us a little bit about some of the longer-term outcomes data? Can we get into just some of those details? You'd mentioned earlier about four years in terms of how well patients do after this procedure. Is it specific to nasal symptoms? Does it have an impact in other areas of quality of life?

[Dr. Nora Perkins]
Yes, really, it does encompass other areas as well. To your point, the NOSE scores continue to stay reduced significantly. I think patients in general, when they're breathing better through their nose, they feel better rested. There's lots of data to support, treating nasal airway obstruction will not reduce patient's apnea-hypopnea index if they have sleep apnea. They will feel like they're breathing better, they'll feel like they have more energy, they feel like they have more oxygen.

I love when patients say that. "I feel like I'm getting more oxygen." I'm like, "Your oxygen was fine every time we've checked it. The fact that you feel like you're getting more oxygen certainly is a good thing." Yes, that four-year data really does show sustained results with obstructive symptoms.

I think again, occasionally we underestimate patient's quality of life with nasal symptoms. Yes, we are not treating cancers, we are not treating somebody's heart disease or something, but the impact of airway obstruction day to day is significant. Patients do appreciate that. You've all heard this, patients come in, "You've changed my life." It's always nice you pat yourself on the back, but I really think we shouldn't underestimate those patients. They really do feel like you've changed their lives. They're able to do things they couldn't do before. They're sleeping better, their exercise is better. Maybe they're able to sleep with their mouth closed. There's lots of things there that are improved.

[Dr. Gopi Shah]
Yes, absolutely. For the billing for this, for the insurance part of it, there is a specific CPT code for the VivAer or for radiofrequency treatment of the nasal valve, right? Word on the street is that commercial insurance isn't really covering it, but Medicare is. What's been your experience?

[Dr. Nora Perkins]
I've had similar experiences. For my local payers, Medicare, great, they will cover it. I believe now any Medicare plan would have to cover it, any locally managed Medicare plan. Commercial payers in our area have sort of fluctuated a little bit. There was coverage and there wasn't and there was. That's always a challenge for us, right? It's extra, but I continue to submit them to the commercial payers. I continue to do peer-to-peers.

You can push for the external reviews because when you have patients who really have exhausted other procedures, you got to offer these people something. In my opinion, you have a treatment option. Why their insurance won't pay this? Very frustrating. I also offer patients-- Let's say somebody hasn't gotten to that point. They don't want to have a septoplasty. They don't want to have anything more invasive in their commercial pay. The likelihood of it getting covered is very low. I will always offer them a cash option.

It is something that was initially really uncomfortable for me because I was not used to it. I'm not a facial plastic surgeon. I'm not typically talking about the price of my services and how they can finance it and whatnot, but I've gotten more comfortable with it. I don't think we should underestimate our patients because again, this is a significant quality of life disease. If you have a treatment option that is going to improve that quality of life, patients are often willing to pay out of pocket for it. You can't predict who will agree to it and who won't. Generally, I just offer it to any patient who doesn't have coverage as an option.

[Dr. Gopi Shah]
It's an option, which is always helpful for patients.

[Dr. Ashley Agan]
It's a really good point. I'm always-- I've had patients before that have told me about-- I remember a patient who was having their tonsil stones lasered out by a dentist. Every few weeks they would go get their tonsils lasered and it was costing, I don't know, $500 a pop or something crazy. I was just like, "Whoa." They finally got tired of it and we took the tonsils out. You're right, sometimes depending on how bad the problem is, people are willing to do what they got to go do to try to get better. I think that is an important consideration. I think that it's because of the devices, their disposables, the pricing, I feel like you're able to offer a pretty reasonable cash price with this.

Also, I think you make a good point, Nora, we shouldn't underestimate our patients. The point that you both make of they know their symptoms, they know how it affects them, they know their finances, and how they also want to financially pay for different treatments. We all know that health insurance companies don't always cover all the needs that a patient might require. Having those options, I think, are very helpful, can be.

(10) Building Your Procedural Skill Set

[Dr. Gopi Shah]
Starting to round it out, I wanted to ask you, Nora, how do you get started? Any tips or are there courses out there or what tips do you have for a person that's maybe been in practice and wants to start getting into in-office procedures or the new graduate? Because I can tell you, Ash and I have spent a lot of time at an academic center and I don't think that in-office procedures was necessarily the bread and butter or even a chunk or a part of the clinical experience, surgical experience.

[Dr. Nora Perkins]
Yes, I think the first thing that I would recommend, especially if you're a practicing physician already or a resident who's a recent graduate, is reaching out to your rep because they have a wealth of resources and information to help you. They can set you up with docs who do a lot of these. They can invite you to courses where you can learn the techniques and learn the anesthetic protocols and speak to other physicians so that, again, you don't necessarily have to listen to the rep about how you should do it, but you can talk to other physicians.

I would encourage everyone to work with their rep. They have seen hundreds of cases. They are trained in this device and this procedure, in the pathology, and although they are not surgeons, I am happy to take any advice from somebody who's seen tens, hundreds, however many other physicians do this procedure and may be able to offer things that I didn't even think about, but that somebody else has done and they've seen success with. I think reaching out to the rep and working with the industry people is very important.

The other thing I would say is if you're thinking about doing these type of procedures, adding the NOSE score routinely is very, very helpful because you're going to identify patients. There was that fairly recent study. We're looking at 3,500 patients. 37% of them had severe, extreme nasal airway symptoms, even if they weren't coming to the office for nasal airway. You're going to pick up patients in your practice. You do not have to necessarily market for this. These people are already in your practice and do the modified Cottle because if you're not making that part of your physical exam, then you're missing patients. If you stick a speculum in somebody's nose and ask them how they're breathing, they're going to feel amazing, but you've already gone past the nasal valve.

I think that's an important thing. The last thing I would say is if you want to start doing office procedures, set aside a block in your schedule to do them because if you're trying to squeeze it in at your lunchtime, if you're trying to squeeze it into a regular appointment slot, you're going to have a lot of difficulty. You're going to feel rushed. If you give yourself an afternoon and you put on two in-office procedures, if you give yourself time and your staff time and the patients time, it's going to be a wonderful experience.

Everyone's going to do really well and you're going to say, "Wow, I really like these. This patient's happy. I'm happy. It was fun. The staff liked it, and the patient did well afterward." I think that setting aside that time is really important. Worst case scenario, if you set aside Thursday afternoons and Monday comes around and you don't have office procedures, maybe you take the afternoon off. I know that sounds crazy, but it's not the worst thing in the world. Book a massage, go do something fun, or you could add on just regular office visits if you wanted to do that too.

I think actually setting aside the time is the best way to-- if you build it, they will come, right? Now you have time. This person who you diagnosed today, put them on for next Thursday. You have time set aside. That would be, I think, my biggest recommendation for bringing people from the OR into the office as far as their procedures are concerned.

[Dr. Ashley Agan]
Yes, that's such a good point because it's your time, you have so much more control over when things can happen, whereas when you book cases in the OR, sometimes it's like, "Well, it looks like the soonest we can get you on is next month or the month after." You don't always have a lot of control over how you're going to be able to schedule that, whereas when it's your schedule, it's like, "Okay, are you available? Is the patient available? Okay. See you next week." Being able to offer that added level of customer service and take care of people on their timeline is really awesome too.

[Dr. Nora Perkins]
Yes. That was a huge driver for me of bringing things into the office setting was that you don't really have as much control. Even if you're in an ambulatory surgery center where efficiencies are better, you still have your procedure day or your surgery day, and maybe it's full. You have to wait till the next one. When you're in the office, you have so much more control over things. You're much more efficient.

At this point now that I've been doing procedures for quite a while, I will squeeze in post-ops, or I will squeeze in people who just need to be seen, but I don't make it a crazy day because I'm still being incredibly efficient. I'm enjoying what I'm doing. The patients are happy. Everyone is enjoying it, right? The staff is enjoying it. It makes for a really lovely day in the office.

[Dr. Gopi Shah]
That's awesome, Nora. Thank you so much for coming on. For any of our listeners who might have questions for you, are you on any social media? If not, they can always reach out to us on BackTable. We can overlay the message.

[Dr. Nora Perkins]
Yes. Reach out to you guys. I'm happy to talk to anybody who has any interest of moving things into the office because I really do feel like it's an incredibly helpful option for us as surgeons. I think it's great for patients. I think it's great for the healthcare system overall. I also don't think that you have to be a special surgeon. I think anybody can do these cases. You just need to have the right tools, anesthesia protocols, and then anybody can be successful doing these.

[Dr. Gopi Shah]
Awesome. Thank you for taking the time.

[Dr. Ashley Agan]
Thank you.

[Dr. Nora Perkins]
Thank you guys so much for having me. I appreciate it.

Podcast Contributors

Dr. Nora Perkins

Dr. Nora Perkins is an otolaryngologyst with Albany ENT & Allergy Services in New York.

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). (2024, February 13). Ep. 158 – Nasal Airway Management: Evolving Practices in Diagnosis and Treatment [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.