BackTable / ENT / Podcast / Transcript #54

Podcast Transcript: Keeping up with Technology for In-Office Sinus Procedures

with Dr. Brian Weeks and Dr. Ashley Sikand

We talk with Dr. Ashley Sikand and Dr. Brian Weeks about performing In-Office Sinus procedures, including differences in technique, and keeping up with the latest technologies. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Specializing in Office-Based Procedures

(2) In-Office Procedures for Nasal Obstruction

(3) Scheduling Considerations for Office-Based Procedures

(4) Utilizing ClariFix Cryotherapy and the Latera Nasal Implant

(5) Anesthesia Protocol for Sinus Work

(6) Patient Selection for Office-Based Procedures

(7) Equipment Recommendations for In-Office Procedures

(8) Working With Industry as an Otolaryngologist

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[Gopi Shah MD]
Hello everyone. And welcome to the back table ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shah and I'm a pediatric ENT here in Dallas, Texas.

And today I have two very awesome guests on a great topic. I have Dr. Ashley Sikand. He's an otolaryngologist at Nevada Sinus Relief in Las Vegas. His focus is on the diagnosis and management of sinus disease and nasal disorders of the nose. He's an expert in endoscopic sinus and skull-based surgery, as well as the pioneer of office-based, less invasive techniques. We also have Dr. Brian Weeks, who's an otolaryngologist at the SENTA Medical Clinic in San Diego, California. He specializes in sinonasal disease, sleep and thyroid problems. And they are here today to talk to us about in-office procedures for nasal obstruction. Welcome to the show guys.

[Brian Weeks MD]
Awesome to be here at Gopi. Thanks so much for having us, really, really excited to be here.

[Ashley Sikand MD]
Thank you.

[Gopi Shah MD]
Can you tell us a little bit about yourself and your practice?

[Brian Weeks MD]
Yeah, I'll start off Ash. Brian Weeks, I think one of the neat things about my practice and my journey in otolaryngology is that I'm a second-generation otolaryngologist. So I was able to join my dad and practice and my dad's currently been practicing in some sort for 52 years. So he started SENTA Clinic 52 years ago. And it's been a really special time and it's made, all the innovations and all the things that we're doing differently, that much more impactful because I have it from my perspective and then also from my dad's perspective. So yeah, I really love it. So happy I'm an ear nose and throat specialist. I almost went into plastic surgery. I was thinking it would be cool to be a heart surgeon and I thank my lucky star every day that I chose ENT.

[Ashley Sikand MD]
Great. Thanks, Brian. I think one of the unique things about my practices is that I'm in a nine-physician specialty ENT practice here in Las Vegas. And, the practice has existed since 1968. My practice is focused on doing office-based rhinology I also do outpatient rhinology at the surgery center, but, I sort of evolved that way since about 2007, when we first started doing in-office cases, using a balloon sinus dilation, and have been really fortunate to adapt those exciting and interesting new technologies to help patients in a new venue and, collaborate with other physicians like Dr. Weeks and so on across the country. So that's been an interesting and, evolving journey over time.

(1) Specializing in Office-Based Procedures

[Gopi Shah MD]
How did you find yourself specializing in office-based procedures and is that kind of how you guys began working together?

[Ashley Sikand MD]
Yes on both fronts. With the advent of balloon sinus dilation technology, I'm, I think, an early adopter and, one of my mentors, Dr. Winston Vaughan was involved in the First in Man studies for balloon sinus dilation, and got me interested in using the technology for us in the hospital and then the surgery center. And when it switched over from using fluoro techniques to transillumination. I was able to think about bringing it to the office. And then I collaborated with another eminent rhinologist, named Michael Sillers in Alabama, formerly president of the American Radiologic Society and writing the first paper on, in-office, balloon sinus dilation techniques.

And then I got involved with, other, colleagues like Dr. Weeks in, presenting and developing something called a sinus forum and, also, collaborating and writing a number of research papers and expanding the use of techniques in the office to help patients without requirements for a hospital or general anesthesia. So I'll let Dr. Weeks, comment further on our collaboration and his journey as well.

[Brian Weeks MD]
Yeah. I mean, such an interesting reflection, but I think the first thing I learned is, when something comes across your bow, don't be closed minded be open-minded. I'll just tell a quick story. It’s actually quite funny. I'm in my office. I'm just starting in practice. This is in late 2006. I'm working hard and I'm there late at night and we'd had some break-ins at the hospital. Our old office was connected to the hospital and there were some break-ins. And so I'm sitting at my desk. I was always the last person out of the office. And I hear somebody walking in the hallway and I'm like, okay, nobody's supposed to be here. I know I'm the only person. So I had a baseball bat in my office. So I picked up the baseball bat and I have the baseball bat cocked back, as if somebody's coming to try to steal from me and I have it cocked back and this guy walks into my door and he's obviously like professional dress, in nice clothes. And I was about to swing the bat at him and I go, “Yeah, what do you want? How can I help you?” He goes, “I'm looking for Dr. Brian Weeks.” And I was like, “Okay, well, yeah, I'm Dr. Brian Weeks.” And he goes, “Hey, my name's Tom O'Neill. And I work for a small startup company called Acclarent.” And I was like, okay.

So anyway, so he gives me a brochure and he goes, we created this technology treat sinuses. Okay. I mean I listen and it immediately sounded like, wow, that sounds like a really cool idea. We all knew about angioplasty. So the long, and the short is I got invited to go up. I ultimately came aboard a member of the scientific advisory board and have Acclarent, right after the CLEAR study came out. But I was on the board with, Howard Levine, Mike Sillars, Ray Weiss, P Catalano, Fred Coon, I mean all these eminent rhinologists around the country. And you know, so that was one of the first lessons I learned was don't poo-poo new technologies, just because you don't know anything about it. Be open-minded. And then the second thing I'll tell you, it's really funny, is after we had developed a couple of technologies within the balloon platform to allow us to be more successful and even less invasive and less cumbersome. We decided to do the study called the Oreo study. So I remember I recruited the first patient for the Oreo study. And we did this case in the office and it was like this woman with an isolated frontal sinusitis or chronic frontal sinusitis. And we had all this equipment and we knew nothing about anesthesia. We knew nothing about the way to do this. And this case was awful. It took like two hours. I had like five people in the room with me. The patient was screaming and it was one of those miserable experiences. And so those are two really interesting reflection points for me because it's sort of the beginning of these journeys. And now like we can do six or eight or 10 office cases in a day, seamlessly, patients feel nothing. It's just a really cool way to reflect on the journey. But yeah, Ash and I have been able to work together on quite a few, studies and papers and courses. And we run a couple of courses now every year in Vegas. And so it's been an incredibly rewarding journey.

[Gopi Shah MD]
Those are great, reflection points for sure. How do you, keep going? I mean, it's very easy to be discouraged, when you have a case like that, whether it's obviously in the OR, but much more in your clinic when the patient's awake.

[Brian Weeks MD]
Yeah. I mean, I'll start. And Ash I mean, I'm sure you can share some wonderful anecdotes as well. I think those types of adversity, either, strengthened you or defeats you. And the way I looked at it was I felt like we were really doing something great. I mean, one of the things that we learned after the Oreo study was done and we were delivering something that had a real place.

I mean, it is balloon sinuplasty for every patient, of course not. Is it for appropriate patients with disease that's amenable to that? Yes, it is. And there's a large body of patients, but I guess what energized me was the fact that I felt like we were doing something significant that was ultimately going to change the way medicine was practiced. And that was compelling enough that it made it worthwhile. So that, for me, the light was that, we were giving back something to our field.

[Ashley Sikand MD]
Yeah, I think I'll say that a key point that I'd like to emphasize for my colleagues is that you're never alone in your quest to improve patient care and advance through challenges and achieve better results. And by that, I mean, I was always fortunate to be surrounded by colleagues I could reach out to, across the country, Brian being one of them, but he's mentioned a number of others. And, in addition to that, you build your own team here, right? So, people, everybody from, physician assistants to medical assistants, to office managers and so on. So you're all working as a team. You may be sort of quarterbacking it, but it's important to have all those elements and they foster a better care for the patient. And, then finally I think we all owe some gratitude to our patients for, in Brian's anecdote, putting up with our first procedures in the office and, in whatever element or area that we're trying to progress and encountering some challenging situations. So I think all of those combinations, keep us motivated: our friends, our colleagues, the nurses, and the people we work with. And then of course, the patients that we're trying to help.

(2) In-Office Procedures for Nasal Obstruction

[Gopi Shah MD]
Yeah, that’s great. 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.

[Brian Weeks MD]
Yeah, I can add, I think to dovetail on that and compliment it. The other area that we're really seeing kind of a rebirth, if you would, is dealing with the nasal valve. And first off, when I was in my training, I trained at the Baylor College of Medicine. I'm proud. I had a wonderful training, great county hospital, and I'll absolutely second what Ash said about the oral surgeons. I mean, our clinic and oral surgery were back to back, so we had a common hallway and we would also cover facial trauma with plastics and oral surgery. And those guys would like basically do mandible fractures in the clinic. And I would go down there and I learned, like there was a doctor named James Johnson who was an older oral surgeon who was retired and would come and teach the residents. And I learned so much from that man about how to anesthetize the lower jaw and the upper jaw and the dentition. And so, yeah, that’s made the office journey that much easier.

I mean, the other thing that I would say about anesthesia particularly, with nasal surgery is go back to your textbooks and, and understand sort of what you're trying to achieve. I mean, I went back and reviewed the anatomy of the trigeminal nerve, specifically V1 and V2, for the nose. And, you think, well, if I just do this block, this it'll work, but specifically, there are very, very small branches that you can block, kind of tactically and it achieves incredible anesthesia. But for the nasal valve, I mean, honestly, the biggest thing that's advanced our ability to treat that is first of all, awareness and secondly technology, and with technology breeds awareness. I mean, when I was in my training the only people that dealt with the nasal valve were the facial plastic surgeons, and they would do batten grafts and spreader grafts, and it was a kind of a big deal for the patient. And you're kind of like, wow, I don't know if I really want to be doing that, I'll just say most of the plastic surgeons.

And so for that, it's kinda like eustachian tube dysfunction. I mean, I can't tell you how many people I've seen for eustachian tube dysfunction who come to me and say, I saw my ENT. I saw three ENT and they told me there was nothing wrong. What that really means is we don't have anything to do for you. So, sorry. But now that we have these amazing treatments that are very amenable to local anesthesia, and really office-based therapies. I mean, I think there's been an emergence. And clearly, when you review the current literature and look at quality of life scores and NOSE scores and things like that, you'll see that addressing the nasal valve, as part of a triad of nasal airway obstruction anatomic issues is really, really impactful on improvement in breathing.

[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.

(3) Scheduling Considerations for Office-Based Procedures

[Gopi Shah MD]
So when these patients come, do you feel like you do everything on like one single procedure day or let's say for the person that's just starting out that may not be able to fill a half-day or a day of procedures. Should they just block a morning and have that one patient or do you ever do you know, people that they see patients in between and then kind of have an hour in between in the mid-morning for a procedure? How does the scheduling work or is that just physician dependent on what they feel works in their practice?

[Ashley Sikand MD]
I’ll go first, but you know, I mean, it's, good to have, two of us here, so we probably do things a little bit differently. And that's also evolved for me as well. I think when I first started, I used to, I had one afternoon a week because the number of patients I selected was less because I wasn't doing things like septoplasty and so on at that time. But now it's kind of changed. I do half days. So I do, four half days a week in which we do office procedures. And then all I do during that time is focused on the case at hand. For me, it's easier patient flow. I use two rooms to do that. And so one room serves as a preop and postop room and the other is the actual procedure room where I have everything set up and that flow works well for me. We have a team that usually consists of my medical assistant, sometimes my physician assistant helping me. And then, frequently we have, either medical students, residents, or the visiting otolarygologists from other parts of the country observing as well. So that's, how it's evolved for me. I'll let Brian describe his office flow.

[Brian Weeks MD]
Yeah, Gopi, Ash, I love it. I think it's great. The way you're doing it. What I would basically say to anybody who's contemplating getting started or trying to figure this out is right at the beginning definitely err on the side of giving yourself a little bit of extra time, because what'll end up happening is if you feel rushed or things don't go as smoothly as expected you don't ever want to feel that time crunch. When I started out, I was bouncing between my office and the OR on the same days. And what I found was I was always either late to one of the places and I was always stressed. So I would advise, when you’re starting out, book an extra hour, maybe more than you think you need at the beginning. And ultimately what will happen is, I think, as your volume grows and as your confidence grows, your volume will grow. The patients are there. It's just a matter of you kind of finding out that you can actually do as much as you want to do in the office. And you're, as long as you're being sensible and just growing your confidence, that will naturally be how things transpire.

And then I think from efficiency's sake, we have a pretty streamlined process just like Dr. Sikand does where we have our PAs and our MAs working. We have a really good patient flow, so I can frequently have a patient anesthetizing and I'll be seeing a pre-op or post-op or a new patient in between. And that's where the efficiencies come in. And for my practice in particular, I have dedicated full days in the office and I either do one or two full days a week. And then I have dedicated days in the hospital or surgery center. And then I have dedicated days where I just see patients. The caveat to that is I consider office procedures as sinus and eustachian tube dilation and LATERAs, and ClariFix is a procedure that I do frequently and that's just rolled right into my normal patient flow. So those patients are not part of a procedure day because ClariFix is very, very quick. After the anesthesia, it takes me about seven or eight minutes, total time, and the patient room.

(4) Utilizing ClariFix Cryotherapy and the Latera Nasal Implant

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

[Brian Weeks MD]
No, it's no problem. So I'll tell you exactly. So LATERA is the lateral nasal wall implant, and that is the stabilizing implant, that stabilizes the internal nasal valve. And it's made specifically for dynamic nasal valve collapse. So it prevents that or improves that. And then ClariFix is posterior nasal nerve or postganglionic branches of the sphenopalatine cryoablation.
So it's a freezing and there's other technologies too. There's a competitive technology called RhinAer. And then LATERA’s kind of competitive technology is something called Vivear and that's more, in my opinion, ideal for a static nasal valve hypertrophy, as opposed to dynamic nasal valve collapse.
[Gopi Shah MD]
And then in terms of the, a deviated septum in the clinic, is it more for that posterior nasal spur that you can kind of cut down on or I mean, I would imagine the super twisted crooked that's kind of out in the front, probably not. And is there a device for this or is it the standard numb them up, create the flap…

[Ashley Sikand MD]
Yeah. So when I'm talking about septoplasty, I'm talking about a full septoplasty with either a hemitransfixion or Killian incision, elevating mucoperichondrial, mucoperiosteal flaps, and treating whatever needs to be treated with the vomerine bone deviation or deflection, as well as the caudal septum, dealing with the cartilaginous deflection as well. So I'm talking about our standard septoplasty, the caveat there for doing the office is you have to be able to endoscopically get back to the region of the palatine nerve distribution in order to block it. So I usually place my block medially, fairly close to the poster nasal septum and the local anesthesia migrates laterally and it includes the nerve. So if you cannot do that, then the patient is probably not a good candidate for doing the office because the palatine block beautifully anesthetizes most of the nasal septum. And you need that on board, not only for local anesthetic, but also helps really minimize any bleeding. But then you have to do infiltration of the caudal septum as well separately. So, I rely on, on sort of what I call, back migration of the anesthesia. So injecting the mucosa, and then the anesthetic effect will backflow, to the very anterior caudal septum. And, if you get good anesthesia before you actually undertake it.

The whole concept of just a spur and you just take that off, that's pretty easy. And that's been done before with the just elevating a flap, taken off with a Takahashi or whatever. So, I don't really consider that a fault. You can bill it as a endoscopic septoplasty, as we all know, appropriately so. But, when I talk about doing the septoplasty, I'm talking about doing something more on that. There have been, I think, some tools developed for septoplasty and other options. I’ll let Dr. Weeks maybe comment on all of that.

[Brian Weeks MD]
Yeah. I mean, I've actually been with Dr. Sikand for his septoplasties, he does a full-on submucous resection septoplasty and I do it too. I probably do fewer septoplasties in the office then than Dr. Sikand does, but I still do, quite a few.

And then, yeah, as far as devices developed to, help us with septal surgery in the office. There's really one device that I know of on the market right now. It's called the tract balloon and it's made by Acclarent. Actually a very, very good device, for the right type of nasal airway obstruction. I think the only issue there Gopi, is that there's really not a code to bill for it. And it's not an inexpensive– it's not a ridiculously expensive device, and it could cost about $400 or $500, but it's not something that we really have a code for. So you can't bill for it. And I think that does make it a little bit challenging just as we think about the office and the expense to the physician. But as an access tool for someone who's not comfortable doing septal surgery, but wants to maintain those patients in an office setting, it's actually a useful tool as a complementary device to the other platforms that we have.

[Gopi Shah MD]
And is that then kind of pushing the swell body out or does it actually kind of make like a mini fracture, along the cartilaginous, how does that work?

[Brian Weeks MD]
Yeah, it's a great question. The way I can describe it for people that don't know, most people are familiar with the airway balloon that I've used for subglottic stenosis, things like that. It's very similar in its design to the airway balloon. It's a high pressure, a non-compliant balloon, and it actually does fracture, the vomerine bone and it also effectively out fractures the inferior turbinates so you get that duality of treatment, but yeah, it's meant to actually, microfracture or fracture and reposition the septum. I think the difficulty is it's effective when you have something going on at the maxillary crest and you can sort of fracture the crest over. It's not a great tool for cartilage simply because cartilage has memory, right? And you dilate it and then it just gradually creeps back, over hours to days. But I think it’s effective dealing with bony cartilaginous junction issues, certainly spurs and then maxillary crest deformities. And if you fracture those structural areas over, the cartilage frequently comes with it.

[Gopi Shah MD]
So, this is not an in-office question, but just a personal question. Doyles or no Doyles? Splints after septoplasty or no splints after septoplasty?

[Brian Weeks MD]
No splints for me. I think that the patients that have had them just always report they're really uncomfortable.

[Ashley Sikand MD]
So I do place Doyle splints, but I take them out the next day. So it's just overnight. I’ve done it without them. But, I guess personally, we got some more call backs on those patients, that were having some bleeding, not anything that one would put packing in for, but it was more annoying than if you put in the splint. So they'd call me. And it gives me an option to check the patient the next day, just counsel them again and make sure they're on the right treatment plan with rinses and so on.

[Brian Weeks MD]
Full transparency. Gopi, I actually do put packing in the nose on most patients. I put a laminated Merocel sponge and I take it out the next morning. So it's in for anywhere from 16 to 20 hours. And it's very tolerable and most of the patients are still sleepy from their anesthesia, so it's really not cumbersome, but the Doyle splint I've heard from a lot of patients, they're hard, they're uncomfortable. And after most people leave them in about five days, that's really uncomfortable.

[Ashley Sikand MD]
Yeah, this is something I didn't know about your practice is that you placed the Marocel, it's pretty similar. We both take them out within 20 hours.

[Gopi Shah MD]
And it sounds like it's more for hemostasis than it is to kind of hold anything in the middle if you will.

[Ashley Sikand MD]
For me, it's for hemostasis mostly. Yeah.

(5) Anesthesia Protocol for Sinus Work

[Gopi Shah MD]
All Right. So, going back, we talked about blocks some anxiolytics. Do you have an anesthesia protocol or does it depend on, okay, I know I need to do the SP for my septoplasty, but I might be blocking something different for the LATERA valve splint or implant?

[Ashley Sikand MD]
Right. So, I think we talked about this, Dr. Weeks and I, in some of our courses we presented together, but we have very similar protocols, but they do vary a little bit. There is some variation depending on what the procedure we are accomplishing. Definitely a little different if you're doing ClariFix or LATERA, which requires a different type of anesthesia protocol. But I'll just comment on my anesthesia protocol for sinus work, whether it's a balloon dilation polyps, as well as for if I'm doing septoplasty or turbinate work. I guess it can be divided into three sections. The first is, what do you do for anxiolysis? So that's number one. And number two, what do we use for surface anesthesia or topical anesthesia. And third, what type of infiltrative anesthesia protocol do we have?

So just, briefly for anxiolysis, I'm like Dr. Weeks where we're in states that have pretty significant and clear guidelines, our state boards do on what type of anesthesia, what type of anxiolysis we can deliver in an office setting. And, we conform to that because The American Society of Anesthesiologists looks at minimal sedation, or anxiolysis in the same section. And that is not considered to be conscious sedation. So the patient is verbally responsive, he or she can protect their airway. And there's minimal cognitive impairment in those patients. So an example would be if you provided somebody with a triazolam or lorazepam, relatively low dose, like a sleeping pill basically. And so I use a lorazepam and typically I use 1 milligram. Occasionally in younger patients who I feel have will higher anxiety, I'll use a two milligrams lorazepam and that's equivalent to five to 10 milligrams of Valium, in that zone. Then, I typically have not used any opioids, but recently, and I’ll let Dr. Weeks comment as well, we are trialing a rapid onset sublingual opioid that does not cause respiratory depression and I think in certain settings and certain situations, that'll also be quite helpful in providing that type of anxiolysis for the patient.

Moving on to surface anesthesia. I really emphasize it. I spray the patient's nose with our lidocaine and Neo-Synephrine mixture, 4% lidocaine, and a 50 50, then I place pledgets, the same mixture. And then, most importantly, I use Pontocaine gel. And that is very a potent, topical anesthetic, 6% Pontocaine gel. And I place it myself with a blunt needle under endoscopic guidance on all the areas that I'm going to be touching, really. It doesn't take very long. The application probably takes some like two, three minutes total and it works very rapidly.

And after that, I find patients do not have a problem with my next step, which is infiltrative anesthesia. So depending on what I'm doing, whether it’s septoplasty work, turbinate work, or any significant level of balloon sinus dilation. Other than just to say from working on an isolated frontal sinus, I use a sphenopalatine block, then also infiltrate the middle turbinate and superior to the middle turbinate as well as, as well as the inferior turbinate if I’m working on that. So, we still don't use very much actual infiltration. Even when I'm doing a septoplasty, I'd probably say a 10 CCs or less of 1% lidocaine with 1:100,000 epinephrine or 1:200,000 epinephrine for patients who may have some cardiovascular issues. So my patients are monitored with their O2 stats and their heart rate. And, that's a protocol that we've been using now for over a decade. And, I think, if you set expectations, really communicate with your patient, communicate with your team, develop a great team and create an atmosphere that puts the patient at ease. We have music playing in the background. Patients that want to use headsets, they can. Things like this. I think that really makes for the best office-based experience. So I'll let Dr. Weeks comment on any differences he has in his anesthesia technique, plus how he manages the ClariFix and LATERA patients.

[Brian Weeks MD]
Yeah, thanks Ash. That was comprehensive. And I mean Dr. Sikand is a master at topical anesthesia, for sure. I think our protocols are very similar. I use actually two milligrams of Ativan. The thing about benzos in particular is that they're incredibly safe. There's zero risk of respiratory depression. I mean, literally you can give it in the oldest patient and they'll look like they had way too much to drink at the party, but they're never going to stop breathing and they don't have any problems with those types of catastrophic things. So they're very safe. I use those in conjunction with a similar topical and infiltrative– I use just liquid 4% tetracaine mixed with oxymetazoline and that works really, really well, but I would agree tetracaine or Pontocaine is the workhorse anesthetic in office procedures.

As far as LATERA goes, again, I anesthetize the vestibular alar, vestibular junction, internal inside the nose with some topical, either tetracaine gel or tetracaine soap cottonoids, sort of for about 10 minutes. And then when I come into the room, the patients had their anxiolysis medications before, and we give those, we have the patient take those about two hours before their procedure. Then, when they come into the room, after I've let the gel worker remove the cottonoids, I do V2 blocks. And really the emphasis of the V2 blocks is the lower part of the canine fossa injection. So I start, I don't go all the way up to the infraorbital foramen, I go about halfway up and then I inject. And really what we're trying to do there is we're trying to get the lower perforating branches of V2. And then we're trying to get the septal branches, which is what innervates the alar rim and the internal vestibular mucosa. And once you block those effectively on both sides, then the last part of the injection is you actually have marked the nose where you want your implants to sit and you infiltrate the tract of the implant. And the key with all this, the reason you're doing the V2 blocks is so that they don't feel those injections in the ala and in the tract, because those are quite uncomfortable. Yeah, I go back and forth with my colleagues. There's a guy who's an otolaryngologist in Texas named Jose Berrera, who's a very gifted guy. He's a facial plastics guy and Jose and I go back and forth all the time on a local anesthesia for LATERA. He's a big supratrochlear guy. So supratrochlear branches off of V1, but I always say one of the most uncomfortable blocks, and there no way to numb it up. So you can do it that way too. And V1 provides a lot of surface anesthesia to the nose. But either way, once you've done those injections, I mean, literally the patient feels nothing. We use double skin hooks to provide countertraction as we're placing our implants and finding that sweet plane, and the patients don't feel anything. You can literally do your procedure without any concern for the patient being uncomfortable. And, the procedure itself is extremely quick once good anesthesia is achieved.

And then ClariFix, it's really topical tetracaine throughout the nose more generally, and then focally at the treatment spot. And it takes about 10 to 15 minutes. The key with local anesthesia, if I was giving anybody just starting out kind of one take home high-level message, it would be: don't be in a rush. Let the anesthetic work. If you give it time, if you let the tetracaine sit in the nose, the nose becomes extremely numb and you can do very well. And if the patient's uncomfortable, the doctor's uncomfortable and it's a miserable experience. So, let the medicines work for you.

[Gopi Shah MD]
Yeah, it's funny because in the OR where we're for Afrin pledgets in the nose, I have to tell whoever I'm with, make sure we're not putting anything in the nose unless we've been five minutes by the clock because I get so like, okay, let's go. And so you have to give it time.

In terms of hemostasis, you mentioned oxymetazoline pledget. And I would imagine with epi infiltrative anesthetics also, is there anything else in terms of hemostasis? I think you also mentioned that when they're not under general anesthesia in terms of blood pressure and things like that, and they're calmer, that that's also to our advantage.

[Brian Weeks MD]
Yeah, a hundred percent, again, something that might seem counterintuitive is that office patients that are awake, they really don't bleed very much. It's really surprisingly shocking in a way. But definitely people should believe that cause it's true. I always have a couple of different hemostatic agents in my office. I have HemoPore usually have at least one kind of container that I can mix of either SURGIFLO or FLOSEAL. And, those are for very unique or unexpected situations. And then I have nasal packing, gel foam, Merocel sponges in my office. And then the last thing we have is we have cautery available. We have Hyfrecators and suction cauteries available. I was telling the group today with the course I'm at, the group I was speaking to that you can get a used Valleylab cautery machine on eBay for like 200 bucks. So it's pretty funny, but you could literally have a cauter in your office tomorrow, for a couple of hundred bucks. And it's pretty much a good idea to have that just in case of a rare emergency. I barely ever use it. I don't even know when the last time I've used it is, but just to be prepared.

[Ashley Sikand MD]
Yeah, I would agree with that, with all those comments. I also use a topical epinephrin on cottonoid pledgets. And, I found the one caveat where you do get some bleeding is really inflamed sort of osteo-middle complex in those patients who have dental infections where the pass has been in the sinus for a year or more. And it's very inflamed and I mean, it's not like there's a lot of bleeding, but you want to mitigate any. So I find the use of topical epinephrine 1:1000 on cotton pledget has been very helpful in that situation. And of course, the more meticulous you are with your local anesthesia, the better your hemostasis is going to be upfront. So, that's another take home point, just sort of backing onto what Dr. Week said.

(6) Patient Selection for Office-Based Procedures

[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.

[Gopi Shah MD]
Yeah. The scoping age adolescents, they are tough. They are tough, you can't papoose them. We got papooses in my clinic, but we can't do that once they're past like five. But the best patients are under six months or over 60, but, all right.

Really quickly, just one other kind of in terms of equipment, you'd mentioned having a cautery. If somebody wants to start doing these procedures, what would you definitely need to have?

(7) Equipment Recommendations for In-Office Procedures

[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.

And one thing I would just say, I mean, Dr. Sikand and I have a lot of interests together, we have a couple companies that we've built and we have a technology company and so we're constantly developing tools. And so we're always thinking of the next thing in ENT, and one of the things we've worked on is a new kind of endoscopy platform. So I won't talk too much about it cause that's beyond the scope of this, but maybe one other day, we can come on and tell you a little bit more about it, but what I would say is that one of the things we have in mind is that this equipment is extremely expensive and in some ways, prohibitive to a young, new otolaryngologist. And that's very limiting, I mean, when you have to put something in the size of a refrigerator and the tower and the cart into your exam room, that takes a lot of space and it's sort of against what we're preaching with an office-based mobile kind of cutting edge platform. And so we were thinking about that when we created our newest innovation, which hopefully we can talk to you about sometime in the near future.

(8) Working With Industry as an Otolaryngologist

[Gopi Shah MD]
That sounds great. BackTable has a whole innovation show. And so it would be great to get you guys on, Eric Gantwerker is one of the hosts for that. He's a pediatric ENT. And it's something that definitely, I think would be great to highlight your story there. Y'all mentioned a lot of benefits in terms of working with industry, whether it's having, when you're first starting out in practice, working with industry to help get demos and help you get started. You talked abouthow sometimes with new devices and techniques, you have to be open because that's where we kind of see the problems maybe we have missed before. And it sounds like also in terms of research opportunities, when you're starting something new and you have something in your practice, there is also research, opportunities.

What other benefits do you see? Or why should physicians partner more with industry? I feel like we don't, in terms of, in teaching, in academic medicine, personally, it's not something that we tend to even, I think, talk to our residents about, I realize now it might be a bit of a disservice if they don't know how to leverage that for their practice.

[Brian Weeks MD]
Well, I mean, for me, it's a really great question. I think it's a spot-on question, especially for the modern graduating otolaryngologists. I mean, without industry we wouldn't have the technology that we have today, there's nothing wrong with companies wanting to develop tools to make money. And that's what drives our ability to have tools. Right. What I would say is that just because an industry partner brings you a tool doesn't mean it's a good tool, but you should always at least have an open-minded evaluation and an assessment. And honestly, what I've learned with industry is that there's some incredibly intelligent, incredibly great people. I mean, probably one of the greatest influences in my entire career in medicine is a guy named Josh Makower. And Josh, he's one of the greatest medical innovators in our country. He's the founder and creator, and now he's the director of the Stanford Biodesign program. All Josh does is teach young physician-scientists how to innovate and how to build amazing technologies. Josh was the co-founder of Acclarent and I think he's founded and sold seven medical device companies and Josh is only in his mid-fifties. But I mean without my, kind of intro to industry, I'd never would have met him. We are really lucky to have industry focused on ENT. We've had what, three or four billion dollar plus market cap companies emerge in otolaryngology in the last decade. That's unbelievable. The only other fields that are like that probably in all of medicine are orthopedics and cardiology. I take my hat off to the academy because I think a long time ago, the approach from the academy was industry's evil. We can't talk to those people. They're just trying to give us pens and bring us lunch and sell us stuff.

[Gopi Shah MD]
Well, you can't take a pen.

[Brian Weeks MD]
Right. Now, you can't do that anyway. That's what I was going to say. So now they can't even bring us a coffee without us having to report it. But what I would say is, without those people, we wouldn't have the innovation that we have in our field. And to the Academy's point, I think they've done an incredible job of embracing it. There's a guy named Ron Coopersmith, who was one of my residency classmates. And Ron is head of the program that interfaces otolaryngology with industry. And so I take my hat off to the Academy. They've done a great job trying to embrace that relationship and move things forward.

[Gopi Shah MD]
Are there any downsides in partnering with industry that you've found in your experience or things that a physician coming out or is interested in should kind of look out for?

[Ashley Sikand MD]
Yeah, within our training programs and not just the actual academic program, but in courses that we're trying to deliver to young physicians or physicians in training, we should probably develop in them or inculcate a sense of being able to critically evaluate technology. I'll look at it from the perspective of the literature, look at it in terms of, does this make sense? Is it going to really improve the life of my patient? Is going to deliver what it's supposed to deliver? So some critical analysis capability I think would be great. And I went throughout my residency program and didn't really interface with the industry. I think that's probably still the case to a large extent, at least as a resident. And when I was in fellowship with, Rod Perkins at Stanford, he was also somebody who had innovated and developed a number of companies. My time there allowed me to be able to critically evaluate or at least try to critically evaluate emerging technology. So I think it's very important to absolutely have an open mind, but, bring a scientific bearing and the bearing of a physician that has the best interest of the patients at the top.

[Gopi Shah MD]
Yeah. Well, Thank you guys so much for taking the time to talk with me today, for our listeners, just remember what, Dr. Weeks says be open, don't poopoo, new techniques and what Dr. Sikand said, you're never alone to advance through challenges, build your own team. Those are just some straight up life pearls, if you will. Thank you for swinging by if you're a new listener and for our old listeners. Thank you for returning. You can find us on SoundCloud, Spotify, iTunes, Apple, and Gaana. Please follow us on Instagram and Twitter at _BackTableENT. We love feedback. Reach out to us for topics, ideas, speakers, or if you ever want to come on the show. It's a wrap.

Podcast Contributors

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

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.