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BackTable / ENT / Podcast / Transcript #77

Podcast Transcript: In-Office Procedures for Chronic Rhinitis

with Dr. Stan McClurg

In this episode, Dr. Stan McClurg, a private practice rhinologist at Ascentist Healthcare in Kansas City, shares his approach to diagnosis and treatment of chronic rhinitis patients using the in-office RhinAer procedure. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Exploring Chronic Rhinitis: Patient Presentation

(2) Categorizing Chronic Rhinitis Patients

(3) Methods of Allergy Testing

(4) Utilizing the Scope for Diagnosis

(5) Comparing Treatment Options for Chronic Rhinitis

(6) Breaking Down the RhinAer Procedure

(7) Comparing the VivAer & the RhinAer

(8) Post-Op Care for In-Office Procedures

(9) Comments on Revision Surgeries

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In-Office Procedures for Chronic Rhinitis with Dr. Stan McClurg on the BackTable ENT Podcast)
Ep 77 In-Office Procedures for Chronic Rhinitis with Dr. Stan McClurg
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[Gopi Shah MD]
This week on the BackTable podcast.

[Stan McClurg MD]
This is an excellent tool to treat something that previously was not very easily treated. It's similar to the nasal valve. People never looked for the nasal valve until they actually had a treatment for it. I do the modified Cottle on pretty much every patient to try to find patients that would potentially benefit. The runny nose patient has always been a patient that nobody wants to see because there's not really therapy for, but now, it's a patient that has a pretty good therapy that's an in-office procedure that patients can benefit pretty significantly from. I think it's an awesome opportunity to introduce this treatment for patients that previously had no significant treatment options.

[Gopi Shah MD]
Hey, everybody. Welcome to the BackTable ENT podcast. We're a podcast that focuses on all things otolaryngology, and we got a really great show for you today. Thanks for stopping by. 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 radiofrequency products include VivAer for addressing nasal airway obstruction and RhinAer for chronic rhinitis. Learn more at aerinmedical.com. Now, back to the show.

[Ashley Agan MD]
All right. Hey everybody, welcome to the BackTable ENT podcast. My name is Ashley Agan. I'm a general ENT in Dallas, Texas.

[Gopi Shah MD]
My name is Gopi Shah. I'm a Pediatric ENT. How are you doing today, Ash?

[Ashley Agan MD]
Bonjour, Gopi.

[Gopi Shah MD]
Bonjour, bonjour.

[Ashley Agan MD]
Excited to be across the mic from you today, [crosstalk] excited for our guest. It's timely to talk about rhinitis because I'm quite rhinitisy today, so-- It's fading. I'm taking some notes for myself.

[Gopi Shah MD]
The drip, maybe a clog. I don't know.

We have an awesome guest today. We have Dr. Stan McClurg. Dr. McClurg is a rhinologist practicing in Kansas City, Missouri at Ascentist Healthcare. He performed sinus and skull base surgery in the OR as well as awake in-office sinus surgeries and procedures. He's here today to talk to us about chronic rhinitis. Welcome to the show, Stan.

[Stan McClurg MD]
Hey, thanks for having me. I might talk about chronic rhinitis as well.

[Gopi Shah MD]
I was hoping we're going to get that part deleted, edited, but now, we'll keep it in. We're keeping it.

[Ashley Agan MD]
It's not French, just those French classes kicking on you. You got to [inaudible 00:02:49]. [chuckles]

[Gopi Shah MD]
I don't have my [unintelligible 00:02:51] set up in the background this morning as we do stay [crosstalk] have that.

[Stan McClurg MD]
Do you mean like that?

[Gopi Shah MD]
Yes.

[laughter]

If there's extra, it vibes to my brain. Tell us a little bit about yourself, Stan.

[Stan McClurg MD]
I am originally from Paola, Kansas, a small town just south of Kansas City. I then and went and did a chemical engineering bachelor program at K-State, Kansas State University. I then went to KU Med for medical school where I met my wife who is actually a OB-GYN at KU. She's the program director there. She'll be happy that I mentioned that. Then we both went to the Ohio State University for residency.

[Gopi Shah MD]
My husband is from Columbus.

[Stan McClurg MD]
Oh, yes?

[Gopi Shah MD]
Yes.

[Stan McClurg MD]
That was great time. Once you graduate there, you have to stay “the” or they will actually fire you.

[Gopi Shah MD]
Once you marry under the family, you got to say “the” as well. [laughs] I get it.

[Stan McClurg MD]
After that, I went to UNC in Chapel Hill and did a rhinology and skull base fellowship there. Afterwards, I moved back to Kansas City. I am now part of a practice at Ascentist Healthcare where we actually have 34 physicians in our group and 13 of those are ENTs. I'm the sole rhinologist for them. It's a great practice. I love being in private practice and I love even more being a rhinologists in private practice.

[Gopi Shah MD]
Awesome. UNC, so rhinology powerhouse. That's pretty awesome.

[Stan McClurg MD]
Yes, they are.

[Gopi Shah MD]
I used to read a lot of Dr. [unintelligible 00:04:34] papers on all the pediatric skull base stuff and the measurements and, I don't know. I didn't know him [crosstalk] I met him once and I was like, "I've read all your papers."

[Stan McClurg MD]
I probably did some of those measurements myself at some point as well. You're welcome.

[Gopi Shah MD]
Then I got to work a little bit with Dr. Senior and Dr. Kimple on the recent CF guidelines.

[Stan McClurg MD]
Both were amazing.

[Gopi Shah MD]
They were great. Anyways, shout out to the program there.

(1) Exploring Chronic Rhinitis: Patient Presentation

[Ashley Agan MD]
Well, awesome. You're going to talk to us today. We're going to focus the conversation on chronic rhinitis. Just to kick things off, maybe we can just talk about what this looks like when these patients are coming to your practice and what symptoms there are, and what questions you're asking, that sort of thing.

[Stan McClurg MD]
I've actually found that the type of patients that are presenting with this has shifted. Initially, it was patients that presented after everything else had been fixed, like a patient with chronic sinus infection or allergies or something else would fix all the other issues, and then they still have this pesky runny nose or postnasal drip. Then we'd just throw ipratropium bromide at it and be done with it.

There's so many patients out there that have that issue, but they just refilled every year and they continued with their Atrovent nasal spray, but there was no other treatments for them. That was the initial patients that I was seeing and potentially doing pre-procedures on. Then more recently, I've actually been getting patients sent directly to me for chronic rhinitis or post-nasal drip.

It's through word of mouth and a little bit of advertising and just people finding out that there is actually a treatment for chronic runny nose and post-nasal drip that I'm getting people that present pretty much entirely just for that, are already telling me what procedure they want done on them. [chuckles]

[Gopi Shah MD]
Did the ipratropium work on those patients?

[Stan McClurg MD]
Yes. It actually works pretty well. Interesting fact, there is actually two different strings out there. The normal one is the 0.06% and then there's also a 0.03%. Some people are super sensitive. It can sometimes cause dry mouth and/or potentially even dry eye when you do the nasal spray, or people will complain that it dries them out too much. Interestingly, and I'll probably talk about this a little later, but I actually use that as a criteria to see if they'll benefit from an in-office procedure such as RhinAer. If they respond to those nasal sprays, I find that they have a much higher likelihood of responding to the procedures.

(2) Categorizing Chronic Rhinitis Patients

[Gopi Shah MD]
These are patients that have a runny nose, but that maybe do have allergies or don't have allergies. How do you think of it as you're categorizing patients? Because when I think rhinitis, it's like inflammation in the nose, right, from all causes maybe and then you divvy it out from there.

[Stan McClurg MD]
Yes. Actually, the definition of chronic rhinitis is constant runny nose for greater than four weeks. It can be from multiple different sources. One study showed that of the patients that have chronic rhinitis, about 43% have allergic rhinitis, and then non-allergic is about 23%, and there's a mixed varietal in there of about 34%. Initially, as I was working with these patients, I wasn't really thinking of allergic rhinitis as a potential patient that could be fixed with a procedure like this.

I was filtering out all the allergy patients and sending them off to allergy. More recently, I found out that you can actually treat the allergic rhinitis patients with a procedure like this as well. You don't really have to filter all them out, but it's nice to do a little initial workup to try to find which category they're in. If they're the chronic rhinitis, a non-allergic, or mixed rhinitis. Then get allergy testing to try to figure out what allergic component they have.

[Gopi Shah MD]
Do all the people with chronic rhinitis-- not all the people, what percent also just have a clogged nose too? Do those go hand in hand or you've already helped them open their-- it's not a blockage, but it's just their runny?

[Stan McClurg MD]
I would say probably about half and half, probably about 50% of patients will present and say, "I have a runny nose, but I also have nasal obstruction." Then there's these other patients, about half of them that say, "I only have runny nose, I can breathe fine." I found that the older patient, the classic old lady with a tissue in her hand that goes through five boxes of Kleenex a day, that's the patient that usually doesn't complain of a nasal obstruction, it's more just the chronic runny nose.

I think when they're at the bridge club, they all have tissues in their hands, that they think it's normal.

[Gopi Shah MD]
It's normal. [laughs]

[Ashley Agan MD]
You have your patients who have a vasomotor rhinitis picture where it's like they have runny nose when they eat or something [crosstalk]

[Gopi Shah MD]
Or exercise.

[Ashley Agan MD]
Like where it's specific, situational, are those patients-- do you think about them differently? Are they still managed in a similar way? Are they still potentially candidates for procedures and things like that?

[Stan McClurg MD]
Yes, so vasomotor rhinitis I think is a different animal. I usually give patients the ipratropium bromide to try out. It really depends on how significant their problems are. Frequently, it's mixed where they have a baseline fairly runny nose and then it's just worse when they eat or something like that. I leave it up to the patients on whether or not--some people will say, "Oh, I just used the nasal spray before I go out on a date, so that my nose doesn't run in front of my date." Otherwise, they tolerate it, and manage it fine. I feel like it depends on how much of a burden it is. It's a gradient as to how much chronic rhinitis versus vasomotor rhinitis they have.

(3) Methods of Allergy Testing

[Ashley Agan MD]
Yes, that makes sense. Before choosing the medical therapies, when you're doing your allergy testing, do you have a preference on whether it's skin testing or in-vitro testing?

[Stan McClurg MD]
I usually prefer skin testing. I think it's more sensitive, and you can find a little bit more specifics on what types of allergens the patient have. Then you can follow it up with intradermal testing in that scenario as well. For some people that potentially can't do skin testing, then I think that in-vitro testing is fine.

[Ashley Agan MD]
What do you think about patients who have negative allergy testing, but they come to you and have seasonal variations and their runny nose?

[Stan McClurg MD]
I treat them just like they have allergic rhinitis. If it's seasonal, there's something out there that they just weren't tested for, or they had a negative test at that time, but I treat them with the same intranasal steroids and possibly Azelastine if they need that. It's a difficult thing to say. "Yes, you've been diagnosed with non-allergic rhinitis, but you do have an allergy out there, so we're going to treat you like if you have allergies." It's just a difficult scenario sometimes.

[Ashley Agan MD]
I think sometimes patients have trouble wrapping their head around that because the treatment can be so similar. Sometimes I'll slip up and be like, "Yes, and how are your allergies da da da? They'll remind me, like, "Remember I don't have allergies because I tested negative. It's like, "Well, yes, yes, but we're managing you with Flonase and Azelastine and that sort of thing so it can be tricky.

[Stan McClurg MD]
Potentially, those patients would actually be pretty good candidates for an in-office procedure, because they don't have the option to get allergy shots or sublingual immunotherapy. Some of the more recent studies have shown that patients with allergic rhinitis have a similar benefit to patients with just chronic rhinitis, runny nose, to these procedures. Those are actually probably people you should be talking to about potentially doing a procedure like this.

(4) Utilizing the Scope for Diagnosis

[Gopi Shah MD]
Okay. I was just going to say one last question, in terms of that initial patient coming into your clinic, sometimes I feel like the chronic rhinitis diagnosis can be difficult to make in terms of teasing it out from CRS, or-- because we said it could be four weeks, maybe it's just another sinus infection or something like that. Do you have ways where you clinically say, "No, this is just rhinitis, this isn't necessarily something else going on," or is that after your exam, because sometimes the rhinitis diagnosis, not to say it's an exclusionary diagnosis, but because rhinorrhea can be part of-- or postnasal drainage can be part of so many other things.

[Stan McClurg MD]
Postnasal drip is a tough one, but I think the scope is key. When you do the rigid nasal endoscopy, initially, I use a 3-millimeter or 30-degree endoscope, and you can see pretty much everywhere up there. You're looking for any purulence, polyps, or anything like that. Sometimes you can see, clear rhinorrhea or other findings that could help you make the diagnosis. Quite honestly, most patients that have chronic rhinitis only, they'll tell you that they don't get sinus infections. It's just a constant runny nose that never goes away and it never fluctuates.

They never get facial pressure or pain, and colored drainage, I think is one of the highlights is, when people say, "I have postnasal drip." I always ask them, what color is it? A lot of people will laugh and say, "I never look at it." Then I say, "Well, you should consider looking at your snot every once in a while."

The people that have chronic rhinitis, they'll say, "It's always clear whether it's thick or thin, or other, but it never has purulent yellow-green color to it.”

[Gopi Shah MD]
Because if it did you would be more concerned that there is sinus infections or-

[Stan McClurg MD]
Correct, yes.

[Gopi Shah MD]
-[unintelligible 00:15:14] infectious process.

[Stan McClurg MD]
Yes. I'm getting CT scans on most patients as well that have those type of presentations. That'll help me rule out any chronic mucosal inflammation as well.

[Gopi Shah MD]
Do you spray, decongest the nose before you take a look or do you never decongest to take a look or what's your thoughts on that?

[Stan McClurg MD]
I used to spray everybody but then when COVID hit, I stopped, just because I was terrified of mucosal atomization of the COVID virus. I stopped spraying but I still needed to scope. I found that patients really didn't have any change on whether or not they could tolerate the scope or not. I think the key is actually using a small endoscope. I use the pediatric, the three millimeter, and I equate it to a game of operation that we used to play as children. "If you don't touch the sides and they don't feel it and it doesn't go buzz."

I have stopped spraying patients for pretty much all endoscopies, other than post-op debridements. Also, when you don't spray them, they don't have the throat numbness, and the tastes and all that stuff that they frequently complain about.

[Ashley Agan MD]
Yes, it's true. I feel like some patients complain more about the spray than they do about the scope.

[Stan McClurg MD]
I think it's different with the flexible, because the flexible, you bump into a lot of things when you're doing that, but the rigid I think you have a lot more control over.

[Gopi Shah MD]
Kids, I feel like the spray could sometimes set you back 10 steps because just to get the spray close to the nose and to take a look is-- in itself can be, and then they complain like you guys said, the taste and that numbness feeling, then by the time you're like, "Oh, here I actually need to get my exam now. It's like, "Are we game over yet? Have I bumped into the sides of the operation of the [unintelligible 00:17:09]?"

[Ashley Agan MD]
Before we move on too far, you mentioned the postnasal drainage patients. I do think that is a tricky group because if the complaint is postnasal drainage, and when you scope them, you don't necessarily see thick drainage coming back from the nose into the throat. What do you make of that? They deny reflux and they say, "No, it's coming down. I know that I can feel it, it's coming down from my nose and it drips all day and at night I feel it, and it drips down. It makes me cough and it wakes me up." How do you take that apart and figure out what's going on?

[Stan McClurg MD]
It's a very frustrating patient. The postnasal drip can come from about a thousand different sources, so you have to delineate where it's coming from. I tell patients, the back of the throat is very difficult at figuring out where mucus is coming from unless you have anatomical knowledge, like the three of us.

Doing reflux treatment potentially, and trial there to see if it improves, I'll do a ipratropium bromide challenge for them. If they are definitive it's coming from their nose, then I'll do a one-month trial of 0.06% ipratropium bromide just to see if it benefits them, and then see them back in a month. If it doesn't, then I basically tell them it's most likely not going to benefit from a procedure. It's probably not coming from your nose. We can send them off to Laryngology to see if there's potentially like a vocal cord issue with a polyp or nodule or untreated reflux, silent reflux, something like that. Allergies can also potentially do it as well, but it's a little bit longer route to work up the isolated postnasal drip patient.

[Ashley Agan MD]
With your ipratropium challenge, you choose that nasal spray as opposed to Flonase or Azelastine or some other nasal spray because it's an anticholinergic and it-

[Stan McClurg MD]
Yes.

[Ashley Agan MD]
-simulates what would happen if you ablated those nerves? Tell me more about that.

[Stan McClurg MD]
It actually recreates what we would potentially do with a procedure such as rhinorrea ClariFix. It specifically isolates the posterior nasal nerve as an anticholinergic to decrease mucus production and some nasal congestion within the nose. Other nasal sprays don't really do that. Luckily, ipratropium bromide is generic, so it's pretty cheap. What I find is that people that respond to the ipratropium bromide, even just a little response or it goes away in an hour or something like that but they do have a response, I find that they have a much higher likelihood of RhinAer working on them.

What I usually tell them is, for patients that respond to ipratropium bromide, they'll have about an 80% chance of improvement with a procedure such as RhinAer, and of that, they'll improve anywhere from 60 to 100%. However, if they don't respond to ipratropium bromide and they're dedicated, this is coming from the nose, it drops down to about 40 to 60% in improvement with RhinAer. It's not zero but it helps me set expectations for patients on if we were to do a procedure, what a potential response they would have.

That's actually a change in mindset of a lot of surgeons. A lot of surgeons will say, "I'm only going to do a procedure if it's going to fix it 100% septal deviation or removal of polyp," or something like that. We gauge ourselves on, "Did we fix the problem or did we not?" When you start dealing with chronic rhinitis and these in-office procedures, you have to be okay that treating something very good is enough. That's the end result is that you're going to help it get better. It may not be 100% but you're going to actually make things better. It's a change in mindset in thinking of the surgeon.

[Gopi Shah MD]
That's a good point. Some of it's what we're doing is quality of life. If we can make the quality of life better and it's not like you have an alternative to "fix it." It is an improvement, which is good.

[Stan McClurg MD]
Right. We used to do video endarterectomies for patients for this and I've done a couple of those in my life. The dry eye that you get from hitting the branch to the [unintelligible 00:22:03] nerve is-- it can be debilitating for patients. It gives them something else to complain about but it's a tough surgery and it can be potentially pretty detrimental to a patient.

(5) Comparing Treatment Options for Chronic Rhinitis

[Gopi Shah MD]
I think this is probably a good segue to start talking about these procedures that we have available now to be able to offer patients like you said, have tried the ipratropium bromide and it works. Now they're like, "Wow, this works, but I sure would love to not have to give this to myself three times a day or four times a day." The frequent dosing can be difficult. Can you talk about the different options that we have now?

[Stan McClurg MD]
Yes. The first product out there was ClariFix which uses cryoablation to freeze the posterior nasal nerve. It works pretty well. I did start using that initially and I had decent results. However, the post-treatment headache, the ice cream headache, it's significant. They quoted about 17% but I find it's more like 40. I'd have to prepare patients for that. They form a crust at the very back in the sphenopalatine region where you do the treatment and that crust can sometimes cause postnasal drip and postnasal drainage as it's healing. It's actually causing a different source for the problem that you're trying to treat.

More recently, the RhinAer has come out and it uses radiofrequency ablation to treat the nerve a little bit more aggressively in my hands. I find that you actually get a little bit better results with the RhinAer because you're treating the nerve in multiple different spots. You can also treat the inferior turbinate itself, which the ClariFix you weren't really able to. I find that you get more bang for your buck and patients actually have better responses with the RhinAer.

[Gopi Shah MD]
What is your protocol or your pathway to saying, "Okay, this is a good option. Let's talk about moving forward with that."? What is your trial? You do just a month of the ipratropium and then it's like, "Okay, this potentially is an option." Does it matter if other things are going on? What is your assessment? Especially for those patients who come in and already know that they want it and they're like, "I'm here for the RhinAer procedure." [chuckles]

[Stan McClurg MD]
Yes. I think there's it falls into the two different categories. The people that respond really well and that's usually a slam dunk and they're willing to do it, I'm willing to do it. Stepping back a little bit, you have to assess the patient with a scope to make sure they're a good candidate. If they have a horrible septal deviation then you feel like you can't get to the location you need to. The sphenopalatine region of the posterior attach one of the middle turbinate, they may not be a candidate for anything unless you take them to the operating room.

For patients that have good anatomy and have good response, I think those patients all of them, will probably end up getting a procedure like this. The patients that don't have great response and or have bad anatomy, we have to talk about the pros and cons of, "If we try this procedure, there's a possibility that I can't get back to where I need to. There's also a possibility that it's not going to fix your problem. However, we're at the end of the line here for your issue. There's no other steps and this step of RhinAer, it's not going to burn a bridge. It's not going to-- recovery is minimal. If you want to try this procedure, I'm happy to do it. We just have to set our expectations that there's a possibility it might not fix your problem but there's no other steps. If you want to do something, this is it." Does that make sense?

[Gopi Shah MD]
Yes. You said that it can also address the turbinate a little bit. Explain to me, so you're going in, you have a wand or a paddle, the handpiece.

[Stan McClurg MD]
It's a stylus.

(6) Breaking Down the RhinAer Procedure

[Gopi Shah MD]
A stylus. Okay. You're putting it as you said, right below the posterior attachment of the middle turbinate where the nerve would be, and then you said three places. Can you describe to me in detail where and then you said you're addressing the turbinate, so does it also shrink the turbinate and are you just putting it on top of the mucosa?

[Stan McClurg MD]
Yes, so there's actually a newer stylus that came out, the RhinAer 2.0, it has an offset to it so it's not just flat at the end, it actually tilts back a little bit. It'll fit into the sphenopalatine region just at the attachment of the posterior middle turbinate pretty well. You start there and the tip of the stylus is a little bit smaller, so it fits a little bit easier back there. You start there.

I usually typically do, three to five treatments, just walking interior as you do it and then step down and walking interiors, you're doing that. Then you follow it down to the posterior aspect of the inferior turbinate. You can actually do some treatments on the inferior turbinate as you come out.

The newer wand, you can do a total of 22 treatments. That's the max so you can do 11 on each side. Some people will actually do treat the inferior turbinate because it does shrink it back. It can allow you to visualize and find the posterior nasal nerve site a little bit better. You could treat that inferior turbinate initially. I'll do that sometimes to actually see the posterior nasal nerve area a little bit better.

The cool thing about this is that there's no incisions so minimal bleeding from this, you're just pushing tissue out of the way and it helps the patients with nasal obstruction because you're actually reducing the inferior turbinate and also helps with visualization during the procedure.

[Gopi Shah MD]
Can you talk about your clinic setup and maybe a little bit about your anesthesia protocol and how you get these patients ready for the procedure in the office?

[Stan McClurg MD]
When I first started doing procedures in the office, I actually started with inferior turbinate reduction. Submucous resection of inferior turbinate, which I never really learned in residency or fellowship. I just made up and it went really well. You're using the submucous microdebrider blade to remove some tissue so you have a little bit of bleeding.

Then I stepped up to doing in-office sinus surgeries, which I still do occasionally. I would do all of those procedures in my procedure room. Then my next step was treating the nasal valve with VivAer and using that instead of submucous resection for inferior turbinates because I get pretty good results with minimal bleeding for that. Then that segued into doing ClariFix and/or RhinAer.

I actually now do those procedures just in the regular exam room for multiple reasons. It's a very easy procedure. Patients are comfortable with it. They've already been there with their initial assessment and it really helps with the flow of my day. I'm not using up a dedicated procedure time or a dedicated procedure room. It's just fit into the day. I've trained my office staff, my medical assistant will actually do the initial application of the tetracaine afrin pledgets. They'll do that, let them sit for 15 to 20 minutes.

Then when I go in, I do my injection and I use just straight-up lidocaine. I do not use epinephrine in this because it causes the tachycardia and anxiety and you really don't need it beacuse it doesn't bleed very much. I use a RAN needle. I don't know if you're familiar with a reinforced anesthetic needle. It's a very long needle. It's a 27 gauge tip with an outer sheath on it.

When you do the injection, it doesn't spray as much of the lidocaine down posterior oral pharynx and nasopharynx. I've been that even more than the initial bend to actually get to the location.

[Gopi Shah MD]
Wow. That injection, is that just right at the location, just one spot right where you are going to treat, and then it blanches and goes to that whole area, or do you do more than one poke, and then, you [crosstalk]-

[Stan McClurg MD]
I usually do one or two depending on-- I want to see the blanching. The bleb is important. It helps with the conduction of the energy for the RhinAer wand itself. You want to see that. It also helps with, of course, patient tolerance of the procedure. If I don't get it well on the first one then I'll do a second one. I will also mention that injection can be hard. [laughs] For some people that maybe aren't comfortable doing those injections, I usually recommend that they start trying it in the operating room.

When they're doing sinus surgery, it's a little bit hard to hold that needle in the correct location to actually insert it and not run into everything. You don't want to do that while a patient's awake, so do it while they're asleep, practice it so you can get to the correct spot to do those injections.

[Gopi Shah MD]
That's good advice. It's even harder with a spinal needle compared to the RAN needle.

[Stan McClurg MD]
Correct.

[Gopi Shah MD]
The RAN needle does help a lot because it's more rigid, doesn't flop around the nose as much. [laughs] Are your pledgets-- what percent-- is it separate solutions of afrin and tetracaine or you have a compounded afrin-tetracaine gel or what's actually on your pledgets?

[Stan McClurg MD]
I just use a 50/50 mix of 4% tetracaine and afrin. You want to make sure you wring those out. If you don't, then they get the horrible throat numbness and they start clearing the throat and coughing. It's just miserable. Make sure you wring them out really well. As I put them in, I've actually taught my medical assistants this too, is you bend the very distal portion of the pledget to try to sneak it up into the middle meatus as you put it in. It's not 100% effective, but as you do that, if you bend it laterally, it'll actually sneak up into the location where you're trying to get two a little bit easier. I do two of them, let them sit 15 to 20 minutes.

[Gopi Shah MD]
Do you keep your patients sitting up?

[Stan McClurg MD]
Yes, they're mostly sitting up, not laying flat. That's how I scope patients and that's my setup in the office.

[Ashley Agan MD]
I was just going to say, your pledgets are your standard sinus pledgets with the strings that are used for sinus surgery?

[Stan McClurg MD]
Correct. Yes.

(7) Comparing the VivAer & the RhinAer

[Gopi Shah MD]
The RhinAer device, it's using the same console as the VivAer, right?

[Stan McClurg MD]
Correct. Yes

[Gopi Shah MD]
It's different though. When you plug it in, the machine knows that this is for RhinAer and when you hit the pedal it's doing the time cycle that you would for RhinAer and the amount of energy.

[Stan McClurg MD]
When you plug it in, there's actually a microchip in the cord itself that will tell it whether it's a RhinAer or a VivAer. The RhinAer is just 12-second treatments. When you are doing the treatment, it goes very rapidly and it goes up to I think 61 degrees Celsius. It's temperature controlled so it doesn't get extremely hot back there, but it's the same unit. If people are doing VivAer in the office, it's very easy to incorporate the RhinAer as well because you just need to buy the separate stylus and plug it into the same unit.

[Gopi Shah MD]
You would never use-- if you were out of one stylus, you would never use the other stylus just in a different location because it is a different amount of energy in a different time cycle and all those things.

[Stan McClurg MD]
It's also a different size. The length of the VivAer is not far enough to get back to the location that you need to get to. The newer wand, the RhinAer 2.0 you can actually bend it a little bit easier and it fits better posteriorly with the smaller diameter of the shaft as well.

[Gopi Shah MD]
Anything else for the procedure part of it before we move on to post-op care?

[Stan McClurg MD]
I was mentioning previously how I'll do the initial endoscopy to see if patients are going to be a good candidate based on anatomy. With the more recent changes that they've made with the new wand, I'm actually finding that I can sneak this new one into more smaller areas at the back of the nose. If they have a large posterior spur or even a significant septal deviation, just because of the size of this new one, you can actually get in there and treat the location you want to. I'm doing more and more procedures that previously maybe I couldn't because I couldn't get the wand to the correct location.

[Gopi Shah MD]
Do you use a pediatric 30-degree rigid scope for these as well?

[Stan McClurg MD]
I actually use a 0 for these. I like to have the light cord going off towards me and it the 0, you can do that 30, you can't really do that.

[Gopi Shah MD]
Makes sense. Can you do this in the operating room or do you for your patients who you just maybe-- every now and then, you have a patient that's like, "Put me out, you can't-- I can't even have a scope. You're going to have to knock me out."

[Stan McClurg MD]
Yes, I do these procedures in the operating room as well and for the people that potentially might need a septoplasty to gain access, I'll do it in those scenarios. I've also been doing-- [chuckles] some of the other patients and from other ENTs in my group have caught wind of this procedure with pamphlets or whatever. I'll actually do combination procedures. If they're getting a rhinoplasty or something, but they also have postnasal drip, I'll just jump in and do a rhino right before they get their rhinoplasty. It's a good adjunct for other procedures as well.

[Gopi Shah MD]
I wonder if the if the TRACT balloon would help with your deviated patients. I've used it for-- Are you familiar with it? It's an Acclarent balloon that helps push things out to the way. I've used it for my eustachian tube dilation patients that where they have a spur or a deviation to that side and I need to get back to the nasopharynx and I can't, so along the floor of the nose. Of course, there's quite a bit of inferior turbinate out fracture that happens as well as pushing that septum over.

I wonder if it would help you gain access for this. It's a little bit higher up in a slightly different location, but I don't know, something to think about for your office patients.

[Stan McClurg MD]
I think it probably could. The only issue I have with that is when you push it from one side, it goes to the other side. You potentially can cause a nasal obstruction on the opposite side of where you're doing the TRACT balloon. I think it would probably help gain access.

(8) Post-Op Care for In-Office Procedures

[Ashley Agan MD]
What's your post-op? Do they need to be doing any saline or is there any post-op care? Then that immediate, excuse me, post-op stuff and then how long it lasts for, that kind of stuff.

[Stan McClurg MD]
Actually one of the cool things about this is there's minimal post-op care necessary.

[Ashley Agan MD]
They don't have to do saline? Come on. Stan, you're a rhinologist, everybody does saline afterwards.

[Stan McClurg MD]
[laughs] Yes, they have to do saline. I tell them they can if they want to.

[Ashley Agan MD]
That's not something they need to do-

[Stan McClurg MD]
I don't think it really helps other than getting a little bit of the blood that might have occurred from the procedure. You can do it for the first couple of days. I will sometimes send them home with some afrin nasal spray just in case they have a nosebleed. There's always that concern that you could cause a bleed from this sphenopalatine artery or something like that. I've never actually seen that myself. I didn't take care of a patient that maybe someone else did, but I didn't cause it myself.

I usually see patients about a month out afterwards and one of the things we talk about is how for whatever reason, it sometimes takes a little while for them to have a significant response from this procedure. I'll see them about a month, month out, and usually at that point if they're going to have a good response, it's actually fluctuating. They'll have one day that's good, one day that's bad and then alternate and I'll talk to them about how that's actually a good response. Usually, at about two months or so, they'll notice that there's even more improvement. That's happened for most of my patients is it'll fluctuate initially and then get better after about six to eight weeks.

I also find that in that interim, they can use the ipratropium bromide as well and in combination of the RhinAer plus the ipratropium bromide usually works very effectively. Maybe they don't have to use it like once a day or when they use it, it lasts for much longer than it previously did.

[Gopi Shah MD]
At what point do you tell them, "This is as good as it is going to get, and this is the final outcome we can expect."?

[Stan McClurg MD]
For most patients, I'll just see them at about one month and then potentially see them at two months if there is any concerns. I usually tell them by about three to four months, that's usually the end result that they're going to be getting. Quite honestly, I just don't see patients back after that very frequently, just because I think they're happy and they don't really need any further treatment. There's been some studies showing that this treatment lasts at least two years. It's only been out for a little bit longer than that, so the studies are ongoing.

Similar to VivAer, they keep on coming out with a new study every year to show that it's still working. Currently, it's about four years out so I think they'll probably continue to do that, but it has been shown that it has long-lasting results. Then at the same time, say 10, 20 years down the road, it comes back, they realize how easy this procedure is and they'll just come back and we'll get a touch-up.

(9) Comments on Revision Surgeries

[Ashley Agan MD]
Have you had to do any revisions yet, or is that just so rare?

[Stan McClurg MD]
I've had to do a couple of revisions on the ClariFix. What I've actually done is transitioned over to doing the RhinAer on those patients just to switch it up. Usually what happens is they'll have a really good response. Most of them have then subsequently gotten COVID for whatever reason, and then it just totally screws up their posterior nasal nerve and they start having running nose again. I can't really explain the pathophysiology of that, but I've had probably about five patients in that scenario. We just do it again and it works the second time as well.

[Ashley Agan MD]
They were doing well and then they got COVID and then their nose started running like before and then you repeat the procedure and then they're good again.

[Stan McClurg MD]
Yes, and I'm not going to do a study on that. I really don't want to.

[Ashley Agan MD]
You don't want to be the expert for it [laughs] get on that COVID--

[Stan McClurg MD]
On covid rhinitis, none of them [laughs]

[Gopi Shah MD]
One question for you. We talked about how with the device you can address the rhinitis with a posterior nasal nerve, but you also said, "Hey, you can reduce some of the posterior inferior turbinate with it as well."

[Stan McClurg MD]
Yes.

[Gopi Shah MD]
For the patients that have significant nasal obstruction with the rhinitis and they have big inferior turbinates, can you just then use the wand and bring an interior with the 11 options that you have, or are there patients where you're like, "Hey, I need to actually do something more"? I don't know if you want to say more or a different device that's more specific for inferior turbinate reduction. My question is, is the device an adjunct to give you a little bit of, or does it actually also do turbinate reduction as well?

[Stan McClurg MD]
Initially, when I was doing these procedures, I would do a submucous resection as well for those patients that have inferior turbinate hypertrophy as well as the chronic rhinitis. Then I realized that the RhinAer wand itself actually does a pretty good reduction and you can use the multiple treatments along the entire length of the inferior turbinate. It zaps it pretty good. Postoperatively, I have difficulty finding difference between the patients that I did the submucous resection versus the RhinAer wand itself. Then you're actually just using the same wand, so you don't have to open up a second one and eat that cost.

I would say if patients have continued nasal obstruction afterwards, you could offer them a submucous resection as well, but I haven't run into that scenario quite honestly.

[Gopi Shah MD]
This could potentially be for your allergic rhinitis patients as well.

[Stan McClurg MD]
That's actually one of the interesting scenarios is, I started doing this for the chronic rhinitis patient that maybe was not an allergic. More recently I've been adding on this as an adjunct for allergy patients. Even if they test positive with skin testing, I give this as an option for maybe a little bit more immediate relief of some of their symptoms, the nasal obstruction, the runny nose.

I've had quite a few patients that are interested in doing this because they don't want to wait the 6 to 12 months for their shots to start working. It's like a jumpstart to getting their allergy therapy ramped up a little quicker. It also opens up this entirely new avenue of patients. All those patients that we previously dumped into the allergy bucket that we very rarely see and they just see their allergist or your allergy nurses, you could actually spin this out as an option for those patients themselves and get those patients back in to potentially do a procedure on. It could potentially open up a pretty large volume of patients to be seen.

[Gopi Shah MD]
Does it last the same amount of time you think in terms of does it help for the same amount of time as for the two years potentially as your non-allergic rhinitis?

[Stan McClurg MD]
I would actually think it would probably potentially last longer just because you're also doing allergy therapy at the same time. I just think that it ramps things up a little quicker and patients get a more immediate response than they have subsequent allergy therapy that's treating their ongoing symptoms.

[Gopi Shah MD]
That's very interesting. As we wrap things up, any final thoughts or pearls that you want to leave our listeners?

[Stan McClurg MD]
This is an excellent tool to treat something that previously was not very easily treated. It's similar to the nasal valve. People never looked for the nasal valve until they actually had a treatment for it. Now I do the modified [unintelligible 00:45:42] pretty much every patient to try to find patients that would potentially benefit. The runny nose patient has always been a patient that nobody wants to see because there's not really therapy for it, but now it's a patient that has a pretty good therapy that's an in-office procedure that patients can benefit pretty significantly from.

I think it's an awesome opportunity to introduce this treatment for patients that previously had no significant treatment options.

[Gopi Shah MD]
Yes, it's exciting to be able to have something to offer for sure.

[Stan McClurg MD]
Yes.

[Gopi Shah MD]
Well, thank you so much for coming on this show, Stan. If our listeners wanted to contact you, reach out to you for any other questions, are you on social media or website or anything like that?

[Stan McClurg MD]
Yes. I have a Facebook page Kansas City Sinus or you can reach out to me just through my website. I'm happy to talk to anybody that's referred through you guys or the local Aerin rep usually can reach me and get a hold of me if there's any questions.

[Gopi Shah MD]
Awesome. Sounds great. Thanks for taking the time. It was fun.

[Ashley Agan MD]
Thank you, Stan.

[Stan McClurg MD]
Thank you. It's been great.

[Gopi Shah MD]
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend. If you have any questions or comments, direct messages @_BackTable ENT, on Instagram, LinkedIn, or Twitter. BackTable ENT is hosted by Gopi Shah and-

[Ashley Agan MD]
Ashley Agan.

Podcast Contributors

Dr. Stan McClurg discusses In-Office Procedures for Chronic Rhinitis on the BackTable 77 Podcast

Dr. Stan McClurg

Dr. Stan McClurg is a private practice rhinologist at Ascentist Healthcare in Kansas City.

Dr. Ashley Agan discusses In-Office Procedures for Chronic Rhinitis on the BackTable 77 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses In-Office Procedures for Chronic Rhinitis on the BackTable 77 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2022, November 15). Ep. 77 – In-Office Procedures for Chronic Rhinitis [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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