Incorporating Office-Based Rhinology into Your Practice

[Gopi Shah MD]
While we're on the topic of equipment, can you talk to us about some other tools that you have that you feel are important to you the success of being able to do these in-office procedures?

[Scott Fortune MD]
Always start with the basics. The first basic for this is good visualization. You need some good telescopes. If you can, you need at least 4k resolution. Having good visualization is so important. You got to be able to see what you're doing to do it well.

[Gopi Shah MD]
In terms of scope size, do you find that you do most of these with a 4 mm or 2.7 since they're awake and you don't want them to feel as much, but it's smaller and so things get blurry faster?

[Scott Fortune MD]
The scopes we use are more pediatric size. It gives us a little more room to maneuver around in the nose. Nowadays, I think from most scope providers, you can get a wide field view. Even if you're using a 3 mm telescope or a 2.7, as you mentioned, you can still get a view that's equivalent to a 4 mm. Once you get a 4 mm scope in there, it's surprising. Even with a patient decongested, it really limits your degree of freedom. If you can use the lower profile scopes, I'd really recommend that. My go-to scopes are the 0 and the 30, but I do occasionally pull out a 45 if I really need to visualize the maxillary natural ostium really well, I find that 45 to be important for that.

Once you have your scopes, then there's a decision point, a fork in the road, if you will. If you don't have a lot of equipment, you can ask your rep of whatever company you prefer to bring you what you need. You can borrow it, you can start small and add on or you can just get the whole package. Just to summarize, you'll need good endoscopes. You'll need some sinus instruments. You'll need some small Blakesley Thru-Cut Forceps. You'll need a Bayonet, but if you can get an alligator, either an otologic alligator or we were lucky to find an alligator forceps that's about 8 cm long and this is really useful for placing those small pledges far back in the nose.

[Gopi Shah MD]
This is a small detail, but in terms of pledget size, when you say the small ones, what size do you tend to? Is it-

[Scott Fortune MD]
We use two kinds of pledgets. We use 0.5 x 3s. Those are the ones we place on the first round, and there, we just put them as far back in the nose as the patient can tolerate to start with, but once we start the second round of topical after we've injected, we use 0.5 x 1s or 0.5 by 2s, so the smallest size you can get and that's important because you need a small profile to tuck in lateral to the middle turbinate, medial to the middle turbinate, especially you need a small one to tuck into the torus if you want to do some Eustachian tube work or if you want to get a pledget in sphenoethmoidal recess or around the superior turbinate, you need a small one. We found that 0.5 x 1s or 0.5 x 2s are most useful for that.

[Gopi Shah MD]
Do you cut the strings off or do you have the ones with the strings?

[Scott Fortune MD]
We use the ones with the strings. I don't cut the strings off for two reasons. One, you have a slightly sedated patient and if that falls down their throat, they may not notice it. The other is that sometimes patients will swallow and the act of swallowing, even if their throat is not anesthetized will start to pull the cotton down their throat. To me, you need a rescue line there to keep that from happening. You don't want your cotton pledgets becoming a foreign body that you've got to deal with outside your office.

[Ashley Agan MD]
There's a lot of growth for sure. Dr. Fortune, what is a procedure that's a good one to start with for somebody trying to incorporate office-based rhinology in their practice?

[Scott Fortune MD]
I would recommend considering your first step is treating those patients with chronic rhinitis. If the patient has a positive response to the ipratropium and doesn't want to use medication for a long period of time, that they're probably a good candidate for treatment of chronic rhinitis. You've basically got two options there. They're the opposites of one another. You can cool it down or you can heat it up. You can offer cryotherapy or you can offer radiofrequency ablation. Both of those have been shown in studies to be safe and effective. The percentage responses in those studies are typically above 70%. A good rule of thumb for procedures for chronic rhinitis is that about four out of five are going to improve and improve, for some, means they don't need the nasal spray, but it's important to set a good expectation for patients.

I find that either the cryotherapy wand or the radiofrequency device is low enough in profile that you can often maneuver some septal deviations and things like this and not have to address that also. Let's assume that they want to do that and they're going to do it without the pre-meds. The process is still the same. They're set up on a procedure day. They will come and they'll still get their acetaminophen an hour ahead of time, and then 15 minutes ahead, they'll get their first round of pledgets. Shortly after that, they'll get their Afrin spray, then they're moved over to the procedure room and then they get their first set of the long pledgets that we discussed with the lidocaine and epi mixture. I've altered my technique just a little bit and I want to tell you why.

Now what I will do is take the pledgets out of the left, inject, put the pledgets back, wait about three, four or five minutes and you got to figure out what you're going to do with those few minutes because when you're not doing anything, they're the longest three, four or five minutes of your life and then I will take the pledgets out and do the procedure on the left side and then repack that and then go and inject the right and do the procedure on the right. Doing that, I've found that I avoid that anesthetic wearing off problem.

A key point especially for chronic rhinitis treatment is a good sphenopalatine injection. That's especially important for cryotherapy because the one pitfall in this procedure is the ice cream headache. A good way to prevent that ice cream headache is to make sure you get a good sphenopalatine injection. We talked about that reinforced anesthesia needle. That's a key tool to provide a good sphenopalatine block. The one little modification for cryotherapy is I will provide that block before I do the procedure, and then as soon as I get that cryo wand out of the nose, I'll apply a little bit more of the local in that area. That seems to blunt the ice cream headache quite nicely.

If you do get one, just have some hot liquids on hand. That's another good way to manage an ice cream headache is to give the patient some hot coffee or some hot tea. The ice cream headache is not such an issue with radiofrequency. For either one, the cryotherapy balloon, which is you can get from Stryker or the RhinAer wand, which you can get from Aerin medical, the device goes back right over the sphenopalatine area and then you apply the treatment, and with the cryo wand, your treatment time is 30 seconds. Then you need to let the wand sit where it is for 45 seconds because if you pull it straight out, you're going to pull out a large piece of mucosa with it.

The cryo wand cools off to such a temperature that the balloon device freezes to the tissue for a moment. To allow that to release, you need to give about 45 seconds. You'll know when you can take the wand out because all of the frost will be gone from both the balloon and from the mucosa. Then what I'll do at that point is just give the balloon a slight little wiggle. If it's not stuck at all in the mucosa, you can take it out. The radiofrequency device treatment time is 12 seconds. Once the wand has gone through a full cycle of treatment and cooling which lasts 12 seconds, you can take it straight off of the mucosa. That's another slight subtle difference between the two procedures.

For both, I'll see them back in about five weeks. What we will do is have them come back. We'll have them tell us their history. We'll examine their nose and we will do that symptom score because sometimes the patients don't realize what difference there has been in their preop and postop symptoms. That symptom score is a nice way to say, "Well, you had this before the procedure and now you're down to this level. That's a good objective measure of your response to the treatment."