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BackTable / ENT / Article
PROPEL Sinus Implant: Advanced Applications in Pre-, Post- & Non-Operative Sinus Care
Iman Iqbal • Updated Jan 20, 2025 • 37 hits
Sinus drug delivery devices like PROPEL are indicated for post-operative sinus surgery, providing targeted, localized treatment to reduce inflammation and maintain sinus patency. While its primary role is in post-operative care, the PROPEL device is also being utilized in new pre-operative and non-operative applications, potentially offering new options for managing sinus conditions in a variety of clinical scenarios.
This article examines the expanding role of PROPEL with commentary from otolaryngologist Dr. Rajiv Pandit on the BackTable ENT Podcast. You can listen to the full episode below.
The BackTable ENT Brief
• According to Dr. Pandit, the PROPEL stent effectively maintains sinus patency, prevents turbinate lateralization, and provides uniform steroid delivery, improving post-operative outcomes.
• PROPEL may offer a safe, minimally invasive alternative for managing conditions like nasal polyps and congestion in special populations, such as pregnant women.
• In patients with mild obstruction or smaller polyps, PROPEL can be paired with in-office balloon dilation for targeted treatment, reducing the need for traditional surgery.
• PROPEL may be particularly beneficial for fragile patients, including those with cardiac conditions or pregnancy, where extensive surgical interventions may not be feasible.
• Techniques like basal lamella incisions optimize the medialization of the middle turbinate when combined with PROPEL Contour, providing stable healing and improved airflow.
• PROPEL’s mesh design delivers consistent steroid coverage, addressing widespread inflammation and promoting balanced mucosal healing.
• Clinicians have explored PROPEL’s use in challenging areas like the sphenoid sinus, nasopharyngeal stenosis, and ear canal stenosis, demonstrating its adaptability and potential for future indications.
Table of Contents
(1) Deploying the PROPEL Sinus Implant in Pre-Operative & Non-Operative Cases
(2) Advanced Strategies for Using the PROPEL Contour in Post-Operative Care
Deploying the PROPEL Sinus Implant in Pre-Operative & Non-Operative Cases
The PROPEL sinus implant offers a versatile solution for managing specific sinus conditions, particularly in complex or non-operative scenarios. Dr. Pandit posits that PROPEL can provide significant relief for pregnant women with a history of nasal polyps or severe nasal congestion. In these cases, the implant can be placed without the need for imaging, offering a safe, minimally invasive alternative to traditional surgery while deferring more extensive interventions until after delivery. This approach is equally valuable for patients with cardiac conditions, where imaging or surgery may not be feasible.
For patients with smaller polyps or mild obstruction who are not yet candidates for traditional sinus surgery, the PROPEL sinus implant can be effectively combined with in-office balloon dilation. This targeted placement allows for precise steroid delivery, reducing inflammation and maintaining sinus patency. These minimally invasive techniques provide significant symptom relief, improve airflow, and can reduce the need for more extensive surgical interventions, offering patients a less invasive path to improved quality of life.
PROPEL is also being explored in other sinus conditions and anatomies, including applications in the sphenoid sinus, sphenoethmoidal recess, nasopharyngeal stenosis, and even ear canal stenosis. While such uses require caution to mitigate risks like device migration, they highlight the implant’s potential to address complex anatomical and pathological challenges.
[Dr. Gopi Shah]
I wanted to ask, we've talked a lot about the use in post-op, but what about pre-op settings? You gave a perfect example of a patient that may have a history of chronic sinusitis or nasal obstruction, especially in a woman that's nursing or pregnancy. In other patients, is there a utility in terms of a PROPEL for a patient that has-- new patient, otherwise not operated on that might have like Grade 2 polyps or something like that? Do you ever do it before you've gotten a surgery?
[Dr. Rajiv Pandit]
I have. That's something that you have to be very careful about. I had a woman who was pregnant, a second trimester, had a history of polyps, had previous surgery and wanted something done. She was desperate. I wasn't going to do a CT because she was pregnant. I did a nasal endoscopy. I made sure that I could have good visualization and made sure I wasn't dealing with encephalocele or something unusual or a neoplasm. At that point I did go ahead and do PROPEL. She was so thrilled. She was so thrilled. She was so thrilled. We saw a whole bunch of other women that were pregnant, and it wasn't from the referring physicians.
What I found out was she had discussed this on a Facebook forum of expecting mothers. I was having-- for a few months, I think for like six to nine months, I had a bunch of women during pregnancy who had the same issue. We're dealing with severe congestion. They didn't all have polyps and just had allergies, but it was just interesting how when you make one person happy-- She was one that a lot of people were concerned about doing something because they couldn't necessarily image her, they weren't comfortable doing a procedure, but the PROPEL was a great, great option, until we could do a more thorough workup after the delivery.
[Dr. Gopi Shah]
Have you used them in your other fragile patients or your cardiac patients or patient granted? I know there's a lot more that we do in the office in terms of sinus work now, but do you do them on a sinus surgery naive patient, with small polyps that you might-- is there a role for PROPEL otherwise, or is it, "No, you really need to have everything opened up and cleaned out," and the real goal is to prevent and cool things down until we get our rinses and it's more effective as opposed to--
[Dr. Rajiv Pandit]
Yes, what I'll do in that case is I will-- a patient that, say, needs a traditional sinus surgery, I will do an in-office balloon dilation just to be able to get the PROPELs into the right area and to make sure that they stay in place. We've had those patients that have small mini polyps in the ostiomeatal complex. It's not huge, but it's definitely enough to obstruct their breathing. They'll get recurrent infections. They probably need a fast of some sort, but they may do fine with just a little plucking of the polyps, a little dilation, putting those PROPELs in and you watch them. You'd be surprised how many of those actually do pretty well. Far fewer of them now need traditional sinus surgery.
I think there's definitely a role for a mid-lane basic procedures in the office in conjunction with a PROPEL. I don't think that I would do the PROPEL alone because it's a little difficult to get it into where you want it unless you dilate that space.
…
[Dr. Gopi Shah]
We've talked about placement in nasofrontal recess, maxillary sinus ethmoid. Is there ever a role for the sphenoid sinus?
[Dr. Rajiv Pandit]
There is, but I believe it's still off-label.
[Dr. Gopi Shah]
Okay. [laughs] I know there's a lot of important structures there, but why don't we just put it at the door, or [chuckles] maybe we shouldn't, I don't know.
[Dr. Rajiv Pandit]
No, I have, I have put PROPELs in a number of places. I had a patient, adult patient with nasopharyngeal stenosis. I drill that down, I put a PROPEL there, I put a PROPEL in the sphenoid sinus when you've had those severe polyploid cases. I even did ear canal stenosis and I use a Mini PROPEL and then I put packing inside there to help with that. I've been pretty bold about using it off-label. I'm careful in terms of making sure that it's not going to migrate or go somewhere where it shouldn't. I think it's a great-- the sphenoethmoidal recess is a great place to put it when you have that posterior polyploid disease.
[Dr. Ashley Agan]
Yes, and it's going to break down in a month. It's not like it's going to erode through anything like a foreign body reaction would.
[Dr. Rajiv Pandit]
Exactly.
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Advanced Strategies for Using the PROPEL Contour in Post-Operative Care
The PROPEL Contour, an advanced version of the standard PROPEL, is designed to address common challenges in post-operative sinus care. More specifically, the PROPEL Contour has been tuned to better maintain sinus patency and prevent the lateralization of the middle turbinate. Its increased tensile strength allows for versatile applications, enabling surgeons to achieve multiple objectives simultaneously. For instance, in office-based procedures, the stent can be strategically placed to support the nasofrontal recess while exerting gentle pressure on the middle turbinate to ensure medialization. This technique also stabilizes the uncinate process, creating a more stable and open ostiomeatal complex for optimal healing and airflow.
To further enhance outcomes, a surgical technique involving a targeted incision at the basal lamella can be employed. This prevents contraction during healing, ensuring the middle turbinate remains medialized. When used in combination with the PROPEL Contour, this approach maximizes the benefits of the stent's tensile strength, offering patients improved post-operative breathing and reduced risk of complications.
According to Dr. Pandit, the PROPEL Contour also excels in delivering consistent anti-inflammatory treatment. Its design ensures steroid release along the entire mesh, providing uniform coverage of mucosal surfaces. This feature is critical for addressing widespread post-operative inflammation and promoting balanced healing.
[Dr. Gopi Shah]
In terms of the PROPEL stent, I had just two questions. One was for the Contour one. You had mentioned that there's increased tensile strength. When you put that in, does that help you keep that middle turbinate medialized? You had mentioned putting it either the nasofrontal recess or-- I was just wondering, given that tensile strength, does that help you also medialize the middle turbinate at all?
[Dr. Rajiv Pandit]
You're making me share a little pearl, a little trick that I think is wonderful that I learned from actually going to other in-office sinus surgeons and watching them do procedures. I didn't create this. I learned it and implemented it. One of our biggest issues with the ostiomeatal complex is exactly that, it's the lateralization of the middle turbinate. The PROPEL, as you mentioned, the Contour has great tensile strength. That's a great thought. How can we get one to benefit? What I've learned is that the nasofrontal recess, when you have the hourglass opening, the Contour, putting it inside the entire recess and having the apposition go like this inferiorly works great.
However, in the office setting, you often are dealing with patients that don't have as severe disease in the nasofrontal recess, or it doesn't extend all the way into the frontal sinus. It's mostly maybe in the inferior portion of the recess, this peri-ethmoid cavity. What I have learned is that I can actually do three things with one Contour, especially in the in-office setting. In the in-office setting, what I will do is I will put the PROPEL partially into the nasofrontal recess, and I will slant it so that the bottom part is pushing against the middle turbinate. Now we'll put the whole thing behind the uncinate after doing the maxillary sinus dilation.
That way, I am actually keeping the nasofrontal recess open. I'm making sure the uncinate stays medialized, and I'm making sure the turbinate stays medialized. Now, how do I maintain that space, especially since the PROPEL is only there for 30 days and that the middle turbinate may then lateralize again? This is a trick I learned from another surgeon, is that I take the caudal elevator and I make an incision where the middle turbinate comes around. Just where the basal lamella is, just above that, where the middle turbinate comes around and joins the ethmoid bulla. I'll use a caudal to make an incision there.
It's like making a crack to keep that door hinge open, and then that'll get the middle turbinate to medialize, so then when you put the Contour in there, it allows that incision to heal without contracting, and leaves the middle turbinate medialized. I have found this-- I'll do a pre-op photo and then I'll do a post-op photo, and I will show the patients, "Look at what we've done with your middle turbinate. That's why you're breathing better, because you have this entire ostiomeatal complex that's now open. That's where I'm taking full advantage of the tensile strength of the contour.
…
[Dr. Gopi Shah]
Then, sorry, one other question about the actual stent. You have to remind me, is the delivery of the steroid just at the tips, or is it along the tines as well of the mesh, or is it just at the points of the mesh?
[Dr. Rajiv Pandit]
It's along the entire mesh. That is very useful in-- inflammation is going to be along the entire pathway. It's been very-- I wasn't sure if it was going to be concentrated in the tips, but I have found that it is actually, just in terms of the mucosal surfaces afterwards, they're pretty even afterwards. I can tell you practically, it does look like the steroid is leaching into the mucosal surfaces evenly across the entire PROPEL.
Podcast Contributors
Dr. Rajiv Pandit
Dr. Rajiv Pandit is a clinical instructor and section chief of otolaryngology at Methodist Dallas Medical Center is Dallas, Texas.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2024, July 16). Ep. 181 – Localized Drug Delivery for CRS [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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