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BackTable / ENT / Article
VivAer vs RhinAer vs ClariFix: In-Office Rhinitis Procedures
Taylor Spurgeon-Hess • Updated Jul 26, 2023 • 5.4k hits
Dr. Stan McClurg explains the benefits and potential drawbacks of VivAer vs RhinAer vs Clarifix, which are all revolutionizing the treatment landscape for chronic rhinitis. These in-office solutions, while distinct in their methodology, can provide long-lasting relief to patients. Further insights into the RhinAer procedure provides a comprehensive understanding of the procedure's execution in an exam room, highlighting the interplay between proficient medical personnel and state-of-the-art medical devices. Lastly, an explanation of the RhinAer and VivAer devices offers a clearer picture of the expanded range of treatment options available to patients with chronic rhinitis and nasal airway obstruction.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• ClariFix relies on cryoablation, targeting the posterior nasal nerve; however, it may lead to post-treatment headaches and crust formation in the treated area, potentially causing postnasal drip.
• RhinAer utilizes radiofrequency ablation for a more aggressive approach to nerve treatment, offering the added benefit of treating the inferior turbinate, often yielding comprehensive results.
• Patient nasal anatomy plays a crucial role in choosing between RhinAer vs ClariFix, with severe septal deviation possibly requiring an operating room environment.
• The RhinAer procedure employs a specific stylus, the RhinAer 2.0, designed to fit the sphenopalatine region and the inferior turbinate for targeted treatment.
• The RhinAer procedure takes place in an exam room, starting with an initial application of tetracaine afrin pledgets by a medical assistant, followed by an injection administered by Dr. McClurg using a reinforced anesthetic needle (RAN needle).
• Despite sharing the same console, the RhinAer and VivAer devices are differentiated and adjusted via a microchip in the cord.
• The RhinAer device operates at a temperature-controlled 61 degrees Celsius for 12-second treatments, with the RhinAer 2.0 stylus offering better maneuverability for treating challenging nasal anatomies.
• The RhinAer and ClariFix procedures can be carried out in an office or an operating room and may be combined with other interventions such as septoplasty or rhinoplasty.
Table of Contents
(1) RhinAer vs ClariFix
(2) The RhinAer Procedure & Clinic Setup
(3) RhinAer vs VivAer
RhinAer vs ClariFix
Dr. Stan McClurg introduces two in-office procedures available for patients with chronic rhinitis, particularly those who have responded positively to ipratropium bromide treatment but are seeking a longer-lasting solution: RhinAer vs Clarifix. RhinAer uses radiofrequency ablation to treat the nerve more aggressively and can also treat the inferior turbinate, which ClariFix doesn't allow. ClariFix, on the other hand, uses cryoablation to freeze the posterior nasal nerve, providing good results but often causing significant post-treatment headaches and a crust formation in the treatment area, which can cause postnasal drip. McClurg finds RhinAer provides more comprehensive results. However, the suitability of these procedures depends on the patient's nasal anatomy. In the case of severe septal deviation, the procedure may not be feasible unless performed in an operating room.
[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."
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The RhinAer Procedure & Clinic Setup
Dr. Stan McClurg provides a detailed explanation of how the RhinAer procedure is performed in-office for chronic rhinitis patients. The procedure employs a stylus, specifically the RhinAer 2.0, which has an offset to fit perfectly in the sphenopalatine region at the attachment of the posterior middle turbinate. The stylus is used to perform three to five treatments, moving anteriorly with each treatment. It can also be used on the inferior turbinate, reducing it and helping with nasal obstruction.
The procedure is performed in an exam room rather than a dedicated procedure room, with the initial application of the tetracaine afrin pledgets done by a medical assistant. Following this, Dr. McClurg performs an injection with lidocaine using a reinforced anesthetic needle (RAN needle) to numb the area. The RhinAer procedure causes minimal bleeding and does not require any incisions.
[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.
RhinAer vs VivAer
While RhinAer and ClariFix are used to treat chronic rhinitis, VivAer is designed to treat nasal valve collapse. The RhinAer device shares the same console with VivAer, but a microchip in the cord enables the machine to differentiate between the two, adjusting the time cycle and amount of energy used accordingly. The RhinAer device provides 12-second treatments at a temperature-controlled 61 degrees Celsius. Despite the shared console, the RhinAer and VivAer styluses are not interchangeable due to differences in length and the amount of energy they deliver.
The newer RhinAer 2.0 stylus, with its more flexible and smaller diameter shaft, is better suited for reaching deeper into the nasal cavity, allowing for treatment of patients who may have been previously considered unsuitable due to anatomical features such as a large posterior spur or significant septal deviation. Both procedures can be performed both in the office and in the operating room and can be combined with other procedures like septoplasty or rhinoplasty.
[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.
Podcast Contributors
Dr. Stan McClurg
Dr. Stan McClurg is a private practice rhinologist at Ascentist Healthcare in Kansas City.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
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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