SINUVA vs PROPEL: Localized Drug Delivery After Sinus Surgery

[Dr. Gopi Shah]
Is the Mini specifically for the outflow track or the Contour supposed to be going in the ostiomeatal complex? Tell me about the differences between them and how you use each one.

[Dr. Rajiv Pandit]
Sure. Some of what I'm going to say is likely to be off-label, but I'm going to be speaking freely as an otolaryngologist that has been using these products for 13 years. The standard PROPEL was designed to go into the ethmoid cavity. It fits perfectly in the ethmoid cavity. It comes in a straight delivery device. After sinus surgery, after you've opened up the anterior and posterior ethmoid cavities, and that's often an area where you really need to keep that clean for irrigations. It's the pathway often to irrigating to the sphenoid sinus after total ethmoidectomy. The superior ethmoids, polyps there can obstruct the nasofrontal recess.

The standard PROPEL was a fantastic choice post-operatively, especially after polyploid surgery. That would go straight into the standard PROPEL into the ethmoid cavity. The Mini came out for two purposes. For when you're doing anterior ethmoidectomy, so you don't have as much of a distance to cover, for office-based procedures, and then also for the nasofrontal recess when you have one of those long cylindrical nasofrontal recesses, as opposed to the hourglass type where the Contour is actually better designed.

The Contour has more of an hourglass shape to it. It actually has a little bit more tensile strength. It provides great apposition for those openings that are more funnel-shaped in the interior portion of the nasofrontal recess. The Mini, it was used for anterior ethmoidectomy, the nasofrontal recess when you have more of that cylindrical shape, and for in-office procedures. Then the Contour is best put in tight nasofrontal recesses where you need that apposition along the side. Also, I have found it fantastic for those very challenging maxillary sinus disease where you just have a flimsy opening, you're concerned the mucosa will just close back over and you need something to keep that open. The Contour serves a great job there.

I would say in the operating room, I use primarily the standard PROPEL along with the others, but that's where I use that. I rarely use a standard PROPEL in my office for in-office cases, but I do use the Contour probably the most in my in-office cases. Now that's changed because we now are doing more and more in-office as our anesthetic techniques have improved, as products have become more in-office friendly in terms of smaller footprints. For an in-office, it's not just how cool the technology-- how useful it is for the patient, but it's how much space does it take?

As that footprint has come down, we've been able to utilize more and more OR techniques in the office, which therefore means that the OR Propels we now use more in the office.

[Dr. Ashley Agan]
What patients are you using this for? The nasal polyp patients seem to be like the obvious candidates, but beyond that, how do you think of-- in your decision-making of like when you're done with a case and you're deciding whether or not you want to leave a PROPEL?

[Dr. Rajiv Pandit]
That's a great question. Let's look at traditionally what we did. Traditionally after surgery, we would use nasal irrigations. We would put patients on oral steroids, Prednisone primarily, to reduce that post-operative inflammation and give them the chance to stabilize, get back on their regular medications, start immunotherapy, do conservative things like using an ear purifier, saline irrigation, all that kind of stuff. What's really nice is, it's a lot of work after surgery to get patients to learn this entire new regimen that they have to do. Especially when you have younger patients in areas where there's a lot of pollen, like in North Texas, it's just hard to get someone in their 20s or early 30s that's maybe starting a new job, that has a new family to remember to start doing this entire regimen.

Post-operatively PROPELS, continuing to do that for a few months has been extremely helpful in my patients. It's a matter of just compliance and efficacy and convenience. What we do for our patients, as you said, Ashley, the polyploid patients, it's a no-brainer in terms of the benefit that PROPEL has. A number of studies have shown that using PROPELs into the nasofrontal recess, say if you take the average nasofrontal opening is about 7 millimeters, it'll often shrink down to about 5 millimeters or slightly less in about 40% of the patients over the course of 90 to 180 days.

What the post-operative, if you put in-- what I do about 30 days later, I'll put in another PROPEL in the nasofrontal recess. I find that 90 to 180 days later, it's retained the same size. The PROPEL has been proactive in preventing stenosis, especially in the frontal sinus, as we all know, that's our most challenging area. In a way, that's very convenient for the patient. They don't have to worry about it. They don't do irrigations twice a day, they're traveling. You do the surgery in September when we have the highest ragweed in the country here in North Texas, that's when the PROPEL becomes very useful.

I've learned that PROPEL works very good prophylactically in patients that have had surgery, whether or not they've had polyps, and that's been backed up by studies.

[Dr. Gopi Shah]
What about like in the acute setting, acute sinusitis complicated by like an intracranial complication and abscess or a Pott's or something like that. Have you ever used a PROPEL in the frontal in an acute setting for the same reasons that, "Hey, my frontal has a higher chance of scarring if I'm doing surgery on the frontal, and especially while it's acutely inflamed"?

[Dr. Rajiv Pandit]
I have not used it primarily in the acute setting. I would say in those like an orbital decompression or a Pott's situation, I think at that point we're focused on the possible complication that we're dealing with. We're focused on getting as much of the purulence out of there, removing the pressure, culturing the purulence, making sure you're actually covered against the pathogens. In that acute inflammatory setting, I'm a little concerned about how much of that steroid will actually be leaching into the tissues. We know that an acidic environment makes it very difficult to have-- Inflammation is fine in terms of steroid penetration.

An acidic purulent environment is going to make it very difficult for that steroid to effectively work. I think in that case, we have to get rid of the infection. What I'll do is, I will do that PROPEL in the office post-operatively, once we know that we've gotten the purulence out of there. I'm also concerned that PROPEL will-- when the purulence it's coming out, when it'll dry up, it'll coat the PROPEL. I also want to have a clearer view of that area. In that case, you want to delay the use of the PROPEL.

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I've rarely had an entire PROPEL come out, and usually that's a technical error where you may have put it in the wrong size into a location, didn't have enough support. That has happened. The patients describe-- their descriptions are often humorous. I find that leaving them in is the best option. I will tell you in terms of-- we often talk about what's the problem? What are the complications that can occur? I have had very few complications, because you're not doing anything permanent. You're putting something that can be removed if it is misplaced when you're concerning it. It's something that dissolves.

The worst thing that can happen most of the time is it may be ineffective for some reason. It's coated in purulence or coated in blood if it's a post-operative case and you haven't achieved hemostasis. I did have one patient in the past 13 years, is very sensitive to migraines. This patient was an attorney who had a very busy workload and had migraines. When I put the PROPEL post-operatively into the nasofrontal recess on one side that was stenosing about 90 days out, the patient developed headaches that were either a triggered a migraine or triggered a regular headache that led to a migraine.

I actually removed the PROPEL about two weeks later and the migraines stopped. Now, was it the patient's workload? Was it psychosomatic? Was it a placebo effect? I don't know, but that was the worst case scenario that I've had with a PROPEL where I could say maybe the PROPEL triggered that migraine. I have not seen any major issues with leaving the PROPEL in until it dissolves.

[Dr. Ashley Agan]
Other than like an acute active infection, like we talked about, any other contraindications, any other patients you would say that you're taking for sinus surgery where you would say, "Oh, I would definitely not recommend it for that"?

[Dr. Rajiv Pandit]
Yes. I think if you have a patient with glaucoma, you always have to confer with the ophthalmologist as far as localized steroid delivery near the eyes. I think that would probably be the only direct contraindication that I can see from a practical perspective. We discussed earlier that an acute purulent state is a relative contraindication. Anyone that might have any any sort of immunocompromised situation where you're concerned, although I really haven't seen topical steroids impact a person's immunocompromised status, but no, if you have someone that's severely immunocompromised, you might need to think about that.