In-Office Turbinate Reduction Surgery

[Gopi Shah MD]
Just going back to the nose and the sinus. In terms of breathing treatment through the nose options, other than saline rinses, nasal steroid sprays, what are our options?

[Madan Kandula MD]
Going back to what I was saying before, that simple basic of: you have a nose issue, you have a nose and sinus issue, you've got an anatomy issue or a lining issue. What you're describing is treating the lining. Any medication, whether it's a nasal spray, Flonase, Budesonide, you name it, those are lining treatments. It depends on the patient. Many of our patients have already, they've come to us, they've tried rinses, they've tried Flonase, they've been on antibiotics for sinus conditions. They've been there, done that. At the end of the day, it's up to us to process that, look at them, and say, "Let's come after this, and let's see."

Typically at that new patient visit, it’s evaluating what somebody's done, evaluating what the health of the lining is, and determining, should we try Dymista and whatever the right different angle may be. Let's try that. Let's maximize the lining treatment. Do we need to do allergies testing? If so, let's think about that. Most of the time, the biggest change we can make for our patients is impacting the anatomy. If somebody can be treated with lining treatments, that's fine, but most folks have a combined issue.

Our philosophy is really an anatomy first, office first mindset as it relates to getting that anatomy open. Keep it simple. Let's go for the low-hanging fruit. The lowest-hanging fruit in our specialty is turbinate hypertrophy. Medications can take the edge off of that lining. If we effectively diagnosed, and effectively offered and treated folks with in-office turbinate reductions, just because it's so much easier from an access standpoint, we would change the state of health in this country in a profound way.

That one simple thing, and it's something we all learned how to do in our first year of ENT residency, and yet the thing that frustrates me is there are millions of people out there who are suffering needlessly, noses that are blocked up. It's something that takes us five minutes to do and we're unwilling to do as a specialty, not because we don't. I'm sure there are people out there who don't believe it like, "No, that's not true," and I understand that. And then there's the whole empty nose ghosts that haunt our psyches, and I understand that too. At the end of the day, I'd say, I'd rather give somebody patent anatomy versus having them suffer with a challenged anatomy.

[Ashley Agan MD]
On the topic of turbinates, how do you decide if turbinate hypertrophy is the key to unlocking better nasal breathing for the patient? As a follow-up, what is your turbinate reduction method of choice?

[Madan Kandula MD]
Here's what I'd say. I am humble, meager, weak. It's impossible for me to know for sure. Some of these turbinates, is it their septum? Is it their nasal swell body? Is it the valve? Is it that they've got sinus outflow tracks that are tight or that they've got inflammation in the sinuses, or the allergy part of things? There's a lot of things where it's like, "Ah, you know" but it's hard to give you a straight answer without seeing an individual patient.

The assumption for somebody who's coming to us with, "Gosh, I've got congestion. I have a hard time breathing my nose." Maybe it's just happening at night for them. When you lay down and your left side stuffs up. When I lay on my left side and I flip over, and we look in there and things look tight, turbinate reduction is something that's going to come to us. That is the most likely intervention that we're going to think towards for a patient, and that might be a combination. Oftentimes, it is with swell body reduction, many times with balloon sinuplasty if that's indicated, so forth and so on. That is the key to unlocking the nasal airway. It's the simplest thing we can do. It's a very reproducible result.

We have a variety of techniques. It is the reality. Basically, a volumetric reduction by whatever means necessary is effective. Whether that's coblation, whether that's microdebrider. I've reduced turbinates probably every single way that's possible. The only common theme is if you do it effectively, you get good results. Again, the things I'm saying, there's controversy in the nuance. To me, what is an effective turbinate reduction? An effective turbinate reduction is reducing inferior turbinates front to back.

I don't know how. I don't understand the physics of those in our specialty who profess that it's only the anterior head of the inferior turbinate that matters. I took physics, and that doesn't make any sense at all. How is that possible, that that's where it's at? Somebody's going to have to educate me on that one. Again, to me, we, and I'd say it started with me, like to impact turbinates in a meaningful way. We're not shy about it. It's just saying, "This is an issue, let's get it out of the way."

[Ashley Agan MD]
Very well said. Transitioning to talking about office procedures and what can be done in the office, do you have almost like a menu of options that you sit down and talk to patients about and be like, "Look, this is the technology we have. This is what can be done in the office, and then out of all of these things we do, these five things might be something that could help you in particular." How does that look like, and what is on your menu?

[Madan Kandula MD]
Sure, that's a good way to look at it. From an anatomy standpoint in the nose, the components or the areas that we consider: septum, turbinates, swell body. I always felt like turbinates and swell body, they're the same thing, it's just a different location of a turbinate. It's a septal turbinate. Still, I feel like it’s especially still learning about what do you do with that one? Basically, you've got the septum, you've got the turbinate, whether it's inferior or septal turbinate, you've got the valve, for the majority. Some people might have polyps and some people might have adenoid hypertrophy, but if you took the large majority, those are the components. It depends on the patient, it depends on the situation. Out of those components, that our preference as far as intervening is the turbinates first. So inferior and septal, and then it depends. Septum versus valve tend to be backburner kind of things. The septum is very easy conceptually. You see it, you can address it. We tend to do our septums in the OR, which there's a whole conversation around, "Why do you do that?"

There's a reason we do that, but regardless, I'd say we tend to do our septums in the OR which then says, "What can we do in the office to help you?" Then you start saying from a pure nose standpoint, we can reduce the turbinates, typically the inferior and the septal turbinate. The valve, basically, we assess, we evaluate and we say, "Boy, that's a backburner issue." We talk to our patients who have those issues, meaning that it's more of an uphill battle. In my hands with all sorts of techniques and technology through the decades that I've been doing this, I cannot achieve consistent results with nasal valve issues, whether internal or external. I can't.

It's very nuanced. It's a real thing. I'm definitely on the side of the fight on the valve that it is an issue, but if you address the internal issues first, the likelihood of you needing to address that valve is minimal. There are valve maximalists who say every patient who has a nose problem has a valve problem. I've seen it too many times with our patients where you see somebody with a valve issue, you see somebody with obstruction internally, you correct the internal obstruction, and they're fine. They don't need anything else, and if they do need something else, focusing on the nose, that's our algorithm. If somebody has valve collapse or narrowing there, then it's something we identify, we talk about, we say, "We're going to get these internal issues corrected in the office and we're going to see how you're feeling." If you're feeling like you're where you need to be, wonderful. If you're not, it depends on the situation, but we might consider VivAer or LATERA rarely. We don't do a ton of rhinoplasty at this point, so if somebody really needs that functional rhinoplasty, we've got folks we can tuck them in with. That's the nose component.

From a sinus component as it relates to anatomy, it's evaluating their scan, evaluating their symptoms, evaluating their history, and putting that all together. The most common treatment that we'll offer for our patients who have sinus issues is balloon sinuplasty for the maxillary and frontal sinuses. The thought there is that common sinus outflow of tracks, of frontals coming into anterior ethmoids, maxillary is coming into anterior ethmoids.

That area, if it is tight, if it is even slightly compromised, that's a domino that once it starts tipping, is going to start clipping off downstream. If we can get those areas open, it's helpful. What I said out of the gate, nose and sinus anatomy patent, that's the most key area. If you have basically adequate outflow, adequate airflow into those areas, that impacts actual nasal breathing, which is a very controversial thing for me to say, but it's true. I see it all the time. It also just impacts the health of the nose and the sinuses.

Our most common treatment is balloon sinuplasty for the maxillary frontal sinuses, turbinate reduction, nasal swell body reduction combined together. We're coming to that conclusion after evaluating all of these specific possibilities for a patient for whom they've got a deviated septum. That is something that, if you didn't correct that, you're not going to help this person, we'll do that right out of the gate kind of thing. There's a mindset and a likelihood about how we practice, but every patient's unique and every clinician needs to make sure that they know that they're in control, and they can do it if necessary.