.png){kind=small}
.png){kind=small}
BackTable / ENT / Podcast / Transcript #109
Podcast Transcript: Cryotherapy for Chronic Rhinitis and Nasal Congestion
with Dr. Jeff Suh
In this episode of BackTable ENT, Dr. Shah interviews rhinologist Dr. Jeffrey Suh (UCLA) about cryotherapy as a new treatment for chronic rhinitis. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Understanding Chronic Rhinitis: Etiologies & Treatment Options
(2) Evaluating Chronic Rhinitis: The Role of Nasal Endoscopy
(3) Beyond Steroid Sprays: Procedures for Chronic Rhinitis
(4) Cryotherapy Procedure Technique & Patient Selection
(5) Sinus Surgery Plus Cryotherapy: A One-Two Punch for Chronic Rhinitis
(6) Anesthesia & Other Procedural Considerations for Cryotherapy
This podcast is supported by:
Listen While You Read
Follow:
Subscribe:
Sign Up:
[Dr. Gopi Shah]
My name is Gopi Shah and I'm a pediatric otolaryngologist, and today I have a very special guest. I have Dr. Jeffrey Suh. He is a professor of Otolaryngology at the University of California, Los Angeles. He completed medical school and residency at UCLA and pursued a rhinology fellowship at the University of Pennsylvania. Jeff is here today to talk to us about cryo therapy for chronic rhinitis and nasal congestion. Welcome to the show. Jeff, how are you?
[Dr. Jeffrey Suh]
Very good. Thanks, Gopi. Thanks for having me.
[Dr. Gopi Shah]
Can you first tell us a little bit about yourself and your practice?
[Dr. Jeffrey Suh]
Sure. I've been at UCLA now for 12 years. I'm a rhinologist here at a very busy tertiary academic hospital. As you mentioned, I'm a Los Angeles native. I did my college, med school, and residency all at UCLA. Then I spent a year to do my rhinology fellowship training at the University of Pennsylvania.
[Dr. Gopi Shah]
Awesome. Well, today we're going to talk about chronic rhinitis and congestion. I'm just getting started, how do some of these patients present to you?
(1) Understanding Chronic Rhinitis: Etiologies & Treatment Options
[Dr. Jeffrey Suh]
Chronic rhinitis is a very common condition. I think all of us at some point have had a runny nose for a number of reasons, whether it's from allergies, whether it's from being sick, or just any number of other causes, like just eating spicy food, causing our nose to run. It's a very common problem that affects a lot of different people. What's fascinating is that as an ENT, we don't really think very much of this condition. In fact, it's not as exciting as some of the other surgical conditions we treat, like chronic sinusitis, or even nasal obstruction but it's a problem with a very high prevalence that until recently didn't really have that many surgical options for our patients.
[Dr. Gopi Shah]
In terms of in your history, when a patient comes to you, what kinds of questions do you always ask them? What are you trying to tease apart? How do you distinguish chronic sinusitis from just chronic rhinitis? Sometimes to me, that can be difficult.
[Dr. Jeffrey Suh]
Yes, no, that's a great question. It's a really important thing for a surgeon to differentiate. There's so many different causes that have very similar symptoms in their nasal cavity in the sinuses. In order to offer the best treatment, we have to really get down to what's causing the symptoms. For rhinitis, which is basically runny nose, there can be any number of different causes for this condition. Each one can be treated differently.
For example, if you have chronic sinusitis, you can have drainage from your sinuses, you can have congestion obstruction, mucus in the nose and the treatment options are very different. It could be using antibiotics, topical steroids, needing surgery in the sinuses, whether it's allergies. For allergies, it's really identifying the cause of the allergies, whether it's environmental, food, and then for some people, it's non-allergic causes of rhinitis, which is the focus of many of these surgical treatments that have been developed over the last five or six years.
[Dr. Gopi Shah]
We said certain risk factors are going to be allergies, non-allergic causes, can you get into some of the non-allergic causes that you're asking about?
[Dr. Jeffrey Suh]
The classic patient that I see that has non-allergic rhinitis, and it happens to all of us, are the fine eating spicy food then I love spicy food and my nose starts to run after I eat that is kind of a classic symptom of gustatory rhinitis, which is basically a non-allergic cause of a runny nose that's pretty common and affects a lot of us. Another one that I hear from my patients or the ones that are really active, that they run outside when the air is cold and their nose runs as they're running.
That can be bothersome, if they're running long distances, it can happen quite a bit for these people, and they're looking for a treatment option for this. The other classic patients that I see with non-allergic rhinitis are my elderly patients, the one that comes from nursing homes that are coming in on walkers or canes, and they're in their nursing home, they're saying that all the time their nose is running. They're distressed by this, they're distressed so much they want to go to the doctor's office and find a treatment option. Prior to cryotherapy or the other treatments that are now available surgically for us, we would just try to put them on sprays and the sprays were not that effective.
[Dr. Gopi Shah]
It's like, here, do I wipe my nose? Usually we're talking about clear rhinorrhea.
[Dr. Jeffrey Suh]
Clear rhinorrhea, both sides and without typically any allergic trigger, they're just doing their normal things in life and their nose starts to run.
[Dr. Gopi Shah]
It's embarrassing. You're in the middle of talking to somebody and you can feel it and then do you have anything to wipe your nose, it definitely has its embarrassing moments. I've had my issues with rhinitis before. So, the patient comes in, you're teasing the history, what are the triggers? Is there a certain length of time that you look forward to make it chronic? Is it usually that three-month mark that we think of in sinus?
[Dr. Jeffrey Suh]
That's really it, you want to make sure that it's not an acute issue. Viruses, other types of infections, certain environmental exposures can cause injury to the mucosa and cause a reaction causing a runny nose and rhinitis, and congestion. We really want to tease out the duration of the symptoms. A lot of the time, if it's acute, it'll resolve just with conservative medical therapy, or just watching and waiting. It's really that the symptoms that persist, and these patients often say that for years, or for months, or for as long as they can remember, they've had a runny nose.
They're the ones that are seeking care from the ENT doctor's office because it's out of the normal of what they would typically expect their nose to feel like.
[Dr. Gopi Shah]
How often is something like just nasal congestion or nasal obstruction associated with the symptoms, that when we're thinking of the chronic rhinitis patient, not the chronic rhinosinusitis patient?
[Dr. Jeffrey Suh]
I would say that, typically, the symptoms can overlap. There's some people that do have nasal obstruction, other symptoms of their sinuses at the same time as rhinitis, but the classic patient that presents with chronic rhinitis, really just presents with runny nose as their primary symptom. There can be other factors, you can have mixed symptoms where there's some allergic component and a non-allergic component.
They can have some sinus issues and rhinitis, but typically, it's the classic, I'm exercising and my nose runs, I'm eating spicy food and my nose runs, or I'm just sitting around doing nothing and I'm not in an environment where my allergies are active and my nose is running. Those are the targets for some of these really novel procedures that have been developed recently for us.
(2) Evaluating Chronic Rhinitis: The Role of Nasal Endoscopy
[Dr. Gopi Shah]
When the patient's with you, you've gone through your history, tell me what your physical exam looks like, are you always scoping just anterior rhinoscopy gives you an idea, tell me what you do.
[Dr. Jeffrey Suh]
In my practice as a rhinologist, I always want to make sure that any surgical intervention that I might suggest has a very high chance of working. The reason why I think endoscopy is important, so I use rigid endoscopes, is that I want to make sure that there's no other cause of the symptom that might need to be addressed and addressed differently than some of the other options for vasomotor rhinitis. My nasal endoscopy will include looking at the septum determinants, the sinuses, the nasal pharynx. It's surprising how often people can have adenoiditis or nasal pharyngitis as a cause of their post-nasal drip or nasal symptoms. We see it a lot in kids actually, that they–
[Dr. Gopi Shah]
Now you're talking my language: the adenoiditis.
[Dr. Jeffrey Suh]
That can be a very bothersome symptom that overlaps quite a bit with rhinitis, and especially in younger people and kids because they've always had it, they don't know what the difference is. Part of the nasal endoscopy is always checking out the nasal pharynx to making sure that there's no other cause of their symptoms that can be addressed differently than with nasal sprays.
[Dr. Gopi Shah]
Do you use nasal decongestants when you scope, do you scope without any of those? Tell me about that.
[Dr. Jeffrey Suh]
Typically, the patients will find the pediatric nasal endoscopes that are used to be more comfortable than the standard adult ones but I always try to pre-medicate before I do an endoscopy with a combination of Lidocaine and Afrin spray. The Afrin will decongest, the turbinates and the nasal mucosa and then the Lidocaine just makes it so it's a little bit less uncomfortable. Especially when I really tried to examine the nasal pharynx or the deeper parts of the sinuses, and then you give it about 10 minutes and usually the procedure isn't too bad.
[Dr. Gopi Shah]
You're using the PD like 2.7-millimeter rigid scopes. Always just a zero or do you like a 30? What angled or unangled scopes do you like?
[Dr. Jeffrey Suh]
Yes, I typically use a 33 scope. I use 3-millimeter or a 2.7-millimeter scope in the office. The angled scope gives me the ability to inspect the sinuses as I go in and out. If I just use a zero, it's really great for the nasal cavity. Good for looking at the nasal pharynx, but the angled scopes give you an advantage to also examine the sinuses as you're going in and out.
[Dr. Gopi Shah]
For these patients, when I think of nasal endoscopy for like a chronic rhinosinusitis patient, maybe we'd see a polyp, maybe if we see pus or edema. Are there certain findings with just chronic rhinitis or does their nose look pretty otherwise healthy? If there's allergies, it might play a role, but tell me about what you see usually.
[Dr. Jeffrey Suh]
In a classic patient, let's go back to the 85-year-old elderly patient that comes in on a walker from a nursing home. When you examine them in the office after you decongest their nose with the spray, their nose actually looks pretty normal. They might have the standard findings of maybe a slightly deviated septum, maybe a little bit of turbinate hypertrophy, but the sinuses are clear, the nasopharynx is clear. There's no signs of any infection on the turbinate or in the sinuses, and their nasal exam would otherwise be normal. In the past coming out of residency, we would say there's really nothing we can do. Just go back to see the allergist, use those nasal sprays, and it was really nice to meet you.
[Dr. Gopi Shah]
That's so sad.
[Dr. Jeffrey Suh]
It is. It was so sad for them.
[Dr. Gopi Shah]
At this point, what's part of your workup? If the patient hasn't had allergy testing, when do you consider something like that or how do you manage this patient?
[Dr. Gopi Shah]
When the patient's with you, you've gone through your history, tell me what your physical exam looks like, are you always scoping just anterior rhinoscopy gives you an idea, tell me what you do.
[Dr. Jeffrey Suh]
In my practice as a rhinologist, I always want to make sure that any surgical intervention that I might suggest has a very high chance of working. The reason why I think endoscopy is important, so I use rigid endoscopes, is that I want to make sure that there's no other cause of the symptom that might need to be addressed and addressed differently than some of the other options for vasomotor rhinitis. My nasal endoscopy will include looking at the septum determinants, the sinuses, the nasal pharynx. It's surprising how often people can have adenoiditis or nasal pharyngitis as a cause of their post-nasal drip or nasal symptoms. We see it a lot in kids actually, that they–
[Dr. Gopi Shah]
Now you're talking my language: the adenoiditis.
[Dr. Jeffrey Suh]
That can be a very bothersome symptom that overlaps quite a bit with rhinitis, and especially in younger people and kids because they've always had it, they don't know what the difference is. Part of the nasal endoscopy is always checking out the nasal pharynx to making sure that there's no other cause of their symptoms that can be addressed differently than with nasal sprays.
[Dr. Gopi Shah]
Do you use nasal decongestants when you scope, do you scope without any of those? Tell me about that.
[Dr. Jeffrey Suh]
Typically, the patients will find the pediatric nasal endoscopes that are used to be more comfortable than the standard adult ones but I always try to pre-medicate before I do an endoscopy with a combination of Lidocaine and Afrin spray. The Afrin will decongest, the turbinates and the nasal mucosa and then the Lidocaine just makes it so it's a little bit less uncomfortable. Especially when I really tried to examine the nasal pharynx or the deeper parts of the sinuses, and then you give it about 10 minutes and usually the procedure isn't too bad.
[Dr. Gopi Shah]
You're using the PD like 2.7-millimeter rigid scopes. Always just a zero or do you like a 30? What angled or unangled scopes do you like?
[Dr. Jeffrey Suh]
Yes, I typically use a 33 scope. I use 3-millimeter or a 2.7-millimeter scope in the office. The angled scope gives me the ability to inspect the sinuses as I go in and out. If I just use a zero, it's really great for the nasal cavity. Good for looking at the nasal pharynx, but the angled scopes give you an advantage to also examine the sinuses as you're going in and out.
[Dr. Gopi Shah]
For these patients, when I think of nasal endoscopy for like a chronic rhinosinusitis patient, maybe we'd see a polyp, maybe if we see pus or edema. Are there certain findings with just chronic rhinitis or does their nose look pretty otherwise healthy? If there's allergies, it might play a role, but tell me about what you see usually.
[Dr. Jeffrey Suh]
In a classic patient, let's go back to the 85-year-old elderly patient that comes in on a walker from a nursing home. When you examine them in the office after you decongest their nose with the spray, their nose actually looks pretty normal. They might have the standard findings of maybe a slightly deviated septum, maybe a little bit of turbinate hypertrophy, but the sinuses are clear, the nasopharynx is clear. There's no signs of any infection on the turbinate or in the sinuses, and their nasal exam would otherwise be normal. In the past coming out of residency, we would say there's really nothing we can do. Just go back to see the allergist, use those nasal sprays, and it was really nice to meet you.
[Dr. Gopi Shah]
That's so sad.
[Dr. Jeffrey Suh]
It is. It was so sad for them.
[Dr. Gopi Shah]
At this point, what's part of your workup? If the patient hasn't had allergy testing, when do you consider something like that or how do you manage this patient?
(3) Beyond Steroid Sprays: Procedures for Chronic Rhinitis
[Dr. Jeffrey Suh]
It all goes back to the first initial exam, the history, and then the physical exam. When I have residents that are with me in the clinic, it's always trying to understand the etiology of their symptoms, create a differential diagnosis, and then ideally pursuing medical therapy before recommending any types of surgery. There is some benefit for a CT scan, sometimes of the sinuses. If you see any signs of chronic inflammation, polyps, like you mentioned, or drainage from the sinuses, and standard medical therapy isn't ineffective, then sometimes radiology can give more insight into some things that might need to be addressed in the sinuses themselves.
Given the typical chronic rhinitis patient, everything being normal on the first nasal endoscopy, often it is trying to differentiate whether there might be some allergic triggers, so an allergic rhinitis versus a non-allergic. If there's something in the story that points toward an allergic rhinitis, then typically I think, seeing an allergist, understanding the triggers for their allergies, trying antihistamines, nasal steroid sprays would be beneficial. Then if it's purely non-allergic rhinitis, then there's a really great spray, which is Atrovent or ipratropium bromide, which I'll typically use as a litmus test for the benefits of seeing if maybe a surgery would work for this patient.
[Dr. Gopi Shah]
In a spray naïve patient, we'll say that for some reason they got to you without ever trying a spray. For the patient that doesn't have an allergy history, the nose doesn't look like an allergy, or maybe they had allergy testing and it was negative. Would you start with the ipratropium bromide, or would you start with something like the nasal steroid spray? Is there an algorithm? I feel like what I've always read is, well, for allergic or non-allergic rhinitis, we do the sprays and there's a nasal steroid spray, the antihistamine spray. Is there that algorithm or is it like, no, you don't have to do it that way and you can try this because I'm looking for this.
[Dr. Jeffrey Suh]
The nasal steroid sprays, they're quite effective and people do use them for non-allergic and allergic rhinitis, and I feel that if there's congestion, if there's signs of allergies like sneezing, itchy watery eyes, and other things, that would make me feel that there's allergic component, then the nasal steroid sprays are really effective. The biggest thing I try to teach my patients is these sprays generally have very little effect for the first few weeks. It's not a spray that's meant to be used just once and then see how it goes.
A lot of them have this feeling that they never work, and they usually don't work if they're not used long enough, so I say if you're going to try nasal steroid spray, such as Flonase, or Nasonex, or Nasacort, give it at least a month before you make a judgment if it's effective or not. For pure non-allergic rhinitis, I feel that Atrovent works phenomenally for just the drip.
If a patient comes in with symptoms that seem like they're very specific for just chronic rhinitis without an allergic component, then I find that the reason why the patients are drawn toward Atrovent is that there's not that buildup that we need with the Flonase or the nasal steroid spray. If you use Atrovent right now, then whatever trigger there would normally be, whether it's eating the spicy food, or running outside, it will stop that drip immediately.
The patient will just know that when they try the Atrovent if it works to prevent whatever the next trigger would be, it's likely to be non-allergic rhinitis. The only downside of the Atrovent spray is that it doesn't last for very long, it works for about two hours, three hours. It's really good to identify the potential cause of the rhinitis, but it's not necessarily the best long-term treatment option because the spray would've to be used pretty regularly.
[Dr. Gopi Shah]
How often do you prescribe it? Twice a day, or four times a day?
[Dr. Jeffrey Suh]
It's really as needed. They can use it before whatever meal would make their nose run. They can use it before the exercise. They can use it throughout the day. I don't find the spray to have any addictive qualities like decongestant sprays like Afrin. There's no withdrawal. There's no buildup. It's just that they might be using it pretty frequently.
[Dr. Gopi Shah]
They have to use it 30 minutes before or does it work pretty instantaneously in your experience?
[Dr. Jeffrey Suh]
I typically say that they should use it 30 minutes before the event. Usually, by then it works, but some patients say it works pretty quickly, even faster than that.
[Dr. Gopi Shah]
This patient that's come to your clinic, you send them home and you're going to try the Atrovent or the ipratropium bromide, when is your follow-up? How long do you tell them to try it for?
[Dr. Jeffrey Suh]
In my experience now, I feel that the Atrovent works pretty quickly and they get a pretty good sense if it's working because that's not the most common spray that a lot of their primary care doctors or allergist would give them. It's something they haven't had before, so when they try, they're like, "Wow, this works really well." Or they're, "Well, it's not working at all." Then when they come back to me, whether it's by messaging me on our EMR or emailing me, or coming back for another appointment, they tend to know pretty quickly if it's going to work, couple weeks, and I always give them the option.
I'm like, well, I feel like we're going to try this spray. It's going to work pretty quickly. Just let me know what you feel. Typically I just give them an option of just messaging me and letting me know if it works. Then we just will chat about it, whether or not they like the spray, they could see it as being a long-term option, or if they just want to know what other options are out there besides using the spray.
[Dr. Gopi Shah]
Then is there any role for saline rinses or saline mist for chronic rhinitis? Does that do anything? We love to wash everything out, but does it help their symptoms at all?
[Dr. Jeffrey Suh]
Yes.
[Dr. Gopi Shah]
I use saline rinses twice a day. Am I going to not have a runny nose the next time I'm outside in the afternoon when it's cold?
[Dr. Jeffrey Suh]
Saline rinses are phenomenal. We've been using them for our patients with chronic sinus disease forever for allergies, and patients are drawn toward because it's safe, it's homeopathic, there's no medications that are in it, and it makes them feel better. With rhinitis, it does help with maybe the congestion of the turbinates, maybe eliminating any allergy that might be triggering some of the symptoms, maybe washing away some of the mucus, but for classic chronic rhinitis, I don't feel like it's as effective because typically, the etiology of the rhinitis in this situation is a nerve stimulation, that something is causing the nerve to be stimulated.
Then rinsing doesn't really have the same effect as it would in someone that's being exposed to dust, pollen, allergens, cat hair in that way, or our patients with chronic sinusitis that are actually trying to get out the mucus from their sinuses, so the rinses is really effective. This is more of a, at least in the way that I look at, more of a stimulation of the nerve rather than something that is in or on the sinuses.
[Dr. Gopi Shah]
Let's say a patient responds and they say, "Hey, it's been a month, it's not working," or, "It's really helpful, but I don't want to carry my spray around or be on a spray." What do you do next?
[Dr. Jeffrey Suh]
This is the exciting part of where things have changed from when I finished residency. Before we had these really phenomenal treatment options, and there's a few now, we would just say, great, just keep on using those sprays. Please don't come back and see me. There's really not much more I can do to offer you any surgical treatment, and follow-up with your primary care doctor or your allergist.
Now we have these great options where you can say if you're happy with the spray and you're not using it very much and now that you understand the etiology or the reasons that you're having your rhinitis, you can use this spray if you like, but now in the last six, seven years, there are some very simple procedures we can do both in the office or in the operating room that will duplicate the effects of the spray, is a way that I usually phrase it for a year or two or more.
[Dr. Gopi Shah]
Today we're going to focus on cryotherapy. Is that what you traditionally use or have a preference for?
[Dr. Jeffrey Suh]
It is, yes.
[Dr. Gopi Shah]
Is there anything else besides the cryotherapy and the radiofrequency?
[Dr. Jeffrey Suh] There are some old-school surgical techniques that we all learn in residency and what cryotherapy is, it's typically what I use. I find it to be the most effective and it covers kind of a wide treatment area and we'll kind of discuss this, whereas radio frequency is a newer option that also kind of targets this nerve called the posterior nasal nerve. The earlier branch of this nerve, and I love talking about the anatomy of the sinuses.
(4) Cryotherapy Procedure Technique & Patient Selection
The posterior nasal nerve is the end nerve that we focus on for our surgical treatments for rhinitis, and it's kind of the area that the Atrovent spray also works on. The earlier part of this nerve is called the Vidian nerve. When we are residents, we learn about this surgery, which is basically cutting the Vidian nerve, so a Vidian neurectomy. That surgery works because you're basically cutting off the nerve that's responsible for drip inside the nose, but unfortunately, the Vidian nerve also innervates the lacrimal gland. If you disrupt the innervation of the lacrimal gland, then the patients can't cry or they can't tear so they get dry eyes. It's not a very good surgical procedure because of the consequences of the surgery itself. This is a much more direct treatment just for the rhinitis that our patients have.
[Dr. Gopi Shah]
Yes, and the Vidian neurectomy, it can bleed a lot, the dry eye. There's a lot more to it than just we're going to go in and you have to open up, do a real FESS-
[Dr. Jeffrey Suh]
Right.
[Dr. Gopi Shah]
-to get your exposure at an easy, quick little in and out. In terms of cryotherapy, what happens?
[Dr. Jeffrey Suh]
This procedure, I think I first heard about it in 2017 and again, I was fascinated by the idea that there's a new treatment option for patients that have rhinitis. The procedure is quite simple. The area of the middle meatus. It's the area that all of us when we do sinus surgery, we enter to do our maxillary antrostomies and our apicoectomies. Specifically, it's where the middle turbinate attaches to the lateral nasal wall.
There is a structure called the basal lamella. Where the basal lamella attaches to the lateral wall behind the mucosa, a nerve comes out called the posterior nasal nerve. What cryotherapy is, it's in the form that we use it for ClariFix. It's a balloon that you insert inside the middle meatus, and then when you activate the cryogen, it fills the balloon with cold liquid nitrogen essentially that will have the effect on the mucosa and the nerve underneath the mucosa, which is the posterior nasal nerve.
You just repeat it on the left and the right side on these patients that have rhinitis, when the cryogen acts for about 30 seconds before you turn it off and then you pull out the device, it's quite simple, and typically the actual procedure component itself is less than a minute per side.
[Dr. Gopi Shah]
In terms of patients who benefit, is this going to be a zero difference in outcomes for allergic versus non-allergic rhinitis? Is it better for a certain subgroup of the rhinitis patient? Who's this for?
[Dr. Jeffrey Suh]
In my experience, I use it in all of my patients that have non-allergic rhinitis that are either candidates for the surgery because of a positive Atrovent response, or in patients that have a mixed rhinitis. They might have allergic rhinitis, which is pretty common, and there's some component that I suspect is a non-allergic rhinitis. I would say the majority of otolaryngologists that I know do it in patients with non-allergic rhinitis and patients with mixed rhinitis, but the literature suggests that patients with allergic rhinitis also have some benefit.
I'm not fully clear on the mechanism of which it would work in patients with allergic rhinitis because it seems to me that it's more of a histamine-driven allergic response, but patients and ENT doctors have had benefit in this population.
[Dr. Gopi Shah]
Both groups could somehow get some benefit. Is it less beneficial? Is the benefit a little bit less in the allergy or do those patients, the allergy patients, get the same amount of benefit as your non-allergic rhinitis patients?
[Dr. Jeffrey Suh]
It's very similar in benefit, which again is surprising to me that patients with allergic rhinitis also benefit from the procedure. For me, the patient that I really suggest this procedure to are the Atrovent responders, which tend to be the ones that have non-allergic rhinitis as their primary diagnosis.
[Dr. Gopi Shah]
How do you counsel patients before this in terms of post-op pain recovery or the buzzword? We hear about the ice cream headache. What's that?
[Dr. Jeffrey Suh]
There's two settings that the procedure can be done in. It can be done in the office when the patient's awake under local anesthesia, and that is a very different conversation that you might do in the conjunction with some other procedure in the operating room. The easiest one, and well maybe we'll start with that, are the procedures that are done in a patient that's having surgery for another reason.
For example, let's say you examine the patient in the office, you think they're a fantastic candidate for let's say cryoablation or ClariFix and you would love to do it, but their anatomy isn't optimal. Let's say their septum is crooked, and if you can't get into the area of the minimal meatus where you would do the procedure, you have to fix the septum to get access to do the procedure.
If the patient's asleep and you fix the septum, you reduce the turbinate like you would for their nasal obstruction and you do the ClariFix, then it just adds about 30 seconds per side. After you finish the septoplasty, you would ask your nurse for the ClarFix and you would do it on the left and right side, and it really doesn't add very much time, and by the time the patient's awake, there really are no other side effects to the procedure. The cold, the thawing, it's already happened already by the time they're in the recovery room, they feel great.
[Dr. Gopi Shah]
Do you have to take your cryo over or does your OR already have the equipment?
[Dr. Jeffrey Suh]
It's a different process to get it in the operating room as it is in the office. I've used it in both locations. In the office, at least for ENT doctors, they have to go through the standard trial process to get it approved by the hospital, the household administration, you have to weigh the pros and cons of cost and efficacy. In my hospital, we carry it, we've carried her for a long time, and in this scenario, whether it's with sinus surgery, which is something that I do not infrequently or again for access purposes as part of a septoplasty surgery, it's really effective. It's really easy.
I think it's a great way for those otolaryngologists that haven't used the procedure to give it a shot. There's really no difference in terms of your anesthesia protocol because the patient is already asleep. What I would recommend, you just get your local rep to come in to make sure that the nurses know how to set everything up with the ClariFix device and you just do it as part of your standard surgeries you do in the nose endoscopically.
(5) Sinus Surgery Plus Cryotherapy: A One-Two Punch for Chronic Rhinitis
[Dr. Gopi Shah]
For the patients that do have, let's say, chronic sinusitis, let's say they don't have polyps, or let's say they do, how do you know which patients would also benefit from getting the cryo at the same time as their sinus surgery? It makes sense in terms of access for the septoplasty or nasal obstruction, but how do you know which patients like, "Hey, this one actually needs the cryo too."
[Dr. Jeffrey Suh]
The majority of my practice are for patients that have chronic sinusitis as a rhinologist. The type of patient that clued me in that there might be some benefit for ClariFix in my patient with chronic sinusitis came really after the fact. Patients with chronic sinusitis have chronic sinus issues for a number of reasons, whether it's allergies or infection or abnormal anatomy or genetics, or any number of causes.
Once you identify that a patient needs to have sinus surgery, you do your sinus surgery and the standard medical therapy is using topical steroids in irrigation long term in the majority of these patients. What I've found in having been in practice now for over a decade is that I will do the best sinus surgery I could possibly do, put them on the correct medical therapy for what I think is the etiology of their sinus issues, and then they'll still have rhinitis after I do my sinus surgery, and for some people that is really bothersome.
They might be very happy with not having infections or not having polyps or getting their sense of smell and taste back, but they could still be very annoyed by the fact that their nose runs all the time. Then what I was doing in those patients is saying, "What did I miss?" Did I miss something in the initial diagnosis because I was so focused on their sinuses? What I found is that there are some patients that have chronic sinusitis that also have chronic rhinitis that would benefit from having ClariFix done during the same operation.
Now I'm very tuned into my patient's symptoms beforehand and I might try them on Atrovent before their sinus surgery if they have some benefit. I'll just add that on to the sinus surgery, and I feel like they're benefiting from that additional procedure to address the symptoms that might not have been addressed only with sinus surgery.
[Dr. Gopi Shah]
It's still clinically that the chronic rhinitis and then chronic sinusitis, I think those are hard to distinguish as two separate things, right? You think of post-nasal drainage, runny nose rhinitis as part of chronic rhinosinusitis and it does make sense that, well if the atrovent works, then maybe that posterior nasal nerve is playing a role here as well. Do you have them do your standard sinus rinses, nasal steroids for a month, and then add the Atrovent to see if it's helping or not?
How can you tell that the Atrovent is helping us with maximal medical management for chronic rhinosinusitis, sometimes it's three antibiotics, nasal steroid spray, maybe oral steroids, antihistamine nasal spray and we're going to do the flows. Oh, and I need you to rinse four times a day.
[Dr. Jeffrey Suh]
It's really totally true. When I see patients for the first time, especially the ones that haven't had a lot of medical therapy, I'm throwing on all these different medicines at the exact same time. A lot of the patients will be like, "Well, which one is the one that's actually working for me? Is it the antihistamine spray? Is it the nasal steroid spray? Is it just that I'm rinsing my sinuses and add in another spray like Atrovent, which one is the one that's actually working?"
What I tell my patients generally is that each one has a different mechanism of action and each one will take a different amount of time to work. Usually, the nasal steroid sprays, whether they're using a standard nasal steroid spray like Flonase or maybe rinsing their sinuses with a steroid in their sinus irrigation, typically nasal steroid sprays we say will take about three to four weeks to work before they really notice the benefit.
Whereas Atrovent again, works immediately that if they use the Atrovent spray now, within 30 minutes they're going to notice a benefit. The overlap is, most of the antihistamine sprays work pretty quickly too, and the Atrovent spray works pretty quickly. Usually, I have them separate those two first, but the nasal steroid spray, I have them starred because it can take a few weeks for that to work, but the antihistamine spray or the Atrovent spray, I try to have them stagger it so they can tell which one is benefiting them more.
[Dr. Gopi Shah]
That makes sense when you put it that way because I think of all the things I put my kids on and I'm like, "Oh yes, and I need you to--" Anyways. Let's talk about the patients that you're doing this procedure on in the office. Tell me how you get it set up. Do you have a procedure day in the office? Are you bouncing back and forth? Are you numbing him up in a special way? Tell us how you go through it with them?
[Dr. Jeffrey Suh]
Everybody's practice is different. I've noticed that some of my colleagues have procedure days where they'll group their in-office procedures all together. They'll have a few rooms going simultaneously where they can provide anesthesia, recovery, and time to do the procedure, and just in a day where they're maximizing their procedure room or their in-office procedures altogether.
For me, I just have very limited clinic time. I will bounce around rooms where once I identify the patient being a good candidate, and what that means is anatomically, they have the right anatomy to allow me to do the procedure. No subtle deviation and importantly, also whether or not you think as a doctor, the patient can tolerate the procedure. Some patients that are really anxious or just the sight of the scope or the idea of doing something awake horrifies them or make them pass out or have a vasovagal reaction, you tend to deselect those patients for an office procedure.
[Dr. Gopi Shah]
No papoose?
[Dr. Jeffrey Suh]
Right.
[Dr. Gopi Shah]
I'm just kidding.
[chuckles]
[Dr. Jeffrey Suh]
Yes.
[Dr. Gopi Shah]
Just kidding, that's my world.
(6) Anesthesia & Other Procedural Considerations for Cryotherapy
[Dr. Jeffrey Suh]
Patients that are great candidates, that are excited about doing it in the office, that don't want to miss any work, that don't want to go through the procedure in the operating room, these are the ones we target for office procedures. If they check off all the boxes where every step of the way you don't see any barriers, then you offer them an in-office date for this procedure.
Typically as surgeons, we have to get authorization for the procedure. We have to submit for the codes to be done in the office, and then we have to get the device to the office and then just make sure that we have enough time for the procedure. Usually, I don't do it the same day that I diagnose them. I'll bring them back. Usually, I have an hour blocked off for this patient.
Now, again, I could be doing other things at the same time, but it takes time for the patient to numb the nose adequately. Every doctor has their own anesthesia protocol, and I'll talk about mine, which is different from most, I think, but I can talk about what I think has been effective for me. The biggest thing about this procedure is that there's two phases that need to be addressed with the anesthesia.
The first part is the part that makes sense. It’s that when you put the probe in the nose and you freeze the nose, if the nose is not adequately anesthetized, they can feel coldness or discomfort during the procedure itself. The standard things we do as ENT doctors, to numb the nose for biopsies or balloon dilation of the sinuses tend to work really well for the actual procedure itself to get rid of the discomfort during the freezing.
What I typically start with is the combination of the lidocaine and the Afrin spray that we use for any of our patients to get a nasal endoscopy. Then I'll give that a little bit of time to work. Then I'll put in some pledgets that are soaked with lidocaine into the middle of the meatus specifically, and part of it will cover the inferior turbinate. We call this the landing zone. Anywhere that the cryogen will be touching, I try to put the anesthetic in, which is usually the lateral nasal wall, the middle turbinate, and really the top of the inferior turbinate where the probe will be touching as well. That's the easy stuff. I think it's 3% lidocaine.
I noticed that other doctors have had some phenomenal benefit with tetracaine applied topically. Some compounding pharmacies can provide tetracaine into a goo, and that provides really deep anesthesia into the tissue, more so than lidocaine. I use the lidocaine and the Afrin spray and then lidocaine on the topical half by three pledgets. Then after that's been numbed up for a while, then I'll use some 1 % with 1 to 100,000 epinephrine, like I would do during sinus surgery or a balloon surgery in the area of the middle meatus.
I'll pretty much inject where the sphenopalatine artery is, right where the basal lamella is attached to the lateral nasal wall. That's the direct anesthetic into the area where the procedure is going to be most effective.
[Dr. Gopi Shah]
What needle length and size do you use for your SPA injection?
[Dr. Jeffrey Suh]
In most situations, I use a 25 gauge regular needle we use for local anesthetic for procedures. Sometimes it's not long enough, so I'll have a spinal needle available if I need to. Typically the standard 25 gauge needle would work but for people that it's a difficult area to reach or it's a little bit deeper, then I use a spinal needle.
[Dr. Gopi Shah]
Do you bend your needle, give it a little 45 bend and then just turn your wrist?
[Dr. Jeffrey Suh]
I do bend the needle. You always have to bend it laterally, and it takes a little bit of practice. It's very similar to the way that I think many of us have been doing in-office balloon procedure anesthesia.
[Dr. Gopi Shah]
You're using your 30-degree scope for all this? Is that your preference or do you feel like you can see things better off where you need to see?
[Dr. Jeffrey Suh]
For me, I think I might have one zero-degree endoscope in the office, but I know you could do it with a zero-degree endoscope. I just like to have the ability to look around corners. I'm just used to doing it with the 30, but I would say most otolaryngologists and most anatomy would be favorable to do this with a zero-degree scope. Really, whatever you have in the office. Once the nose is really decongested with the Afrin, you tend to have a really good view unless the septum is in the way.
[Dr. Gopi Shah]
You're just spraying. You're not doing Afrin pledgets. Oh, no, you are. You're doing the lidocaine 3% with Afrin as your pledget?
[Dr. Jeffrey Suh]
Right. The first spray is part Afrin, part lidocaine, and then the pledgets are lidocaine with some Afrin on the pledgets then the local anesthesia. Again, what I've noticed is that some doctors that do quite a bit of these procedures in the office, they'll skip the local anesthesia injection and just use the tetracaine and they've had some great results. I just can't get compounded medications in my academic practice.
[Dr. Gopi Shah]
Then what are you doing in the second part, or are you doing the cryo between the first and second part?
[Dr. Jeffrey Suh]
After the local injection, I'll give that a good 10, 15 minutes to take effect. Usually, by that time, everything is numb in the nose. The patient can't feel anything and they're complaining about some of the lidocaine dripping down the back of their throat. They're like, "This is really uncomfortable." Then you know they're ready. Then again, you do a final assessment to make sure that the patient is calm, they're excited about doing this. Then you have the time and the environment to make sure that this procedure goes well.
[Dr. Gopi Shah]
I assume they're upright, they're not laying down. You do this up right. Is that your preference?
[Dr. Jeffrey Suh]
Yes, sitting upright or maybe slightly tilted back, but definitely not lying on their back. Mostly upright and again, it almost parallels the way that we would do balloon cystoplasty for a lot of our patients in the office. They're sitting upright, they're comfortable, their nose is really numb at this point. There's some things that I do to prepare for the other post-procedural symptoms.
I break it up into the procedural discomfort and then the post-procedural discomfort. You've alluded to this a few times where usually the topical anesthetics works really well to make it so the procedure itself, which is the freezing, is not uncomfortable at all. Then after the procedure is done, which we'll talk about, there's this delayed effect which can hit about 5 to 10 minutes later, where as the frozen mucosa is thawing, they can develop an ice cream headache like we get when we eat something that's too cold, too quickly.
Sometimes it's pretty uncomfortable. Other times it's really not that bad at all. All of us as surgeons that do this in the office have different ways we try to get that post-procedural ice cream headache to be as low as possible.
[Dr. Gopi Shah]
What do you do for that? Does it last for just a few minutes, or is this something that they're going to feel for a couple of hours? Then how do you manage it?
[Dr. Jeffrey Suh]
What I've researched, actually is it's just that very thing. When I was doing the procedure initially in the office, in about 30 minutes, the ice cream headache would resolve. They would walk out of the clinic. They'd be totally comfortable. They'd be happy. They did it. It wasn't that bad. then you just wait for the benefits to kick in a few weeks after the procedure.
For some people, the ice cream headache can be pretty uncomfortable where their head hurts, their palate can hurt, their upper teeth can hurt, and it can be pretty severe. Some people describe it as a 10 out of 10 in terms of discomfort. Some people say it's a 5 out of 10, and it's not too bad. Then we would do all these different things to make it better, whether it's doing more local anesthesia.
I've noticed that if you gargle hot water, then the heart palate discomfort gets better a little bit more quickly but it's always over in about 30 minutes. It just said, how do we get to that 30 minutes without it being too uncomfortable? I would say back in, I think, 2019, I was discussing this post-procedural ice cream headache with one of my colleagues. Tobey Steele is a rhinologist up at UC Davis. We talked about our patients were having the same discomfort.
Then it sounded very nerve-related pain to me, that it must have been the nerve being affected in the way that we wanted to be effective and it was really the nerve pain that was causing the ice cream headache. Then for some of our patients that have nerve-related pain, we give a medication called Gabapentin. Gabapentin, it's a medication that some diabetic patients use for their nerve pain in their feet, tends to be pretty effective, or certain type of headache conditions. This medication is used on label 4.
We decided to give it a shot to give this medication off-label for the sinuses. What we ended up doing in our protocol is giving the Gabapentin 600 milligrams one hour before the procedure. We looked at patients in two different arms. We looked at a group of patients that didn't get the Gabapentin and a group of patients that did get the Gabapentin. We monitored their pain every five minutes and developed these graphs to figure out where the pain was and wanted to see if there was any statistically different level of pain between the two groups of patients.
We found that, yes, with the Gabapentin, at all time points, the pain was no greater than a 5 out of 10. Whereas, again, in the patients without Gabapentin, it could be quite severe in some situations. It really dropped the peak of the pain. It didn't get rid of the pain completely, just limited the amount of the pain that patients were feeling into a way that was quite bearable and much more tolerable.
Now, for all of my patients that get this procedure in the office, I pre-medicate them with a little bit of the Gabapentin before, and I found that it's made a big difference in the amount of discomfort they have in the 10 to 30 minutes after the procedure's done.
[Dr. Gopi Shah]
Have you noticed any risk factors or patient characteristics where you're like, "This person is probably going to get an ice cream headache or this one's probably going to be fine?" Have you noticed anything like that in your data?
[Dr. Jeffrey Suh]
No. I think location is one factor that if you're really burning using the cryogen in the correct spot and you're really getting the nerve where it's supposed to be coming out of, then they tend to get this procedure. I can't really predict which ones won't get it. I just assume that all patients will have an ice cream headache to some extent. Then for some, it's worse than others. For some people, it's really quite debilitating and other people describe it as being just a little bit more discomfort after the procedure, then it wears off pretty quickly.
For that reason, because all patients I feel get it to some extent, even with the anesthetic protocol that I use, I really rely on the Gabapentin to make it more tolerable.
[Dr. Gopi Shah]
In terms of going into the procedure so the balloon's-- it's the size of a small pledget like a square. It's not that small. It's like the one-half-by-half-square pledget size. When you go in, how do you know you're in the right spot? It's going to cover a large area but the area we want to cover is pretty posterior.
[Dr. Jeffrey Suh]
The benefit of this device versus the radiofrequency ablation device which we also use in our hospital is that the horizontal and the vertical segments of the basal lamella, meaning where the middle turbinate turns in the coronal plane and attaches to the lateral nasal wall is a barrier that will stop the tip of the balloon, which is the top the ClariFix device. When you put the ClariFix device, which the tip is the balloon into the middle meatus so we can see the middle turbinate, we can see the lateral nasal wall, and we slide it in the middle meatus.
When it stops, it means that it's hit the basal lamella. That's the endpoint of where the balloon needs to go. In some ways, the ClariFix requires less visibility or less exposure of the middle meatus than the radiofrequency device, which really requires you to see the exact area that the probe is being touched into. The ClariFix balloon will hit the basal lamella, which is the end posterior portion of the middle meatus.
Then you run the balloon for 30 seconds. If you hit that area in the middle meatus, that's the exact area that it needs to be in. Then the cryogen really spreads everywhere in the middle meatus, which is why I feel that even with a little bit less exposure to the area less access, you know it's going to work.
[Dr. Gopi Shah]
Is there a certain setting or is it one of those where you put the wand in and there are settings for you or do you–
[Dr. Jeffrey Suh]
Yes, it's really just an on-and-off. You put in the middle meatus, you flip the trigger, which is the safety and then you squeeze the trigger, and either your nurse or your assistant will look for that 30-second mark, and then they'll let you know that the 30 seconds are done. You turn off the gas, and then you have to wait for a little bit because just like if you touch your tongue on something that's frozen, it'll be stuck. Typically, you have to let it thaw for about 30 to 45 seconds after the freezing.
In that way, when you take out the ClariFix device, it's not stuck to the mucosa because one of the potential or theoretical risks of this procedure is that it can cause bleeding if you damage the mucosa. You want to wait until a good 30 to 45 seconds after you finish the freezing before you gently wiggle the device to pull it out of the nose so you don't damage mucosa on the way out.
[Dr. Gopi Shah]
That's a good tip. I wouldn't have thought about that. Here I am with the full nosebleed or torn mucosa. We've talked about the radiofrequency as well as the cryo and it sounds like you have access to both technologies. How do you know which one you're going to choose for who or do you have a preference at this point in your practice? At the end of the day as surgeons, there are certain things we just like to use better in terms of whether we're more facile with it, more familiar with it and those are our preferences which play a role.
[Dr. Jeffrey Suh]
The literature suggests that cryoablation and radiofrequency ablation if done in the correct area, they can both have a positive effect in terms of symptom management because the postal nasal nerve is being disrupted in both techniques. There's a lot of different factors that will lead a surgeon to choose one device over the other and luckily we're able to use both.
One of the benefits of ClariFix over the radiofrequency ablation device, which is called RhinAer is if the visibility into the middle meatus is restricted because of anatomical issues, again, the septum being deviated just a narrow nasal cavity, the ClariFix device because there are some tactile feedback when you hit the basal lamella, you know you're in the right spot. You don't exactly have to see that it touches the basal lamella.
You just know that what you're touching is the posterior sense of the middle meatus which is where the cryogen probe needs to be. If there's a little bit less visibility, I will say more patients are candidates in the office with the ClariFix procedure than the radiofrequency option. For the radiofrequency, you really need to see where the footplate of the probe is going to touch the lateral nasal wall in order to have the best effect of the nerve being ablated appropriately.
Then hospitals, they will choose one device over the other. Sometimes cost is a factor. The hospital might say to a surgeon, well, of the two devices, we choose one over the other. As a surgeon, just taking comfort in knowing that both are effective, but the hospital might choose one over the other might lead you to say, I believe in the concept of the procedure to treat chronic rhinitis. I'll use one device over the other just because this is just what's available to me.
[Dr. Gopi Shah]
Those are good points. In terms of post-op, do they have to do saline, Flonase? is there any post-op care for these patients, ointments?
[Dr. Jeffrey Suh]
Typically, there'll be some swelling in the mucosa of the middle meatus after the ClariFix, and it can last for about a week or two. I'll put patients on their nasal sprays. I'll say if you were on Flonase before or Atrovent, you might need to use that spray for a few weeks before we really get a sense if the procedure worked. Sinus irrigation will help too. It will help take away any mucus that might be there because of the procedure causing swelling in the middle meatus. Some people feel a little bit of pressure in their sinuses and the rinses and the sprays will often help but also, they do nothing.
It'll eventually recover in a week or two and they'll feel normal. Then typically I say after a few weeks, we'll really get a sense if the procedure worked. In terms of how often the procedure works, typically it's about 80%. If you choose your patients really well, you have a very good chance of the patient benefiting from the procedure in the symptoms that the procedure is meant to address, whether it's congestion or rhinitis. There was a good paper that was published that demonstrated efficacy in this procedure and typically patients that respond to Atrovent before the procedure have over an 80% chance of the procedure working.
If you're an Atrovent nonresponder before surgery, less than a third responded. That's why I really feel that Atrovent preoperatively is a litmus test to the success of the procedure, that if you benefit from Atrovent, I can almost say to the patient, you'll feel like you're living on Atrovent for a year or two after the procedure is done.
[Dr. Gopi Shah]
For the patients that don't respond to Atrovent, what do you do? Are you ever just like, we have nothing else that we should try to do this because there's still a 30% chance or is that silly? Are there other things that you do?
[Dr. Jeffrey Suh]
Those patients, again, I try to temper the expectation because I'm not quite as excited because as a surgeon, I want it to always work in our patients all the time. When something doesn't have the greatest chance of being effective, I don't want to subject a patient to a procedure that might not work for them. Then I think of it as a last resort. In those situations I'll be please try the nasal steroid spray, try the irrigation, see the allergist. Really focus on any other thing that we could possibly treat before we do this procedure.
If none of those things are effective and we're back to square one where you're totally desperate to get something done, and all other medical therapy options and other diagnoses have been eliminated, then we can give it a shot knowing that we've tried everything else first. Whereas the Atrovent responders, I really do feel that this is a phenomenal treatment option for non-allergic rhinitis in this population that are Atrovent responders, and in some ways, it's almost a first resort if they don't want to use the sprays anymore.
[Dr. Gopi Shah]
In terms of success, is this like we did it once and you're good for 5 to 10 years or is this like, listen, this is on average a two-year thing and that's a good outcome? What defines a good outcome?
[Dr. Jeffrey Suh]
Typically, I would say that if they get a year of symptom benefit is what I used to feel was the gold standard, because again, the nerve is not being cut or damaged. It's just being stunned until it can regenerate over the course of a year or so. We would expect that the nerve function would come back, therefore, the rhinitis would come back after the nerve fully regenerates. Recently, studies have shown that the efficacy does extend out to two years, where patients that benefited from the procedure can have sustained benefit for a while.
I've repeated the procedure in my own experience for patients after a year and they've also been able to benefit from the procedure again after the effects started to wane. I've had patients that I've done it on that have never come back afterwards and have done really well for a few years afterwards. It really depends. I tell them going into it that you might have to do this again. The setting situation would be the same or if they handled it well in the office the first time we would do it back in the office the second time.
[Dr. Gopi Shah]
We talked about during the procedure, we can cause bleeding or if we take out the wand too soon we can cause mucosal injury. Any long-term complications with this?
[Dr. Jeffrey Suh]
I've never seen anything past the ice cream headache. Typically, if you remove the probe slowly, the mucosa won't be traumatized and besides a little bit of edema in that area for the next week or so, it recovers totally normal. It's really just how do we make the procedure as comfortable as possible for the patients in the office if you choose to do it in the office. Again, every doctor has their own anesthesia protocols and I found that the use of Gabapentin has been pretty effective. Once you get them past that 30 minutes and they're in their car in the parking lot driving home, they feel pretty good.
[Dr. Gopi Shah]
Then one last question for you. In terms of if you have to do a revision or are there ever scenarios where you may have used one technology and then for-- are there any other reasons or scenarios where you might try again with a different technology?
[Dr. Jeffrey Suh]
There is. Even with the same technology, one of my colleagues at Mass Eye and Ear, Dr. Ben Bleier has done some really phenomenal anatomic studies at where the posterior nerve exits into the sinuses and into the nasal cavity. There are some anatomic variants where the posterior nerve fibers are actually in the inferior meatus as opposed to the middle meatus. I've had some patients initially that didn't fully respond to the procedure and I took them back for an inferior meatus cryoablation.
That also was effective in this small subset of people where maybe the nerve fibers anatomically aren't where we expect them to be. I went back to try again because these patients were still Atrovent responders. They just didn't respond to the procedure itself. I was looking for other answers. My colleagues that do the radiofrequency ablation as their preferred choice, they might do -- typically when I do RhinAer, it's three different locations of the footplate across the lateral nasal wall where we expect the nerve to be.
You might consider doing more ablations than what's typically done to see if we can cover a bigger area. Again, just because anatomically we want to make sure we get the nerve where it exits into the nasal cavity and it might take different sites to actually achieve the effect that we want.
[Dr. Gopi Shah]
With the cryo technology, would you ever do under the middle meatus and the inferior meatus at the same time at the same plate or do you just need to, hey, I'm going to do-- this is where it's most likely where the posterior nasal nerve is coming out, so we're going to start with that as opposed to cryoing the whole nose?
[Dr. Jeffrey Suh]
Right. The downside that are in doing the inferior meatal cryoablation is that they'll tend to get a lot more palate discomfort during the procedure because you're basically on the pterygoid plate right next to the greater palatine nerve. There might be some spread of the cryogen further lateral. They can have a lot of palate discomfort. In addition to the ice cream headache, then now they're going to have a lot of palate discomfort. I really have to choose those patients very carefully that they're ready to do this in the office.
In the operating room, there's very little downside because the patients are asleep. By the time the surgery is over, all the post-procedural discomfort will have already worn off. In the office, it does take a very specific type of patient that you can do both the inferior meatal procedure on and the middle meatal procedure. Again, most anatomic posterior nasal nerves do come out of the middle meatus. You'd capture the vast majority of people into the middle meatus. I wouldn't say you have to do it in both places in the office. I would say most of the time the procedure is very effective in the middle meatus only as the sole site for the procedure.
[Dr. Gopi Shah]
You're using the same wand balloon on both sides.
[Dr. Jeffrey Suh]
Yes. The limiting step for the wand is really the amount of cryogen. You have two cartridges when you do the procedure and it lasts for about a minute per cartridge. The typical cryoablation that we do is for about 30 seconds. If you do it on one side, you have about 20 to 30 seconds left of that cryogen where if it activated without you potentially trying to or if you ran out a little bit faster, what we typically do is we do one cryogen container on one side, we'll burn the extra gas, we'll just empty it and then we'll put the other cartridge in for the other side. You have one minute of gas per each side, but typically we just use 30 seconds of it.
[Dr. Gopi Shah]
In terms of the cryo, is there any special handling of the cartridges, do you have depth special gloves or anything like that?
[Dr. Jeffrey Suh]
No, it's a separate, it's like a paintball cartridge. It's a little CO2 cartridge that you just drop into the back of the device. The whole packaging is sterile. It's usually done on the field if you're doing it in the operating room but in the clinic, the nurses will just put on some gloves and drop the cartridge in on the backside. Yes, it's really simple. It doesn't require any special handling. It doesn't really require very much training. It's very simple to do.
[Dr. Gopi Shah]
It can go in your regular trash bin?
[Dr. Jeffrey Suh]
Yes.
[Dr. Gopi Shah]
Do you see these patients back in a couple of months or what's your follow-up like?
[Dr. Jeffrey Suh]
Usually, what I say is that if there's any concerns after the procedure, just please let me know. I'll give them kind of an open-ended appointment in a month or so, where they can come back to have me take a look to make sure that they've healed well. I used to do that all the time. Now I really just say, just let me know if there's any issues at all. If you have any discomfort or the procedure didn't work, or if you want me to take a look at your nose or your sinuses, then schedule an appointment at that point.
Otherwise, just shoot me a message. Let me know how it worked. Most people at that point say that, again, by the time they got home, they didn't really have any discomfort and they're really happy with the results.
[Dr. Gopi Shah]
Well, thank you so much, Jeff. As we round out, are there any final pearls that you want to leave our audience with?
[Dr. Jeffrey Suh]
Yes. I would say to the otolaryngologists and the people that would treat this disease process, often, for at least ENTs, it's really an afterthought for a lot of the more exciting surgeries that we do, but this disease is pretty common. If you ask our patients that have nasal complaints, it's a lot more than we initially would have expected. When we start asking about it, you realize just how bothersome this is and how much it can really impact their quality of life. There are some phenomenal new treatment options and ClariFix being one of them.
To really provide patients with an alternative to medical therapy that is really effective, really easy to do, and really something that we can add into our practices, where even though we weren't trained in it during residency, it's not very hard to learn how to do it. Our patients really do benefit from it and I've really enjoyed being able to help patients in a different way than what I was able to do before.
[Dr. Gopi Shah]
If anybody in our audience wanted to learn more about cryo or reach out to you, are you on any social media or is there a way they could get in touch with you?
[Dr. Jeffrey Suh]
Yes, so definitely email is the best way. I provide my email to all my patients and any colleagues that would want to reach out to me. I try to hide on social media. I'm not really on social media, but, yes, if anyone wants to reach out, just shoot me an email. You can call the office at any point. I'm really happy to give my anesthesia protocol or any tips that I've had in the last six years of doing the procedure.
[Dr. Gopi Shah]
Awesome. Well, thank you so much, Jeff. I learned a ton. I think it's a wrap.
[Dr. Jeffrey Suh]
Thank you very much.
Podcast Contributors
Dr. Jeffrey Suh
Dr. Jeffrey Suh is an otolaryngologist with UCLA that specializes in rhinology, sinus, and skull base surgery.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, May 9). Ep. 109 – Cryotherapy for Chronic Rhinitis and Nasal Congestion [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.
Up Next
Articles
Nasal Cryotherapy for Chronic Rhinitis: ClariFix
Chronic Rhinitis Treatment & Management
Topics
