Podcast Transcript: Nasal Airway Management: Evolving Practices in Diagnosis and Treatment

[Dr. Gopi Shah]
It's a good idea. Then moving on to your specifics of the procedure itself.

[Dr. Nora Perkins]
Yes, for the procedure itself, typically I'll start with the turbinate. I start anteriorly on the turbinate. I will progressively work myself, maybe the superior aspect of the anterior inferior turbinate, and then go right below that, and then stepwise work more posteriorly. Like I said, I will often treat the entire turbinate. I will often take a freer and out-fracture the turbinate as well because that is giving everyone a little bit more space, and with the local anesthetic, patients tolerate that really, really well.

Then I will treat the septal swell, and that definitely with the amount of decongestion can be a little challenge. You want to have your treatment area in mind at the beginning before you really get started. After it's been anesthetized, that area is very easy to treat and you do see some pretty immediate treatment response in that area.

You see it on the turbinates as well, but I think the septal swell is even more pronounced where you can see that tissue really retract. Then I go to the nasal valve last and typically I'm treating three sites. I usually start in the middle of the nasal valves and I'll treat that area and then I'll move more superiorly toward the apex and then I'll move more inferiorly. If somebody still has some collapse or if they just have a larger space, I may do a fourth treatment site. Trying not to overlap.

[Dr. Gopi Shah]
For the nasal valve, the device has a full cycle where it's heating and then you hold it while you're cooling. For the soft tissue, how long are your cycles for that because you don't need that cooling cycle, right?

[Dr. Nora Perkins]
Exactly. Yes. Typically, I'm holding it in place for about 18 seconds there. We're leaving it and then removing it. I know that people have mentioned this before, but it does make a funny little beep when you take it off before the cycle has ended. Just reassuring patients that that's just the noise the machine makes. That's generally what I would recommend.

Because these patients are awake, I think it's really important. If there's anything that may feel weird, sound weird, I pretty much talk to the patient through the case. Now they may be snoozy and maybe I'm just talking and they're not really listening, but I think it's helpful for people to just hear you say, "You're going to feel pressure here. You're going to hear a little crackly noise," especially when you out-fracture the turbinate, that can be really loud. Letting them know, "Hey that's a great sound." Very positive reinforcement. "That means we're creating more space in your nose, we're going to give you more room to breathe."

I think just constantly letting patients know what to expect and that everything is going as expected as you want it to go can really be helpful in an awake patient, especially if they are a little bit nervous even with the anxiolytic because sometimes patients are still fighting the anxiolytic if you will, or still just a little nervous. Generally, talking them through can really overcome that.

Patients afterward are pleasantly surprised with how simple the procedure was, how comfortable it was. They often are like, "Wow, that was it? I shouldn't have been worried about that. That was not anything like what I was expecting." Even though we've had a pretty extensive discussion about what to expect, I think they know patients who have had FESS, they know patients who have had septoplasty. They may know patients who had their entire nose packed. Even though that has nothing to do with what we're doing for that patient, a nasal surgery is a nasal surgery. They may be worried about some of those things.

[Dr. Gopi Shah]
For this technique, any complications I would need to worry about during the procedure or anything immediate post-op that you found?

[Dr. Nora Perkins]
I warn every patient that with any nasal procedure, nosebleed is always a potential complication. Fortunately, I have not seen nosebleed afterward. I think the only time patients really notice it is if they have crusting and if they pick at their crusting, which is true of any nosebleed. From a complication standpoint, there are not any serious adverse events that have been reported. I have not seen that. I can't even really describe this as a complication, but again, maybe some delayed crusting on areas that I potentially overlapped or treated aggressively in the nasal valve, but the ointment continues to allow those areas to heal. I really haven't seen any other complications.

[Dr. Gopi Shah]
Patients when they're following up, you see them three weeks later, do we expect that they are feeling better at that point? How quickly do they see their results?

[Dr. Nora Perkins]
I counsel everyone that they're typically not going to see full results for about six to eight weeks afterward, but typically at three weeks they notice improvement. They're generally feeling like they can breathe better through the nose. The one exception would be if they do have a lot of crusting, those patients still feel a little congested, a little obstructed.

I try to not remove the crust, although sometimes, as you guys know, any debridement, it's really hard when you see that and you know that they'll feel better if you took that crust off. You have to play it by ear. If it's really loose and barely hanging on by a thread. Fine, I'll take it off. Otherwise, I just reassure them this is going to continue to get better, these crusts are going to go away.

[Dr. Gopi Shah]
Do they feel worse? In the beginning, right after the procedure, I usually tell patients like, "Things are going to swell up. You might feel like you have a cold." Do you see that too?

[Dr. Nora Perkins]
Yes, I would agree with that. I think initially that day they feel pretty good, and then the first week, they start to get congested. Part of it's the crusting and part of it I think, to your point, is a little bit of swelling and an edema, but just reassurance. Selfishly that's part of the reason I see them back at three weeks. It's like seeing a post-tonsil patient, I don't really want to see you Week 1 because you're probably not going to be happy. You're going to have a lot of symptoms. I know you're okay, but it's not going to be a great visit.

At three weeks, you're going to say, "Hey, that first week I was a little congested, I felt a little sore, I felt a little crusty, but now I feel pretty good." That's generally why I would recommend doing that. I also don't think there's any medical reason to see them back sooner.

[Dr. Gopi Shah]
Nora, can you tell us a little bit about some of the longer-term outcomes data? Can we get into just some of those details? You'd mentioned earlier about four years in terms of how well patients do after this procedure. Is it specific to nasal symptoms? Does it have an impact in other areas of quality of life?

[Dr. Nora Perkins]
Yes, really, it does encompass other areas as well. To your point, the NOSE scores continue to stay reduced significantly. I think patients in general, when they're breathing better through their nose, they feel better rested. There's lots of data to support, treating nasal airway obstruction will not reduce patient's apnea-hypopnea index if they have sleep apnea. They will feel like they're breathing better, they'll feel like they have more energy, they feel like they have more oxygen.

I love when patients say that. "I feel like I'm getting more oxygen." I'm like, "Your oxygen was fine every time we've checked it. The fact that you feel like you're getting more oxygen certainly is a good thing." Yes, that four-year data really does show sustained results with obstructive symptoms.

I think again, occasionally we underestimate patient's quality of life with nasal symptoms. Yes, we are not treating cancers, we are not treating somebody's heart disease or something, but the impact of airway obstruction day to day is significant. Patients do appreciate that. You've all heard this, patients come in, "You've changed my life." It's always nice you pat yourself on the back, but I really think we shouldn't underestimate those patients. They really do feel like you've changed their lives. They're able to do things they couldn't do before. They're sleeping better, their exercise is better. Maybe they're able to sleep with their mouth closed. There's lots of things there that are improved.

[Dr. Gopi Shah]
Yes, absolutely. For the billing for this, for the insurance part of it, there is a specific CPT code for the VivAer or for radiofrequency treatment of the nasal valve, right? Word on the street is that commercial insurance isn't really covering it, but Medicare is. What's been your experience?

[Dr. Nora Perkins]
I've had similar experiences. For my local payers, Medicare, great, they will cover it. I believe now any Medicare plan would have to cover it, any locally managed Medicare plan. Commercial payers in our area have sort of fluctuated a little bit. There was coverage and there wasn't and there was. That's always a challenge for us, right? It's extra, but I continue to submit them to the commercial payers. I continue to do peer-to-peers.

You can push for the external reviews because when you have patients who really have exhausted other procedures, you got to offer these people something. In my opinion, you have a treatment option. Why their insurance won't pay this? Very frustrating. I also offer patients-- Let's say somebody hasn't gotten to that point. They don't want to have a septoplasty. They don't want to have anything more invasive in their commercial pay. The likelihood of it getting covered is very low. I will always offer them a cash option.

It is something that was initially really uncomfortable for me because I was not used to it. I'm not a facial plastic surgeon. I'm not typically talking about the price of my services and how they can finance it and whatnot, but I've gotten more comfortable with it. I don't think we should underestimate our patients because again, this is a significant quality of life disease. If you have a treatment option that is going to improve that quality of life, patients are often willing to pay out of pocket for it. You can't predict who will agree to it and who won't. Generally, I just offer it to any patient who doesn't have coverage as an option.

[Dr. Gopi Shah]
It's an option, which is always helpful for patients.

[Dr. Ashley Agan]
It's a really good point. I'm always-- I've had patients before that have told me about-- I remember a patient who was having their tonsil stones lasered out by a dentist. Every few weeks they would go get their tonsils lasered and it was costing, I don't know, $500 a pop or something crazy. I was just like, "Whoa." They finally got tired of it and we took the tonsils out. You're right, sometimes depending on how bad the problem is, people are willing to do what they got to go do to try to get better. I think that is an important consideration. I think that it's because of the devices, their disposables, the pricing, I feel like you're able to offer a pretty reasonable cash price with this.

Also, I think you make a good point, Nora, we shouldn't underestimate our patients. The point that you both make of they know their symptoms, they know how it affects them, they know their finances, and how they also want to financially pay for different treatments. We all know that health insurance companies don't always cover all the needs that a patient might require. Having those options, I think, are very helpful, can be.