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BackTable / ENT / Podcast / Transcript #68
Podcast Transcript: In-Office Procedures for Nasal Valve Obstruction
with Dr. Mary Ashmead
In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Gopi Shah speak with Dr. Mary Ashmead, a Dallas/Fort Worth based rhinologist (Texas Ear, Nose, & Throat Specialists) about in-office procedures for nasal valve obstruction. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Approach to Patients with Nasal Obstruction
(2) Conducting a Focused Examination for Nasal Pathology or Complaint
(3) Considerations and Treatment Options for Nasal Obstruction
(4) VivAer: Nasal Valve Specific Procedures Addressing Nasal Obstruction
(5) Anatomical Specific Approaches Utilizing VivAer
(6) Following VivAer Treatment Results and Recovery Management
(7) Considerations When Selecting Patients for VivAer treatment
(8) Alternatives to VivAer for Nasal Valve Collapse
(9) Approach and Protocol: Anesthesia and Anxiolytics
(10) Procedure Revisions and Additional Considerations When Treating Nasal Obstructions
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[Ashley Agan MD]
Hey, everybody. Welcome to the back table, ENT podcasts. We've got a great show for you today. quick introductions. My name is Ashley Agan. I'm a general ENT in Dallas, Texas.
[Gopi Shah MD]
And my name is Gopi Shah. I'm a pediatric ENT. How are you doing today Ash?
[Ashley Agan MD]
I'm wonderful. How are you, Gopi?
[Gopi Shah MD]
Surviving the 107 degrees, hydrating.
[Ashley Agan MD]
Melting.
[Gopi Shah MD]
Trying to take a walk, getting shorter breaths in 10 minutes, but you know, we have an awesome, awesome show today. we have Dr. Mary Ashmead. She is an otolaryngologist and rhinologists practicing in Dallas Fort worth for Texas ear nose and throat specialist.
Dr. Ashmead specializes in in-office rhinology, including Sabika submucosal, turbinate reduction, septoplasty and nasal valve procedures, as well as office sinus surgery from sinus dilation techniques to full and office primary fests and revision procedures. Dr. Ashmead is here to talk to us today about in-office procedures for nasal valve obstruction.
Welcome to the show. How are you doing this morning?
[Mary Ashmead MD]
Hi. Thanks. It's good to be here. I appreciate you guys taking the time.
[Gopi Shah MD]
Mary, you want to first tell us a little bit about yourself and your practice.
[Mary Ashmead MD]
Sure. So we have a single specialty group in Texas, ear nose and throat specialists. We are in private practice in between Dallas and Fort Worth. And I have four wonderful partners and a new PA. We have four offices. I am rhinology trained, but I do a lot of general ENT still in my practice. So little bit of everything here and there. So we focus on in-office solutions for everything, not just for sinus surgery and nasal obstruction, but other things as well. So it's a good time.
(1) Approach to Patients with Nasal Obstruction
[Ashley Agan MD]
That's awesome. today we're going to try to zero in and focus on the nose and taking care of patients with, you know, nasal obstruction specifically. So, I guess we can just start out by setting the stage, you know, when a patient walks into your clinic, you know, How are they presenting? What is that first visit? And what does the first evaluation look like?
[Mary Ashmead MD]
Yeah. So a lot of these patients will come in for nasal obstruction, right? Not all of them, but a lot of them will, and it'll be, I'm coming in for sinus or allergies or sometimes for nasal obstruction or nasal blockage. And, you kind of have to figure out what their actual symptoms are. You know, I stress that the word congestion is. No word in my office because it means too many things. Right. Do you mean, do you mean blockage? Do you mean obstruction? Do you mean drainage? Do you mean pressure? Which one are we talking about? Because man, how many times, especially early on, he'd go through a whole visit thinking that you're talking about one of those things and then you like, oh man, I sure hope this helps to my drainage. Like, oh, okay, let's talk about that.
[Gopi Shah MD]
You're like, is GERD back on the table?
[Mary Ashmead MD]
So, you know, patients sometimes know exactly how to describe their symptoms but not always. The tricky part is that a lot of these nasal obstruction patients come in for something totally different, right? They're there for ear wax or my ears feel full. You start to examine them and talk to them and sure enough, they have really significant nasal obstruction. There's, you know, some great studies that have looked at how much we're missing as doctors in patients with nasal obstruction. Really it's about one in five people, all comers in our office for as far as general ENT scales, one in five will have severe to extreme nasal obstruction. And that's not always why they're there. They've been told that they needed surgery or something major and they say, well, “I'm not doing that”. And then just kind of stop talking about it. So a lot of them will come in with nasal complaints, but I think we're doing a disservice. If we don't at least kind of do a cursory exam or, ask about nasal obstruction. Because otherwise we're going to miss some of these patients.
[Gopi Shah MD]
Do you kind of have a list of, like an ENT review of systems that you kind of go through for all patients? So, if the earwax patient is coming in or the hoarse patient is coming in, there's still a full-on list. You're not just diving straight into the specific chief complaint.
[Mary Ashmead MD]
I could probably do that better. Actually. It's not a bad idea.
[Gopi Shah MD]
Personally I haven't and I don't always do that.
[Mary Ashmead MD]
Yeah, I would love to. So we've, we've done that. There's something called the nose challenge where every single patient that comes in the door gets a nose score. And so you can pick up these patients. It just takes extra time to get these things done. But I think it's worthwhile at least to mention it, or if you start to see narrowing when you’re doing the normal exam. Then, you kind of dive into some of those questions. It's hard when you're busy and you're three patients behind, and you're just trying to take care of the reason that they came in that day. But they're there and we're missing them.
[Gopi Shah MD]
Yeah. The other thing I find hard about some of the screening questionnaires is how do you incorporate them in your clinic? Then you might have this form or something that they've done electronically. Where do you put that information? Like, are you looking back at it? Are you following it? You know what I mean? Like we have all these great tools, but it's incorporating them into your practice. I feel like it isn't always well thought out or easy to do, to enhance your practice. Sometimes it can feel like it makes it harder.
[Mary Ashmead MD]
Yes, I generally, if it's important, I generally will put it into the H&P. And so I'd put it in there, a patient presented initially with nose score of 75 and it gets scanned into their chart, but I'm not sure how often I'm actually going to go back and look at that later, unless we start to do something and I want to compare, so I have it there, but it's not always readily accessible if their score is low, it can be hard.
(2) Conducting a Focused Examination for Nasal Pathology or Complaint
[Ashley Agan MD]
And so what does your exam look like when you're seeing patients? Let's say it is a patient that does have some sort of nose complaint. so, it's hard for me to breathe through my nose or I'm having a lot of drainage from my nose. Like where you're kind of zoomed in and thinking about that.
[Mary Ashmead MD]
So I have a pretty standard at least to start, right until you start finding things, exams, looking at everything from front to back. I do scope almost all of these patients, unless I can tell whether we need to try some Flonase first or we're going to try something easy. You know or you're here for something else and we haven't done some of the initial steps,
[Ashley Agan MD]
Right when it's like a bonus symptom. They're like, oh yeah. “And I also have..”.
[Mary Ashmead MD]
So, if we're really going to focus in, and evaluate this, I start just looking on the outside of the nose right here. Just general. You know, how narrow is that middle third? Where are the nasal bones? What does the external valve look like? Just kind of having them tilt their head up. Where are we looking here? There with kind of normal breathing and then take a stronger sniff in and see what's moving. And then from there. Looking at the internal valve. So that area where that upper lateral and lower lateral cartilage meet that scroll area, inside the nose. And I look at that with a scope. So I think if you are a person who loves nasal specula and a headlight. I know lots of these people too, you're going to miss these because you're going to stint it wide open, and you're going to be looking back saying “Hey, this all looks great”. So you can do that to look farther back, but if you're really trying to examine that front structure, you need to not manipulate it upfront.
You need to look at it in its native position. Where are we? Then do the same thing, taking a normal breath and then taking a stronger sniff. And is that internal valve collapsing? Is there a dynamic collapse? Is it a static collapse? And then from there I will do a normal Cottle and not just kind of flay everything out. Like you would with a, a speculum to some extent, hold out the external valve, the internal valve, hold out the cheek, whatever you want to do there. So does this make it better or worse? And if it doesn't change their breathing at all, then you can kind of start to look farther back like, “oh yeah, that is better”. And then you kind of have to start ferreting out. Is it internal? Is it external? Where exactly is this problem? And, and I usually use a little loop curette, something that's very, unobtrusive or something. That's just a little wire loop. Sometimes if I run out of those in the office, I'll use a normal little ear curette or something small where you can lift and support that one little spot of that internal valve, just ever so slightly. You want to be making very small movements. Does this make your breathing better? If they say, yes. You're like, okay. I need to note that down. And then we look farther back. So then I start looking at the turbinates and we look at the mucosa. What does the lining of the nose look like?Is it boggy? Is it edematous? Where are the turbinates sitting? Are they hypertrophic?
[Ashley Agan MD]
Are you looking with a rigid scope or a flexible scope? And do you decongest.
[Mary Ashmead MD]
Rigid. I use and yes, but after. So I look at all of my nasal obstruction patients. My assistant has pretty strict instruction. Don't spray these people. Sometimes, when you're coming in, it's a sinus post-op, she'll spray them ahead of time. Kind of keep things moving. But these, I don't want to spray them at first. I want to see what they do. So I will look, I'll use a zero. I use one of the pediatric ENT scopes. I have a couple that I really like with a little battery pack. So I can move around from room to room. We have several of them in the office and look at that turbinate. And sometimes I'll actually try to palpate it a lot of times I want before if I'm not going to spray it. But to see how easily it compresses? Does it compress? Yes or no. And then you look back at the septum and look high up in the septum. And you look at that swell body area, which is kind of this black box for a lot of ENT that haven't heard a lot about it. And it's this kind of controversial thing, is it real? Is it not real? But that area on the swelling that we've all seen is a swelling on the septum that we've all seen back there that sometimes blocks the middle turbinate.
[Gopi Shah MD]
Yeah, it's in your way during fess, right? Every time that's the thing that you're just like, please, like, what do I, what do I need to do?.
[Mary Ashmead MD]
And, you are like “oh, look, there's a little septal deflection to the right”. And then you look on the other side. “Oh, it's a little septal deflection to the left, wait a minute”. And sometimes it is, you know, sometimes the bone is thicker there, or it kind of splays out and, but sometimes it's soft and you can feel that in the clinic, it tickles a lot. And so you have to tell the patients, all right, I'm going to press this little spot. This is going to feel weird.
[Gopi Shah MD]
So you're using your fingers or a cotton swab?
[Mary Ashmead MD]
No, so I'm still looking with my camera and I'm looking with my scope and sometimes I'll have it up on the screen and I'll show them, which is helpful. And I'll record it. And I kind of show them the changes that I'm making. Do you breathe better? Yes or no. But then I'll take that same little loop curette up there at the septum, that same little loop curette or something else that you have on hand that's small. And then you press on it and does it collapse in? Or you touch it and it's firm, right. So you can tell every once in a while you can compress it. You see a really large one and you compress it and you can ask them if they breathe better. And sometimes they'll say yes, but most of the time I go, “I can't tell it tickles too much, it tickles too much”. Then you pull it back out and say, I'm sorry, just needed to see if this was soft or not. So I do all of those things and then I decongest, so this is slow. Like this takes a little bit of time.
Then we decongest and then we start over and I do the entire thing again. Because some people you'll do that modified Cottle, the real mild, I'm just going to hold right here and they don't feel any different. But then you decongest them. And then it takes them like, oh this is better. But man, now that Cottle’s really positive. So you can unmask this nasal valve issue in some patients where if we just decongest and you look and you're like, oh, we're just going to do turbinates. Well, they're still going to have that problem. They're still going to have that nasal valve narrowing. doesn't mean that you have to necessarily treat all of them, but to know, okay, if we do something small, we may not get as much improvement as if we did multiple things together at the same time. So we talk about it. So decongestant, then you start over not necessarily at the outside, but looking at the external valve and breathing and the internal valve. And then I repeat the Cottle and then sometimes I'll, I'll kind of still feel that turbinate, you know, is it still soft? We decongested, but it's still soft. Okay. There's just a lot of extra tissue.
Feeling that swell body, I generally feel that one time. I don't feel it more than once because they aren't super happy with that. And then you're obviously looking for all the other things. Are there polyps, is there something posteriorly, is there evidence of sinusitis? So that kind of takes you down a different road other than this is a structural problem or structural with some allergies on top of it. Here in Texas everybody has problems at least to some extent these days. So repeating that whole thing again. But if you, if you use a headlight and a speculum, you're going to miss these issues here in the front. I think that's the key part. And if you don't look at all, then you're going to miss all of them.
(3) Considerations and Treatment Options for Nasal Obstruction
[Ashley Agan MD]
Yeah. So kind of just moving on to treatment options. Assuming that you're probably going to offer medical therapy first or allergy. Assuming you've got patients, who've already kind of failed that and they're at the point and they're like, okay, I want you to do something, please fix this. So what kind of things are you thinking about as in what, what tools do you have to offer.
[Mary Ashmead MD]
Right. So conservative stuff, like you said, we talk about nasal steroid spray. We talk about topical antihistamines. I actually will have them do Afrin at night, especially if they're talking about nighttime symptoms, I'll have them use Afrin very, very deliberately. And only for very short periods of time. I have them use nasal dilators. I actually have them usually try something, whether it's a breathe right strip on the outside, which is a little bit easier to use. You kind of have to show them exactly where to place that or the internal nasal dilators. Whether it's nose cones, sinus cones. There's some on Amazon. There are some others that are developed by ENTs that can help. Like hey, if I just work on this nasal valve area is this enough for you? And then we'll be fine. So helping them kind of sort through which parts of their symptoms are the biggest ones for them, I think is really helpful. And then to do a decongestant with something mechanical, whether it's a, breathe right strip or a nose cone to say, okay, this, this is, this fixes it. Especially when you have patients with a deviated septum. Like, Hey, how, how important is it that I fixed this septum? And I think it's really hard as ENTs because we're so visual to look at something and not fix it right.
[Ashley Agan MD]
Yeah, for sure.
[Mary Ashmead MD]
You know, that patient that says they don't have any nasal obstruction symptoms and don't snore and you really can't get any sort of symptom. But you look in their nose and their septums are just like very far over to leave that alone. And that's where we have to start talking to our patients. to figure out what their goals are and trying to figure out how many areas. So we talk about the different areas of obstruction. So we have an external valve on the front, the internal valve. We have the turbinates, we have the septum, we have the swell body. We have the swelling, just thinking about rhinitis in general. And how many of those areas do we need to treat to take care of the symptom? And so I talked to patients about, well, we have this, this symptom of nasal obstruction and there's all these things, supporting it, all of these kind of legs on the table. And how many of these table legs do we have to knock out before the symptom is better?
And so we have treatments for all of these, we have all of our topical things. We talk about septoplasty and we talk about the nasal valve. And then we talk about the turbinates. And so specifically, anyone who responds to a modified Cottle in the office. The data is really good that they will respond to a nasal valve procedure without having to fix or work on anything farther back. And so to sit there and talk to the patient about what their expectations are. Goes into what we just talk about. It takes time to talk to people about all of their options, surgical, nonsurgical, procedural, in the OR, in the office. But it's important to get their goals before we kind of jump into you should have XYZ surgery.
[Ashley Agan MD]
Yeah. I'm sure it can be overwhelming because you have all these, you know, the big list of things that can be done. And then you start dividing it into things that can be done in the OR, things that can be done in the office. And then, and in the combinations of them like that. What about this one with this one and this one. So do you feel like you mentioned having them try breathe-right or nose cones. Do you routinely say, okay, I want you to at least go away and use this for X amount of time. And then if you come back and tell me it works, then I can be confident that a nasal valve procedure is the right thing. Or is that kind of it, how do you go about it?
[Mary Ashmead MD]
Sometimes. Right. And so this is where that, again, that patient conversation can be so important because there's the people that are there and they've tried the normal stuff and they are ready to be fixed. And so then I don't necessarily send those people out and say, oh, try some Afrin, try some nasal dilators. Don't we know that their septum is bad and their symptoms are worse on that side. But they also respond to the Cottle and they have turbinates that are big. And so then it's okay, well, let's talk about this. What kind of a patient are you? There is a, let's get it, all done. All the things that we see that are contributing and, and let's work on all of them. And it's a little bit more recovery, right? So there's a little bit more to go through versus, “Hey, I want to start and I want to do conservative things”. I want to do things that are easy. And if that means I have to do a couple of things in the office, but I don't overdo it. I'm happy. And you have both of these, you have both of these patients, right?
And so I try to get pretty early once you can just kind of decide that we're looking at procedures, which patient are you? Are you upfront? All of the things, or are we a, I'd rather be conservative and patients generally know. It's the same type of conversation when someone comes in with sinusitis and well are we going to get allergy testing? Are we going to try medicines? Are we going to get a CT scan? Are you a shotgun? Let's get all the information now? And then figure it out sooner. Or let's do one thing at a time. And that is work. That's true for nasal obstruction. We want to be more conservative and they'll tell you like, oh, I want to, I want to do the easy things first. Great. Let's talk about it. Versus I want to do them all. And then, so then once you kind of get that idea, then we start talking about office versus operating room. And there's obviously some patients that really you, you're not going to necessarily do in the office for many different reasons.
[Gopi Shah MD]
You can barely get that loop curate on that swell body. You probably aren't doing them in the office.
[Mary Ashmead MD]
Right. So you know, you walk the scope into the room and they're already getting bug eyed like, oh, “I hate going to the dentist. They always have to knock me out. I have all these troubles”. Okay. Well, let's not really talk about that too much. Let's talk about the things that we can do, in the operating room or we talk about some anxiolytic medications to talk about doing some things in the office. So, thinking about septoplasty and then turbinate reduction, which starts 10,000 ways to reduce turbinates and everyone kind of has their own little proclivities there. But then nasal valve, is this something that they were interested in changing the outside of their nose? Are they really wanting the outside to stay the same? Do we want to be conservative? Do we need to get back to work really fast? how thick is their skin? If we're going to talk about implants, is this going to show on the skin? How concerned are we about these things? And so then we start to talk about all of these different procedures, and start to narrow down. What's going to be the right thing for them? And if we can already tell, like, okay, we're going to need some cotton. We're gonna need to talk about this a little bit more. That's when I send them home here, try these nasal dilators. Let's come back and, and cause we're kind of starting to go a little bit long and let's kind of have this conversation again.
[Gopi Shah MD]
Well, it also gives the patient some time to think about and process. I mean, there's a lot of different structural anatomy, what's actually causing a functional problem. And then, you know, it kind of gives them maybe an idea to better understand how different things feel. And so I feel like that's probably, you know you said, that you can kind of as a clinician sense. Okay. At what point, you know, do we need to slow down or, Hey, let's try some of this just to get a, be on the same page. So the expectations are, you know, we're both aligned with that as well. Is there ever a role for any imaging for your nasal obstruction patients or does it just depend on what you see on your exam and scope?
[Mary Ashmead MD]
So if we have facial pain or we start talking about, posterior drainage and recurrent infections. And we see some evidence of swelling, a little farther back on the scope. I have a low threshold for imaging, but if all of those questions are negative, I don't have headaches. I don't have pressure. I don't have infections. I don't have drainage. And you get a really good exam. I generally don't.
[Gopi Shah MD]
Yeah, that makes sense
[Mary Ashmead MD]
I generally don't, I think you can if you're not really sure. Like, “Hey, I don't get a really good look at that middle meatus” because the septum is too large, you know, I think it's, it's fine. But if we have, if we have no symptoms to support it in your exam, just as nasal, just nasal obstruction. This is a structural problem. You don't really need it.
(4) VivAer: Nasal Valve Specific Procedures Addressing Nasal Obstruction
[Ashley Agan MD]
So do we want to jump in and talk specifically about the nasal valve and kind of what procedures you're doing. And more about that particular part of addressing nasal obstruction.
[Mary Ashmead MD]
All right. So, for those patients who do respond well to the modified Cottle in the office, and so you can kind of mimic the types of results you can get with a radiofrequency procedure. Like VivAer we talk about it. And I show them videos of what we can expect. This is what to go through. And sometimes we will kind of piggyback this with turbinates as well, if we have other problems. But if they respond well to that modified Cottle in the office, we have really good data to say that they will respond to the VivAer procedure. And it's data that lasts out to four years now. That we get lasting relief from this office procedure that we can offer our patients who don't want surgery, and they don't want to change the outside of their nose and they are having trouble breathing through their nose. And so then we start to go through exactly what it is and how it works and, uh, whether or not this would be a good option.
[Ashley Agan MD]
And for listeners who don't know what it is, can you kind of do your spiel about. What is it?
[Mary Ashmead MD]
Yeah. So,VivAer is a disposable handpiece or stylist that delivers bipolar radiofrequency energy. So it's a little paddle that we can use to shrink down this tissue and to help, to stiffen and retract and change and remodel that internal nasal valve. And so there's a video, an animation on their website that I will show them say, this is what we're trying to accomplish. And then they usually ask, well, what's radiofrequency energy, you know, how does this work? And I tell them that it causes tissue vibration that causes things to heat up. And so if you put this against a grape, it makes that grape kind of slowly implode because they immediately think burning, right? Like, oh, you're going to go burn my nose. No, that's not what we're doing. This is it's temperature controlled. It does not overheat this little paddle that delivers this energy in a way that will remodel and reshape that small area that's most important. And so we talk a little bit about the nasal valve and how, this is the area that's the smallest and the nose. And we talk a little, very small amount about physics, which is always a good time. but there's no incisions. And the end, you can do this in the office and, we can give you some relaxing medication beforehand, or you can, we can numb everything up, and you can drive yourself home and go straight back. And recovery is minimal. And so we talk about this, this procedure and go through the details. So the short answer is that this is a remodeling we're trying to remodel the inside of your nose so you can breathe better.
[Gopi Shah MD]
So when you actually perform it, when you have the stylist or the paddle, where do you put it
[Mary Ashmead MD]
Right? So that's the most important part. So I do, there's lots of different ways to do this. Some people use a headlight. I still use the scope because that's how I've examined the patient. And that's what I'm used to. So I will lay them down in a normal position. Like I'm doing sinus surgery. I lay them back. Other people will do this upright, which I think if you're using a headlight, most people will keep the patient upright. And then if you're using a scope, I think it's a little simpler, a little easier to lay them down. And you're holding this stylist against that little scroll area where those tissues come together. And so you're putting this inside of the nose and then you're lifting up and out. I've actually started holding some pressure on the outside, to model and hold that cartilage. So it starts to bend the way that we want it to. So we want to go from concave to convex work. We're trying to make millimeter changes. We're not trying to make big changes. I'm trying to make small changes and to hold that stylus out. So there is a heating period. Again, that's temperature control to 60 degrees, and then there's a cooling period and you hold that position. So you're holding this inside, you're lifting up and out and, and compressing a little bit on the outside to change and mold that cartilage. And so once that cooling position is complete, then you remove it. I go back in with the camera and I watch exactly where I came out and then I move slightly farther down. So we March our way down that internal valve. And it's usually three to four treatments per side. Depending on their specific anatomy, it's usually three to four of these cycles and you kind of see these little railroad tracks of where you've treated. And so you look and you see any move it just slightly down below, and then you repeat. Then you hold it out and then we can press slightly, heating cycle, cooling cycle. And each cycle is 30 seconds. So we're not talking long periods of time here. Usually it was about six or seven minutes from start to finish. Numbing is a whole other thing which we can talk about, but the actual procedure is about six to seven minutes to do. And that includes walking everybody through it and, and keeping everybody comfortable, so marching through. And then, and then going to the other side and doing the same thing on the other side.
[Ashley Agan MD]
And you're looking with a scope to make sure you're, you know, kind of not overlapping and treating, you know, accidentally treating the same area. You're kind of, you know, you start at the top and then you get it in position. Then you take the scope out and use that hand to hold pressure.
[Mary Ashmead MD]
I do that. Sometimes. So I have trained my medical assistant to help with that lateral lateral pressure. I have taken the scope out if I really know exactly where I want it to be, and I really want to kind of hold the other opposite sides. But she can do that too. You can do it both ways to make sure that you're getting the best outcome, but I do like to place it with the scope. You want to make sure you're not going into the bony aperture, so you kind of would make sure you're not, on that bone to one, it's just not going to work there. Or you’re just causing extra swelling that you're not going to be gaining from so that you're in that right place where that valve is. You're kind of straddling that area, working your way down and then either pulling the scope out and holding or, training an assistant to do that for you. You can do it either way and there's data to say that you don't necessarily need to hold the outside. What I found is that when I don't, the patients think that I'm trying to turn their head. And so we talk about it, you know, there's a lot that I walked through with the patient while they're numbing on kind of what to expect. It's going to feel like I'm trying to pull your head over to the side. I'm not, I'm just trying to hold this area open. I found that when I'm holding lateral pressure like that, it turns that off a little bit in the patient's mind. Oh, I don't need to turn my head. They're not, she's not trying to move me or trying to gain some space there.
[Ashley Agan MD]
Yeah. So there's quite a bit of pressure to deflect that tissue out, you’re really pulling.
[Mary Ashmead MD]
Yeah. You want to hold this out significantly? If the patient was totally relaxed, their head may turn a little bit. That's why it's helpful, especially if you're doing this in the operating room. For whatever reason, you know, if we're doing this, in addition to a septum that you didn't want to address in the office, or if you're not doing septoplasty in the office. You have to hold a little bit so that you don't, keep turning their head over to the side.
[Gopi Shah MD]
And so that, sorry to go back to the pedal. You're putting it when you put it at the scroll area it's on the skin. Nothing is direct. You're not making, you said no incisions and you're not putting the paddle on the cartilage. So it's just in the nose.
[Mary Ashmead MD]
Right. In the nose against the mucosa because it’s right where you would do the Cottle. And so this slides in, you know, it's several millimeters. It's a good size to lift up and out. So there's no incision. You hold this on the mucosa, you, and then you lift
[Gopi Shah MD]
There's no risk of, if you held it in the same position too long for causing like a hole or going through the mucosa and going directly to the cartilage or anything like that, could that ever happen?
[Mary Ashmead MD]
So there has never, there's not been any adverse, significant adverse reaction with this. And the other thing that's helpful too, is that it is temperature controlled. So it will, you can hold it there. You can treat the same spot multiple times. It's never going to get above 60 degrees Celsius. So that temperature controlled mechanism, as opposed to some of the radio frequency turbinate devices that you can really get in there with some of those, there's some built-in resistance to that. And plus if you're watching and you're noticing that you're not re-treating the same spot multiple times to deliver that energy through, the electrodes with this thermal coupler that will get deep enough without getting too deep.
[Ashley Agan MD]
And are you seeing any tissue changes when you do it? Like, is there any, you get any sort of feedback to know is, this is adequately treated. Like, do you already see any sort of regression of that tissue to be like, okay, I'm done this looks great. Or is it, does it take time for that to heal? And I know you said you could kind of see some of the railroad, like will there be tracks of where you've been?
[Mary Ashmead MD]
Yeah, that's a great question. So I find that I see more of that real-time feedback when it's static collapse. For the dynamic collapse you don't see as much of that, because again, with the dynamic collapse, we're trying to strengthen and stiffen these structures. Because that's one of the great things about this device is that it does work for. It works equally well for dynamic and static collapse. So for the dynamic folks, you don't necessarily see as much of that instant improvement, but for the static people, yes, you will. And you'll, and you can actually ask them immediately afterwards, take a breath in. Does that feel more open? Yeah, it does. I'm like, okay, great. It's going to get stuffy. So enjoy it right now because it's not going to last. It's not going to last for the whole of next week. But yes, you do see some of that shrinkage immediately. Not to the same extent, like a submucosal resection necessarily, But you can, and you can use this device on the turbinates too. You can use it on the swell body. Actually see more changes there where this will indent, where you've treated. You see it on the, on the, the static valve collapse patients too, but you can also see it in those areas where it compresses in.
(5) Anatomical Specific Approaches Utilizing VivAer
[Ashley Agan MD]
And how do you use it when you use it on the septal swell body and the turbinates? Is it different or the same?
[Mary Ashmead MD]
So it's, it's the same as that you're, you're pressing through. I tend to do most of my turbinates with a shaver. Unless I really only need a little bit of space for those big bulky turbinates. I prefer to use a shaver and we talk about it. But for those patients who are on blood thinners, or we don't want to make an incision, or who don't want to have to deal with any bleeding, then, it's definitely a good option. I usually do, about 10 to 12 seconds. So I don't go through the full heating, cooling cycle. When I'm using the VivAer wand on the turbinate and the swell body, usually about 10 to 12 seconds and then move on to the next place. But it's the same. You hold it against, you press, and then you kind of step on the little foot pedal.
[Ashley Agan MD]
It just doesn't need the cooling cycle?
[Mary Ashmead MD]
Yeah. So you don't need the cooling cycle for soft tissue. That's really just for the cartilage. You have to tell the patients though, because when you come off of the foot pedal early, it makes a different beeping sound. And so if you have those patients who are really paying attention, I tell them “you're gonna hear some beeps and sometimes it will be one way and sometimes it will beep another way. And that is telling me things and you don't need to worry about it”. And so I know if I'm going to step off the foot pedal earlier and it's going to sound different. It's like, all right, here's those different beeps. It's going to sound different. And so that way they don't think that something's going wrong, especially for when you're working on an awake patient.
[Gopi Shah MD]
So it's the same thing. You just put it directly on the mucosa. We said no cooling cycle for the turbinates. Do you put it on a cooling cycle for the swell body, or you don’t need it there either?
[Mary Ashmead MD]
No. And again, cause it's, we're just dealing with soft tissue.
(6) Following VivAer Treatment Results and Recovery Management
[Ashley Agan MD]
And do you see that shrink down in real time?
[Mary Ashmead MD]
Yes. It can be really satisfying. I usually let my patients have a family member in the room. I know that that is definitely a personal decision for you as a surgeon. But I do. And I think that it makes it so that the patients feel comfortable. I do say I can only have one patient. So if you're squeamish with procedures, you're welcome to have you in the waiting room, but you're welcome to stay if you want to. And I'll walk them through it too. And then you tell like “Hey, look, look how much better this looks like, look, look at how this contracts and how much more open cause you can see it”. So you can see it and show them.
[Gopi Shah MD]
Is there any sort of rebound intra-nasal swelling for any of these locations that you have to tell them about or, is there any, and I know we, so it didn't affect the way the appearance of the noise, but do you ever have any temporary, external swelling or anything?
[Mary Ashmead MD]
Yes. So we talk about all of those things. So like any radiofrequency procedure, really it's six to eight weeks before it's really completely finalized. Right? So just like when you use coblation technology or anything else in, within the nose or turbinates. It does take some time for that to completely finalize. The other thing that you do get, you get a crust and this is the most annoying part for the patient. And I tell them this, like, you know, the procedure is very easy and recovery is very easy, but you're going to get this little scab on the inside of your nose, where we do this, this little nasal valve procedure. And that can stick around for several weeks. I do have them, use ointments. I have them use ointments twice a day until that scab goes away. I will sometimes switch them over after a couple of weeks to just something like saline gel or something that is not petroleum based. But we talk about that scab and like, it's going to be better sooner, but it will be even better when the scab.
You do also tend to get some tenseness on the tip of the nose. So what I tell patients and with their family members there, you know, “tomorrow, you may look at the tip of your nose and think, oh, that looks a little swollen, or it feels tense or tight. Like when you've had a sunburn and your skin feels tight, it's not going to look different to someone who doesn't know you”. I've had patients go straight to the grocery store after the procedure. So you don't look different, but it does feel a little bit tense, or feel a little bit tight for a few days. I give my patients an optional little pulse dose of prednisone. I just do, I do 40 milligrams once a day for five days. And I tell them that this is optional. Steroids have side effects. And we go through those. But I want you to have this on hand, my procedure days on Fridays. And so I want you to have this so that if it feels tense or it feels uncomfortable, you can take this. If you're doing great, you don't have to in the long run. This is not going to make any difference with healing, but in the short term, it can make it a little bit more comfortable. And this is an option for you that I want you to have.
[Ashley Agan MD]
Anything else that you counsel to look out for? Does the nose look red and swollen or anything, or is that the worst? It gets just a little bit of tip tenseness.
[Mary Ashmead MD]
Yeah. A little bit of tip tenseness. And then that scab that's really it. I have had no other problems. It's a little sore, like it's bruised on the outside. So if you manipulate the nose and that can stick around for a few weeks it doesn't hurt at baseline. But if you hit it like, oh yeah, it's a little bit sore. Not really a risk for infection or anything else because of the nature of the process of the handpiece itself.
[Ashley Agan MD]
And so patients probably can just get by with Tylenol Motrin. So I'm like probably aren't requiring narcotics?
[Mary Ashmead MD]
I usually give them a couple of Tramadol. For my patients that I premedicate, for my nervous people. We talk, we go through all of this kind of extensively. We could talk about anesthesia protocols for a couple hours. So I'll give them a couple of Tramadol to take ahead of time. And then there's a couple extra there in case they need it. I've never had anybody ask me for more than that though.
(7) Considerations When Selecting Patients for VivAer treatment
[Ashley Agan MD]
Awesome. Any other pitfalls or things to, to note as far as you know, doing the procedure or, complications or other things to know?
[Mary Ashmead MD]
I think the main thing is to know that it doesn't work great for external valve collapse. Right. And so talking to patients about it and really kind of going through exams and how much of this is internal versus external valve. And when you're doing that modified Cottle to really make sure you're only moving that internal valve, that would be the main thing.
[Gopi Shah MD]
I was going to say, in terms of, it sounds like for patient selection. So, the modified Cottles have a very important physical exam correlation, for patients where it's a bigger external valve problem. Are there any other pearls for patient selection? Perhaps there was a history of septorhinoplasty or any medical conditions that you look for? I know what patients can tolerate in the office or not, but just for the, uh, radio-frequency technique, itself.
[Mary Ashmead MD]
Right. So, the post-septo-turb patient who’s still unhappy, and there's actually a pretty high level of this. This has been looked at that there's more than we would think going back. You know, a decade and patients who had a septoplasty and turbinate reduction that still have symptomatic nasal obstruction. Those are prime people to be looking at their nasal valve. Those are our prime people. It's great. If we can find them ahead of time and you can treat them all together. Sometimes it's hard. Sometimes you don't find that valve collapse until you've straightened out that septum and now they have more airflow and now things are collapsing more. So it's a tricky thing to say treat everybody upfront then may not need that. But those patients who've had surgery before who have had a turbinate reduction and you look in their nose and you get in the nasal speculum and you look and it looks perfect and their septum looks great. And they're like, oh, if I still can't breathe. Great. Yes, those are, those are great patients to look at. But also the, the dynamic valve collapse patients. The, I have trouble when I'm exercising or I have trouble when I sniff in hard and the harder I'm breathing. The more I'm collapsing and they have really thin skin. And so you don't want to change the outside and they are not looking to make external changes. These patients are great. Great to consider a radiofrequency procedure because you're really just going to gain a little bit of space on the inside without changing anything else that they're happy with
Other patients are patients who have had a rhinoplasty, not just a septoplasty, but had a rhinoplasty. You know, we're trying to make the nose smaller. And, and that can really narrow that valve. You can get a lot of extra cartilage there. Sometimes it can really narrow that internal valve. It looks perfect. They're so happy with their external results, but internally they have trouble.
Another group are the snorers, the people who are, you know, “Oh, I'm just snoring. I wanna fix this. And I use this breathe right strip and it's great.” those aren't great people to look for. The tricky part that I've found is that it doesn't always work. You sometimes have to overlook the septum. If they respond to the Cottle, it's hard. So going back to before, when you see this thing, you want to fix it, but we know that our outcomes don't always correlate to what we see. And so, hey, I'm responding to this thing. Okay your septum is bad. Well, we may just be looking for better. I'm trying to fix my snoring so I can breathe fine. It doesn't need to be perfect. I don't want something big. I don't want to go to the operating room. I don't have time for a big recovery. I just want to breathe better. Great patients to look at radiofrequency ablation.
[Ashley Agan MD]
And are there any other tools that you're thinking about for these patients with nasal valve collapse? Are you doing LATERA implants or anything else?
(8) Alternatives to VivAer for Nasal Valve Collapse
[Mary Ashmead MD]
So for the dynamic valve collapse, patients who are really at baseline, they're fine, but when they exercise, they have trouble. LATERA can be an option, especially if they have thicker skin. You know, sometimes with the LATERA, especially if it's really thin, thin skin, you can see the implant on the outside. They can get infected, I have been asked to take one out before. We ended up holding the course because it does kind of dissolve, but it's a great option for it's a good option for the dynamic valve collapse patients. It doesn't work for static valves. And so that's where looking at their exam can be helpful. And then we talk about implants. And a lot of patients, if you give them an option to say, I'm going to put this foreign thing into your nose versus I'm going to remodel what you have, I don't want an implant. And I understand that. I understand that, We also talk about septorhinoplasty and so like, hey, we have facial plastics colleagues. Some are kind of open approaches to nasal valve collapse. Especially the static valve collapse patients, but if we're talking at all about cosmetics. I will send those to my facial plastics colleague and say let's talk about this.
[Gopi Shah MD]
So if there's a cosmetic concern, those are going to be the ones that you might potentially just go straight to facial plastics for potential open or cartilage grafts.
[Mary Ashmead MD]
Right? Yeah. If you're, if you're wanting to make changes to the outside, That's, it becomes a very different conversation than I just want to breathe better. And I want the outside to stay the same.
[Ashley Agan MD]
And when you're doing your open rhinoplasty, for patients who want that approach, is that always in the operating room, are you doing that in the office too.
[Mary Ashmead MD]
So in the office, when it's really, I have a decent little excess overhang of the upper lateral cartilage. And you feel like you, if you just need to trim a little bit of that extra and then kind of resuspend it. That can be done in the office. It's a little uncomfortable. I do use a headlight for those. And so you have to get kind of close up into their, into their personal space. So it's a little bit trickier, but yeah, you can do that. I've done that. If it's something that's very minor, But anything that's going to involve a larger incision or anything. Those are things that I'm not going to do in the office, or I'm going to refer them to my facial plastics colleagues in general, because I don't do a lot of those. I really want to focus on internal and endoscopic things rather than something big and open and I'll work. I'll have no problem referring for someone who is interested in something like that.
(9) Approach and Protocol: Anesthesia and Anxiolytics
[Ashley Agan MD]
And I mean, we've been talking for a while, but I feel like I can't let you go without at least touching a little bit on what your anesthesia protocol is and what you like to use for anxiolytics for patients who want something. And I mean, cause it sounds like you're able to offer quite a bit in the office, which is great. it's so much more efficient for your time and for the patient's time and for recovery. And I mean, I feel like if you can, the more you can do in the office, the better.
[Mary Ashmead MD]
I agree and patients like it too. cause there's about at least a third of patients that we set up for something in, or say no and they don't get scheduled. Because they don't decide for whatever reason, but office procedures people are generally game for that. So I think that's important. Anesthesia for VivAer is really important. It can make or break how your case goes. Not necessarily the anxiolysis that is a very personal decision, but the topical is extremely important. So thinking about alliances, I use Halcyon or Triazolam, I will generally use a pretty low dose. I use 0.125 which is very low. I use 0.125 and I say, this is kind of like a half a glass of a margarita. We can talk about that or wine to see, just to give them a sense of how they respond. And so, the people who are more sensitive than medications, we do really low doses. The people who are like, oh, that's no big deal for me. I'm like, okay, well, let's take two. and I'll give you a third that if you're still feeling anxious, when you come in, we'll, we'll take another because we'll have time for that to kick in. So it's a little bit faster on and off, than kind of the more traditional Valium, if I'm going to be doing a longer case.
I will use Valium sometimes. So I use translate I'm I generally will do, Phenergan more for a cough suppressant. But sometimes for nausea, we're going to take, a Tramadol at the same time. So a low dose of a Tramadol low dose of Phenergan. Also, it makes them a little bit sleepy for those anxious people, it can be really helpful. Especially if I'm going to be needing to do a spheno-palatine block. Sometimes that medicine can leak out. Then they have this kind of cough reflex and Phenergan helps with that too, to some extent. So we offer it, but it's, so it's probably about 60, 40 in my office. 60% want to take something and have a driver and 40% say no I’ll be fine with straight local.
[Ashley Agan MD]
And do you have them and do you have them take it before they come in?
[Mary Ashmead MD]
I do. So I have them take that. So I have a whole text message that goes out. Ideally it's about a week before, but in practice, it's probably more like three days or so that goes over medications. So we've already talked about this whole thing in the clinic, but it may have been a few weeks, sometimes a little bit longer. “Hey, here's a reminder on what we talked about with those medications”. And so I generally have them take them about an hour before they come in 40, about 45 minutes to an hour before they even come in. And then it's about a 20 minute numbing protocol. So it's plenty of time for those things to work, plenty of time for those things to work. So they come in and then we start with the topical numbing. So this is not like a turbinate reduction or a posterior nerve ablation where you can rely on a nerve block heavily. You really need to get the topical right. It's pretty important for VivAer here and you're within the nose to do this. Well, I use a 4% topical compounded tetracaine lidocaine gel that I get from one of my local pharmacies in a little tub, and I will make a little arch out of a pledget. Usually it's about half of the pledget of the normal standard links. It's a little bit shorter than that. I tailor it to the size of the person's nostril. So I actually will look with a scope and see, okay, is this a little bit larger? And maybe I'll do about half. If its a small little nose. I'll make it more like a third of that kind of standard pledget size. And then I will put on my gel. I do sometimes put a little bit of Afrin, just my normal Afrin, lighter cane to moisturize it more than anything else, but ring it out a little. And then I put a layer, a little thin layer of my gel on the side with the, with the lines. so that I know not to waste the gel. You don't need it. You don't need it on the inside of that art. She just needed it on the outside.
So little thin layer. And then I fold it into the arch with a pair of bayonets. I use bayonets for this. I use micro alligators for placement farther in the nose. So if we're doing swell bodies or turbinates, you numb those up and how you normally do. I use lidocaine. I will spray those people beforehand, too. If we're doing something farther back, whether it's a septoplasty or swell bodies or turbinates. I will spray those people and then place a normal. Horizontal vertical you've oriented pledget in the usual location. But then for the valve, with this arch that I placed with a bayonet, it's a little bit off center. You want the lateral portion to come all the way down to the floor. You want it to come all the way down to get that whole side of the nose. And then as this comes in medially, you really have to tuck it in up medially at the septum, right? So you have to get way up there. It doesn't need to come all the way down the septum side, cause we're not really generally doing a whole lot there, anteriorly at the septum, but it really needs to get all the way up there into that little crease. So I'll use my bayonets or sometimes I'll use an ear curate really to make sure it gets all the way up there in that corner.And you want to have good tissue opposition of that pledget. So if you just put in something kind of straight in the nose, normal way, it's not going to get along the edge, right? It's not going to get that whole area numb and they're going to be uncomfortable. So that's why I use this archway. Other people will use a cotton ball and that's another way to do it too. So take a cotton ball that kind of fits in that area, kind of coated on the outside with gel and put that in the nose. But then they're totally blocked, which is fine. But it's a little bit more comfortable if you use the arch, they have a little space to breathe, so they're not just completely nose closed off. Cause I let them sit there for about 15-20 minutes. I'll usually go see another patient. We'll have a post-op or a CT scan review or something else that I'll schedule at the same time. So all a mile, my someone else will be rooming that patient getting the scan pulled up and I'll be getting, the patient num, and so get that arch placed all the way up and I will actually go back and check it about 10 minutes later and make sure it hadn't, hasn't fallen down to make sure it's really coating that outside. I also put a little bit outside. I learned this from Dr. San McClurg, we were at a conference together. About putting a little bit on the outside. There's this extra little nerve that comes in, laterally. So that bottom edge that last third or fourth treatment along that line, sometimes they feel that a little bit more. And so there's lots of ways to address that.
One is just to let the topical sit there longer at least 20 minutes, or you can put a little bit of your BLT cream or something else that you use the tetracaine works to, out at that nasal crease laterally. And that we'll get that last little part. You can also use an infraorbital block for that. I haven't really needed that, but some people rely on that. I have an extra syringe in the room in case I need to, and you don't have to go all the way infraorbital . But just a little sublabial to that area. So I have something on hand for that if I have trouble and it's uncomfortable, or if I maybe rushed a little bit was drying and maybe they only sat for 10 minutes. And they're feeling that last little spot, and that's just normal lidocaine with epinephrine. You don't necessarily need the epinephrine. I try to avoid it in that, in the office. If I don't think I need it, because it just adds a little bit of that adrenaline effect to an already kind of nervous patient. And so unless I'm going to be doing something that I really needed to stick around for awhile. I'll use plain lidocaine if I have it around.
[Ashley Agan MD]
And you're cutting the pledget in half or third. Is that right?
[Mary Ashmead MD]
Yeah. So, yes to make that little arch or , a little rainbow. It's about half to two, a third of the normal length. So they sit there and I tell them, your teeth may go numb. They may not. Don't worry if they do, don't worry if they don't, but just so you know, this might happen. Cause otherwise they kind of, “Hey, my teeth went numb.” It's okay. Don't worry about it. And once as I'm kind of putting those pledgets in. I'm going to walk them through everything that we're about to do. Okay. We're going to move. So right now I have a staging room while my main procedure room is getting turned over. My goal is to have two separate rooms that I can just kind of go back and forth, but not there yet. We're going to move down to the procedure room. It's a big, comfortable chair. When I lay you backwards, room lights are going to be on. Have some music. You can bring your own headphones if you want to, but I let them know it's going to be about 10 minutes. I do generally put a little gauze pad over their eyes for most of my procedures. You don't have to do that. Everybody's different. I tell them, I'm going to put this here. My light's really bright. if you don't want it there, we can take it off. I know some other doctors who will do this in the normal exam room, just because that's where their patients have been and they're comfortable there. $specially if we're, if it's just a straight VivAer, there's nothing else, you know, no turbinates in the septum, just, very anteriorly. So it's going to be five minutes in and out. And that's great.
My chairs are more comfortable in my procedure room, so I like that they're comfortable. And I have blankets because our room is cold and you try to make it comfortable. And spa-like for them, you know, “Alexa play spa music”. You can only, you can only listen to so many pan flutes though, and it starts to grate on you. I used to let the patient choose what they wanted to listen to. Except I had one patient choose Christmas music, and it was a really long case that we were doing. And I really regretted that decision. And so now we try to just have something on that's unobtrusive, but just something else to kind of take their mind off of it.
And so we move into the procedure room and I lay them down and we put the gods over the nose and I have the lights down and I'm looking with my scope and I have it up on my big screen. So their extra person can kind of see what they're doing or see what I'm doing and seeing what's happening. And then I use a little one CC syringe, just a little TB syringe with a short 30 gauge needle with just some lidocaine. And you're going to put this right where you're going to be placing your wand, your paddle. And so you don't have to get all the way up to the tip with that needle. Usually it's about, I don't know, a fourth of the way down first little, little injection. You have to stay really superficial. You don't want to go too deep with this. and when you're using a headlight, I think it's a little bit easier to know exactly how far in your wall. You have more of a global picture, but when you're using a scope, I have found it's a little easier for me to get a little too deep. And so I'll put that 30 gauge in and I'll pull it back a little bit before I inject. You want to see a very small little bleb, you want to see a very small little bleb just in that mucosa, because that helps with transduction of the energy. So you actually want, even if they're totally numb, you still want it to. You're not really relying on this for anesthesia. It's a small amount. I use about 0.2 to 0.3 per side. It's a very small injection and you want to see this in bleb out just a little bit, and it will kind of push up towards that corner. And then I'll come down about three or four millimeters and then I'll come down about three or four millimeters and I'll make a second one. And it's usually just those two little injections and I'll save if I need more, a little bit farther down. but again, we're not relying on this for anesthesia.This is just making that little extra bit of, of, blebbing within the mucosa so that we can get this energy where we need to go. So you want, you want that to be there just very small amounts though, cause you don't want to be too much. Cause then it won't, you'll have too much depth to get through. And that's why I like using the one CC syringe. you know, you're not going to put it in too much. I used to use a three or a five. It was harder to have as much control as I wanted to get just that little bleb. And that's why I use the 32. Not necessarily for just patient comfort. They're already numb there. I just want to be very specific about where this is going.
[Ashley Agan MD]
Are you doing multiple sites or just one, like you walking up and doing like little bleb, bleb, bleb, like where you're going to ablate.
[Mary Ashmead MD]
So I usually use two, two blebs is usually enough. Sometimes if I, they have a long pathway and I think I'm going to need to do four treatments. I will make a third, a little farther. But usually it's usually two. And then if we're going to treat, if we're going to treat turbinates with the same wand, that's a little bit more standard 27 gauge lidocaine and then the same with the swell bodies. Those you feel more of the epinephrine effect on the septum than you do on the turbinates? So if you haven't done a lot of septal injections, make sure you tell the patients the risk, especially if you don't have plain lidocaine on hand, Like right now it's on backorder for us. So I'm having to use 1% with epinephrine. It's going to feel like you just climbed up a flight of stairs. Like it's going to be about a 22 second delay and you're going to feel this, oh, I just climbed up that flight of stairs. Now, if they're on a beta blocker, then I'm probably not going to feel too much of that. But I tell them, you may feel this, because if you don't, they get anxious like, oh, what just happened? This is unusual. And so I'll feel their pulse and we'll make sure that everything's coming back down before we get started, but they feel that, and they feel it more on the septum. If you're used to injecting turbinates, they feel it some but the septum, it, they really feel it. So you have to be a little bit careful and you should, it's about two CCS into the septum you try to get underneath. You want to be a little bit deeper. There's a couple of little blood vessels in that area. Every once in a while, you'd get a little bleeding there in which you can then use the VivAer wand to treat, but it's never fun to inject and then you see this little pulsing there. It's never fun. So you want to go a little bit deeper, uh, for the injections there,
[Gopi Shah MD]
Do you spray everybody with Afrin ahead of time? Or do you not do any, uh, thing for hemos? Like if you're, if you're doing plain lidocaine do you usually still do Afrin for hemostasis or is it usually not too bloody? For the nasal valve?
[Mary Ashmead MD]
For the nasal valve? No, I don't. You really get such minimal bleeding at all. really you get more bleeding from the little pinhole from your injection and the turbinate than from anything else. But if I'm doing anything posteriorly, if we're doing turbinate , if we're doing swell bodies, I will spray them ahead of time.
(10) Procedure Revisions and Additional Considerations When Treating Nasal Obstructions
[Gopi Shah MD]
And then how often do you have to, do you ever have to go back and touch up areas ? Do you give them like six to eight weeks? And if there's still a concern, uh, do you ever have to go and revise? Is that part of this at all? Or what do you find in your practice?
[Mary Ashmead MD]
I haven't had to revise a valve area. Sometimes I will add on. Uh, more posterior turbinate treatment. You know, we're taught that the anterior third of the turbine is the only spot that is really important for nasal obstruction. But sometimes you have those people with a really big posterior Mulberry tip
[Gopi Shah MD]
Yeah.
[Mary Ashmead MD]
And you've done, whether it's, you've done a submucosal resection or man, it was really shrunken down from your Afrin and you didn't really see it ahead of time. I try to comment on that in the office for the very first time that I'm doing that scope beforehand. Oh man, we have some posterior turbinate hypertrophy. And so sometimes I'll have to go back and add that in. You can actually out fracture these patients pretty comfortably in the office. If it's a, if it's a bony area, kind of about that midway back, I have this big scrolled, middle and inferior turbinates. you can out fracture them. You can use your own instrumentation. You can use the VivAer wand for that too. so if I haven't treated farther back, yes, I have had to go back and add something. They're generally not having to do a whole lot about what the, with the turbines, because if I think that the radiofrequency will not be enough for the turbinates, I'm generally going to do a submucosal resection, but you can touch up those areas. It's not something that's standard, but I would definitely wait that full eight weeks, at least if not a little bit longer before I really consider adding anything else.
[Ashley Agan MD]
Well we've talked a lot. This is a great really comprehensive, uh, talk about the procedure. What are we missing? Is there anything that we've left out or anything else that you want to just make sure that listeners know and are aware of? What else?
[Mary Ashmead MD]
The first one would be to talk to your reps. They have seen us do this procedure. They've seen people who've done a lot of them and they can be really helpful tools. And it's always hard for us to take instruction from someone who's not a surgeon like us, but they've seen a lot. And they've seen the things that have made it more successful for other people. And can be really helpful in connecting you with one of us or somebody who has done more. Say, “Hey, I'm having trouble or my anesthesia isn't right. what am I doing wrong”? Because it should be very comfortable. It should be very comfortable. And it's relatively simple. And the patients, you know, it's like, I think it's about a 95% responder rate. If you choose your patients correctly, your score will drop significantly. So we should be able to make these patients better. And so for having trouble, we got to figure out, you know, what are, what are we missing? And the second one, I think we went over it to some extent, but talking to our patients about their goals and what they're willing to go through to get there is the most important part of this to say, I want the end all be all. I want this to be fixed forever. And I don't want to have to think about it. I don't care what I have to go through to get there versus the person that says, “Hey, I just don't want to have to, I don't want to snore. I use these breathe right strips and it makes it better. what's the least I can do to fix that problem”. And it takes time and it's hard to not look at someone and say, oh, “well you need this”. And then walk out of the room and have somebody else schedule it. but to have these kind of longer conversations with our patients about their goals and their outcomes and what we expect to happen and what we can offer them, I think is really important.
[Ashley Agan MD]
Yeah, well said.
[Gopi Shah MD]
Thank you so much, Mary. I've learned a ton, especially just, I love all the specific details about your anesthesia protocol, the anxiolytics, and sort of the little 30 gauge needle to make those injections I think is super helpful.
[Mary Ashmead MD]
A little things that make it easier. Right. It always makes you go “ oh that definitely helps”.
[Ashley Agan MD]
If listeners want to reach out to you or find you online or on social media. Do you have any platforms that you are, available on or, website or, you know, where would you send people
[Mary Ashmead MD]
I don't know. I do not know how to answer that question. That is probably the east, we want to talk about it. The easiest way would probably be to go through your Aaron rep and they can connect us and we can, we can meet and go over problems or issues that you're having. I'm not super Instafamous for, for my medical practice at this point in time. Just add that to the list of things that we all have to do in addition to raising our kids and getting them to camp making it to work in the morning.
[Ashley Agan MD]
Well, awesome. Well, this has been great. Thank you so much for taking the time. We appreciate it.
[Mary Ashmead MD]
Thanks for having me. It's been a pleasure.
Podcast Contributors
Dr. Mary Ashmead
Dr. Mary Ashmead is a practicing rhinologist with ENT Southlake in Texas.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2022, August 23). Ep. 68 – In-Office Procedures for Nasal Valve Obstruction [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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