Podcast Transcript: In-Office Procedures for Chronic Rhinitis

[Gopi Shah MD]
Okay. I was just going to say one last question, in terms of that initial patient coming into your clinic, sometimes I feel like the chronic rhinitis diagnosis can be difficult to make in terms of teasing it out from CRS, or-- because we said it could be four weeks, maybe it's just another sinus infection or something like that. Do you have ways where you clinically say, "No, this is just rhinitis, this isn't necessarily something else going on," or is that after your exam, because sometimes the rhinitis diagnosis, not to say it's an exclusionary diagnosis, but because rhinorrhea can be part of-- or postnasal drainage can be part of so many other things.

[Stan McClurg MD]
Postnasal drip is a tough one, but I think the scope is key. When you do the rigid nasal endoscopy, initially, I use a 3-millimeter or 30-degree endoscope, and you can see pretty much everywhere up there. You're looking for any purulence, polyps, or anything like that. Sometimes you can see, clear rhinorrhea or other findings that could help you make the diagnosis. Quite honestly, most patients that have chronic rhinitis only, they'll tell you that they don't get sinus infections. It's just a constant runny nose that never goes away and it never fluctuates.

They never get facial pressure or pain, and colored drainage, I think is one of the highlights is, when people say, "I have postnasal drip." I always ask them, what color is it? A lot of people will laugh and say, "I never look at it." Then I say, "Well, you should consider looking at your snot every once in a while."

The people that have chronic rhinitis, they'll say, "It's always clear whether it's thick or thin, or other, but it never has purulent yellow-green color to it.”

[Gopi Shah MD]
Because if it did you would be more concerned that there is sinus infections or-

[Stan McClurg MD]
Correct, yes.

[Gopi Shah MD]
-[unintelligible 00:15:14] infectious process.

[Stan McClurg MD]
Yes. I'm getting CT scans on most patients as well that have those type of presentations. That'll help me rule out any chronic mucosal inflammation as well.

[Gopi Shah MD]
Do you spray, decongest the nose before you take a look or do you never decongest to take a look or what's your thoughts on that?

[Stan McClurg MD]
I used to spray everybody but then when COVID hit, I stopped, just because I was terrified of mucosal atomization of the COVID virus. I stopped spraying but I still needed to scope. I found that patients really didn't have any change on whether or not they could tolerate the scope or not. I think the key is actually using a small endoscope. I use the pediatric, the three millimeter, and I equate it to a game of operation that we used to play as children. "If you don't touch the sides and they don't feel it and it doesn't go buzz."

I have stopped spraying patients for pretty much all endoscopies, other than post-op debridements. Also, when you don't spray them, they don't have the throat numbness, and the tastes and all that stuff that they frequently complain about.

[Ashley Agan MD]
Yes, it's true. I feel like some patients complain more about the spray than they do about the scope.

[Stan McClurg MD]
I think it's different with the flexible, because the flexible, you bump into a lot of things when you're doing that, but the rigid I think you have a lot more control over.

[Gopi Shah MD]
Kids, I feel like the spray could sometimes set you back 10 steps because just to get the spray close to the nose and to take a look is-- in itself can be, and then they complain like you guys said, the taste and that numbness feeling, then by the time you're like, "Oh, here I actually need to get my exam now. It's like, "Are we game over yet? Have I bumped into the sides of the operation of the [unintelligible 00:17:09]?"

[Ashley Agan MD]
Before we move on too far, you mentioned the postnasal drainage patients. I do think that is a tricky group because if the complaint is postnasal drainage, and when you scope them, you don't necessarily see thick drainage coming back from the nose into the throat. What do you make of that? They deny reflux and they say, "No, it's coming down. I know that I can feel it, it's coming down from my nose and it drips all day and at night I feel it, and it drips down. It makes me cough and it wakes me up." How do you take that apart and figure out what's going on?

[Stan McClurg MD]
It's a very frustrating patient. The postnasal drip can come from about a thousand different sources, so you have to delineate where it's coming from. I tell patients, the back of the throat is very difficult at figuring out where mucus is coming from unless you have anatomical knowledge, like the three of us.

Doing reflux treatment potentially, and trial there to see if it improves, I'll do a ipratropium bromide challenge for them. If they are definitive it's coming from their nose, then I'll do a one-month trial of 0.06% ipratropium bromide just to see if it benefits them, and then see them back in a month. If it doesn't, then I basically tell them it's most likely not going to benefit from a procedure. It's probably not coming from your nose. We can send them off to Laryngology to see if there's potentially like a vocal cord issue with a polyp or nodule or untreated reflux, silent reflux, something like that. Allergies can also potentially do it as well, but it's a little bit longer route to work up the isolated postnasal drip patient.

[Ashley Agan MD]
With your ipratropium challenge, you choose that nasal spray as opposed to Flonase or Azelastine or some other nasal spray because it's an anticholinergic and it-

[Stan McClurg MD]
Yes.

[Ashley Agan MD]
-simulates what would happen if you ablated those nerves? Tell me more about that.

[Stan McClurg MD]
It actually recreates what we would potentially do with a procedure such as rhinorrea ClariFix. It specifically isolates the posterior nasal nerve as an anticholinergic to decrease mucus production and some nasal congestion within the nose. Other nasal sprays don't really do that. Luckily, ipratropium bromide is generic, so it's pretty cheap. What I find is that people that respond to the ipratropium bromide, even just a little response or it goes away in an hour or something like that but they do have a response, I find that they have a much higher likelihood of RhinAer working on them.

What I usually tell them is, for patients that respond to ipratropium bromide, they'll have about an 80% chance of improvement with a procedure such as RhinAer, and of that, they'll improve anywhere from 60 to 100%. However, if they don't respond to ipratropium bromide and they're dedicated, this is coming from the nose, it drops down to about 40 to 60% in improvement with RhinAer. It's not zero but it helps me set expectations for patients on if we were to do a procedure, what a potential response they would have.

That's actually a change in mindset of a lot of surgeons. A lot of surgeons will say, "I'm only going to do a procedure if it's going to fix it 100% septal deviation or removal of polyp," or something like that. We gauge ourselves on, "Did we fix the problem or did we not?" When you start dealing with chronic rhinitis and these in-office procedures, you have to be okay that treating something very good is enough. That's the end result is that you're going to help it get better. It may not be 100% but you're going to actually make things better. It's a change in mindset in thinking of the surgeon.

[Gopi Shah MD]
That's a good point. Some of it's what we're doing is quality of life. If we can make the quality of life better and it's not like you have an alternative to "fix it." It is an improvement, which is good.

[Stan McClurg MD]
Right. We used to do video endarterectomies for patients for this and I've done a couple of those in my life. The dry eye that you get from hitting the branch to the [unintelligible 00:22:03] nerve is-- it can be debilitating for patients. It gives them something else to complain about but it's a tough surgery and it can be potentially pretty detrimental to a patient.