BackTable ENT & Allergy

In this episode, Dr. Stan McClurg, a private practice rhinologist at Ascentist Healthcare in Kansas City, shares his approach to diagnosis and treatment of chronic rhinitis patients using the in-office RhinAer procedure.

---

CHECK OUT OUR SPONSOR

Aerin Medical

https://aerinmedical.com/

---

SHOW NOTES

First, Dr. McClurg talks us through his patient base. When he initially started as a rhinologist, he would get referrals for patients with persistent rhinitis after a procedure. Before in-office procedures for chronic rhinitis were developed, he recommended ipratropium bromide spray to patients and referred them for allergy testing. However, his recent patient referrals have been for isolated chronic rhinitis (defined by consistent rhinorrhea for more than 4 weeks) with no other ENT problems. With these patients, he performs allergy skin testing to make sure the diagnosis is not really allergic rhinitis that can be treated with desensitization therapy. He also uses a rigid nasal endoscope to check the patient’s nose for colored purulence and polyps, two clues that can point to a diagnosis other than chronic rhinitis. When he scopes his patient, he does not use a decongestant spray and uses a small endoscope to avoid patient discomfort. If he believes that a patient has chronic rhinitis, he will perform a ipratropium bromide challenge; he asks patients to use the spray for 1 month. If their symptoms are mitigated by the spray, then he is more optimistic that an in-office procedure will mitigate the chronic rhinitis. If the patient fails the trial, the secretions are probably coming from a source other than the nose, and the diagnosis is unlikely to be chronic rhinitis.

Next, Dr. McClurg speaks about different in-office treatments for chronic rhinitis. He first explains his experience with ClariFix, a procedure that uses cryoablation to freeze the posterior nasal nerve. He has found that 40% of his patients experience the known side effect of post-treatment headache. Additionally, some of them may have crusting in the sphenopalatine region that causes post-nasal drip. Since then, he has switched to using the RhinAer system, which delivers radioablation through a stylus to treat the posterior nasal nerve more aggressively. It also has the capability of treating the inferior turbinate. Dr. McClurg notes that patients with normal nasal anatomy and a good ipratropium bromide response are the best candidates for this procedure. 80% of his patients see a favorable result after surgery.

He then describes his RhinAer in-office procedure. He does these procedures in exam rooms in order to help with flow of his day and make his patients more comfortable. He only uses lidocaine to anesthetize the patient, as he has found that epinephrine causes tachycardia and anxiety. The procedure, including anesthesia time, takes him about 10 minutes. However, he adds that he has performed this procedure in the OR as an adjunct procedure after a septoplasty or a rhinoplasty.

Finally, he describes his recommendations for postoperative care. He encourages his patients to do daily saline rinses. He notes it takes about 6-8 weeks for the RhinAer procedure to show a good response. During this time, he recommends that patients use ipratropium bromide concurrently in order to obtain an optimal response.

In this episode of BackTable ENT, Dr. Varun Varadarajan interviews Dr. Edward Dodson, President of Project Ear and a neurotologist at the Ohio State University Wexner Medical Center, about his humanitarian efforts in the Dominican Republic.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/nUekSE

---

SHOW NOTES

Dr. Dodson was first introduced to Project Ear when he joined his mentor and Project Ear founder, Dr. Paul Lambert, on a mission trip to Dominican Republic in 1995 to perform ear surgeries. Although they could only operate on 12 patients, seeing hundreds of patients waiting in line for medical care was eye-opening for him.

Dr. Dodson then shares about preparations needed for the Project Ear medical mission trips. He emphasizes the importance of their local neurotologist liaison, Dr. Roberto Batista, who helped Project Ear by performing preoperative and postoperative care for patients in exchange for equipment. In the first years of the organization, the doctors had to learn which supplies to bring and how to store them as well as how to organize staff and supplies in order to pass through customs. Dr. Dodson notes that he used to sterilize wasted equipment from American ORs during their first trips. Later, Project Ear was able to partner with Ohio State University and could give credit to residents who participated on the trips and negotiate time for employees to travel. Because the mission hospital they worked with allowed trainees, he was allowed to take senior level American residents to the Dominican Republic. Furthermore, Dr. Dodson also sought out to teach DR residents independently at another hospital and brought them new medical equipment. This initiative led DR residents to be granted permission to participate in Project Ear surgeries as well as rotate at Ohio State. Currently, multiple ENT subspecialties, besides neurotology, and audiology are now represented within Project Ear.

Next, Dr. Dodson speaks about Dominican Republic-related topics. He explains that the most common ear conditions he sees are chronic draining ears, perforation, cholesteatomas, congenital atresia, stapedectomy, and otosclerosis. When the COVID-19 pandemic hit, he and his Project Ear colleagues started teaching via Zoom through giving lectures and Grand Rounds talks to Dominican Republic residents. Dr. Dodson and Dr. Varadarajan also reflect on the open-mindedness and creativity required to operate in a resource-limited environment. Dr. Dodson also explains about how he navigated relationships with local ENT doctors in the area.

Finally, he shares advice and resources for doctors looking to start their own medical mission trips. He emphasizes the importance of understanding the time it takes to plan and lead a trip as well as determining that your medical services are actually wanted in the country.

---

RESOURCES

Project Ear

https://projectear.org/

Coalition for Global Hearing Health

https://coalitionforglobalhearinghealth.org/

AAO-HNSF Humanitarian Efforts List

https://www.entnet.org/get-involved/humanitarian-efforts/

In this episode of BackTable ENT, Dr. Gopi Shah discusses 3D imaging and other surgical technology with Dr. Cristobal Langdon, an academic and private practice rhinologist and skull base surgeon working at Hospital Sant Joan de Déu Barcelona.

---

EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/OqKifW

---

SHOW NOTES

First, Dr. Langdon speaks about common conditions he treats as a skull base surgeon, such as Rathke cleft cysts and craniopharyngiomas. Most of his referrals come from neurosurgeons and opthamologists once the decision to take a transnasal approach over an open approach is made.

Next, he talks about pre-operative preparations. During his initial patient visit, he scopes his patients with a flexible scope and tries to record every scope procedure for educational and planning purposes. Every patient receives an MRI, and a CT scan is usually already obtained. Dr. Langdon does not prescribe any antibiotics or corticosteroids before surgery. Then, he discusses how he uses 3D models for surgical planning. For him, 3D models are useful in deciding between different surgical approaches and practicing difficult surgeries. He requests that his models are made true to size by biomedical engineers. He also tells his engineering team which structures need to be constructed (i.e.-nerves, carotid arteries, etc.). Then, Dr. Shah and Dr. Langdon discuss the implications of virtual reality for surgical education.

Then, the doctors discuss the use of technology in the operating room. Dr. Langdon does not often use image guidance. He sometimes uses neurosurgical guidance, but warns against becoming dependent on technology and not learning patient anatomy well. He thinks image-guided instruments are nice, but not necessary to have. Like Dr. Shah, he uses intrathecal fluorescein to look for CSF leaks. Then, the doctors also discuss the pros and cons of different types of flaps and packing.

Finally, Dr. Langdon speaks about his postoperative saline regimen. He recommends that all his pediatric patients use at least 100 mL for each side every 12 hours. Dr. Shah likes to show the patient and their families educational videos of sinus rinses before surgery so they are prepared postoperatively. Both doctors concede that synechiae (scar tissue) may form in kids, but they rarely take pediatric patients back to the OR for debridement.

---

RESOURCES

Dr. Langdon’s Youtube

https://www.youtube.com/c/BarcelonaRhinologySchool

In this episode of BackTable ENT, Dr. Julie Wei, Dr. Alain Sabri (Mayo Clinic Abu Dhabi), and Dr. Kerry Olsen (Mayo Clinic Rochester) discuss personal and professional strategies to overcome physician burnout.

---

CHECK OUT OUR SPONSOR

Laurel Road for Doctors

https://www.laurelroad.com/healthcare-banking/

---

EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/HKydZd

---

SHOW NOTES

First, the doctors discuss their personal motivations for engaging in wellness. For Dr. Sabri, wellness evolved as his career matured. Eventually, he moved abroad and studied cross-cultural practices of wellness. For Dr. Kerry, leadership roles forced him to have concern about the wellness of his employees, leading him to create his own company, 12 For Health. For Dr. Wei, a medical condition forced her to think about her life outside of the OR. All three doctors agree that head and neck surgeons have one of the highest burnout rates and the first step to solving this problem is recognizing burnout as a problem and not being ashamed of it.

Then, they discuss the impact that corporate influence has on medicine and physician wellness. Many physicians may feel stuck in a system they have no say in. Dr. Olsen encourages healthcare corporations to prioritize patient and physician welfare over finances while Dr. Sabri encourages institutional leadership to actually listen and elicit change when their physicians provide feedback. Dr. Olsen then explains how raising salaries to justify longer hours actually incentivizes doctors to cut their hours and makes it easier for them to leave. Additionally, both Dr. Wei and Dr. Sabri agree that the feelings of burnout can fluctuate from day to day.

Next, the doctors emphasize the importance of feeling valued as a physician and engaging in self-care techniques. Dr. Olsen advocates for training physicians to be leaders who get to know their team well and recognizes good work at an appropriate time. Dr. Sabri criticizes the American “hyper statistical” view that does not respect people for the work they do. He advises physicians to select the right institution for them and have the courage to walk away and reinvent themselves in new positions when they feel like they are not receiving the respect they deserve. Self-care techniques the doctors recommend from personal experience are: re-reading patient and mentee thank you notes, meditation, stretching, team sports, having a coffee with a friend, and learning how to say no to excess work and toxic relationships.

Finally, the doctors discuss how institutional leadership can help women surgeons succeed and prevent burnout. Dr. Olsen adds that leadership needs to change if the current leaders are not effective and explains ways to form effective work units.

In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak about allergic fungal rhinosinusitis with Dr. Amber Luong, vice president of the American Rhinology Society and professor of otolaryngology at McGovern Medical School.

---

CHECK OUT OUR SPONSOR

Cook Medical Otolaryngology

https://www.cookmedical.com/otolaryngology

---

SHOW NOTES

Allergic fungal sinusitis (AFS) is a subtype of chronic rhinosinusitis with nasal polyps that present with allergic inflammation against fungal antigens. It has some unique features, such as very expanded sinus cavities and a thick, sticky mucin. Oftentimes, patients have an allergy sensitivity and elevated IgE levels in the thousands. Diagnosis is usually made based on the Bent and Kuhn Classification, which is based on clinical/phenotypic criteria. However, Dr. Luong notes that AFS can have geographically diverse presentations. She has noticed that there is a higher AFS prevalence in the South because of the more hot and humid weather. Looking towards the future, she predicts that molecular pathophysiology will be more important in diagnosis, as distinction between the AFS endotypes can serve as targets for therapy. Her research laboratory works on finding these molecular targets.

Next, the doctors discuss typical AFS patient presentations. Dr. Luong usually sees young patients in their 20s with unilateral disease. If they have bilateral disease and other symptoms, it is most likely cystic fibrosis, not AFS. Additionally, AFS patients will have expanded sinuses on CT that may cause a mild headache. Dr. Shah adds that in severe cases, smell and vision loss is possible. However, AFS generally has a low symptom burden because patients get used to the symptoms. Dr. Luong notes that she usually only orders a CT scan. No MRI is needed unless other complications are noted (vision loss, meningitis, skull base / cranial nerve invasion). She orders labs like CBC with differential and total IgE levels.

Next, she shares surgical pearls for treating AFS. She believes that the first surgery is critical to controlling the disease and preventing recurrence. She performs a full FESS on the impacted side and inserts a PROPEL stent that releases steroids locally. Because the sinuses are difficult to clear, she uses angled scopes, warm saline, and the hydrodebrider to complete this task. Although the microdebrider with navigation can be helpful, she doesn’t really use it.

Finally, she shares her steroid regimen. She prescribes at least 40 mg of prednisone in adult patients 3-4 days before surgery. Postoperatively, she prescribes an oral steroid taper starting at 30 mg and decreasing the dosage by 10 mg each week. Additionally, she gives her patients a post-operative nasal rinse that consists of mupirocin and budesonide. She emphasizes the importance of making the postoperative regimen as easy as possible to ensure daily compliance. Finally, the doctors discuss trends in AFS patient follow up.

In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Mandan Kandula, founder of ADVENT, an ENT private medical practice, about embracing in-office procedures and building an efficient ENT private practice.

---

CHECK OUT OUR SPONSOR

Stryker ENT

https://ent.stryker.com

---

SHOW NOTES

First, Dr. Kandula talks about his journey to becoming a private practice ENT doctor. He became a proponent of office-based treatments when he opened up his solo private practice and has carried this approach into his expansion of ADVENT. Another approach he takes in his medical practice is simplifying all airway problems to identify the defect in the “breathing triangle”, a term he coined for the nose and throat. In order to identify the airway problem in patients, Dr. Kandula emphasizes the importance of defining a healthy airway, which he defines as normal anatomy and lining. Additionally, he notes that ENTs must assess the nose, throat, and sinuses together before choosing a treatment plan for the patient.

Another approach he takes in his medical practice is training nurse practitioners and physician assistants to deal with purely medical ENT matters, such as triage, intake, histories, and physicals. He even trains his NPs and PAs to perform scope examinations and to administer local anesthetic. Dr. Kandula prefers to free up time for his ENT surgeons to have extended conversations with patients and operate in the office or in the OR. However, he emphasizes the importance of having well-trained NPs and PAs. He also outsources sleep study reads to be more efficient.

The doctors then discuss treatments for obstructive sleep apnea. Dr. Kandula usually sees OSA patients who have already tried non-surgical options, such as nasal rinses and sprays. For OSA that is caused by an anatomical issue, he notes that turbinate hypertrophy is the most common cause. For these cases, he will perform a thorough turbinate reduction. He also obtains CT imaging to view the sinuses in order to assess if they are affecting airway patency.

Finally, Dr. Kandula speaks about challenges with insurance with regards to in-office procedures. His office usually takes the lead in dealing with insurance authorizations and repealing insurance denials. He explains that it is more difficult for academic ENTs to change to in-office procedures. Another challenge that doctors might face is the high cost of in-office equipment. He recommends working with industry and getting loans to help offset the financial burden of medical technology.

In this episode of BackTable ENT, Dr. Shah and Dr. Agan speak with Dr. Colleen Plein about functional nasal breathing in the treatment of facial pain, sleep apnea, postural defects, and improving general quality of life.

---

CHECK OUT OUR SPONSOR

Laurel Road for Doctors

https://www.laurelroad.com/healthcare-banking/

---

EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/cP8H2Q

---

SHOW NOTES

First, Dr. Plein defines functional nasal breathing, which is unobstructed nasal breathing with a closed mouth. Nasal breathing is the best way to optimize airflow through the nose because the nose humidifies and filters air, the sinuses produce nitric oxide to increase oxygen delivery to tissue, and a slower breathing rate can be established, which stabilizes blood pH. Dr. Plein then explains the evolutionary transition from nasal to mouth breathing in humans. The “Great Leap Forward” involved the descension of the larynx and posterior displacement of the tongue so humans could develop speech. Unfortunately, these anatomical changes allowed airways to be more easily obstructed. Additionally, narrowing of the human skull occurred because humans now chew less due to our processed diets. The lack of mastication caused hypoplasia of the maxilla and mandible, which led to narrowing of nasal aperture.

In a child with mouth breathing, Dr. Plein emphasizes the importance of early orthodontic intervention; early maxillary expansion is more likely to occur because the sutures have not fused yet. Besides turbinate reduction therapy, she encourages non-invasive therapies for children such as myofunctional therapy and eating less processed foods. The doctors also discuss different pathologies linked to mouth breathing besides obstructive sleep apnea. Dr. Plein explains how mouth breathing can lead to TMJ pain, poor posture, facial pain, and migraines.

Next, Dr. Plein gives her tips for examining a mouth breathing patient. She believes that taking a thorough clinical history is important and always asks about snoring, posture, headaches, shoulder/neck pain, as some patients don’t realize they have problems with nasal breathing. She also mentions that some patients who grind their teeth may be using a mouth guard that pushes the tongue further back, which can worsen sleep apnea. She notes that tongue scalloping and outwardly oriented teeth are indicative of tongue thrust, which is diagnostic of sleep apnea. She has a low threshold for recommending home sleep tests and always examines the nose with nasal endoscopy. During endoscopy, she does Cottle’s maneuvers to look for static and dynamic nasal valve collapse. In addition to a scope exam, she gets CT imaging of the sinuses.

Next, Dr. Plein emphasizes the importance of collaborating with myofunctional therapists, dentists, orthodontists, and TMJ physical therapists to care for her nasal obstruction / mouth breathing patients. Finally, she summarizes some non-invasive technology and medications that can help optimize nasal breathing, such as intranasal steroids, antihistamines, nasal irrigation, Breathe Right strips, and a gluten-free diet.

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Kutz interview Dr. Marc Bennett, a Vanderbilt University ENT professor, about the importance of quality improvement, and initiatives and tips for quality initiative research.

---

EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/BFTSrG

---

SHOW NOTES

First, Dr. Bennett delineates his path to quality improvement research and education. His father was involved in quality improvement in the pharmaceutical industry, and he was always interested in systems-based improvement. Additionally, he was encouraged by a mentor to find a niche outside of clinical medicine.

Next, the doctors discuss collaboration with hospitals and medical schools to encourage more quality improvement initiatives. For enticing hospital systems to care about quality initiatives, Dr. Bennett recommends showing them that administrative data is very important for financial and billing reasons as well as hospital rankings, which are important to patients and the public. Additionally, he encourages medical school lecturers and residency directors to incorporate quality improvement projects and measures in their trainee curriculums. For students and residents with a vested interest in quality improvement, identifying a mentor and starting with a simple project is the best way to explore the research field.

Next, Dr. Bennett discusses important aspects of quality improvement research. First, he highlights the importance of using run charts to compare mortality and complications across populations over time. Run charts can be further analyzed to see differences between different providers, statistical significance, and outliers. When collecting data from electronic health records, he collaborates with billing departments in order to identify relevant CPT codes. He also notes that the AAO-HNSF collects self-reported data from individual institutions as well. Then, he uses data analysis programs like Vizient and Leapfrog to organize and interpret data.

Finally, Dr. Bennett shares how otolaryngologists can improve quality of care in their everyday practice, most notably through proper documentation. He discusses the pros and cons of using dot phrases and emphasizes the importance of standardization of format and coding.

---

RESOURCES

Vizient:

https://www.vizientinc.com/

Leapfrog:

https://www.leapfroggroup.org/

In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Seilesh Babu discuss Eustachian tube dysfunction and balloon dilation as a therapeutic option.

---

CHECK OUT OUR SPONSOR

Acclarent

https://www.jnjmedtech.com/en-US/companies/acclarent

---

SHOW NOTES

First, Dr. Babu provides background on Eustachian tube dysfunction. In kids and adults, Eustachian tube dysfunction can present as a sensation of “ear fullness”, recurrent fluid in the ear, or discomfort with pressure challenges, such as flying or scuba diving. Medical management involves nasal steroids, allergy medications, anti-reflux medications, avoidance of allergens, and doing a modified Valsalva maneuver at home. Additionally, ear tubes and balloon dilation are procedural options.

Next, Dr. Babu explains his workup for Eustachian tube dysfunction patients. He takes a thorough patient history and examines the patient’s tympanic membrane, nasopharynx, and serous outflow using a flexible scope. He orders an audiogram for all of his patients but notes that tympanograms are not as critical. For patients with discomfort during pressure challenges, he will consider doing a balloon dilation or placing an ear tube. For patients presenting with “ear fullness”, a more in-depth examination must be done through a trial tympanostomy tube or a myringotomy.

He also looks for red flags, which indicate Eustachian tube dysfunction may not be the correct etiology for their ear symptoms. These red flags include: aggravation of symptoms upon tube insertion, symptoms of dizziness and vertigo, autophony, and pulsatile tinnitus. Although it is rare, a diagnosis of Patulous Eustachian tube dysfunction must be considered. If the patient does not have these red flags and has had multiple ear tubes without symptom relief, they may be a good candidate for balloon dilation.

Dr. Babu then delineates his procedure for a Eustachian tube balloon dilation. He performs this procedure in the OR using the Acclarent AERA Eustachian tube dilation system. He inflates the balloon to achieve a pressure of 12 atm, keeps it dilated for 2 minutes, then removes the instrument. Some procedural pearls he shares are: putting the scope and balloon in at the same time to minimize bleeding in the nasopharynx and guiding the instruments in a lateral direction towards the external ear canal. He usually waits 2-3 weeks before reassessing the patient for recurrent symptoms. Upon discharge, he encourages patients to avoid nose blowing and Valsalva maneuvers, as these actions can cause a pneumothorax or pneumomediastinum. Common postoperative symptoms include minor nose bleeds and the sensation of a sore throat. Dr. Babu usually performs the balloon dilation in conjunction with other OR procedures, such as myringotomies and tympanoplasties, for efficacy.

Finally, the doctors discuss the specifics of billing for the Eustachian tube dilation procedure. In recent years, a specific billing code has been assigned for balloon dilation, and insurance companies are beginning to authorize this procedure for a variety of patients.

Devices discussed in this podcast are currently available in the US only.

Acclarent, Inc. 223616-220810

---

RESOURCES

Acclarent:

https://www.jnjmedtech.com/en-US/companies/acclarent

AERA® Esutachian Tube Balloon Dilation System:

https://www.jnjmedtech.com/en-US/product/Acclarent-aera-eustachian-tube-balloon-dilation-system

Howard, A., Babu, S., Haupert, M., & Thottam, P. J. (2021). Balloon Eustachian Tuboplasty in Pediatric Patients: Is it Safe?. The Laryngoscope, 131(7), 1657–1662. https://doi.org/10.1002/lary.29241

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.

---

CHECK OUT OUR SPONSOR

Aerin Medical

https://aerinmedical.com/

---

SHOW NOTES

First, Dr. Ashmead describes her typical work up for a patient presenting with nasal valve obstruction in the clinic. She explains that “congestion” is a common but ambiguous chief complaint that patients use when they are unable to be specific about their nasal problems. She emphasizes the importance of doing a thorough ENT review of systems and asking about nasal obstruction for patients with chief complaints other than nasal valve obstruction as well because one-fifth of patients with severe nasal valve obstruction are missed. Before she observes her patients, all of them will complete a NOSE score as well. During the physical exam, Dr. Ashmead observes the nasal bones and external nasal valves first and then uses a rigid scope to examine the internal valve, turbinates, septum, and nasal mucosa. She does not routinely give her patients a nasal decongestant before doing her primary scope exam, as she wishes to examine the patient’s nose in its native state. Then, she will administer a nasal decongestant and go through the second scope exam again. Miscellaneous issues she will look for include nasal polyps and sinusitis. For conservative treatments, she generally prescribes nasal steroid spray, topical antihistamines, Afrin at night, nasal dilators, Breathe Right strips, and nose cones.

Then, Dr. Ashmead delves into the different in-office procedures she employs for nasal valve obstruction patients. The type of therapy she embarks on will depend on the kind of patients she sees. Some of her patients will want to fix everything at once up front and others will want multiple procedures in smaller steps. Additionally, some patients will choose the operating room setting over the office setting. Finally, other details to consider are the patient’s desire to keep the same appearance of their nose, the patient’s skin thickness, and recovery time.

Dr. Ashmead recommends the VivAer procedure for patients with a positive modified Cottle maneuver test, dissatisfied patients post-septoplasty/turbinate reduction, rhinoplasty patients with a narrowed internal valve, and snorers. The VivAer procedure uses bipolar radiofrequency energy to shrink tissue and allow the surgeon to remodel the internal nasal valve, turbinates, and swell body. There are different cooling and heating cycles that take a total of 6-7 minutes to complete. During this procedure, Dr. Ashmead uses a scope to visualize where to place the small paddles. She notes that rebound swelling, nasal tip tension, and the development of scabs are three common minor consequences of this procedure. Next, she discusses the Latera nasal implant, which can only be used in dynamic valve collapse. She does not use this synthetic implant often, as it can get infected and many patients do not want an implant in their noses. A third option she mentions is a septal rhinoplasty, a procedure that she often refers to her facial plastics colleagues.

Finally, Dr. Ashmead goes into detail about her anesthesia procedure and the role of anxiolytics in her practice. Her patients will take either 0.125 mg of halcion or triazolam one hour before they arrive at her office for the procedure. In longer cases, she will prescribe her patients Valium. She emphasizes the importance of thorough topical numbing; she usually uses a 4% topical compounded tetracaine/lidocaine gel. Generally, she avoids administering epinephrine in the office, as adrenaline can aggravate an already nervous patient. Finally, she does everything she can to soothe the patient, such as having separate procedure rooms with soothing music and dimmed lights.

---

RESOURCES

VivAer Procedure:

https://vivaer.com/hcp/