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.

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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.

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RESOURCES

VivAer Procedure:

https://vivaer.com/hcp/