Dr. Reddy:
Hey guys, welcome to another episode of We Nose Noses. I’m Dr. Reddy, joined by Dr. Smith. And today we are going to be talking about advancements in sinus surgery, specifically the no need for packing after a sinusal procedure or packingless surgery. So today we’ll be focusing on that advancement in sinus surgery. Dr. Smith, do you wanna first start off and maybe tell our listeners what packing even is?
Dr. Smith:
Sure. So historically, there’s a lot of patients will come in and if they are considering or have a need for sinus surgery, a lot of people have this predetermined thought that, I know somebody or I knew somebody that had sinus surgery and they were miserable because they had to go back to the doctor in a couple of days and have this long, you packing or gauze removed from the nasal cavity. So, historically when sinus procedures were done, packing was placed into the nasal cavity and that would be like a long kind of thin ribbon gauze that would be layered into the nasal cavity to try to help stop bleeding. So by putting pressure up against the raw surface or the raw tissues in the nasal cavity, you could kind of pack or put pressure against those raw areas and prevent bleeding after sinus surgery. And so a lot of things have advanced to help prevent the need for that packing. And Dr. Reddy and myself will talk about some of the advances and some of them are a little bit more historical, but some of the older advances and some of the newer advances that have led us to be able to get away from packing altogether.
Dr. Reddy:
Correct. Yeah. And typically patients that have had surgery, from other doctors because there’s actually plenty of doctors even now that still use packing. And we don’t use packing unless we have an urgent or emergent situation that requires it. But there’s a lot of changes that have happened in ENT over the years that have led to this. One of the big changes is that endoscopic sinus surgery kind of morphed into what we call functional endoscopic sinus surgery. And so that functional aspect of endoscopic sinus surgery has changed our viewpoint on how we perform surgery so that the procedure itself is more minimally invasive. There’s what we call more mucosal sparing techniques and there’s more preservation of normal sino nasal architecture. And by putting an emphasis on that, it potentially reduces the likelihood of big bleeding, which would then require packing.
So for example, a turbinate reduction, which is commonly done in conjunction with sino-nasal surgeries. In the old days, or even currently by a lot of other doctors, there’s been a big push in the beginning at least to just maybe remove the turbinate or have an aggressive turbinate surgery, which would then lead to more likelihood of catastrophic bleeding or even more than normal bleeding, which would then require packing. But the way that we currently do a turbinate reduction, it’s much more mucosal sparing, it’s more conservative, and so you’re less likely to get that big time bleeding.
Dr. Smith:
Yep. So in addition to the endoscopes as Dr. Reddy was talking about. So that’s the endoscopic approach, which are those long kind of thin cameras that we can look into the nasal cavity. know, historically a lot of physicians and docs would use a headlight or a mirror with a light and a speculum to try to look into the nasal cavity. So visualization is certainly the one big thing that’s helped us. And you know, another tool that’s helped us a lot with this mucosal sparing technique that Dr. Reddy was talking about as the advent and, microdip readers or these mini shavers, these, these devices are small kind of thin rod-like, shavers that allow us to go in and, just touch the area that we’re trying to resect or remove. And so without tearing or pulling the mucosa, cause the lining in the sinus and nasal cavity is very kind of fragile and frail. And so if you grasp it and try to pull on it, a lot of times a lot of it, you’ll kind of a vault it or tear a lot of it out that you don’t want to tear out. And so with these shavers and these microdebreders, we’re able to really just trim the area that we’re trying to get into without tearing and pulling a lot of the other linings out, which significantly decrease the bleeding. Because a lot of the bigger vessels are attached to some of the external linings. And so if you go to grasp a big section of it out, you may tear off a big section, create a lot of bleeding necessitating packing. And just like Dr. Reddy was saying with the turbinate as well, those shavers can be used in addition in the turbinate reduction. You can make a small window into the turbinate as Dr. Reddy alluded to and go underneath it, underneath of the lining, the mucosa and trim out the sections that are necessary underneath it, kind of do a more conservative or a selected turbinate reduction based off of where the patient really needs it.
Dr. Reddy:
Yep. So the techniques from how we do surgery have changed dramatically. And we also screen patients better, right? For bleeding issues, even prior to surgery. Do you want to touch on some of those screening?
Dr. Smith:
Sure, so bleeding disorders are one thing that we always check out for. So we look for family history of bleeding disorders, medications that can cause bleeding have evolved. Of course, we all know about the typical things like the anti-platelet or blood clotting medications, the blood thinning medications. So there’s a lot of these medications that are out there now. And so there’s a lot of different restrictions and timing with, with coming off of some of those medications. And of course, some of the not so well known medications that can thin the blood, you know, the nonsteroidal anti-inflammatories like Motrin, things like fish oil, some supplements like ginseng, garlic, ginkgo biloba.
A lot of these other supplements can thin the blood, even things like Pepto-Bismol or other products that are over the counter that have salicylates in them can thin the blood. So we’re a lot more aware of things and medications that can thin the blood and cause these. Even like a very common thing that we see patients on a lot are antidepressant medications. know, historically we all do surgery on patients on antidepressant medications, but we do know that there’s a little bit higher of a risk potentially with antidepressant medications, some of them have antiplatelet like activity that can make somebody more likely to bleed too. So just a knowledge of the different medications that are out there and how they may interact with the bleeding system helps a lot as well try to decrease the need for packing in the nose.
Dr. Reddy:
Yeah, and we’re sometimes able to mitigate some of these issues by not only identifying it, but potentially stopping these medications prior to surgery. Sometimes we start medications to reduce bleeding. For example, if there’s extensive nasal polyps, sometimes we’ll start off with steroids prior to surgery to decrease bleeding risk. We may even give a medication in the surgery, like TXA, for example, is now being used relatively routinely across the country for decreasing intraoperative bleeding risk.
There’s biologic medications that we now have access to that can potentially also reduce perioperative bleeding. So those are all options. And then, you know, even in the operating room, there’s a lot of tools that we have now that decrease bleeding and prevent the need for packing. So I’ll touch on one of them and maybe you can touch on some of other ones.
There’s all of these different thrombotic agents that are used, that are dissolvable, that have different types of consistencies, and they can be used in different parts of the nose and the sinus passages. For example, there’s a foam that I routinely use called flow seal or surgical flow that can be instilled in the nasal cavity and the sinus cavity to kind of help decrease all this tiny little bleeding, oozers that can happen after surgery. There’s also other
sponge-like devices that dissolve slowly over time. There’s multiple companies that make these devices. Stryker makes some, Medtronic makes the others, and they go by different names. But essentially, these are dissolvable packing that patients generally don’t feel in their nose that can avoid the discomfort from the real packing, which is what they’re afraid of. Is there anything else that you want to go over with?
Dr. Smith:
Sure. Just like you were saying with the thrombin and so that we can even use little cotton pads soaked in thrombin agents or epinephrine, which can help shrink blood vessels and control bleeding easier. And sometimes if you can control the bleeding to a small little tiny spot, you can use certain, caudery devices that can be used safely in the nose now. So there’s a typical electric caudery device, but there’s also a, a small bipolar, which is a very kind of detailed, fine, by, caudery device that can just pinpoint a tiny little area within the nasal cavity. And these have become smaller and smaller and smaller, allowing us to get these in and access some really difficult reach sections within the sino nasal cavity. so caudery devices have come a long way. we even have small surgical clips that we can apply on certain, arteries and vessels within the nose, that we can kind of address a larger vessel that might cause some bleeding issues. If there’s a known bleed or an issue that we can address with like addressing one specific vessel. Whereas in the past, if you didn’t have these kind of microscopic clips or these small cautery devices, you would just have to put pressure up against there with packing to try to get it to stop and leave it in there for about a week or so. But now thanks to all these smaller, more detailed pinpoint accuracy devices were able to cauterize one of those vessels if we identify it and get it to slow down.
Dr. Reddy:
When’s the last time you’ve had to pack someone routinely after a sinus surgery?
Dr. Smith:
I’d actually have to say, and I typically tell all my patients this, I’ve never had to pack anybody and I don’t plan on doing it. I can’t remember ever having to pack somebody after a sinus surgery.
Of course, we’ve all had bleeds that have occurred after sinus surgery. Thankfully, not too many, but when they happen, we’re typically able to, in the office, slow down the oozing and bleeding and control it even here in the office. And some of that technology is because we have the same OR-grade equipment that we would have or operating room-grade equipment that we have available. We have that here in the office and we’re able to visualize suction, cauterize or put a little dissolvable hemostatic agent there, which really has saved a lot of patients from packing or needing to go back for further operations.
Dr. Reddy:
Yep. Yeah. I can’t remember the last time I’ve had to, it’s probably been many years since I’ve ever had to pack someone routinely after a surgery. But you know, the likelihood is basically in our practice, if you’re getting a sino nasal procedure done, over 99 % chance you’re not gonna have any packing in your nose that needs to be removed later.
Dr. Smith:
Correct. Yeah. As Dr. Reddy said, a lot of those are dissolvable. So those little sponges or gels and things that we put in there, usually as patients start to irrigate and do sinus rinses after surgery, they just turn into a kind of a liquid and slowly kind of dissolve out of there. So most of time there’s nothing that needs to be removed.
Just some suctioning and things afterwards to help keep the science cavity clear. Great.
Dr. Reddy:
Anything else, Todd?
Dr. Smith:
No. Do you have anything?
Dr. Reddy:
Nope. Excellent. Well, thank you for joining us. We’ll catch you on the next episode. Take care.
