Dr. Reddy: Hey guys, welcome to another episode of We Nose Noses. I’m Dr. Reddy with Dr. Smith. And today we are going to talk a little bit more about our mini series that we were discussing previously on advancements in sinus surgery and sinus procedures.
Today’s topic, we we we will be discussing advancements in powered instrumentation for our sinonasal procedures. and Traditionally, we, you know, sinus surgery has been done by these instruments that are non powered, you know, graspers and cutters and ah manipulators and things like that but now with the advent of power instrumentation, it’s changed and revolutionized the way that we do these procedures. um Dr. Smith, do you want to get started?
Dr. Smith: Sure. So we still use, as Dr. Reddy was talking about, these graspers, these these tissue forceps, if you will, that go in there and have the ability to open and close on tissue or soft tissue or bony structures and kind of bite through them or grasp them to remove things.
However, The whole goal of sinus surgery is to remove obstruction, not necessarily to remove all of the underlying tissue and the anatomy in the in the nasal and sinus kind cavities.
So the big advancement comes with how do you do this type of a procedure with sparing as much of the tissue in the in the sinus and nasal cavity as possible. because that tissue has functioned. And we’ve talked about this in some of our previous podcasts about the whole role of the sinuses, ah these trauma cushions that have this mucociliary self-cleansing mechanism to keep these trauma cushions healthy.
And so the goal with sinus surgery is to remove the offending obstruction in the sinuses and allow the sinuses to do a better job of self-cleansing themselves.
And so all of the the lining in the sinuses have these little hair cells or these little cilia that sweep mucus in a pattern up and around the sinus. And then we all kind of drain it through the nose.
So when we do sinus surgery historically, and we would look in there with a little headlight and maybe a speculum and we use these grasping instruments, we undoubtedly did a lot of unnecessary kind of trauma or damage to the linings in the sinuses, especially if they’re very diseased and and inflamed.
Instead of just taking out small little pieces of the of the offending obstruction, you may end up stripping a lot of the sinus mucosa in the sinus. And so the the need for a tool or an instrument to be able to get into the sinuses and to create the least amount of damage possible to the areas that you didn’t want to, you know, obstruct or, or remove or, or, or kind of demucosalize the, the lining in the sinuses is called them in the nasal cavity is called the mucosa.
And so we want to be as gentle to most of the mucosa as possible. um So Dr. Reddy can talk maybe about like the first tool.
Dr. Reddy: Yeah. So if we just think of powered instrumentation for the sinuses, um what’s the purpose for why they even exist?
It’s really to make the procedure more efficient um and make it more precise. Right. So we’re trying to make the surgeries more precise by like, like you mentioned, trying to spare as much of the normal tissue as possible while, while maybe addressing the abnormal tissue while at the same time improving the efficiency of the procedure so that there’s less amount of time that the patient has to be under general anesthesia or undergoing a procedure while awake.
The different categories of these types of powered instruments, that the way I think of it. So one major category is instrumentation that removes soft tissue in the nose. That can be things like nasal polyps. It can be things like diseased mucosa. It can be things like pus and pulmonary infection and fungus, right?
So that’s one category. Another category is bony tissue removal. So there’s instrument instrumentation that can help drill bones and and reshape bony anatomy. And we’ll go through each one of these separately. And then another major category is the instruments that help with cleaning your nose, like the power washes, washers of the nose, things that can irrigate and suction and clean and things like that. So those are the three major categories, agree. Would you agree?
Dr. Smith: Yeah.
Dr. Reddy: So maybe you want to go over, do you want to go over one of those categories?
Dr. Smith: Sure. Yep. I’ll talk about the microdebreeder, which is the ah she it probably, yeah, everybody’s favorite instrument.
Dr. Reddy: My favorite.
Dr. Smith: Yeah, and so the microdebreeder is a little powered shaver ah that goes in and has a suction ah activity that sucks in mucosa or polyps or growths or fungal soft tissue type of um material. And as that suctions in a little rotating blade within the within the device, um swings around and helps trim off a precise small piece of the soft tissue that’s in there causing some obstruction. And it can remove some bone, thin bone, um mainly. And a lot of the sinuses have little thin septations or little tiny dividers. And so it can go through some thin bone as well.
But the main purpose of the microdebreeders to help and assist with removing mainly soft tissue um with some benefit in removing some thinner bony obstructions. And those microdebreeders or shavers come in a slew of different methods. So in the beginning, um there were ones that just kind of swung around and had like a very larger bore opening. And now, you know, they’ve even gotten more precise with more blades within them, so they cause less pulling on the tissue. Because, again, we’re trying to get away from pulling unnecessarily and evolving or removing and the tissue that we want to leave behind. And so the the kind of the more blades and the faster these things evolve. revolve, the less trauma to surrounding tissue. So a lot of these shavers now also come in different angles.
And so there’s straight blades that go straight into the sinus cavity and nasal cavity. There are angled ones at certain different angles that get up kind to the harder reach sinuses like the forehead sinus or the frontal and the cheek sinus or the maxillary. And that allows us to get into these more difficult to reach places that we otherwise wouldn’t necessarily be able to get into easily kind of with precision through the nasal cavity without these kind of angled tools.
There are even ones that are that are made to get inside the turbinate to remove some of the tissue within the turbinate and try to spare again. a a lot of it has to do with sparing the the tissue on the outside or or unnecessarily removing too much tissue. And so these microdebreeders have really helped a lot to not only make things quicker and and more precise because they’re sucking in the tissue and any ah like a little bit of bleeding as well. But also a lot more precise, accurate with a lot of with diminished collateral damage.
Dr. Reddy: Yeah, I would say that the microdebrider is probably one of the most revolutionary instruments in sinus surgery. It’s allowed us to go from four to six hour sinus surgery cases and save maybe over 50% of potential operative time. um And it’s really quite remarkable, remarkable technology, even though we just use it on a daily basis.
We’re talking about instruments that are really tiny with ah with an aperture that’s actually doing the work of a couple of millimeters, three millimeters or four millimeters. And these really precise instruments have not only a suction component, a cutting component, but also even an irrigating component.
Dr. Smith: Correct.
Dr. Reddy: And, and And the way that they’re shaped and designed um have been slowly improved over the years so that there’s a lot of, it doesn’t clog as much and things like that. But now even most navigation, ah most of these instruments can be also navigated enabled. So when we move the instrumentation in your nose, we can actually see it in three dimensions on your individual CAT scan.
Dr. Smith: Some of them are, yeah, as you mentioned, combination. There’s ones with, um, coagulation or cautery that can burn a little blood vessel on them too. So sometimes these little tiny instruments are packing multiple functions within within one within one tool.
Dr. Reddy: Yep. And most most recently, we’re lucky enough that we even have a microdebrider in the office, which is quite rare. But I think as time goes on, It will probably be standard of care where the ENTs even have access to this technology, not only in just the operating room, but also in the office.
The second category is the bony removal instruments. And this is not used properly. as commonly right as the microdebrider, for example, it’s typically used in, in cases where people need like revision surgeries or people that have anatomy that, um, the bony aspect of their sinuses are actually obstructing, um, their sinus blockages, whereas most people with soft tissue. And so it’s not used as commonly, but we still use it quite frequently. um Do you want to go over some of the bony?
Dr. Smith: Sure. So there are also bony tumors like osteomas or a little bony growths that can occur that can obstruct some of sinuses. But again, like some of these harder to reach sinuses, like up in the forehead, the frontal sinus in the past, if you couldn’t access it, or if there was enough bony obstruction, you would literally have to bypass the sinus. So you would go in there and maybe chisel out the sinus or, or scrape out to try to get as much opening as possible.
Now with these precision drills, uh, you’re able to get in there. And so there’s a drill that you can use with a different types of bits at the end of them. Some of them are more, um, fine cutting. And so those are um more like ah diamond shaving down or or or just kind of ah polishing down the the bone. And some of them are more heavy fluted cutting burrs. So there’s all sorts of different drill bits.
However, they they all have a purpose of trying to widen the natural opening and getting into the sinuses or in the case of an osteoma or a bony tumor, trying to remove that tumor. Whereas in the past, if you couldn’t get to it, you were either going to chisel and open up unnaturally going through the forehead or the skin and then get into the sinus to try to remove those or just say, “hey, this is in there we can’t get to it easily, so we’re just going to leave it alone.”
Dr. Reddy: Or even using a little curette and just scoop. Scooping out tiny little curettes for potentially hours.
Dr. Smith: Right, yeah.
Dr. Reddy: So yeah.
Dr. Smith: So those, those devices have drastically helped. And there are even these more, these ultrasonic bone aspirators that can be used to in sinus and neurosurgical procedures to gently take down bone in areas like around the orbit or along the skull base. You can take down the bone on these really deep spots, abutting nerve or a major artery without doing deep damage to that nerve and artery or brain tumor.
And so you can take down these tissues easily with some of these piezoelectric or radiofrequency aspiration type of tools. And so those all remodel and and remove bone as well. And those things have drastically helped these more complex surgeries involving the orbit and the skull and and brain, etc.
Dr. Reddy: Yep. And the last category of power instrumentation that we typically commonly use are the irrigators and the cleaners. So one one such irrigator is called the hydrodebrider. So you can just imagine these instruments that can be curved in multiple different directions, um depending on what the sinus anatomy is like and depending on which sinus you’re trying to reach. So if you want to reach the maxillary sinus in your cheek or the frontal sinuses over here in your forehead, um you can bend these instruments. Specifically for those particular sinuses or they come pre-bent and then basically they’re like a power washer. Whereas in the before, what you would do is just take a bulb syringe and kind of irrigate out the nose almost like a neti pot or a neomed sinus rinse.
But now what you can do is you can put the ah power wash essentially right into this affected sinus. And it will irrigate that area out with a higher velocity stream of air of liquid while at the same time suctioning um the liquid as well. And whatever debris that comes out, whatever bacteria there’s in there, um you know, there’s a thing called biofilms that a lot of people, a lot of patients with chronic sinus symptoms have where the bacteria is kind of sticky, essentially all over the nose and the nasal cavity. And this helps kind of break up the biofilms.
But in my experience, the thing that helps the most with is for patients with allergic fungal sinusitis where you can have these fungal balls in the sinuses that are very difficult sometimes to get out.And these, these machines allow you to break all the fungus up and suctioned out. So we don’t leave even a tiny little piece anywhere.
Dr. Smith: Cause even with a large, like maximum opening into these sinuses. Sometimes it can be really tricky to get almost like 180 degree turn back into the sinus and try to get these pieces of debris out, which again, historically you would be going in there with different angled suctions and different scopes, trying to look around the corner. And you may miss pieces and parts of it.
And as Dr. Reddy alluded to, these films often sit deep in the sinus and are really difficult to get out with just manual um kind of disimpaction. So these these really flushing tools, which I would have thought would have been your favorite tool that’s out there that’s powered, since Dr. Reddy even does these as well in the office.
And so these these are amazing. you know In our training, I never would have thought that this would be something that you could do you know, awake in the office with patients and and very easily. So um yeah we can get in there in the office and patients tolerate it really well, thanks to the fact that these not only irrigate through, but suction at the same time and are kind of self-contained power washers. It’s absolutely amazing that these things exist now.
Dr. Reddy: Great. So I think that’s all we have to say about powered instrumentation on this episode. We’ll see you on the next one. Take care.
