Search for tag: "endoscopic"

Interviewer: Three types of surgery can be used to treat craniosynostosis, which one depends on a few different factors. If the synostosis is caught early enough, the newer endoscopic procedure can be used.

Pediatric plastic surgeon Dr. Faizi Siddiqi and pediatric neurosurgeon Dr. John Kestle are here to discuss the three different types of surgery for a synostosis and why they would consider one over the other. So, first of all, how early does a child need to see you for the less invasive endoscopic procedure to be an option?

Dr. Kestle: So the endoscopic method we've been doing since '07, and we've found that the best time to do it is usually between two and three months of age. So we have to see the patient before that and the earlier the better. The surgery is done under a general anesthetic, and the surgery typically lasts about two hours, and most of them spend one night and can go home the next day. Occasionally, they need two nights. It's done with, for example, sagittal synostosis with two incisions -- one just behind the soft spot and one toward the back of the head. And then we work under the skin to remove the fused bone.

Removing the fused bone doesn't really change the shape much at all immediately. It just releases the bone. And then about two weeks after the surgery, they start wearing a special helmet that's designed for surgical patients, that is a little snug front to back and a little loose on the sides, and it just guides the growth so that as the baby's head growing, it's taking on a more normal shape. They wear the helmet for about six months, some shorter, some longer, and we just monitor the growth pattern and make that decision. And they'll go through several custom-made helmets over the course of the treatment as they grow.

Interviewer: Generally, I'd imagine a less invasive procedure is always better. Why is this procedure better than say the traditional treatments?

Dr. Kestle: Well, it's got a shorter hospital stay, a much lower rate of blood transfusion. It's a lot less swelling associated with the surgery. It's easier on the babies, and the results are at least as good.

Interviewer: Is there a reason, other than age, why a child would not be eligible for the endoscopic surgery?

Dr. Kestle: We don't often do it in children that have syndromes where they might have multiple malformations in other parts of the body, such as Crouzon syndrome or Apert syndrome. And in addition to those other malformations, they have synostosis. Those children usually need the more traditional, bigger surgery. But any child that has one suture fused is a great candidate for the smaller surgery.

Interviewer: Dr. Kestle, you're a neurosurgeon. So you handle that part of the procedure?

Dr. Kestle: Yes.

Interviewer: Okay. And then Dr. Siddiqi, you're a pediatric plastic surgeon. With the endoscopic procedure, both of you are in the operating room at the same time. Just kind of walk me through how the surgery goes. Dr. Siddiqi, you start the surgery.

Dr. Siddiqi: So we're in the OR together. It's a team approach. So once the anesthesia team have completed their part, which is getting the baby asleep and making sure the IVs are put in and everything is safe to proceed, that's when we position the baby for surgery. I would make the initial incisions. For example, for sagittal synostosis, we make two incisions on the top of the scalp. Again, that's one of the advantages of doing it this way versus the bigger procedure because you have two small incisions. Through those incisions, we expose the area that we want to operate on, which is that fused sagittal suture. And once everything's exposed and visible, then Dr. Kestle would take over.

Dr. Kestle: What we do is remove a little bit of bone under each incision. And that allows us to get underneath the bone. Underneath the bone is a layer called the dura, which is a covering layer over the brain. It's kind of like leather, like a thin leather. And we use the endoscope to separate that layer from the bone, and that allows us to safely cut the bone and remove it. Once the bone is removed, we look at the dura and make sure it's okay. We stop any little bits of bleeding, but there usually isn't much. And we check the bone edges, which sometimes ooze, and make sure that any bleeding is stopped. And then at that point, Dr. Siddiqi and his team continue working.

Dr. Siddiqi: Yeah. So we take out or remove additional segments of bone. There are these little triangles we take out, about four them. Again, afterwards, we make sure that the bone edges are, you know, clean. They're not bleeding. Again, that's one of the other advantages to doing it this way. The blood loss is quite small, minimal compared to the traditional way. Most of the time, it's maybe 10 or 15 milliliters of blood. So once those triangles are removed, then we close the incisions. Then the anesthesia team takes over, and the baby's, you know, woken up and then taken to the recovery room.

Interviewer: What does the recovery look like then for a child? And, you know, what kind of outcomes can parents expect?

Dr. Kestle: With the small surgery, they don't need to go to the intensive care unit. They stay in the hospital in a regular room, and the parents can stay with them. The vast majority of those children are here for one night. Occasionally, they need two nights. The criteria for going home are pain control and feeding. They get some swelling toward the back of the head, that gradually goes down over the first week at home. Stitches dissolve on their own. And within a day or two, they're back to their usual self as far as feeding and behavior goes.

Interviewer: And Dr. Siddiqi, how long does it take for the head then to regain more of what would be considered a normal shape?

Dr. Siddiqi: Yeah. So as Dr. Kestle mentioned earlier on, the shape doesn't change after the surgery, right after. It's once they're in the helmet. The helmet is critical for reshaping the head. And typically, they're in the helmet usually two to three weeks after the surgery. It's a custom helmet. You know, it just guides the growth of the head, and over the ensuing, you know, three to six months, we have a more normal head shape. And hopefully, after six months of helmeting, that's all they need.

Interviewer: And the incisions that were talked about out in the endoscopic surgery, are those visible or are those in the hairline?

Dr. Siddiqi: You know, they're in the hairline. And again, another advantage to doing it this way is the incisions are on the top of the scalp, the head, and those scars heal very nicely. They're quite thin and they're barely perceptible. You only notice them when the hair gets wet. Again, with the bigger procedure, you have a much bigger incision from ear to ear, which is much more noticeable.

Interviewer: Let's talk about the more traditional procedures in the event that a parent is in a situation where their child is older than six months old or there's other reasons why they might have to have that. What are the two procedures, and can you explain those a little bit?

Dr. Siddiqi: Yeah. So sometimes, you know, we do see kids who are, you know, two, three months old and they're eligible for the smaller procedure, but for various reasons, let's say they live out of state or they don't want to do the helmeting, they would like to do the traditional, what's called cranial vault reconstruction with orbital advancement. So then we would wait until they're 10 to 12 months of age to do that procedure. Essentially, that's a much more involved procedure, but it's a procedure that's, you know, well described. People have been doing it for, you know, 30, 40 years. You know, the results that you get are comparable to the endoscopic procedure, but, again, it's how you get there.

So with this procedure, you have to expose the entire skull. So that means an ear-to-ear incision through the top of the scalp. I would expose that, mark out where I want Dr. Kestle to make the cuts and remove the segments of bone that we want to reconstruct and reshape. Then Dr. Kestle would remove those pieces of bone, make sure that the lining of the brain is okay, make sure everything is okay. Then I would reshape all those bones and reconstruct the skull in a more normal configuration, and everything is stabilized with plates and screws. And these are resorbable plates and screws. They dissolve in about a years' time. So we put everything back together and close the scalp. That's a four or five-hour process. Much more blood loss than with the endoscopic procedure.

They typically would go to the intensive care unit for one night, and they typically would be in the hospital three or four nights. Oftentimes there's quite a bit of swelling. The eyes can get swollen shut, and it would take maybe 10 days to 2 weeks for that swelling to go down.

Again, the advantage is you don't need a helmet. It's all done in one stage. You know, the compromise is that it's a much bigger operation.

Interviewer: If parents are evaluating a center or physicians to do this procedure, what advice would you give to them to, you know, pick out the best place for them?

Dr. Kestle: I think it's a procedure that is usually done very safely, and children do very well and go home quickly. We are exposing the layer over the brain, and there is a potential for bleeding. And so I think that experience matters. And I think that you do want to be treated by people who do this a lot and people who can handle problems, which are rare, but if they arise, they need to be dealt with appropriately. So I think it's a big advantage to being treated by people who have experience with this, who are in a children's hospital with pediatric-trained specialists, including anesthesia and a pediatric intensive care unit if they need that.

Interviewer: And you mentioned a third procedure, a cranial vault distraction, when might that be used?

Dr. Kestle: So there are some children where their brain is in trouble or potentially in trouble because they have presented very late or they have multiple sutures that are closed. And in that situation, we want to make the skull bigger to give the brain room to grow. Probably the best way to do that these days is a procedure called distraction, where some implants are inserted and then the skull is gradually expanded over time.

Dr. Siddiqi: You know, with cranial vault distraction, again, the idea is to give the brain as much room as we can because of the fact that more than one suture is fused. And the way that's done is I would ask Dr. Kestle to make some cuts on the bones. And then I would put these little devices, they're called distractors, on either side of the cuts. And then three days after surgery, we would have the family start turning those distractor devices. Typically, it would be total of one millimeter a day. So over the ensuing three to four or five or six weeks, the bones are slowly being separated. And what happens is that, as they're separated, there's new bone being formed in the gap. And over time, that new bone will solidify. So we're not only expanding the volume for the brain, we're also creating new bone. This is really the only way we can expand the brain to this degree using these devices. We couldn't do it as a single-stage procedure.

Interviewer: Between the two procedures, the endoscopic procedure, the less invasive, and the cranial vault reconstruction, are there any tangible differences and outcomes or how the head is going to look or anything like that?

Dr. Siddiqi: I would say like the overall head shape is probably going to be comparable, just the head shape itself. But again, as I said, it's how do you get there? You know, how long does it take? What are the risks involved? In terms of the shape itself, with the endoscopic procedure, overall the head feels and looks quite smooth at the end of the day when everything is healed. Whereas with the bigger procedure, you know, we're taking all the bones out or in multiple pieces, putting it back together. So when everything is healed in a year, two, three years' time, you do feel some irregularities over where the bones are joined together. But overall, the head shape is probably comparable. But, you know, I think you get an overall smoother head shape. And I think it probably looks a little bit better as well.

Dr. Kestle: And obviously, the scar is different as well. In the endoscopic, there's two scars on the top of the head that hide really well. And the bigger surgery has an ear-to-ear incision, which also usually heals really well. But as people age and start to lose hair, it's a lot more obvious.

Interviewer: So you or a loved one have opted to have endoscopic spinal surgery rather than one of the more traditional methods. What can you expect on the day of the procedure and afterwards?

We're here with Dr. Mark Mahan. He's an associate professor of neurosurgery at the University of Utah Health. Now, Dr. Mahan, when it comes to endoscopic spinal surgery, what can someone expect, you know, leading up to the procedure, the day after? Where do they start? And what should they be expecting?

Dr. Mahan: The wonderful thing about endoscopic spine surgery is that in, I would say, 99% of the cases, it's outpatient surgery. So that is a little bit of a reframing of what an individual will be expecting, because it's not a traditional come to the hospital, stay there for several days, eat wonderful hospital food, stay in wonderful hospital beds. This is something that you would anticipate going to one of our outpatient locations. A patient would expect to arrive that day. Typical requirements are for, you know, for any surgery are, you know, no eating from the night before, coming in, unfortunately, you know, sort of extra early because we all like to end our days early, and so we try to get started early.

And then you would expect that you're going to be meeting a whole host of new individuals that are going to come in and take care of you. And meaning that we're going to have nurses and others that will come in and check-in and make sure that you're ready. We'll go through a surgical consent. That's an important part for me personally because I want to make sure that everybody understands, ahead of time, both what the surgery entails, what the risks are, what your expectations will be both in recovery as well as long term. And so that we all can meet in a common understanding about what our goals are and what you'd be facing. And then through also about, you know, how to best optimize your recovery long term.

And then after surgery, obviously, these are generally performed under general anesthesia, which is the type of anesthesia where you would have a breathing tube. And so waking up, coming around is usually a time when most people don't remember, fortunately, and then just recovery, make sure that you've, you know, that you're ready to go, you're steady on your feet, that you're eating, you're feeling well, and then we get you back to your car and you can go home.

Interviewer: So how long are you actually in the operating room for a procedure like this?

Dr. Mahan: Typically, it really depends on what the problem is we're seeking to treat. Some of the disc surgeries go really, really quick, like on the order of about half an hour.

Interviewer: Oh, wow.

Dr. Mahan: Now some of the more complex narrowing can be two hours. It really truly depends on what the work that needs to be done.

Interviewer: Now, after the patient is home, what can they expect? We're dealing with pain control, recovery. How long until they're back on their feet, etc.?

Dr. Mahan: Yeah, now, pain control is a particular focus of mine because I really want every individual to really have that smooth glide path because, you know, even though that the endoscopic technique is meant to minimize tissue trauma, it is still a spine surgery. It is still the goal of removing something from your spine. I don't want to make that sound scary, but I don't want to make other people feel like, oh, it's a magical procedure, right? It's not. There's a reality here that we're removing something that's pressing on the nerves and causing pain and discomfort.

And so that you would expect to have some irritation or some discomfort from having something removed from your spine. And so what I do is I do everything I can to possibly minimize it. Number one, endoscopic techniques, minimal incisions, minimal approaches. Number two, often using a lot of numbing medication can really make the recovery much more straightforward. So we'll use a long-acting anesthetic into the muscles of the spine to make them comfortable and relaxed even before we even start doing surgery.

So the first step, block the muscles. Make it comfortable. It also leads to some numbness of the skin where the skin incision is so that that is not too much discomfort. But the block will wear off. So the things that we do is try to, obviously, avoid a lot of powerful pain medications because powerful pain medications can have their side effects and consequences. So we're using things like ice, heat, anti-inflammatories, and then we talk about milder pain medications so that you don't get into the complications associated with strong pain medications.

Interviewer: Now other than the pain management that happens afterwards, when they go home, are they up for a day or two? Are they on their back for a day or two? On their belly? Like, what are you having a patient do to heal up from a procedure like this?

Dr. Mahan: In the majority of the cases, you're doing exactly what you want to do.

Interviewer: Oh wow.

Dr. Mahan: Yeah, the limitations really come down to if somebody has had a disc herniation, we want to minimize the risk of re-herniation, meaning that another part of the disc fractures out and presses against the nerve roots, which can occur. Other than the disc herniations, I want the individual doing as much as they feel comfortable doing. Oftentimes that sometimes means tempering people. I had one patient the day after surgery he asked if he could go on a snow bike up the mountain. And I was like, it was one of those moments where you have that sort of, you know, common sense questions, like, well, just tell me what would happen if you got halfway up there and you had a back spasm? You had difficulty coming back?

Interviewer: Right?

Dr. Mahan: And, you know, he's like, well, maybe that's not the greatest thing to do today. And you're, like, yeah, the day after surgery may not be the greatest day to go nuts. But people will be walking more. People will be doing more activities. And we want that. We want them to go back to the way that they will choose to live their life.

Interviewer: Now, it's impressive that they are kind of up the next day, or a day or two after their procedure. Maybe a little bit tempered from what they were normally doing. But, you know, not going back up and doing crazy mountain biking, or that snowmobile trip, like you mentioned. But how long until a patient is, you know, all the way healed and sees the most benefit from the procedure, and they're back to normal?

Dr. Mahan: That is an excellent question. And it really is patient-specific. So if somebody had a more profound nerve pressure or nerve injury, and it's been there for a long period of time, meaning that it's going to take longer for their recovery, right? So if you've had a problem that is minor in nature, and it's a short duration, your recovery is going to be quick. If you have a very profound problem that is of long duration, you know, there may be a new normal, even with spine surgery. We can't always erase everything that occurs in time, but you know, we're going to try.

Interviewer: If your loved one is experiencing some sort of serious spine issue, perhaps stenosis or herniated disc, you may be looking into spinal surgery. Now, typically you might be imagining your back being opened up for major surgery, but there's another option that is available.

We're here with Dr. Mark Mahan. He is an associate professor of neurosurgery at University of Utah Health. Now, Dr. Mahan, we're talking today about endoscopic surgery for the spine. Why don't you kind of talk me through exactly what happens with an endoscopic procedure like this and how it differs from say what I as a layperson think when I think about back surgery?

Dr. Mahan: Endoscopic spine surgery is very similar to what people would refer to as traditional spine surgery, meaning that we're the same goals. We're there to decompress the nerves and in doing so with either removing disc fragments or treating narrowing that presses on the nerve roots, but doing it in a much smaller, much less traumatic fashion than previously accessed.

For most of us, the spine is really kind of in the center of the body, so getting there is always an art, to put it mildly. The older techniques, they work great for treating their intended targets, but the problem is, is there's a fair amount of tissue trauma involved with getting there.

And I've been intrigued for quite some time of finding a way of doing that same surgery, but in a way that does not cause the same tissue disruption, tissue trauma, and as a consequence, the same sort of pain or disability and recovery.

Like for so many things in medicine, we stand on the shoulders of others. Other pioneers had really developed using endoscopes previously, starting in about the 1980s, to create the same surgical corridor but through a much smaller opening. So now with the modern surgical endoscopes, we get beautiful illumination. We get beautiful magnification. We get beautiful video representation of the soft tissues in a way that we're able to perform those same delicate procedures, but through oftentimes really small, like 7 millimeters size skin incisions. That's, you know, 7 millimeters means it's less than your nail width depending on your fingers, but somewhere between your index finger. That's how big the skin incision is.

So that also means that that translates it's not just the skin incision size, it's because now you're going to go down with a very narrow caliber set of tools. So the things that you're going to be doing is that you're not going to be opening up as widely. You're not going to be disrupting joints. You're not going to be getting as much bleeding because we're constantly irrigating.

In fact, the operative field never actually gets to see air. There's none of the circulating air even in an ultra sterile OR environment that actually makes contact with the tissue. We're using constant irrigation with sealing. And so, again, it provides beauty and clarity to the surgeon but also minimizes any risk of infection or other bleeding type complication with regard to the surgery itself.

Interviewer: And again, as someone who's a layperson who might be kind of curious about this, how long have surgeons in the medical field been doing this kind of procedure? It seems kind of new I guess to me.

Dr. Mahan: I'd say it hasn't been done at a large volume for quite some time. There were some initial pioneers who were in the 1980s when they were coming out with the initial endoscopes who were starting it and trying it.

And you can imagine what using 1980s technology meant kind of dark kind of grainy, not necessarily with the same precision. Things really got a boost I would say in the, you know, the 2010s with the introduction of more modern, you know, high-definition televisions, easier access to those techniques, and then just greater popularity.

So we started seeing that the endoscopic technique was really taking off in Germany, and there there's a couple of key innovations that allowed it to be safe for the spine. So whereas you can think of joints having arthroscopes, those are endoscopes specific for joints, those were a little earlier take on, but they were using really high-pressure pumps and those high-pressure pumps would be dangerous if not lethal in the spine. So we had to really develop lower pressure technologies. You had to develop specific tools sets that were able to do the same sort of meticulous and very detailed work we do with the spine.

We saw that those tools and techniques and instrumentation sets really start about 2010-ish, and so there's a very small fraction of spine surgeons in the United States who are trained to do this, unfortunately, because I think it's the technique that should really predominate. And I do, you know, have the good fortune of being able to go train other spine surgeons on how to do this and adopt this technique, which I really enjoy teaching the other spine surgeons how to do it because hopefully it will become the dominant technique and it's not just a single or specialty practice.

Interviewer: It sounds like this procedure has been getting more and more popular over the last two decades, and you sound confident that it could be the next standard practice for a procedure like this. What is it that you see in this particular type of procedures and what are some of the pros and cons of it that make you think that this is going to be the way that surgery is going to be going?

Dr. Mahan: I really like the fact that it has minimal tissue trauma, which means that it has quicker recoveries. So when you ask about the pros and cons, the certain positive that I particularly love and I particularly enjoy about the surgery is that it provides rapid recovery for my patients. That the next day when I talk to my patients or find out how they're doing, they're describing that they're already back to more activities oftentimes than they were before surgery, which is relatively rare.

When we think about surgery, where most people are like, "Yeah, I've got a down period," and I don't have patients coming back to me with like down periods. They're like, "I'm out walking." I hear reports over and over again. They're like, "I am walking now more like the day after surgery than I was in like the several months leading up to surgery." It is that dramatic as far as differences in outcomes. So that's the most certain person and positive note.

Now, some of the other positives I particularly like, again, its lower blood loss. It has a substantially lower risk of infection. There's a substantially lower risk of a specific complication that occurs in spine surgery and that's spinal fluid in leaks or thecal sac injuries. And that's unique to the endoscopic technique is again, we're using sealing to put a little bit of pressure and create space and so the thecal sac is moved away and so you have less risk of that specific complication.

There are downsides, right? I tell all my patients almost repeatedly, you know, if it's powerful enough to help, it's powerful enough to harm. There are cases where people have injured, you know, individuals with using minimally invasive techniques. Endoscopic spine surgery is no stranger to that.

I would certainly say that I think, in my hands, the complication rate is lower, but it's not it's a freebie. It's not like there are no risks. Secondarily and I think the most of the negatives really accrue to the surgeon. You imagine like if you had to do the same work, let's say it's painting a wall, and you were given the choice of a big paintbrush or a tiny paintbrush, which do you think would lead to be faster endpoint?

Interviewer: It's the big brush, right?

Dr. Mahan: The big brush. It's the big brush. The big brush is going to do something quicker. And so, if you force the surgeon to do the same procedure with tinier tools, it's going to take longer. And the way that the insurance in the United States reimburses surgeons, it's on sort of work product. And so again, they pay you to paint the wall. If you can paint the wall faster, then it can be a choice.

Interviewer: What are the success rates like on a procedure like this?

Dr. Mahan: The success rate on anything in life really kind of depends on what your probabilities of success are. So if I take somebody who has relatively straightforward problem and has a very focal problem that's apparent on MRI and is clear on their physical exam and their description of their symptoms, we're going to have a good success rate whether it's an open technique or an endoscopic procedure.

If it's something that's a little bit more challenging, somebody has multiple problems, multiple medical issues, other interdependencies, you know, things that are going on in their lives that are either participating or motivating the pain, then we're going to be less successful. But so for that, let's take the good situation which is for most people where they are.

This is, you know, somebody who has singular problems, relatively identifiable things that could fix their problem, and they're going to have an 80% to 90% success rate with a surgical treatment and it's going to be durable. We want to do a simple procedure that doesn't necessarily create problems that need treatment later.

There are some spine procedures out there that cause further problems down the road. This is one of the ones that leaves a person essentially with more or less their native anatomy, their normal anatomy. And so the goal there is that the only thing that contributes to future problems is really, you know, the nature of time and body's ability to resist time but not the surgery itself.

Interviewer: Say that a patient has now received their diagnosis, they know they have one of these spine issues like we've talked about earlier. What is their first step? Say they're listening to this right now and they're intrigued about this procedure, what is their very first step to get more information and maybe even meeting up with someone like you or another trained professional?

Dr. Mahan: One of the things that we want oftentimes in medical practice, and this applies to a lot of things, is that we want somebody to ideally for somebody to come to me or to come to one of another trained practitioners. If they've had a degree of workup, meaning that they've been evaluated, they've been seen by somebody, and that the process has already been started.

For example, a classic thing is that sometimes you have back pain that can be treated with physical therapy, some exercises, some stretching, maybe some modest medications, right? We're talking about like anti-inflammatories and other things that can get you back to recovery that you don't need surgery for. And so both insurance and the surgeons really want to have that evaluated ahead of time so that when you're coming to somebody, it's meaningful. It's a meaningful use of the patient's time. That you're not coming to see somebody who's going to talk about surgery when you don't need it.

And so it's not a waste of the patient's time. It's not a waste of, you know, of resources or other things. So an initial evaluation, maybe some time with the physical therapist, trial of medications. And then if those aren't working and the MRI, which is a critical component of all of our evaluations, because that's where we can come back to saying is an anatomical surgery going to fix your problem.

And so we need a view of that anatomy, and fortunately, MRIs just do such a beautiful job of doing that is that. If an MRI shows that there's a problem, then clearly there's something that we may be able to intervene on and achieve a good outcome.

Interviewer: Wow. So it sounds like it's a kind of newer procedure and you've got to find the right doctor to do it, the right surgeon and you got to make sure that you have done your homework, gotten your imaging and your workups and everything but maybe they're curious about this type of procedure and treatment, where is somewhere where they can get more information?

Dr. Mahan: Well, one place to start would be the University of Utah website. We have a lot of wonderful information there that can give you the breadth because no patient has the same and what no problem is the same either. So there's oftentimes very distinct treatments that endoscopic spine surgery may not be for you. I would love to think that it is, but at the same time, realistically, there are plenty of things that may need to be done and it may not be endoscopic spine surgery and so that's a great resource to go to.

Interviewer: How do you know if endoscopic sinus surgery or just sinus surgery is right for you? We'll talk about that next on The Scope.

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Interviewer: The purpose of this podcast is to help you understand if sinus surgery might help the issue that you're suffering from. You may have already done some research on the internet or have been to a doctor and they told you a few things, you may have forgotten some stuff or want a second opinion, and that's what we're going to find out. We're going to find out some basic information if sinus surgery is going to help your issue.
We're with Dr. Richard Orlandi. He's an expert in this thing at University of Utah Healthcare. Before we get into how do you know it's right for you, let's talk about how does the surgery change people's lives that do need this type of surgery?

Dr. Orlandi: The surgery can have a really big impact on the overall quality of life, not just the sinus problems. We know that patients with chronic sinus problems have a quality of life that's similar to someone in heart failure, way worse than diabetes, high blood pressure, things like that. And so what we're looking at is the overall picture, not just the sinus problems, but just not just the sinus symptoms, and so we're looking at sleep issues and the disorders in sleep.
Another thing that really affects quality of life is loss of sense of smell. We see that commonly with patients with sinus problems and the reason that's such a big deal is not only can you not smell spoiled food, natural gas, things like that, but much of what we perceive as sense of taste is really sense of smell. So when we lose our sense of smell, we really lose our ability to appreciate the food we're eating. We're looking at fatigue and we're looking at depression. These are things that are much higher in patients with sinus problems than our regular population and we're looking to really target those.

Interviewer: So people with sinus problems, not having a great life right now.

Dr. Orlandi: Absolutely not. It really impacts people in a much bigger way than we often think.

Interviewer: What sinus issues can sinus surgery help? Let's start right there.

Dr. Orlandi: Most of the time we're doing sinus surgery for people with chronic sinus problems or chronic sinusitis. It's a long-standing inflammation of the sinuses. Most people will feel symptoms of congestion, pressure in the face and in the sinuses, they're having frequent infections, those are the things we're mostly targeting.

Interviewer: Yeah. And a patient comes in generally for the infections, or is it the pain, or is it kind of all the above? Is there any one thing that they . . .

Dr. Orlandi: It's really all of the above. A lot of times we see patients because they've been to their primary care doctor over and over again for sinus problems and they're looking for a better long-term solution.

Interviewer: Okay. Are there some issues that this type of surgery won't help?

Dr. Orlandi: Yeah. I think the one that we most typically see is when patients are referred for facial pain or headaches and it's really not their sinuses. So clearly we're not going to be able to help them in that situation.

Interviewer: But in some instances that is caused by their sinuses, it sounds like.

Dr. Orlandi: It is, and so it takes doing some looking into it with an examination, with questioning, with sometimes a CAT scan to really be able to find out what's going on.

Interviewer: Yeah, and you're the expert in doing that.

Dr. Orlandi: One of them here, yes

Interviewer: One of the experts. Fair enough. All right. So beyond what issues it can help and it won't help, are there some people who are better suited for this procedure than others?

Dr. Orlandi: We usually try medications first to try to avoid surgery, and I think that's an important point. We go through people's medications, their history, what they've been on, what has worked, what hasn't worked, and really try to target different solutions for their problem. When those things have failed, then we start looking at surgery.

Interviewer: Now, are there questions somebody should ask before they consider a procedure like this or if they are?

Dr. Orlandi: I think that definitely they want to make sure that all their options have been exhausted. Obviously, surgery is an option, it's not the option. So we want to make sure that a patient is really going through all of those different options and making sure they've exhausted them. Now having said that, there is interestingly some evidence coming out more recently last year, too, about delaying surgery too long may lead to not as great an outcome. We don't know that yet and I don't think we're ready to jump into surgery, but we don't want to delay forever either.

Interviewer: I think you're showing right now again why somebody should come to a specialist such as yourself who has dealt with this before. You know, the research, the literature on that sort of thing. So, how would somebody move forward with this surgery? They've been to a specialist. What would be the next step, then?

Dr. Orlandi: Once they've been to a specialist, had a thorough evaluation, looked at all the options, and they decide to have surgery, then we go ahead and schedule that and we get everything ready ahead of time. We want to make sure that the medication is optimized at that point. Even though it's failed and they're requiring surgery, we want to do everything we can to try to reduce the inflammation prior to surgery and that, we think, leads to a better successful outcome.

Interviewer: Interesting. Are there some other things, other considerations people should think about that I haven't hit on?

Dr. Orlandi: No, I think you've hit on all of them. We really just want to get a thorough evaluation of all the options and then make a decision together. We try to make sure the patient, at least at our office we really want to make sure they understand all of the different options, the pluses and minuses associated with those, and that they really understand what the surgery is all about, what they can expect from it. Sinus surgery is not a cure. It's not like getting your appendix out. It's not like getting your gall bladder out. It's really important to understand that the surgery's important, but it's a part of their overall management. Unfortunately, sinus problems are a little bit like high blood pressure, diabetes. We manage it, we don't cure it.

Interviewer: All right. Any additional resources . . . I know somebody that might be considering this might want to learn a little bit more information. Do you have any good ones you could drive them to?

Dr. Orlandi: We've got some great information on our website here at the University of Utah at University Healthcare. We've got a number of different diagrams. Some people learn more visually, some people more reading through it, and so we have a lot of the explanations about the surgery risk, benefits and alternatives, those sorts of things there.

Interviewer: And how would they find that website? If you just go to Google and Google . . .

Dr. Orlandi: University of Utah sinus surgery, you're going to find it.

Interviewer: Going to get you right there. All right, well thank you very much. Appreciate that.

Dr. Orlandi: My pleasure.

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Interviewer: What is Endoscopic sinus surgery? We'll talk about that next on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Endoscopic sinus surgery is more commonly just referred to as sinus surgery. This podcast's purpose is to tell you what this procedure is, how it compares to some other alternatives, and if there are any risks or side effects, and how it changes people's lives.
We're with Dr. Richard Orlandi who's one of the experts here at University of Utah Healthcare and Sinus Surgery. I think when somebody goes in to get surgery, the first thing they want to know is what difference is this going to make. How is it going to change my life? Let's ask that question first.

Dr. Orlandi: Absolutely. I think that's a great question and obviously the most important one. What can people expect? You know, sinus surgery is not a cure, and that's one of the first things I try to tell people. It is going to help with the management of your sinus problems overall, but it's not going to cure them. So it's going to require additional medical therapy afterwards. But what we're talking about is going in and opening up the sinuses primarily to let them drain, let air in, get medications in there to the surface of the sinuses to try to reduce the inflammation. That's the overall purpose.

Interviewer: So when you say, "open them up", is that the problem, because usually things are little too constricted in there?

Dr. Orlandi: Yeah. What we're finding is that with the sinuses, they drain through small openings into the nose. We think of the nose as a hallway and sinuses are like rooms off of that hallway. That opening between the room and the hallway is small. It's supposed to be. But when we have long-standing inflammation, the lining, or call it the wallpaper, will swell up and block off that doorway so things can't get in. Air can't get in and the secretions in the sinuses can't get out and that sets us up for chronic sinus problems.

Interviewer: Does that kind of turn into scar tissue? Is that what's going on?

Dr. Orlandi: No, it just stays really inflamed and it just won't, that inflammation just won't back down.

Interviewer: No matter what you do.

Dr. Orlandi: Absolutely. We try different things with medical therapy but when that doesn't work then we start looking at making the openings wider.

Interviewer: So somebody that's suffering this type of thing that this surgery might help, it makes a significant impact to their quality of life after they have it, from what I understand.

Dr. Orlandi: It's a huge impact. Sinus problems we know are correlated with sleep issues, with depression, with fatigue, not just the sinus symptoms themselves, and so when we get that sinus inflammation under control through a combination of surgery and medications, we're able to reduce those factors in people's lives as well.

Interviewer: I've heard they refer it to as endoscopic sinus surgery. You have told me that it's just sinus surgery, that all of it is endoscopic, which indicates that at one point it was different. So what exactly is endoscopic and how's that compare to the way things used to be done?

Dr. Orlandi: The endoscopic refers to using a scope. It's like a fiber optic-type scope that we use that goes through the nostrils. Previously sinus surgery was done by making incisions underneath the upper lip, alongside the eye, between the eye and the nose, and up in the forehead and the hairline. Rarely those things are still done for unusual circumstances, but now everything is pretty much done through the nostrils.

Interviewer: So a lot less invasive.

Dr. Orlandi: Obviously, yes, and much easier to tolerate, much less painful afterwards.

Interviewer: Gotcha. What are some of the risks or side effects that somebody should be aware of if they're considering this type of surgery?

Dr. Orlandi: Knowing those risks is important as you weigh the risks and benefits, obviously, and make a decision about sinus surgery. The sinuses are right next to the eyes and they're right next to the brain, and those two areas we worry about during sinus surgery. We think about it as sinus surgeons and make sure that things are safe. Injury to the eyes, including damage to the vision, and injury in the brain that could lead to a spinal fluid leak are the two things we worry about, and those are fortunately extremely rare. But any surgeon is going to have that in the back of his or her mind.

Interviewer: Yeah. It sounds kind of terrifying, but out of all the procedure you do, just not likely.

Dr. Orlandi: No, far less than 1%, and that's important to know.

Interviewer: Gotcha. What about some side effects afterwards?

Dr. Orlandi: Clearly, like many surgeries, we're going to make the problem worse for a few weeks or months before we make it better. So more swelling, inflammation, obviously people are going to be bleeding from the nose. Some surgeons will use packing, others do not. Most of the packing that's used now is dissolvable to try to cut down on bleeding. But those are some of the things that we look at immediately after surgery.

Interviewer: Singers or people that use their voice for a living, are they concerned that that's going to change?

Dr. Orlandi: Luckily, not a huge impact, but the voice does resonate through the nose and sinuses, and for a professional singer or someone who spends a lot of time with their voice, like yourself, we are going to see that the voice will change slightly in how it resonates.

Interviewer: Yeah, maybe for the better, in my case.

Dr. Orlandi: It can be for the better.

Interviewer: All right. What are some alternatives to surgery? If somebody just goes, "Gosh, I don't know. This seems like a huge commitment," what else can be done?

Dr. Orlandi: Yeah, the surgery, very rarely are we're dealing with a life or death problem here, right? So the surgery is always as an option but not necessarily does one have to have it. Continuing with the medical therapy is always an option and a lot of patients elect that. The surgery, obviously, isn't appealing for some folks and we certainly understand that.

Interviewer: And the benefits, though, in some patients, tell me a personal story of maybe somebody that had just some great results.

Dr. Orlandi: Yeah, I think that we see people when often they've gotten to that point where they just are done with, they've done everything, has gone as far as they can with the medical therapy, with medications, rinses, sprays, antibiotic pills, even steroid pills, and they're just not getting there. We're able to take a patient like, that open things up, and then get that medication accessing the sinus surface and keep that inflammation down. And you're taking someone who's . . . again, that fatigue and depression can really be an issue, and it really helps people out in addition to resolving a lot of the inflammation and pain and pressure in the sinuses.

Interviewer: This is your opportunity to address any myths or misconception that people might have about this procedure. What are those?

Dr. Orlandi: You know, a couple of them. One is that - and we talked about this already - that I'm going to have my surgery and it's going to cure my sinus problem. I'd love to believe in that myth, but unfortunately it's just not true. We talked a lot about, I hear people talk about I'm going to have my sinuses scraped. Yeah, that doesn't sound very good, does it?

Interviewer: No.

Dr. Orlandi: And what instead we find is, what we're doing is actually opening up the holes that we talked about and actually really preserving that natural lining. We want that lining there because if we scrape it out, not only does it sound horrible, but it's going to lead to more scar tissue. So we're actually very careful to preserve the function of the sinuses.

Interviewer: We've covered a lot of ground in what is sinus surgery or endoscopic sinus surgery. Is there anything that I left out that a patient might want to know about this procedure?

Dr. Orlandi: No, I think that maybe the last thing that's important is, you know, when you have your gallbladder taken out, you have it taken out, you're cured, you may have one visit with your surgeon afterwards to make sure everything is healed up, and you're done. Sinus surgery is not like that. It requires tailoring the medical therapy afterwards. It's very individualized. We do see patients for a few visits after the surgery, sometimes three or four or more, to really tailor their medication to make sure that they're getting the most out of the surgery.

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