so happy to be here with you all. Uh This is gonna be a little bit like the nose cone camera view on a drone strike. We've been flying high with dr kelly and getting a high altitude view of new value and healthcare delivery from dr martin. We're now going to plunge back into the clinic environment and I'm going to try to give you an idea of just what the scope of practice in a modern head neck clinic environment is and just how much diagnostic and therapeutic intervention that we're capable of in an outpatient environment. You may see this as what your mom or dad would regard as E. N. T. Physician Those days have long ago changed. We try to maintain some high touch care in our department and really be compassionate and careful with patients. But otolaryngology and head neck surgery long ago has evolved into a very sophisticated and increasingly specialized system of care. And part of that is driven by the complexity of the anatomy and the proximity of all of the structures that involve special sense proximity to the brain, the eye, cranial nerve distributions as dr Griffith alluded to before. But then we've got all of these upper aero digestive structures and very very complex vascular charity and neurological systems. So currently in a in the head neck surgical office there there's a vast array of technology and capabilities. Oto microscopy allows us to do some microscopic interventions and careful diagnosis of people's ear problems. We have high definition video endoscopy that's applicable in the sino nasal tract for Lauren Jill applications and also diagnosis of differential and esophageal pathologies. Sinus ct imaging is a standard part of our office practice and it allows us to immediately review pathology in the sino nasal track with patients create a plan and very often allow them to see exactly what the justification for various surgical interventions are. Audie a logical assessment, Rebecca lewis referred to a lot of the sophisticated audie a logical testing that is currently done not just in a cochlear implant program, but every day in a head and neck office, which includes not just ideology but temp Anoma tree and and various other measures of cochlear function that are very useful speech and swallowing assessment has been integrated with ent and head neck surgery for a long time. That currently is going to become a a very, very integral part of our practice with our own speech and swallowing pathologists. And then many of the diagnostic procedures that required tissue acquisition. Uh Those things used to require open biopsies but many of them now are amenable to either unguided or guided needle biopsies in our clinic therapeutically. We are constantly taking skin lesions off and reconstructing those things that are appropriate in a local anesthetic or mildly sedated environment. Uh soft tissue infections and upper aero digestive pathologies can be drained often without going to the path to the hospital as uh dr griffiths demonstrated previously with perry to Chancellor abscess external ear canal lesions, uh repairs of the ear drum injections for sudden hearing loss and Meniere's disease as dr Volker had referred to. Those things can be done in our offices. And then uh many of the endoscopic treatments that are applicable for vocal cord disorders such as augmentation, injections, for vocal cord paralysis and for vocal fold, Boeing and weakening of the voice with age. Those things can all be done. Thyroid cysts and other cervical masses sometimes can be treated in our offices. Many of the things which vexed patients the most such as hearing loss can be cured. Uh earwax is probably the most gratifying problem that a patient can have when they walk into the office because they they walk out able to hear again and that can be done painlessly either with or without the microscope. Uh So as you all know, things like middle area fusions are very common. That's another cause of conductive hearing loss. Those things can be drained in the office with or without application of ventilating tube. And and then we have some things on the horizon which will probably stun and amaze all of us. Well, cochlear implantation is I believe a miraculous thing. There will be in the near future the ability to regenerate nerve cells within the cochlea. And those will likely be office based treatments that can help people to actually regrow some of their neurological function. Uh simple things like repairing eardrum perforations. Those were always relegated to the operating room. But in the office, smaller perforations can be treated under local anesthesia by placing fat grafts in the eardrum and achieve sealing off of the the whole. As demonstrated here, I'm going to spend the majority of what I talked about here on nasal dysfunction and nasal obstruction. one. It's kind of a favorite topic of mine, but also nasal anatomy is quite complex and it's it's not that familiar to many people in the room. The nose is a is a complicated interface for special sense for respiratory health, immunological response and is affected by infectious diseases. And it also is a primary structure for facial form. Besides being a conduit for airflow has been discussed before, humidifier, cation filtration and vocal residents are all determined within the nasal tract. Olfaction. As dr Anwar was discussing earlier is linked to our primitive Ryan and cephalon and as such it has very strong connections to and implications for not just being able to perceive roses versus the cat next door. But it is involved in memory, emotion, identification of kin food, safety, pheromone detection, and sexual arousal. Covid, if anything, has brought to the fore the appreciation of just how important that olfaction is the allergic response. As many of us in the room, whether we're primary care physicians, otolaryngologist or allergists. We we understand just how involved that the noses with the allergic response. Uh And besides histamine release sneezing mucus Salieri clearance. All of those things are fundamental processes occurring there in the back of the nose. There's a deposit of nasal Frenzel lymphoid tissue, which is a first line response to infectious agents. And it's also a reservoir for trapping those infectious agents there, whether they're viral, bacterial or fungal. Covid again is an object lesson for us all in that. But the most important function of the nose is to be able to support devices such as this which give us our identity and our sense of humor. Essential nasal anatomy crosses a wide spectrum of morphology. So we have to appreciate that understand that the nose doesn't just reside by itself. But it is a fundamental part of the rest of facial anatomy. I'm gonna run through quickly some of the nasal anatomy internal and external. That will explain some of the other office interventions that we do. So the nasal exterior is both bony and the upper part of the nose and then there are complex cartilaginous structures that form the projection and support for the lower nose. There are a number of different muscles that attach to the nose which both dilate and also compress the nostrils so they in effect do control some airflow and they're also involved in emotional and expressive movements of the face. The nasal interior, looking at the midline is cartilaginous in the front. This is the central wall of the nose, then bony and the upper and the back portion of the nose. You can see that the brain rests on a thin separator between the, between the cranial cavity and the inside of the nose. The lateral wall of the nose does have olfactory mucosa in the upper and lateral aspect and then the turbine 8s, which as you know, are part of regulation of respiratory resistance and airflow and also produce secretions and new coastal clearance. So the nasal interior was discussed before as demonstrated on cat scan and this will show very well how the interior of the nose is relatively complex. There are a number of channels that need to stay open for the sinuses to drain properly. Uh And the relationship between the septum and terminates is fundamental to airflow. There's an unfortunate complexity of neural innovation of the inside of the nose. Part of this is sensory, some of it is secret Torrey and determines how much how much secretion is produced and what the consistency and viscosity of that secretion is how how the nasal function is determined has both circadian variation as well as postural changes that are effective. If anyone is with a tendency to nasal congestion has laid down at night with your head turned to one side, you realize that that side that's dependent quickly will get congested. If you happen to have a septal obstruction and terminating enlargement on the other side of your nose. Pretty soon you're not breathing at all dr Kochar demonstrated the anatomical limits of the external and internal nasal valves, which are very important for perception of nasal airway pattinson. One thing that should be noted. It's scary to go back to high school physics, but the venturi effect is a is a known physical property where if you are trying to force air through a narrow tube at a high rate of speed, that there is a vacuum effect on the inside of that tube. This is exactly what happens to the inside of the nose when someone is trying to forcefully inhale when they've got restricted airflow, uh and weakened side walls in the region of the external or internal nasal valve. Uh one thing that was discussed before and which deserves some reiteration is that nasal endoscopy is a very fundamental part of what allows us to accurately diagnose what's going on in the inside of the nose to monitor people's responses to treatment and also to guide therapeutic interventions. So, nasal hemorrhage, for instance, that used to be something that was routinely treated by packing the nose, which is a hellacious experience if you've ever had it done. But now with nasal endoscopy, we very often are able just under local anesthesia to topically treat nasal bleeding or to use electric Kateri to do specific focused sealing off of blood vessels so that the patient walks out of the office without a nasal pack in and pretty much able to go back to their to their regular life nasal polyps and other lesions can be endoscopic lee excised in the office and then balloon sina plasticky was alluded to as it's a corollary of the balloon you station tube dilatation, balloon sina plastic is an effective thing for people that get not really chronic sinusitis, but people that are prone to having recurring episodes of acute sinusitis. So if their anatomy is narrow and then they are stimulated with either allergic infectious or other environmental challenges, they may just over and over again developed sinusitis which is a big problem. So rather than going in and having to do a big sinus operation that endoscopic lee creates a large windows or openings into the nasal interior. A balloon can be inserted that then is able to dilate a stay narcotic channel that leads into one of the sinuses so that it functions better. So in the upper left you can see obstruction of the left frontal and beth Boyd remnant. The obstructed left frontal duct is demonstrated in the upper right and then after insertion of the balloon over a catheter, just like with the station to balloon debilitation, the functional opening of frontal sinuses much larger and this helps to resolve those acute and recurrent infections. Vaso motor dysfunction is something that many primary care physicians will encounter in their practice as patients get older, the neural control for the production and the distribution of secretions in the nose changes just like hearing nerve cells and i nerve cells deteriorate with age. The same thing happens in the inside of the nose. And so the video nerve which comes in from the skull base in the back of the nose and then gives off posterior nasal nerve Going to the turbine 8s. That often becomes dysfunctional with age. And patients will bitterly complain that their nose runs right after they get up in the morning. It will run when they get out of the shower, it runs when they think about eating food and it's it's embarrassing and and vexing for them. Uh There are some nasal sprays that can be helpful for that but they don't always work. So uh one thing that can be considered is a non invasive treatment that can be done in the office. There's there's two basic varieties of this. one uses cryotherapy in the upper diagram there you see a catheter attached to a balloon that's placed into the back of the nose, under the posterior aspect of the middle turbinate and basically nitrogen gas is injected into that balloon which freezes and it will cause a cryo ablation of the nerve entering the back of the nose. There's another alternative which uses radio frequency energy that's delivered through a probe. So this is basically microwave energy that is being applied to create controlled heating of nasal nerves that entered the back of the nose as well. Some of these non invasive technologies can be used in our offices to impact the pattern. See of the nasal airway as well. If you look at the lower diagram there, the septum would be towards the left aspect of that schematic and then the nasal valve where the upper lateral cartilage impresses on the nasal airway from the side and also the inferior turbinate that's shown to be swollen there, that restricts the nasal airway. Uh There is a way of non invasively treating again with this temperature controlled application of radio frequency energy to create a more open airway. As you would see in the upper diagram, coagulation is another form of radio frequency energy that we use In the office environment. It's done under local anesthesia. So you've got a probe which basically delivers microwave energy creates heating inside the the soft tissue part of the turbine eight. And then that's that's done for a specified period of time in a number of locations and that will cause the terminate to shrink and open the airway up one aside, just like when dr Anwar was talking about the patch Elice you station tube as being something that could produce kind of a paradoxical sense of cheerfulness, just like closed. You station tube would, there is such a thing as what's called the empty nose syndrome. This cat scan demonstrates a person who has had overly enthusiastic nasal surgery and when you look there, the septum is midline for sure. But you don't see any turbine eights projecting into that airway. So that person even without a speculum, you'd be able to see their nasopharynx looking through their nostril and this is a patient that would bitterly complain about having a stuffy nose or one which is excessively dry, may be prone to crusting and colonization with staff. So it's a situation that really we we want to avoid at all costs. We do have effective treatments in the clinic for uh snoring and sleep apnea. Um even if the tonsils are not especially large if the if the person has hypertrophic Avila, if they have a dependent soft palate that's floppy and lacks. There are treatments that have been developed such as pillar implants which are fabric stems that are injected with a specialized needle into the end of the palette that just like struts in an airplane wing can produce some stiffening of that palette. And and have been demonstrated in some studies to show effectiveness for certain degrees of snoring and sleep apnea. And then the Olivo implants which are a little bit different. They have, they have barbed projections so that when the implant is injected sub mucosal E. Or into the muscular aspect of the palette that the implant can be drawn back and it will engage the soft palate tissues and actually hold it in a more up and forward position. Lorenzo diagnosis and treatment that's something that dR Meadows are we will talk about and much more details. So I'm going to leave that for him. Video stra bOSc api let's see if I can activate this This will this will show maybe you can see a wave like vibration of the vocal cords that's acting at a high rate of vibration when that's normal. Then the patient has excellent vocal quality and it also demonstrates good opposition of the vocal cords. And he I'm sure will discuss other interventions that can really be useful. This really shows here an example of someone with a vocal cord paralysis in the left upper. When the cords are brought together. You can see that gap between the two vocal cords and the vocal folds is the actual term. And then in the lower right. After there's been injection of material that medial eyes is the cord. You can see the effect of bringing the vocal chords together in a much better opposition in the in the lower left botulinum toxin. Great on steaks and cleans nylons too. There there are an incredible number of uses for botulinum toxin. Um it's been used as dr Kochar referred to in facial paralysis and sink unisys for people with overactive salivary glands and for ones who have salivary cysts or fist july. We can use botulinum toxin injections to decrease the unwanted flow of saliva which is both choking and also socially embarrassing. Uh TMJ syndrome. We all see plenty of patients that have TMJ problems. Whether it's giving them headaches, trees mus or or problems with their dental occlusion. Even these people often will not get that much better with anti inflammatories and even with dental splints but we use botulinum toxin that's injected selectively into mass giocatori muscles that can provide great relief to these patients and keep them from wearing all their teeth away. As you all know, hyperhidrosis of the scalp palms. Axillary is a social problem that can be treated with botulinum toxin as can many of the effects of facial aging. Vocal dystonia will be talked about by dr medicine for sure, interestingly, scar management can be affected by Botox injections or botulinum toxin injections as well. Uh there's a certain amount of stress across a scar that will determine whether it heals as a fine line or whether it becomes hypertrophic, raised or depressed. And when Botox is injected into the vicinity of a scar repair or revision, it often will make the resulting scar much better quality and much less conspicuous parenthetically when I've injected botulinum toxin for various other things into into patients foreheads. I've seen many times that acne breakouts that have been vexing to them at any age will stop or become markedly improved because it's a eck eck eck Ryan Secretary problem of the skin. So uh as far as uh as far as the office environment and the sophistication of the clinic really. We barely scratched the surface. There are many other things that we'll be able to do in the in the upcoming years and look forward to sharing those with you
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