Scott Webb (Host): We all need to breathe, right, and when we have trouble breathing due to a short term or chronic condition, we might need the expertise of my guest today, Dr. Chad Glazer. He's dual Board Certified in Facial Plastic and ENT Surgery. And today we're going to talk about sinus surgery, functional nasal surgery, and septoplasty.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about nasal surgery and septoplasty and sinus surgery, and a whole bunch of good stuff today. Before we get there, let's talk about what a patient might go through or experience or other therapies that might be tried before they get into the office with you, before you start talking sinus surgery.

Chad Glazer, MD: I'd like to first start off by, you know, breaking the two into two parts. So there's nasal obstruction where people just don't breathe well through their nose. There are people that suffer from sinusitis, either acute or chronic, where the cardinal symptoms of sinusitis include increased mucopurulent drainage or discolored drainage from the nose accompanied by facial pain and pressure and worsening of nasal breathing when they are symptomatic. So a lot of times people come to my office and tell me their sinuses are bothering them. So it's sort of my job at the beginning to try to differentiate between nasal obstruction and sinusitis. Again, whether it's acute or chronic. And sometimes people have both. And again, that's all part of the workup.

Host: Right. So you get maybe a family history, but certainly a patient history, an examination, figure out what's going on. So maybe we could talk a little bit before we get to when someone might need sinus surgery. What are some of the signs and symptoms, you know, that people might be going through and, and generally, what do folks experience that causes them to kind of speak up and come see you?

Chad Glazer, MD: A lot of times it's just not breathing well through their nose or again having a lot of issues with drainage from the nose, facial pain, and pressure and worsening nasal breathing when they're symptomatic; you know, being signs of acute sinusitis. A lot of times people have seen their primary care doctor or urgent care. They've been treated with antibiotics.

They've been treated with nasal steroid sprays. They have been treated with oral antihistamine. Some people also have an allergy component on top of this. And sometimes will have been worked up by an allergist and then show up to see me. Sometimes, all of that workup is done by us, and those treatments are done by myself or my nurse practitioners to get them ready to see if we can actually cure their disease process or if surgery is actually going to be necessary.

But before we go to the operating room, everyone will have gone through maximal medical management for nasal obstruction. That includes use of a nasal steroid spray for about four weeks. Flonase, Nasonax, a lot of those are available over the counter now. It used to be that we had to prescribe those, so some people come in already having tried that.

For sinus surgery, we like to also add on some nasal rinses with either the NetiPot or the NeilMed bottle. And there are other varieties that are out there along with possibly an oral antihistamine such as Zyrtec, Allegra or Claritin. Again, sometimes people have already done this. Sometimes we start the treatment process with again, either myself or my nurse practitioner, but at some point when all of these fail to work and the patient is still suffering, then we start talking about other options for surgery.

Host: Yeah, so let's do that. Let's talk about the surgical options, right? So you say whether it's because of insurance or otherwise, you know, other medical management things will have been tried, other therapies will have been tried. So let's talk about that, you know, why or when someone would need sinus surgery and what that process is like.

Chad Glazer, MD: Sinus surgery and functional nasal surgery, septoplasty, nasal valve reconstruction, turbinate reduction are all what I view as quality of life issues. No one walks out of the office and has a significant medical issue or it doesn't make it because they're having sinus infections or they're not breathing well through their nose. But it is a real quality of life issue. So people have difficulty with work and exercise and sleep. People with sleep apnea trying to use CPAP that can't breathe well through their nose have difficulty. So there are a lot of different reasons why people get to my office with these problems.

But at the end of the day, they've all gotten to my office with those problems and you know, have usually failed to respond to the medical management. So the next step is to finish the workup. So, and folks that have just nasal obstruction and no evidence of sinus chronic or recurrent sinusitis, usually my physical exam, plus or minus an endoscopic exam that we do just awake in the office with a small scope to look a little further back at the septum in the nasal valve area is enough to finish the workup. For sinus surgery, we'll always get a CT scan, because a lot of times I'm using an image guidance platform that tracks my instruments that is sort of up live during the surgery.

So, that allows us to help with my knowledge of the anatomy and having the CT scan done and our instruments tracked to do these sinus procedures safely. So, all of the sinus procedures that we do nowadays, with the exception of radical cancer surgeries and things that most people don't have any concern with,, are done endoscopically.

So for sinus surgery in particular, there's no external incision on the face or the nose. It's all done through the nose, and that allows us to address any of the sinuses. And folks have four paired sinuses that make up the total sinus cavity, the macular sinuses, frontal sinuses, ethmoid sinuses, and sphenoid sinuses.

And during sinus surgery, based on symptoms as well as the CT scan, will make a decision on which of those sinuses to get open during the surgery, to help, you know, alleviate the patient's problems.

Host: Yeah, I think it's interesting. You talked about anatomy and you know, for most of us, we think of our sinuses, we think of our noses and the breathing part of it, but we have sinuses, if you will, other places around our face. Maybe you could just sort of, take folks through that just a little bit, the anatomy of it. When you talk about these pairs of sinuses, where are they exactly?

Chad Glazer, MD: Yep. So the cheek sinuses are below the eyes and those are the maxillary sinuses. The ethmoid sinuses actually line the middle or the medial part of the eyes and the septum separates the two pairs of sinuses in the midline which is both cartilage and bone there. You have the frontal sinuses that are in the forehead, and then you have the sphenoid sinuses that are all the way back and actually your pituitary gland sits right above your sphenoid sinuses. So it's a way that we can access actually through the nose to do pituitary surgery in combination with a neurosurgeon, but again, for this conversation that's beyond the scope. But the sinuses sit in some pretty important territory in between the eyes and the brain, you know, sitting right above.

Host: Yeah, and it's good that we have experts like you saw, because it seems like it's pretty close quarters and you're going in through the nose, as you said, you know, the surgeries we're talking about today, there's no external incisions or anything. So, really awesome to have you and your expertise to be able to help folks. And let's talk about what septoplasty is and when would a patient, or why would a patient need that?

Chad Glazer, MD: This gets into the nasal obstruction part of it. With sinus surgery, it's also important to understand the anatomy of the septum because sometimes you're limited in access with your scopes. Even if patients aren't having nasal obstruction, sometimes we need to remove a part of the septum from the inside to help access during sinus surgery and also for follow up after sinus surgery.

So the entire complex, so the nasal cavity and the sinuses are all taken into account in my view as one, and again, if we separate out and they're not having sinus issues and we're just looking at the nasal obstruction part of it, then I'm looking at not just the septum, but the inferior turbinates as well as the other cartilages that help to support the nose.

You have lower lateral cartilages and upper lateral cartilages and bone that all form the nose and all have a differing degree of importance as far as nasal obstruction is concerned. And so a lot of times when people are seeing me, they have a high degree of nasal obstruction and a lot of times it's not just the septum.

And that's where functional nasal surgery comes in, where we are addressing some of the cartilage in the nose, in addition to the septum and the inferior turbinate. So, for that procedure, I would not just open the nose from the inside, but also make a small incision on the columella, which is the vertical part that's just above the lip there, a very small incision that I use for both functional and cosmetic surgery, so it heals very nicely.

But that allows me access to see all of the cartilages and the bone that make up the nose. And I'm able to take that apart, take out the deviated part of cartilage from the septum that's affecting a part of the nasal breathing, and then I actually repurpose that cartilage and put that back into the nose in different places as grafts to help open the nasal airway where it's appropriate, whether that's at the internal nasal valve, or the external nasal valve or to provide additional support to the tip of the nose. So basically anything that comes out, I'm putting back in, in a different way to build a stronger nose that actually works.

 And that procedure, again, usually in my hands, because I'm seeing people with a higher degree of nasal obstruction as a facial plastic surgeon. Sometimes people have failed just a septoplasty in the past, or a turbinate reduction in the past. So they're seeing me as the second or third opinion. And these are the procedures that we're offering now for these patients.

Host: Yeah. So let's talk then about the benefits of either sinus surgery and or this, you know, a functional nasal surgery. What are the ultimate benefits for the patients?

Chad Glazer, MD: So I think that patients, after they have surgery, and again, you know, these surgeries are done with the patients asleep. So we protect the airway. But it's same day surgery, they're home the same day. Recovery time is about a week. A lot of people are relieved when I tell them that I don't pack the nose so people are breathing out of their nose from day one after the surgery.

So it's a lot different than what it used to be. You hear horror stories in the past of people pulling strips of gauze out of the nose because that's how they used to pack off the nose afterwards. So that's no more. I use flexible stents that go in, that come out at a week, but you're breathing through them the whole time.

So people usually tolerate that very well. And afterwards, as long as they're feeling good at a week, there aren't a whole lot of restrictions. And that's maybe a bit of a different, you know paradigm than what people were used to in the past. So, I think it's important for people to know that and understand that going into it.

But as far as quality of life goes, and again, like I said at the beginning, we're doing a lot of these procedures for quality of life, you know, helping to prevent people missing work and school and not getting enough sleep because they either don't breathe well or they're battling constant sinus infections.

It's a big drag on the entire system when people start to miss work and school because of these conditions, or not function as well on the athletic fields, or not function as well in schools. So, or at work. Getting these people back to feeling better, which is what we do; the vast majority of the time with these procedures, as long as you select the patients that are appropriate for surgery, I'd say 9.9 out of 10 of these folks, end up doing very, very well and are super glad that they had the surgery and feel better than they have, you know, in their entire life. I mean, most people when we take those stents out at one week, say that they've never been able to breathe out their nose as well, or that their sinuses have never felt as clear.

Host: It's really amazing. As we know, breathing is essential to life. We can breathe through our mouths when we need to, of course. But for folks who have, you know, whether it's a chronic infections or whatever it might be, obstructions, things that are preventing them from breathing normally, I'm sure it is a huge relief.

So they're, you know, breathing well, looking good, feeling good, back to work, back to playing, whatever it might be. So good stuff today. Doctor. Thanks so much. You stay well.

Chad Glazer, MD: Thank you very much, Appreciate being on.

Host: And to learn more about sinus surgery, go to franciscanhealth.org.

And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.