Getting a Second Opinion: I Dont Want Sinus Surgery!

If you’ve been told you need sinus surgery but want to explore other options, this episode is for you! Dr. Reddy and Dr. Smith discuss alternative treatments, second opinions, and creative ways to manage chronic sinus problems without surgery.

What you’ll learn:

• The importance of maximizing medical therapy before considering surgery
• How alternative treatments like compound rinses, nasal steroids, and breathing techniques may help
• The impact of lifestyle factors like stress, diet, and sleep on sinus health

Audio Transcript:

Dr. Reddy:

Hey guys, Dr. Reddy here with Dr. Smith. We have another episode of We Knows Noses today. So today we will be talking about how do we how can we treat sinus problems in a patient that does not want a sinus procedure or sinus surgery. So sometimes, you know, we’ll, we’ll have patients that might be candidates for sinus surgery or candidates for sinus procedures, and either they don’t want a procedure or they medically cannot get a procedure. And they want to think about maybe out of box kind of solutions, um, to potentially help with their sinus symptoms. So that’s a pretty common thing that I see, yeah especially because we see a lot of second opinion consultations for patients.

You know we will typically see a patient that’s seen another ENT doctor and that doctor has recommended a sinus surgery. And then the patient comes to see us and they ask, Hey, is there anything else we can do maybe to avoid a surgery? And we’ll kind of go over options. Do you want to get started on that? What do you think?

Dr. Smith:

Yeah, the first thing I always have when I have a patient that comes in with like a second opinion and they were recommended sinus surgery is to really clearly make sure that that patient has what we consider maximal medical intervention or medical therapy. And that really can run the gamut. So if you look at like what maximal medical therapy is, from like an insurance standpoint versus what truly is maximum medical therapy, they may be different. And there are some times that certain therapies will work for one patient may not work for another patient.

And so it all comes down to one education with the patient and, and, and, discussion to make sure that we understand that a lot of times when sinus surgery is recommended, it’s because there’s a chronic underlying problem. This is something that’s been going on for months and months and months, not days or weeks or even up to a month it’s typically, these are issues that have been going on slowly over time. And what I always tell patients is the difference between a chronic sinus patient is that a chronic sinus patient has an issue with the self-cleansing mechanism, right? So their self-cleansing mechanism in their sinus isn’t working.

They now have a change in the biome or the bacterial envelope or environment that’s within the sinus.

And so the biggest thing that we need to do, which is what helps keep the sinuses healthy to begin with, is get air into the sinuses and get mucus cleansed and out of the sinuses.

So there are a bunch of different things that we have in our kind of arm that we can try to get the aeration better in the sinuses or the mucus production um to assist with the self-cleansing mechanism of the sinuses.

And so the one thing which I know you guys have heard and talked over, us talk about over time, but nasal steroids, right? So, you know, I have a lot of patients that say, oh, I use nasal steroids for, I use Flonase and it didn’t work, or I use Flonase, it didn’t work, I use Rhinocord, it didn’t work. And so Nasal steroids are great. They do work and they’re often effective and safe to use for long periods of time. But getting them up into the sinuses can be a really ah tricky conundrum. Like how do you get the nasal steroids up into the little passageways that really need the the anti-inflammatory activity? And so, delivery of steroids, but also letting patients know like, hey, this is something that may need to you may need to stay on even when you’re feeling well, because a lot of patients with chronic sinus symptoms or chronic sinus disease have episodes where they feel pretty good.

They go on an antibiotic and a steroid and the inflammation cools down and they feel pretty good. but the self-cleansing mechanism and the underlying sinus health is still there. And so patients need to first understand that often a nasal steroid is a prolonged treatment, not just a short-term treatment for chronic sinus disease. And so nasal steroid sprays, like the traditional sprays are great, but there are even better ones out there. We can do nasal steroid deliveries in irrigations and rinses, like the sinus rinses. We can do nasal steroid deliveries in these exhaler delivery devices, um which ah right now there’s Xhance, which is a fluticasone delivery system that helps more aerosolize.

So assuming that you’ve tried all these different things and your doctor’s been working you up appropriately and you’ve failed all these things, there are other things that we can do that are a little different or outside the box that can also help. Dr. Reddy, do you want to talk about some of those things?

Dr. Reddy:

Yeah, so just to recap, this is a typical patient we get that’s seen other ENTs in the past and doesn’t want surgery. Right. And it’s coming to us for another opinion. And so out of the box thing, things that we can try. So first we can try compound rinses. So compound rinses are you are typically made up at a compound pharmacy. So the typical CVS and Rite Aid or Walgreens don’t usually make these compound formulations, but what you can do is you can have the patient use a sinus rinse that’s that has saline in it, just like a normal sinus rinse.

And you can add whatever medication you want on top of it. And these, these can include things like antifungals, antibacterials. um There’s even antivirals and you can add medication that helps called mucolytics that break mucus up and all sorts of other things even.

Now, technically these medications, these compound medications are not FDA approved. However, they have been, a lot of them have been studied, you know, usually individually and different ENT studies, and they’re taught to be relatively safe.

The efficacy is controversial with some of these things. um Many people think the irrigation is probably more important than what’s actually within the irrigation. um But anecdotally, i think we’ve had some success where we’ve had some patients that were miserable and did and weren’t candidates or didn’t want surgery. And some of these things may have helped them over the long run you have anything to add about the compound rinses at all?

Dr. Smith:

No, I think that’s perfect. Just a delivery. and Sometimes we can even do like a culture in the nasal cavity with an endoscope in the office and sometimes get those compounds kind of tailored to what you bacteria may be evident in your sinus cavity.

Dr. Reddy:

Yeah. did do you um Do you ever have the patient make a compound rinse themselves at home? Do you have them do that?

Dr. Smith:

Yeah. and So I’ll have patients sometimes make their own rinses.

I may even have them add in in addition to that um things that are like detergenting detergents within the sinus cavity. So, you know, it seems like a little crazy and patients often look at me like I have two heads, but I’ll often recommend even baby shampoo. So I have patients use like Johnson Johnson baby shampoo, have them use some, you know, small, very small amount into the rinse, which can help detergent. And the thought is back to some of the previous discussions over past episodes about biofilms. It may help kind of break up some of the fats and lipids in these biofilms that keep these bacteria kind of held up in the sinuses.

Dr. Reddy:

Yeah. Any other… alternative, out of the box, maybe wacky things that you’ve recommended to patients?

Dr. Smith:

Yeah, either seen or recommended. you know In the past, I would have thought like rinsing out the sinuses with betadine solutions would be crazy. However, you know in in looking at research and having patients having done these in the past, um you know these bactericidal or bacteriostatic agents such as betadine can help in very low dilute quantities, help kind of reduce some of the bacterial burden within the sinuses and the nasal cavity. Even like gentian violet can be helpful, which is a very old school um topical treatment back used into the, into the old world war timeframe to help kind of sterilize wounds. It can be used topically to coat sinus cavities. um And then yeah I think it might have been you that actually saw that the one of the new packing materials ah for post sinus surgery has some junction valid in it. Yeah.

Dr. Reddy:

Yeah, it seems some of this stuff might seem a little voodoo and it it might be, but you know there is some evidence that some of this stuff works. And for patients that are desperate and don’t want to you know have an intervention, if you try some of these low risk things, it might be helpful. you know Another thing that’s gaining in popularity um That’s also controversial as breathing techniques for sinus issues.

There’s a book called breath by James Nestor. He wrote a New York Times bestseller, very, very popular with some of our patients. A lot of our patients actually have read this book and come seen us.

I myself have only skimmed part of this book, but Um, you know, there’s, there’s, there may be evidence that different types of breathing techniques might improve some of the ventilation in the nose and the sinus issues in your nose. Um, you know, but again, this stuff has not been proven in randomized clinical trials. Um, Now it had to do with the nitric oxide release in the tissues, which you had mentioned in previous episodes as well, which has some bacteriostatic principles as well.

And you’ll even see rinses on the market now with these more natural um antibacterial principles. So I know that, do you know, you have patients that use any of those, the the rinses with the the sugars that are

Dr. Reddy:

Yes. Yeah. You know, I’m not familiar with some of the details with it, but there’s all sorts of things out on the market. Now, some of the stuff you may have to be careful with, with what you get, especially online. um But, you know, generally speaking, most of this stuff, if it’s mostly with saline, it’s probably relatively safe. Yeah.

Dr. Smith:

And so you’ll see those xylitol. Xylitol. Yeah. yeah Those xylitol components as well that may have some antiseptic or antidepressants. um antibacterial principles within them. um But yeah, ah agreed. Like there’s, there may not be great evidence-based medicine that suggests that across big studies that these things work, but we certainly have seen them anecdotally. There is evidence in multiple studies that suggests that there may be benefit for these. So um those are things that are worth trying for patients if they’re really desperately trying to avoid a procedure to be done.

Dr. Reddy:

Yeah. What about, other things lifestyle related like diet um sleep position and stress levels what what do you think about all those things?

Dr. Smith:

Yeah those are kind of issues those are absolutely great points and stress levels is one thing that i often harp on but i don’t necessarily always ah ah talk about diet and and exercise as much as i ought to But stress is a huge thing. And and as as you know, um stress can change cortisol levels in the body make you less, ah you know, epped to ah fight off infections or bacteria and viruses and as as well.

And so in patients who have recurrent sinus disease disease, Sometimes getting more viruses makes them more susceptible to more chronic and flare-ups and and and infections. So all of those things, as you mentioned, are extremely important in improving sinus health.

Dr. Reddy:

Yeah, and sometimes you know sleep kind sleep positions might be helpful if you sleep with your head ah your bed elevated slightly. Yeah. If you sleep on your back, sometimes the sinus passages may potentially be able to be drained in a more natural way because your sinuses are ah supposed to drain into the back of your throat and you’re supposed to swallow it.

So gravity can kind of help a little bit if your head of your bed is elevated and you’re laying on your back as opposed to on your stomach for some people. um and ah diet, right? So there’s, now there’s more and more evidence coming out that there’s some portions of a diet that can be more pro inflammatory.

And so if you have a diet that’s more anti inflammatory, then there’s a possibility at least that, you know, your sinus inflammation might be less as well.

Dr. Smith:

Yeah, histamine rich foods may cause more inflammation in the nasal cavity, especially if someone’s already predisposed to have a histamine problem. Yep.

Dr. Reddy:

Anything else to add?

Dr. Smith:

No, I think you hit all the great points.

Dr. Reddy:

Very good. Well, we’ll catch you guys on the next episode. Thank you. Take care.

After exploring all other options, sometimes sinus surgery still provides the best long-term relief for patients with stubborn chronic sinusitis.