Rhinology and Skull Base Surgery Insights and Innovations

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm joined by my colleague, Dr. Christopher Roxbury, rhinologist and skull base surgeon, and one of our newest staff members in the Department of Otolaryngology-Head and Neck Surgery. Dr. Roxbury, welcome to Head and Neck Innovations.

Christopher Roxbury: Thanks for having me this morning. I'm glad to be here.

Paul Bryson: Our listeners may not fully know, but you did spend time here in fellowship training, and then I'll let you tell the listener where you've been since, but at a personal level it's great to have you back and it's going to be a great opportunity for our patients and just for our team to have you back. So if you'd be so kind, can you give us some background on yourself and where you're from, where you trained, how you came to Cleveland Clinic and how you came back to Cleveland Clinic?

Christopher Roxbury: Thanks, Paul. Yeah, it's great to be back here. So I'm an East Coaster, originally grew up in New Jersey and then spent 13 years in Baltimore at Johns Hopkins. I did my undergraduate, my med school, and my residency there. At some point, I guess either I got sick of being in Baltimore or they got sick of me, so I came here for my fellowship in rhinology and skull base surgery. And then I was on staff actually after my fellowship for one year here. Really enjoyed being here, loved working with all the team members here in the Head and Neck Institute and some of the other institutes that we work with on the skull base side. For family reasons I ended up leaving and going to University of Chicago for the last five years, where I had the opportunity to build a really busy skull base practice really from scratch there. So it was a really interesting opportunity. And while I was there, I also got interested in the inner workings of the hospital and some of the logistic issues that patients have to deal with from an access side of things. And actually at that time was able to pursue an MBA at the [University of Chicago] Booth School of Business where I did concentrations in operations management and business analytics to help me really develop ways to improve patient experience and how we deliver care to our patients.

Paul Bryson: Yeah, I mean, congratulations on that. I think it is a special opportunity when you're able to go to business school and take a different look and maybe have a different lens as you approach care delivery to that end. And then also with your surgical practice, what are some of the types of procedures that you specialize in your practice? Maybe the listener is familiar with rhinology, but just as for myself, endoscopic skull base surgery has just been such a dynamic field. I can think of the end of my own training in 2008 and 2009, some of the emerging procedures and surgical pathology that we would address. But now if we fast forward almost, I mean, gosh, almost 20 years, what are some of the significant advancements, and just kind of walk us through some of the tech and surgeries and things that you're going to be doing here.

Christopher Roxbury: You're right, Paul. So it's been really a fascinating field, and I think one of the things that really drew me to rhinology is sort of the innovation and the development of really these endoscopic techniques that we can now employ for patients over the last two decades or so.

In my practice, I take care of patients with sort of the whole spectrum of rhinology conditions. The most common conditions that I treat are nasal obstruction, people who can't breathe well through their nose. Maybe that's from a deviated septum or enlarged turbinates that block the airway. I see a lot of patients with chronic sinusitis, which is an inflammatory condition of the perinasal sinuses, the airspace that sort of are adjacent to the nose. And then my clinical area of interests are really those patients with skull-base disorders. So those are patients that have tumors of their nose and sinuses, which are oftentimes benign, but in some cases can be malignant. And then I also take care of patients that have cerebral spinal fluid leaks. So those are patients that sometimes just spontaneously develop a brain fluid leak into their nose, or patients that have a brain fluid leak as a result of a surgery that we've done to remove a tumor.

Paul Bryson: Yeah, I mean, so a lot of heterogeneity. When you think about the approaches, depending on the listener's background, they're going to be aware of possibly some classic approaches to the anterior skull base through the nose. What have you seen over time? I'll take you back to my training going through the nose to do pituitary surgery, but I feel like that's just the front door now. I mean, there's a lot more that's going on. Can you comment on some of those, I guess, what do they call the different portals and different pathways to the skull base?

Christopher Roxbury: So I think the biggest, there's sort of a few really large innovations that have happened that have allowed us to really tackle more complex cases. So this all sort of started with pituitary surgery, which lends itself very well to a transnasal or endonasal approach, and we use high definition endoscopes to look through the nose. And those endoscopes have gotten really, really great recently in terms of their ability to visualize at the microscopic level what's going on and the different pathologies that we're treating. So that's one advancement that's really helped us. And then in addition to that, the surgical instrumentation that we now have - that both hand instruments and powered instruments - that help us to tackle tumors has really made it a lot more facile to tackle some of these tumors in even more advanced locations. So now we can really remove tumors endoscopically or address CSF leaks, endoscopically that range from very anterior part of the skull base, the very front where the frontal sinuses are all the way down to the craniocervical junction.

We'll sometimes tackle patients that have either an infection or tumors that are at the base of the skull where it meets the neck. And so due to those advances in our instrumentation and really our collaborations with other fields, our neuroradiologist that helps us get a better understanding of the intricacy of the anatomy and the relationship between the tumor and the neurovascular structures, our neurosurgeons, who we do a lot of these cases combined with, really allows us now to not just take out benign pituitary tumors through the nose, but also address sort of more complex pathologies.

Paul Bryson: Yeah. So it's fair to say all of this technology is improved and broadened your maybe patient selection and surgical planning from the early days of 2006.

Christopher Roxbury: Certainly, it certainly has.

Paul Bryson: I guess maybe we can put your business school hat on a little bit - when you think about access to care and even in identifying variation in postoperative care in rhinology and skull base surgery, what are some of the, I guess, lessons learned and how here at Cleveland Clinic or even in your other roles, what's sort of been your strategic approach for getting patients in having it be an efficient visit to the system and then also taking care of them after surgery?

Christopher Roxbury: So when I see patients in clinic, I really want it to be a patient-centered experience. Each patient has not only their own individualized perceptions of their symptoms that are bringing them in, but also their own background that really molds how they're experiencing their illness. And so when they come in for the clinic visit, we start off by really discussing what they've been dealing with, because most of what I take care of on the inflammatory side is a quality of life condition. I really want to hone in on what's the symptom that bothers the patient the most. And so we spend a lot of time talking about that. What are the things that are really disruptive to your day-to-day functioning that are really making it difficult? And so we spend a lot of time trying to figure that part out so that then I can really tailor a good plan.

After we get done talking about the condition and what the patient's been experiencing and how long they've been dealing the symptoms, we'll move on to our exam. And oftentimes in the office we'll do a nasal endoscopy with those same high definition endoscopes that we discussed earlier where we can really get a good sense of the nasal anatomy, what's potentially the culprit in the patient's condition. I really enjoy the field of rhinology because a lot of times just based on how they're telling you their symptoms have started and what they're experiencing, and then that endoscopic examination, we can have a pretty good idea of what the diagnosis is, whether that be something simple like a deviated septum or nasal allergies or something that they maybe didn't expect. I have patients that come in and they say, “Hey, I've had some nasal stuffiness for the last several months and didn't really think too much of it, and then I'm telling them, I'm worried you might have a cancer in your nose.” So I think really developing that patient relationship from the beginning and then making sure I'm doing my best to explain what I think's going on to prepare them for the next phases is the utmost importance.

Paul Bryson: This seems to dovetail not just in your work here locally, but also through the American Rhinologic Society. Can you comment on some of the quality and patient experience improvements that you're working on or that you've found to be valuable to patients?

Christopher Roxbury: So there's a few things. In my own work, I've really gotten interested in healthcare delivery and specifically in the variations in care and in the field of rhinology and skull base surgery in particular, there's a lot of different variation in how patients are managed postoperatively. From simple things such as when do we start irrigating patient's noses afterwards, when do we allow them to drive a car, get out on an airplane? And then in terms of how we're taking care of their nasal passages, how often, and when are we debriding them? A debridement is sort of when we clean out the nose, we help to remove some of the absorbable packing material that oftentimes goes in after the case.

So we did a study recently looking at that. We said, patients are getting postoperative debridement very commonly after from either inflammatory sinus disease cases, sinus surgeries that we do or skull base surgeries for tumors. And we said, well, just anecdotally, there's a lot of variation. When are we doing the debridement? How many are we doing of them? And so we looked at a large database and we were able to sort of say, okay, what's the current state in terms of throughout the U.S. - how many debridement patients are we getting after sinus surgery? And what might be the factors that play a role in that variation? And of course, our hypothesis was that it really depends on who your surgeon is, where they trained, what their philosophy is on debridement. And so we were able to do a statistical analysis with a random effects model, which basically helped us to decide where is the variation coming. We were able to see that about 40% of the variation in how many debridements a patient got after surgery was actually just due to their surgeon. So basically that tells us that there's not a whole lot of guidance, so people are kind of doing what they were trained to do, and we need to as a field think about how do we maybe make it a little bit more standardized. And so one of the things that kind of dovetail from that that we're currently working on is we said, okay, well if there's all this variation in debridement, does that really matter? Are these debridements helping patients? Is it something that maybe the people who aren't doing as many should be doing more, or vice versa?

So we're now kind of in the preliminary stages of gathering some data looking at revision surgery rates. So those patients that are having debridement, are they less likely to have a revision surgery? And so what we were able to actually see is that patients that had one debridement within about 14 days of the surgery actually had about a 7% decrease in their likelihood of having a revision surgery. Opposite side of the spectrum, we saw people who had more than four debridement were at higher risks, so they would have about a 16% higher risk of getting a revision surgery. Now the question with that is, are those patient-related factors? Are those patients who are getting more debridement, are they just not healing as well? And so we'll definitely need to do more, perhaps some multicenter studies, to look at that, and from a more granular level see what's going on in those patients that are perhaps getting debrided more.

Paul Bryson: And what does the revision look like? Is it like a targeted revision in one area after a more extensive functional surgery?

Christopher Roxbury: Exactly.

Paul Bryson: It's very interesting to try to address it and maybe control for the heterogeneity.

Christopher Roxbury: For sure. And it's definitely a question that I think has been out there for a long time from sort of the beginning of sinus surgery. What are we supposed to do with these patients? And so the database that we're working with is called the market scan database and has hundreds of thousands of patient records. So we're able to really, with big data, kind of get some idea on sort of what's happening. And we were able to see at least that it does seem as though debridements are helpful, those patients that get them in a timely fashion, patients that had their first debridement greater than three weeks after surgery, they were at one of the higher risk groups to get a revision. But to your point, we can't necessarily say was it just that maybe they had a little scarring that they then had to have a small procedure to revise, or was this a full revision sinus surgery? And of course, as people who are in the field of rhinology know, the patients that have polyps, which are sort of inflammatory swellings of the nasal linings, those patients have always been known to be at the higher risk of revision. And we did see that in that data. We were able to at least look at patients with polyps versus those without. But certainly I'm hoping a basis for some future studies to give us a better understanding of how to optimize that postoperative healing.

Paul Bryson: And hopefully you find willing partners at other places rightly, where you can be like, yeah, we're just going to look at this for sure.

Christopher Roxbury: Yeah, see, that's the really nice thing. And through the American Rhinology Society I’m Chair of the Quality Improvement Committee, and through that committee we have this initiative where we're developing what are called expert practice statements. They're basically evidence-based reviews of the literature with a consensus panel of experts throughout the American Rhinology Society, often people from multiple centers throughout the U.S. where we sort of synthesize the available literature with respect to a specific question. And then through a Delphi method, we come to consensus on various factors. So we've done these on topics such as how to reconstruct the skull base after a CSF leak. There was one recently published back in January on postoperative care and skull base surgery. And then we've got a few additional ones that are in the works, one on how do we manage high pressure in our spontaneous CSF leak patients? How do we deal with their increased intracranial pressure? And then another one on our skull-based malignancy population, how do we surveil them after their treatments? What imaging studies are we optimally to get and when? So a lot of collaboration, which is excellent, and a lot of people who are obviously very interested in all of these questions. And so I'm hopeful that these initiatives will help us to just at the end of the day, provide better care to our patients.

Paul Bryson: Well, congratulations on these efforts. It's great. I'm looking forward to seeing the studies when they hit publication and presentation. It's been great to have you on the podcast. As we wrap up, any take home messages for our listeners?

Christopher Roxbury: Yeah, I think the take home message, and the one that I tell a lot of my patients, is that there's a lot that we can do for nasal conditions nowadays, things have advanced a lot even in the last decade. So if you have something that you're concerned about, if your nose is stuffy or your nose is running too much, don't just say, “Hey, this is maybe a cold or allergies,” and sort of put it by the wayside. It's very easy to do that. And thankfully, most of the time when I see patients that come in with those symptoms, it is something benign like allergies. But I do see a lot of patients that come in and we say, “Hey, we found a tumor in your nose.” And then we can, luckily, most of the time we catch it early enough where we can remove it through an endoscopic procedure where we don't need any cuts or scars on the face, and we can really improve their postoperative recovery. So I just want to put a plug in for people to say, let's not ignore our nasal conditions because they can be, in some rare cases, dangerous things, and at the very least, something that we can help improve your quality of life with.

Paul Bryson: For more information on Cleveland Clinic’s Section of Rhinology, Sinus, and Skull Base Surgery, please visit ClevelandClinic.org/Rhinology. That's ClevelandClinic.org/Rhinology. And to speak with a specialist or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr. Roxbury, thanks for joining Head and Neck Innovations.

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