Engineering parallels for this medical issue

Since I work in engineering, that is often the yard stick I use to analyze problems. I can see many parallels to the surgically caused issue of ENS. Based on what I have seen, ENS as a result of surgery is not surprising to me and I am not alone:

E. Huizing 2002: “Unfortunately, a wide nasal cavity syndrome due to reduction or resection of the inferior turbinate (and/or middle turbinate) is still frequently seen. When caused by (subtotal) turbinectomy, it can hardly be considered a complication. In our opinion, it is a “nasal crime”. This iatrogenic condition can easily be avoided by reducing a hypertrophic turbinate using one of the intraturbinal function-preserving techniques (see p. 279).”

There are no standards or specifications for surgery. One doctor that I had  talked to mentioned that an air gap of about 2mm was “normal”. Another referred to the radius of the turbinate heads normally being some number of millimeters. These are specifications. There should be more of this. Some refer to reducing the bottom free 1/3 which would leave about 70% but others take far more or all out. There is NO uniformity of opinion among all doctors. Having no specifications  generally leads to poor results. I don’t think everyone needs CFD analysis but if the goal is to get someone a little more air, there should be some general guidelines in terms of percent or mm of gap as a target.

As I pointed out in an earlier post, Nasal turbinate reduction has been a debated topic for 100 years. There have been many conflicting studies which means there IS NO AGREEMENT.  When I look at 100 years worth of nasal studies that are conflicting, I don’t see enough to convince me that aggressive surgeries are safe. Any doctors proposing total or sub-total turbinectomies owes that patient an honest assessment of risks and disclosure as a part of legal informed consent that these procedures are not completely understood and carry higher risks. To really understand the actual results of nasal surgeries, much more data needs to be collected. What I see are many limited independent studies by different groups spaced over many years.

Part of engineering a product is about “process control” which is the micro details about how and why things get done a certain way every time. A large part of this is data collection!

Now when I look at nasal surgeries and I see one doctor doing a conservative out-fracture only, another doing conservative SMRs, or perhaps an isolated septoplasty and then I see others doing sub-total and total turbinectomies, with some doing additional septoplasties that doesn’t pass my basic sniff test. All of these results cannot leave patients with normal baseline measurements of the type reported here or healthy functional noses. Certainly people deserve more care than manufactured goods.

When I look at the freedom that exists during these nasal surgeries it is no surprise to me at all that surgical results are uneven and poorly understood. I know doctors probably love that freedom but perhaps even if only for one year, what they need to do if they want to solve this issue is to come together and create a national database where they at least log some basic data on each nasal surgery and report some details like we would do if we had to understand and solve an issue. I would like to see such things as:

-name of patient (to be able to track issues in later years)

-type of surgery, SMR, sub-total, total, radio frequency,etc.

-whether septoplasty was also performed

-estimated % turbinates removed or reduced

-if anterior heads were touched, if so a rough guess for radius before and after

-estimated airway gap in mm before and after surgery

-whether Electro-Cautery was used and if so how much? More than usual needed? which side? Are settings/voltage level standardized? Since there is more bleeding in aggressive surgeries I am sure there is also more Electro-Cautery too.

-was there also an out-fracture?

-number of subsequent patient visits regarding satisfaction

-complications

After a program like this (with a very high number of surgeries/year) I bet an understanding would soon emerge. A simple spreadsheet with check boxes and some blank spaces to be filled out post surgery and sent in monthly would probably be sufficient.

 

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