| Frequently asked ENS questions |
| Does Alloderm shrink over time? I have noted mild shrinkage in implanted ENS patients as the alloderm incorportates. If the alloderm is placed into an avascular bed, or if it were to become infected, then it is possible that the alloderm can shrink considerably; I have seen this occur with Alloderm placed against bone. Does it fluctuate early on while healing? Yes, absolutely, as the swelling from surgery comes & goes. Lifecell corp reports it will shrink in mobile areas (e.g., lips); the nose is static. If it did shrink more could be added also. There is now a competing material to alloderm to consider: Allomax. Why can medicine not solve this through tissue engineering? This may be possible in the future, but not at this point in history, A turbinate contains multiple components and it hangs suspended in space within the nose. A narrow attachment makes establishing blood supply to a graft a difficult/impossible prospect. Vessel anastamosis is not possible deep in the nose; it requires open visualization such as in the neck, etc. Yes, cartilage and cartilage structures can be grown, but a turbinate also needs to have a covering of respiratory epithelium, and submucosa below. Respiratory epithelium cannot reliably be grown at this time. Can't growth factors induce growth/hypertrophy of the remaining tissue? VEGF, and similar compounds, can induce vascular proliferation in the heart. These medicines risk blindness through vessel ingrowth at the retina, but this is off set by revascularizing an ischemic area within the heart. ENS is severely debilitating, I agree, but one could argue not life threatening. The nose is so close to the eye that I would suspect the eye would be a great risk from an intraturbinal injection of a growth factor; certainly blindness has been reported from intraturbinal steroid injections. I doubt the FDA would ever approve VEGF for intranasal injection. Are vitamins helpful? Vitamins are wise for everyone as our diets tend to be poor/deficient. I am not aware of any vitamin or homeopathic remedy for ENS, but neither am I aware of any that will worsen the condition. I am happy to hear about success/failure with various items. How long does it take Alloderm to incorporate into the body? I give patients at least 2 weeks of antibiotics post implant to allow the area to remain sterile while healing is beginning to occur. Alloderm is a foreign body until the body grows into it, so it is a race between bacteria and the patient's body. It then takes months for the body to fully take over/incorporate Alloderm. Can the nasal cycle occur with implanted Alloderm, or it this nasal function damaged? Alloderm will, over time, take on the characteristics of the tissue it is implanted into. If it is placed submucosally into the vascular capacitance tissue, then I believe it can take on this function partially - it also will form simple scar/fibrous tissue as well (non-functional, but bulky) I do not believe the function is damaged, as radiofrequency or cautery treatmants to the submucosal tissue (more damaging to the submucosa than a tunnel/incision) are temporary. Is the nose more moist after an implant? This appears to be the case. As the rate of airflow is reduced, less moisture is stripped from the nasal mucus, hence the nose is more moist. Moisturization still remains important though. Where is Alloderm implanted? This depends on where tissue is missing from. It is placed either submucosally into the inferior turbinate, or subperichondrial to the septum, or subperiostial at necessary bony locations. Seeing a CT scan gives me an idea as to where tissue is missing, and what can be done, but physical exam & scoping are ultimately of greater importance. Is the lateral wall no good per Friedman? This was not a definitive article, and I would disagree somewhat, but yes the lateral wall (meaning with IT's absent) is tough to graft. What about injectable Alloderm (Cymetra)? It seems to burst the nasal mucosa quickly after injection. It can work below a strong barrier such as perichondrium, periosteum, alloderm. I want to sue the doctor that did my surgery - will you help? I cannot help in this area. I am trying to gather ENS patient cases to research & publish this information. Being an expert witness helps an individual, but then would discredit the work I am trying to accomplish which may help many patients. Are other doctors working on ENS? Just Dr. Grossan in LA. There may be others, and I hope to expand the interest so other around the country (USA) and world will be able to treat ENS. How much does implant surgery cost? This varies based on where/what surgical approach is used. Often the bill would be in the $5-15,000 range. I do not have control over costs, just codes. I can do surgery on indigent patients from Cuyahoga Cty OH, but others end up having to pay or use insurance. I have had pretty good luck getting coverage approved for patients. I have 2 practice sites now. Can SIS be used? Sure, it is a collagen product as well - but porcine. It is thin, so many layers would be needed. Tissue clay? I am not sure - contact the people involved with that one. Silicon? It is a foreign body and tends to extrude/become infected. What is a "cotton test?" Placing moistened cotton, or cosmetic puff portion(s) into the nose to see if inhibiting the airflow improves the symptoms. This suggests that an implant at that location would be beneficial. The implant likely brings mucosa into the airstream for sensation, but also deflects air into an area that has maintained more normal sensation (i.e., not operated upon, or healed properly). Do not wear cotton sleeping - it might go into your throat & choke you. Only use it for a few hours at a time as it will collect secretions. If you wanted to put it in deeper then tie a thread to it & trail this out of the nostril to pull it out again. Do not stick anything straight up into the top of the nasal vault as the skull is thin up there & injury could result. You should discuss this technique with your ENT or primary doc before attempting it; perhaps your ENT will place the cotton. Can a turbinate be transplanted? No, not with current medical technology. The blood vessels deep inside the nose cannot be attached. Nor would immunosuppressives be wise or accepted here. Can mucosa be grafted? There are no donor sites from the same person. The nose has respiratory epithelium; the answer is no. I have chronic nasal/facial pain - could I have ENS? You most likely do not have ENS. You would be best served by a pain therapy specialist. Implants have proven most useful for abnormal breathing, and have had less effect (no help in some) for chronic pain. The pain associated with ENS is a more minor issue, and if pain is your main issue then you do not have ENS. Please be aware that I am not a pain specialist. I can see you in the office if desired, but I am no longer answering private emails nor assessing CT scans from "potential" patients. The volume/time/emotional expenditure are overwhelming. I am sorry. |