Everything you ever wanted to know or should know about Balloon SinuplastyThis primer is developed specifically for prospective patients who have heard about in-office balloon sinuplasty and are wondering if that is something that will help them with their sinus symptoms.
Balloon sinuplasty is a culmination of the ‘minimally invasive’ approach to helping patients with chronic or recurrent sinusitis. The ‘minimally invasive’ moniker is a term used across specialties to describe an intervention which is designed to accomplish a relief of disease without the traditional surgical cutting required by previously existing techniques. This is the story of minimally invasive sinus surgery that has culminated in today’s in-office balloon sinuplasty techniques.
Definition of Sinusitis - Acute vs Chronic
Chronic sinusitis is defined as inflammation of the sinuses which lasts longer than 12 weeks. It is an affliction which is the most common chronic disease in the United States. It is distinguished from ‘acute’ sinusitis by its duration. Typically, someone with acute sinusitis describes having ‘cold’ symptoms which may gradually improve over a few days but which linger and develop over the ensuing days or weeks to an illness which involves facial pressure, headache, pain, discolored drainage, and nasal blockage. Acute sinusitis is treated with steroids and antibiotics and is usually self limiting. Surgical intervention is only required if these episodes occur four or more times a year or are particularly debilitating when they occur. Also, if a complication of acute sinusitis arises (spreading to the eye or brain, or forming an abscess), then surgical intervention is often indicated.
Patients with chronic sinusitis present with months or years of pretty much nonstop symptoms. They may have one or more of the symptoms associated with acute sinusitis. The distinguishing feature is the length of the illness.
How are Patients Evaluated for Chronic Sinusitis?
Evaluation of the patient with chronic sinusitis begins with a thorough history, involving the length of time of the symptoms, the severity and location of the symptoms, factors that make the symptoms worse, factors that make the symptoms better, and prior evaluation and treatment attempts. A thorough physical examination is performed including vital signs, inspection of the head and neck area including evaluation of the eyes, ears, nose, mouth and throat. All of these areas can suggest underlying factors related to the sinuses. Nasal endoscopy is performed next. This is a procedure where a small telescope is placed through each nostril to better visualize the inside of the nose. This gives the physician an ability to assess the airway for blockage (eg deviated septum, enlarged turbinates, polyps, other abnormal anatomic findings). It also allows the surgeon to view the areas where the sinuses drain into the nose, These areas might be affected by inflammation, polyps, or anatomic obstruction. The distance from the front of the nose to the back of the nose is approximately three inches. Issues and obstructions that can lead to sinusitis may occur at any place along this pathway.
A CAT scan of the sinuses is performed not only to verify and sometimes quantitate the findings from the nasal endoscopy, but also to evaluate the inside of the sinuses, areas not visualized by the nasal endoscopy. This gives valuable information about the precise issues leading to the patient’s symptoms and also gives a road map for possible intervention.
Medical and Allergic Management of the Patient with Chronic Sinusitis
Medical management typically consists of saline lavage, intranasal steroids, intranasal antihistamines, systemic antihistamines, antibiotics (if a bacterial infection is suspected) and in some severe polyp cases, systemic steroids. Leukotriene inhibitors (such as Montelukast) may also be used if underlying allergies are suspected. Allergy testing with possible subsequent immunotherapy is performed to allow further insight into the etiology of the sinus disease.
The exact order and duration of medical management varies depending upon the severity of symptoms, duration of symptoms, and exact issues identified. It is generally accepted that at least four weeks of medical therapy be unsuccessfully attempted before intervention is considered.
The Revolution and Evolution of Minimally Invasive Sinus Surgery and Balloon Sinuplasty
Way back when, from the late 19th century until the mid 1980s, intervention for chronic sinusitis was reserved for the most seriously afflicted patients. This was an era when the paradigm for surgical treatment of chronic sinusitis involved surgically removing the affected sinus. If the involved sinus was the maxillary sinus (the sinus located in the cheek), then an incision below the lip was performed and the maxillary sinus contents were removed. If the involved sinus was the ethmoid or frontal sinus, then the incision made would be below the eyebrow and onto the bridge of the nose. Sometimes, in particularly bad frontal sinus disease, a bicoronal incision from ear to ear across the top of the head was required. Again, these incisions were made to gain wide access into the sinus so that the entire sinus contents could be removed.
In the early 1980s, the true revolution in surgical care of the sinuses happened. It actually started in Austria by a sinus physician named Messerklinger. Through years of careful observations inside the nose using a telescope he discovered that one thing that sinus sufferers had in common was a blockage of the outflow tract of the affected sinus. He reasoned that if he could open that outflow tract he could help the sinus go back to normal. This was the birth of minimally invasive sinus surgery.
The paradigm of minimally invasive sinus surgery was brought into the United States in 1985 at the first American course taught at the Johns Hopkins Hospital in Baltimore. I had the privilege of being the Assistant Chief of Service and Chief Resident of the Department of Otolaryngology at Johns Hopkins at the time. The implications of this new paradigm were profound. It was estimated at that time that 20,000,000 Americans suffered from chronic sinusitis. Imagine that there was now an outpatient minimal downtime procedure for them. The procedure in its infancy was known as ‘functional endoscopic sinus surgery’ indicating that it restored the function to the diseased sinus, was done through a telescope (endoscope), but that it was still surgery (involving manipulation of tissue).
The two decades following this American introduction featured evolution of this technique. In 1989 we added the KTP laser to our minimally invasive endoscopic instruments. The first KTP laser case was done in the United States by us in Boca Raton in 1990. It immediately enabled us to expand the indications for minimally invasive sinus surgery by allowing us to laser polyps and other diseased tissue. The laser was gradually replaced by the microdebrider which is still used today as a means of greatly accelerating the healing process.
The next major evolution in minimally invasive sinus surgery was the adaption of computer or stereotactic guidance to the procedure. This means that while the surgeon is performing the procedure, the instruments are being tracked in three dimensions on a computer directly in front of him. Given the fact that the sinuses are anatomically situated between the brain and the eyes, this gave the surgeon added assurance as to the safety of this procedure. Computer guidance for sinus surgery was initially described at the Universities of Pittsburgh and Pennsylvania. In Boca Raton, we became the third American site to do the FDA studies on this new application of computer guidance. It received the FDAs blessing in 1992 and has remained the standard of care for minimally invasive sinus procedures. Known as Computer Assisted Endoscopic Sinus Surgery (or CAESS), this is the standard procedure for most endoscopic sinus procedures including removal of polyps or tumors from the sinuses.
Balloon sinuplasty is the ‘latest and greatest’ innovation to further minimize healing time and inconvenience of restoration of sinus function to the patient. It was developed by the scientific team that originally developed balloon catheters for the heart. Following their success in the heart, they turned towards the sinuses. The concept was pretty straightforward. Use the balloon instead of endoscopic instruments to open up diseased sinuses and it will be a simpler experience for the patient. The first balloon cases were done under fluoroscopic guidance. Even though for the patient healing was quicker, the technology was somewhat cumbersome. It progressed by having an extremely bright light on a wire at the end of the balloon. The wire was passed into the nose through the nostril and guided into the affected sinus(es). The balloon was then passed over the wire, inflated, deflated, then removed. This was far less cumbersome than the fluoroscopic technique and was a better experience for both surgeon and patient.
The next major evolution in balloon sinuplasty technology was combining stereotactic guidance to the balloon itself. The first United States computer assisted balloon sinuplasty was performed in our office surgical facility in Boca Raton in June of 2014. We felt that this was a landmark technologic breakthrough, as it allowed us to combine the best of the essentially noninvasive balloon technology with precise guidance afforded by the computer guidance system. Since that time this combination of technology has enabled us to move essentially all sinus surgery to the office setting.
What All of this Means to the Patient Suffering from Chronic Sinusitis
Basically, there’s hope. While minimally invasive techniques to treat chronic sinusitis aren’t for everyone, they have brought relief to hundreds of thousands of patients to date. We require all patients to be examined with both nasal endoscopy as well as computerized tomography (CAT scan). We recommend allergy testing if we determine that this is a likely etiology of the sinus problem. All patients require medical and/or allergic management prior to the decision to undergo intervention.
There are four areas that we focus on in evaluating patients for intervention. First, obviously, are the sinuses. Between the history, the nasal endoscopy, and the CAT scan, we develop a fairly complete picture of sinus disease. The second area is the nasal septum. We check that for deformities that may be contributing to the patient’s symptoms. Third, we evaluate the inferior turbinates. These may become enlarged from long standing allergies. Such enlargement may respond to medical management. If it doesn’t, then this is addressed during the intervention. Finally, we evaluate the structure of the nose to see if this is contributing to functional breathing compromise.
Once this evaluation is complete, then the surgical plan is formulated. In most cases, even if adjunct procedures such as a septoplasty or turbinate reduction are required, the surgery can still be performed in the office setting. The balloon sinuplasty procedure by itself normally takes approximately 30 minutes. If other procedures are added, then the time increases. Patients recover approximately 20 to 30 minutes in the office and then are discharged. They are seen back in the office within several days of the procedure and then as needed. Depending upon the problem they may be seen weekly for several weeks following the procedure or sometimes maybe not for a month. Postoperative discomfort it typically minimal with patients returning to full activities anywhere from one day to five days depending upon which procedure(s) is required.
About the Author
Nathan E. Nachlas, MD is a double board certified physician in otolaryngology as well as facial plastic and reconstructive surgery. He is a summa cum laude graduate from Yale University, attended medical school at the University of Chicago, and trained in Otolaryngology/Head and Neck Surgery at the Johns Hopkins Hospital in Baltimore. US News and World Report has named Johns Hopkins Hospital the number one Otolaryngology/Head and Neck Surgery program in the United States. Dr. Nachlas completed his fellowship training in Facial Plastic and Reconstructive Surgery in Beverly Hills, California. He developed the ‘total nose’ approach almost 30 years ago as he started his practice in Boca Raton, Florida. He has pioneered many of the advances in minimally invasive sinus procedures over the past three plus decades.
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