Balloon Sinus Dilation - Clinical Tree

Introduction

Sinus surgery continues to evolve, greatly enhanced by technological innovations. Thirty years ago, largely due to advances in endoscopic visualization, functional endoscopic sinus surgery (FESS) became less extirpative than traditional operative sinus surgery. Now another stage in this evolution is occurring toward minimally invasive sinus procedures such as office-based balloon sinuplasty. This technique, performed under local/topical anesthesia, affords several distinct benefits over sinus surgery under general anesthesia: less patient down-time, less bleeding, reduced need for postprocedure pain medication, and more rapid return to work. These advantages of balloon-sinuplasty, when coupled with equal efficacy for similar chronic sinusitis disease severity, provide a valuable alternative for patients and otolaryngologists.

Key Operative Learning Points

1.
Balloon sinus dilation (BSD) is an operative procedure performed for medically recalcitrant recurrent acute sinusitis and chronic rhinosinusitis.
2.
It can be safely performed in both the outpatient and inpatient settings.
3.
Principles of BSD rely on expansion of narrowed sinus tracts while preserving sinus mucosa.
4.
Success of the procedure requires appropriate patient selection and the use of proper technique.
5.
Rate of success and revision of BSD are comparable to those achieved for FESS for properly selected patients.

Preoperative Period

History

1.
History of present illness
- a.
  Has the patient experienced symptoms of chronic rhinosinusitis: nasal congestion, facial pressure, and/or nasal discharge?
- b.
  Are these symptoms chronic (>12 weeks) or recurrent with four or more episodes per year?
- c.
  Are there factors such as infections of high severity or duration, antibiotic intolerance, or associated medical conditions that warrant early intervention?
- d.
  What medical therapy has the patient tried? This may include nasal saline rinses, both oral and topical decongestants, antihistamines, nasal steroids, and antibiotics. Have these medical therapies been successful? Ask for the length of the symptom-free period.
- e.
  Has the patient undergone any prior imaging (computed tomography [CT] scan of the sinuses)?
- f.
  Has the patient undergone allergy testing?
- g.
  Does the patient have a dental (odontogenic) source of sinus pain?
2.
Past medical history
- a.
  Are there associated medical conditions? Ask for history of allergies, gastroesophageal reflux, and headaches (particularly migraine).
- b.
  Surgical history. Have there been previous septal surgery and/or sinus surgical procedures?
- c.
  Family history
- d.
  Allergies to local anesthetics (lidocaine, bupivicane)
- e.
  Medications:
  - 1)
    Anticoagulants
  - 2)
    Antihypertensive

Physical Examination

1.
Anterior rhinoscopy
- a.
  Are there enlarged inferior turbinates or anterior septal spurs that account for additional nasal obstruction? These may need to be addressed at the same time as the BSD and, if severe enough, may require that the procedure be done under general anesthesia.
2.
Nasal endoscopy
- a.
  Are there other middle meatal anomalies that will make access to the meatus difficult? Examples include nasal polyps, concha bullosa, lateralized middle turbinate, and superior septal deviation.
- b.
  Is there polypoid tissue along the bulla ethmoidalis that will need to be addressed at the same time as the balloon dilation with a limited anterior ethmoidectomy? Limited nasal polyps may not preclude BSD, but more extensive polyposis may require consideration of larger sinus openings through FESS.

Imaging

1.
CT of the sinuses without contrast
- a.
  Pay attention to narrowing of the ostiomeatal complexes and the nasofrontal recesses. Also note any large obstructive polyps that may make BSD inappropriate. Also, diffuse ethmoid disease (anterior and posterior) would preclude BSD and make FESS more appropriate. Hyperdense regions in the sinuses may indicate that fungal elements are present such as in a mycetoma or allergic fungal rhinosinusitis, making FESS more appropriate.

Indications

1.
Mild to moderate chronic rhinosinusitis of the maxillary, frontal, or sphenoid sinuses recalcitrant to medical therapy ( Fig. 102.1 )
2.
Recurrent acute sinusitis of the maxillary, frontal, or sphenoid sinuses
3.
Revision cases of scarring or stenosis of the maxillary, frontal, or sphenoid ostia
4.
Can be used as a stand-alone technique or in conjunction with other sinus surgery (known as a hybrid technique)
5.
Specific application to those with patients unfit for surgery: on anticoagulants, pregnant, age-related medical conditions (heart or lung problems)

Contraindications

1.
Diffuse nasal polyposis or granulation tissue
2.
Severe ethmoid disease (anterior and posterior)
3.
Anatomic nasal obstruction that otherwise would require general anesthesia (large obstructive septal deviation)
4.
Fungal sinusitis where removal of fungal debris is necessary
5.
Concerns for sinus masses that need removal (large maxillary mucocoele)

Preoperative Preparation

1.
Preoperative consent: Discuss risks of injury to the orbit, bleeding, cerebrospinal fluid (CSF) leak, scarring, and rates of revision.
2.
For awake sedation
- a.
  Preoperative dosing of benzodiazepine (Valium 10 mg) and narcotic (hydrocodone 7.5 mg) 90 minutes prior to procedure
- b.
  Counseling that the patient may hear loud noises (cracking bones) during the procedure

Operative Period

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