Randomized controlled trial: hybrid technique using balloon dilation of the frontal sinus drainage pathway

Balloon Sinus Dilation Versus Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis: Systematic Review and Meta-Analysis

OBJECTIVE

To determine the efficacy of balloon sinus dilation (BSD) compared to functional endoscopic sinus surgery (FESS) or medical management for chronic rhinosinusitis (CRS).

METHODS

A qualified medical librarian conducted a literature search for relevant publications that evaluate efficacy of BSD. Studies were assessed independently by 2 reviewers for inclusion in the systematic review and meta-analysis.

RESULTS

From 315 abstracts reviewed, 18 studies were included in qualitative review, and 7 were included in meta-analysis. Quantitative analysis included 4 randomized clinical trials (RCTs) and 3 cohort studies comparing baseline and post-operative Sinonasal Outcome Test (SNOT)-20 scores in BSD and FESS. A meta-analysis restricted to the studies reporting SD for changes from baseline (2 RCTs, 1 cohort) showed the pooled difference in means to be 0.435, less than a clinically meaningful difference of 0.8. A separate sensitivity analysis of the studies including 4 additional studies with imputed values of SD for changes from baseline showed the pooled difference of means to be 0.237 assuming the highest level of correlation (Corr .8) between the pre- and post-intervention scores.

CONCLUSIONS

There is limited high-quality evidence that assesses the efficacy of BSD versus FESS in the management of CRS patients. To better inform CRS management, future studies should compare BSD with endoscopic sinus surgery, hybrid procedures, and/or medical management alone using validated objective and patient-reported outcome measures.

Frontal Sinus Balloon Sinuplasty—Patient Satisfaction and Factors Predicting Reoperation

Objective

To explore predictive factors of postoperative outcome of frontal sinus balloon dilation.

Study Design

Retrospective questionnaire study.

Setting

Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Finland.

Methods

We reviewed electronic records of all patients who underwent frontal sinus balloon dilatation (successful or attempted) in our clinic from 2008 to 2019. We documented patient characteristics, preoperative imaging results, intraoperative factors, possible complications, and reoperations. Those who underwent frontal sinus balloon sinuplasty were sent a questionnaire regarding their current symptoms and long-term satisfaction with surgery.

Results

In total, 258 operations (404 frontal sinuses) were reviewed, with a technical success rate of 93.6% (n = 378). The revision rate was 15.7% (n = 38). Previous sinonasal surgery predicted a higher revision rate (p = .004, odds ratio [OR] = 3.03, 95% confidence interval [CI] 1.40-6.56). Patients with hybrid surgery had significantly fewer reoperations compared to the balloon only group (p = .002, OR = 0.33, 95% CI 0.16-0.67). The response rate of the questionnaire was 64.5% (n = 156), of which 88.5% (n = 138) reported a long-term benefit from the balloon sinuplasty. Patient satisfaction was higher (p = .02, OR = 8.26, 95% CI 1.06-64.24) among patients using nasal corticosteroids.

Conclusion

Technical success rate and patient satisfaction after frontal sinus balloon sinuplasty are high. Balloon sinuplasty seems insufficient in reoperations. A hybrid approach appears to result in fewer reoperations than a balloon only approach.

Hydraulic dissection technique during endoscopic sinus surgery using a novel balloon sinus dilation device

BACKGROUND

More than a decade after its introduction, some rhinologic surgeons have incorporated the technique of balloon sinus dilation (BSD) technology into "hybrid" endoscopic sinus surgery (ESS) procedures. A novel BSD device which can be placed over standard surgical instruments, including surgical navigation instruments, has recently been introduced. We present a case series in which this device was used as a hydraulic dissection tool to aid safe efficient surgery in difficult-to-access locations of the paranasal sinuses during hybrid ESS procedures.

OBJECTIVE

Highlight the potential role of hydraulic dissection techniques during ESS utilizing BSD.

METHODS

Retrospective case series of patients who underwent ESS performed in part with a novel BSD device.

RESULTS

A total of 10 patients who underwent hybrid ESS with BSD were reviewed. In all 10 cases, the novel BSD device was used without complication. The device was used over straight and curved suctions while being tracked with surgical navigation in all cases. Thirteen posterior ethmoid dissections, 12 sphenoidotomies, and 8 frontal sinusotomies were assisted with the device. For the selected dissections in which the balloon was utilized, the operating surgeon found it to be helpful in creating more space in difficult to access areas which allowed for continued safe surgical dissection.

CONCLUSIONS

Sinus balloon devices can be used as a hydraulic dissection tool and may be a useful adjunct during ESS. The novel dilation system used in this study, which deploys a sinus balloon device over standard surgical instruments with surgical navigation, provides even more opportunity to accurately dissect difficult areas of the paranasal sinuses safely and efficiently. Further studies evaluating the exact role of sinus balloon devices used as a hydraulic dissection tool during ESS are warranted.

LEVEL OF EVIDENCE

4.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Equine Nasal Endoscopy: Treating Bullae Disease and Sinus Disease

The nasal conchal bullae (dorsal and ventral) are separate, air-filled structures within their respective dorsal and ventral nasal conchae. Computed tomography scans have assisted with the increasing diagnosis of empyema of the nasal conchae. This condition is usually associated with dental or sinus disease. Drainage of affected bullae is considered critical for resolution of clinical signs. The ventral conchal bullae can be easily viewed with a standard 10 mm diameter flexible endoscopy via the middle nasal meatus. This approach can also be used for fenestration of the bullae, using a diode laser, equine laryngeal forceps, or bipolar vessel sealing device.

Clinical Consensus Statement: Balloon Dilation of the Sinuses

Objective

To develop a clinical consensus statement on the use of sinus ostial dilation (SOD) of the paranasal sinuses.

Methods

An expert panel of otolaryngologists was assembled to represent general otolaryngology and relevant subspecialty societies. The target population is adults 18 years or older with chronic or recurrent rhinosinusitis (with or without nasal polyps, with or without prior sinus surgery) for whom SOD is being recommended, defined as endoscopic use of a balloon device to enlarge or open the outflow tracts of the maxillary, frontal, or sphenoid sinuses, as a standalone procedure or with endoscopic surgery. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.

Results

After 3 iterative Delphi method surveys, 13 statements met the standardized definition of consensus while 45 statements did not. The clinical statements were grouped into 3 categories for presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. Strong consensus was obtained for not performing SOD in patients without sinonasal symptoms or positive findings on computed tomography (CT) in patients with symptoms only of headache or sleep apnea without criteria for sinusitis. In addition, strong consensus was met that CT scan of the sinuses was necessary before performing SOD and that surgeons need to understand and abide by regulations set forth by the US Food and Drug Administration if they choose to reuse/reprocess devices.

Conclusion

Expert panel consensus may provide helpful information for the otolaryngologist considering the use of SOD for the management of patients with a diagnosis of rhinosinusitis. This panel reached consensus on a number of statements that defined the use of SOD as inappropriate in the management of a variety of symptoms or diseases in the absence of underlying sinusitis. When patients meet the definition of chronic sinusitis as confirmed by CT scan, SOD of the sinuses can be indicated and/or effective in certain scenarios. Additional consensus statements regarding proper setting and safeguards for performing the procedure are described.

Recent advances in the surgical management of rhinosinusitis

Rhinosinusitis affects a significant portion of the US population, and its management imposes a substantial burden on the healthcare system. The treatment of chronic rhinosinusitis includes initial medical management prior to consideration of surgical intervention. However, if surgery does become necessary, several factors must be considered in order to optimize outcomes. This review evaluates surgical patient selection, perioperative medical management, and the extent of operative intervention, with the goal of improving surgical results, decreasing the need for revision surgery, and enhancing the patient's quality of life. Specific variations in patient genotypes and phenotypes will be further explored with regard to their implications on surgical outcomes. Additionally, the evidence behind pre- and post-operative antibiotic and steroid use will be evaluated. Finally, we will review evolving surgical tools and techniques that are currently being utilized for the treatment of specific subsets of rhinosinusitis.

Frontal Sinus Surgery: The State of the Art

Aim:

Review and describe the essential components of modern frontal sinus surgery.

Background

Frontal sinus surgery has evolved considerably over the last century, and advances in imaging, optics, and instrumentation have contributed to contemporary treatment paradigms. Outcomes assessment has had an important role in identifying indications for surgery and future areas of research.

Review results

Numerous advancements are part of modern frontal sinus surgery and the treatment of frontal sinusitis. Anatomic studies have revealed variations that are associated with disease and pose challenges for surgery. Open approaches remain relevant in situations of difficult disease or as part of combined approaches. Endoscopic surgery, however, is central to contemporary surgical management of frontal sinus disease. Evolving instrumentation and the development of new implantable devices are increasingly relevant in the endoscopic era. Outcomes research has refined indications for surgery and identifies areas for ongoing research.

Conclusion

State-of-the-art frontal sinus surgery is the product of significant evolution and advancement. Modern surgery is reflective of improved optics and new instrumentation, and the central role of endoscopic approaches in treating frontal sinus disease. Outcomes research has been essential for developing an evidenced-based approach to frontal sinus surgery.

Clinical significance

A review of the essential components of state-of-the-art frontal sinus surgery for the practicing otolaryngologist.

How to cite this article

Marino MJ, McCoul ED. Frontal Sinus Surgery: The State of the Art. Int J Head Neck Surg 2016;7(1): 5-12.