Balloon sinuplasty versus surgical management of chronic rhinosinusitis

Evaluation of balloon sinuplasty for the treatment of pediatric chronic rhinosinusitis

PURPOSE OF REVIEW

This year marks 10 years from the publication of the clinical consensus statement on pediatric chronic rhinosinusitis (CRS). Balloon sinuplasty did not meet criteria for consensus at that time because there was insufficient evidence on its efficacy and safety. The purpose of this review is to summarize the current evidence on balloon sinuplasty treatment for pediatric CRS.

RECENT FINDINGS

Balloon sinuplasty is not a cost-effective measure compared to adenoidectomy and endoscopic sinus surgery (ESS). In the pediatric population, benefits include short operative time, reduced tissue manipulation, and potential for decreased antibiotic courses. Alternatively, balloon dilation has increased equipment costs and there is a lack of robust prospective data that fully elucidates balloon sinuplasty's role in the management of pediatric CRS.

SUMMARY

Pediatric otolaryngologists should continue to perform first-line adenoidectomy and consider ESS based on imaging and other validated clinical scoring systems. Balloon sinuplasty has not yet been proven as an effective treatment for pediatric CRS and further large-scale investigations are required to overcome its lack of cost-effectiveness.

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset

INTRODUCTION

As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for endoscopic sinus surgery (ESS). The aim of this study was to investigate the safety of day-case ESS in England.

DESIGN

Secondary analysis of administrative data.

METHODS

We extracted data from the Hospital Episodes Statistics database for the 5 years from 1 April 2014 to 31 March 2019. Patients undergoing elective ESS procedures aged ≥17 years were included. Exclusion criteria included malignant neoplasm, complex systemic disease and trans-sphenoidal pituitary surgery. The primary outcome was readmission within 30 days post-discharge. Multilevel, multivariable logistic regression modelling was used to compare outcomes for those operated on as day-cases and those with an overnight stay after adjusting for demographic, frailty, comorbidity and procedural covariates.

RESULTS

Data were available for 49 223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/2015 to 78.7% in 2018/2019. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar.

CONCLUSIONS

Our data support the view that ESS can safely be performed as day-case surgery in most cases, although it will not be suitable for all patients. There appears to be scope to increase rates of day-case ESS in some hospital trusts in England.

Image guided dilation of sinus ostium in revision sinus surgery

PURPOSE

Assess if a rigid, image-guided balloon could be used effectively and safely in revision sinus surgery.

MATERIALS AND METHODS

A prospective, non-randomized, single-arm, multicenter study to assess the safety and device performance of the NuVent™ EM Balloon Sinus Dilation System. Adults with CRS in need of revision sinus surgery were enrolled for balloon sinus dilation of a frontal, sphenoid, or maxillary sinus. The primary device performance endpoint was the ability of the device to (1) navigate to; and (2) dilate tissue in subjects with scarred, granulated, or previously surgically-altered tissue (revision). Safety outcomes included the assessment of any operative adverse events (AEs) directly attributable to the device or for which direct cause could not be determined. A follow-up endoscopy was conducted at 14 days post-treatment for assessment of any AEs. Performance outcomes included the surgeon's ability to reach the target sinus (es) and dilate the ostia. Endoscopic photos were captured for each treated sinus pre- and post-dilation.

RESULTS

At 6 US clinical sites, 51 subjects were enrolled; 1 subject withdrew before treatment due to a cardiac complication from anesthesia. 121 sinuses were treated in 50 subjects. The device performed as expected in 100 % of the 121 treated sinuses, with investigators able to navigate to the treatment area and dilate the sinus ostium without difficulty. Ten AEs were seen in 9 subjects, with 0 related to the device.

CONCLUSION

The targeted frontal, maxillary or sphenoid sinus ostium were safely dilated in every revision subject treated, with no AEs directly attributed to the device.

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.

Otolaryngologist Characteristics and Outlier Use of Balloon Sinuplasty in the Medicare Population

OBJECTIVE

Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization.

STUDY DESIGN

Retrospective analysis of Medicare claims data and the National Physician Compare database.

METHODS

Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year.

RESULTS

Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P < .001), performance of 10 or fewer total endoscopic sinus surgeries per year for 3 or more years (OR, 3.90; 95% CI, 1.59-9.57; P = .003), and high number of overall services per beneficiary (OR 6.70; 95% CI, 1.19-37.84; P = .031). Provider sex, years of experience, and geographic setting were not associated with outlier status.

CONCLUSION

Outlier BSP patterns are associated with a few otolaryngologists who are more likely to be identified in small practices and record low numbers of endoscopic surgeries. Although BSP is an appropriate and effective tool, identification of outlier patterns may help to facilitate peer-to-peer counsel.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Tension Pneumocephalus Following Balloon Sinuplasty

Balloon sinus dilation (BSD) is a common method of relieving sinus outflow obstruction. With the rising utilization of BSD, increasing numbers of BSD-related complications have also been reported. Here, we report a case of pneumocephalus and cerebrospinal fluid leak following BSD of the frontal sinus. Additionally, a review of the literature regarding BSD complications was performed.

Radiologic Analysis of Balloon Sinuplasty in a Human Cadaver Model: Observed Effects on Sinonasal Anatomy

BACKGROUND

Balloon sinuplasty is increasingly used in the outpatient clinic for treatment of chronic rhinosinusitis, but radiologic analysis of its effects on sinonasal anatomy is largely uncharacterized in the known literature.

OBJECTIVE

The purpose of this study is to examine the anatomic effects of balloon sinuplasty in a cadaveric model.

METHODS

Five fresh cadaver heads underwent sequential endoscopic balloon dilation of maxillary ostia, frontal recess outflow tracts, and sphenoid ostia bilaterally by fellowship-trained rhinologists. Pre- and post-procedural CT imaging was obtained. CT scans were imported into Mimics™ software and sinonasal anatomy was analyzed systematically.

RESULTS

Visual confirmation of balloon dilation was achieved in all 3 sites bilaterally in each cadaver. Radiologic analysis demonstrated that the frontal sinus outflow tract was appropriately dilated 60% (6/10 sites) of the time while the agger was inadvertently dilated 30% of the time (3/10). The sphenoid os was successfully dilated 70% (7/10 sites) of the time. In two cases, a posterior sphenoethmoid (Onodi) cell was dilated instead of the sphenoid. Successful dilation of maxillary os was noted 60% of the time (6/10 sites). No significant change in maxillary os was noted after balloon dilation. Normal middle turbinates were significantly medialized following balloon dilation 75% (6/8 sites) of the time.

CONCLUSIONS

While the goal of balloon sinuplasty is to improve natural sinonasal drainage by dilating existing outflow tracts, as evidenced by radiologic evaluation the procedure appears not to achieve this in all cases, while occasionally creating unintended changes in sinonasal anatomy as well. These unrecognized changes in anatomy may be responsible for the post-procedure change in symptomatology that some patients experience.

Exploring Balloon Sinuplasty Adverse Events With the Innovative OpenFDA Database

Background

Balloon sinuplasty (BSP) has become a common, minimally invasive treatment for chronic sinusitis. Like any surgical procedure, there are definite risks when using it as a stand-alone procedure or in conjunction with other revision procedures.

Objective

To explore the adverse events of BSP using the openFDA cloud with regard to malfunction and injury following surgery.

Methods

Between January 2015 and December 2018, the Food and Drug Administration’s (FDA) openFDA database was queried for adverse event use. Reports were further categorized by procedure location, injury type, device malfunction, procedure (stand-alone BSP vs hybrid), and source of complication (anatomical or surgeon related).

Results

Seventy-eight events were reported to the FDA in the study period. Majority of cases consisted of device malfunctions (64.1%), while patient injuries consisted of 43.5%. Frontal sinus procedures had the greatest presence of adverse events (47.4%) with the majority reporting significant cerebrospinal fluid (CSF) leaks ( P < .001) and device retention ( P = .021). Orbital complications ( P = .004) were found to be significantly associated with dilation of the maxillary sinus. Skull-based injuries were the only factor incident in which surgeon-reported anatomical complications were significant ( P = .018).

Conclusions

As balloon dilation procedure continues to rise in the United States, significant adverse events continue to occur. Frontal sinus BSP leads to the highest number of complications and a 4.75 reported CSF leaks yearly. Based on real data, surgeons performing the procedure should be acquainted with common BSP-related injuries so they can prepare for those circumstances and share informed consent with their patients.

Early experience with feasibility of balloon sinus dilation in complicated pediatric acute frontal rhinosinusitis

BACKGROUND/OBJECTIVE

Complicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life-threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis.

METHODS/RESULTS

We present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty.

CONCLUSIONS

Prior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease.

LEVEL OF EVIDENCE

4.

Review and Analysis of Research Trends in Surgical Treatment of Pediatric Chronic Sinusitis

Background

Chronic sinusitis is a common otolaryngologic complaint with a significant impact on patients’ quality of life. There is current debate and differences in quality of evidence regarding the best surgical management approach to pediatric chronic sinusitis.

Objective

To investigate changes in publishing trends over time in surgical management of pediatric chronic sinusitis.

Methods

A systematic literature review was conducted in January 2019 using Embase, PubMed, and Web of Science, of all articles that included surgical treatments for pediatric chronic sinusitis. Publications were grouped into 3 time periods: pre-1998, 1999–2008, and 2009–2018. In addition, a subgroup of publications pertaining to endoscopic sinus surgery, balloon sinuplasty, and adenoidectomy were grouped into 2-year periods since 1988 to compare the number of publications on each topic and to examine overall trends.

Results

A total of 327 abstracts were included in the data collection and analysis. There was an overall significant increase in total number of publications ( P < .0001), total number of authors ( P = .001), and comparison studies ( P = .003) from pre-1989 to 2018. Relative number of prospective studies, systemic review, and case studies/expert opinions have not significantly increased over time when comparing decades ( P > .05). Among the surgery types, functional endoscopic sinus surgery has the most amount of publications regardless of year despite a statistically significant increase in publications pertaining to balloon sinuplasty in the pediatric literature from 1999–2008 to 2009–2018 ( P = .001).

Conclusions

Studies on pediatric chronic sinusitis have increased significantly during each of the last 2 decades with an increase in the concomitant number of authors and comparison studies. Although most publications are still Level C or D evidence, there has been a nonsignificant increase in Level A evidence in the past decade. Endoscopic sinus surgery still remains the most studied procedure despite the recent increase in publications on balloon sinuplasty.

Current indications for balloon sinuplasty

PURPOSE OF REVIEW

The purpose of the review is to evaluate the current indications and contraindications for balloon sinuplasty and review the clinical trials performed in this area.

RECENT FINDINGS

The indications for balloon sinus dilatation are somewhat similar to those for endoscopic sinus surgery. Balloon sinus ostial dilation (BSD) has been found to be most effective in the treatment of recurrent acute sinusitis (RARS) and chronic rhinosinusitis without nasal polyposis (CRSsNP) that has been refractory to medical therapy. Multiple randomized clinical trials have demonstrated the efficacy of BSD in improving quality-of-life outcomes in patients with limited CRSsNP in both the clinic and operating room settings. However, because BSD merely dilates blocked sinusal ostia without removing tissue, it is typically restricted to addressing disorder involving the frontal, sphenoid, and maxillary sinuses. Individuals who have significant disease of the ethmoid sinus may have BSD adjunctively with endoscopic sinus surgery. BSD is unsuitable as a primary treatment modality in pansinus polyposis, widespread fungal sinusitis, connective tissue disorders at an advanced stage, or potential malignancy. A recent expert clinical consensus statement also concluded that BSD is not appropriate for treatment of patients with headache that do not meet the diagnostic criteria for CRS or RARS or patients who do not have both positive findings of sinus disease on computed tomography and sinonasal symptoms.

SUMMARY

Balloon sinuplasty is an option in the treatment of sinusitis that has failed appropriate medical therapy. Evidence is best for limited disease in patients with CRSsNP affecting the frontal, sphenoid, and maxillary sinuses. Because BSD can be performed in the office setting, it can be a viable therapeutic alternative in patients with comorbidities who are unable to tolerate general anesthesia.

Adenoidectomy With Balloon Catheter Sinuplasty: A Randomized Trial for Pediatric Rhinosinusitis

OBJECTIVES/HYPOTHESIS

To compare treatment outcomes in pediatric patients with chronic rhinosinusitis (CRS) using adenoidectomy and maxillary sinus irrigation with or without balloon catheter sinuplasty (BCS).

METHODS

Prospective, randomized, and blinded. Patients between 2 and 12 years who met clinical and computed tomography criteria for CRS unresponsive to maximal medical therapy and no prior sinus- or adenoid-related procedures were eligible. Twenty-five patients were randomized, had surgery, and completed the follow-up. The control group underwent adenoidectomy with maxillary sinus irrigation alone; the treatment group underwent the same, with the addition of maxillary BCS for the maxillary sinus irrigation. Patients and parents were blinded to group assignment throughout the follow-up time frame. A validated questionnaire, the Sinus and Nasal Quality of Life Survey (SN-5), was used to measure health status changes and quality of life (QOL) at baseline, 6 months, and 12 months postintervention. Data was analyzed using t tests and multivariate linear regression.

RESULTS

There were 12 patients in the BCS group and 13 in the control group. Other than a higher atopic history in the control group (P = 0.047), there were no significant differences (P = 0.07) in the two groups (demographics and baseline SN-5 scores). Following surgery, both groups demonstrated similar improvement in QOL scores and median SN-5 scores in all domains (number of sinus infections, nasal obstruction, allergy symptoms, emotional distress, and activity limitations).

CONCLUSION

The addition of BCS to adenoidectomy/maxillary sinus irrigation did not provide additional QOL and sinonasal symptom improvement in the surgical treatment of pediatric CRS.

LEVEL OF EVIDENCE

1b Laryngoscope, 128:2893-2897, 2018.

Modified In-Office Maxillary Balloon Sinus Dilation for Post-Procedure Sinus Monitoring and Access

Introduction  As experience grows with in-office balloon sinus dilation (BSD) procedures, technique modifications will evolve to meet specific needs. The major disadvantage with the maxillary BSD procedure is that the intact uncinate process prevents visualization of and instrument access into the maxillary sinus both intraoperatively and postoperatively. Combining a partial or complete uncinectomy procedure with maxillary BSD could be beneficial in selected patients with certain maxillary sinus problems.

Objective  The primary objective of this study was to see if, in selected patients, combining an uncinectomy and maxillary sinus BSD together allowed visualization of and access to the maxillary sinus cavity at the time of the procedure and at follow-up visits.

Method  A chart review was completed for BSD cases performed from 2013 through mid-2015 identifying patients who underwent partial or complete uncinectomy with in-office maxillary sinus BSD. A total of 14 patients were identified, with 26 sinuses treated. The data collected included: difficulty or problems in performing an uncinectomy with the maxillary sinus BSD; visualization and access to the maxillary sinus cavity both intraoperatively and at follow-up visits; and occurrence of complications or late adverse sequelae. All patients completed a minimum 6-month follow-up.

Results  Combined uncinectomy and maxillary sinus BSD procedures were easily completed for all patients without complications, and no late adverse sequelae were encountered. The maxillary sinuses could be visualized and accessed, if needed, intraoperatively and at all follow-up visits.

Conclusions  In selected subsets of maxillary sinus conditions this procedure modification can provide significant benefits. A case is presented for illustration.

Sinus procedures in the Medicare population from 2000 to 2014: A recent balloon sinuplasty explosion

OBJECTIVE

To describe sinus procedure trends from 2000 to 2014, particularly following the introduction of balloon sinuplasty Common Procedural Technology (CPT) codes in 2011.

STUDY DESIGN

Retrospective review of Medicare billing data available to the public.

METHODS

Procedure and beneficiary data from 2000 to 2014 and provider data from 2012 to 2014 were obtained online from the Centers for Medicare and Medicaid Services. Sinus CPT codes were classified as balloon sinus procedure (BSP) or nonballoon sinus procedure (nBSP). Providers billing for sinus procedures were categorized as BSP only, nBSP only, or both. For comparison, data on septoplasty procedures from 2000 to 2014 were obtained.

RESULTS

From 2000 to 2014, the total number of sinus procedures per 10 thousand beneficiaries (PP10K) nationwide increased by 3.7% annually. From 2011 to 2014, nBSP PP10K decreased by 3.1% annually, and BSP PP10K increased by 59% annually. Septoplasty PP10K changed by < 1% annually between 2000 and 2014. States with the highest BSP PP10K from 2012 to 2014 were Kansas, Texas, and Louisiana. Providers performing sinus procedures increased by 30.9% from 2012 to 2014. There was a 244% increase in BSP-only providers, a 0.7% increase in nBSP-only providers, and an 83.3% increase in providers using both. Septoplasty providers increased by 4.1%.

CONCLUSION

Although the total number of sinus procedures increased from 2000 to 2014, the number of BSP increased at a substantially greater rate since the introduction of CPT codes for these procedures in 2011. Nationwide increases in sinus providers were driven by new providers performing balloon-guided procedures.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1976-1982, 2017.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

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

BACKGROUND

The objectives of this study were as follows: (1) to evaluate frontal sinus ostial patency following balloon dilation with the Ventera Sinus Dilation System, compared with frontal sinusotomy (Draf 2a); and (2) to compare mean blood loss and mean surgical time for frontal sinusotomy using balloon dilation compared with traditional surgical methods.

METHODS

A single blinded, randomized, controlled, prospective study was performed at St. Paul's Sinus Center, Vancouver, a tertiary referral rhinology center. Thirty patients undergoing functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS) were randomized to a hybrid approach with exposure of the frontal recess using standard instrumentation and then balloon dilation of 1 frontal sinus drainage pathway and traditional frontal sinusotomy for the opposite side. Blood loss and surgical time for opening the frontal sinus drainage pathway was recorded for each side. Patients acted as their own controls. Ostial patency and size were assessed 5 weeks and 3 months postoperatively using endoscopy. Ostial patency was also recorded at 1 year following surgery.

RESULTS

All frontal sinus ostia in both groups (n = 30) were successfully opened and were patent with both techniques 3 months postoperatively. All frontal sinus ostia assessed at 1 year (73%) remained patent and none required revision frontal surgery. Balloon dilation showed a mean surgical time of 655 seconds compared to 898 seconds for traditional FESS (p = 0.03). Mean blood loss was less with balloon dilation (58 mL vs 91 mL; p = 0.008).

CONCLUSION

A hybrid balloon technique successfully dilates the frontal sinus drainage pathway with reduced blood loss. Also, short-term patency appears to be comparable to traditional frontal sinusotomy.

Operative utilization of balloon versus traditional endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic sinus surgery (ESS) STUDY DESIGN: Cross-sectional analysis

METHODS

Cases identified by Current Procedural Terminology codes as BCD (2,717) or traditional ESS (31,059) were extracted from the State Ambulatory Surgery Databases 2011 for California, Florida, Maryland, and New York. Patient demographics, surgical center and surgeon volume, mean charge, and operating room (OR) time were compared.

RESULTS

There were 33,776 patients who underwent sinus surgery in the included states in 2011. Of these, 4.6% of maxillary, 5.6% of sphenoid, and 13.9% of frontal procedures were performed using BCD. Adjusted analyses found increased use of BCD in patients with chronic diseases(P < .001). Patients who had limited sinus surgery were less likely to have BCD compared to patients who had all four sinuses instrumented (P < .001). Surgeons who performed a medium (odds ratio 1.38 [1.14-1.65]) or high (odds ratio 1.71 [1.42-2.07]) volume of ESSs were more likely to use BCD compared to those who performed a low volume (P < .001). However, among surgeons who utilized BCD, there was a minimal relationship between the percentage of surgeries performed with BCD and the surgeon's total number of cases (R(2) = 0.055). Compared to traditional ESS, the median charges for maxillary/ethmoid procedures (mini-ESS) involving BCD were approximately $4,500 (P < .001) and maxillary/ethmoid/sphenoid/frontal procedures (pan-ESS) were approximately $2,950 (P = .003) greater, whereas the median OR time involving BCD was 8 minutes less for mini-ESS procedures(P = .01) but not statistically different for pan-ESS procedures (P = .58).

CONCLUSIONS

In the study sample, balloon technology was used in 8.0% of ESS cases in 2011. Procedures using BCD were on average more expensive compared to traditional ESS procedures, with minimal decrease in OR time.

Current utilization of balloon dilation versus endoscopic techniques in pediatric sinus surgery

OBJECTIVES

To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic surgery (ESS) in pediatric patients.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Hospital and freestanding ambulatory surgery centers in California, Florida, Maryland, and New York

SUBJECTS

Patients less than 18 years who underwent BCD(316) or ESS(2346), as identified by CPT codes from the State Ambulatory Surgery Databases 2011.

METHODS

Patient and facility demographics, mean charges, and operating room time were examined using bivariate and multivariate analyses.

RESULTS

A total of 2662 children underwent surgery, with BCD used in 10.6% of maxillary, 8.4% of sphenoid, and 11.8% of frontal procedures. Adjusted analysis found that children with asthma, allergic rhinitis (AR), GERD, or concomitant adenoidectomy were more likely to have BCD compared to patients without these comorbidities, asthma odds ratio (OR) = 1.94 (95% CI, 1.84-3.41), AR OR = 1.77 (95% CI, 1.03-3.07), GERD OR = 2.79 (95% CI, .59-4.90), or without adenoidectomy OR = 2.50 (95% CI, 1.84-3.41). Patients with cystic fibrosis were less likely to have BCD, OR = 0.33 (95% CI, 0.11-0.95). Median charges for patients undergoing maxillary antrostomy alone by BCD (P = .042) or with adenoidectomy (P < .001) were approximately $2100 and $4200 greater than the median of patients undergoing those procedures with ESS. However, operating room time was similar (P = .81) between patients undergoing maxillary antrostomy, regardless of whether BCD was used, but was longer (P < .001) in those undergoing maxillary antrostomy and adenoidectomy when BCD was utilized.

CONCLUSIONS

BCD was used in 11.9% of pediatric sinus surgery and had higher average charges with no decrease in OR time compared to procedures that only utilized ESS. Future research is necessary to evaluate whether BCD may lead to improved outcomes and eventually decreased operating room time for pediatric patients with chronic rhinosinusitis.

The normal uncinate process: histology and clinical relevance

In this three-center, prospective, non-randomized, controlled trial, we performed a qualitative and quantitative histological and morphometric assessment of the normal uncinate process (UP). The soft tissue and bony elements of the normal UP of 16 adults were investigated and compared with 28 age- and gender-matched archival reference-group samples of neighboring structures of the inferior and middle turbinates. A series of measurements were taken and included the thickness of the mucosal layers and bone, epithelial height, basement membrane thickness, number of lamina propria inflammatory cells, and the area fraction (AF) of the epithelium, connective tissue, glands, veins and arteries. The data showed that the medial and lateral mucosal layers are built of loose connective tissue and harbor various inflammatory cell population, abundant glands, and thin-walled small-caliber venules. In-between, there is a thin lamellar compact bone (≤ 80 μm) or a significantly thicker cancellous bone (110-400 μm; P < 0.001). Both mucosal layers are similar in thickness, epithelial height, basement membrane thickness, and AF of soft-tissue constituents. A comparison with the lateral aspect of the inferior and middle turbinates showed that the AF of the connective tissue, total submucosal glands, submucosal serous and mucous glands, and veins of the lateral mucosa are significantly different (all P < 0.001). This diversity may point to different physiological roles for the UP and the inferior and middle turbinates. The UP rich glandular network, which is probably responsible for drainage and ventilation of the maxillary sinus into the ethmoid infundibulum laterally and the frontal sinus into the middle meatus medially, supports the argument that it is preferable, particularly for the less complicated cases, to keep the normal physiology of the ethmoid infundibulum and use bone- and mucosa-sparing techniques for the management of refractory chronic sinus disease.

Mometasone implant for chronic rhinosinusitis

The Propel mometasone-eluting stent (Intersect ENT, Palo Alto, CA) is the first Food and Drug Administration-approved device for delivering steroid medication into the ethmoid cavity following surgery. The implant is composed of a biodegradable polymer in a lattice pattern that expands in a spring-like fashion to conform to the walls of a dissected ethmoid cavity and contains a total of 370 μg of mometasone furoate designed for gradual release over 30 days. The purpose of this article is to review the mode of action and the evidence supporting the efficacy of this novel technology. Three recently published clinical trials have demonstrated that the mometasone-eluting stent produced statistically significant reductions in inflammation, polyp formation, and postoperative adhesions. In addition, the implant has been found to significantly reduce the need for postoperative administration of oral steroids and to decrease the frequency of postoperative lysis of adhesions. Minimal adverse effects were reported in these trials and included infection, crusting, and granulation tissue formation. Although the placement of steroid-impregnated packing, stents, sponges, and gels has previously been used in the postoperative sinus cavities, the Propel mometasone-eluting stent introduces a new mechanism for localized and controlled delivery of topical therapy directly to the nasal mucosa for chronic rhinosinusitis.

Sinonasal manifestations in cystic fibrosis

Cystic fibrosis is a genetic disease, characterized by accumulation of thickened mucous secretions in exocrine glands. Although the major clinical manifestations of the disease are pancreatic and pulmonary disease, the majority of cystic fibrosis patients will develop sinonasal manifestations as well. This paper outlines the etiology, evaluation, and management of the nasal and sinus manifestations in patients with cystic fibrosis.

State of the art treatment of nasal polyposis

BACKGROUND

Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis.

METHODS

A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy.

RESULTS

Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation.

CONCLUSION

Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.

Balloon sinuplasty: a minimally invasive option for patients with chronic rhinosinusitis

Rhinosinusitis affects ~37 million people in the United States and accounts for almost 2% of all primary care office visits. Chronic rhinosinusitis (CRS) is often successfully managed in the primary care setting using antibiotics, topical or oral steroids, and saline nasal irrigation. Surgery is an option when medical management fails. Balloon sinuplasty is a minimally invasive endoscopic treatment, which is often used in combination with surgery. It aims to restore ostial patency with minimal mucosal damage, and it is indicated for dilatation of the paranasal sinuses for diagnostic and therapeutic purposes. The technology gently displaces, microfractures, and molds the bone surrounding the sinus outflow and may be used alone or in combination with conventional endoscopic surgery. Recent uncontrolled retrospective and prospective studies have reported the effectiveness and safety of balloon sinuplasty, including radiographic evidence of sinus patency and improved sinus-related quality of life scores for up to 2 years after balloon dilation. An examination of adverse events during a postmarketing assessment of balloon sinuplasty identified a total of 3 major complications among 28 500 patients, with a total of > 85 000 treated sinuses. While randomized controlled trials comparing balloon sinuplasty with conventional functional endoscopic sinus surgery have not been conducted, existing prospective and retrospective assessments suggest that balloon sinuplasty is a viable option for sinus intervention, either alone or in combination with conventional surgical treatment.