Balloon Sinuplasty: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

The Value of Multiple Medication Trials Prior to Balloon Sinuplasty in the Management of Chronic Sinonasal Disease

Introduction  In patients with chronic rhinosinusitis, conservative interventions with extended medical trials are often attempted prior to procedural treatment. Balloon sinuplasty (BSP) is an established procedure for symptomatic relief from chronic rhinosinusitis. However, data suggesting the suboptimal efficacy of prolonged medication management trials, prior to BSP, is lacking. Objectives  The purpose of this study was to evaluate the efficacy of prolonged medication management trials, prior to BSP, for patients with chronic rhinosinusitis. Methods  A retrospective review was performed for all adults with chronic rhinosinusitis who received extended medical management prior to their BSP at two outpatient clinics, from November 1, 2013, to June 31, 2018. The patients' Sino-Nasal Outcome Test (SNOT) scores were compared between baseline, post-medication trials, and post-BSP. Results  The SNOT scores of a total of 64 patients were collected. Overall, patients showed a significant worsening of symptoms during the medication management trials from baseline ( p  = 0.002126) but significant improvement of symptoms after undergoing BSP ( p  < 0.0001). Conclusion  The patient symptom burden worsened and prolonged during medication management trials. The BSP procedure alone showed significant improvement in the quality of life for chronic rhinosinusitis patients, when considering their SNOT scores. The worsening of patients' symptoms during medication management may invalidate the necessity of prolonged medication management trials.

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.

Posttreatment Imaging of the Paranasal Sinuses Following Endoscopic Sinus Surgery

Endoscopic sinus surgery is a minimally invasive option for the treatment of several nonneoplastic indications, particularly for medically refractory sinusitis and polyposis. Numerous interventions can be performed through endoscopic sinus surgery, many of which may be performed together during the same procedure. There are also a variety of complications that can result from endoscopic sinus surgery. Radiological imaging plays an important role in the evaluation of patients after endoscopic sinus surgery. Thus, it is important to be familiar with the expected and complicated imaging findings associated with endoscopic sinus surgery, which are reviewed in this article.

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.

Improving patient care via development of a protein-based diagnostic test for microbe-specific detection of chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The hypothesis is that signature bacterial proteins can be identified in sinus secretions via high-throughput, proteomic based techniques. Nontypeable Haemophilus influenzae (NTHI) is the most common bacterial pathogen associated with sinusitis and serves as proof of principle pathogen for identifying biomarkers.

STUDY DESIGN

In vitro and in vivo studies using proteomic-based analysis of cultures of NTHI and a novel, experimental chinchilla polymicrobial sinusitis model.

METHODS

Nano-liquid chromatography /tandem mass spectrometry (nano-LC-MS/MS) was performed to annotate the secretome from an NTHI biofilm. A model of NTHI-induced sinusitis was developed in a chinchilla, and NTHI proteins were detected in chinchilla secretions. A reference standard RT-PCR-based assay was adapted to allow for sensitivity and specificity testing of the identified signature biomarkers in human patients.

RESULTS

Outer membrane proteins P2 (OMP-P2) and P5 (OMP-P5) were identified as promising candidates for the detection of NTHI biofilms and positively detected in nasopharyngeal secretions of chinchillas experimentally infected with NTHI. An RT-PCR based test for the presence of NTHI biofilms demonstrated 100% sensitivity and 100% specificity when tested against eight unique strains commonly found in human bacterial rhinosinusitis.

CONCLUSIONS

Proteomic analysis was successful in identifying signature proteins for possible use as a biomarker for chronic rhinosinusitis (CRS). OMP-P2 and OMP-P5 were validated as promising candidates and were positively detected from nasopharyngeal secretions from chinchillas experimentally infected with NTHI. Collectively, these data support the use of OMP-P2 and OMP-P5 as biomarkers for a human clinical trial to develop a point-of-care medical diagnostic test to assist in the diagnosis and treatment of CRS.

Chapter 12: Surgery for sinonasal disease

Surgery for chronic rhinosinusitis is an effective complement to a well-designed medical regimen. Functional endoscopic sinus surgery is among the most common surgeries performed for sinonasal disease refractory to maximal medical therapy. Nasal surgery techniques, such as septoplasty and inferior turbinate surgery, may assist in both relieving the symptom of nasal obstruction and providing access for sinus surgery. Although rare, open sinus techniques are occasionally required.

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.

Case report of orbital violation with placement of ethmoid drug-eluting stent

BACKGROUND

Delivery of topical therapy is a mainstay in the treatment of chronic rhinosinusitis (CRS). Ethmoid sinus stenting has recently been introduced as a minimally invasive mechanism to deliver medication. We review available literature on ethmoid stenting and present a case report involving orbital violation and a fixed, dilated pupil.

METHODS

Case report and literature review.

RESULTS

A 37 year-old female underwent endoscopic placement of bilateral ethmoid sinus drug-eluting stents for CRS at an outside facility. Postoperatively she complained of right-sided ocular pain and pressure. She was seen in the emergency setting on post-operative day (POD) 2 and had a dilated right pupil. A computed tomography (CT) scan was performed and read as normal. The left stent was removed successfully on POD 19; the right could not be removed in the outpatient setting secondary to pain. The patient was transferred to our facility on POD 21. The CT from POD 2 was reviewed and demonstrated violation of the lamina papyracea and orbit with the stent abutting the lateral orbital wall. On POD 24, the patient underwent medial orbital decompression and successful stent removal but continues to have a dilated pupil in the affected eye.

CONCLUSION

This is the first reported case of orbital violation with placement of an ethmoid drug-eluting stent. The literature shows feasibility in cadaveric studies but the practitioner must be diligent in placement. Ethmoid sinus stenting is an option for topical treatment of ethmoid sinusitis but practitioners must be cognizant of potential risks when counseling patients.

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.