Medical therapy versus sinus surgery by using balloon sinus dilation technology: A prospective multicenter study

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.

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.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures

OBJECTIVE

Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions.

STUDY DESIGN

Retrospective review.

SETTING

Single institution, level 1 trauma center.

METHODS

Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery.

RESULTS

Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoid complex fractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed.

CONCLUSION

Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

Prevalence and clinical presentation of sinusitis in pediatric age group in Aseer, Saudi Arabia

Background:

Paediatric rhinosinusitis is mostly different than that in adults. More frequently, children presented with cough, bad breath, crankiness, low energy, and swelling around the eyes, besides a thick yellow-green nasal or post-nasal discharge. About 5- 13% of childhood viral upper respiratory tract infections may advance to acute rhinosinusitis, with some of them developing a chronic condition.

Aim:

To assess prevalence and clinical presentation of sinusitis in the paediatric age group in Aseer, Saudi Arabia.

Methodology:

A retrospective record-based study was conducted in Abha Maternity and Children Hospital in Abha city, Saudi Arabia between January 2015 and January 2018. All medical records during the study period for children whose from to 15 years old attended the hospital and diagnosed as having sinusitis were included.

Results:

The study included 100 children with complete files whose ages ranged from less than 1 year to up to 13 years old with a mean age of 5.3 4.2 years. Nearly 51% of the children aged 4 years or less and male were 53 (53%). Past history for chronic rhinosinusitis (CRS) was positive among 30 children. Regarding clinical presentations of rhinosinusitis (RS) as reported by the children caregivers, fever was the most reported complaint (50%) followed by red eye (44%), ringing nose (42%), cough (41%) and headache (36%). Mucous culture was positive among 58 cases. The most isolated pathogens were streptococcus pneumoniae (45.6%), Haemophilis influenza (24.6%).

Conclusions:

In conclusion, the study revealed that CRS is a common disease in children at different ages, especially, maxillary and frontal sinuses. In most of the cases, medical treatment is highly appreciated; though, surgical intervention may be needed in a small percentage.

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.

Medicare Reimbursement for Balloon Catheter Dilations Among Surgeons Performing High Volumes of the Procedures to Treat Chronic Rhinosinusitis

Importance

Chronic rhinosinusitis is among the most common and costly conditions treated by physicians. After failure of medical treatment, surgical intervention in the form of endoscopic sinus surgery is traditionally offered. Balloon catheter dilation (BCD) has become a less-invasive alternative with increasing popularity among otolaryngologists.

Objective

To evaluate the most recent BCD data in the Medicare population, with a specific focus on the percentage of procedures performed by surgeons who perform high volumes of this procedure, their reimbursements, and their national geographic distributions.

Design, Setting, and Participants

This retrospective review included data from 2011 through 2017 from Medicare Part B National Summary Data Files and Medicare Provider Utilization and Payment Data. Patients with procedures including Current Procedural Terminology codes 31295 (maxillary sinus dilation), 31296 (frontal sinus dilation), and 31297 (sphenoid sinus dilation) were included.

Exposures

Balloon catheter dilation of the paranasal sinuses.

Main Outcomes and Measures

Total and mean reimbursements over time to physicians for BCDs, as well as the percentage of BCDs performed by and reimbursed to ear, nose, and throat (ENT) surgeons who perform high volumes of BCDs (>10 procedures) in a given year.

Results

The total number of BCDs rose from 7496 in 2011 to 43 936 in 2017 (a 486% increase). The overall reimbursement increased from $11 773 049 in 2011 to $63 927 591 in 2017 (a 433% increase). From 2012 to 2016, ENT surgeons who performed high volumes of the procedures rose from 101 to 382 surgeons (a 270% increase). In 2016, 25 214 of 41 960 BCDs (60.1%) were performed by ENT surgeons performing high volumes of the procedure, compared with 5603 of 13 109 procedures (42.7%) in 2012. In a line of best fit, at the 75th percentile of procedure volume, there was an increase of 4.2 BCDs in the median number of procedures done per physician per year, compared with an increase of 1.5 BCD procedures per physician per year in the line of best fit for the 50th percentile.

Conclusions and Relevance

Balloon catheter dilation continues to increase in popularity among otolaryngologists treating chronic rhinosinusitis. Most BCDs are performed by ENT surgeons who perform high volumes of the procedure.

Outcomes and Complications of Balloon and Conventional Functional Endoscopic Sinus Surgery

Background

Since the Food and Drug Administration approval of balloon sinuplasty (BSP) in 2005, no nationally representative population-based studies have examined the outcomes and adverse events of BSP.

Objective

To assess the rates of complications and revision surgery in patients who received BSP, functional endoscopic sinus surgery (FESS), or a hybrid procedure.

Methods

Using one of the nation’s largest commercial insurance databases, we conducted a retrospective cohort study of pediatric and adult patients diagnosed with chronic rhinosinusitis between 2011 and 2014 who underwent BSP, conventional FESS, or a hybrid procedure. The primary outcomes were surgical complication and revision rates within 6 months of initial surgery.

Results

A total of 16,040 patients who underwent sinus surgery were included. Overall, 2,851 patients underwent BSP, 11,955 underwent conventional FESS, and 1 234 underwent a hybrid procedure. BSP surgery was more likely to have been performed in an office setting (86.53%) compared to FESS (0.74%). The complication rate was 5.26% for BSP and 7.35% for conventional FESS. Revision rates were 7.89% for BSP, 16.85% for FESS, and 15.15% for a hybrid procedure.

Conclusion

Despite the low overall risk, major complications occur with BSP including cerebrospinal fluid leak, pneumocephalus, orbital complications, and severe bleeding. Otolaryngologists should discuss these risks with their patients. Prospective studies are still needed to compare outcomes of BSP with those of FESS.

Medical Therapy Versus Balloon Sinus Dilation in Adults With Chronic Rhinosinusitis (MERLOT): 12-Month Follow-up

Background Chronic rhinosinusitis (CRS) is a devastating disease affecting nearly 30 million people in the United States. An interim analysis of data from the present study suggested that, in patients who had previously failed medical therapy, balloon sinus dilation (BSD) plus medical management (MM) provides a significant improvement in the quality of life (QOL) at 24 weeks postprocedure compared to MM alone. Objective The primary objective of this final analysis was to evaluate the durability of treatment effects through the 52-week follow-up. Methods Adults aged 19 and older with CRS who had failed MM elected either BSD plus MM or continued MM. Patients were evaluated at 2 (BSD arm only), 12, 24, and 52 weeks posttreatment. Balloon dilations were performed either as an office-based procedure under local anesthesia or in the operating room per physicians' and patients' discretion. The primary end point was change in patient-reported QOL as measured by Chronic Sinusitis Survey (CSS) total score from baseline to the 24-week follow-up. Secondary outcomes including changes in CSS, Rhinosinusitis Disability Index (RSDI), and Sino-Nasal Outcome Test (SNOT) total and subscores, sinus medication usage, missed days of work/school, number of medical care visits, and sinus infections from baseline to the 52-week follow-up are reported here within. Results BSD led to sustained greater improvements in self-reported QOL using the CSS and RSDI total scores with a trend toward improvement in the SNOT-20 total score from baseline to the 52-week follow-up compared to continued MM. There were no changes in medication usage apart from nasal steroid usage for which the MM cohort had an increase in usage. There were no device-related serious adverse events. Conclusion The current analysis highlights the safety, effectiveness, and durability of BSD in CRS patients aged 19 and older who had previously failed MM.

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.