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

Effect of Partial Uncinectomy After Balloon Sinuplasty on Maxillary Sinus Irrigant Penetration: A Cadaveric Study

Objective

The uncinate process may play a role in the amount of irrigation penetrance. In this cadaver study, we aimed to investigate if the addition of partial uncinectomy provides better maxillary sinus irrigation penetrance than balloon sinuplasty (BSP) alone.

Study Design

Cadaveric study.

Setting

Simulation laboratory at the Mayo Clinic in Florida.

Methods

Five fresh-frozen human cadaveric heads (10 sides) were used to assess maxillary sinus irrigation penetration after 3 interventions performed sequentially: irrigation penetrance with no intervention, irrigation after BSP, and irrigation after BSP and partial removal of the uncinate. Penetrance was recorded with intrasinus endoscopy and scored by 4 blinded observers using a scale from 0 (no irrigation) to 5 (fully irrigated). The diameter of the maxillary ostium was measured before and after BSP. Internal consistency was evaluated with Cronbach’s alpha.

Results

Mean ostium size increased from 4.1 to 6.8 mm after BSP (P = .013). Cronbach’s alpha was 0.93. The median scores of irrigation penetration after no intervention, BSP, and BSP and partial uncinectomy were 2.5, 3, and 4, respectively. We found a significantly higher penetrance following partial uncinectomy plus BSP versus BSP alone (P = .008). Both interventions had a statistically significant difference in irrigation penetrance as compared with no intervention (P = .0001).

Conclusion

Maxillary sinus irrigation penetration increased from baseline after BSP. The addition of a partial uncinectomy to the balloon dilation of the maxillary sinus was associated with a statistically significant increase in irrigation penetrance scores as compared with BSP alone.

Long term outcomes of balloon sinuplasty for the treatment of chronic rhinosinusitis with and without nasal polyps

OBJECTIVES

The aim of this study was to evaluate the 4-year outcomes and effectiveness of balloon sinuplasty in the treatment of chronic rhinosinusitis (CRS).

MATERIAL AND METHODS

We evaluated the long-term outcomes in terms of symptoms, nasal endoscopy and computed tomography of 110 patients with CRS submitted to balloon sinuplasty in Centro Hospitalar do Funchal retrospectively. Sinus symptoms were determined by the Sino-Nasal Outcome Test (SNOT-22), endoscopic examination determined by Modified Lund Kennedy score (MLK) and computerized tomography scan of paranasal sinuses (CT-PNS) was evaluated through Lund Mackay scores (LM). Data was collected from 82 patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and from 28 patients with nasal polyps (CRSwNP).

RESULTS

Local anesthesia procedures were performed in 45.5% of the patients. First follow up was obtained at 2 years (median 22.45 ± 13.6 months) and at 4 years (median 44.45 ± 14 months) after balloon sinuplasty. The mean baseline SNOT-22 score was of 50.26 ± 15.33 for patients with CRSsNP and 52.25 ± 18.06 in CRSsNP patients. Both scores were reduced to 7.00 ± 13.5 and 10.00 ± 22.50 at 4 years follow-up respectively. Baseline MLK score was 4.90 ± 2.12 for patients in CRSsNP group and 10.00 ± 2.00 in the CRSwNP group Both scores were reduced to 1.65 ± 1.67 and 4.86 ± 2.16. The overall mean average LM CT-PNS score was 8.71 ± 4.728 preoperatively for the CRSsNP and 16.18 ± 3.9 in patients with CRSwNP and were reduced to 1.00 ± 1.75 and 8.69 ± 4.6 after BSP. SNOT 22, MLK and LM scores showed consistent improvement over baseline at all time points until the end of the study (median 44.45 ± 14 months). Significant improvements were recorded at all time points in the patient's symptom score, nasal endoscopy scores and imaging scores (P < 0.0001).

CONCLUSION

Balloon sinuplasty appears to be safe and effective for the treatment of CRS with great long-term outcomes.

Efficacy and safety of paranasal sinus balloon catheter dilation in pediatric chronic rhinosinusitis: a systematic review

Objective

Chronic rhinosinusitis (CRS) negatively affects quality of life (QoL), and balloon catheter sinuplasty (BCS) has shown good outcomes in adult patients. However, there has not been much research on the effects of BCS on pediatric patients. The objective of this review is to systematically assess the literature for studies demonstrating the effectiveness and safety of BCS in pediatric CRS patients.

Data sources

PubMed, Embase and Cochrane Library.

Study selection

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA) to conduct our study. Observational- and interventional-based studies reporting efficacy and/or side effects of BCS among pediatric populations were included. Efficacy was evaluated by clinically reliable measures including Sino-Nasal 5 (SN-5) QoL scale. Antibiotic usage and revision surgery were also evaluated.

Data extraction

Articles were screened, and data were obtained. Study design, sample size and demographics, treated sinuses, criteria of inclusion, adjunct procedure(s), follow-up time, and outcomes measured were reported.

Main findings

Out of 112 articles identified, 10 articles were included: two interventional controlled trials and eight observational studies. All studies evaluating QoL by SN-5 showed a remarkable reduction in SN-5 score postoperatively. Improvement in the computed tomography (CT) and endoscopic findings for up to 1 year after operation was reported. Furthermore, the majority of patinets treated with BCS did not recieve any course of sinusitis-indicated antibiotics during long-term follow-up, and they had low surgical revision rates. Minor side effects were reported, most commonly synechia.

Conclusion

Available evidence suggests that BCS is safe and effective for the treatment of CRS in pediatric patients. Future randomized controlled studies with large sample size are warranted. Such studies can further determine the efficacy of BCS in managing children with CRS.

3-year follow-up after balloon sinuplasty in children with chronic rhinosinusitis

OBJECTIVE

Balloon sinuplasty could restore nasal sinus drainage and airflow, limiting the damages and lowering the risks. This study aimed to assess the 3-year clinical efficacy, safety, and satisfactory degree of balloon sinuplasty through multiple aspects. Also the experience about treatment for postoperative adhesion was described.

MATERIALS AND METHODS

A study was performed in 30 children who had failed medical therapy, and received Balloon sinuplasty of selected sinuses. Data in 3-year follow-up including questionnaire, VAS, CT, and nasal endoscopy findings were collected. Also postoperative nose-related medications or auxiliary therapies, revision surgery, and incidence of complications were collected. The satisfactory degree of children and parents were assessed.

RESULTS

Compared to preoperative, the VAS scores, questionnaire (SN-5 or SNOT-22) scores and Lund-Mackay scores were significantly lower. In the 3-year follow-up, most of them did not require nose-related medications or auxiliary therapies, and were free of symptoms, or the symptoms did not affect their daily activities. None of the 30 children had complications of facial pain, teeth numbness, facial deformity, and dysosmia. However, nasal cavity adhesion still remained the most frequent. The satisfactory degree was relatively high.

CONCLUSION

The 3-year follow-up demonstrated that balloon sinuplasty had high clinical efficacy and safety, the satisfactory degree of children and parents remained relatively high. Improved the upper respiratory infection and increased the immunity, which were considered effective methods to reduce the risk of recurrence. Nasal spraying of steroids and nasal irrigation in three months after surgery cold help prevent the nasal cavity adhesion.

[Balloon sinuplasty in children - Russian first experience]

AIM

To evaluate and compare the clinical outcome and impact of balloon sinuplasty and functional endoscopic sinus surgery (FESS) on the quality of life of pediatric patients and adolescents suffering from chronic rhinosinusitis (CRS).

MATERIAL AND METHODS

A retrospective study was performed of 47 children with failed medical therapy, who were scheduled for surgery. The first one pediatric balloon sinuplasty was performed by Ilya Zyabkin in Filatov Children's City Hospital on the 30-th of August 2012.They underwent treatment by balloon sinuplasty of selected sinuses in 553% (n=26) cases and hybrid FESS with BSP - in 44.7% (n=21). Data were collected, including perioperative CT Lund-Mackay score and SN-5 quality of life findings.

RESULTS

Compared with preoperative values, Lund-Mackay scores were significantly lower at 1 year (p<0.05) in 92,3% (n=12) patients after surgery. Moreover, balloon sinuplasty improved sinusrelated quality of life score in 93.3% (n=42) patients for up to 1 year after operation (p<0.05).

CONCLUSION

Balloon sinuplasty showed a clinical curative effect in the treatment of children and adolescents with refractory CRS, and was relatively safe by itself. BSP allows to postpone, if necessary, FESS or avoid circular mucosal trauma and infundibulotomy in hybrid FESS with balloon sinuplasty technique.

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.

The role of industry influence in sinus balloon dilation: Trends over time

OBJECTIVE

Balloon dilation (BD) is a controversial alternative to conventional sinus surgery. The role of industry on practice patterns remains unknown. The aim of this study was to determine whether industry payments from BD manufacturers influence practice patterns for otolaryngologists and evaluate how these payments change over time.

METHODS

Retrospective cohort study using Medicare Provider Utilization and Payment (PUP) Data and Center for Medicare and Medicaid Services Open Payments (OP) general payment datasets. A total of 294 otolaryngologists identified in the PUP dataset who performed BD procedures from January 1, 2013, to December 31, 2015, were cross-referenced in the OP dataset from January 1, 2014, to December 31, 2016, for BD manufacturer payments. Payments to surgeons performing BD stratified by amount, type, and number of procedures performed were primary outcome measures.

RESULTS

Of the 294 otolaryngologists reporting BD procedures, 223 (76%) received payments from a company that manufactures BD devices. Receipt of $2,500 in BD payments was associated with performance of one additional BD procedure, and consulting fees were most positively associated with performing additional BD procedures (P = 0.006). The providers receiving the most in BD payments were more likely to continue to receive the most in payments, regardless of number of BD procedures performed. Performing more BD procedures did not correlate with decrease in other sinus procedures.

CONCLUSION

Payments to otolaryngologists from manufacturers of sinus BD devices are associated with the performance of an increased number of such procedures. Surgeons should consider the impact of interactions with industry when evaluating patients for BD procedures.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1540-1545, 2018.

The XprESS Multi-Sinus Dilation System for the Treatment of Chronic Sinusitis: A NICE Medical Technology Guidance

The XprESS multi-sinus dilation system (XprESS) is a minimally invasive alternative to functional endoscopic sinus surgery (FESS) used in the treatment of people with chronic or recurrent acute sinusitis refractory to medical treatment. The manufacturer of XprESS, Entellus Medical, claims the technology is as effective as FESS in improving quality of life and is associated with quicker recovery times and reduced costs. The Medical Technologies Advisory Committee (MTAC) at the National Institute for Health and Care Excellence (NICE) selected XprESS for evaluation. Nine trials published in 13 papers were correctly identified by the company as relevant to the decision problem, including one randomised controlled trial (REMODEL study). From this evidence, the company concluded that XprESS is as beneficial as FESS for a range of clinical endpoints. The External Assessment Centre (EAC) agreed with the company's conclusion in a subgroup of patients, but judged that the evidence did not generalise to patients within the NHS fully. The company constructed a de novo costing model. XprESS generated cost-savings of £1302 per patient compared with FESS. The EAC critiqued and updated the model's inputs, with differences in results driven by changes in assumptions on procedure duration, length of hospital stay and the proportion of procedures undertaken in an outpatient setting under local anaesthetic. Although cost-incurring in the base case, XprESS generated cost savings under certain scenarios. The MTAC reviewed the evidence and supported the case for adoption, issuing positive draft recommendations. After public consultation NICE published this as Medical Technologies Guidance 30.

Clinical curative effect and safety of balloon sinuplasty in children with chronic rhinosinusitis

OBJECTIVE

Balloon Sinuplasty for the management of paranasal sinus inflammatory diseases was introduced in otolaryngology in 2005. Over the past decade, evidence strongly supports its safety and efficacy for the treatment of chronic rhinosinusitis (CRS) in adults. Because it requires no bone or tissue removal, this procedure could be suitable in children. We present our initial experience of its use for the treatment of CRS in children.

MATERIALS AND METHODS

A prospective study was performed of 30 children with failed medical therapy, who were scheduled for surgery. They underwent treatment by balloon sinuplasty of selected sinuses. Data were collected, including age, VAS score, CT score, and nasal endoscopy findings.

RESULTS

The procedure was successful in 61/65 sinuses (93.84%). Balloon sinuplasty improved sinus-related quality of life scores as well as computed tomography (CT) and endoscopic findings for up to 1 year after operation (p < 0.05).

CONCLUSION

In this initial study, balloon sinuplasty showed a clinical curative effect in the treatment of children with refractory CRS, and was relatively safe. Structural abnormalities in sinus ostia and hypoplastic sinuses may not be amenable to balloon catheter sinuplasty.

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.

Surgical management of rhinosinusitis in onco-hematological patients

Objectives

In onco-hematological diseases, the incidence of paranasal sinuses infection dramatically increase and requires a combination of medical and surgical therapy. Balloon dilatation surgery (DS) is a minimally invasive, tissue preserving procedure. The study evaluates the results of DS for rhinosinusitis in immunocompromised patients.

Methods

A retrospective chart review was conducted in 110 hematologic patients with rhinosinusitis. Twenty-five patients were treated with DS technique and 85 patients with endoscopic sinus surgery (ESS). We considered the type of anesthesia and the extent of intra- and postoperative bleeding. Patients underwent Sino-Nasal Outcome Test (SNOT-20) to evaluate changes in subjective symptoms and global patient assessment (GPA) questionnaire to value patient satisfaction.

Results

Local anesthesia was employed in 8 cases of DS and in 15 of ESS. In 50 ESS patients, an anterior nasal packing was placed and in 12 cases a repacking was necessary. In the DS group, nasal packing was required in 8 cases and in 2 cases a repacking was placed (P=0.019 and P=0.422, respectively). The SNOT-20 change score showed significant improvement of health status in both groups. However the DS group showed a major improvement in 3 voices: need to blow nose, runny nose, and facial pain/pressure. The 3-month follow-up GPA questionnaire showed an higher satisfaction of DS group.

Conclusion

Balloon DS represents a potentially low aggressive treatment and appears to be relatively safe and effective in onco-hematologic patients. All these remarks may lead the surgeon to consider a larger number of candidates for surgical procedure.

A previously unreported serious adverse event during balloon sinuplasty

Balloon sinuplasty is considered as a minimally invasive procedure for the treatment of chronic rhinosinusitis. In this case report we describe how a patient undergoing balloon sinuplasty sustained an intraoperative cardiac arrest with no cardiac history. Postoperative investigations were all normal. The patient was discharged on the first postoperative day and further outpatient tests were normal. We postulate that this event occurred due to profound vagal stimulation either on instrumentation of the maxillary mucosa or when the orbit was accidently breached during instrumentation of the right frontal recess. The authors conclude that balloon sinuplasty, despite being minimally invasive surgery, should be performed under the supervision of an anaesthesiologist with the ability of cardiac monitoring and immediate treatment because of possible arrhythmias.

Unexpected consequences of transnasal balloon dilation of the maxillary ostium

BACKGROUND

Nasal irrigations and topical sprays have been demonstrated to have benefit in chronic sinusitis. Increasingly, it is evident that delivery system, patient anatomy, and inflammatory process have significant impacts on irrigant distribution.

METHODS

Intrasinus endoscopy was performed during sinus irrigation of 5 thawed fresh frozen cadavers (10 sides) before and after transnasal dilation of the maxillary, frontal, and sphenoid ostia with a 5-mm balloon.

RESULTS

Guidewire insertion created false passages through maxillary fontanelle on all of 10 attempts; 1 of 10 frontal insertions entered the ostia in a submucosal plane, while all 10 sphenoid attempts were successful without complication (p < 0.0001). Average minimum ostial dimension increased from 1.73 mm to 3.6 mm (p < 0.0001) after dilation. Obtaining an ostial size of 5 mm was associated with significantly improved irrigation penetration relative to a minimum dimension of 4 mm or less (p = 0.019). After balloon dilation of the true ostia, irrigation of the sphenoid increased, irrigations into the frontal sinuses were unchanged, and irrigation into the maxillary sinuses decreased.

CONCLUSION

Guidewire insertion in this study was noted to frequently create a false passage during maxillary sinus ostial dilation. After balloon dilation, irrigant penetration was increased into the sphenoid sinus for heavy and mist irrigators whereas the maxillary sinus had diminished irrigant penetration for heavy and NetiPot irrigators.