Feasibility of balloon sinuplasty in patients with chronic rhinosinusitis: the Graz experience

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.

Chronic rhinosinusitis phenotypes

OBJECTIVE

To review the current knowledge surrounding different chronic rhinosinusitis (CRS) presentations and the relative roles of nasal polyps, eosinophilia, and allergies in discerning phenotypes.

DATA SOURCES

PubMed literature review.

STUDY SELECTIONS

Articles discussing the various phenotypes of CRS with emphasis on pathologic and immune mechanistic studies that distinguish disease.

RESULTS

Current guidelines primarily separate CRS based on the presence or absence of nasal polyps. This is largely driven by the tendency of eosinophilic disease to present with nasal polyps (NPs) in contrast to noneosinophilic presentations, which less often lead to the development NPs. Further separations have been proposed based on expression of aeroallergen sensitization.

CONCLUSION

The presence of NPs may only poorly predict the presence of an underlying eosinophilic process and as such may have poor utility in forming the basis for recommending eosinophil-target therapies. Similarly, there is little evidence to support a significant role for aeroallergen exposure in contributing to the presence, severity, or natural history of CRS. Appropriate separation of CRS into specific phenotypes will allow therapeutic approaches to be individualized to each distinct presentation.

Flexible microsensor technology for real-time navigation tracking in balloon sinus ostial dilation

Background:

Microsensor navigation has the potential to aid balloon sinus ostial dilation by providing real-time tracking of balloon devices within the complex anatomy of the sinonasal cavities.

Objective:

This feasibility study evaluated the incorporation of a new microsensor technology into a flexible guidewire for use with current instruments in balloon sinus ostial dilation.

Methods:

A retrospective study was conducted to include seven men and one woman (age range, 33–68 years), who underwent balloon sinus ostial dilation with flexible microsensor navigation in the operating room setting. All the procedures were performed at target sinuses with the patient under general anesthesia, in conjunction with subsequent endoscopic sinus surgery.

Results:

Balloon dilation was attempted at the maxillary (n = 3), frontal (n = 14), and sphenoid (n = 1) sinuses. In all the cases, the surgical navigation system displayed the flexible wire tip as it was advanced to the target sinus ostia; this visual feedback for wire position guided the balloon placement. Successful balloon dilation with assistance of flexible microsensor navigation was performed on most sinuses, except a single frontal sinus with adjacent type 2 frontal cells.

Conclusion:

Flexible navigation technology may be combined with balloon sinus technology to facilitate localization of instruments in the sinus anatomy. Additional optimization of both the device and software technology is warranted.

Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter

Rhinosinusitis is a commonly diagnosed disease in the USA. Rhinosinusitis is classified as acute, recurrent, or chronic (with or without nasal polyps). While acute rhinosinusitis is diagnosed by history and physical examination, chronic rhinosinusitis and recurrent acute rhinosinusitis are diagnosed based on symptoms and the presence of disease on either a sinus CT scan and/or endoscopy. Management of uncomplicated acute rhinosinusitis includes analgesics, saline irrigation, and/or intranasal steroids. Antibiotics and intranasal steroids are recommended for acute bacterial rhinosinusitis. Intranasal and oral steroids with antibiotics are recommended to treat chronic rhinosinusitis although the evidence for antibiotics is weak. Biologics such as omalizumab and mepolizumab are being investigated for the treatment of chronic rhinosinusitis with nasal polyps. Surgery may be indicated in management of refractory chronic rhinosinusitis and rarely for acute bacterial rhinosinusitis. This review discusses highlights of the updated 2014 practice parameter and up-to-date evidence from other literature sources.

Augmented reality for endoscopic sinus surgery with surgical navigation: a cadaver study

BACKGROUND

Augmented reality (AR) fuses computer-generated images of preoperative imaging data with real-time views of the surgical field. Scopis Hybrid Navigation (Scopis GmbH, Berlin, Germany) is a surgical navigation system with AR capabilities for endoscopic sinus surgery (ESS).

METHODS

Predissection planning was performed with Scopis Hybrid Navigation software followed by ESS dissection on 2 human specimens using conventional ESS instruments.

RESULTS

Predissection planning included creating models of relevant frontal recess structures and the frontal sinus outflow pathway on orthogonal computed tomography (CT) images. Positions of the optic nerve and internal carotid artery were marked on the CT images. Models and annotations were displayed as an overlay on the endoscopic images during the dissection, which was performed with electromagnetic surgical navigation. The accuracy of the AR images relative to underlying anatomy was better than 1.5 mm. The software's trajectory targeting tool was used to guide instrument placement along the frontal sinus outflow pathway. AR imaging of the optic nerve and internal carotid artery served to mark the positions of these structures during the dissection.

CONCLUSION

Surgical navigation with AR was easily deployed in this cadaveric model of ESS. This technology builds upon the positive impact of surgical navigation during ESS, particularly during frontal recess surgery. Instrument tracking with this technology facilitates identifying and cannulation of the frontal sinus outflow pathway without dissection of the frontal recess anatomy. AR can also highlight "anti-targets" (ie, structures to be avoided), such as the optic nerve and internal carotid artery, and thus reduce surgical complications and morbidity.

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.